Correctional Training Facility Cycle 7 Medical Inspection Report

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Connect with us on social media Cycle 7, Correctional Training Facility | iii Contents Introduction 1 Summary: Ratings and Scores 3 Medical Inspection Results 5 Deficiencies Identified During Case Review 5 Case Review Results 5 Compliance Testing Results 6 Institution-Specific Metrics 7 Population-Based Metrics 9 HEDIS Results 9 Recommendations 11 Indicators 14 Access to Care 14 Diagnostic Services 21 Emergency Services 25 Health Information Management 31 Health Care Environment 37 Transfers 44 Medication Management 51 Preventive Services 59 Nursing Performance 62 Provider Performance 66 Specialized Medical Housing 74 Specialty Services 80 Administrative Operations 88 Appendix A: Methodology 91 Case Reviews 92 Compliance Testing 95 Indicator Ratings and the Overall Medical Quality Rating 96 Appendix B: Case Review Data 97 Appendix C: Compliance Sampling Methodology 101 California Correctional Health Care Services’ Response 109 Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | iv Illustrations Tables 1. CTF Summary Table: Case Review Ratings and Policy Compliance Scores 4 2. CTF Master Registry Data as of January 2024 7 3. CTF Health Care Staffing Resources as of January 2024 8 4. CTF Results Compared With State HEDIS Scores 10 5. Access to Care 18 6. Other Tests Related to Access to Care 19 7. Diagnostic Services 23 8. Health Information Management 34 9. Other Tests Related to Health Information Management 35 10. Health Care Environment 42 11. Transfers 48 12. Other Tests Related to Transfers 49 13. Medication Management 56 14. Other Tests Related to Medication Management 57 15. Preventive Services 60 16. Specialized Medical Housing 78 17. Specialty Services 85 18. Other Tests Related to Specialty Services 86 19. Administrative Operations 89 A–1. Case Review Definitions 92 B–1. CTF Case Review Sample Sets 97 B–2. CTF Case Review Chronic Care Diagnoses 98 B–3. CTF Case Review Events by Program 99 B–4. CTF Case Review Sample Summary 99 Figures A–1. Inspection Indicator Review Distribution for CTF 91 A–2. Case Review Testing 94 A–3. Compliance Sampling Methodology 95 Photographs 1. Patient Waiting Area 37 2. Expired Medical Supply Dated August 28, 2023 38 3. Expired Medical Supply Dated August 28, 2023 38 4. Medication Stored With Medical Supply 39 5. Medical Supply Stored in the Same Area as Biohazardous Waste 39 6. Medical Supply Stored in the Same Area as Biohazardous Waste 39 7. Expired Medical Supply Dated March 9, 2022 40 Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 1 Introduction Pursuant to California Penal Code section 6126 et seq., the Office of the Inspector General (the OIG) is responsible for periodically reviewing and reporting on the delivery of the ongoing medical care provided to incarcerated people1 in the California Department of Corrections and Rehabilitation (the department).2 In Cycle 7, the OIG continues to apply the same assessment methodologies used in Cycle 6, including clinical case review and compliance testing. Together, these methods assess the institution’s medical care on both individual and system levels by providing an accurate assessment of how the institution’s health care systems function regarding patients with the highest medical risk, who tend to access services at the highest rate. Through these methods, the OIG evaluates the performance of the institution in providing sustainable, adequate care. We continue to review institutional care using 15 indicators as in prior cycles.3 Using each of these indicators, our compliance inspectors collect data in answer to compliance- and performance-related questions as established in the medical inspection tool (MIT). In addition, our clinicians complete document reviews of individual cases and also perform on-site inspections, which include interviews with staff. The OIG determines a total compliance score for each applicable indicator and considers the MIT scores in the overall conclusion of the institution’s compliance performance. In conducting in-depth quality-focused reviews of randomized cases, our case review clinicians examine whether health care staff used sound medical judgment in the course of caring for a patient. In the event we find errors, we determine whether such errors were clinically significant or led to a significantly increased risk of harm to the patient. At the same time, our clinicians consider whether institutional medical processes led to identifying and correcting individual or system errors, and we examine whether the institution’s medical system mitigated the error. The OIG rates each applicable indicator proficient, adequate, or inadequate, and considers each rating in the overall conclusion of the institution’s health care performance. In contrast to Cycle 6, the OIG will provide individual clinical case review ratings and compliance testing scores in Cycle 7, rather than aggregate all findings into a single overall institution rating. This change will clarify the distinctions between these differing quality measures and the results of each assessment. 1 In this report, we use the terms patient and patients to refer to incarcerated people. 2 The OIG’s medical inspections are not designed to resolve questions about the constitutionality of care, and the OIG explicitly makes no determination regarding the constitutionality of care the department provides to its population. 3 In addition to our own compliance testing and case reviews, the OIG continues to offer selected Healthcare Effectiveness Data and Information Set (HEDIS) measures for comparison purposes. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 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 Correctional Training Facility, 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 June 2023 to November 2023.4 4 Samples are obtained per case review methodology shared with stakeholders in prior cycles. The case reviews include death reviews between November 2022 and June 2023, and emergency cardiopulmonary resuscitation reviews between May 2023 and October 2023. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 3 Summary: Ratings and Scores We completed the Cycle 7 inspection of Correctional Training Facility (CTF) in May 2024. OIG inspectors monitored the institution’s delivery of medical care that occurred between June 2023 and November 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 CTF adequate. quality at CTF inadequate. OIG case review clinicians (a team of physicians and nurse consultants) reviewed 42 cases, which contained 849 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 May 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 13 adequate and seven 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 413 patient records and 1,132 data points and used the data to answer 89 policy questions. In addition, we observed CTF’s processes during an on- site inspection in February 2024. The OIG then considered the results from both case review and compliance testing, and drew overall conclusions, which we report in 13 health care indicators.5 5 The indicators for Reception Center and Prenatal and Postpartum Care did not apply to CTF. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 4 We list the individual indicators and ratings applicable for this institution in Table 1 below. Table 1. CTF Summary Table: Case Review Ratings and Policy Compliance Scores Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 5 Medical Inspection Results Deficiencies Identified During Case Review Deficiencies are medical errors that increase the risk of patient harm. Deficiencies can be minor or significant, depending on the severity of the deficiency. An adverse event occurs when the deficiency caused harm to the patient. All major health care organizations identify and track adverse events. We identify deficiencies and adverse events to highlight concerns regarding the provision of care and for the benefit of the institution’s quality improvement program to provide an impetus for improvement.6 The OIG found no adverse events at CTF 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 CTF. Of these 10 indicators, OIG clinicians rated seven adequate and three inadequate. The OIG physicians also rated the overall adequacy of care for each of the 20 detailed case reviews they conducted. Of these 20 cases, 13 were adequate and seven were inadequate. In the 849 events reviewed, we identified 286 deficiencies, 80 of which OIG clinicians considered to be of such magnitude that, if left unaddressed, would likely contribute to patient harm. Our clinicians found the following strengths at CTF: • Staff performed well in completing laboratory and radiology tests and reporting the test results to the providers. • Provider appointments often occurred within ordered time frames. • Staff performed well in medication continuity for patients who transferred into and out of CTF. Our clinicians found the following weaknesses at CTF: • Provider performance needed improvement due to poor clinical assessment and decision-making, lack of attention to detail, and lapses in following through on documented plans for patients. • Nursing and medical leadership often did not conduct clinic reviews for emergency events and did not always identify opportunities for improvement. • Nurse-to-provider notifications, timely reassessments, and nursing interventions during emergency events needed improvement. 6 For a further discussion of an adverse event, see Table A–1. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 6 Compliance Testing Results Our compliance inspectors assessed 10 of the 13 indicators applicable to CTF. Of these 10 indicators, our compliance inspectors rated one proficient, two adequate, and seven inadequate. We solely tested policy compliance in Health Care Environment, Preventive Services, and Administrative Operations as these indicators do not have a case review component. CTF showed a high rate of policy compliance in the following areas: • Nurses reviewed health care services request forms and conducted face-to-face encounters within required time frames. • Providers evaluated patients returning from outside community hospitals within required time frames. Moreover, providers also timely evaluated newly arrived patients to CTF. • CTF nursing staff and providers excellently completed nursing and provider assessments of patients admitted to the outpatient housing unit (OHU) within required time frames. CTF showed a low rate of policy compliance in the following areas: • Staff frequently did not maintain medication continuity for chronic care patients, patients discharged from the hospital, patients admitted to the specialized medical housing unit, and patients who had a temporary layover at CTF. • Staff did not perform well in ensuring approved specialty services were provided within specified time frames. • Providers often did not communicate results of diagnostic tests timely with complete letters. Most patient test result notification letters were missing the date of the diagnostic service, the date of the results, or whether the results were within normal limits. • Health care staff did not consistently follow universal hand hygiene precautions during patient encounters. • CTF’s medical warehouse and clinics had multiple expired medical supplies. • Nursing staff did not regularly inspect emergency medical response bags. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 7 Institution-Specific Metrics CTF is located five miles north of the city of Soledad, in Monterey County. The institution’s primary mission is to provide custody, care, treatment, and rehabilitation for Level I and II general population. CTF runs multiple medical clinics where staff members handle nonurgent requests for medical services. The institution also treats patients needing urgent or emergent care in its triage and treatment area (TTA) and patients requiring outpatient health services and assistance with the activities of daily living in its OHU. In addition, patients departing from or arriving to the institution are screened in the receiving and release (R&R) clinic. California Correctional Health Care Services (CCHCS) has designated CTF as a basic care institution. Basic care institutions are located in rural areas, away from tertiary care centers and specialty care providers whose services are more frequently used by higher-risk patients.7 These institutions provide limited specialty medical services and consultations for generally healthy patient populations. As of February 19, 2025, the department reports on its public tracker that 81 percent of CTF’s incarcerated population is fully vaccinated for COVID-19 while 65 percent of CTF’s staff is fully vaccinated for COVID- 19.8 In January 2024, the Health Care Services Master Registry showed CTF had a total population of 4,165. A breakdown of the medical risk level of the CTF population as determined by the department is set forth in Table 2 below.9 Table 2. CTF Master Registry Data as of January 2024 Medical Risk Level Number of Patients Percentage* High 1 192 4.6% High 2 466 11.2% Medium 1,388 33.3% Low 2,119 50.9% Total 4,165 100.0% * Percentages may not total 100% due to rounding. Source: Data for the population medical risk level were obtained from the CCHCS Master Registry dated 1-22-24. 7 Notably, institutions designated as “basic” are generally expected to have a total high risk medical population of approximately 5%. At nearly 16%, CTF’s high risk population is over three times the expected ratio. However, this institution is still assigned a medical staffing package consistent with its basic designation. We considered this disadvantage in reaching our inspection findings. 8 For more information, see the department’s statistics on its website page titled Population COVID‑19 Tracking. 9 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: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 8 According to staffing data the OIG obtained from CCHCS, as identified in Table 3 below, CTF had three vacant executive leadership positions, eight primary care provider vacancies, 5.5 nursing supervisor vacancies, and 179.8 nursing staff vacancies. Table 3. CTF Health Care Staffing Resources as of January 2024 Executive Primary Care Nursing Nursing Positions Leadership * Providers Supervisors Staff † Total Authorized Positions 6.0 13.0 41.5 339.1 399.6 Filled by Civil Service 5.0 5.0 36.0 159.3 205.3 Vacant 3.0 8.0 5.5 179.8 196.3 Percentage Filled by Civil Service 83.3% 38.5% 86.7% 47.0% 51.4% Filled by Telemedicine 0 2.0 0 0 2.0 Percentage Filled by Telemedicine 0 15.4% 0 0 0.5% Filled by Registry 0 4.0 0 110.0 114.0 Percentage Filled by Registry 0 30.8% 0 0 28.5% Total Filled Positions 5.0 11.0 36.0 269.3 321.3 Total Percentage Filled 83.3% 84.6% 86.7% 79.4% 80.4% Appointments in Last 12 Months 0 2.0 0 21.0 23.0 Redirected Staff 0 0 0 0 0 Staff on Extended Leave ‡ 0 0 3.0 20.0 23.0 Adjusted Total: Filled Positions 5.0 11.0 33.0 249.3 298.3 Adjusted Total: Percentage Filled 83.3% 84.6% 79.5% 73.5% 74.6% * 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 1-22-24, from California Correctional Health Care Services. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 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 CTF’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)—CTF’s percentage of patients with poor HbA1c control was significantly lower, indicating very good performance on this measure. Immunizations Statewide comparative data were not available for immunization measures; however, we include these data for informational purposes. CTF had a 49 percent influenza immunization rate for adults 18 to 64 years old and a 56 percent influenza immunization rate for adults 65 years of age and older.10 The pneumococcal vaccination rate was 82 percent.11 Cancer Screening When compared with statewide Medi-Cal programs—California Medi-Cal, Kaiser Northern California (Medi-Cal), and Kaiser Southern California (Medi-Cal)—CTF’s colorectal cancer screening rate of 83 percent was higher than all three Medi-Cal programs. 10 The HEDIS sampling methodology requires a minimum sample of 10 patients to have a reportable result. 11 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: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 10 Table 4. CTF Results Compared With State HEDIS Scores CTF California California Kaiser Kaiser Cycle 7 California NorCal SoCal HEDIS Measure Results * Medi-Cal † Medi-Cal † Medi-Cal † HbA1c Screening 100% – – – Poor HbA1c Control (> 9.0%) ‡,§ 5% 36% 31% 22% HbA1c Control (< 8.0%) ‡ 87% – – – Blood Pressure Control (< 140/90) ‡ 90% – – – Eye Examinations 83% – – – Influenza – Adults (18 – 64) 49% – – – Influenza – Adults (65 +) 56% – – – Pneumococcal – Adults (65 +) 82% – – – Colorectal Cancer Screening 83% 37% 68% 70% Notes and Sources * Unless otherwise stated, data were collected in February 2024 by reviewing medical records from a sample of CTF’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 titled 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 CTF 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: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 11 Recommendations As a result of our assessment of CTF’s performance, we offer the following recommendations to the department: Access to Care • Medical and administrative leadership should analyze the success of the measures they have taken to address the unavailability of the health care services request forms (CDCR form 7362) and implement any further remedial measures if needed. Diagnostic Services • The department should develop and implement strategies, such as an electronic solution, to ensure providers create patient letters that contain all elements required by CCHCS policy when they endorse test results. Emergency Services • Nursing leadership should determine the root cause(s) of challenges that prevent nurses from performing thorough assessments and reassessments, notifying the provider of abnormal clinical findings, and providing appropriate interventions for patients with emergent and urgent conditions. Leadership should implement remedial measures as appropriate. • Medical and nursing leadership should determine the root cause(s) of challenges in completing thorough clinical reviews of urgent and emergent events in which patients transfer to the community hospital and in identifying opportunities for improvement. Leadership should implement remedial measures as appropriate. Health Information Management • CTF leadership should develop and implement strategies to ensure staff properly scan and label documents in the electronic health record system (EHRS), as required by CCHCS policy. 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. • 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. • Nursing leadership should determine the root cause(s) for staff not ensuring the emergency medical response bags (EMRBs) are regularly inventoried and sealed and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 12 Medication Management • Health care leadership should develop and implement measures to ensure staff timely make available and administer chronic care medications, newly ordered medications, community hospital discharge medications, and medications for patients temporarily housed at the institution. Leadership should implement remedial measures as appropriate. • Nursing leadership should develop and implement measures to ensure nursing staff document administering medications, patient refusals, and no-shows in the electronic health record in accordance with CCHCS’s policies and procedures. Leadership should implement remedial measures as appropriate. Preventive Services • Nursing leadership should develop and implement measures to ensure the nursing staff monitor patients who are receiving TB medications according to CCHCS policy. • Medical leadership should determine the root cause(s) for challenges to timely providing vaccinations to chronic care patients and should implement remedial measures as appropriate. Nursing Performance • Nursing leadership should ensure nurses assess patients with urgent complaints the same day and notify the providers when patients’ conditions are warranted. Leadership should implement remedial measures as appropriate. Provider Performance • Medical leadership should analyze the root cause(s) of poor assessments, emergency care, medical record review, specialty follow-up, documentation, specialized medical housing care, and chronic condition management and should implement remedial measures as appropriate. • Medical leadership should develop strategies to ensure complete and thorough review of emergency cases and implement remedial measures as appropriate. Specialized Medical Housing • Nursing leadership should develop strategies to ensure nurses perform thorough patient admission assessments and notify providers of any abnormal changes in patients’ conditions and should implement remedial measures as appropriate. Specialty Services • CTF leadership should determine the root cause(s) of challenges to timely providing specialty appointments and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 13 • CTF leadership should ascertain the challenge(s) to the receiving specialty reports within required time frames and should implement remedial measures as appropriate. • Medical leadership should determine the root cause(s) of providers not following specialists’ recommendations or not clearly documenting the medical rationale for not following specialist’s recommendations and should implement necessary remedial measures. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 14 Indicators Access to Care In this indicator, OIG inspectors evaluated the institution’s performance in providing patients with timely clinical appointments. Our inspectors reviewed scheduling and appointment timeliness for newly arrived patients, sick calls, and nurse follow-up appointments. We examined referrals to primary care providers, provider follow-ups, and specialists. Furthermore, we evaluated the follow-up appointments for patients who received specialty care or returned from an off-site hospitalization. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Adequate (81.6%) Case review found CTF provided good access to care. CTF offered excellent access to clinic providers and nurses, and good access to providers after hospitalizations and emergency care. Nurses and providers almost always evaluated transfer-in patients within required time frames. Providers often timely evaluated and completed initial history and physicals for specialized medical housing patients. However, specialty services access needed improvement. After reviewing all aspects of access to care, the OIG rated the case review component of this indicator adequate. Compliance testing showed CTF performed satisfactorily in access to care. Staff performed excellently with nurses’ reviews of patient sick call requests, completing face-to-face nurse encounters, offering provider follow-up appointments for patients returning from hospitalizations, and provider appointments for patients who transferred into CTF. Staff also often completed provider chronic care follow-up appointments and provider appointments for patients who returned from specialty services. However, CTF scored low for maintaining patient sick call forms in the housing units. Based on the overall compliance score result, the OIG rated this indicator adequate. Case Review and Compliance Testing Results OIG clinicians reviewed 218 provider, nursing, urgent or emergent care (TTA), specialty, and hospital events requiring the institution to generate appointments. We identified 14 deficiencies relating to Access to Care, 11 of which were significant.12 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 often occurred timely (MIT 1.001, 80.0%). OIG clinicians found providers usually completed chronic care 12 Access to care deficiencies occurred in cases 2, 11, 12, 18, 21, 22, 24, 41, and 42. Significant occurred in cases 2, 12, 18, 21, 22, 24, and 42. Notably, we considered the number of access deficiencies in light of the significantly larger high-risk medical population CTF must attend to as compared with most institutions designated “basic.” Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 15 appointments within ordered time frames. We identified three deficiencies, two of which were significant, as described below:13 • In case 12, the patient with uncontrolled diabetes required an appointment with a CTF provider for preoperative clearance prior to surgery; however, that CTF provider appointment did not occur until after the surgery was complete. • In case 21, the patient with asthma, high cholesterol, and chronic back pain was not scheduled for a chronic care appointment with a provider for 20 months. The patient should have been seen more frequently. Both compliance testing and case review found patients did not always have access to health care services request forms (CDCR form 7362). This is discussed further in the Clinician On- Site Inspection section below. Access to Specialized Medical Housing Providers CTF provided fair access to specialized medical housing providers. OIG clinicians found providers usually performed patient intake history and physicals timely; however, we found the following deficiency: • In case 2, during a 25-day period, the patient with a history of frequent medical procedures, hospitalizations, and emergency encounters was not seen by a primary care provider. The patient should have been assessed more frequently. Access to Clinic Nurses CTF performed excellently with access to nurse sick calls and provider-to-nurse referrals. Compliance testing showed nurses always reviewed medical requests for services the day they were received (MIT 1.003, 100%) and frequently completed face-to-face appointments within required time frames (MIT 1.004, 93.3%). OIG clinicians reviewed 54 nursing sick call requests in 23 cases and identified no deficiencies related to clinic nurse access. Access to Specialty Services CTF provided variable access to specialists. Compliance testing revealed an excellent completion rate of high-priority specialty appointments (MIT 14.001, 93.3%), a very good completion rate of routine-priority specialty appointments (MIT 14.007, 86.7%), but a poor completion rate of medium-priority specialty appointments (MIT 14.004, 66.7%) within ordered time frames. Case review found seven deficiencies in access to specialty services, five of which were significant.14 These are discussed further in the Specialty Services indicator. 13 Access to provider deficiencies occurred in cases 11, 12, and 21. 14 Specialty services access deficiencies occurred in cases 1, 12, 18, 22, 41 and 42. Significant deficiencies occurred in cases 2, 12, 18, 22, and 42. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 16 Follow-Up After Specialty Services Compliance testing revealed provider appointments after specialty services usually occurred within required time frames (MIT 1.008, 76.2%). Case review clinicians found the following one deficiency, which was significant: • In case 24, the patient returned from an off-site MRI and was supposed to be seen 14 days later by a CTF provider; however, that appointment did not occur.15 Follow-Up After Hospitalization CTF performed outstandingly in completing provider follow-up appointments after hospitalization (MIT 1.007, 95.8%). Case review found similar results, with only one deficiency, which was significant: • In case 21, the patient was hospitalized for seven days for acute respiratory failure and status asthmaticus.16 The patient was scheduled to see his primary care provider in five days after hospital discharge; however, that appointment did not occur for one month. Follow-Up After Urgent or Emergent Care (TTA) Providers generally evaluated their patients following a TTA event as medically indicated. OIG clinicians reviewed 36 TTA events and identified one deficiency, which was significant: • In case 24, TTA staff evaluated the patient for a red, swollen, and painful arm, indicative of an infection. The provider requested a follow-up appointment within five days; however, this appointment did not occur. Follow-Up After Transferring Into CTF CTF performed very well with access to care for patients who had recently transferred into the institution. Compliance testing showed very good access to intake appointments for newly arrived patients (MIT 1.002, 92.0%). Case reviewers did not find any deficiencies. Clinician On-Site Inspection OIG clinicians met and discussed care access with CTF’s executive leadership, medical and nursing leadership, the correctional health services administrator (CHSA), and schedulers. CTF had seven outpatient clinics, an OHU, a TTA unit, and on-site specialty services requiring appointment scheduling. The registered nurse (RN) clinics were scheduled with a concerted effort between RN medical services triage and the schedulers. Factors affecting provider appointment availability included a loss of three physicians and restructuring of the outpatient clinics, which increased the patient panels for the remaining physicians. To reduce provider appointment backlog, the providers worked extended hours, and the chief 15 An MRI is a magnetic resonance imaging scan. The scan creates detailed images of the organs and tissues to detect diseases and abnormalities. 16 Status asthmaticus is an acute, severe asthma exacerbation that does not improve with standard treatments. This condition may lead to respiratory failure and require hospitalization. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 17 physician and surgeon (CP&S) and the chief medical executive (CME) evaluated patients in addition to their administrative duties. At the on-site inspection, OIG clinicians identified few to no health care services request forms available for patient use on the yards. Availability of these forms is critical to patients having access to medical care. Without these forms, the patient’s only alternative to access medical care is to tell custody or medical staff about their symptoms or wait until their symptoms worsen, then go “man down” to initiate an emergency event.17 Custody on several yards informed OIG clinicians that regardless of how many forms they put out, the patients hoard the forms, reducing the supply of the forms very quickly. In some yards, when asked how to replenish the forms, medical and custody staff either didn’t know or gave differing responses, indicating the inmates could obtain them from the clinic custody or yard nurses. However, in our observations, clinic custody could not always readily locate the forms, and the patients had limited nursing access on the yards. The OIG’s compliance nurses made similar observations at their on-site inspection. The CHSA is responsible for managing the health care services request forms. Both the CHSA and her staff confirmed they are aware of the form availability problem and reported they are establishing more defined protocols for replenishing supplies as well as increasing locations where forms can be obtained. In addition, the CHSA clarified staff must complete a warehouse request form to request new health care services request forms, and they are educating custody and medical staff on how to obtain, use, and process these forms. Compliance On-Site Inspection Only one of six housing units randomly tested at the time of inspection had access to health care services request forms (MIT 1.101, 16.7%). In four 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. The remaining housing unit did not have a health care services request form available at the time of our inspection. 17 Man down is term to signify when a patient is incapacitated and needs emergency help. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 18 Compliance Score Results Table 5. Access to Care Scored Answer Compliance Questions Yes No N/A Yes % Chronic care follow-up appointments: Was the patient’s most recent chronic care visit within the health care guideline’s maximum allowable interval or 20 5 0 80.0% 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 23 2 0 92.0% patient seen by the clinician within the required time frame? (1.002) Clinical appointments: Did a registered nurse review the patient’s request 30 0 0 100% for service the same day it was received? (1.003) Clinical appointments: Did the registered nurse complete a face-to-face visit 28 2 0 93.3% within one business day after the CDCR Form 7362 was reviewed? (1.004) Clinical appointments: If the registered nurse determined a referral to a primary care provider was necessary, was the patient seen within the 4 1 25 80.0% maximum allowable time or the ordered time frame, whichever is the shorter? (1.005) Sick call follow-up appointments: If the primary care provider ordered a follow-up sick call appointment, did it take place within the time frame 1 0 29 100% specified? (1.006) Upon the patient’s discharge from the community hospital: Did the patient 23 1 1 95.8% receive a follow-up appointment within the required time frame? (1.007) Specialty service follow-up appointments: Did the clinician follow-up visits 16 5 24 76.2% occur within required time frames? (1.008) * Clinical appointments: Do patients have a standardized process to obtain 1 5 6 16.7% and submit health care services request forms? (1.101) Overall percentage (MIT 1): 81.6% * CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician follow-up visits following specialty services. As a result, we tested MIT 1.008 only for high-priority specialty services or when staff ordered follow-ups. The OIG continued to test the clinical appropriateness of specialty follow-ups through its case review testing. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 19 Table 6. Other Tests Related to Access to Care Scored Answer Compliance Questions Yes No N/A Yes % For patients received from a county jail: If, during the assessment, the nurse referred the patient to a provider, was the patient seen within the N/A N/A N/A N/A required time frame? (12.003) For patients received from a county jail: Did the patient receive a history and physical by a primary care provider within seven calendar days (prior N/A N/A N/A N/A to 07/2022) or five working days (effective 07/2022)? (12.004) Was a written history and physical examination completed within the 10 0 0 100% required time frame? (13.002) Did the patient receive the high-priority specialty service within 14 calendar days of the primary care provider order or the Physician 14 1 0 93.3% Request for Service? (14.001) Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care 9 4 2 69.2% 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 10 5 0 66.7% for Service? (14.004) Did the patient receive the subsequent follow-up to the medium-priority specialty service appointment as ordered by the primary care provider? 5 1 9 83.3% (14.006) Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician Request 13 2 0 86.7% for Service? (14.007) Did the patient receive the subsequent follow-up to the routine-priority specialty service appointment as ordered by the primary care 5 1 9 83.3% provider? (14.009) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 20 Recommendations • Medical and administrative leadership should analyze the success of the measures they have taken to address the unavailability of the health care services request forms (CDCR form 7362) and implement any further remedial measures if needed. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 21 Diagnostic Services In this indicator, OIG inspectors evaluated the institution’s performance in timely completing radiology, laboratory, and pathology tests. Our inspectors determined whether the institution properly retrieved the resultant reports and whether providers reviewed the results correctly. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Inadequate (66.7%) Case review found CTF performed well in diagnostic services. Staff completed radiology and laboratory tests within specified time frames and obtained reports timely. Providers usually endorsed related reports as required and sent patient results notification letters; however, those letters often did not contain all components required by CCHCS policy. Factoring in all aspects of care, the OIG rated the case review component of this indicator adequate. Compliance testing showed mixed performance for CTF in diagnostic services. Staff performed acceptably to excellently in providing radiology services and endorsing diagnostic results. Staff also frequently completed laboratory services and retrieved pathology reports. However, providers performed poorly in generating patient notification 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 We reviewed 119 diagnostic events and identified 62 deficiencies, two of which were significant. All 62 deficiencies related to health information management.18 Test Completion Compliance testing showed CTF always completed radiology services (MIT 2.001, 100%) and often completed laboratory services (MIT 2.004, 80.0%) within required time frames. Of the 199 diagnostic events reviewed by OIG clinicians, CTF always completed diagnostic laboratory and on-site radiology studies within ordered time frames, and almost always retrieved and endorsed results timely. Neither case review nor compliance testing had any STAT laboratory tests in their samples to review (MIT 2.007, NA). Health Information Management CTF staff retrieved diagnostic results promptly and sent them to providers for review. Compliance testing showed providers always timely endorsed radiology reports (MIT 2.002, 18 Deficiencies occurred in cases1, 2, 9, 11–17, 20–25, 41, and 42. Significant deficiencies occurred in cases 9 and 12. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 22 100%) and often timely endorsed laboratory reports (MIT 2.005, 90.0%). This is consistent with case review findings. In both compliance testing and case review, providers performed poorly in communicating laboratory and radiology test results to their patients. Compliance testing showed providers sometimes communicated radiology results (MIT 2.003, 50.0%) and sporadically communicated laboratory test results (MIT 2.006, 20.0%) with complete test results notification letters to patients within required time frames. Case review found 54 of the 62 health information management (HIM) diagnostic deficiencies related to patient notification letters missing required elements. Compliance testing showed staff performance was sufficient in both the retrieval of final pathology reports within the required time frames (MIT 2.010, 80.0%) and provider review and endorsement of the pathology results (MIT 2.011, 80.0%); however, staff never communicated the results of the pathology reports with complete test results notification letters to patients within required time frames (MIT 2.012, zero). In the three pathology related events, case review identified one minor deficiency. Clinician On-Site Inspection We met with CTF’s diagnostic and health information management leadership. According to leadership, the CTF radiology area was undergoing remodeling during the review period. CTF had a portable x-ray unit available; however, the unit could not accommodate lower extremities or patients over 250 pounds. Consequently, patients received most x-rays either at Salinas Valley State Prison (SVSP), the institution adjacent to CTF, or at the local hospital. Leadership also stated, in addition to requiring patient transport out of the institution for imaging studies, sharing x-ray facilities with SVSP was problematic because SVSP is a Level 4 institution, and health care staff needed to consider custody concerns. Furthermore, CTF’s radiology technician had transferred to SVSP due to CTF’s lack of equipment. This resulted in both institutions sharing one radiology technician until new technicians could be hired. Radiology technicians from other institutions staffed weekend imaging clinics, which reduced the radiology backlog. CTF leadership stated hiring radiology and laboratory staff was a challenge. Leadership reported difficulty in recruiting and retaining staff due to the high cost of living locally and better pay at local community hospitals. As with some other CCHCS institutions, a contracted vendor performed on-site specialty imaging, such as CTs and MRIs.19 This vendor uploaded the imaging results directly into EHRS, which staff then forwarded to the providers for review and endorsement. CTF staff stated the service was very efficient in reading and sending the imaging reports back to CTF. 19 A CT is a computed, or computerized, tomography scan. This scan creates detailed images of the organs and tissues to detect diseases and abnormalities. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 23 Compliance Score Results Table 7. Diagnostic Services Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Was the radiology service provided within the time frame 10 0 0 100% specified in the health care provider’s order? (2.001) Radiology: Did the ordering health care provider review and endorse the 10 0 0 100% 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 9 1 0 90.0% 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 N/A N/A N/A N/A the results within the required time frames? (2.007) Laboratory: Did the provider acknowledge the STAT results, OR did nursing N/A N/A N/A N/A staff notify the provider within the required time frames? (2.008) Laboratory: Did the health care provider endorse the STAT laboratory N/A N/A N/A N/A results within the required time frames? (2.009) Pathology: Did the institution receive the final pathology report within the 8 2 0 80.0% required time frames? (2.010) Pathology: Did the health care provider review and endorse the pathology 8 2 0 80.0% report within specified time frames? (2.011) Pathology: Did the health care provider communicate the results of the 0 9 1 0 pathology study to the patient within specified time frames? (2.012) Overall percentage (MIT 2): 66.7% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 24 Recommendations • The department should develop and implement strategies, such as an electronic solution, to ensure providers create patient letters that contain all elements required by CCHCS policy when they endorse test results. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 25 Emergency Services In this indicator, OIG clinicians evaluated the quality of emergency medical care. Our clinicians reviewed the institution’s emergency medical response system 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 Inadequate Not Applicable OIG clinicians found CTF needed improvement in emergency services. In comparison with Cycle 6, we reviewed more events but had a similar number of deficiencies. However, our clinicians found CTF continued to have challenges with nursing assessments and interventions during emergency events. Moreover, medical leadership often did not conduct clinical reviews, or when clinical reviews were conducted, they did not identify opportunities for improvement. Although provider performance with emergency events was sufficient, factoring all the information, the OIG rated this indicator as inadequate. Case Review Results We reviewed 61 urgent or emergent events and found 48 deficiencies. Of these 48 deficiencies, 15 were significant.20 Emergency Medical Response CTF staff mostly timely responded to emergency events throughout the institution, activated emergency medical services (EMS), and notified TTA staff. Our clinicians reviewed 56 emergency events, which required a response from a medical first responder. We identified two significant deficiencies related to emergency response delays.21 The following are examples: • In case 1, the TTA RN responded to a medical alarm for the patient with complaints of severe abdominal pain. However, the RN first responder arrived at the patient 12 minutes after alarm activation, which was four minutes beyond the required time frame established in the CCHCS policy. 20 Deficiencies occurred in cases 1–4, 7, 8, 13, 15, 18–21, 24, and 42. Significant deficiencies occurred in cases 1–4, 7, 8, 13, and 21. 21 First Medical Responder deficiencies occurred in cases 1, 2, 7, 19, and 21. Significant deficiencies occurred in cases 1 and 7. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 26 • In case 7, a medical alarm was activated for the patient found hanging in his cell. Staff did not call 9-1-1 for nine minutes. Cardiopulmonary Resuscitation Quality Our clinicians reviewed six cases in which cardiopulmonary resuscitation (CPR) was initiated.22 Custody and medical staff started CPR promptly, administered naloxone, and activated the 9-1-1 system from the scene.23 However, our clinicians identified two deficiencies in which nurses did not appropriately assess the patients after they had a spontaneous return of circulation. The following are examples: • In case 3, custody staff initiated CPR on the patient who was found unresponsive. However, after the patient regained consciousness, the nurses did not assess the patient’s respiratory rate, reassess the low oxygenation saturation rate, or reassess the patient’s mental status. • In case 4, staff initiated CPR on the patient who was found unresponsive in the OHU. The patient regained consciousness after the third dose of naloxone was administered. However, the nurses did not assess the patient’s respiratory rate or oxygenation saturation rate to ensure the patient was sufficiently breathing. In addition, the nurses did not continue to monitor the patient’s vital signs and mental status every five minutes. Provider Performance CTF providers’ performance was fair in urgent and emergent situations and in after-hours care. In the 61 emergency events we reviewed, the providers generally performed adequate assessments, developed appropriate treatment plans, and ensured patient transport orders were medically appropriate. However, we identified seven provider deficiencies, three of which were significant.24 The following is an example: • In case 13, the nurse contacted the on-call provider about a patient who fell on his left shoulder and was experiencing severe pain with reduced range of motion. In addition, the nurse described the shoulder as a “bone popped out on top of the shoulder.” Although the provider did not examine the patient, the provider documented the shoulder had a slight bulge but was otherwise normal. The provider diagnosed the patient with a shoulder strain, ordered pain medication, and sent the patient to the housing unit for a nurse follow-up in two days. A few hours later, due to severe pain, the patient was sent to the hospital and diagnosed with a shoulder dislocation. The provider should have considered this diagnosis and offered appropriate treatment when first contacted by the nurse. 22 CPR events occurred in cases 3–7 and 9. 23 Naloxone is a medication used for the emergency treatment of known or suspected opioid overdose. 24 Provider related deficiencies occurred in cases 2, 13, 20, 21, 24, and 42. Three significant deficiencies occurred in cases 2 and 13. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 27 Nursing Performance Our clinicians identified opportunities for improvement with nursing assessments for patients evaluated in the TTA. We identified a pattern of incomplete nursing assessments and found nurses did not always recheck vital signs, assess pain levels, or contact the provider for further plan of care. The following are examples: • In case 1, the TTA RN evaluated the patient for abdominal pain, nausea, and vomiting. The nurse administered medication to treat nausea and vomiting; however, the nurse did not reassess the patient for improvement in nausea and did not reassess the patient’s abdominal pain for improvement. Similar deficiencies occurred in cases 2, 4, 8, and 21. • In case 8, the TTA RN evaluated the patient with complaints of severe low back pain and lower extremity numbness. The patient’s blood pressure and pulse were both elevated. However, the TTA nurse did not reassess the patient’s vital signs or pain level for two hours and 40 minutes while in TTA prior to the patient transferring to a higher level of care. • Also in case 8, the TTA RN evaluated the patient with complaints of low back pain and an episode of shortness of breath, dizziness, and constipation. The TTA nurse did not assess the duration of the patient’s symptoms or perform a reassessment when the patient reported additional symptoms, nor did the nurse reassess the patient’s vital signs. Upon assuming care, the RN on the next shift did not perform an independent assessment to include pain level before medication was administered. Furthermore, neither RN notified the provider of the patient’s change in condition after the initial notification to the provider. • In case 21, the TTA RN evaluated the patient for complaints of shortness of breath and chest tightness. The nurse administered two nebulizer breathing treatments and one dose of prednisone per CCHCS nursing protocol.25 Despite these treatments, the patient continued to have wheezing. However, the nurse did not notify the provider immediately of the patient’s symptoms per CCHCS nursing protocol or prior to the patient being discharged back to the housing unit. In addition, the nurse did not obtain expiratory peak flow before and after treatments, assess lung sounds, or reassess chest pain severity and shortness of breath. We also identified six deficiencies related to nursing interventions, two of which were significant.26 The following is an example of a significant deficiency: • In case 2, the OHU patient had an elevated heart rate and severe abdominal pain. A licensed vocational nurse (LVN) consulted a TTA RN, and the patient was transported by wheelchair to the TTA. However, neither the LVN nor the RN accompanied the patient to the TTA; instead, the patient was escorted only by custody staff. Upon arrival to the TTA, the patient had shortness of breath, labored breathing, and lower extremity swelling. Despite the patient’s 25 Prednisone is a steroid medication used to decrease inflammation or swelling. 26 Nursing intervention deficiencies occurred in cases 2, 8, 15, 18, 21, and 24. Significant deficiencies occurred in cases 2, 8, and 21. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 28 presentation, the nurse did not consult a provider until 39 minutes after the patient’s arrival to the TTA. Nursing Documentation CTF nurses intermittently performed thorough documentation for emergency events. We identified eight deficiencies related to nursing documentation.27 The following is an example: • In case 1, the nurse assessed the patient with complaints of abdominal pain. The nurse documented the patient’s abdomen was soft and bowel sounds were present. However, the nurse did not document if the patient’s abdomen was tender or nontender upon palpation. Emergency Medical Response Review Committee Compliance testing showed the Emergency Medical Response Review Committee (EMRRC) often either did not complete the required checklists or did not timely complete reviews (MIT 15.003, 25.0%). Our clinicians reviewed 25 emergency events in which patients transferred to a higher level of care. Although, the supervising registered nurses (SRNs) frequently completed the emergency response checklist form, we found 17 deficiencies in which either the chief nurse executive (CNE) and the CME did not conduct a clinical review or, when clinical reviews were conducted, the CNE and CME did not identify opportunities for improvement.28 The following are examples: • In case 1, the SRN conducted a clinical review on the patient who was transferred to a community hospital emergency room for further evaluation of epigastric pain. However, this clinical review omitted that the TTA nurse did not reassess complete vital signs for the one and a half hours before the patient transferred to a higher level of care. Neither the CME nor the CNE performed clinical reviews. As a result, no training issues were identified, despite the above-noted lapse in reassessment. • In case 8, the SRN and the CME completed the clinical review for the patient who was transferred to a higher level of care for complaints of severe pain and numbness to the lower extremities. However, the CNE did not conduct a clinical review. • In case 21, the SRN completed a clinical review for the patient who was transferred to a higher level of care for difficulty breathing and throbbing head pain. However, neither the CNE nor the CME performed clinical reviews. Clinician On-Site Inspection OIG clinicians had the opportunity to interview TTA RNs and the TTA nursing supervisor. The RNs shared they used the gurney to respond to emergency events in the central, east, and west wings, and would use their one emergency response vehicle when responding to the North A and North B yards. If additional help was needed, CTF fire crew would assist with transport, as a backup. The nurses shared they were notified by radio for emergency alarms 27 Nursing documentation deficiencies occurred in cases 1, 3, 8, and 15. 28 EMRRC deficiencies occurred in cases, 1–4, 7, 8, 19, 21, and 24. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 29 and the clinic RNs and LVNs were the first responders. TTA RNs would also respond when requested. CTF had three TTA examination rooms. TTA staff reserved one of the rooms for observation and used other two rooms to provide emergency care and assess patients. The TTA was staffed with two RNs for each of three shifts. The TTA nurse indicated they were responsible for assessing each patient who returns from a community hospital or a specialist appointment. Furthermore, on the weekends and holidays, the TTA nurses were tasked with issuing medication for paroling patients. During the on-site inspection, our clinicians observed a TTA huddle. The huddle participants included the utilization management RN, off-site specialty nurses, and specialized medical housing nurses. The TTA nurses discussed patients who had been evaluated in the TTA. The participants also discussed patients who were currently admitted to a community hospital and reviewed the off-site specialty appointments for that day. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 30 Recommendations • Nursing leadership should determine the root cause(s) of challenges that prevent nurses from performing thorough assessments and reassessments, notifying the provider of abnormal clinical findings, and providing appropriate interventions for patients with emergent and urgent conditions. Leadership should implement remedial measures as appropriate. • Medical and nursing leadership should determine the root cause(s) of challenges in completing thorough clinical reviews of urgent and emergent events in which patients transfer to the community hospital and in identifying opportunities for improvement. Leadership should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 31 Health Information Management In this indicator, OIG inspectors evaluated the flow of health information, a crucial link in high-quality medical care delivery. Our inspectors examined whether the institution retrieved and scanned critical health information (progress notes, diagnostic reports, specialist reports, and hospital discharge reports) into the medical record in a timely manner. Our inspectors also tested whether clinicians adequately reviewed and endorsed those reports. In addition, our inspectors checked whether staff labeled and organized documents in the medical record correctly. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Inadequate (72.7%) Case review found CTF performed sufficiently with managing health information. Staff timely retrieved, scanned, and endorsed most hospital discharge records and emergency room reports; however, some records were not complete. In addition, retrieval of specialty documents needed improvement. Providers sent patient results notification letters within required time frames, but many notification letters did not contain all CCHCS required components. Overall, the OIG rated the case review component of this indicator adequate. Compliance testing showed mixed performance in this indicator. Staff always timely scanned patient sick call requests, along with almost always timely retrieving and scanning hospital records. However, staff performed poorly in properly scanning and labeling medical records into the correct patient files. 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 849 events and identified 82 deficiencies related to health information management (HIM), of which nine were significant. Six of the nine significant deficiencies related to delayed or missing specialty services documentation.29 Hospital Discharge Reports CTF staff timely retrieved community hospital discharge records and scanned them into the EHRS within required time frames (MIT 4.003, 90.0%). OIG clinicians reviewed 21 off-site emergency department and hospital encounters and identified three deficiencies, only one of which was a significant deficiency. All three deficiencies related to missing or incomplete hospital records.30 29 Deficiencies occurred in cases 1, 2, 9, 11–18, 20–25, 41, and 42. Significant deficiencies occurred in cases 1, 2, 9, 12, and 22–25. Significant specialty services deficiencies occurred in cases 1, 2, and 22–25. 30 Deficiencies occurred in cases 2 and 24. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 32 Specialty Reports CTF’s performance was mixed in managing specialty reports. Compliance testing showed CTF frequently scanned the specialty reports timely (MIT 4.002, 93.3%). However, CTF struggled in the retrieval and timely review of high-priority (MIT 14.002, 60.0%), medium- priority (MIT 14.005, 66.7%), and routine-priority (MIT 14.008, 60.0%) specialty reports. Case review also identified deficiencies in managing specialty consultation reports. Of 72 specialty events, case review identified 18 deficiencies related to health information management, six of which were significant.31 Three of the significant deficiencies related to severely delayed or missing specialty consultation reports. We discuss these findings in the Specialty Services indicator. Diagnostic Reports CTF’s performance in managing diagnostic reports was mixed. In both compliance testing and case review, providers endorsed diagnostic studies timely and often communicated the results to patients with notification letters; however, the notification letters frequently lacked all CCHCS required components. Staff usually retrieved pathology results timely, but providers never communicated the pathology results with complete notification letters within required time frames. Neither case review nor compliance testing had any STAT laboratory tests in their samples to review. Please refer to the Diagnostic Services indicator for further details. Urgent and Emergent Records OIG clinicians reviewed 61 emergency care events and found providers and nurses documented these events well, including on-call telephone encounters. Refer to the Emergency Services indicator for additional information. Scanning Performance CTF performed variably in scanning medical documents. Compliance testing revealed staff did not properly scan, label, or include documents to the correct patient files (MIT 4.004, zero). The OIG clinicians identified six deficiencies related to mislabeled, misfiled, or duplicate medical documents, but only one was clinically significant as described below: • In case 9, staff incorrectly scanned an abnormal electrocardiogram (EKG) result into the wrong patient’s chart.32 Clinician On-Site Inspection We discussed health information management processes with CTF’s medical leadership, HIM supervisors, utilization management (UM) supervisors, office technicians, ancillary staff, diagnostic staff, nurses, and providers. HIM had new leadership and staff who had transferred from SVSP’s HIM department. 31 Deficiencies in specialty services documents occurred in cases 1, 2, 12, 17, 18, and 22–25. Significant deficiencies occurred in cases 1, 2, and 22–25. 32 HIM scanning deficiencies occurred in cases 9, 13, 18, 22, 24, and 25. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 33 In addition to a new management team learning and updating the HIM process, the HIM supervisors reported staffing shortages during the review period. Staff worked overtime to ensure patient documentation was available for medical staff review. Leadership stated most of the HIM positions are entry level, and they frequently lose these staff to promoting levels of office technician, health records technicians (HRT), or analyst positions. Leadership stated another challenge was HIM’s staff location in the institution. Staff work in older buildings, which frequently have electrical outages, preventing the staff from completing their work timely. At the time of our inspection, leadership was considering acquiring laptop computer solutions, which would still work during the intermittent power outages. HIM staff did not have access to any of the outside electronic medical records systems where CTF patients were treated. However, the UM supervisor stated UM staff did have access. UM staff access the local hospital records system, which expedites receipt of hospital discharge and emergency room records. Once the UM staff obtain those records, HIM staff scan them into EHRS and forward them to the providers for review and endorsement. HIM leadership acknowledged sometimes staff scanned incomplete records or scanned the records incorrectly. To remedy this, HIM leadership discussed their plan to train staff to ensure hospital and emergency room records are complete and staff scan all documents correctly. During their case reviews, OIG clinicians identified problems with receiving off-site specialty reports. CTF leadership explained an HRT is assigned to obtain and scan off-site specialty reports, then forward them to the providers for endorsement. HIM supervisors reported implementing a daily log to ensure staff timely obtain records. When the specialist directly enters on-site reports into EHRS, HIM supervisors stated the HRT ensured the reports were entered timely and forwarded them to the providers for review and endorsement. Regarding the patient results notification letters with missing components, HIM supervisors stated medical leadership was responsible for training the providers to timely and correctly complete patient notification letters. The CP&S demonstrated a new enhancement to the existing letter generation program that the CP&S believed would help. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 34 Compliance Score Results Table 8. Health Information Management Scored Answer Compliance Questions Yes No N/A Yes % Are health care service request forms scanned into the patient’s electronic 20 0 10 100% health record within three calendar days of the encounter date? (4.001) Are specialty documents scanned into the patient’s electronic health record 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? 18 2 5 90.0% (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 20 5 0 80.0% review the report within five calendar days of discharge? (4.005) Overall percentage (MIT 4): 72.7% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 35 Table 9. Other Tests Related to Health Information Management Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Did the ordering health care provider review and endorse the 10 0 0 100% radiology report within specified time frames? (2.002) Laboratory: Did the health care provider review and endorse the laboratory 9 1 0 90.0% report within specified time frames? (2.005) Laboratory: Did the provider acknowledge the STAT results, OR did nursing N/A N/A N/A N/A staff notify the provider within the required time frame? (2.008) Pathology: Did the institution receive the final pathology report within the 8 2 0 80.0% required time frames? (2.010) Pathology: Did the health care provider review and endorse the pathology 8 2 0 80.0% report within specified time frames? (2.011) Pathology: Did the health care provider communicate the results of the 0 9 1 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 9 6 0 60.0% frame? (14.002) Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the required time 10 5 0 66.7% frame? (14.005) Did the institution receive and did the primary care provider review the routine-priority specialty service consultant report within the required time 9 6 0 60.0% frame? (14.008) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 36 Recommendations • CTF leadership should develop and implement strategies to ensure staff properly scan and label documents in EHRS, as required by CCHCS policy. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 37 Health Care Environment In this indicator, OIG compliance inspectors tested clinics’ waiting areas, infection control, sanitation procedures, medical supplies, equipment management, and examination rooms. Inspectors also tested clinics’ performance in maintaining auditory and visual privacy for clinical encounters. Compliance inspectors asked the institution’s health care administrators to comment on their institution’s infrastructure and its ability to support health care operations. The OIG rated this indicator solely on the compliance score. Case review does 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 (52.6%) Overall, CTF performed poorly with respect to its health care environment. We found medical supply storage areas contained expired medical supplies, contained compromised sterile medical supply packaging, or stored medical supplies directly on the floor; several examination room areas were unsanitary; emergency medical response bag (EMRB) logs were missing staff verification or missing documentation of inventory checks when seal tags were changed; and staff did not properly wash their hands throughout 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 CTF had no outdoor waiting areas. Patients had enough seating capacity while waiting for their appointments (see Photo 1). These waiting areas had temperature control, running water, and toilets. During our inspection, we did not observe overcrowding in any of the clinics’ patient waiting areas. Clinic Environment All clinic environments were sufficiently conducive for medical care; they provided reasonable auditory privacy, appropriate Photo 1. Patient waiting area (photographed on 2-7-24). waiting areas, wheelchair accessibility, and nonexamination room workspace (MIT 5.109, 100%). Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 38 Eight of the 10 clinics we observed contained appropriate space, configuration, supplies, and equipment to allow clinicians to provide proper medical services (MIT 5.110, 80.0%). In two clinics, the examination room had unsecured confidential patient medical records. Clinic Supplies Only one of the 10 clinics followed adequate medical supply storage and management protocols (MIT 5.107, 10.0%). We found one or more of the following deficiencies in nine clinics: staff members’ food stored with medical supplies; expired medical supplies (see Photo 2, below left); unorganized, unidentified, or inaccurately labeled medical supplies; cleaning materials (see Photo 3, below right) or medications stored with medical supplies (see Photo 4, next page); medical supplies stored in the designated biohazard waste location (see Photos 5 and 6, next page); and medical supplies stored directly on the floor. Photo 2. Expired medical supply dated August 28, 2023 (photographed on 2-6-24). Photo 3. Cleaning materials stored with medical supplies (photographed on 2-7-24). Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 39 Photo 4. Medication stored with medical supplies (photographed on 2-7-24). Photo 5. Medical supplies stored in the same area as biohazardous waste (photographed on 2-6-24). Photo 6. Medical supplies stored in the same area as biohazardous waste (photographed on 2-6-24). Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 40 Five of the 10 clinics met requirements for essential core medical equipment and supplies (MIT 5.108, 50.0%). In the remaining five clinics, we found one or more of the following deficiencies: examination tables missing disposable papers; a nonfunctional ophthalmoscope; and either inaccurate or incomplete daily glucometer quality control logs. We examined EMRBs to determine if they contained all essential items. We checked whether staff inspected the bags daily and inventoried them monthly. Three of the eight applicable EMRBs passed our tests (MIT 5.111, 37.5%). With the remaining five EMRBs, we found one or more of the following deficiencies: staff failed to ensure the EMRB compartments were sealed and intact; staff had not inventoried the EMRBs when seal tags were replaced; and an EMRB contained a medical item with compromised packaging. In addition, the treatment cart in the TTA did not meet the minimum inventory level at the time of inspection. Medical Supply Management None of the medical supply storage areas located outside the medical clinics contained adequately stored medical supplies (MIT 5.106, zero). We found expired medical supplies stored in the medical warehouse (see Photo 7). According to the CEO, the institution did not have any concerns about the medical supply process. Health care managers and medical warehouse managers expressed no concerns about the medical supply chain or their communication process. Infection Control and Sanitation Staff appropriately cleaned, sanitized, and disinfected two of eight applicable clinics (MIT 5.101, 25.0%). In six clinics, we found one or more of the following deficiencies: staff did not maintain cleaning logs; staff did not empty biohazard waste after each clinic day; the floor under an examination room sink was unsanitary; and an examination room Photo 7. Expired medical supply dated March 9, 2022 drawer was unsanitary. (photographed on 2-7-24). Staff in seven of nine applicable clinics properly sterilized or disinfected medical equipment (MIT 5.102, 77.8%). In two clinics, we found one or more of the following deficiencies: previously sterilized medical equipment had compromised packaging; clinical staff did not describe the appropriate sterilization cleaning process; recently sterilized medical equipment packaging did not change color to indicate Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 41 appropriate sterilization; and staff did not date stamp and initial the packaging of sterilized medical equipment. We found operational sinks and hand hygiene supplies in seven of 10 clinics (MIT 5.103, 70.0%). The patient restrooms in three clinics either lacked antiseptic soap or disposable hand towels. We observed patient encounters in seven clinics. In five clinics, clinicians did not wash their hands before or after examining their patients (MIT 5.104, 28.6%). Health care staff in all clinics followed proper protocols to mitigate exposure to bloodborne pathogens and contaminated waste (MIT 5.105, 100%). Physical Infrastructure CTF’s health care management and plant operations manager reported all infrastructure in clinical areas was in good working order and did not hinder health care services. At the time of our medical inspection, the institution reported two Health Care Facility Improvement Program projects. The projects were renovating the Specialty Services Clinic and the Restricted Housing Unit’s Medication Distribution Room. Both projects started in March 2021. The institution estimated the projects would be completed by summer 2023 and the first quarter of 2024, respectively. The institution reported the activation of the Specialty Services Clinic had been delayed pending delivery of necessary furniture. However, they did not expect the delay to hinder the institution’s ability to deliver specialty services to their patients (MIT 5.999). Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 42 Compliance Score Results Table 10. Health Care Environment Scored Answer Compliance Questions Yes No N/A Yes % Infection control: Are clinical health care areas appropriately disinfected, 2 6 2 25.0% 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 7 2 1 77.8% 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 2 5 3 28.6% 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 1 9 0 10.0% storing bulk medical supplies? (5.107) Clinical areas: Do clinic common areas and exam rooms have essential core 5 5 0 50.0% medical equipment and supplies? (5.108) Clinical areas: Are the environments in the common clinic areas conducive 8 0 2 100% to providing medical services? (5.109) Clinical areas: Are the environments in the clinic exam rooms conducive to 8 2 0 80.0% providing medical services? (5.110) Clinical areas: Are emergency medical response bags and emergency crash carts inspected and inventoried within required time frames, and do they 3 5 2 37.5% contain essential items? (5.111) Does the institution’s health care management believe that all clinical areas This is a nonscored test. Please see the have physical plant infrastructures that are sufficient to provide adequate indicator for discussion of this test. health care services? (5.999) Overall percentage (MIT 5): 52.6% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 43 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. • 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. • Nursing leadership should determine the root cause(s) for staff not ensuring the emergency medical response bags (EMRBs) are regularly inventoried and sealed and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 44 Transfers In this indicator, OIG inspectors examined the transfer process for those patients who transferred into the institution as well as for those who transferred to other institutions. For newly arrived patients, our inspectors assessed the quality of health care screenings and the continuity of provider appointments, specialist referrals, diagnostic tests, and medications. For patients who transferred out of the institution, inspectors checked whether staff reviewed patient medical records and determined the patient’s need for medical holds. They also assessed whether staff transferred patients with their medical equipment and gave correct medications before patients left. In addition, our inspectors evaluated the performance of staff in communicating vital health transfer information, such as preexisting health conditions, pending appointments, tests, and specialty referrals; and inspectors confirmed whether staff sent complete medication transfer packages to receiving institutions. For patients who returned from off-site hospitals or emergency rooms, inspectors reviewed whether staff appropriately implemented recommended treatment plans, administered necessary medications, and scheduled appropriate follow-up appointments. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Proficient (87.0%) Case review found CTF performed well in the transfer process. The receiving and release (R&R) nurses mostly completed health care screenings appropriately and performed excellently in maintaining medication continuity for patients who transferred into and out of the institution. Compared with Cycle 6, nursing improved in completing appropriate nursing assessments for hospital returns and in scheduling nurse and provider appointments timely. Factoring all the information, the OIG rated the case review component of this indicator adequate. Compared with Cycle 6, CTF’s overall compliance performance greatly improved for this indicator. CTF still needed to improve in completing initial health screening forms. However, the institution performed perfectly in completing the assessment and disposition section of the screening process and in ensuring medication continuity for newly transferred patients. Based on the overall compliance score result, the OIG rated this indicator proficient. Case Review and Compliance Testing Results We reviewed 40 events in 19 cases in which patients transferred into or out of the institution or returned from an off-site hospital or emergency room. We identified 18 deficiencies, three of which were significant.33 33 Deficiencies occurred in cases 1, 2, 19–22, 24, 26, 27, 31, 41, and 42. Significant deficiencies occurred in cases 20, 24, and 42. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 45 Transfers In Our clinicians reviewed 10 events in which patients transferred into the institution from other institutions. We identified only two deficiencies related to incomplete nursing assessments, neither of which was significant.34 Our clinicians found the R&R nurses mostly completed the initial health screening form thoroughly and did very well with scheduling nurse and provider appointments timely. Compliance testing showed R7R nurses needed to improve in completing the screening form timely and providing an explanation for questions answered “yes” on the form (MIT 6.001, 48.0%). However, compliance testing also revealed nurses performed excellently in completing the assessment and disposition section of the form (MIT 6.002, 100%). Compliance testing showed CTF performed excellently with maintaining medication continuity for patients who newly transferred into the institution (MIT 6.003, 100%). Similarly, patients who transferred within the institution almost always received their medications without any interruptions (MIT 7.005, 92.0%). However, compliance testing staff needed to improve medication continuity for patient layovers at the institution (MIT 7.006, 60.0%). Analysis of the compliance data showed the low score was mostly due to patients not receiving their medication at the next dose interval. As with compliance testing, our clinicians found new patient arrivals received their medications without a break in continuity. Compliance testing showed CTF performed very well with ensuring providers evaluated new patient arrivals within required time frames (MIT 1.002, 92.0%). However, specialty services appointments for patients who arrived to CTF intermittently occurred within required time frames (MIT 14.010, 55.0%). Analysis of the compliance data showed specialty appointments either did not occur or were not scheduled timely. Transfers Out Our clinicians reviewed nine transfer-out events and found two deficiencies in which nursing did not communicate the patients’ pending specialty appointments.35 Compliance testing showed CTF performed excellently with placing required medications and documents in the transfer packets (MIT 6.101, 100%). Our clinicians reached similar findings. Hospitalizations Patients returning from an off-site hospitalization or emergency room are at high risk for lapses in care quality. These patients typically experienced severe illness or injury. They require more care and place a strain on the institution’s resources. In addition, because these patients have complex medical issues, successful health information transfer is necessary for good quality care. Any transfer lapse can result in serious consequences for these patients. 34 Transfer-in deficiencies occurred in cases 26 and 27. 35 Transfer-out deficiencies occurred in cases 31 and 41. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 46 Our clinicians reviewed 21 events in which patients returned from a hospitalization or emergency room encounter and identified 14 deficiencies, three of which were significant.36 Both compliance testing and our case review clinicians found CTF performed very well with ensuring patients received follow-up appointments after hospitalizations or emergency room encounters (MIT 1.007, 95.8%). CTF also performed well in timely retrieving and scanning hospital records (MIT 4.003, 90.0%), and providers usually reviewed hospital reports within five calendar days of discharge (MIT 4.005, 80.0%). Nursing generally performed complete assessments and interventions; however, our clinicians found three deficiencies related to nursing assessments when patients returned from hospitalizations, and one deficiency related to documentation.37 The following is an example: • In case 22, the patient returned from the community hospital and complained of generalized abdominal pain. However, the nurse did not palpate the patient’s abdomen or subjectively assess the date of the patient’s last bowel movement. Compliance testing showed CTF performed poorly with maintaining medication continuity for patients who returned from hospitalizations or emergency room encounters (MIT 7.003, 32.0%). Analysis of the compliance data showed, in eight out of 25 case samples, patients received their medications up to five days late, including antibiotics and medications for blood pressure, cholesterol, seizures, and diabetes. Our clinicians found five deficiencies related to medication continuity for hospital returns, one of which was significant.38 Please see the Medication Management indicator for further discussion. Clinician On-Site Inspection Case review toured the R&R unit and interviewed the R&R RN. The nurse shared CTF staffed one RN in R&R each shift and a certified nurse’s assistant (CNA) on the afternoon shift. The nurse was knowledgeable about the transfer process, including reconciliation of medications and pending specialty appointments. The nurse stated nursing staff assessed an average of three to four patients daily for transfer-ins and three to four patients daily for transfer-outs. Furthermore, the nurse shared R&R nurses assisted the TTA RNs with assessing and screening patients returning from off-site specialty appointments and hospitalizations, which could average 20 patients at a given time. The nurse expressed challenges in the R&R while screening patients upon return from off-site specialty appointments or hospitalizations because the patients experienced long wait times due to only one nurse assigned to the task. CNAs assisted with taking vital signs during the screening process when available. The nurse reported they had a good working relationship with their supervisors and custody staff. 36 Hospital return deficiencies occurred in cases 1, 2, 19–22, 24, and 42. Significant deficiencies occurred in cases 20, 24, and 42. 37 Nursing assessment and documentation deficiencies occurred in cases, 1, 21, and 22. 38 Medication deficiencies relating to hospital returns occurred in cases 2, 19, 20, 22, and 42. Significant deficiencies occurred in case 20. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 47 Compliance On-Site Inspection R&R nursing staff ensured both of the two patients transferring out of the institution on the day of our inspection had their required medications, transfer documents, and assigned durable medical equipment (MIT 6.101, 100%). Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 48 Compliance Score Results Table 11. Transfers Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution: Did nursing staff complete the initial health screening and answer all screening 12 13 0 48.0% 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 25 0 0 100% symptoms were present; and sign and date the form on the same day staff completed the health screening? (6.002) For endorsed patients received from another CDCR institution: If the patient had an existing medication order upon arrival, were medications 7 0 18 100% 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): 87.0% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 49 Table 12. Other Tests Related to Transfers Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution: Based on the patient’s clinical risk level during the initial health screening, was the 23 2 0 92.0% patient seen by the clinician within the required time frame? (1.002) Upon the patient’s discharge from the community hospital: Did the patient receive a follow-up appointment with a primary care provider within the 23 1 1 95.8% 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? 18 2 5 90.0% (4.003) For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements and did a provider 20 5 0 80.0% 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 8 17 0 32.0% within required time frames? (7.003) Upon the patient’s transfer from one housing unit to another: Were 23 2 0 92.0% medications continued without interruption? (7.005) For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications 6 4 0 60.0% administered or delivered without interruption? (7.006) For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the sending 11 9 0 55.0% 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: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 50 Recommendations The OIG offers no specific recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 51 Medication Management In this indicator, OIG inspectors evaluated the institution’s performance in administering prescription medications on time and without interruption. The inspectors examined this process from the time a provider prescribed medication until the nurse administered the medication to the patient. In addition to examining medication administration, our compliance inspectors also tested many other processes, including medication handling, storage, error reporting, and other pharmacy processes. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Inadequate (47.5%) Case review found CTF’s performance was sufficient for this indicator. Our clinicians found staff often timely administered chronic care and new prescription medications, and performed excellently managing medications for patients who transferred into and out of the institution. However, we identified opportunities for improvement in medication continuity in one specialized medical housing case and in five cases for patients returning from the hospital. Factoring all the information, the OIG rated the case review component of this indicator adequate. Compliance testing showed CTF had a mixed performance in medication management. Staff performed excellently in employing general security, storing narcotic medications in medication rooms, and providing medications for patients transferring within the institution. However, staff needed improvement in timely providing chronic care medications, newly ordered medications, hospital discharge medications, and medications for patients en route to another institution, but who layover at CTF. Based on the overall compliance score result, the OIG rated this indicator inadequate. Case Review and Compliance Testing Results We reviewed 135 events in 28 cases related to medications and found 25 medication deficiencies, four of which were significant.39 New Medication Prescriptions Our clinicians found CTF performed very well with new prescription medications. We found four deficiencies in two cases where the patients received their newly prescribed medication between one to two days late.40 In contrast, compliance testing showed CTF only occasionally administered new medications timely (MIT 7.002, 44.0%). Compliance data case samples showed nurses delivered most newly prescribed medications up to four days late, including antibiotics, and medications to treat high blood pressure, pain, and a diabetes. 39 Medication deficiencies occurred in cases 2, 8, 10, 11, 15, 17, 19–22, 41, and 42. Significant deficiencies occurred in cases 2, 15, and 20. 40 New medication deficiencies occurred in cases 17, 22, and 42. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 52 Chronic Medication Continuity Our clinicians found CTF performed well with ensuring patients received their chronic medications timely. We identified four deficiencies, one of which was significant.41 The following is the significant deficiency: • In case 15, the patient was scheduled to receive cholesterol medication; however, the patient received the medication nine days late. In contrast, compliance testing showed CTF performed poorly for chronic care medication continuity (MIT 7.001, 11.1%). Analysis of the compliance testing data showed, in 16 out of 18 case samples, the pharmacy did not timely fill and dispense medications as ordered, including medications for blood pressure, diabetes, and cholesterol. Hospital Discharge Medications Our clinicians identified a pattern of deficiencies in which staff did not timely administer medications for patients returning from a hospitalization.42 The following is a significant deficiency: • In case 20, the patient returned from a hospitalization but did not receive chronic care medications for blood pressure, diabetes, and acid reflux disease. The medication administration record showed the patient received the medications 31 days late. Compliance testing showed CTF performed poorly with maintaining medication continuity for patients who returned from hospitalizations or emergency room encounters (MIT 7.003, 32.0%). Please see the Transfer indicator for further discussion. Specialized Medical Housing Medications Our clinicians found seven medication deficiencies in specialized medical housing, two of which were significant. The following is an example: • In case 2, the nurses did not always administer the patient’s scheduled insulin or obtain blood sugar checks per sliding scale, as ordered, for this patient, who was insulin dependent for diabetes. Compliance testing showed CTF performed poorly with timely making available and administering medications upon patient admission (MIT 13.003, 30.0%). Compliance data showed, in seven out of 10 case samples, most patients received their medications from several minutes to two days late, including an antibiotic and medications for blood pressure, seizures, cholesterol, and pain. 41 Chronic medication deficiencies occurred in cases 15, 22, and 42. Significant deficiencies occurred in case 15. 42 Medication deficiencies related to hospital returns occurred in cases 2, 19, 20, 22 and 42. A significant deficiency occurred in case 20. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 53 Transfer Medications Our clinicians found CTF performed excellently with maintaining medication continuity for patients who transferred into and out of the institution. Compliance testing showed CTF performed excellently with maintaining medication continuity for patients who transferred into the institution (MIT 6.003, 100%) and found patients who transferred within the institution almost always received their medications timely (MIT 7.005, 92.0%). However, compliance testing showed patient who laid over at CTF while en route to another institution only intermittently received their medications without interruption (MIT 7.006, 60.0%). Please see the Transfer indicator for further discussion. Medication Administration Compliance testing showed CTF performed sufficiently with ensuring tuberculosis (TB) medications were administered as ordered (MIT 9.001, 80.0%). However, the nurses rarely conducted weekly monitoring for patients on TB medications and frequently did not assess for any signs and symptoms (MIT 9.002, 8.0%). Clinician On-Site Inspection During the on-site inspection, case review clinicians interviewed the medication nurses in X- wing and North A clinic. The nurses were knowledgeable about the medication process. We found North A clinic had a good keep-on-person (KOP) medication process to ensure patients were notified when they had medication refills available. The medication nurses explained patients who have KOP medications would receive a ducat that stated the patient had four days to pick up their medications.43 They received an additional ducat prior to the fourth day as a last call before staff returned the medication to the pharmacy. The medication nurses reported they did not always attend huddles due to administrating medications at the time the huddles occur. However, they communicated any medication concerns by messaging the provider and routinely communicated with the clinic LVN coordinator and the RN. We also attended the clinic huddles and found good communication regarding medication compliance and expiring medications. Medication Practices and Storage Controls The institution adequately stored and secured narcotic medications in all eight applicable clinic and medication line locations (MIT 7.101, 100%). CTF appropriately stored and secured non-narcotic medications in four of 10 clinic and medication line locations (MIT 7.102, 40.0%). In six locations, we observed one or more of the following deficiencies: the medication storage cabinet was disorganized; nurses did not maintain unissued medications in original labeled packaging; the treatment cart log was missing daily security check entries; and medications were not securely stored as required by CCHCS policy. Staff kept medications protected from physical, chemical, and temperature contamination in five of the 10 clinic and medication line locations (MIT 7.103, 50.0%). In three locations, staff 43 A ducat is a pass that allows patients to move around in an institution. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 54 did not consistently record the room temperatures. In the remaining two locations, the medication refrigerator was unsanitary. Staff successfully stored valid, unexpired medications in eight of the 10 medication line locations (MIT 7.104, 80.0%). In two locations, nurses did not label the multi-use medications as required by CCHCS policy. Nurses exercised proper hand hygiene and contamination control protocols in only one of six applicable locations (MIT 7.105, 16.7%). In five locations, some nurses neglected to wash or sanitize their hands before donning gloves, before administering medications, or before each subsequent regloving when gloves were compromised. Staff in all medication preparation and administration areas demonstrated appropriate administrative controls and protocols (MIT 7.106, 100%). Staff in two of six applicable medication areas used appropriate administrative controls and protocols when distributing medications to their patients (MIT 7.107, 33.3%). In four locations, we observed one or more of the following deficiencies: medication nurses did not distribute medications to patients within the required time frame; medication nurses did not always verify patients’ identification by using a picture form of identification or by using a secondary identifier; and medication nurses did not reliably observe patients while they swallowed direct observation therapy medications. Pharmacy Protocols CTF did not follow general security, organization, and cleanliness management protocols in its pharmacy (MIT 7.108, zero). At the time of our inspection, the pharmacy’s medication preparation area was cluttered. In the pharmacy, staff did not properly store nonrefrigerated medication. Staff stored medications in an incorrectly labeled container (MIT 7.109, zero). The institution properly stored refrigerated or frozen medications in the pharmacy (MIT 7.110, 100%). 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 PIC or nurse present at the time of the medication area inspection did not complete the medication area inspection checklists (CDCR 7477). This error resulted in a score of zero for this test (MIT 7.111). We examined 25 medication error reports. The PIC timely or correctly processed only 12 of these 25 reports (MIT 7.112, 48.0%). In 13 reports, the form had no documentation of the PIC’s determination or findings regarding the 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 CTF, the OIG did not find any applicable medication errors (MIT 7.998). Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 55 The OIG interviewed patients in restrictive housing units to determine whether they had immediate access to their prescribed asthma rescue inhalers or nitroglycerin medications. Of the applicable patients interviewed, seven of 10 indicated they had access to their rescue medications. Three of the patients possessed their rescue inhalers; however, for two of these three patients, the medication was empty at the time of our inspection, and the remaining patient had an expired rescue medication. We promptly notified the CEO of this concern, and health care management immediately reissued replacement rescue inhalers to the patients (MIT 7.999). Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 56 Compliance Score Results Table 13. Medication Management Scored Answer Compliance Questions Yes No N/A Yes % Did the patient receive all chronic care medications within the required time frames 2 16 7 11.1% 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 11 14 0 44.0% 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 8 17 0 32.0% required time frames? (7.003) For patients received from a county jail: Were all medications ordered by the institution’s reception center provider administered, made available, or delivered to N/A N/A N/A N/A the patient within the required time frames? (7.004) Upon the patient’s transfer from one housing unit to another: Were medications 23 2 0 92.0% continued without interruption? (7.005) For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications administered or delivered 6 4 0 60.0% without interruption? (7.006) All clinical and medication line storage areas for narcotic medications: Does the institution employ strong medication security controls over narcotic medications 8 0 2 100% assigned to its storage areas? (7.101) All clinical and medication line storage areas for nonnarcotic medications: Does the institution properly secure and store nonnarcotic medications in the assigned 4 6 0 40.0% 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 5 5 0 50.0% 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 8 2 0 80.0% 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 1 5 4 16.7% medication administration processes? (7.105) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when preparing medications for 6 0 4 100% patients? (7.106) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when administering medications 2 4 4 33.3% to patients? (7.107) Pharmacy: Does the institution employ and follow general security, organization, and 0 1 0 0 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? 12 13 0 48.0% (7.112) Pharmacy: For Information Purposes Only: During compliance testing, did the OIG This is a nonscored test. Please see the indicator find that medication errors were properly identified and reported by the institution? (7.998) for discussion of this test. Pharmacy: For Information Purposes Only: Do patients in restricted housing units This is a nonscored test. Please see the indicator have immediate access to their KOP prescribed rescue inhalers and nitroglycerin medications? (7.999) for discussion of this test. Overall percentage (MIT 7): 47.5% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 57 Table 14. Other Tests Related to Medication Management Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution: If the patient had an existing medication order upon arrival, were medications 7 0 18 100% 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- 2 0 0 100% packet required documents? (6.101) Patients prescribed TB medication: Did the institution administer the 20 5 0 80.0% medication to the patient as prescribed? (9.001) Patients prescribed TB medication: Did the institution monitor the patient per policy for the most recent three months he or she was on the 2 23 0 8.0% medication? (9.002) Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient 3 7 0 30.0% within required time frames? (13.003) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 58 Recommendations • Health care leadership should develop and implement measures to ensure staff timely make available and administer chronic care medications, newly ordered medications, community hospital discharge medications, and medications for patients temporarily housed at the institution. Leadership should implement remedial measures as appropriate. • Nursing leadership should develop and implement measures to ensure nursing staff document administering medications, patient refusals, and no-shows in the electronic health record in accordance with CCHCS’s policies and procedures. Leadership should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 59 Preventive Services In this indicator, OIG compliance inspectors tested whether the institution offered or provided cancer screenings, tuberculosis (TB) screenings, influenza vaccines, and other immunizations. If the department designated the institution as being at high risk for coccidioidomycosis (Valley Fever), we tested the institution’s performance in transferring out patients quickly. The OIG rated this indicator solely according to the compliance score. Case review does not rate this indicator. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Inadequate (71.8%) CTF had a mixed performance in preventive services. Staff performed well to excellently in administering TB medications, screening patients annually for TB, offering patients an influenza vaccine for the most recent influenza season, and offering colorectal cancer screening for patients from ages 45 through 75. However, staff performed poorly in monitoring patients on TB medications and only sporadically offered required immunizations to chronic care patients. 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. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 60 Compliance Score Results Table 15. Preventive Services Scored Answer Compliance Questions Yes No N/A Yes % Patients prescribed TB medication: Did the institution administer the 20 5 0 80.0% medication to the patient as prescribed? (9.001) Patients prescribed TB medication: Did the institution monitor the patient per policy for the most recent three months he or she was on the 2 23 0 8.0% medication? (9.002) Annual TB screening: Was the patient screened for TB within the last year? 25 0 0 100% (9.003) Were all patients offered an influenza vaccination for the most recent 25 0 0 100% influenza season? (9.004) All patients from the age of 45 through the age of 75: Was the patient 25 0 0 100% offered colorectal cancer screening? (9.005) Female patients from the age of 50 through the age of 74: Was the patient N/A N/A N/A N/A offered a mammogram in compliance with policy? (9.006) Female patients from the age of 21 through the age of 65: Was patient N/A N/A N/A N/A offered a pap smear in compliance with policy? (9.007) Are required immunizations being offered for chronic care patients? (9.008) 3 4 18 42.9% 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): 71.8% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 61 Recommendations • Nursing leadership should develop and implement measures to ensure the nursing staff monitor patients who are receiving TB medications according to CCHCS policy. • Medical leadership should determine the root cause(s) for challenges to timely providing vaccinations to chronic care patients and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 62 Nursing Performance In this indicator, the OIG clinicians evaluated the quality of care delivered by the institution’s nurses, including registered nurses (RN), licensed vocational nurses (LVN), psychiatric technicians (PT), certified nursing assistants (CNA), and medical assistants (MA). Our clinicians evaluated nurses’ performance in making timely and appropriate assessments and interventions. We also evaluated the institution’s nurses’ documentation for accuracy and thoroughness. Clinicians reviewed nursing performance across many clinical settings and processes, including sick call, outpatient care, care coordination and management, emergency services, specialized medical housing, hospitalizations, transfers, specialty services, and medication management. The OIG assessed nursing care through case review only and performed no compliance testing for this indicator. When summarizing nursing performance, our clinicians understand that nurses perform numerous aspects of medical care. As such, specific nursing quality issues are discussed in other indicators, such as Emergency Services, Specialty Services, and Specialized Medical Housing. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Not Applicable Our clinicians found overall satisfactory nursing performance for this indicator. We found nurses generally performed appropriate assessments and interventions for transfers and in specialized medical housing and the outpatient clinic setting. In addition, CTF nursing performance was sufficient in medication management. However, we identified opportunities for improvement with nursing assessments and interventions. Factoring all the information, the OIG rated this indicator adequate. Case Review Results We reviewed 257 nursing encounters in 40 cases. Of the nursing encounters we reviewed, 94 occurred in the outpatient setting and 50 were sick call requests. We identified 62 nursing performance deficiencies, 12 of which were significant.44 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. OIG clinicians identified 16 deficiencies related to nursing assessments in the outpatient clinic, three of which were significant.45 Nurses generally provided appropriate nursing assessments and interventions. However, we found opportunities for improvement with 44 Deficiencies occurred in cases 1–4, 8, 11, 15–22, 24–27, 31, 32, and 40–42. Significant deficiencies occurred in cases 1–4, 8, 11, 20, 21, 24, and 42. 45 Outpatient nursing deficiencies occurred in cases 1, 11, 15, 16, 19, 20, 24, 32, and 40. Significant deficiencies occurred in cases 11, 20, and 24. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 63 nurse sick call triage. We found nurses did not always evaluate the patient the same day for urgent complaints or did not schedule a follow-up appointment with the provider when the patients’ conditions warranted. The following are two examples: • In case 11, the sick call nurse evaluated the diabetic patient who complained of loose bloody stools for four days. The patient thought it was related to hemorrhoids or a side effect from a prescribed medication, dulaglutide.46 However, the nurse did not co-consult with the provider for further evaluation or schedule a follow-up appointment. • In case 24, the nurse triaged a health care request for a patient who complained of muscle pain, bloody stool, irregular heart rate, and headache. The patient was on a blood thinner medication and should have been seen the same day. However, the patient was not seen until two business days later. Complete and accurate nursing documentation is an essential component of patient care. Without proper documentation, health care staff can overlook changes in patients’ conditions. CTF staff generally documented care appropriately. OIG clinicians identified five deficiencies related to nursing documentation. The following is an example: • In case 15, the patient complained of a nonhealing right knee wound. The nurse assessed the patient and obtained a one-time order for wound care. However, the nurse did not document a description of the wound, the treatments provided, or type of dressing applied. Emergency Services We reviewed 61 urgent or emergent events and found 48 deficiencies, 15 of which were significant. Nurses mostly responded promptly to emergent events and initiated CPR timely. However, nursing assessments, interventions, and documentation needed improvement, which is detailed further in the Emergency Services indicator. Hospital Returns We reviewed 21 events that involved returns from off-site hospitals or emergency room encounters. CTF nurses generally performed complete nursing assessments and interventions, which are detailed further in the Transfers indicator. Transfers Our clinicians reviewed 10 cases involving the transfer-in and transfer-out process. We found nurses performed well overall in the transfer process. The nurses mostly completed the initial healthcare screening form and scheduled nurse and provider appointments timely. Please refer to the Transfers indicator for further details. 46 Dulaglutide is a medication used to lower blood sugar levels for adults with type 2 diabetes. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 64 Specialized Medical Housing Our clinicians reviewed five cases with a total of 89 events. Nurses generally performed complete assessments and evaluated the patients frequently. Please refer to the Specialized Medical Housing indicator. Specialty Services We reviewed 12 cases in which patients returned from off-site specialty services appointments or consultations. Nurses performed well in the Specialty Services indicator. Our clinicians identified only two deficiencies related to nursing assessments and documentation.47 These deficiencies did not impact the overall care of the patient. Medication Management OIG clinicians reviewed 135 events involving medication management and found nurses generally administered patients’ medications as prescribed. Please refer to the Medication Management indicator for additional details. Clinician On-Site Inspection OIG clinicians interviewed nurses and nursing supervisors in the TTA, the OHU, R&R, outpatient clinics, and medication clinics. We attended huddles in the central building and North A clinics. The huddles were informative, well organized, and collaborative. At the time of the inspection, staff reported no appointment backlogs for the provider, the RN, or the LVN care coordinator lines. The clinic RNs assessed an average of 12 to14 patients per day, and the providers evaluated an average of 8 to10 patients per day. OIG clinicians discussed some deficiencies regarding nebulizer breathing treatments administered by the LVN. We interviewed the LVN care coordinators and found they performed patient nebulizer breathing treatments for patients who had an as needed order. The nurses shared they performed pre- and post-peak flow readings to evaluate medication effectiveness and would defer to the clinic RN for any further assessment as needed. The nurses and the LVNs reported they felt supported by nursing leadership and had a good working relationship with custody staff. Furthermore, the nurses shared they had a collaborative patient care team, and they worked well together. 47 Minor nursing deficiencies related to off-site specialty returns occurred in cases 17 and 25. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 65 Recommendations • Nursing leadership should ensure nurses assess patients with urgent complaints the same day and notify the providers when patients’ conditions are warranted. Leadership should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 66 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 Inadequate Not Applicable CTF providers delivered poor care, similar to their performance in Cycle 6. Although providers documented sufficiently and delivered good continuity, OIG clinicians found many areas needing improvement. We identified instances of poor provider assessments and decision-making as well as physical examinations not performed. Furthermore, lapses of provider care in the specialized medical housing unit with untimely physician rounding, missed or inaccurate patient assessments, and poor medical decision-making negatively affected patients. We also found providers did not thoroughly review patient medical records. Lastly, providers made errors with specialty services. After careful consideration of all these factors, the OIG rated this indicator inadequate. Case Review Results OIG clinicians reviewed 112 medical provider encounters and identified 84 deficiencies, 39 of which were significant. In addition, we reviewed the quality of care in 20 comprehensive case reviews. Of these 20 cases, we found 13 adequate and seven inadequate.48 Two of the inadequate cases related to CTC patients. Outpatient Assessment and Decision-Making Providers generally made good assessments and sound decisions; however, we identified many deficiencies.49 The following are significant examples: • In case 21, the nurse contacted the on-call provider about an asthmatic patient with a history of smoking an average of a pack of cigarettes a day for 30 years, who complained of having had a productive cough for eight days. The nurse heard coarse crackles in the patient’s right and left upper lung lobes, which could have indicated pneumonia or another infectious process that might have 48 Deficiencies occurred in cases 1, 2, 9–13, 15, 17–24, 41, and 42. Significant deficiencies occurred in cases 2, 9, 11– 13, 17, 18, 21, 22, and 24. 49 Decision-making deficiencies occurred in cases 1, 9, 17, 19, 21–24, and 42. Significant deficiencies occurred in cases 9, 21, 22 and 24. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 67 required an antibiotic. The provider ordered a cough suppressant and topical sore throat relief medication without further monitoring or additional assessment of the patient, despite the patient’s high risk for complications. • In case 22, the patient returned from coronary artery bypass surgery, that was performed five days earlier.50 A patient returning from this surgery would not be able to perform the regular activities of daily living, including walking extremely long distances or obtaining his own meals. The provider ordered the patient to be sent to a regular housing unit instead of specialized medical housing, where the patient’s health and physical safety could be closely monitored and assistance be given as needed. The patient was not moved to specialized medical housing until nearly two days later when the patient requested further medical care. • Also in case 22, neither of the two providers who were involved in the patient’s post-surgery care ordered pain medication promptly. The patient did not receive his first dose of pain medication until nearly two days after his return from the hospital. • In case 24, the nurse contacted the provider about the patient, who complained of head and neck pain, bloody stool for four days, abdominal pain, and irregular heartbeats. The patient was on immunosuppressant and blood thinning medications. The provider ordered the patient be seen for his complaints two days later instead of being seen immediately. We also identified a pattern of providers not performing appropriate physical exams. The following are examples: • In case 17, the provider documented the patient’s bilateral lower extremity swelling was controlled; however, the provider did not examine the patient’s lower extremities. • In case 22, the provider documented an assessment and plan for the patient’s knee pain and ordered a knee x-ray and brace. The provider did not document any knee complaints in the review of systems or history of present illness and did not perform a specific knee examination. The record was not clear as to what the medical indications were for this x-ray or the brace. • In case 23, the provider evaluated the cancer patient for right rib pain. The provider documented the patient’s pain was likely from the liver; however, the provider did not document a musculoskeletal examination, including ribs or chest wall, or an abdominal examination. 50 A coronary artery bypass surgery is a major surgery to restore blood flow around a blocked heart artery by taking a healthy blood vessel from another part of the body and using it to create a new path for blood flow in the heart. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 68 Outpatient Review of Records Providers usually endorsed diagnostic studies and specialty reports timely. However, we identified a pattern of providers not thoroughly reviewing patient electronic health records and identified significant deficiencies.51 The following are examples: • In case 18, the provider documented the patient, who had a history of aortic valve replacement, was on a blood thinning medication; however, the patient had not been on the medication since 2020. • Also in case 18, the patient was scheduled to see a provider for the patient’s concerns about worsening memory. The provider did not review the patient’s chart appropriately and, therefore, did not understand the reason for the appointment, mistaking it for a duplicate of a recent chronic care appointment. The provider cancelled the appointment without seeing the patient. Consequently, the patient was not assessed for concerns about worsening memory. • In case 22, the provider ordered for the patient to return to the yard from the specialized medical housing unit after a heart bypass surgery. The provider started the patient on amiodarone for 90 days; however, in the hospital discharge report, the cardiothoracic surgeon clearly recommended the patient take amiodarone only for a total of 24 days after discharge.52 The medication should have been stopped as recommended by the cardiovascular surgeon. It was continued for over seven months without appropriate monitoring because the provider did not thoroughly review the patient’s hospital discharge report. Emergency Care In the 61 emergency events OIG clinicians reviewed, providers were available for consultation with TTA nursing staff and usually documented emergency events well. Although providers generally managed patients appropriately, we found providers occasionally misdiagnosed medical problems or ordered incorrect modes of emergency transport.53 Significant deficiencies are described below: • In case 2, the provider sent the diabetic patient with end-stage liver disease, who had severe abdominal pain and lethargy, to the hospital by basic life support transport urgently rather than emergently. The patient did not leave CTF until one hour after the lethargy was documented. In addition, the provider did not order a finger stick blood glucose check on this insulin dependent diabetic patient with lethargy, delaying the possible diagnosis of low sugar. When hospital staff checked the patient's finger stick blood glucose, the blood glucose was, in fact, very low and the patient required medical intervention. 51 Review of records deficiencies occurred in cases 18, 21, 22, and 24. 52 Amiodarone is a medication used to treat and prevent serious abnormal heart rhythms. It is used to restore normal heart rhythm and maintain a regular, steady heartbeat. Amiodarone can cause side effects on the heart, liver, thyroid, and lungs. 53 Provider related emergency care deficiencies occurred in cases 1–4, 7, 8, 13, 19–21, 24, and 42. Significant deficiencies occurred in cases 2, 7, 13 and 21. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 69 • Also in case 2, the nurse documented contacting the provider about the patient’s return from the hospital after a procedure to drain fluid from the patient’s abdomen. The nurse reported the patient was confused, disoriented, and had an elevated heart rate. Patients who undergo this procedure can develop significant electrolyte imbalances, and the provider should have ordered laboratory tests to check for electrolytes. In addition, the provider did not order the patient to be sent to a higher level of care until over one hour later, and ordered for transport back to the hospital urgently rather than emergently, which was medically indicated. This action delayed appropriate emergency care to the patient. The patient did not leave CTF via ambulance until nearly three hours after staff identified the patient’s altered mental status. OIG clinicians found, when the EMRRC reviewed emergency events, the committee often missed critical findings. Our clinicians further found, because the CTF CME or designee in the EMMRC often did not perform clinical reviews of emergency events as required by policy, the CME did not identify these missed findings or take remedial measures. We discuss this further in the Emergency Services indicator. Chronic Care Providers usually managed patients’ chronic health conditions appropriately. However, we identified 18 deficiencies in chronic care management, 10 of which were significant.54 Examples of significant deficiencies are described below: • In case 11, the nurse and the provider discussed the patient’s request to change the dosage time of one of his diabetes medications due to severe diarrhea after this medication’s injection. The nurse documented the provider agreed to change the medication dose time to 11:00 a.m. and would order a provider follow-up appointment to assess the medication change. The provider ordered the medication change but did not order the follow-up appointment. This placed the patient at risk of worsening diabetes or electrolyte imbalances from the diarrhea. • Later in case 11, the patient submitted more medical requests for help with the continued diarrhea. Eventually the patient refused the medication. A provider follow-up appointment was finally scheduled; however, the provider did not evaluate the patient until 20 days after the patient’s initial complaint of severe diarrhea. The provider documented the patient had diarrhea and blood in the stool but did not document an assessment of the patient’s bloody stool, which could have been related to more significant problems such as internal bleeding. The provider also reduced the patient’s medication but did not order a provider follow-up appointment to ensure the patient’s negative side effects from the medication had resolved and the patient’s diabetes did not worsen. • In case 12, the provider reviewed the diabetic patient’s very elevated hemoglobin A1c level, which indicated uncontrolled diabetes.55 The provider sent a patient notification letter stating a chronic care appointment had been 54 Chronic care deficiencies occurred in cases 1, 10–12, 17, 21, 22, and 24. Significant deficiencies occurred in cases 11, 12, 21, and 24. 55 Hemoglobin A1c is a blood test that measures the average blood glucose over the previous 12 weeks. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 70 scheduled; however, the provider did not order the appointment. Five weeks later, a different provider ordered the necessary follow-up chronic care appointment. The provider evaluated the patient more than three months after the abnormal hemoglobin A1c test result was available. In the interim, the patient’s diabetes was out of control, increasing the risk of diabetic related complications. The provider should have evaluated the patient sooner. • In case 21, the nurse contacted the provider by phone about a patient who was released from a seven-day hospital stay for asthma and acute respiratory failure. The patient complained of continued shortness of breath. The provider documented the patient’s recent hospitalization, continued symptoms, and a need for a follow-up appointment with a provider for the next day. The provider did not order the follow-up appointment and did not evaluate the patient. The patient was not scheduled with a provider for reassessment until almost one month later. Specialized Medical Housing Although providers were efficient at completing new patient admission history and physical examinations within required time frames, OIG case review clinicians found specialized medical housing providers delivered poor care to the patients. OIG clinicians reviewed 29 provider events in five specialized medical housing cases and found 20 provider performance deficiencies, 11 of which were significant. We identified delayed provider rounding, missed or poor patient assessments, poor medical decision making, and missing or poor documentation. We discuss this further in the Specialized Medical Housing indicator. Specialty Services OIG clinicians identified 14 deficiencies, eight of which were significant and related to poor decision making by the CTF providers. These deficiencies included ordering specialty services for inappropriate time frames, not ordering needed specialty services, or not following specialists’ recommendations.56 The following are examples of significant deficiencies: • In case 11, the patient was on treatment for a fungal infection called coccidiomycosis. When the patient’s chest x-ray and coccidiomycosis laboratory results normalized, the provider did not discontinue the patient’s antifungal medication or timely consult an infectious disease specialist for further recommendations. The patient remained on this medication unnecessarily until another provider discontinued it more than six months later. The provider did not receive any recommendations from an infectious disease specialist until the provider ordered an eConsult more than four months later.57 • In case 17, the provider endorsed a hematology specialty report with recommendations for the patient be referred to a tertiary care hematology 56 Deficiencies occurred in cases 1, 11, 17, 22, and 24. Significant deficiencies occurred in cases 11, 17, 22, and 24. 57 eConsult is an electronic specialty consulting service whereby providers can inquire of specialists about medical questions and receive advice and recommendations for patient care. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 71 specialist to assist in his care since his treatment was failing.58 The provider did not order the referral until five weeks later, delaying care to the patient. • Also in case 17, the hematology specialist evaluated the patient on three separate occasions over a seven-month period. At each appointment, the hematology specialist documented the patient should not receive aspirin if his platelet count was over a certain level due to the high risk of bleeding. During most of this period, the patient’s platelet count was over this level. The provider did not discontinue aspirin, as recommended by the specialist, and did not document why the provider did not follow the recommendations. The provider did not discontinue the aspirin for approximately eight months, which placed the patient at medical risk. Outpatient Documentation Quality Documentation is important because it shows the provider’s thought process during clinical decision-making. Except for the specialized provider performance mentioned above, providers usually documented accurately in the outpatient and emergency settings. Patient Notification Letters After providers endorsed diagnostic studies, they usually sent notification letters to patients. However, we identified 54 deficiencies related to incomplete letters, which did not contain all the components required by CCHCS policy.59 Provider Continuity CTF offered good provider continuity. OIG clinicians identified only one case with poor clinical provider continuity.60 Clinician On-Site Inspection We met with the CME, the CP&S, and providers to discuss provider related issues. The CME had worked at CTF for many years while the CP&S was relatively new to his position, promoting from a line physician position. They reported the CP&S evaluated patients in the clinic and took calls due to physician staffing. The CME also evaluated patients and responded to calls as needed. CTF had seven clinics, an OHU, a TTA unit, and on-site specialty services. A part-time physician was assigned to the OHU two days a week, and other providers were assigned the rest of the week. To help retain staff, medical leadership offered a work schedule of four ten-hour workdays, which the providers reported to be very happy with. Providers were assigned to teams of two, and they coordinated regular day off coverage and leave with each other. 58 A hematology specialist evaluates and treats disorders of the blood. 59 Incomplete patient test result notification letters occurred in cases 2, 11–17, 20–25, 41, and 42. 60 Poor provider continuity occurred in case 11. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 72 Medical leadership had implemented several creative uses of Microsoft Teams for huddles and staff communication. Each morning before clinic huddles and clinics started, the providers met to discuss events from on-call the night prior. The on-call provider completed a clear, organized spreadsheet of all medically significant calls that had occurred. The spreadsheet included the patient’s identifying information and which primary care provider was responsible for the patient’s care. In addition, the on-call provider documented the issues addressed and follow-up needed. This documentation was very helpful in ensuring patient care occurred after emergencies because it allowed both the primary care provider and the partner physician responsible for that yard to understand which post-emergency patients needed to be seen. The format was clear and comprehensive, which was important due to the physician alternate work week schedule. Using Microsoft Teams also allowed the physicians to communicate quickly and efficiently with nursing staff about patient care issues and to document histories and thought processes in Teams regarding patients who had presented to the on-call provider overnight. The one concern identified with using Teams was these communications were then not included in the patient’s electronic medical chart. When asked what challenges the institution faced, medical leadership mentioned hiring and retaining providers was difficult. During the case review period in 2023, CTF had three to four vacant full-time provider positions. CTF neighbors with Salinas Valley State Prison (SVSP), whose physicians receive a 15 percent pay incentive for similar work. This may have discouraged providers from staying at or applying to CTF if SVSP had open positions. Moreover, CTF is in Monterey County, an area with a higher cost of living, but no increased cost of living adjustment is offered to prospective staff. Medical leadership expressed general difficulty recruiting physicians to correctional facilities. To accommodate the shortage of physicians, CTF leadership had consolidated the central yard clinics from four clinics to three, increasing the patient load to the providers. The providers worked extended hours to meet patient care demands. The CP&S and the CME also both worked patient care lines to help reduce backlogs and took on-call duties to reduce the this burden on the providers. One registry provider was on site. B1 Yard was essentially manned part-time by different physicians for at least six months, resulting in poor continuity of care on that unit because of the loss of a physician. Two providers were long-term telemedicine physicians who worked on-site at CTF prior to moving to telemedicine. Other telemedicine providers intermittently provided coverage as well. The OHU provider only worked part-time and was on-site two days per week, but was also assigned to cover the restrictive housing unit. Providers reported using laptops for home calls. They expressed they could obtain more history and offered improved patient care due to the use of laptops. One provider mentioned having the laptop allowed a more flexible schedule, since they could complete entering information into EHRS from home. Providers expressed satisfaction and felt supported and heard by their medical leadership. Their main concern was the continued provider shortage, which some reported made taking calls unsustainable in the long term and caused burn out. The CP&S demonstrated a new patient notification letter system CCHCS developed to help overcome the continued deficiencies in missing elements in patient results notification letters. In the demonstration we received, the provider was required to generate the letter, then later endorse the results separately in the EHRS. Previously, the provider endorsement occurred concurrently with patient notification letter generation. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 73 Recommendations • Medical leadership should analyze the root cause(s) of poor assessments, emergency care, medical record review, specialty follow-up, documentation, specialized medical housing care, and chronic condition management and should implement remedial measures as appropriate. • Medical leadership should develop strategies to ensure complete and thorough review of emergency cases and implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 74 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, CTF’s specialized medical housing consisted of an outpatient housing unit (OHU). Ratings and Results Overview Case Review Rating Compliance Rating and Score Inadequate Adequate (80.0%) In case review, CTF’s medical care was mixed for specialized medical housing patients. Nurses performed satisfactorily overall, as they generally performed good assessments, completed admission assessments timely, and conducted daily rounds. However, our clinicians identified a pattern of incomplete admission assessments and lapses in provider notifications for patient change of condition. Moreover, provider performance was poor with questionable medical decisions, missing documentation, and untimely patient evaluations. Factoring all aspects, the OIG rated the case review component of this indicator inadequate. Compliance testing similarly showed mixed performance in this indicator. CTF showed poor medication continuity for newly admitted patients in the OHU. In contrast, providers timely completed history and physical examinations, and nurses frequently completed initial assessments within required time frames. Based on the overall compliance score result, the OIG rated the compliance component of this indicator adequate. Case Review and Compliance Testing Results We reviewed 89 OHU events that included 29 provider events and 34 nursing events. Due to the frequency of nursing and provider contacts in specialized medical housing, we bundle up to two weeks of patient care into a single event. We identified 42 deficiencies, 17 of which were significant.61 Provider Performance Overall, provider performance needed significant improvement as OIG clinicians found specialized medical housing providers performed poorly in clinical care of the patients. OIG clinicians reviewed 29 provider events in five specialized medical housing cases and identified 20 provider performance deficiencies, 11 of which were significant. We rated two of the five cases inadequate due to poor provider performance. The deficiencies included 61 Deficiencies occurred in cases 2, 20, 22, 41, and 42. Significant deficiencies occurred in cases 2, 22, and 42. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 75 untimely physician rounding, missing or inaccurate assessments, poor medical decision making, and lapses in documentation.62 The following are examples of the significant deficiencies: • In case 2, the provider evaluated the patient with end-stage liver disease, but did not address the abnormal laboratory test, which indicated possible hepatic encephalopathy.63 The provider also did not perform a neurologic assessment for this condition even though the provider had documented signs of encephalopathy at the previous appointment. When the patient transferred to the hospital the next day, the hospital physicians documented the patient had altered mental status and ordered medication to treat the encephalopathy. • Also in case 2, the nurse messaged the provider for an acute change in the patient’s condition of “weeping” legs. The nurse ordered a dressing change, and the provider cosigned the order two days later. Acute leg weeping can be a sign of fluid overload or low protein in end-stage liver disease. The provider did not timely evaluate the patient for this condition. • Furthermore, in case 2, the provider did not evaluate the patient for 25 days despite the patient’s active and ongoing symptoms of end-stage liver disease, frequent hospitalizations, emergency encounters, and messages from nurses. • In case 22, the provider evaluated the patient who had coronary artery bypass surgery seven days prior. The patient complained of chest pain, shortness of breath, and dizziness. The symptoms could have been indicative of a heart attack. The provider documented the surgeon would be contacted to discuss the chest pain. However, the provider did not contact the surgeon to obtain further recommendations on this high-risk patient’s chest pain symptoms, did not document a review of vital signs for the patient, and did not address the patient’s symptoms of dizziness. Provider documentation is critical to ensure covering providers have current information, especially if the institution does not have a full-time OHU provider, as with CTF. OIG clinicians identified six instances of providers ordering tests or treatments without documenting the medical reasoning.64 The providers sometimes also did not examine or assess the patient for the related symptoms. The following are examples: • In case 2, the nurse messaged the provider the patient’s blood pressure had been elevated for the past few days. The provider responded “OK” but did not document an assessment or decision making in the patient’s electronic medical record. • In case 22, the patient, who had undergone coronary artery bypass surgery, complained of nausea and dizziness. The symptoms could have been related to 62 Cases 2, 22, 41 and 42 involved specialized medical housing providers. Deficiencies occurred in cases 2, 22, 41, and 42. Significant deficiencies occurred in cases 2 and 22. 63 Hepatic encephalopathy is a brain disorder caused by impaired liver function. Symptoms include altered mental status, neuromuscular impairment, and coma. 64 Providers did not document medical decision making in cases 2, 22, 41, and 42. Specialized medical housing provider performance deficiencies occurred in cases 2, 22, 41, and 42. Significant deficiencies occurred in cases 2 and 22. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 76 heart problems or surgical complications; however, the provider did not evaluate the patient for these symptoms. Rather, the provider ordered symptomatic care and did not document a progress note with medical reasoning, nor assess the patient’s symptoms for potential causes. • In case 42, the provider evaluated the diabetic patient, who was taking steroid medications for complaints of phimosis.65 The provider did not document a history of symptoms or a physical examination. The provider documented this diagnosis and a treatment of steroids without documenting objective evidence supporting this was truly the patient’s condition. Compliance testing showed providers always completed new admission history and physicals within required time frames (MIT 13.002, 100%), and case review found similar results. Nursing Performance Compliance testing and our clinicians both found CTF performed very well with ensuring nurses timely completed the initial nursing assessments for newly admitted patients (MIT 13.001, 90.0%). Our clinicians identified 13 deficiencies related to nursing care, two of which were significant.66 Our clinicians found nurses generally performed good nursing assessments and conducted daily rounds on the patients. However, we identified a pattern in four cases where nurses missed components of the admission assessment and, in another three cases, nurses did not notify the provider when the patient’s condition warranted.67 The following are examples: • In case 41, the nurse documented the patient complained of nausea, dizziness, and pain to the abdominal area with cramping and discomfort. However, the nurse did not palpate the patient’s abdomen or notify the provider of the change in condition. Further, the nurse did not reassess the patient for symptom improvement. • In case 42, the patient was admitted to the OHU after hospital discharge for chronic obstructive pulmonary disease.68 However, the nurse did not complete a thorough admission assessment to include listening to heart sounds or bowel sounds. Medication Administration Compliance testing showed CTF performed poorly with medication continuity for patients newly admitted to the OHU (MIT 13.003, 30.0%). Our clinicians identified seven deficiencies related to medication administration, two of which were significant. Please refer to the Medication Management indicator for further discussion. 65 Phimosis is a medical condition in which the foreskin of the penis cannot be fully retracted over the head of the penis, leading to discomfort, difficulty in urination, infection, and urinary obstruction. 66 Nursing deficiencies occurred in cases 2, 20, 22, 41, and 42. Significant deficiencies occurred in cases 2 and 42. 67 Deficiencies related to incomplete admission assessments occurred in cases 2, 20, 22, and 42. Deficiencies related to a lack of provider notification occurred in cases 2, 41, and 42. 68 Chronic obstructive lung disease (COPD) is a chronic and progressive lung disease with damage to the lung and restrictive airflow. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 77 Clinician On-Site Inspection OIG clinicians interviewed the OHU RN and the nursing supervisor. The CTF OHU had 17 medical beds and three additional beds utilized for alternative housing. At the time of our inspection, the OHU had a census of 17 with an average daily census of 13. The OHU staff consisted of one RN on morning shift, one LVN on swing shift, one LVN on the night shift as well as a designated provider assigned two days a week. The TTA RN would cover for nursing consultation on swing shift and night shift. The nurses stated they performed nursing rounds twice a day and completed thorough assessments daily. The nurses reported they received medical supplies and medications timely, and after hours they used the Omnicell in the TTA for needed medications.69 Compliance On-Site Inspection At the time of our on-site inspection, the OHU had a functional call light communication system (MIT 13.101, 100%). 69 An Omnicell is an automated medication dispensing machine. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 78 Compliance Score Results Table 16. Specialized Medical Housing Scored Answer Compliance Questions Yes No N/A Yes % For OHU, CTC, and SNF: Did the registered nurse complete an initial 9 1 0 90.0% assessment of the patient on the day of admission? (13.001) Was a written history and physical examination completed within the 10 0 0 100% required time frame? (13.002) Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient 3 7 0 30.0% within required time frames? (13.003) For specialized health care housing (CTC, SNF, hospice, OHU): Do specialized health care housing maintain an operational call 1 0 0 100% system? (13.101) For specialized health care housing (CTC, SNF, hospice, OHU): Do health care staff perform patient safety checks according to institution’s local 0 0 1 N/A operating procedure or within the required time frames? (13.102) Overall percentage (MIT 13): 80.0% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 79 ` Recommendations • Nursing leadership should develop strategies to ensure nurses perform thorough patient admission assessments and notify providers of any abnormal changes in patients’ conditions and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 80 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 Inadequate (74.1%) Case review found CTF delivered satisfactory specialty services for their patients. Specialty services access was fair, and nurses performed well. In contrast, providers sometimes performed poorly in ordering specialty referrals within the appropriate priority time frame and in following specialists’ recommendations. Staff also needed improvement in retrieving specialty consultation reports. Considering all aspects, the OIG rated the case review component of this indicator adequate. Compared with Cycle 6, compliance testing showed CTF still needed improvement in this indicator. CTF performed very well in providing initial high-priority and routine-priority specialty services, and in subsequent follow-up appointments for medium-priority and routine-priority specialty services. However, CTF scored low in providing initial medium- priority and preapproved specialty services, as well as in timely retrieving and endorsing specialty reports. Based on the overall compliance score result, the OIG rated this indicator inadequate. Case Review and Compliance Testing Results We reviewed 109 events related to specialty services; 72 were specialty consultations and procedures and 37 were nursing encounters. We identified 30 deficiencies, 11 of which were significant.70 Access to Specialty Services Compliance testing showed CTF performed very well in completing high-priority appointments (MIT 14.001, 93.3%) and well in providing routine-priority specialty appointments within ordered time frames (MIT 14.007, 86.7%). However, testing showed CTF needed improvement in providing medium-priority specialty services (MIT 14.004, 66.7%). OIG clinicians identified seven deficiencies related to specialty access to care, five of which were significant.71 The following are examples: 70 Deficiencies occurred in cases 1, 2, 11, 12, 17, 18, 22–25, and 41. Significant deficiencies occurred in cases 1, 2, 12, 18, and 22–25. 71 Specialty access deficiencies occurred in cases 2, 12, 18, 22, 41, and 42. Significant deficiencies occurred in cases 2, 12, 18, 22, and 42. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 81 • In case 18, the provider ordered a cardiology follow-up appointment for a patient with a history of aortic valve replacement; however, the specialty appointment occurred almost four months late. • In case 22, the patient had a four-vessel heart bypass surgery which required a follow-up appointment from the heart specialist. A provider cancelled the appointment, but a different provider recognized this error and reordered the appointment, resulting in a new appointment that was delayed an additional seven weeks. The patient was not seen by the heart specialist for almost five months after the surgery occurred. • In case 42, staff ordered three outstanding specialty appointments for the patient: an ophthalmology and two pulmonology specialty appointments. The patient was admitted to the hospital. However, upon the patient’s return from hospitalization, staff did not appropriately reconcile and reorder these three appointments. Consequently, the patient either did not timely receive, or did not receive at all, these specialty services. Compliance testing indicated CTF needed significant improvement with ensuring transfer patients from other institutions received their preapproved specialty services within the originally scheduled time frames (MIT 14.010, 55.0%). OIG clinicians did not identify any specialty transfer deficiencies in its three transfer-in cases. CTF struggled with providing patients their subsequent high-priority specialty follow-up appointments as ordered by the primary care provider (MIT 14.003, 69.2%) but performed satisfactorily on medium-priority and routine-priority specialty service follow-up appointments (MIT 14.006, 83.3% and MIT 14.009, 83.3%). When specialty services were denied, CTF needed improvement with informing patients of the denial within required time frames (MIT 14.012, 65.0%). Provider Performance Compliance testing showed providers sufficiently completed the post-specialty primary care provider follow-up appointments within required time frames (MIT 1.008, 76.2%). Case review only found one significant access deficiency with a provider follow-up appointment after a specialty procedure as follows: • In case 24, the patient returned from an off-site cardiac MRI. The results were abnormal, with evidence of previous heart scarring and reduced pumping function. The patient was scheduled to see his primary care provider 14 days later to follow up, but this appointment did not occur. Case review identified 14 provider performance deficiencies related to specialty services; eight of which were significant. These deficiencies included: providers not ordering appropriate services for patients leading to delays or omission of care; providers not contacting specialists to correct an error or address an abnormal finding; and providers not Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 82 following specialists’ recommendations without documenting medical justification.72 The following are examples: • In case 22, the provider cancelled a cardiology specialty referral for the patient who required a cardiology follow-up after his coronary artery bypass surgery completed eight days prior. The documentation stated the referral was cancelled because the patient would be scheduled with the “local MD.” This delayed cardiology specialty follow-up care for the patient. • Also in case 22, the provider endorsed the cardiothoracic surgeon’s follow-up report, which documented the patient needed to continue cardiac rehabilitation after the patient’s cardiac bypass surgery; however, the provider did not order the cardiac rehabilitation prior to or after the surgeon’s evaluation. • In case 24, the provider evaluated the patient at a follow-up appointment after a neurology specialty consultation and nerve conduction test. The test showed bilateral upper extremity carpal tunnel syndrome and bilateral ulnar neuropathy.73 The provider did not address the patient’s bilateral carpal tunnel diagnosis nor discuss positional or conservative care measures to improve the patient’s symptoms; did not give the patient braces for treatment for the right wrist (the patient had previously been given a left wrist splint); and did not discuss bracing options and positional or conservative ulnar neuropathy treatments with the patient. We detailed more information in the Provider Performance indicator. Nursing Performance Case review found nurses performed well in assessing patients who returned to the CTF from off-site appointments. We identified only two minor deficiencies.74 Health Information Management CTF performed variably in obtaining specialty reports timely. Compliance testing showed CTF frequently scanned reports timely (MIT 4.002, 93.3%). However, compliance testing found staff needed improvement in retrieving routine-priority, medium-priority, and high- priority specialty reports, and providers needed improvement in endorsing reports within required time frames (MIT 14.008, 60.0%, MIT 14.005, 66.7%, and MIT 14.002, 60.0%). OIG clinicians reviewed 72 specialty consultations or procedures and identified 18 deficiencies related to health information management, six of which were significant.75 The following are examples of significant deficiencies: 72 Provider performance deficiencies occurred in cases 1, 11, 17, 22, and 24. Significant deficiencies occurred in cases 11, 17, 22, and 24. 73 Carpal tunnel syndrome is a disorder caused by pressure on a nerve in the wrist. This may result in hand pain, numbness, tingling, weakness, and loss of function. Ulnar neuropathy is a disorder of the ulnar nerve, a nerve from extending from the neck to the hand. Symptoms may occur in the elbow or hand and, similar to carpal tunnel syndrome, results in pain, numbness, tingling, weakness, and loss of function. 74 The deficiencies occurred in cases 17 and 25. 75 HIM specialty deficiencies occurred in cases 1, 2, 12, 17, 18, and 22–25. Significant deficiencies occurred in cases 1, 2, and 22–25. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 83 • In case 1, the gastrointestinal specialist performed esophagogastroduodenoscopy (EGD) and colonoscopy procedures with biopsies.76 CTF staff scanned the biopsy results from these procedures into the patient’s electronic health record more than one month later. These biopsy results could have contained time-sensitive information, such as colon cancer, and the delay in obtaining the results placed the patient at risk. • In case 2, a hematology specialist evaluated the patient, but CTF staff did not scan the specialist’s report until more than nine months later. • In case 22, a cardiothoracic surgeon evaluated the patient, but CTF staff scanned the specialist’s report into the patient’s electronic health record nearly 11 months later.77 • In case 23, an RN documented a telemedicine specialty cancer appointment occurred; however, at the time of the clinician on-site inspection, approximately seven months later, staff still had not scanned this specialty report into the patient’s electronic health record. • In case 25, an interventional radiologist performed a chemoembolization procedure for the patient.78 However, staff did not obtain the procedure report until 28 days later. Clinician On-Site Inspection During the on-site inspection, we discussed specialty services processes and case review deficiencies with medical leadership, health information management supervisors, ancillary staff, diagnostic staff, nurses, and providers. When asked about difficulties obtaining specialty services, CTF leadership stated no local specialists for dermatology, podiatry, allergy, audiology, gastroenterology, or orthopedic surgery were available within the specialist network CCHCS used. For patients requiring these services, such as a simple hearing test or diabetic toenail care, custody staff must transport the patients to a contracted provider located far away from CTF. CTF leadership described using CCHCS telemedicine orthopedic services to determine whether a patient was a surgical candidate because of a local shortage of contracted orthopedic surgeons during the review period. CTF leadership further explained, if a patient was a candidate, the patient would be referred to a different contracted orthopedic surgeon for another initial evaluation and possibly surgery. While this practice could delay care to the patient, it allowed the institution to screen whether patients with orthopedic symptoms required the long-distance transport. Staff scheduled both on-site and off-site initial specialty appointments according to the priority level the provider documented on the referral and executive management approved. Staff scheduled follow-up appointments per the specialist’s recommendations. Leadership reported, even though a specialist would recommend when a patient should have a follow-up 76 An EGD is an esophagogastroduodenoscopy. In this procedure, the specialist uses a camera to examine the esophagus and the stomach. 77 A cardiothoracic surgeon performs surgery of the heart, lungs, esophagus, and other organs in the chest. 78 Chemoembolization is a procedure to deliver cancer-treating medication to a tumor while reducing the tumor’s blood supply. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 84 specialty appointment, often that specialist was not available during the recommended time frame, which led to delays in meeting compliance dates. In regard to our finding that providers entered incorrect priorities on specialty referrals, both medical leadership and providers reported receiving no special direction regarding specialty services priority ordering. However, some providers mentioned they knew which services CTF could not obtain within the high-priority time frames (up to 14 days). Therefore, they often ordered those as medium-priority (up to 45 days), regardless of the medical indication. Staff described reconciling outstanding specialty orders in several situations. For newly arrived patients with outstanding specialty consultations, if the referral was pending and scheduled, the UM RN entered and reconciled the order into the CTF system. If a follow-up specialty services appointment was pending, the CTF providers reconciled the orders. In addition, if a patient was sent to the hospital for more than 24 hours, the providers had to ensure outstanding specialty orders prior to hospitalization were reconciled and reordered. Although the providers are responsible for entering post-hospital specialty reconciliation orders in EHRS, the UM nursing staff reported they also track those orders to monitor whether the providers reenter the cancelled specialty services orders upon the patient’s return and to ensure the compliance date remains the same. If they find no order written, the UM nursing staff message the providers; however, the providers are primarily responsible. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 85 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 14 1 0 93.3% Service? (14.001) Did the institution receive and did the primary care provider review the high-priority specialty service consultant report within the required time 9 6 0 60.0% frame? (14.002) Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care provider? 9 4 2 69.2% (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 10 5 0 66.7% Service? (14.004) Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the required time 10 5 0 66.7% frame? (14.005) Did the patient receive the subsequent follow-up to the medium-priority specialty service appointment as ordered by the primary care provider? 5 1 9 83.3% (14.006) Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician Request for 13 2 0 86.7% Service? (14.007) Did the institution receive and did the primary care provider review the routine-priority specialty service consultant report within the required time 9 6 0 60.0% frame? (14.008) Did the patient receive the subsequent follow-up to the routine-priority specialty service appointment as ordered by the primary care provider? 5 1 9 83.3% (14.009) For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the sending 11 9 0 55.0% 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 20 0 0 100% services within required time frames? (14.011) Following the denial of a request for specialty services, was the patient 13 7 0 65.0% informed of the denial within the required time frame? (14.012) Overall percentage (MIT 14): 74.1% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 86 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 16 5 24 76.19% occur within required time frames? (1.008) * Are specialty documents scanned into the patient’s electronic health record 28 2 15 93.33% 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: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 87 Recommendations • CTF leadership should determine the root cause(s) of challenges to timely providing specialty appointments and should implement remedial measures as appropriate. • CTF leadership should ascertain the challenge(s) to the receiving specialty reports within required time frames and should implement remedial measures as appropriate. • Medical leadership should determine the root cause(s) of providers not following specialists’ recommendations or not clearly documenting the medical rationale for not following specialist’s recommendations and should implement necessary remedial measures. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 88 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. Case review does 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 (74.3%) CTF’s performance was mixed in this indicator. While CTF scored excellently in many applicable tests, it needed improvement in multiple areas. The EMRRC either only occasionally completed the required checklists or did not timely complete reviews. In addition, staff conducted medical emergency response drills with incomplete documentation or missing required emergency response drill forms. Lastly, the nurse educator did not ensure all newly hired nurses received the required onboarding training. 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 CTF, 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. Eight patient deaths occurred during our review period. We found no evidence in the submitted documentation the preliminary mortality reports had been completed. These reports were overdue at the time of OIG’s inspection (MIT 15.998). Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 89 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 3 9 0 25.0% packages the committee reviewed include the required documents? (15.003) For institutions with licensed care facilities: Did the Local Governing Body (LGB) or its equivalent meet quarterly and discuss local operating N/A N/A N/A N/A procedures and any applicable policies? (15.004) Did the institution conduct medical emergency response drills during each watch of the most recent quarter, and did health care and custody staff 0 3 0 0 participate in those drills? (15.101) Did the responses to medical grievances address all of the patients’ 10 0 0 100% appealed issues? (15.102) Did the medical staff review and submit initial patient death reports to the 7 1 0 87.5% CCHCS Mortality Case Review Unit on time? (15.103) Did nurse managers ensure the clinical competency of nurses who 9 1 0 90.0% administer medications? (15.104) Did physician managers complete provider clinical performance appraisals 8 1 0 88.9% 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 0 1 0 0 onboarding and clinical competency training? (15.110) Did the CCHCS Death Review Committee process death review reports This is a nonscored test. Please refer to the timely? Effective 05/2022: Did the Headquarters Mortality Case Review discussion in this indicator. process mortality review reports timely? (15.998) What was the institution’s health care staffing at the time of the OIG medical This is a nonscored test. Please refer to Table 3 inspection? (15.999) for CCHCS-provided staffing information. Overall percentage (MIT 15): 74.3% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 90 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 91 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 CTF Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 92 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: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 93 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: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 94 Figure A–2. Case Review Testing Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 95 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: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 96 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: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 97 Appendix B: Case Review Data Table B–1. CTF Case Review Sample Sets Sample Set Total CTC/OHU 2 Death Review/Sentinel Events 2 Diabetes 5 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 9 Specialty Services 3 42 Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 98 Table B–2. CTF Case Review Chronic Care Diagnoses Sample Set Total Anemia 1 Anticoagulation 4 Arthritis/Degenerative Joint Disease 12 Asthma 4 Cancer 2 Cardiovascular Disease 6 Chronic Kidney Disease 3 Chronic Pain 10 Cirrhosis/End-Stage Liver Disease 5 Coccidioidomycosis 1 COPD 4 Deep Venous Thrombosis/Pulmonary Embolism 2 Diabetes 16 Gastroesophageal Reflux Disease 7 Hepatitis C 14 Hyperlipidemia 23 Hypertension 18 Mental Health 22 Migraine Headaches 1 Seizure Disorder 2 Sleep Apnea 5 Substance Abuse 9 Thyroid Disease 1 172 Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 99 Table B–3. CTF Case Review Events by Program Diagnosis Total Diagnostic Services 126 Emergency Care 98 Hospitalization 34 Intra-System Transfers In 10 Intra-System Transfers Out 9 Outpatient Care 364 Specialized Medical Housing 89 Specialty Services 119 849 Table B–4. CTF Case Review Sample Summary Sample Set Total MD Reviews Detailed 20 MD Reviews Focused 2 RN Reviews Detailed 16 RN Reviews Focused 18 Total Reviews 56 Total Unique Cases 42 Overlapping Reviews (MD & RN) 14 Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 100 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 101 Appendix C: Compliance Sampling Methodology Correctional Training Facility 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 25 OIG Q: 4.005 • See Health Information Management Community (Medical Records) (returns from Hospital community hospital) MIT 1.008 Specialty Services 45 OIG Q: 14.001, • See Specialty Services Follow-Up 14.004 & 14.007 MIT 1.101 Availability of 6 OIG on-site review • Randomly select one housing unit Health Care from each yard Services Request Forms Diagnostic Services MITs 2.001 – 003 Radiology 10 Radiology Logs • Appointment date (90 days – 9 months) • Randomize • Abnormal MITs 2.004 – 006 Laboratory 10 Quest • Appt. date (90 days – 9 months) • Order name (CBC, BMP, or CMPs only) • Randomize • Abnormal MITs 2.007 – 009 Laboratory STAT 0 Quest • Appt. date (90 days – 9 months) • Order name (CBC, BMP, or CMPs only) • Randomize • Abnormal MITs 2.010 – 012 Pathology 10 InterQual • Appt. date (90 days – 9 months) • Service (pathology-related) • Randomize Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 102 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 25 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 25 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: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 103 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 25 OIG Q: 4.005 • See Health Information Management Community Hospital (Medical Records) (returns from community hospital) MIT 7.004 RC Arrivals — N/A at this OIG Q: 12.001 • See Reception Center Medication Orders institution MIT 7.005 Intrafacility Moves 25 MAPIP transfer • Date of transfer (2 – 8 months) data • To location/from location (yard to yard and to/from ASU) • Remove any to/from MHCB • NA/DOT meds (and risk level) • Randomize MIT 7.006 En Route 10 SOMS • Date of transfer (2– 8 months) • Sending institution (another departmental facility) • Randomize • NA/DOT meds MITs 7.101 – 103 Medication Storage Varies OIG inspector • Identify and inspect clinical & med Areas by test on-site review line areas that store medications MITs 7.104 – 107 Medication Varies OIG inspector • Identify and inspect on-site clinical Preparation and by test on-site review areas that prepare and administer Administration Areas medications MITs 7.108 – 111 Pharmacy 1 OIG inspector • Identify & inspect all on-site on-site review pharmacies MIT 7.112 Medication Error 25 Medication error • All medication error reports with Reporting reports Level 4 or higher • Select total of 25 medication error reports (recent 12 months) MIT 7.999 Restricted Unit 10 On-site active • KOP rescue inhalers & nitroglycerin KOP Medications medication listing medications for IPs housed in restricted units Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 104 Quality No. of Indicator Sample Category Samples Data Source Filters Prenatal and Postpartum Care MITs 8.001 – 007 Recent Deliveries N/A at this OB Roster • Delivery date (2 – 12 months) institution • Most recent deliveries (within date range) Pregnant Arrivals N/A at this OB Roster • Arrival date (2 – 12 months) institution • Earliest arrivals (within date range) Preventive Services MITs 9.001 – 002 TB Medications 25 Maxor • Dispense date (past 9 months) • Time period on TB meds (3 months or 12 weeks) • Randomize MIT 9.003 TB Evaluation, 25 SOMS • Arrival date (at least 1 year prior to Annual Screening inspection) • Birth month • Randomize MIT 9.004 Influenza 25 SOMS • Arrival date (at least 1 year prior to Vaccinations inspection) • Randomize • Filter out IPs tested in MIT 9.008 MIT 9.005 Colorectal Cancer 25 SOMS • Arrival date (at least 1 year prior to Screening inspection) • Date of birth (45 or older) • Randomize MIT 9.006 Mammogram N/A at this SOMS • Arrival date (at least 2 yrs. prior to institution inspection) • Date of birth (age 52 – 74) • Randomize MIT 9.007 Pap Smear N/A at this SOMS • Arrival date (at least three yrs. prior to institution inspection) • Date of birth (age 24 – 53) • Randomize MIT 9.008 Chronic Care 25 OIG Q: 1.001 • Chronic care conditions (at least Vaccinations 1 condition per IP — any risk level) • Randomize • Condition must require vaccination(s) MIT 9.009 Valley Fever N/A at this Cocci transfer • Reports from past 2 – 8 months institution status report • Institution • Ineligibility date (60 days prior to inspection date) • All Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 105 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: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 106 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 20 Specialty Services • Arrived from (other Arrivals Arrivals departmental institution) • Date of transfer (3 – 9 months) • Randomize MITs 14.011 – Denials 20 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 N/A at this LGB meeting • Quarterly meeting minutes institution minutes (12 months) MIT 15.101 Medical Emergency 3 On-site summary • Most recent full quarter Response Drills reports & • Each watch documentation for ER drills MIT 15.102 Institutional Level 10 On-site list of • Medical grievances closed Medical Grievances grievances/close (6 months) d grievance files Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 107 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 9 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: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 108 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 109 California Correctional Health Care Services’ Response Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7, Correctional Training Facility | 110 Office of the Inspector General, State of California Inspection Period: June 2023 – November 2023 Report Issued: May 2025 Cycle 7 Medical Inspection Report for Correctional Training Facility OFFICE of the INSPECTOR GENERAL Amarik K. Singh Inspector General Shaun Spillane Chief Deputy Inspector General STATE of CALIFORNIA May 2025 OIG