OIG
High Desert State Prison
O I G
FFICE OF THE NSPECTOR ENERAL
S W I G
TEVE HITE, NSPECTOR ENERAL
M R A
ANAGEMENT EVIEW UDIT
H D S P
IGH ESERT TATE RISON,
S
USANVILLE
A W D R
CTING ARDEN AVID UNNELS
N 2001
OVEMBER
S C G D G
TATE OF ALIFORNIA RAY AVIS, OVERNOR
OFFICE OF THE INSPECTOR GENERAL
STEVE WHITE, INSPECTOR GENERAL
MANAGEMENT REVIEW AUDIT
REPORT
ACTING WARDEN DAVID RUNNELS
HIGH DESERT STATE PRISON
SUSANVILLE, CALIFORNIA
NOVEMBER 2001
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 1
CONTENTS
EXECUTIVE SUMMARY..........................................................................................................3
EXECUTIVE SUMMARY..........................................................................................................3
BACKGROUND..................................................................................................................6
OBJECTIVES, SCOPE, AND METHODOLOGY....................................................................7
PROBLEMS OF MANAGING A LEVEL IV PRISON IN A REMOTE AREA............................7
FINDINGS AND RECOMMENDATIONS
INSTITUTION PROGRAM
FINDING 1...........................................................................................................10
FINDING 2...........................................................................................................11
FINDING 3...........................................................................................................12
FINDING 4...........................................................................................................13
FINDING 5...........................................................................................................14
FINDING 6...........................................................................................................16
FINDING 7...........................................................................................................16
FINDING 8...........................................................................................................17
FINDING 9...........................................................................................................18
FINDING 10.........................................................................................................19
FINDING 11.........................................................................................................19
FINDING 12.........................................................................................................20
FINDING 13.........................................................................................................22
HEALTH CARE PROGRAM
FINDING 1...........................................................................................................24
FINDING 2...........................................................................................................25
FINDING 3...........................................................................................................26
FINDING 4...........................................................................................................26
FINDING 5...........................................................................................................28
FINDING 6...........................................................................................................28
VIEWS OF RESPONSIBLE OFFICIALS..................................................................ATTACHMENT A
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 2
EXECUTIVE SUMMARY
This report presents the results of a management review audit of High Desert State Prison
conducted by the Office of the Inspector General from April 2001 through August 2001. The
purpose of the audit was to provide a baseline review in accordance with California Penal
Code Section 6051. The audit focused on institutional processes relating to communications,
investigations, security, personnel, training, medical services, dental services, and financial
matters.
High Desert State Prison has had a series of wardens since it opened in August 1995. The
current acting warden, David Runnels, assumed the position in November 2000 when
Warden Roy Castro transferred to the California Correctional Center. Runnels previously
served as chief deputy warden at High Desert State Prison from June 1998 to November
2000. As acting warden, he is responsible for overseeing all institution operations except for
medical, dental and psychiatric programs; which are under the direction of the recently hired
chief medical officer/health care manager, Norman Baron, M.D.
In assessing the institution’s operations, the Office of the Inspector General staff toured the
facilities and observed operations, conducted interviews and surveys of employees, met with
inmate advisory committees, and reviewed pertinent documents related to key systems,
functions, and processes. Overall, the Office of the Inspector General found that the
institution has performed satisfactorily, considering that: the custody operation is
responsible for housing and programming some of California’s most dangerous inmates, the
prison has difficulty hiring staff because of its remote location, the prison is continually
overcrowded, and it is under severe budget constraints.
Acting Warden Runnels is confronted with the challenges of having to manage a high-
security, overcrowded institution with the potential for violence on a daily basis. More than
60% of the inmate population is classified as Level IV, and there are constant concerns
about inmate and staff safety. Prison gangs have been responsible for numerous incidents
since the institution opened, and recently a correctional officer at the facility was critically
injured during an assault on staff members. The inmates, many serving life terms with no
possibility of parole, are uncooperative and difficult to program. As a result, a large
proportion of the inmate population is constantly on modified programming. During a
modified program or lockdown situation, inmates are locked in their cells for extended
periods of time, with limited opportunities to exercise or to interact with staff and other
inmates, and custody personnel are generally required to escort all inmate movement.
High Desert State Prison experiences recruitment and retention problems because of its rural
location. Also, it must compete for staff resources with its neighboring institution, the
California Correctional Center. Staff retention issues affect not only vacancies but also
operational policies. The staff and the inmates commented on the lack of stability within the
facility’s management structure in recent years, which has created an uncertain environment.
Changes in management can affect inmate programming and operational practices because
each new manager has a particular approach. Several staff members stated that the
institution’s operations have been improving, but that management must be given the
opportunity to establish greater stability in order for recent efforts to be sustained.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 3
In addition, like almost all California prisons, the institution is operating at nearly twice the
capacity for which it was designed. The institution was designed to house 2,200 inmates but
is currently housing about 4,300. The majority of the inmates must be doubled celled, which
can create a security problem if the inmates are not appropriately matched: Classification
and custody personnel must be cognizant of each inmate’s background to ensure that they do
not place inmates or staff members at risk. The institution appears to be in good physical
condition, but overcrowding causes undue wear and tear on the facility and equipment and
the plant operations staff must ensure proper maintenance for facilities and systems that are
working in excess of the design capacity.
Another issue is the institution’s projected $1.4-million budget shortfall. The deficit is the
result of a number of factors, including increased workers’ compensation costs, overtime,
and department-mandated budget reductions. To help mitigate the deficit, headquarters
instructed the institution to leave non-critical positions vacant as well as to reduce
inventories and supplies to minimum operating levels. Only purchases directly related to
critical health, safety, and security issues are being allowed.
Overall, the management review audit revealed no major issues of concern regarding non-
medical areas under the direction of the warden. The majority of the notable deficiencies
were in the health care program, which is under the direction of the health care manager.
Following is a list of notable deficiencies, by program area.
FINDINGS—INSTITUTION PROGRAM
• The inmate appeals system contains deficiencies that undermine the integrity of the
appeals process and subject inmates to possible safety risks.
• Inmate services during lockdown are inadequately documented.
• Inmate appeals are not processed within the prescribed time limits.
• Inmates paroled from the Susanville institutions pay an extra $55 transportation cost
compared to inmates paroled from the Folsom institutions.
FINDINGS—HEALTH CARE PROGRAM
• Inmate medical records are inadequately documented.
• Inmate medications could be tampered with before they are administered.
• Inmates on psychotropic medication are not included in the mental health delivery
system.
• Inmates are not receiving dental services required by state regulations.
• Inmates are not provided with the medical, psychiatric, and dental chrono forms (CDC
Form 128 C) in a timely manner.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 4
• Inmate medications are not adequately accounted for and controlled.
• Inmate medical appeals are not processed within the prescribed time limits.
Some of the recommendations of the Office of the Inspector General regarding these
situations will require the involvement and support of California Department of Corrections
headquarters management, because they require changes to departmental policies and
procedures.
Throughout the review process, the staff of the Office of the Inspector General received
excellent cooperation and assistance from the staff of High Desert State Prison.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 5
INTRODUCTION
The Office of the Inspector General conducted its management review audit of High Desert
State Prison pursuant to its authority under California Penal Code Section 6051. This statute
provides that the Office of the Inspector General is required to perform a baseline audit of
any California Department of Corrections institution whenever the warden position becomes
vacant and a new warden is appointed. The purpose of the baseline audit is to inform the
new warden about program deficiencies and to provide recommendations for improvement.
The baseline review includes, but is not limited to, issues relating to communications,
investigations, security, personnel, training, medical services, dental services, and financial
matters.
BACKGROUND
David Runnels was assigned as interim warden at High Desert State Prison in November
2000 when Warden Roy Castro was appointed warden at the California Correctional Center.
Warden Runnels was the chief deputy warden at High Desert State Prison from June 1998
through November 2000. He began his state career in 1982 as a correctional officer with the
Deuel Vocational Institution in Tracy and was later promoted to correctional sergeant at
California State Prison, Solano. He held various positions at Solano, including employee
relations officer, business manager, correctional captain, and correctional administrator.
High Desert State Prison opened in August 1995 and became one of nine institutions in the
state to house Level IV male inmates. The prison’s design is considered the most secure
within the California correctional system: it has two 180-design facilities, which give the
custody staff a 180-degree view from the control booth. The prison is located on 325 acres
in Susanville, adjacent to the California Correctional Center. It houses approximately 4,300
minimum- to high-maximum-custody inmates. More than 60% of the inmate population is
designated Level IV. The institution also operates a 190-bed reception center for inmates
being remanded to the care of the California Department of Corrections from Northern
California counties.
The 4,300 inmates are divided among five facilities. Facilities A and B are of the 270-design
and house both Level III and Level IV inmates. (Building 5, located in Facility A, houses the
majority of the reception-center inmates.) Facilities C and D are of the 180-design and house
Level IV inmates as well as inmates assigned to administrative segregation. Facility E is the
minimum-support facility, located just outside the secure perimeter, and houses only Level I
inmates.
The institution’s mission is to provide for the confinement of general population Level I,
Level 3, and Level 4 inmates who are willing to participate in vocational, academic, or
support services programs.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 6
High Desert State Prison is one of the largest employers in Lassen County. It has an annual
operating budget of more than $100 million and currently employs more than 1,200 full-
time staff members.
OBJECTIVES, SCOPE AND METHODOLOGY
The objectives of the management review audit were to evaluate the institution
management’s performance in:
1. Planning, organizing, directing, and coordinating all correctional, business management,
work-training incentive, and related programs; and
2. Formulating and executing a progressive program for the care, treatment, training,
discipline, custody, and employment of inmates.
In order to accomplish these objectives, the audit team performed various procedures in the
general areas of communications, investigations, institution safety and security, inmate
programming, health services, dental services, personnel, training, and financial
management. Those procedures included:
1. Performing analytical reviews of financial information and data trends;
2. Conducting interviews with the warden, the administrative staff, custody and non-
custody employees, and inmates;
3. Gathering input from randomly selected employees via questionnaire regarding the
warden’s and the chief deputy warden’s effectiveness in communication;
4. Touring the facilities and observing their operations; and
5. Gathering, reviewing, and analyzing pertinent documents related to key systems,
functions, and processes, to substantiate the observations made through on-site visits and
interviews.
PROBLEMS OF MANAGING A LEVEL IV PRISON IN A REMOTE LOCATION
The remote location of High Desert State Prison, coupled with its large population of Level
IV inmates, presents particular management challenges.
• Lockdowns. High Desert State Prison has had numerous lockdowns since opening in
August 1995. This is not uncommon for Level IV institutions, which incarcerate a large
number of inmates who have violent backgrounds and gang affiliations and are serving
life terms. The prison’s lockdowns affect inmate access to medical care, access to
education and work programs, and other inmate privileges such as canteen and visiting.
Therefore, it is not surprising that the institution experiences an increase in the number
of appeals filed by inmates during lockdowns. These appeals create additional workload
for correctional staff members who must address the issues and respond to the inmates in
a timely manner. Lockdowns also mean that academic and vocational instructors are not
able to provide instruction to students, which has a major impact on inmate education
and training. During lockdowns, teachers are redirected to assist with mail processing,
with documenting property obtained during cell searches, and with community events.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 7
The following chart displays the average number of inmates affected by a lockdown or
modified program during the period of February 4, 2001 through July 1, 2001.
Inmate Population* Inmates on Modified Inmates on Lockdown Percentage on
Program (average) Status (average) Modified/Lockdown
3,940 1,042 1,427 62.7%
* Excludes administrative segregation and reception center inmates.
From June 10, 2001 to August 2, 2001, the entire institution except the minimum-custody
facility was on lockdown status.
• Recruitment and Retention. The remote location of High Desert State Prison has a
major impact on recruitment and retention of staff. This is especially true in the area of
medical services. The prison has a high vacancy rate for both medical technical
assistants and registered nurses. California in general is experiencing a nursing shortage,
and the institution is currently competing with hospitals as far away as the Sacramento
area to retain the existing staff, with some hospitals even offering hiring incentives to
potential employees.
The prison also has difficulty recruiting correctional officers. Over the last three years,
the institution has received only 30% of what it requested from the academy. The
shortage of correctional officers is currently a statewide problem, but it is even greater in
hard-to-recruit areas such as Susanville. The high number of vacancies at the prison
means that its correctional officers are often required to work a significant amount of
overtime to cover shifts.
• Lack of Stability in Leadership Positions. It is critically important for a prison,
especially a Level IV institution, to have a strong and stable leadership to provide focus
and direction for both staff and inmates. Yet High Desert State Prison has continually
experienced a great deal of turnover at the management level. Since opening in August
1995, the prison has had seven wardens or acting wardens, as shown below.
• David Runnels (acting) - November 2000 to present
• Roy Castro - July 1998 to November 2000
• Denise Mayle (acting) - July 1998
• Susan Yearwood - July 1997 to June 1998
• Robert Ayers (acting) - April 1997 to June 1997
• Richard Gile (acting) - January 1997 to April 1997
• William Merkle - September 1994 to December 1996 (member of the activation
team from September 1994 through August 1995)
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 8
There also have been numerous rotations at the positions of chief deputy warden,
associate warden, and facility captain. High Desert State Prison records show that from
January 1998 to June 2001, the institution has had seven chief deputy wardens. During
the same period, there have been 10 associate wardens at Complex 1, six at Complex 2,
six at Central Operations, and five at Business Services. Facility captains have had a
similar turnover pattern. In just the last two years, each of the four facilities has had five
different captains in charge of facility operations.
The turnover in leadership positions has made it difficult for management to build
relationships with the staff and to provide consistent policy direction in the operation of
the institution.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 9
FINDINGS AND RECOMMENDATIONS
INSTITUTION PROGRAM
FINDING 1
The Office of the Inspector General found deficiencies in the inmate appeals system at
High Desert State Prison that undermine the integrity of the appeals process and
subject the inmates to possible safety risks.
High Desert State Prison inmates complained to the Office of the Inspector General that
their appeals are often lost or ignored. Some of the inmates said they suspect the custody
staff reads the complaints, especially those concerning staff members, thereby jeopardizing
the inmates’ safety. Although those assertions cannot be validated, the Office of the
Inspector General found deficiencies in the inmate appeals system at the institution that
compromise the integrity of the process. In particular, the present procedures do not
adequately ensure that appeals submitted by the inmates reach the appeals office and that
they are not intercepted or reviewed by those with a direct interest in the complaint.
How appeals are submitted. During normal institution operations, inmates can file appeals
either by sending them to the appeals office through the prison’s internal mail system or by
placing them in the appeals lock-box located in each housing unit. Appeals sent by mail are
picked up from the inmates by members of the housing staff, collected by the first-watch
inside patrol officer, and taken to the institution mail-room. Appeals dropped into lock-
boxes are collected every night by the first-watch inside patrol officer, who delivers the
appeals to the program office. At the program office, the facility captain or designee reviews
the appeals, decides which are to be handled at the formal level and which at the informal
level, and forwards those to be handled at the formal level to the appeals office. The appeals
office logs the formal-level appeals and coordinates and prepares responses.
Procedures during lockdowns. When the institution is in lockdown, as is frequently the
case, inmates are confined to their cells and therefore are denied access to the lock-boxes.
As a result, the inmates must rely on the housing staff to gather appeals and give them to the
first-watch inside patrol officer. The inmate places the appeal in the cell door and a member
of the housing staff picks it up to be collected by the first-watch inside patrol officer.
Inadequate separation of duties. Whether under normal operations or during lockdowns,
the present system allows the appeals to pass through the hands of those who might have an
interest in the complaint. Under normal operations, members of the housing staff who might
be subjects of an appeal have access to any appeals submitted by mail when they pick up the
appeals from the inmates. During lockdowns inmates lose the option of bypassing the
housing staff by dropping appeals into the lock-box. As a result, the staff members who pick
up the appeals are the same employees who provide inmates with day-to-day oversight and
who may be the subjects of complaints.
Similar problems in the inmate appeals system statewide. Inmates from throughout the state
have written to the Office of the Inspector General alleging similar problems at other
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 10
institutions and expressing general mistrust of the prison appeals process. Through audits of
the inmate appeals systems and processes of other institutions and of the Department of
Corrections Inmate Appeals Branch, the Office of the Inspector General has identified
significant systemic deficiencies.
RECOMMENDATION
The Office of the Inspector General recommends that the Department of Corrections
undertake a thorough revamping of the inmate appeals system statewide to address the
deficiencies in the inmate appeals system.
FINDING 2
The Office of the Inspector General found that the institution cannot document that
the inmates received hot meals and showers during lockdowns.
According to California Department of Corrections Operations Manual, Section 54080.5,
“A minimum of two hot meals shall be served every 24 hours with three meals provided at
regular hours during each 24-hour period.”
In addition, California Code of Regulations, Title 15, Article 5, Section 3060, requires the
institution to provide the means for all inmates to keep themselves and their living quarters
clean and to practice good health habits. Section 54080.21.6 of the Department of
Corrections Operations Manual specifically states:
Inmates undergoing disciplinary detention shall be provided the means to keep
themselves clean and well groomed. Haircuts shall be provided as needed.
Showering and shaving shall be permitted at least three times per week.
The Office of the Inspector General reviewed documents for the period of June 10, 2001
through July 31, 2001 to determine whether inmates received hot meals and showers during
a recent lockdown. The institution was unable to produce evidence that hot meals were
served for five out of a possible 52 days (9.6%). The documentation on showers did not
specify which inmates received the showers. In many cases, the housing unit log simply
stated that lockdown showers started, with no indication of which cells were completed. In
other cases, the documentation noted that showers were completed in section A, B, or C but
with only one section completed each day. Under this schedule, only one section would
actually receive three showers during a seven-day period; the remaining two sections would
not be in compliance with the three-shower-per-week requirement.
If the institution cannot provide documentation of services such as hot meals and showers
during lockdowns, the California Department of Corrections opens itself to possible
litigation with potentially high cost to the State. In addition, inmates may become hostile
when denied these rights and, as a result, may cause harm to the staff or to other inmates.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 11
RECOMMENDATION
The Office of the Inspector General recommends that the warden ensure that
staff members document services provided to each inmate during lockdowns to
ensure that inmates are provided with mandated services and to avoid potential
litigation.
FINDING 3
The Office of the Inspector General found that inmate appeals, especially appeals
related to medical issues and to the Americans with Disabilities Act, were not
processed within the prescribed time limits. Furthermore, modification orders
resulting from medical appeals were not implemented.
California Code of Regulations, Title 15, Section 3084.6 provides: “First level appeals shall
be completed within 30 working days, second level responses within 20 working days, or 30
working days if first level is waived.”
The Office of the Inspector General found that these requirements are not being met at High
Desert State Prison. Of 78 appeals sampled for the period of July 2000 through March 2001,
36 (46%) were not processed in a timely manner either at the first or the second formal level
review, or at both levels. The sample included 13 appeals related to medical issues and three
related to the Americans with Disabilities Act.
Appeals were overdue by between one day and 106 days, as described below.
• Of 42 appeals reviewed at the first level only, 18 (43%) were overdue. Of these 18
overdue appeals, six related to medical issues and one related to the Americans with
Disabilities Act. Of the 18 overdue appeals:
• Twelve were overdue by 1-30 days.
• Four were overdue by 31-60 days.
• One was overdue by 62 days.
• One was overdue by 106 days.
• Of 16 appeals reviewed at the second level only, six (38%) were overdue by 1-30 days.
• Of 20 appeals reviewed at both the first and the second levels, 12 (60%) were overdue.
Of the 12 late appeals, one related to a medical issue, and two related to the Americans
with Disabilities Act. Of the 12 overdue appeals:
• Six were overdue at both the first and the second level reviews. At the first level
review, four appeals were overdue by 1-30 days, one was overdue by 34 days, and
one was overdue by 35 days. At the second level review, five appeals were overdue
by 1-30 days, and one appeal was overdue by 58 days.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 12
• Three appeals were overdue at the first level review by 8-26 days.
• Three appeals were overdue at the second level review by 1-20 days.
Further evidence that health care appeals are not being processed on time can be found in
the reports submitted by the appeals office to the chief deputy warden. The July 2001 report
of overdue appeals shows 50 medical appeals at the first level, including five overdue from
2000, and 18 medical appeals at the second level. The report also shows 14 appeals at the
first level and two appeals at the second level relating to the Americans with Disabilities
Act.
High Desert State Prison has also failed to follow through on several modification orders.
Modification orders are actions to be taken by the appropriate division head in response to
an appeal that has been partially or fully granted at the formal level of review.
The July 2001 report of overdue appeals included six late-appeal modification orders to the
health care manager. Of the six modification orders, two should have been completed during
2000, but neither had been completed as of July 2001. One of these modification orders
directed the health care manager to issue a chrono of the appellant’s physical limitations and
directed a classification committee to determine his health care status. The other
modification order directed the health care manager to replace an inmate’s prescription
eyeglasses and to have the inmate sign the CDC 813, Board of Control Release Claim Form.
RECOMMENDATION
The Office of the Inspector General recommends that the warden continue overseeing
the inmate appeals process and that the health care manager hold his staff accountable
for processing appeals and implementing modification orders in a timely manner.
FINDING 4
The Office of the Inspector General found that inmates paroled from the Susanville
prisons pay an extra $55 transportation charge compared to inmates paroled from the
Folsom institutions.
The difference in the transportation charge to High Desert State Prison parolees represents
an equity issue over which the Susanville inmates have no control, unless they can arrange
another method of transportation acceptable to the institution.
In compliance with California Code of Regulations, Title 15, Sections 3075.2(d) and (e),
High Desert State Prison and the California Correctional Center arranged with a private
company to transport inmates paroled from the institutions to the Sacramento Greyhound
bus station. The cab company charges the parolees $55 for this service. In July 2001, 191
parolees from the California Correctional Center and 60 parolees from High Desert State
Prison used the shuttle service to Sacramento.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 13
The $55 and the bus ticket from Sacramento are paid from the $200 release allowance each
inmate receives when paroled after serving at least six months. For example, an inmate
paroled to Los Angeles County would spend $55 for the shuttle to Sacramento and $45 for a
bus ticket from Sacramento to Los Angeles, leaving the parolee with $100. A similar inmate
paroled from California State Prison, Sacramento would be transported to the Sacramento
Greyhound bus station by the institution staff at no cost to the inmate, giving the inmate an
additional $55 to spend.
RECOMMENDATION
The Office of the Inspector General recommends that the wardens of the two
Susanville institutions work with the California Department of Corrections
headquarters staff to have additional funds allocated to remotely located
institutions, to make parolee transportation costs more equitable among
institutions.
If the number of parolees using the shuttle service in July 2001 is reflective of the year,
the combined cost for the two institutions would be approximately $166,000 per year.
An alternative may be for the California Department of Corrections to transport the
parolees to a Greyhound bus station closer to Susanville, such as Red Bluff or Redding.
A bus ticket to Los Angeles from either of those locations would cost $59.
FINDING 5
The Office of the Inspector General found numerous safety problems and
documentation deficiencies in the administrative segregation housing units and control
rooms.
While touring and inspecting the administrative segregation housing units and the control
rooms, investigators noted the following problems.
• Exterior windows covered. The exterior windows of several cells in the administrative
segregation housing units in Facility D, Buildings 7 and 8 were covered by paper.
According to the institution’s Operational Procedure #101, covering the windows is
prohibited. This infraction severely limits the amount of light and effectively prevents
the staff from visually monitoring the interior. This situation was brought to the attention
of the building sergeant, who responded that the problem is common and is rectified
when the staff conducts routine cell searches. Given that cell searches are conducted
randomly when the inmates exit for yard time, interviews, and other reasons, it appears
that cell windows can be blocked for varying periods of time, leading to security and
safety problems.
• String found linking cells. The investigators saw string of the type used by inmates to
surreptiously move items from one cell to another stretched on the ground between two
cells. Although investigators pointed out the string to the sergeant, the officer did not
correct the problem.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 14
• Operating procedure binders not updated. Several binders in Facility D, Building 8,
contained local operating procedures and California Department of Corrections
Operations Manual supplements. One of the binders contained operating procedures that
were dated from 1995-96. A second binder contained operating procedures dated
between July 1998 and February 2000. Having outdated and multiple copies of
operational procedures may confuse the staff as to the proper procedures to follow.
• Post orders not updated annually or acknowledged by staff. Several of the post orders
for Facility D, Buildings 7 and 8, and for the main entrance gate have not been updated
annually, as required by Department of Corrections Operations Manual, Section
51040.4. In some instances the correctional officers had not acknowledged that they had
read the post orders and understood the duties and responsibilities of the post, as
required by California Department of Corrections Operations Manual, Section 51040.6.
In addition, the supervisor for the entrance gate did not inspect and sign the post order
each month, as required by California Department of Corrections Operations Manual,
Section 51040.6.
• Custody staff shifts not adequately documented in isolation log. Members of the
custody staff did not consistently sign the CDC-114 isolation log for Facility D, Building
7 when arriving for and departing from their shifts. Based on a 10-day sample, selected
from the June and July 2001 time period, the Office of the Inspector General staff found
instances in which some posts had no documented coverage or only partial coverage. In
other instances, staff members signed in but failed to sign out.
• Medical staff rounds not adequately documented in isolation log. Medical personnel
often failed to indicate on the CDC-114 isolation log their respective classifications. It
was impossible for the investigators to determine from the review whether a medical
person signing in was a medical technical assistant, a registered nurse, a psychiatric
technician, or a doctor. For the dates reviewed, there was no notation that identified
whether a psychiatric technician toured the building or was on duty. On several dates,
the log contained the signature of only one medical person. The isolation log did not
indicate whether medical staff members had made rounds during the third watch, which
contradicted the custody staff’s assertion that a medical technical assistant makes at least
one round inside the administrative segregation unit on the second and third watch. The
investigators assumed that the rounds were being made, but at least one of the medical
technical assistants was negligent in signing in. This lack of supporting signatures could
have legal repercussions if the prison were faced with litigation and the need to show
proof that the medical staff had in fact provided a routine and required medical presence.
• Cell searches not documented. Cell searches were not always recorded in the
administration segregation cell search log when there was an inmate change. This is not
in compliance with Operational Procedure #101, which requires a thorough cell search
after an inmate departs from his assigned cell and before another inmate is assigned. One
important reason for these searches is to hold the inmates accountable for contraband
found in the cells.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 15
• Hazardous metal steps. Metal steps leading from the ground floor to the control booth in
Facility C, Building 5, become slippery when wet, constituting a safety issue that could
result in employee injuries and workers’ compensation cases. The institution control
room staff pointed out the problem and recommended that a non-slip surface be painted
on or otherwise applied to the steps.
RECOMMENDATION
The Office of the Inspector General recommends that the warden ensure that
the staff and the inmates comply with the institution’s existing policies and
procedures. The Office of the Inspector General also recommends that a non-
slip surface be applied to the metal steps leading from the ground floor to the
control room in Facility C, Building 5.
FINDING 6
The Office of the Inspector General found that the design of the cells in the
administrative segregation unit does not allow the custody staff to control the lights
inside the cells.
While touring the administrative segregation unit, investigators noted that the inmates have
sole control over the interior electric lights because the light switches are located inside the
cells. There are no override switches outside the cells or in the control rooms. At night, if an
inmate is taken from or placed in a cell, correctional staff members cannot see into the cell
without a flashlight, creating a safety and security hazard.
RECOMMENDATION
The Office of the Inspector General recommends that in future construction
projects the Department of Corrections design buildings to provide the custody
staff with the capability of overriding and controlling the cell lights from the
outside. According to Warden Runnels, the new 100-bed administrative segregation unit
currently under construction at the prison incorporates this feature, but the department
should also review the possibility of retrofitting the existing housing to allow the custody
staff to control the lighting inside the cells.
FINDING 7
The Office of the Inspector General found that security cameras are not available to
monitor activity on the main yards.
Cameras with videotapes could:
• Enable the staff to observe daily activities;
• Enable the staff to identify and document gang affiliations; and
• Document incidents that occur in the main yards.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 16
During incidents, the videotapes could help identify the inmates involved, serve as
documentation for disciplinary actions, and be used to evaluate the staff’s response to the
incident. The tapes also could be useful in training sessions.
RECOMMENDATION
The Office of the Inspector General recommends that the prison install video cameras on
the main yards.
FINDING 8
The Office of the Inspector General found that improvements are needed in
documenting the preparation and maintenance of category one investigations.
The following deficiencies were noted during review of the documentation for 12 category-
one investigations. The investigations were judgmentally sampled from the institution’s
investigative files.
• The Internal Affairs investigation report, CDC Form 989 A/B, did not include a
signature block for the supervisor’s review or the warden’s approval, as required by the
Office of Investigative Services Investigative Services Guide, Section 4340.
• Certain investigative documents—the advisement-of-rights form and the witness
interview worksheet—were not identified with the case reference number. Furthermore,
these documents, along with other correspondence, were not stamped or marked
“confidential.” Such markings are required by California Department of Corrections
Operations Manual, Sections 31140.7.6 and 31140.13.
• The Internal Affairs Investigation Request, CDC Form 989, was not signed and dated by
the hiring authority, which would provide a record of appropriate authorization.
• The advisement-of-rights form did not contain a signature attesting to its review.
• Pertinent documents, such as closure letters, were noted in the chronology and status
sheets, but copies were not placed in the case files.
• There were unsigned memoranda in the case files. Items of evidence should be reviewed
to determine their authenticity.
• Multiple witness interviews were included on the same tape. This practice could cause
confidentiality problems in the event of discovery requests. Furthermore, lost or
damaged tapes would result in the loss of multiple interviews.
RECOMMENDATION
The Office of the Inspector General recommends that the warden ensure that
the Investigative Services Unit captain (1) reviews the documentation used to
support category-one investigations, and (2) implements a policy of storing
witness interviews on separate tapes.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 17
FINDING 9
The Office of the Inspector General found several procedural errors in the inmate
disciplinary process.
Investigators reviewed a non-statistical sample of inmate rule violation reports from the
institutional register and noted the following problems.
• Rule violation reports signed by someone other than the reporting employee.
Investigators found that the final copy of the rule violation reports were not always
signed by the reporting employee. California Department of Corrections Operations
Manual, Section 52080.3.1, requires that the reporting employee submit the rules
violation report to the employee’s immediate supervisor for review and approval.
• Rule violation reports voided after supervisors’ approval. Reporting employees voided
the rule violation report after the first- and second-line supervisors had approved and
classified the report and copies were given to the inmates. Under California Department
of Corrections Operations Manual, Section 52080.3.8, only the staff member who
initially classified the rules violation or a staff member at a higher level may change the
classification of the rules violation before the hearing is held.
• Rule violation reports time limits not met. A copy of the completed rule violation report
was not provided to the inmate within five working days after the chief disciplinary
officer’s review, as required by California Code of Regulations, Title 15, Section
3320(l).
• Rule violation reports missing from register. Rule violation reports were missing from
the register of institution violations, although they were logged in the institutional
register as having been heard. California Department of Corrections Operations
Manual, Section 52080.15.1, requires that one completed copy of each rule violation
report issued be maintained in chronological order in the register of institution violations
for five calendar years.
RECOMMENDATIONS
The Office of the Inspector General recommends that the warden implement
the following policies and procedures to remedy the procedural deficiencies in
the inmate disciplinary system.
• The reporting employee must sign the rule violation report to authenticate it. In the
rare instance in which the employee is not available, the signed draft report should be
attached to the completed rule violation report for verification of authenticity.
• When the rule violation report has been approved and classified, the disciplinary
hearing should be conducted. Only the staff member who classifies the rule violation
report or a staff member at a higher level, preferably the hearing officer, should be
allowed to void the rule violation report.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 18
• A copy of the completed rule violation report should to be delivered to the inmate
within five working days of the chief disciplinary officer’s audit.
• The rule violation reports should be filed in the register of institution violations in a
timely manner.
FINDING 10
The Office of the Inspector General found that the detention/segregation records for
several inmates housed in the administrative segregation unit in Building D-7 did not
record the inmate’s exercise period or the reason the period was not provided.
The detention/segregation log (CDC Form 114-A) records the daily activities of each
administrative segregation inmate—for example: breakfast, lunch, dinner, shower, exercise.
This documentation is required by California Code of Regulations, Title 15, Section 3344
(b), which states:
A separate record will be maintained for each inmate assigned to administrative
segregation, including special purpose segregated units. This record will be compiled on
CDC Form 114-A, Detention/Segregation Record. In addition to the identifying information
required on the form, all significant information relating to the inmate during the course of
segregation, from reception to release, will be entered on the form in chronological order.
In addition, California Code of Regulations, Title 15, Section 3343 (h), requires that inmates
assigned to special-purpose segregation housing be permitted to exercise a minimum of one
hour per day, five days a week, or at least three days per week for a total of not less than 10
hours a week, unless security and safety considerations preclude such activity.
The investigators found that the detention/segregation records for several inmates housed in
the administrative segregation unit in Building D-7 did not record the inmate’s exercise
period or the reason the period was not provided. The inmates may have been denied
exercise because the institution was locked down due to a state of emergency, but if so, this
should have been noted in the files.
RECOMMENDATION
The Office of the Inspector General recommends that the warden ensure that the
CDC Form 114-A, detention/segregation record, is completed as required.
FINDING 11
The Office of the Inspector General found that performance and probation reports for
employees at High Desert State Prison are not being completed in a timely manner.
The Office of the Inspector General non-statistically selected 61 files of custody and non-
custody personnel to determine whether they contained current performance evaluations. Of
the 61 files reviewed, 13 were for employees who did not require an annual performance
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 19
evaluation, either because they were recent hires or because they had received a probation
report within the last year. Of the 48 files for employees requiring an annual performance
evaluation, only 17 contained a report completed within the required time frame.
The personnel files were also reviewed to determine whether employees serving a
probationary period at High Desert State Prison received timely probation reports from their
supervisors. The review revealed that only eight of 42 employees had a probation report in
their file that had been completed within the required time frame, with the result that most
employees had not received timely feedback on their performance during the probationary
period.
Each month the personnel office prepares for the warden a list of all staff members who
have not received their annual performance evaluations or probation reports. Also, the
monthly in-service training bulletin lists all staff members for whom an annual evaluation or
probation report is due that month.
Although the institution has appropriate procedures for notifying supervisors and managers
of the need to prepare performance evaluations and probation reports, it is apparent that
supervisors and managers are not being held accountable for this function. The failure to
prepare annual evaluations and probation reports deprives management of its ability to
enhance work efficiency, prepare employees for promotion, communicate and clarify work
objectives, and distinguish between superior, average, and poor performance. In addition, if
the need for adverse action arises, supervisors and managers lack written documentation of
the employee’s performance.
RECOMMENDATION
The Office of the Inspector General recommends that the warden hold managers
and supervisors accountable for completing annual performance evaluations and
probationary reports in a timely manner.
FINDING 12
The Office of the Inspector General found that the staff is not completing mandatory
training courses in a timely manner. Also, the training files do not document the
completion of training.
The Department of Corrections Operations Manual, Section 32010.13, requires that all
employees receive 40 hours of training annually. Furthermore, all employees represented by
Bargaining Unit 6 must complete 52 hours of training annually under the unit’s
memorandum of understanding with the State of California. Departmental policy also
requires sexual harassment prevention training during employee orientation.
The Office of the Inspector General reviewed the prison’s system for recording and tracking
training courses attended by custody, non-custody, supervisory, and management staff
members. The training files for 29 custody and 33 non-custody employees were non-
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 20
statistically selected for review to determine whether the employees had met their annual
training requirements.
The first part of the review focused on mandatory training courses. Of the 29 custody
employees whose files were reviewed, 11 were deficient in completing one or more of the
mandatory courses within the required time frame. Of the 33 non-custody employees whose
files were reviewed, 21 were deficient in completing one or more of the mandatory courses
within the required time frame.
Following is a list of the courses where deficiencies most frequently occurred.
Course Mandatory Failed to Meet Percentage of
Courses Required Time Requirement Non-Compliance
Custody Staff
Heat Related Pathology 29 6 20.7%
Fire/Life/Safety 29 4 13.8%
Sexual Harassment 29 3 10.3%
Non-Custody Staff
Sexual Harassment 33 14 42.4%
Fire/Life/Safety 33 5 15.2%
Use of Force 33 4 12.1%
The second part of the review focused on supervisory and management training
requirements. California Code of Regulations, Article 18 requires supervisors and managers
to complete specific supervisory and management courses within specific time periods in
their employment. These courses include: basic supervision; advanced supervision;
management training program; and specific academies for correctional sergeants,
correctional lieutenants, and correctional captains. The training files for 20 supervisors and
managers were non-statistically selected to determine whether the mandatory classes were
completed within the required time frame. Of the 43 courses required, there were 8 instances
in which the staff failed to complete the course or to do so within the required time frame.
Finally, the Office of the Inspector General compared the documentation in the employee
training files to the automated report prepared by the in-service training office to verify the
accuracy of the report. A total of 24 training files were reviewed. Out of a possible 156
training classes, there were 55 cases in which the employee’s training file contained no
documentation of training. In addition, training information in the file frequently contained
no date or signature by the instructor to confirm completion of the course. Most of the
training documentation was in the form of a quiz taken by the employee that, in nearly all
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 21
cases, was not graded or signed by the instructor. Therefore, it is difficult to verify that the
student was successful in meeting the goals and objectives of the training.
RECOMMENDATION
The Office of the Inspector General recommends that the institution hold
employees accountable for completing mandatory training requirements.
Furthermore, steps should be taken to ensure that the documentation in the
training file is adequate to support the automated report.
FINDING 13
The Office of the Inspector General found that High Desert State Prison is budgeted
for programs that have never been activated.
The original education staffing for the prison assumed that the institution would provide
educational programs during the evening hours. According to the institution staff,
headquarters has never approved this plan for implementation. The main issues appeared to
be scheduling conflicts and lack of classroom space. Over the years, the institution
reclassified some of the education positions to meet other institutional needs. For example,
during fiscal year 2000-01, the prison reclassified 6.4 education positions to correctional
officer positions, to provide additional security coverage. The Department of Corrections
headquarters has also redirected positions from High Desert State Prison to provide
additional support at other institutions.
Currently, the institution has 11 academic-teacher vacancies and 10 vocational-instructor
vacancies. According to the supervisor of correctional education programs, the current
staffing is sufficient to provide the necessary inmate programming. The vacancies in
education assist the institution in meeting the 4.9% salary savings requirement and also
offset expenditures not fully funded by headquarters, such as workers’ compensation and
overtime associated with special assignments, the Family Medical Leave Act, and the
suicide watch. It should be noted that the current institution vacancy plan for correctional
officers negotiated with the California Correctional Peace Officers’ Association generates
only a 2.6% salary savings. Therefore, other areas, such as education, facility operations,
and administration, must generate higher salary savings in order for the prison to stay within
the budget allocation.
High Desert State Prison was originally designated to implement an enhanced outpatient
program to treat inmates with mental illness. Because of the difficulty of recruiting mental
health staff to such a remote area, the program was never activated. However, the prison
retains 3.6 correctional-officer positions in its budget for this program. The institution has
correctly chosen not to activate the positions on the post assignment schedule, as there is no
program to support the positions. According to personnel records, the institution was
originally allotted 10.4 positions for the program and headquarters redirected only 6.8 of
these to another institution. The 3.6 excess positions are helping the institution meet the
4.9% salary savings requirement and cover other budget deficiencies.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 22
Leaving these positions vacant for extended periods of time, however, raises the potential
that they will be lost. Government Code Section 12439(a) states, “Beginning July 1, 2001,
and on each July 1 thereafter, the Controller shall abolish any state position that was vacant
continuously for six consecutive monthly pay periods during the period between July 1 and
June 30 of the preceding fiscal year.”
RECOMMENDATION
The Office of the Inspector General recommends that the warden develop a
plan to permanently redirect the excess positions for both the education and the
enhanced outpatient programs to areas of institutional priority.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 23
FINDINGS AND RECOMMENDATIONS
HEALTH CARE PROGRAM
FINDING 1
The Office of the Inspector General found deficiencies in the prison’s documentation of
chronically ill inmates.
The investigators found deficiencies in the health records of asthmatic patients, as well as
those suffering from hypertension.
Asthmatic Inmates. A review of the health records of nine asthmatic inmates revealed
inconsistencies in physician contact with the inmate and in the physician documentation
contained in the inmate’s health record. Specifically, the Office of the Inspector General
found the following:
• Although inmates routinely had medications refilled by the physician, there was no
notation in the medical file that the inmate had been seen by the physician for extended
periods of time, and no indication that an assessment of the inmate’s response to the
medication had been sought. In one case, the physician did not see the inmate for almost
three years, even though medication was consistently reordered.
• Theophylline blood level tests for the purpose of ensuring that inmates are taking their
medication and that blood levels are therapeutic are not routinely ordered. In four cases,
the inmate’s last theophylline level test was more than a year old. The physician had
initialed the laboratory slip, but no orders were written and no follow-up appointment
had been arranged.
The chronic care guidelines published by the Department of Corrections Health Care
Services Division stipulate that patients whose disease process is not well controlled are to
be monitored through the chronic care program monthly or more frequently, as determined
by the physician. Patients whose disease process is well controlled, as documented on two
consecutive visits showing good control, may be seen every six months, as determined by
the physician.
Inmates with hypertension. A review of the health records of 12 inmates with hypertension
revealed that there is rarely documentation to demonstrate that the physician considered the
inmate’s blood pressure and weight when prescribing medication refills. Many of the
records show that physicians ordered blood-pressure and weight monitoring, but there is no
documentation that the physician obtained a current blood pressure and weight before
renewing the inmate’s medication. It should be noted that in all cases medication was
consistently reordered as needed, with no apparent lapses between refills.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 24
The chronic care guidelines published by the Department of Corrections Health Care
Services Division provide that patients who suffer from hypertension should have their
blood pressure checked monthly or more frequently, as clinically indicated. Patients whose
disease process is well controlled on the current treatment regimen, as demonstrated by two
consecutive visits showing good control, should be seen every six months.
RECOMMENDATION
The Office of the Inspector General recommends that physicians review an
inmate’s history and documentation before reordering medication. In addition,
physicians should document their findings when conducting a chart review and
should note the reason they renewed the medication without seeing the patient.
FINDING 2
The Office of the Inspector General found that inmate medications could be tampered
with before they are administered and that inmate medications are not adequately
documented in the medical file.
Medications are delivered to facility clinics daily from the pharmacy and are then delivered
to the inmates by medical technical assistants. The medications may be categorized as hot
medications—those requiring direct observation—or cold medications—those that can be
issued to the inmate in their entirety. Hot medications are distributed on the second and
third watches. Cold medications are distributed by the third-watch medical technical
assistant during the evening pill line.
A review of the process for administering medications to the inmate population revealed
two problem areas. First, due to workload constraints, the medical technical assistants
currently prepare the hot medications at night to administer to inmates the following
morning. As a result, the medications are left unsecured in the clinics overnight. This
process is unsafe because the medications could be tampered with before the medical
technical assistants administer them to the inmates. Second, the third-watch medical
technical assistant places a medication label for cold medications in the clinic label book at
each facility but does not enter this information into the unit health record. This practice is
undesirable because if the inmate is transferred to another facility, the medication
information does not follow the inmate.
RECOMMENDATIONS
The Office of the Inspector General recommends that the prison develop and
implement a policy requiring the medical technical assistants to package the hot
medications within two hours of the time they are administered. As an alternative,
a pharmacy technician could prepackage the medication in unit doses for the
medical technical assistant to administer.
The Office of the Inspector General also recommends that the medical staff immediately
begin placing labels in the medication administration record for all cold medications
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 25
administered to inmates. The medical staff should also document in the record if the
inmate receives or refuses the medication. After the medical administration record is
documented, it should be sent to the unit health record for filing, so that there is a
permanent record in the chart of the inmate receiving the medication.
FINDING 3
The Office of the Inspector General found that 13 inmates on psychotropic medication
are not included in the mental health delivery system.
A comparison of pharmacy prescriptions for inmates receiving psychotropic medication to
those inmates participating in the mental health delivery system revealed that 13 inmates
were receiving psychotropic medication but were not receiving the accompanying mental
health case management. Consequently, these inmates may not be receiving adequate
medical care. The 13 inmates were not seen by a clinician and no treatment plan was
prepared or implemented.
Without appropriate precautions, inmates receiving psychotropic medication could be
subject to heat stroke.
RECOMMENDATION
The Office of the Inspector General recommends that the medical staff ensure that
the inmates are included in the mental health delivery system before providing
them with psychotropic medication.
FINDING 4
The Office of the Inspector General found that High Desert State Prison is not
providing inmates with dental services required under state regulations.
State regulations require institutions to provide every new inmate with a dental exam and
individual treatment plan within 14 days of arrival. The Office of the Inspector General
found that High Desert State Prison routinely does not fulfill this requirement. Moreover,
under its present procedures, the institution has no means of complying with the regulation.
The audit also revealed that the institution has no centralized, computerized system for
tracking dental services provided to inmates and therefore cannot determine which inmates
have received dental services without looking at individual medical files for each inmate.
California Code of Regulations, Title 15, Section 3355.1 provides:
Each newly committed inmate shall within 14 days following transfer from a reception
center to a program facility receive a complete examination by a dentist who shall develop
an individual treatment plan for the inmate.
Inmates arriving at High Desert State Prison do receive a cursory dental screening
examination at the institution reception center. But in a review of the facility’s four dental
clinics, the investigators found that none of the clinics provides a comprehensive dental
examination and individual treatment plan within 14 days of an inmate’s arrival, nor are the
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 26
clinics notified when a new inmate arrives and the 14 days begin ticking. Instead, most of
the efforts of the dental staff are devoted to emergency care. According to the dental staff,
because of insufficient staff resources, clinics schedule dental services according to the
urgency of the request, with the system driven by sick call slips filled out by inmates and
picked up daily by medical or dental personnel. Inmates requiring emergency care, which
usually includes severe tooth pain, receive priority over those needing preventive care, such
as dentures, fillings, and cleanings. With a backlog at every clinic of between 30 and 200
cases, inmates may languish on a waiting list for preventive care for as long as nine months,
by which time they may have left the institution. No inmate receives a comprehensive
dental examination within 14 days of arrival and no inmate receives an individual treatment
plan during his entire stay at the institution.
Lockdowns and a conflict in regulations exacerbate the problem. Two factors contribute
to the failure of the institution to fulfill the Title 15 requirement. The first is the effect of the
institution’s frequent lockdowns on the ability of the clinics to provide dental services.
During normal programming, some of the clinics see as many as 14 patients per day. But
when a lockdown is in effect, the number of patients seen per day falls to between five and
eight because during lockdowns the custody staff must escort inmates to the dental clinic
and only one patient can be seen at a time.
The second contributing factor is an apparent conflict between Title 15, Section 3355.1 and
Section 54050 of the California Department of Corrections Operations Manual, which
allows institutions to give priority to emergency care and to limit care depending on
available funding. Section 54050.1 of the manual provides: “Availability of funds, facilities,
and staff shall govern the level of treatment provided.” Section 54050.9.4 of the manual
assigns the following priority to specified treatment levels:
Urgent/emergency care for inmates in considerable pain or acutely ill needing immediate dental
services (24 hours a day, 7 days a week).
Immediate care for conditions prohibiting inmates from carrying out daily assignment (within 24
to 48 hours).
Routine care for conditions not requiring immediate treatment by a dentist.
No central automated system to record dental care provided to inmates. The Office of the
Inspector General also found that High Desert State Prison has no automated system in place
for tracking sick call requests or services provided to inmates and no computerized central
record showing which inmates in the prison population have received or not received
required dental services. The dental staff relies instead on a manual chronological log to
mark down services requested and rendered each day. As a result, the institution has no
record other than the individual medical files of each inmate to show which inmates in the
institution have received particular dental services. Also, if an inmate has been on a waiting
list for dental care at one facility and moves to another facility, because no central record
exists, the burden is on the inmate to maintain his place on the new waiting list by providing
a copy of his previous request.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 27
RECOMMENDATION
In order to improve inmate access to dental service, the Office of the Inspector
General recommends that the following actions be taken:
• The California Department of Corrections should closely examine the existing
policies and regulatory requirements governing dental care and take action to
eliminate any inconsistencies between Title 15 requirements and those of the
California Department of Corrections Operations Manual.
• The warden should provide additional custody personnel to escort inmates to dental
appointments during lockdowns and additional custody coverage while inmates are
in the dental clinic to allow more than one inmate to be served at a time.
• The health care manager should consider pursuing resources to automate the
scheduling and tracking of dental services or explore other measures to increase the
productivity of the dental staff.
FINDING 5
The Office of the Inspector General found that inmates are not provided with medical,
psychiatric, and dental chrono forms in a timely manner, potentially affecting the
inmates’ health.
Physicians prescribe medical chronos (CDC Form 128 C) for inmates with medical
conditions requiring special accommodations in their day-to-day living. For example, an
inmate with a back problem may require placement in a lower bunk. The inmate is required
to carry the medical chrono form with him at all times to inform non-medical staff members
of the special accommodations. Before the medical chrono is issued, a chrono committee
reviews the physician’s recommendation for final approval. Therefore, a week or more may
pass before the inmate receives his medical chrono form, and the delay could result in a
liability for the institution. For example, an inmate assigned to an upper bunk could have a
seizure while waiting for a chrono form specifying a lower bunk.
RECOMMENDATION
The Office of the Inspector General recommends that the medical department
allow staff physicians to issue temporary chrono forms for a one- to two-week
duration until the permanent chrono has been approved by the chrono committee.
FINDING 6
The Office of the Inspector General found that the controls over the tracking of
prescription drugs are grossly inadequate.
During the Office of the Inspector General’s review, a pharmacist conducting a routine
monthly inspection of the medical clinics found 8,900 doses of psychotropic medications
stored in bags at the Facility B clinic. These medications had enough potency and toxicity to
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 28
kill more than 100 people. The pharmacist informed the chief medical officer and the
warden of this discovery, and the warden immediately assigned the Investigative Services
Unit to conduct an assessment of the issuance of medication and to review the procedures at
each of the medical clinics.
The Office of the Inspector General review found the following weaknesses in the control
and tracking of medications by medical personnel.
• The pharmacist delivers the medications in clear plastic garbage bags to the facility
control room, where clinic staff members pick up the shipment. There is no lock or seal
on the bags to ensure that the contents are not compromised during shipment.
• There are no written uniform operating procedures for the medical clinics. The medical
policies and procedures at the institution are specific to the Correctional Treatment
Center, but they do not provide instruction for the medical clinics.
• Each facility appears to operate independently, and there is a lack of understanding as to
who is responsible for tracking inmate medications. For example, the preliminary
investigation by the Investigative Services Unit revealed that the pharmacist believes the
clinics are to return unused medications to the pharmacy, while the clinic staff believes
that the pharmacy staff picks up these medications monthly.
• The pharmacy does not maintain an inventory of the medications shipped, nor is there a
shipping document that clinic employees can sign to acknowledge receipt of medications
and retain for reconciling inventories. The pharmacy has a computer program that can
record what is stocked in the pharmacy, but the clinics have no inventory procedure.
• Medical clinic employees do not inventory the medications received from the pharmacy,
but rather rely on the pharmacist to deliver the correct amount for dispensing to the
inmates. If there is a discrepancy, a medical error report is submitted to the pharmacy
and additional medication is delivered. Without a reconciliation of what is shipped by
the pharmacy and what is received by the clinic, there could be abuses of the system.
The Investigative Services Unit’s preliminary investigation also revealed that medications
are not securely stored in the clinics. The Investigative Services Unit staff found that, for
Facility A and B clinics, the key that provides access to the nurse’s station also provides
access to the storage area where the medications are kept. Investigators also found,
throughout the four clinics, plastic trays with medications for 33 inmates awaiting return to
the pharmacy. On holidays and weekends, when the pharmacy is not open, the medical staff
obtains medications from a DocuMed machine in a locked room. The machine records
medications dispensed on a thermo tape inside the machine, and there is an accountability
log that the staff is to fill out when using the machine. The pharmacist is responsible for
reconciling the accountability log and the thermo tape. However, according to the
pharmacist, the medical staff does not always fill out the accountability log, so reconciliation
is not possible. The supervising nurse is responsible for controlling access to the room where
the DocuMed machine is located, but there are apparently multiple keys to the room, so this
control is circumvented.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 29
RECOMMENDATION
The Office of the Inspector General recommends that the chief medical
officer/health care manager implement the following actions:
• The plastic garbage bags used to transport medications should be replaced with a
container that allows for a lock or a seal, to ensure that the contents are not
compromised during shipment. The pharmacist should prepare a shipping order
listing all medications included in the container. The clinic employees can sign the
shipping order to acknowledge receipt of the medications. This would also provide
documentation for both the pharmacy and the clinic to update their inventories. A
similar procedure should be implemented for the return of medications from the
clinics to the pharmacy.
• The pharmacy and the clinics should maintain a perpetual inventory of medications,
because the medications are costly and are dangerous contraband in the institution.
• The medications from the pharmacy should be sent directly to the medical clinic, or
the medical staff should pick them up at the pharmacy. The medications should not
be left at the control room.
• Medications should be securely stored at all times due to their value and the danger
of misuse in the institution.
• The supervising nurse should have sole responsibility for access to the DocuMed
machine and for maintaining the accountability log.
• Written operating procedures should be prepared for the health care clinics to assist
them in standardizing their operations and implementing proper controls.
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 30
ATTACHMENT A
VIEWS OF RESPONSIBLE OFFICIALS
STATE OF CALIFORNIA GRAY DAVIS, GOVERNOR
OFFICE OF THE INSPECTOR GENERAL CONFIDENTIAL PAGE 31