High Desert State Prison Cycle 7 Medical Inspection Report

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Connect with us on social media Cycle 7, High Desert State Prison | iii Contents Illustrations iv Introduction 1 Summary: Ratings and Scores 3 Medical Inspection Results 5 Deficiencies Identified During Case Review 5 Case Review Results 5 Compliance Testing Results 5 Institution-Specific Metrics 6 Population-Based Metrics 9 HEDIS Results 9 Recommendations 11 Indicators 13 Access to Care 13 Diagnostic Services 20 Emergency Services 25 Health Information Management 29 Health Care Environment 35 Transfers 42 Medication Management 49 Preventive Services 57 Nursing Performance 60 Provider Performance 65 Specialized Medical Housing 72 Specialty Services 75 Administrative Operations 80 Appendix A: Methodology 83 Case Reviews 84 Compliance Testing 87 Indicator Ratings and the Overall Medical Quality Rating 88 Appendix B: Case Review Data 89 Appendix C: Compliance Sampling Methodology 92 California Correctional Health Care Services’ Response 99 Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | iv Illustrations Tables 1. HDSP Summary Table: Case Review Ratings and Policy Compliance Scores 4 2. HDSP Master Registry Data as of April 2024 7 3. HDSP Health Care Staffing Resources as of April 2024 8 4. HDSP Results Compared With State HEDIS Scores 10 5. Access to Care 17 6. Other Tests Related to Access to Care 18 7. Diagnostic Services 23 8. Health Information Management 32 9. Other Tests Related to Health Information Management 33 10. Health Care Environment 40 11. Transfers 46 12. Other Tests Related to Transfers 47 13. Medication Management 54 14. Other Tests Related to Medication Management 55 15. Preventive Services 58 16. Specialized Medical Housing 73 17. Specialty Services 77 18. Other Tests Related to Specialty Services 78 19. Administrative Operations 81 A–1. Case Review Definitions 84 B–1. HDSP Case Review Sample Sets 89 B–2. HDSP Case Review Chronic Care Diagnoses 90 B–3. HDSP Case Review Events by Program 91 B–4. HDSP Case Review Sample Summary 91 Figures Figure A–1. Inspection Indicator Review Distribution for HDSP 83 Figure A–2. Case Review Testing 86 Figure A–3. Compliance Sampling Methodology 87 Photographs 1. Insufficient Space for Outdoor Waiting Area 35 2. Indoor Waiting Area 36 3. Unlocked, Unattended Computer Monitor Displaying Confidential Patient Information 36 4. Staff Members’ Personal Food Stored With Medical Supplies 37 5. Food Stored Long Term in the Supply Storage Cabinet Location 37 6. Cleaning Materials Stored With Medical Supplies 37 7. Clinic Floor and Wall Was Unsanitary Due to Damage 38 Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 1 Introduction Pursuant to California Penal Code section 6126 et seq., the Office of the Inspector General (the OIG) is responsible for periodically reviewing and reporting on the delivery of the ongoing medical care provided to incarcerated people1 in the California Department of Corrections and Rehabilitation (the department).2 In Cycle 7, the OIG continues to apply the same assessment methodologies used in Cycle 6, including clinical case review and compliance testing. Together, these methods assess the institution’s medical care on both individual and system levels by providing an accurate assessment of how the institution’s health care systems function regarding patients with the highest medical risk, who tend to access services at the highest rate. Through these methods, the OIG evaluates the performance of the institution in providing sustainable, adequate care. We continue to review institutional care using 15 indicators as in prior cycles.3 Using each of these indicators, our compliance inspectors collect data in answer to compliance- and performance-related questions as established in the medical inspection tool (MIT). In addition, our clinicians complete document reviews of individual cases and also perform on-site inspections, which include interviews with staff. The OIG determines a total compliance score for each applicable indicator and considers the MIT scores in the overall conclusion of the institution’s compliance performance. In conducting in-depth quality-focused reviews of randomized cases, our case review clinicians examine whether health care staff used sound medical judgment in the course of caring for a patient. In the event we find errors, we determine whether such errors were clinically significant or led to a significantly increased risk of harm to the patient. At the same time, our clinicians consider whether institutional medical processes led to identifying and correcting individual or system errors, and we examine whether the institution’s medical system mitigated the error. The OIG rates each applicable indicator proficient, adequate, or inadequate, and considers each rating in the overall conclusion of the institution’s health care performance. In contrast to Cycle 6, the OIG will provide individual clinical case review ratings and compliance testing scores in Cycle 7, rather than aggregate all findings into a single overall institution rating. This change will clarify the distinctions between these differing quality measures and the results of each assessment. 1 In this report, we use the terms patient and patients to refer to incarcerated people. 2 The OIG’s medical inspections are not designed to resolve questions about the constitutionality of care, and the OIG explicitly makes no determination regarding the constitutionality of care that the department provides to its population. 3 In addition to our own compliance testing and case reviews, the OIG continues to offer selected Healthcare Effectiveness Data and Information Set (HEDIS) measures for comparison purposes. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 2 As we did during Cycle 6, our office continues to inspect both those institutions remaining under federal receivership and those delegated back to the department. There is no difference in the standards used for assessing a delegated institution versus an institution not yet delegated. At the time of the Cycle 7 inspection of High Desert State Prison, the institution had not 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 September 2023 to February 2024.4 4 Samples are obtained per case review methodology shared with stakeholders in prior cycles. The case reviews include death reviews between March 2023 and November 2023. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 3 Summary: Ratings and Scores We completed the Cycle 7 inspection of High Desert State Prison (HDSP) in August 2024. OIG inspectors monitored the institution’s delivery of medical care that occurred between September 2023 and February 2024. The OIG rated the case review The OIG rated the compliance component of the overall health care component of the overall health care quality at HDSP adequate. quality at HDSP adequate. OIG case review clinicians (a team of physicians and nurse consultants) reviewed 49 cases, which contained 792 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 August 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 one proficient, 16 adequate, and three inadequate. To test the institution’s policy compliance, our compliance inspectors (a team of registered nurses) monitored the institution’s compliance with its medical policies by answering a standardized set of questions that measure specific elements of health care delivery. Our compliance inspectors examined 349 patient records and 1,080 data points, and used the data to answer 86 policy questions. In addition, we observed HDSP’s processes during an on-site inspection in April 2024. The OIG then considered the results from both case review and compliance testing, and drew overall conclusions, which we report in 12 health care indicators.5 5 The indicators for Reception Center and Prenatal and Postpartum Care did not apply to HDSP. The indicator for Specialized Medical Housing also did not apply to HDSP for Cycle 7 because it was closed during our review period. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 4 We list the individual indicators and ratings applicable for this institution in Table 1 below. Table 1. HDSP Summary Table: Case Review Ratings and Policy Compliance Scores Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 5 Medical Inspection Results Deficiencies Identified During Case Review Deficiencies are medical errors that increase the risk of patient harm. Deficiencies can be minor or significant, depending on the severity of the deficiency. An adverse event occurs when the deficiency caused harm to the patient. All major health care organizations identify and track adverse events. We identify deficiencies and adverse events to highlight concerns regarding the provision of care and for the benefit of the institution’s quality improvement program to provide an impetus for improvement.6 The OIG found no adverse events at HDSP during the Cycle 7 inspection. Case Review Results OIG case reviewers (a team of physicians and nurse consultants) assessed nine of the 12 indicators applicable to HDSP. Of these nine indicators, OIG clinicians rated all nine adequate. The OIG physicians also rated the overall adequacy of care for each of the 20 detailed case reviews they conducted. Of these 20 cases, one was proficient, 16 were adequate, and three were inadequate. In the 792 events reviewed, we identified 218 deficiencies, 48 of which the OIG clinicians considered to be of such magnitude that, if left unaddressed, would likely contribute to patient harm. Our clinicians found the following strengths at HDSP: • Staff performed excellently in completing diagnostic tests and providing specialty services timely. • Staff provided very good access to nurses for patients. • Providers and nurses performed well with specialty-related services. Our clinicians found the following weaknesses at HDSP: • Providers sometimes did not perform complete examinations of patients when needed and occasionally did not send complete patient notification test result letters. • Outpatient clinic nurses did not always perform thorough assessments. Compliance Testing Results Our compliance inspectors assessed nine of the 12 indicators applicable to HDSP. Of these nine indicators, our compliance inspectors rated two proficient, one adequate, and six inadequate. We tested policy compliance in Health Care Environment, Preventive 6 For a further discussion of an adverse event, see Table A–1. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 6 Services, and Administrative Operations as these indicators do not have a case review component. HDSP showed a high rate of policy compliance in the following areas: • Staff performed excellently in providing preventive services for their patients, such as influenza vaccination and colorectal cancer screenings. In addition, staff frequently offered tuberculosis (TB) medications, offered immunizations to chronic care patients, and performed TB screening. • Staff performed well in scanning community hospital discharge reports, specialists’ reports, and requests for health care services into patients’ electronic medical records. • The institution completed medium-priority and routine-priority specialty services within required time frames. HDSP showed a low rate of policy compliance in the following areas: • Nursing staff did not regularly inspect or maintain emergency response bags. • Health care staff did not regularly follow hand hygiene precautions before or after patient encounters. HDSP staff frequently failed to maintain medication continuity for chronic care patients, patients discharged from the hospital, and patients with newly prescribed medications. In addition, HDSP maintained poor medication continuity for patients who had a temporary layover at HDSP. • Providers did not often communicate with complete patient test result notification letters timely. Most patient letters communicating these results were missing the date of the diagnostic service, the date of the results, and whether the results were within normal limits. • Patients with chronic care conditions, patients transferring into the institution, and patients returning from outside specialty services appointments did not see their primary care providers within specified time frames. Institution-Specific Metrics HDSP is located approximately eight miles east of the town of Susanville in Lassen County. The institution’s primary mission is to provide housing and programming of general population, sensitive needs high-security (Level IV), and sensitive needs medium- security (Level III) patients. The institution operates several medical clinics in which health care staff members handle routine requests for medical services. In addition, HDSP operates a triage and treatment area (TTA) for urgent and emergent patient care, a receiving and release (R&R) clinic for the assessment of arriving and departing patients, and a specialty clinic. The institution also provides inpatient health care in its correctional treatment center (CTC) for those patients who require a higher level of service. CCHCS has designated HDSP as a basic care institution. Basic care institutions are Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 7 located in rural areas, away from tertiary care centers and specialty care providers whose services would likely be used frequently by higher-risk patients.7 Because of HDSP’s remote location and its basic health care status, the department houses healthier patients at this institution. As of November 5, 2024, the department reports on its public tracker that 62 percent of HDSP’s incarcerated population is fully vaccinated for COVID-19 while 44 percent of HDSP’s staff is fully vaccinated for COVID-19.8 In April 2024, the Health Care Services Master Registry showed that HDSP had a total population of 2,675. A breakdown of the medical risk levels of the HDSP population as determined by the department is set forth in Table 2 below.9 Table 2. HDSP Master Registry Data as of April 2024 Medical Risk Level Number of Patients Percentage* High 1 106 4.0% High 2 198 7.4% Medium 1,253 46.8% Low 1,118 41.8% Total 2,675 100.0% * Percentages may not total 100% due to rounding. Source: Data for the population medical risk level were obtained from the CCHCS Master Registry dated 4-8-24. 7 Notably, institutions designated as basic are generally expected to have a total high risk medical population of approximately 5% or lower. At more than 11%, HDSP’s high risk population is over twice 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: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 8 According to staffing data the OIG obtained from California Correctional Health Care Services (CCHCS), as identified in Table 3 below, HDSP had no vacant executive leadership positions, no primary care provider vacancies, 0.2 nursing supervisor vacancies, and 30.4 nursing staff vacancies. Table 3. HDSP Health Care Staffing Resources as of April 2024 Executive Primary Care Nursing Nursing Positions Leadership * Providers Supervisors Staff † Total Authorized Positions 5.0 8.5 14.2 114.6 142.3 Filled by Civil Service 5.0 1.0 14.0 85.2 105.2 Vacant 0 0 0.2 30.4 30.6 Percentage Filled by Civil Service 100% 11.8% 98.6% 74.3% 73.9% Filled by Telemedicine 0 7.5 0 0 7.5 Percentage Filled by Telemedicine 0 88.2% 0 0 5.3% Filled by Registry 0 0 0 26.0 26.0 Percentage Filled by Registry 0 0 0 22.7% 18.3% Total Filled Positions 5.0 8.5 14.0 111.2 138.7 Total Percentage Filled 100% 100% 98.6% 97.0% 97.5% Appointments in Last 12 Months 1.0 0 2.0 18.2 21.2 Redirected Staff 0 0 0 2.0 2.0 Staff on Extended Leave ‡ 0 0 2.0 5.0 7.0 Adjusted Total: Filled Positions 5.0 8.5 12.0 104.2 129.7 Adjusted Total: Percentage Filled 100% 100% 84.5% 90.9% 91.1% * 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 April 8, 2024, from California Correctional Health Care Services. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 9 Population-Based Metrics In addition to our own compliance testing and case reviews, as noted above, the OIG presents selected measures from the Healthcare Effectiveness Data and Information Set (HEDIS) for comparison purposes. The HEDIS is a set of standardized quantitative performance measures designed by the National Committee for Quality Assurance to ensure that the public has the data it needs to compare the performance of health care plans. Because the Veterans Administration no longer publishes its individual HEDIS scores, we removed them from our comparison for Cycle 7. Likewise, Kaiser (commercial plan) no longer publishes HEDIS scores. However, through the California Department of Health Care Services’ Medi‑Cal Managed Care Technical Report, the OIG obtained California Medi-Cal and Kaiser Medi-Cal HEDIS scores to use in conducting our analysis, and we present them here for comparison. HEDIS Results We considered HDSP’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)—HDSP’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. HDSP had a 19 percent influenza immunization rate for adults 18 to 64 years old and a 77 percent influenza immunization rate for adults 65 years of age and older.10 The pneumococcal vaccination rate was 74 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)—HDSP’s colorectal cancer screening rate of 83 percent was higher, indicating very good performance on this measure. 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: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 10 Table 4. HDSP Results Compared With State HEDIS Scores HDSP California California Kaiser Kaiser Cycle 7 California NorCal SoCal HEDIS Measure Results * Medi-Cal † Medi-Cal † Medi-Cal † HbA1c Screening 98% – – – Poor HbA1c Control (> 9.0%) ‡,§ 8% 36% 31% 22% HbA1c Control (< 8.0%) ‡ 83% – – – Blood Pressure Control (< 140/90) ‡ 91% – – – Eye Examinations 58% – – – Influenza – Adults (18 – 64) 19% – – – Influenza – Adults (65 +) 77% – – – Pneumococcal – Adults (65 +) 74% – – – Colorectal Cancer Screening 83% 37% 68% 70% Notes and Sources * Unless otherwise stated, data were collected in April 2024 by reviewing medical records from a sample of HDSP’s population of applicable patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. † HEDIS Medi-Cal data were obtained from the California Department of Health Care Services publication Medi-Cal Managed Care External Quality Review Technical Report, dated July 1, 2022 – June 30, 2023 (published March 2024); https://www.dhcs.ca.gov/dataandstats/reports/Documents/Medi-Cal-Managed- Care-Technical-Report-Volume-1.pdf. ‡ For this indicator, the entire applicable HDSP 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: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 11 Recommendations As a result of our assessment of HDSP’s performance, we offer the following recommendations to the department: Access to Care • Health care leadership should determine the root cause(s) of untimely provider appointments for chronic care, specialty follow-up, and newly transferred patients and should implement remedial measures as appropriate. Diagnostic Services • The department should develop strategies, such as an electronic solution, to ensure providers create patient letters when they endorse test results and ensure patient letters contain all elements required by CCHCS policy. The department should implement remedial measures as appropriate. Emergency Services • The Emergency Medical Response Review Committee (EMRRC) should develop strategies to ensure they thoroughly assess emergency events, identify staff training issues, and complete clinical reviews within required time frames. The EMRRC should implement remedial measures as appropriate. • Nursing leadership should develop strategies, such as refresher training, to ensure proper oxygen administration during emergency events and should implement remedial measures as appropriate. Health Care Environment • Medical and nursing leadership should determine the root cause(s) for staff not following all required universal hand hygiene precautions and should implement remedial measures as appropriate. • Health care leadership should determine the root cause(s) for staff not following equipment and medical supply management protocols and should implement remedial measures as appropriate. • Nursing leadership should determine the root cause(s) for staff not ensuring emergency medical response bags (EMRBs) are regularly inventoried and sealed and should implement remedial measures as appropriate. Transfers • Nursing leadership should ascertain the root cause(s) preventing receiving and release (R&R) nurses from properly completing the initial health Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 12 screening form before patients are placed in housing and not completing the initial health screening, including answering all questions and documenting an explanation for each “yes” answer. Nursing leadership should implement remedial measures as appropriate. Medication Management • The institution should consider developing and implementing measures to ensure staff timely make available and administer medications to patients and document in the medication administration record (MAR) summaries as described in CCHCS policy and procedures. • Nursing leadership should assess the root cause(s) for nursing staff failing to document patient refusals in the MAR as described in CCHCS policy and procedures and should implement remedial measures as needed. Nursing Performance • Nursing leadership should identify the challenges to ensuring outpatient clinic nurses perform thorough assessments and provide appropriate interventions. Nursing leadership should implement remedial measures as appropriate. Provider Performance • Medical leadership should ascertain the challenges to providers performing complete examinations and thoroughly addressing medical conditions and should implement appropriate remedial measures. Specialty Services • Health care leadership should ascertain the challenges to the timely receipt and provider review of specialty reports and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 13 Indicators Access to Care In this indicator, OIG inspectors evaluated the institution’s performance in providing patients with timely clinical appointments. Our inspectors reviewed scheduling and appointment timeliness for newly arrived patients, sick calls, and nurse follow-up appointments. We examined referrals to primary care providers, provider follow-ups, and specialists. Furthermore, we evaluated the follow-up appointments for patients who received specialty care or returned from an off-site hospitalization. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Inadequate (66.1%) Case review found HDSP performed sufficiently in access to care, which improved compared with Cycle 6. Staff offered satisfactory nurse access and excellent provider follow-up after specialty services, hospitalizations, and TTA encounters. However, we found some provider clinic appointments occurred late. After reviewing all aspects of access to care, the OIG rated the case review component of this indicator adequate. HDSP’s overall compliance testing scored low for this indicator. Staff performed excellently in timely reviewing patient sick calls and frequently completed nurse face-to- face appointments. Providers generally completed follow-up appointments for patients returning after hospitalizations within required time frames. However, HDSP needed improvement in timely completing provider appointments for chronic care patients, newly transferred patients, and patients returning after specialty service appointments. Based on the overall compliance score result, the OIG rated the compliance component of this indicator inadequate. Case Review and Compliance Testing Results OIG clinicians reviewed 179 provider, nursing, urgent or emergent care (TTA), specialty, and hospital events requiring the institution to generate appointments. We identified 20 deficiencies relating to Access to Care, five of which were significant.12 Access to Care Providers HDSP’s performance varied in providing access to providers. Compliance testing showed access to chronic care follow-up appointments (MIT 1.001, 60.0%) and clinic nursing- referred provider appointments (MIT 1.005, 53.9%) needed improvement. Compliance testing also revealed access to sick call nursing-referred provider appointments was poor 12 Deficiencies occurred in cases 2, 10, 11, 16, 18–20, 23, 24, 37, and 42. Significant deficiencies occurred in cases 10, 11, 19, 23, and 24 Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 14 (MIT 1.006, 33.3%). OIG clinicians identified 12 deficiencies in the scheduling of provider appointments, four of which were significant as follows:13 • In case 10, the nurse ordered an appointment for the provider to discuss the patient’s medication refusal to occur within one week. However, the appointment occurred more than three weeks later. • In case 11, staff ordered two different appointments for two different medical problems for one patient. Staff combined these appointments into one appointment, resulting in both occurring late. The appointment for diabetes occurred five days late and the appointment for orthotic boots occurred four weeks late. • In case 19, the sick call nurse assessed the patient with a history of gastroesophageal reflux disease for complaints of stomach burning, pain, nausea, and vomiting. The nurse ordered a provider follow-up appointment to occur within 14 days. However, the provider follow-up appointment occurred 13 days late. • In case 23, the provider ordered a procedure appointment for a steroid injection. However, the appointment occurred more than 10 weeks late. Access to Specialized Medical Housing Providers HDSP’s CTC was closed during our review period. Both compliance testing and case review did not have any applicable samples. Access to Clinic Nurses HDSP performed well with access to nurse sick calls and provider-to-nurse referrals. Compliance testing showed excellent completion of nurses’ reviews of patients’ requests for service the same day they were received (MIT 1.003, 100%). Nurses also generally completed face-to-face appointments within one business day of receiving a patient sick call request (MIT 1.004, 83.3%). OIG clinicians reviewed 65 nursing sick call requests and identified two deficiencies related to clinic nurse access, one of which was significant as follows:14 • In case 24, the nurse reviewed the patient’s sick call request for complaint of left-sided abdominal pain. However, the nurse did not assess the patient’s urgent complaint on the same day. Access to Specialty Services HDSP performed variably in providing specialty services. HDSP performed satisfactorily with providing medium-priority (MIT 14.004, 80.0%) and routine-priority (MIT 14.007, 13 Deficiencies occurred in cases 10, 11, 16, 18–20, 23, and 42. Significant deficiencies occurred in cases 10, 11, 19, and 23. 14 Deficiencies occurred in cases 16, 18, 20, 24, and 37. A significant deficiency occurred in case 24. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 15 80.0%) specialty services as ordered by the provider. However, the institution needed to improve access to high-priority (MIT 14.001, 73.3%) specialty services. OIG clinicians identified no deficiencies with specialty care access. We discuss this further in the Specialty Services indicator section. Follow-Up After Specialty Services Compliance testing revealed completion of provider appointments after specialty services needed improvement (MIT 1.008, 62.2%). OIG clinicians identified one minor deficiency related to the scheduling of a provider appointment after specialty services.15 Follow-Up After Hospitalization HDSP usually ensured providers evaluated patients after hospitalizations. Compliance showed HDSP’s performance in timely providing hospitalization follow-up appointments to be satisfactory (MIT 1.007, 81.0%). OIG clinicians identified only one minor deficiency related to a provider appointment following hospitalization.16 Follow-Up After Urgent or Emergent Care (TTA) Providers generally evaluated their patients timely following a triage and treatment area (TTA) event. OIG clinicians reviewed 17 TTA events and identified one minor delay in a provider follow-up appointment.17 Follow-Up After Transferring Into HDSP Access to care for patients who had recently transferred into the institution was mixed. Compliance testing revealed access to intake appointments for newly arrived patients needed improvement (MIT 1.002, 70.8%). OIG clinicians identified no deficiencies in this area. However, we only had three transfer-in cases to review. Clinician On-Site Inspection OIG clinicians observed morning huddles, which were well attended by the patient care team and staff. HDSP had seven main clinics: facilities A, B, C, D, E, EOP, and Z. Each clinic staffed one to two providers. Clinics E and Z were the only clinics staffed with an on-site provider, who evaluated patients on alternating days. Clinic E staff evaluated low medical risk patients, while Clinic Z staff provided care for high-security patients. Telemedicine providers staffed the other clinics. In addition to its main clinics, HDSP operated a TTA and a specialty clinic, which offered audiology, occupational and physical therapy, orthotics, and colonoscopy services. Office technicians from each clinic attended the huddles and reported scheduling about 10 to12 patient appointments per day for each primary care provider. We spoke with HDSP’s scheduling supervisors regarding the institution’s access to care. They reported provider backlog had decreased from 1,239 at the beginning of the review 15 A minor deficiency occurred in case 20. 16 A minor deficiency occurred in case 23. 17 A minor deficiency occurred in case 2. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 16 period in September 2023, to 96 by the end of the review period in February 2024. At the time of the OIG clinician on-site inspection, the scheduling supervisors reported nursing backlog to be under 20 for the review period. When asked about possible causes for the backlog, the scheduling supervisors cited provider and support staff shortages. They reported three scheduling office technicians out on long-term sick leave for the months of November and December 2023. Compliance On-Site Inspection Three of six housing units randomly tested at the time of inspection had access to Health Care Services Request Forms (CDCR Form 7362) (MIT 1.101, 50.0%). In two housing units, custody officers did not have a system in place for restocking the forms. The custody officers reported printing copies of the forms. The remaining housing unit had no forms available at the time of our inspection. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 17 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 15 10 0 60.0% 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 17 7 1 70.8% 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 25 5 0 83.3% 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 7 6 17 53.9% 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 2 27 33.3% specified? (1.006) Upon the patient’s discharge from the community hospital: Did the patient 17 4 0 81.0% receive a follow-up appointment within the required time frame? (1.007) Specialty service follow-up appointments: Did the clinician follow-up visits 23 14 8 62.2% occur within required time frames? (1.008) * Clinical appointments: Do patients have a standardized process to obtain 3 3 0 50.0% and submit health care services request forms? (1.101) Overall percentage (MIT 1): 66.1% * CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician follow-up visits following specialty services. As a result, we tested MIT 1.008 only for high-priority specialty services or when staff ordered follow-ups. The OIG continued to test the clinical appropriateness of specialty follow-ups through its case review testing. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 18 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 N/A N/A N/A N/A 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 11 4 0 73.3% 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 5 2 8 71.4% provider? (14.003) Did the patient receive the medium-priority specialty service within 15-45 calendar days of the primary care provider order or the Physician Request 12 3 0 80.0% for Service? (14.004) Did the patient receive the subsequent follow-up to the medium-priority specialty service appointment as ordered by the primary care provider? 8 0 7 100% (14.006) Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician Request 12 3 0 80.0% 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 3 2 10 60.0% provider? (14.009) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 19 Recommendations • Health care leadership should determine the root cause(s) of untimely provider appointments for chronic care, specialty follow-up, and newly transferred patients, and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 20 Diagnostic Services In this indicator, OIG inspectors evaluated the institution’s performance in timely completing radiology, laboratory, and pathology tests. Our inspectors determined whether the institution properly retrieved the resultant reports and whether providers reviewed the results correctly. In addition, in Cycle 7, we examined the institution’s performance in timely completing and reviewing immediate (STAT) laboratory tests. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Inadequate (71.1%) Case review found HDSP delivered good performance with diagnostic services. Staff almost always completed diagnostic tests timely and handled STAT laboratory tests well. In contrast, providers needed improvement in sending complete patient test result notification letters. After weighing all factors, the OIG rated the case review component of this indicator adequate. HDSP’s compliance testing scored low for this indicator. Staff often completed radiology as well as routine laboratory tests and retrieved pathology results within required time frames. They also performed very well to excellently in timely reviewing and endorsing laboratory, radiology, and pathology results. However, providers needed improvement in generating patient test result notification letters with all required elements. Based on the overall compliance score result, the OIG rated the compliance component of this indicator inadequate. Case Review and Compliance Testing Results OIG clinicians reviewed 131 diagnostic events and identified 72 deficiencies. Of the 72 deficiencies, 71 related to health information management (HIM) and one related to untimely completing ordered tests.18 Five HIM deficiencies were significant.19 For HIM, we consider test reports that were never retrieved or reviewed to be as severe a problem as tests that were never performed. Test Completion HDSP performed satisfactorily in completing radiology services (MIT 2.001, 80.0%) and very well in completing laboratory services (MIT 2.004, 90.0%) within required time frames. OIG clinicians identified only one deficiency related to untimely test completion.20 Compliance 18 Deficiencies occurred in cases 2, 10, 12–14, 16, and 18–24. A minor deficiency related to test completion occurred in case 10. Deficiencies related to health information management occurred in cases 2, 10, 12–14, 16, 18–21, 23, and 24. 19 Significant HIM deficiencies occurred in cases 10, 13, 18, and 19. 20 A minor deficiency occurred in case 10. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 21 testing had no STAT laboratory samples and case review did not identify any deficiencies related to STAT laboratory test completion. Health Information Management Compliance testing showed providers always endorsed radiology results (MIT 2.002, 100%) and frequently endorsed laboratory results (MIT 2.005, 90.0%) timely. Staff frequently received final pathology reports (MIT 2.010, 90.0%), and providers always reviewed and endorsed pathology reports (MIT 2.011, 100%) within required time frames. However, compliance testing revealed providers never communicated results of pathology studies with complete notification letters within required time frames (MIT 2.012, zero). OIG clinicians identified 61 deficiencies related to incomplete, late, or missing patient test result notification letters and eight deficiencies related to late or missing provider endorsements.21 We also identified one deficiency related to a pathology report.22 The following are examples of significant late provider endorsement deficiencies: • In case 10, the provider reviewed the diabetes, cholesterol, and coagulation test results three weeks after the results were available. Furthermore, the provider reviewed additional coagulation test results almost two weeks after the results were available. While compliance had no applicable STAT laboratory samples to test, OIG clinicians reviewed four STAT laboratory samples and found no deficiencies related to HIM.23 We also discuss the provider test result endorsements and patient test result notification letters further in the Health Information Management indicator section. Clinician On-Site Inspection The OIG physician interviewed the diagnostics services supervisor, providers, and laboratory technicians about diagnostic services. The supervisor reported no staff shortages for the review period for both laboratory and radiology services. The supervisor also reported having a laboratory backlog of three tests and a “considerable” backlog for MRI imaging at the time of the inspection.24 The diagnostic supervisor cited the MRI vendor’s unavailability as the cause for this backlog. However, the MRI vendor had scheduled multi-day MRI clinics with HDSP, which was expected to significantly reduce the backlog. Providers reported laboratory and diagnostic services generally occurred timely. At the time of our on-site inspection, the laboratory technicians reported collecting samples in each yard and transporting the samples to the CTC for processing before sending to the off-site laboratory vendor. They also needed to transport equipment and samples between 21 Deficiencies related to incomplete or missing results letters occurred in cases 2, 10, 12–14, 16, 18, 20, 21, 23, and 24. Deficiencies related to late provider endorsement occurred in cases 2, 10, 13, 18, 19, and 22. 22 A minor deficiency related to a pathology report occurred in case 24. 23 STAT laboratory testing occurred in cases 1, 10, 23, and 24. 24 An MRI is a magnetic resonance imaging showing detailed images of the organs and tissues to detect diseases and abnormalities. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 22 the yards and the CTC. Due to the high volume of samples, transporting multiple samples and bulky equipment was challenging. According to one laboratory technician, each laboratory technician was assigned to a specific yard, and the laboratory technicians helped one another with sample collection. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 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 8 2 0 80.0% 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 6 4 0 60.0% of the radiology study to the patient within specified time frames? (2.003) Laboratory: Was the laboratory service provided within the time frame 9 1 0 90.0% 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 3 7 0 30.0% 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 9 1 0 90.0% required time frames? (2.010) Pathology: Did the health care provider review and endorse the pathology 10 0 0 100% report within specified time frames? (2.011) Pathology: Did the health care provider communicate the results of the 0 10 0 0 pathology study to the patient within specified time frames? (2.012) Overall percentage (MIT 2): 71.1% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 24 Recommendations • The department should develop strategies, such as an electronic solution, to ensure providers create patient letters when they endorse test results and ensure patient letters contain all elements required by CCHCS policy. The department should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 25 Emergency Services In this indicator, OIG clinicians evaluated the quality of emergency medical care. Our clinicians reviewed emergency medical services by examining the timeliness and appropriateness of clinical decisions made during medical emergencies. Our evaluation included examining the emergency medical response, cardiopulmonary resuscitation (CPR) quality, triage and treatment area (TTA) care, provider performance, and nursing performance. Our clinicians also evaluated the Emergency Medical Response Review Committee’s (EMRRC) performance in identifying problems with its emergency services. The OIG assessed the institution’s emergency services solely through case review. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Not Applicable Overall, HDSP showed improvement in providing emergency care compared with Cycle 6. Nurses improved in completing more thorough patient assessments, reassessing patients, providing timely interventions, and properly documenting events. TTA nurses usually performed well during emergencies and completed thorough documentation. First medical responders frequently performed good assessments, intervened as required, and documented well. Cardiopulmonary resuscitation (CPR) performance was satisfactory with opportunities for improvement. Providers often made good decisions and provided good care. Case review found HDSP completed timely clinical reviews but did not always identify the same deficiencies OIG clinicians identified. Factoring all aspects into consideration, the OIG rated this indicator adequate. Case Review Results We reviewed 38 urgent and emergent events and found 17 emergency care deficiencies, seven of which were significant.25 Emergency Medical Response HDSP staff promptly responded to medical emergencies, timely initiated CPR, and notified TTA staff within required time frames. Our clinicians reviewed 27 emergency medical events that required responses from first medical responders. The first medical responders frequently performed good assessments, intervened as required, and documented well. Cardiopulmonary Resuscitation Quality HDSP showed satisfactory performance in this area. Custody and medical staff worked together to provide patients necessary care. We reviewed seven cases in which patients 25 Deficiencies occurred in cases 2, 3, 5, 8, 10, 16, 18, 21, and 24. Significant deficiencies occurred in cases 3, 5, 8, 10, and 16. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 26 required CPR.26 Custody staff immediately initiated CPR and applied the automated external defibrillator (AED). Custody staff recognized when patients had possibly overdosed on opioids, quickly administered Narcan as required, and activated emergency medical services (EMS). Medical staff arrived and provided the required medical care to the patients. The following cases illustrate opportunities for improvement: • In case 3, the patient was found unresponsive and not breathing. Custody staff initiated CPR and administered Narcan. The nurse initally applied oxygen at 6 liters per minute via the ambu bag. Later the nurse applied oxygen at 5 liters per minute via the nonrebreather mask when the patient was awake but continued to have low oxygen readings. A nonrebreather mask and an ambu bag require 10-15 liters per minute of oxygen to be effective in oxygen delivering oxygen.27 In addition, the patient’s blood pressure was severely low, but the nurse did not reassess the low blood pressure until 10 minutes later. • In case 5, custody staff found the unresponsive patient, initiated CPR, and administered Narcan. However, we identified a delay in calling 9-1-1. Staff initiated the medical emergency alarm at 12:33 a.m. but did not call 9-1-1 until 12:39 a.m., six minutes later. • In case 8, custody staff activated a medical emergency alarm for a patient found hanging in his cell. Custody staff initiated CPR. Clinical staff arrived to the scene, applied the AED on the patient, and initiated oxygen. Clinical staff applied oxygen to the patient, who was receiving CPR, with a nonrebreather mask instead of applying the oxygen via an ambu bag, to more rapidly administer the oxygen. In addition, the nurse did not use the appropriate method to stabilize the patient’s head and neck. The nurse should have applied a cervical collar to maintain head and neck alignment instead of manual stabilization. During the case review on-site inspection, nursing agreed with the above deficiencies and provided training to staff. Provider Performance Providers made appropriate triage decisions when patients arrived at the TTA for emergency evaluations. In addition, providers were always available for consultation with TTA staff. We identified two deficiencies related to emergency care, one of which was significant and is further discussed in the Provider Performance indicator. Nursing Performance HDSP TTA nurses usually performed well during emergency events. TTA nurses generally performed thorough patient assessments and intervened timely. In a few cases 26 Patients in cases 3–9 required CPR. 27 A nonrebreather mask and ambu bag both deliver higher amounts of oxygen to be delivered at a rate of 10L/min up to 15L/min to deliver adequate oxygenation. However, the use of the ambu bag is more efficient because it also allows medical staff to manually administer breaths with the 15 liters of oxygen, delivering oxygen more rapidly to the lung of the patient requiring CPR. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 27 we identified problems related to patient assessment and timely provider notification.28 The following case illustrates a significant delay in treatment and reassessment for a patient with chest pain: • In case 16, staff provided emergency services to this patient with chest pain, and nursing staff documented following the chest pain protocol. The patient arrived in the TTA at 1:03 a.m., and the patient reported moderate sharp chest pain. However, the nursing staff did not administer nitroglycerin until 1:27 a.m., 24 minutes after the patient reported chest pain, or reassess chest pain severity until 1:39 a.m., 33 minutes after the patient’s arrival in the TTA. Nursing Documentation TTA nurses often performed thorough documentation for emergency events including timelines. We only identified one deficiency, which was not significant. Emergency Medical Response Review Committee HDSP had fair performance for clinical reviews. The emergency medical response review committee (EMRRC) met monthly and reviewed emergency response care within required time frames. Our clinicians reviewed 18 emergency events.29 Nursing and medical leadership or designees at HDSP performed clinical reviews of the unscheduled transports to the community hospital; however, they did not always identify the same deficiencies as OIG clinicians. Our compliance team findings showed HDSP did not review cases within required time frames, and event checklists were missing or incomplete (MIT 15.003, 25.0%). Clinician On-Site Inspection We toured the TTA during our on-site inspection and interviewed TTA nursing staff. The TTA had four beds and was staffed with two RNs on each shift, one of which would respond to emergencies throughout the institution. Staff reported the TTA had two emergency response vehicles, one of which was out for repair. The TTA had an assigned provider who was available during business hours. During non-business hours, a provider was available via telemedicine. The TTA nursing staff shared their challenges, including the increase of patients in the enhanced outpatient program (EOP), as well as an increase of drug overdoses. The TTA nursing staff reported having no issues with supplies, equipment, or medications needed to provide patient care. They also reported feeling supported by administration and having a good rapport with custody staff; however, nursing morale varied. 28 In cases 3, 16, and 18 the nurses did not complete a thorough assessment or reassess pain level. 29 We reviewed EMRRC events for cases 1, 3–9, 16, 18, 19, and 21–23. Deficiencies occurred in cases 3, 8, 16, and 21. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 28 Recommendations • The EMRRC should develop strategies to ensure they thoroughly assess emergency events, identify staff training issues, and complete clinical reviews within required time frames. The EMRRC should implement remedial measures as appropriate. • Nursing leadership should develop strategies, such as refresher training, to ensure proper oxygen administration during emergency events and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 29 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 Proficient (91.0%) Case review found HDSP performed satisfactorily in health information management. Staff frequently scanned and retrieved medical records within required time frames while providers frequently reviewed diagnostic results timely. We found a pattern of missing, incomplete, or delayed patient test result notification letters; however, many of these were not clinically significant. Considering all factors, the OIG rated the case review component of this indicator adequate. Compliance testing showed HDSP’s performed very well in this indicator. Staff performed excellently in timely scanning patient health care request forms and specialty documents as well as scanning and reviewing hospital discharge reports within required time frames. In addition, staff performed satisfactorily in 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 proficient. Case Review and Compliance Testing Results OIG clinicians reviewed 791 events and found 73 deficiencies related to health information management, five of which were significant.30 Hospital Discharge Reports Staff performed very well in processing hospital discharge records. Compliance testing showed staff almost always timely retrieved and scanned hospital records into the electronic health record (MIT 4.003, 95.0%). In addition, the hospital discharge reports frequently included key elements, and providers often reviewed them properly (MIT 4.005, 85.7%) within required time frames. The OIG clinicians reviewed 12 off-site emergency discharge department and hospital encounters and identified no deficiencies related to HIM. 30 Deficiencies occurred in cases 2, 10, 12–14, 16, and 18–25. Significant deficiencies occurred in cases 10, 13, 18, and 19. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 30 Specialty Reports HDSP’s performance in managing specialty reports varied. Compliance testing showed staff always scanned specialty reports (MIT 4.002, 100%) timely. Providers frequently endorsed high-priority specialty reports (MIT 14.002, 93.3%) timely but needed improvement in endorsing medium-priority (MIT 14.005, 66.7%) and routine-priority (MIT 14.008, 66.7%) specialty reports within the required time frame. OIG clinicians reviewed 54 specialty reports and identified one minor deficiency related to late provider endorsement.31 We also discuss these findings in the Specialty Services indicator. Diagnostic Reports Compliance testing showed staff performed excellently with timely provider endorsements of radiology (MIT 2.002, 100%) and laboratory results (MIT 2.005, 90.0%). Compliance also showed very good pathology report retrieval and excellent provider endorsement (MIT 2.010, 90.0% and MIT 2.011, 100%) within specified time frames. However, compliance testing showed provider communication of pathology results with complete patient result letters was poor (MIT 2.012, zero). OIG clinicians found only one deficiency related to a pathology report, which was not significant.32 Compliance testing had no applicable STAT samples to test, and OIG clinicians identified no STAT laboratory deficiencies. After providers interpreted laboratory results, they were responsible for notifying patients of the results. OIG clinicians identified 61 deficiencies related to incomplete, late, or missing results notification letters and eight deficiencies related to late or missing provider endorsements.33 The following are examples of significant late provider endorsement deficiencies: • In case 13, the provider reviewed the patient’s diabetes test result more than two weeks late. • In case 19, the provider reviewed the patient’s hepatitis C test result more than two weeks late. We also discuss health information management in the Diagnostic Services indicator section. Urgent and Emergent Records OIG clinicians reviewed 38 emergency care events and found nurses and providers documented these events adequately. Providers also documented their emergency care 31 A specialty health information management deficiency occurred in case 25. 32 A minor deficiency related to a pathology report occurred in case 24. 33 Deficiencies related to incomplete or missing results letters occurred in cases 2, 10, 12–14, 16, 18, 20, 21, 23, and 24. Deficiencies related to late provider endorsement occurred in cases 2, 10, 13, 18, 19, and 22. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 31 sufficiently, including off-site telephone encounters. OIG clinicians did not identify any provider documentation deficiencies. We offer additional details regarding emergency care documentation in the Emergency Services indicator. Scanning Performance Compliance testing revealed staff performed satisfactorily in properly scanning, labeling, and including medical records in the correct patients’ files (MIT 4.004, 79.2%). In contrast, OIG clinicians identified only one significant scanning deficiency as follows: • In case 18, HIM staff scanned the patient's EKG into the electronic health record system (EHRS).34 However, HIM staff never forwarded the EKG result to the provider for review. Clinician On-Site Inspection OIG clinicians met with the medical records supervisors and discussed health information processes. The supervisors described the process for retrieving off-site specialty reports with utilization management (UM) nurses and HIM staff. Staff tracked all off-site specialty appointments using spreadsheets and logs. HIM staff printed specialty reports from the contracted specialists’ electronic medical records if they had access to them. If they did not have access to a specialist’s electronic medical records, HIM staff would fax or call the specialist. Upon receiving a specialty report, HIM staff would then update the spreadsheets and tracking logs. To track provider endorsements of reports, the HIM supervisors created a report entitled “Daily Pending Specialty Report.” When a provider had a report or result requiring endorsement, the health record supervisor would email the report to the provider, the chief medical executive (CME), and the chief physician and surgeon (CP&S). Regarding staffing, HIM supervisors reported HDSP had office assistant vacancies during the review period. The supervisors mentioned HIM had periods of time in which staff were out on long-term sick leave, extended vacations, or had accepted other positions. HIM had an office assistant out on long-term sick leave and was in the process of filling vacancies. Health record technician I positions were filled during the review period. 34 An EKG is an electrocardiogram. This non-invasive test measures and records the electrical impulses from the heart and is used to help diagnose heart problems. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 32 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 19 1 10 95.0% health record within three calendar days of the encounter date? (4.001) Are specialty documents scanned into the patient’s electronic health record 30 0 15 100% 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? 19 1 1 95.0% (4.003) During the inspection, were medical records properly scanned, labeled, 19 5 0 79.2% 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 18 3 0 85.7% review the report within five calendar days of discharge? (4.005) Overall percentage (MIT 4): 91.0% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 33 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 9 1 0 90.0% required time frames? (2.010) Pathology: Did the health care provider review and endorse the pathology 10 0 0 100% report within specified time frames? (2.011) Pathology: Did the health care provider communicate the results of the 0 10 0 0 pathology study to the patient within specified time frames? (2.012) Did the institution receive and did the primary care provider review the high-priority specialty service consultant report within the required time 14 1 0 93.3% frame? (14.002) Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the required time 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 10 5 0 66.7% frame? (14.008) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 34 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 35 Health Care Environment In this indicator, OIG compliance inspectors tested clinics’ waiting areas, infection control, sanitation procedures, medical supplies, equipment management, and examination rooms. Inspectors also tested clinics’ performance in maintaining auditory and visual privacy for clinical encounters. Compliance inspectors asked the institution’s health care administrators to comment on their facility’s infrastructure and its ability to support health care operations. The OIG rated this indicator solely on the compliance score. Our case review clinicians do not rate this indicator. Because none of the tests in this indicator directly affected clinical patient care (it is a secondary indicator), the OIG did not consider this indicator’s rating when determining the institution’s overall quality rating. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Inadequate (57.5%) Overall, HDSP performed poorly with respect to its health care environment. We found medical supply storage areas contained unidentified or inaccurately labeled medical supplies as well as disorganized medical supplies. Several clinics did not meet the requirements for essential core medical equipment and supplies. In addition, emergency medical response bag (EMRB) logs were missing staff verification, or inventory was not performed when seal tags changed. Lastly, staff performed poorly in properly washing their hands throughout patient encounters. Based on the overall compliance score result, the OIG rated this indicator inadequate. Compliance Testing Results Outdoor Waiting Areas We inspected the outdoor patient waiting area. The temporary RN clinic location had no indoor waiting area or adequate outdoor waiting area for patients waiting for their clinical appointments (see Photo 1). Health care and custody staff reported taking no additional steps for patients’ protection during inclement weather. Indoor Waiting Areas We inspected indoor patient waiting areas. Patients had enough seating capacity while waiting for their appointments (see Photo 2, next page). 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. Photo 1. Insufficient space for outdoor waiting area (photographed on 4-23-24). Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 36 Photo 2. Indoor waiting area (photographed on 4-23-24). Clinic Environment All clinic environments were sufficiently conducive for medical care; they provided reasonable auditory privacy, appropriate waiting areas, wheelchair accessibility, and nonexamination room workspace (MIT 5.109, 100%). Of the 11 clinics we inspected, seven contained appropriate space, configuration, supplies, and equipment to allow clinicians to perform proper clinical examinations (MIT 5.110, 63.6%). The remaining four clinics had one or more of the following deficiencies: an examination room lacked visual privacy for conducting clinical examinations; clinics had unsecured confidential medical records (see Photo 3); an examination room lacked adequate space; and clinical staff discussed patient information in the clinic’s hallway, which lacked auditory privacy. Photo 3. Unlocked, unattended computer monitor displaying confidential patient information (phototgraphed on 4-23-24). Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 37 Clinic Supplies Only two of the 11 clinics followed adequate medical supply storage and management protocols (MIT 5.107, 18.2%). We found one or more of the following deficiencies in nine clinics: unorganized, unidentified, or inaccurately labeled medical supplies; compromised sterile medical supply packaging; staff members’ personal food stored with medical supplies (see Photo 4); food stored long-term in the supply storage cabinet location (see Photo 5); and cleaning materials stored with medical supplies (see Photo 6). Photo 4. Staff members’ personal food stored with medical supplies (photographed on 4-23-24). Photo 5. Food stored long term in the supply storage cabinet location (photographed on 4-23-24). Photo 6. Cleaning materials stored with medical supplies (photographed on 4-24-24). Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 38 Four of the 11 clinics met requirements for essential core medical equipment and supplies (MIT 5.108, 36.4%). The remaining seven clinics lacked medical supplies or contained nonfunctional equipment. Missing items included examination table disposable paper, a nebulization unit, and lubricating jelly. In addition, we found no clearly designated area to temporarily store biohazard waste bags. We also identified a nonfunctional otoscope. Furthermore, staff had not properly logged the AED or defibrillator performance test within 30 days. We examined EMRBs to determine whether they contained all essential items. We checked whether staff inspected the bags daily and inventoried them monthly. Two of the nine applicable EMRBs passed our test (MIT 5.111, 22.2%). We found one or more of the following deficiencies with seven EMRBs: staff failed to ensure the EMRBs’ 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, several EMRB glucometer quality control logs were either incomplete or inaccurate. Lastly, the treatment cart in the TTA contained a medical supply stored beyond manufacturer’s guidelines. Medical Supply Management HDSP staff stored clinical medical supplies in the medical supply storage areas outside the clinics (MIT 5.106, 100%). 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 disinfected, cleaned, and sanitized three of 11 clinics (MIT 5.101, 27.3%). In eight clinics, we found one or more of the following deficiencies: staff did not maintain cleaning logs; staff did not empty a biohazard waste bin after each clinic day; and the cabinet under the clinic sink was unsanitary. We also found a damaged floor and wall in one of the eight clinics that could not be properly sanitized and disinfected (See Photo 7). Staff in nine of 11 clinics properly sterilized or disinfected medical equipment (MIT 5.102, 81.8%). In two clinics, staff did not mention disinfecting the examination table as part of their daily start-up protocol. We found operational sinks and hand hygiene supplies in the examination rooms in six of 11 clinics (MIT 5.103, 54.6%). The patient restrooms in five clinics lacked antiseptic soap Photo 7. Clinic floor and wall was unsanitary due to and disposable hand towels. damage (photographed on 4-24-24). Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 39 We observed patient encounters in seven clinics. In five clinics, clinicians did not wash their hands before or after examining their patients, before regloving, or before performing blood draws (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 At the time of our medical inspection, HDSP’s administrative team reported no ongoing health care facility improvement program construction projects. HDSP’s health care management and plant operations manager reported all clinical area infrastructures were in good working order (MIT 5.999). Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 40 Compliance Score Results Table 10. Health Care Environment Scored Answer Compliance Questions Yes No N/A Yes % Infection control: Are clinical health care areas appropriately disinfected, 3 8 0 27.3% 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 9 2 0 81.8% warranted? (5.102) Infection control: Do clinical health care areas contain operable sinks and 6 5 0 54.6% sufficient quantities of hygiene supplies? (5.103) Infection control: Does clinical health care staff adhere to universal hand 2 5 4 28.6% hygiene precautions? (5.104) Infection control: Do clinical health care areas control exposure to blood- 11 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 1 0 0 100% health care program? (5.106) Clinical areas: Does each clinic follow adequate protocols for managing and 2 9 0 18.2% storing bulk medical supplies? (5.107) Clinical areas: Do clinic common areas and exam rooms have essential core 4 7 0 36.4% medical equipment and supplies? (5.108) Clinical areas: Are the environments in the common clinic areas conducive 11 0 0 100% to providing medical services? (5.109) Clinical areas: Are the environments in the clinic exam rooms conducive to 7 4 0 63.6% providing medical services? (5.110) Clinical areas: Are emergency medical response bags and emergency crash carts inspected and inventoried within required time frames, and do they 2 7 2 22.2% 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): 57.5% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 41 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. • Health care leadership should determine the root cause(s) for staff not following equipment and medical supply management protocols and should implement remedial measures as appropriate. • Nursing leadership should determine the root cause(s) for staff not ensuring EMRBs are regularly inventoried and sealed and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 42 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 Inadequate (74.3%) Case review found HDSP performed very well in this indicator and showed improvement compared with Cycle 6. We reviewed a comparable number of cases for this indicator but identified fewer deficiencies. Nurses performed thorough and timely initial health screenings for newly arrived patients at HDSP. For patients transferring out of HDSP, nurses often ensured transfer requirements were met. HDSP nurses performed good assessments when patients returned from hospitalization. Case review did not identify any problems with medication continuity for patients returning from the hospital. As a result, the OIG rated the case review component of this indicator adequate. Compliance testing showed mixed results in the transfer process. The institution performed satisfactorily in ensuring medication continuity for transfer-in patients. However, HDSP needed improvement in both completing initial health screening forms and ensuring transfer packets for departing patients included required documents, medications, and durable medical equipment (DME). Based on the overall compliance score result, the OIG rated the compliance testing component of this indicator inadequate. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 43 Case Review and Compliance Testing Results We reviewed 28 events in 15 cases in which patients transferred into or out of the institution or returned from an off-site hospital or emergency room. We identified three deficiencies, none of which were significant.35 Transfers In OIG clinicians reviewed 10 events in which patients transferred into the facility from other institutions. We identified one deficiency, which was not significant.36 OIG clinicians found receiving and release (R&R) nurses completed the initial health screenings thoroughly, scheduled required nurse and provider follow-up appointments, and provided patient education as required. Compliance testing showed nursing staff intermittently completed the initial health screening thoroughly or within required time frames, (MIT 6.001, 52.0%). The low score resulted mostly due to nurses not documenting an explanation when patients answered “yes” to the question regarding whether they had ever been treated for a mental health illness. Compliance testing showed nurses always completed the assessment and disposition section of the initial health screening form (MIT 6.002, 100%). Compliance testing showed medication continuity for patients transferring from yard to yard within the institution was satisfactory (MIT 7.005, 76.0%). For patients arriving at HDSP, our compliance findings also showed satisfactory performance (MIT 6.003, 78.6%). Case review identified one deficiency related to medication continuity.37 In contrast, patients who were en route to other institutions and temporarily housed at HDSP rarely received their medications as ordered (MIT 7.006, 33.3%). Specialty services appointments for patients newly arrived at HDSP occasionally occurred within required time frames (MIT 14.010, 42.9%). These specialty appointments either were not scheduled timely or did not occur. However, compliance testing showed patients who arrived at HDSP were seen by the provider within required time frames most of the time (MIT 1.002, 70.8%). Transfers Out HDSP showed good performance in the transfer-out process. OIG clinicians reviewed six events in which patients transferred out of HDSP and identified two deficiencies, neither of which were significant.38 Nurses often ensured all transfer requirements were met and patients received their ordered medications prior to transferring out of HDSP. Compliance findings showed transfer packets only intermittently included medications, and staff did not document the missing medications (MIT 6.101, 66.7%). 35 Deficiencies occurred in cases 22, 29, and 30. 36 We reviewed cases 2, 16, 22, and 26–28 involving patients who arrived at HDSP from other institutions. A deficiency occurred in case 22. 37 In case 22, the patient who arrived at HDSP did not receive his vitamins, folic acid, and cholecalciferol, as ordered. 38 We reviewed cases 29–31 for patients who transferred out of HDSP. Deficiencies occurred in cases 29 and 30. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 44 Hospitalizations Patients returning from an off-site hospitalization or emergency room are at high risk for lapses in care quality. These patients have typically experienced severe illness or injury. They require more care and place a strain on the institution’s resources. In addition, because these patients have complex medical issues, successful health information transfer is necessary for good quality care. Any transfer lapse can result in serious consequences for these patients. Our clinicians reviewed five events in which patients returned from off-site hospitals or emergency room encounters and did not identify any deficiencies.39 The nurses performed good assessments when patients returned from the hospital. Our clinicians did not identify any deficiencies with provider follow-up appointments for patients after hospital discharge. Compliance results were also sufficient in provider follow-up appointments for patients after hospital discharge (MIT 1.007, 81.0%). Staff frequently scanned hospital discharge documents within required time frames (MIT 4.003, 95.0%), and HDSP providers mostly reviewed hospital documents within required time frames (MIT 4.005, 85.7%). OIG clinicians did not identify any lapses related to the continuity of hospital recommended medications. In contrast, compliance testing showed poor performance for the continuity of hospital recommended medications (MIT 7.003, 15.0%). Compliance data revealed patients did not receive their medications as prescribed. Clinician On-Site Inspection While on site, we toured the R&R and interviewed the nursing staff. The R&R nurse was knowledgeable about the transfer process. The R&R was staffed with one RN on each shift, Monday through Friday. The TTA RN assisted in the R&R on the night shift, weekends, and holidays. The R&R staff informed us, when the R&R was due to have a large number of patients arriving at HDSP, staffing would hire an RN for overtime as available. R&R staff informed us the number of patients who transferred into and out of HDSP varied weekly. An average of 30 patients arrived at HDSP per week, and an average of 25 patients transferred out of HDSP per week. The R&R nurse also informed us the outside specialty nurse communicated pending specialty referrals and appointments to the receiving facility via the electronic health care record message center. The R&R had an automated drug delivery system, which was well stocked per nursing staff.40 While touring the R&R, we observed two separate patient interview rooms. One challenge the nurse reported to us was the lack of space in the R&R, specifically when they had a large number of patients in the R&R. The nursing staff stated they did not have any problems with supplies, equipment, or the pharmacy. In addition, the staff stated their supervising registered nurse (SRN) was 39 We reviewed cases 18–22 for patients who returned from an off-site hospitalization or emergency room encounter. 40 The automated drug delivery system also known as an automated dispensing cabinet, provides drug security and tracking for controlled substances to meet all federal and state requirements. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 45 supportive and custody staff was helpful and team oriented; however, short staffing was a challenge. Compliance On-Site Inspection R&R nursing staff ensured four of six applicable patients transferring out of the institution had required medications, transfer documents, and assigned DME (MIT 6.101, 66.7%). For two patients, the transfer packet did not have required medications. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 46 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 13 12 0 52.0% 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 24 0 1 100% 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 11 3 11 78.6% 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 4 2 3 66.7% required documents? (6.101) Overall percentage (MIT 6): 74.3% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 47 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 17 7 1 70.8% 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 17 4 0 81.0% 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? 19 1 1 95.0% (4.003) For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements and did a provider 18 3 0 85.7% 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 3 17 1 15.0% within required time frames? (7.003) Upon the patient’s transfer from one housing unit to another: Were 19 6 0 76.0% 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 2 4 0 33.3% 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 6 8 0 42.9% 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: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 48 Recommendations • Nursing leadership should ascertain the root cause(s) preventing R&R nurses from properly completing the initial health screening form before patients are placed in housing and not completing the initial health screening, including answering all questions and documenting an explanation for each “yes” answer. Nursing leadership should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 49 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 (63.6%) Case review showed better medication management performance for this cycle compared with Cycle 6. HDSP had a fewer number of deficiencies for this cycle. Patients almost always received newly ordered medication timely. HDSP provided hospital recommended medications without delay, and transfer patients frequently received their medications as ordered. HDSP showed satisfactory performance for chronic medication continuity. The OIG rated the case review component of this indicator adequate. Compliance testing revealed HDSP needed improvement in medication management. HDSP scored low in providing patients with chronic care medications, newly prescribed medications, hospital discharge medications, and medications for patients laying over at HDSP. Based on the overall compliance score result, the OIG rated the compliance component of this indicator inadequate. Case Review and Compliance Testing Results We reviewed 121 events in 26 cases related to medications and found 14 medication deficiencies, two of which were significant.41 New Medication Prescriptions HDSP’s performance with new medication prescriptions was variable. Our clinicians found HDSP performed excellently with new medication prescriptions. We found one deficiency, which was not significant. In contrast, compliance findings showed poor performance (MIT 7.002, 36.0%). Staff did not deliver medications as prescribed by the administration date and time providers had ordered. Examples include medications for infection and asthma. 41 We reviewed cases 1, 2, 8–31 for medication management. Deficiencies occurred in cases 10, 12, 15, 16, 18, 20, 22, and 23. Significant deficiencies occurred in cases 10 and 23. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 50 Chronic Medication Continuity HDSP had mixed results for chronic medication continuity. Compliance testing showed poor performance (MIT 7.001, 23.5%). The low score resulted mostly due to the pharmacy not timely filling and dispensing medications as ordered. OIG clinicians found a few cases in which patients did not receive chronic care medications timely or did not receive them at all. We identified 10 deficiencies, two of which were significant.42 The following were significant deficiencies: • In case 10, the patient received two doses of warfarin (blood thinner) the same day, increasing the risk of bleeding. In addition, on two consecutive days, the patient did not receive the daily dose of warfarin, increasing the risk of blood clot formation. • In case 23, for the month of February 2024, the patient with gastric reflux never received the chronic care medication Sucralfate. Hospital Discharge Medications Case review and compliance testing showed different results for hospital discharge medications. Our clinicians reviewed five events in which patients returned from a hospitalization and did not identify any deficiencies related to hospital recommended medications. Compliance results revealed HDSP rarely ensured patients received needed medications when patients returned from a hospitalization (MIT 7.003, 15.0%). Medications included those prescribed for infection, asthma, gastric reflux, and cholesterol. Specialized Medical Housing Medications Specialized Medical Housing was closed during our review period. Transfer Medications Overall, HDSP’s performance with transfer medications was sufficient. Our OIG clinicians identified one deficiency related to medication continuity for patients who arrived at HDSP and none for those who transferred out of the institution. Our compliance finding showed satisfactory results. New arrivals at HDSP mostly received their medications within required time frames (MIT 6.003, 78.6%). HDSP performed satisfactorily for patients who transferred from yard to yard within the institution (MIT 7.005, 76.0%). However, patients who were en route to another institution and temporarily housed at HDSP only occasionally received medications as ordered (MIT 7.006, 33.3%). Medication Administration Our clinicians found nurses often administered medications as ordered and on time. HDSP had satisfactory performance in administering tuberculosis (TB) medications (MIT 42 Deficiencies related to chronic care medications occurred in cases 10, 12, 15, 16, 20, and 22. Significant deficiencies occurred in cases 10, 20, and 23. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 51 9.001, 83.3%). Nurses only intermittently monitored patients on TB medications properly (MIT 9.002, 58.3%), often either not monitoring patients as ordered or not addressing symptoms such as changes in weight. Clinician On-Site Inspection During our inspection, we toured the outpatient medication rooms and interviewed the pharmacist and the medication licensed vocational nurses (LVNs). The medication LVNs were knowledgeable about the medication processes, including the keep on person (KOP) medications and patient medication noncompliance.43 They reported they had supplies and equipment to perform their duties and pharmacy delivered medications timely. The medication LVNs did not attend daily huddles. They reported any medication concerns to the RN or communicated with the provider. We were informed many patients in each yard received Suboxone.44 Narcan was available to all patients in clinics and the buildings in which the patients resided. The medication LVNs responded to medical emergencies in their assigned yards and had a radio and an emergency bag available in each medication room. In one yard, the medication LVN reported they performed additional duties such as performing EKGs, COVID-19 surveillance and isolation rounds, dressing changes, and providing DME. In B Yard, to alleviate congestion at the medication windows, all diabetic patients would go to building 2 to receive their insulin, Monday through Friday, during the morning shift. During the evening shift, weekends, and holidays, the patients would go to their clinic medication windows. The B Yard care coordinator LVN duties included insulin and vaccine administration and providing self-testing supplies and DME to patients. While we were on site, the medication LVNs reported patients who required COVID-19 surveillance or isolation were housed in Building 3 in A Yard. The medication LVNs would go to the building to administer ordered medications for patients housed in Building 3. A Yard LVNs reported A Yard had many programs the patients attended and bringing patients out of programs for medication administration was challenging. According to A Yard LVN staff, they reported this challenge to supervisors. Other challenges the medication LVNs reported was short staffing and redirection of staff. Overall, while the medication LVNs stated nursing morale varied, they also felt they were able to communicate concerns to their supervisors and work well with custody staff. Medication Practices and Storage Controls The institution adequately stored and secured narcotic medications in all clinic and medication line locations (MIT 7.101, 100%). HDSP appropriately stored and secured nonnarcotic medications in three of 10 applicable clinic and medication line locations (MIT 7.102, 30.0%). In seven locations, we observed one or more of the following deficiencies: the medication storage area was unsanitary; 43 KOP means “keep on person” and refers to medications that a patient can keep and self-administer according to the directions provided. 44 Suboxone is a medication containing buprenorphine and naloxone. Suboxone is used to treat opioid dependence and addiction. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 52 the medication cart was unsecured; nurses did not maintain unissued medication in its original labeled packaging; and daily security check treatment cart log entries were incomplete. Staff kept medications protected from physical, chemical, and temperature contamination in five of 10 applicable clinic and medication line locations (MIT 7.103, 50.0%). In five locations, we found one or more of the following deficiencies: staff did not consistently record the room temperature; staff did not store internal and external medications separately; and the medication refrigerator was unsanitary. Staff successfully stored valid unexpired medications in six of 10 applicable clinic and medication line locations (MIT 7.104, 60.0%). In two locations, medication nurses did not label the multiple-use medication. In the remaining two locations, medications were stored beyond the expiration date on the label. Nurses exercised proper hand hygiene and contamination control protocols in two of seven applicable locations (MIT 7.105, 28.6%). In five locations, medication nurses neglected to wash or sanitize their hands when required. These occurrences include before preparing and administering medications and before each subsequent regloving. Staff in all medication preparation and administration areas showed appropriate administrative controls and protocols when preparing medications for patients (MIT 7.106, 100%). Staff in two of seven applicable medication areas used appropriate administrative controls and protocols when distributing medications to patients (MIT 7.107, 28.6%). In five locations, we observed one or more of the following deficiencies: medication nurses did not always verify patients’ identification using a secondary identifier; medication nurses did not reliably observe patients when they swallowed direct observation therapy medications; and medication nurses did not follow insulin protocols properly. During insulin administration, we observed some medication nurses not properly disinfecting the vial’s port prior to withdrawing medication. Pharmacy Protocols HDSP pharmacy staff followed general security, organization, and cleanliness management protocols in the pharmacy (MIT 7.108, 100%). Staff properly stored nonrefrigerated (MIT 7.109, 100%) and refrigerated or frozen medications in the pharmacy (MIT 7.110, 100%). The pharmacist-in-charge (PIC) correctly accounted for narcotic medications stored in HDSP’s pharmacy (MIT 7.111, 100%). We examined 13 pharmacy related medication error reports. The PIC timely and correctly processed all reports (MIT 7.112, 100%). 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 HDSP, the OIG did not find any applicable medication errors (MIT 7.998). Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 53 The OIG interviewed patients in restricted housing units to determine whether they had immediate access to their prescribed asthma rescue inhalers or nitroglycerin medications. Six of seven applicable patients interviewed indicated they had access to their rescue medications. One patient stated he was not aware his rescue inhaler medication had expired. We promptly notified the CEO of this concern, and health care management immediately issued a replacement rescue inhaler to the patient (MIT 7.999). Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 54 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 4 13 8 23.5% 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 9 16 0 36.0% 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 3 17 1 15.0% 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 19 6 0 76.0% 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 2 4 0 33.3% 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 10 0 1 100% 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 3 7 1 30.0% 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 1 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 6 4 1 60.0% assigned storage areas? (7.104) Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols during medication preparation and 2 5 4 28.6% medication administration processes? (7.105) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when preparing medications for 7 0 4 100% patients? (7.106) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when administering medications 2 5 4 28.6% to patients? (7.107) Pharmacy: Does the institution employ and follow general security, organization, and 1 0 0 100% cleanliness management protocols in its main and remote pharmacies? (7.108) Pharmacy: Does the institution’s pharmacy properly store nonrefrigerated 1 0 0 100% medications? (7.109) Pharmacy: Does the institution’s pharmacy properly store refrigerated or frozen 1 0 0 100% medications? (7.110) Pharmacy: Does the institution’s pharmacy properly account for narcotic 1 0 0 100% medications? (7.111) Pharmacy: Does the institution follow key medication error reporting protocols? 13 0 0 100% (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): 63.6% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 55 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 11 3 11 78.6% 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 4 2 3 66.7% required documents? (6.101) Patients prescribed TB medication: Did the institution administer the 10 2 0 83.3% 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 7 5 0 58.3% medication? (9.002) Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient N/A N/A N/A N/A 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: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 56 Recommendations • The institution should consider developing and implementing measures to ensure staff timely make available and administer medications to patients and document the MAR summaries as described in CCHCS policy and procedures. • Nursing leadership should assess the root cause(s) for nursing staff failing to document patient refusals in the MAR as described in CCHCS policy and procedures and should implement remedial measures as needed. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 57 Preventive Services In this indicator, OIG compliance inspectors tested whether the institution offered or provided cancer screenings, tuberculosis (TB) screenings, influenza vaccines, and other immunizations. If the department designated the institution as being at high risk for coccidioidomycosis (Valley Fever), we tested the institution’s performance in transferring out patients quickly. The OIG rated this indicator solely according to the compliance score. Our case review clinicians do not rate this indicator. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Proficient (85.4%) HDSP performed well in this indicator. Staff performed excellently in offering patients an influenza vaccine for the most recent influenza season and offering colorectal cancer screening for patients from ages 45 through 75. They also performed very well in offering required immunizations to chronic care patients. Staff performed satisfactorily in administering TB medications and in screening patients taking TB medications. However, they needed improvement in monitoring patients taking prescribed TB medications. These findings are set forth in the table on the next page. Based on the overall compliance score result, the OIG rated this indicator proficient. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 58 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 10 2 0 83.3% 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 7 5 0 58.3% medication? (9.002) Annual TB screening: Was the patient screened for TB within the last year? 20 5 0 80.0% (9.003) Were all patients offered an influenza vaccination for the most recent 25 0 0 100% influenza season? (9.004) All patients from the age of 45 through the age of 75: Was the patient 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) 10 1 14 90.9% 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): 85.4% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 59 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 60 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 Compared with Cycle 6, HDSP showed improvement in nursing performance. HDSP nurses usually performed well in providing emergency care to patients and in documenting emergency timelines. When patients returned from the hospital, arrived at HDSP, or transferred out of HDSP, nurses performed good assessments, completed initial health screenings, and ensured transfer-out requirements were met. For those patients who returned from off-site specialty services, the nurses performed thorough assessments, reviewed specialty reports, and communicated with providers as required. During this cycle, case review found better performance for medication management. However, we found opportunities for improvement in outpatient nursing assessments and interventions. As a result, the OIG rated this indicator adequate. Case Review Results We reviewed 215 nursing encounters in 44 cases. We identified 52 nursing performance deficiencies, 15 of which were significant.45 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) 45 Deficiencies occurred in cases 2, 3, 8, 11, 16–21, 23, 24, 29, 30, 32–39, 44, and 46–49. Significant deficiencies occurred in cases 3, 8, 11, 16, 18, 35, and 49. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 61 elements. A comprehensive assessment allows nurses to gather essential information about their patients and develop appropriate interventions. Our clinicians reviewed 116 nursing encounters that occurred in the outpatient setting, 65 of which were sick call requests. Our clinicians identified 38 deficiencies, 11 of which were significant.46 Although, the outpatient clinic nurses generally provided good patient care, we identified opportunities for improvement in nursing assessments and interventions. Similar to Cycle 6, we found a pattern of incomplete patient assessments during face-to-face encounters and interventions. The following are examples of significant deficiencies: • In case 16, the nurse triaged a sick call request for an MRI and a consultation with the neurologist for neck pain. However, the nurse did not perform an assessment or initiate an RN appointment for the symptomatic sick call complaint. • On another occasion, in case 16, the nurse triaged a sick call request as symptomatic for this patient, who complained his legs and back were locking up, he was unable to walk, and he requested a wheelchair. The patient was scheduled for a nurse follow-up within 14 days. However, the nurse should have evaluated the patient the same day of triage due to the reported urgent symptoms and risk of injury. • In case 18, the nurse assessed the patient for a symptomatic sick call with the patient reporting “really bad stomach pains.” However, the nurse did not perform an assessment to include subjective data, vital signs, and an abdominal assessment. During our on-site inspection, the institution concurred with the above deficiency findings. We reviewed three cases involving care management.47 The care management nurses performed good assessments and ensured patients had their ordered DME, medications, and orders for required laboratory tests. They also reviewed the sick call process and the plan of care with the patients. Outpatient Nursing Documentation Complete and accurate nursing documentation is an essential component of patient care. Without proper documentation, health care staff can overlook changes in patients’ conditions. The outpatient clinic nurses mostly performed good documentation. Wound Care This area had an opportunity for improvement. OIG clinicians reviewed four cases involving wound care and found nurses did not always complete thorough assessments of wounds. We identified three deficiencies, none of which were significant, but in which 46 We reviewed nursing sick call events in cases 1, 2, 10–25, and 32–49. Deficiencies occurred in cases 11, 16–20, 23, 32–39, 44, and 46–49. Significant deficiencies occurred in cases 11, 16, 18, 35, and 49. 47 A care manager assessed patients in cases 2, 14, and 18. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 62 we identified a pattern wherein nurses did not measure wound size or assess drainage.48 Below is an example: • In case 20, the nurse evaluated the patient for right-sided stomach discomfort and abscesses to the left lower arm. The nurse documented the first abscess as hard, red, tender, warm to touch, and raised with a scab in the middle. The nurse documented the second abscess as hard, red, tender, warm to touch, and raised. However, the nurse did not measure the wound sizes. Emergency Services We reviewed 38 urgent or emergent events. Overall, TTA nurses responded promptly to emergent events and provided good medical care. They often performed good assessments, interventions, and documentation. However, we identified room for improvement as discussed in the Emergency Services indicator. Hospital Returns Our clinicians reviewed five events involving returns from off-site hospitals or emergency rooms. HDSP nurses performed good patient assessments, reviewed hospital documents, and communicated with providers as required. Please see the Transfers indicator for further details. Transfers We reviewed 16 events involving transfer-in and transfer-out processes. The R&R nurses completed initial health screenings and scheduled required appointments. For patients transferring out of HDSP, nurses often ensured all transfer-out requirements were met, and patients received their ordered medications. For additional details, refer to the Transfers indicator. Specialized Medical Housing The CTC was closed during our review period. Specialty Services HDSP nurses performed very well in assessing patients who returned to the facility from off-site appointments. They frequently performed thorough patient assessments, reviewed specialty reports, and communicated findings to providers. Our clinicians reviewed 38 specialty nursing events and identified two deficiencies, neither of which was significant.49 Medication Management HDSP nurses mostly performed well for medication management. OIG clinicians reviewed 121 events involving medication management and found nurses often 48 Wound care occurred in cases 20, 25, 32, and 44 for wound care. Deficiencies related to incomplete wound assessments occurred in cases 20, 32, and 44. 49 Nursing performance deficiencies occurred in cases 20 and 24. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 63 administered patients’ medications as prescribed. Please refer to the Medication Management indicator for additional details. Clinician On-Site Inspection During our on-site inspection at HDSP, we interviewed various nursing staff and attended outpatient clinic huddles. The huddles were well organized, had good staff participation, and staff discussed required huddle information. In addition to the RN lines, the clinic nurses responded to emergencies in their assigned yards. During our inspection, nursing staff reported the institution had eight patients who were COVID-19 positive and in isolation. The institution reported daily health care meetings regarding these patients. We interviewed the Director of Nursing (DON), who reported recent nursing quality improvement projects, including refreshing staff on KOP medication procedures; activating 9-1-1; triaging and assessing Friday symptomatic sick calls on the same day instead of three days later on the following Monday; and assessing patients for symptomatic sick call complaints rather than waiting for them to be seen by the provider if the patient had a provider appointment the same day. The DON also reported challenges with being short staffed for multiple nursing positions. For example, the new EOP program was recently activated, which created vacancies for psychiatric technicians, and due to the inability to hire into those vacancies, contract registry staff filled those vacancies. The DON expressed nursing morale was low, but stated the relationship between nursing and custody staff was very good, noting they communicated well with each other. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 64 Recommendations • Nursing leadership should identify the challenges to ensuring outpatient clinic nurses perform thorough assessments and provide appropriate interventions. Nursing leadership should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 65 Provider Performance In this indicator, OIG case review clinicians evaluated the quality of care delivered by the institution’s providers: physicians, physician assistants, and nurse practitioners. Our clinicians assessed the institution’s providers’ performance in evaluating, diagnosing, and managing their patients properly. We examined provider performance across several clinical settings and programs, including sick call, emergency services, outpatient care, chronic care, specialty services, intake, transfers, hospitalizations, and specialized medical housing. We assessed provider care through case review only and performed no compliance testing for this indicator. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Not Applicable HDSP providers generally delivered acceptable care. Most providers usually made appropriate medical decisions and ordered appropriate tests, medications, and specialty services. Providers occasionally performed incomplete assessments, which accounted for most of the severe deficiencies. Providers also did not always document nurse co- consultations. After considering all aspects of care, the OIG rated this indicator adequate. Case Review Results OIG clinicians reviewed 99 medical provider encounters and identified 53 deficiencies, 19 of which were significant.50 In addition, our clinicians examined the quality of care in 20 comprehensive case reviews. Of these 20 cases, we found one proficient, 16 adequate, and three inadequate. Outpatient Assessment and Decision-Making Providers generally took good histories, explored different causes for patient symptoms, ordered appropriate tests, provided care with the correct diagnosis, referred patients to proper specialists when needed, and followed through with planned interventions. Providers rarely made questionable or poor decisions. However, providers sporadically performed incomplete examinations or did not address medical conditions. We identified 27 such deficiencies in 11 of the 20 detailed cases we reviewed, nine of which were significant. The following are examples:51 • In case 1, the provider ordered laboratory tests and a provider follow-up appointment to address the patient’s back pain and concern that the “bone 50 Deficiencies occurred in cases 1, 2, 10–18, 20–24, 28, 32, 34, 42, and 43. Significant deficiencies occurred in cases 1, 10, 12, 13, 15, 23, and 24. 51 Deficiencies occurred in cases 1, 2, 10, 11, 15, 17, 18, and 21–24. Significant deficiencies occurred in cases 1, 10, 15, 23, and 24. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 66 infection might have returned.” However, the provider should have ordered the appointment to occur urgently, to address the concerning symptoms. • Also in case 1, the provider reviewed the results of two tests, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), for the patient with a recent history of intravenous drug use and osteomyelitis, and with new complaints of midback pain.52 However, the provider evaluated the patient more than a week later. Furthermore, the provider reviewed an urgent and abnormal MRI result, suspicious for recurrence of osteomyelitis. Despite these results, the provider did not order the follow-up imaging recommended by the radiologist and did not order a sooner provider appointment to follow- up with the patient. • In case 10, the provider evaluated the patient at a telemedicine chronic care appointment and diagnosed the patient with impingement syndrome of the left shoulder.53 The provider documented left shoulder examination findings from another provider’s encounter that had occurred three weeks prior, but did not perform a shoulder musculoskeletal examination to assess for any changes since the prior appointment. • In case 15, the provider evaluated the patient at an episodic care appointment and documented the patient as having shortness of breath on exertion. However, the provider did not perform a subjective or an objective assessment of this complaint. In addition, the provider did not review the patient’s vital signs. On another occasion, in case 15, the provider evaluated the patient at a chronic care and episodic care appointment. However, the provider performed a minimal subjective assessment and did not perform an objective assessment, review medications, or review vital signs. • In case 23, the nurse co-consulted with the provider about the patient’s rib pain and ordered a follow-up provider appointment, which EHRS indicated was completed the same day. However, the provider did not perform an examination of the patient or document a progress note. In case 24, the provider evaluated the patient at a follow-up appointment and documented low oxygen saturation. However, the provider did not address this abnormal vital sign. Also in this case, another provider evaluated the patient at a follow-up appointment. However, this provider did not document reviewing all the patient’s vital signs, including elevated blood pressure. OIG clinicians identified five instances of questionable or poor decision-making, two of which were significant, as described below:54 52 Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are laboratory blood tests. These tests can indicate inflammation in the body due to infection. Osteomyelitis is an infection of the bone. 53 Impingement syndrome of the shoulder occurs when the shoulder tendons are compressed by the bone, causing discomfort, pain, or limited range of motion. 54 Deficiencies in decision making occurred in cases 10, 11, 23, and 24. Significant deficiencies occurred in cases 10 and 23. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 67 • In case 10, the provider endorsed the abnormal and elevated INR test and ordered a follow-up INR test to occur five days later.55 Instead, this follow-up INR test was completed eight days later. The patient’s INR level should have been closely followed and rechecked within one to three days. • In case 23, the provider evaluated the patient at an emergency room follow- up appointment and documented the patient’s lipase as “mildly elevated.”56 However, the provider did not order an imaging study for further evaluation of the pancreas. Considering the patient’s persistent upper abdominal pain and weight loss, the provider should have considered imaging studies to evaluate for potential pancreatic malignancy. OIG clinicians identified one significant deficiency related to lack of timely provider follow- through with planned interventions as follows: • In case 15, the provider evaluated the morbidly obese patient at a follow-up appointment and planned to order weight loss medication. However, the provider ordered this medication almost two months later. Review of Records Generally, providers reviewed medical records carefully. We found two minor deficiencies in which a provider did not review the patient’s laboratory results and specialty procedure report.57 Emergency Care Providers generally made appropriate triage decisions when patients arrived at the TTA for emergency treatment. In addition, providers were available for consultation with TTA staff. We identified two deficiencies related to emergency care, one of which was significant as follows:58 • In case 10, the provider evaluated the patient for left shoulder pain and documented the patient’s elevated INR level. However, the provider performed a steroid injection, which could have increased the risk of bleeding in the shoulder joint considering the supratherapeutic INR level.59 In addition, the patient reported left leg swelling, but the provider did not examine the patient’s legs. Chronic Care In most instances, providers appropriately managed patients’ chronic health conditions. Providers performed well in managing chronic medical conditions such as hypertension, 55 The INR is a laboratory test to measure the body’s blood clotting. This test is used to monitor the effectiveness of blood thinning medications such as warfarin. 56 Lipase is an enzyme in the human body that breaks down fat during digestion. An elevated lipase level may indicate an abnormality of the pancreas. 57 Minor deficiencies in reviewing records occurred in cases 16 and 18. 58 Deficiencies occurred in cases 10 and 24. A significant deficiency occurred in case 10. 59 Supratherapeutic refers to a level of drug that is higher than the maximum level for treatment. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 68 diabetes, asthma, hepatitis C infection, and cardiovascular disease. However, we identified four deficiencies related to chronic condition management, three of which were significant as described below:60 • In case 12, the provider evaluated the patient at a chronic care appointment, where the patient reported diabetic medications compliance and denied symptomatic low sugar levels. The provider also reviewed the patient’s most recent hemoglobin A1c level, which was at an optimal level.61 However, the provider decreased the patient’s diabetic medication, glipizide, dosage which increased the risk of worsening blood sugar control. In addition, the provider did not order future finger stick glucose testing to monitor the effects of this dosage change. • Subsequently in case 12, the provider evaluated the patient at an episodic care appointment to discuss the patient’s hemoglobin A1c levels, which had risen again to a high level. The provider “discussed the need for insulin.” However, the provider did not discuss increasing the glipizide back to the previous dosage under which the patient’s hemoglobin A1c was at an optimal level. • In case 13, the provider evaluated the patient at a chronic care appointment and documented the patient’s uncontrolled diabetes. The provider also documented the patient’s initial refusal of endocrinology follow-up and ordered a new endocrinology consultation. However, the provider did not adjust the patient’s diabetic regimen or consider using eConsult for more prompt treatment, while waiting for a new endocrinology consultation.62 Specialized Medical Housing The specialized medical housing was closed during the review period, so OIG clinicians did not have applicable sample cases to review. Specialty Services Providers appropriately referred patients for specialty consultation when needed. When specialists made recommendations, the providers almost always followed those recommendations appropriately and usually reviewed special reports timely. We discuss providers’ specialty services performance further in the Specialty Services indicator. Documentation Quality Documentation is important because it shows the provider’s thought process during clinical decision-making. When contacted by nurses, providers did not always document 60 Deficiencies occurred in cases 12–14. Significant deficiencies occurred in cases 12 and 13. 61 Hemoglobin A1c is a blood test that measures the average plasma glucose over the previous 12 weeks. 62 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: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 69 the interactions. In addition, some providers did not always document patient encounters. Our clinicians found nine undocumented interactions in seven of the 20 detailed cases we reviewed.63 We identified the following three significant deficiencies: • In case 13, the patient had a chronic care appointment with the provider. However, the provider did not perform an examination or document a progress note. • Also in case 13, the patient had a sick call follow-up appointment with the provider. However, the provider did not perform an examination or document a progress note. • In case 15, the provider evaluated the patient for a dermatology follow-up appointment. However, the provider did not perform a subjective assessment, an objective assessment, review the patient’s vital signs, or document a progress note. Provider Continuity The institution offered excellent provider continuity. Providers were assigned to specific clinics to ensure continuity of care. We identified no deficiencies related to provider continuity. Patient Notification Letters Providers did not always send patient test results notification letters to patients. When they did, the letters did not always contain the four elements required by policy: date of the test; reviewing health care provider’s name; whether the results are within normal limits; and whether a provider follow-up appointment is required and will be scheduled. After endorsing laboratory results, providers are responsible for notifying patients of the laboratory results and the necessary next steps. We identified this lapse in notification in 11 of the 20 detailed cases we reviewed.64 We further discuss patient notification letters in Diagnostic Services and Health Information Management indicators. Clinician On-Site Inspection OIG clinicians met with the CME, the CP&S, and providers. At the time of the on-site inspection, medical leadership reported HDSP had two on-site providers, who were advanced practice providers, and seven telemedicine providers. For several years, HDSP had one on-site physician. However, this provider had moved out of state. Medical leadership reported no current vacancies and being fully staffed two to three months prior to the on-site inspection. Medical leadership remarked HDSP’s remote location and lack of a 15 percent pay differential were challenges to hiring providers. 63 Deficiencies occurred in cases 13, 15, 18, 32, 34, 42, and 43. Significant deficiencies occurred in cases 13 and 15. 64 Providers sent incomplete or did not send letters in cases 2, 10, 12–14, 16, 18, 20, 21, 23, and 24. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 70 The OIG physician discussed the challenges of practicing at HDSP with the CME and the CP&S. They identified not having a physician on site as a difficulty and reported, due to the State’s budget crisis, telemedicine providers no longer travelled to HDSP to be on site. Medical leadership again highlighted HDSP’s remote location as a problem because patients sometimes required transport to Reno, a city over 80 miles away, for specialty services. The OIG physician discussed patient care with the providers. The providers reported their workload had previously increased due to provider departures and stated this increase created appointment backlogs. Nevertheless, most of the providers expressed their morale was generally high. They reported good relationships with custody and support staff. The providers reported feeling supported by both the CME and CP&S and stated they quickly received feedback for any issues or questions. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 71 Recommendations • Medical leadership should ascertain the challenges to providers performing complete examinations and thoroughly addressing medical conditions and should implement appropriate remedial measures. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 72 Specialized Medical Housing In this indicator, OIG inspectors normally evaluate the quality of care in the specialized medical housing units. We evaluate the performance of the medical staff in assessing, monitoring, and intervening for medically complex patients requiring close medical supervision. Our inspectors also evaluate the timeliness and quality of provider and nursing intake assessments and care plans. We assess staff members’ performance in responding promptly when patients’ conditions deteriorated and look for good communication when staff consults with one another while providing continuity of care. Our clinicians also interpret relevant compliance results and incorporate them into this indicator. At the time of our inspection, HDSP’s specialized medical housing consisted of a correctional treatment center (CTC). Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Not Applicable During this cycle, HDSP temporarily closed its CTC unit on April 3, 2023, which reopened on April 8, 2024. Due to this closure, OIG clinicians had no applicable cases to review during the inspection period for this indicator. Our compliance team similarly had no applicable testing samples to evaluate during the inspection period. However, during the week of the OIG compliance on-site inspection, HDSP’s CTC reopened, and the OIG inspectors were able to assess the call light system functionality. We also evaluated HDSP’s local operating procedure when performing patient safety checks. The OIG found both measured areas compliant with the HCDOM requirements.65 Due to the unavailability of information for the inspection period because of the closure, the OIG did not assess this indicator, and instead, designated this indicator as not applicable. 65 HCDOM is the department’s Health Care Department Operations Manual. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 73 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 N/A N/A N/A N/A assessment of the patient on the day of admission? (13.001) Was a written history and physical examination completed within the N/A N/A N/A N/A 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 N/A N/A N/A N/A within required time frames? (13.003) For specialized health care housing (CTC, SNF, hospice, OHU): Do specialized health care housing maintain an operational call N/A N/A N/A N/A 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 N/A N/A N/A N/A operating procedure or within the required time frames? (13.102) Overall percentage (MIT 13): N/A Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 74 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 75 Specialty Services In this indicator, OIG inspectors evaluated the quality of specialty services. The OIG clinicians focused on the institution’s performance in providing needed specialty care. Our clinicians also examined specialty appointment scheduling, providers’ specialty referrals, and medical staff’s retrieval, review, and implementation of any specialty recommendations. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Adequate (75.3%) Case review found HDSP performed very well in specialty services. Staff always provided specialty services within required time frames. Providers almost always evaluated patients for follow-up appointments without delay, and nurses performed appropriate assessments for patients returning from specialty services appointments. Overall, the OIG rated the case review component of this indicator adequate. Compared with Cycle 6, HDSP’s performance in compliance testing for this indicator improved in Cycle 7. Depending on the priority of the specialty service, access to specialty services ranged from needing improvement to excellent. Preapproved specialty services for newly arrived patients sporadically occurred within required time frames, while performances in retrieving specialty reports and prompt provider endorsements varied. Based on the overall compliance score result, the OIG rated the compliance testing component of this indicator adequate. Case Review and Compliance Testing Results OIG clinicians reviewed 112 events related to specialty services, 71 of which were specialty consultations and procedures. We identified five deficiencies in this category, none of which were significant.66 Access to Specialty Services Compliance testing showed variable access to specialty services. While HDSP performed satisfactorily in timely providing medium-priority (MIT 14.004, 80.0%) and routine- priority (MIT 14.007, 80.0%) specialty services, HDSP needed improvement in providing high-priority specialty services (MIT 14.001, 73.3%) as ordered by the provider. Similarly, the institution needed significant improvement in providing specialty access for patients who transferred into the institution with preapproved specialty requests (MIT 14.010, 42.9%). In contrast, OIG clinicians identified no deficiencies with specialty care access. 66 Minor deficiencies occurred in cases 10, 20, 24, and 25. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 76 Provider Performance Access to provider care following specialty services varied. Compliance testing showed the institution’s provision of timely clinician follow-up appointments for specialty consultations needed improvement (MIT 1.008, 62.2%). In contrast, OIG clinicians identified only one untimely provider follow-up appointment, which was not clinically significant.67 We also found providers generally ordered appropriate specialty consultations, followed specialty recommendations, and performed appropriate specialty follow-up assessments. We identified one minor deficiency related to provider assessment.68 Nursing Performance The nurses performed well in assessing patients who returned to the facility from off-site specialty appointments. OIG clinicians identified two minor deficiencies; one related to nursing assessment and the other related to documentation.69 Health Information Management Compliance testing showed the institution almost always timely received, and the provider timely reviewed, high-priority (MIT 14.002, 93.3%) specialty reports. However, staff needed improvement with timely receiving and reviewing specialty reports for routine-priority (MIT 14.008, 66.7%) and medium-priority (MIT 14.005, 66.7%) specialty services. HDSP performed excellently in scanning specialty reports into EHRS in a timely manner (MIT 4.002, 100%). OIG clinicians identified only one minor health information management deficiency with the provider endorsing a specialty report late.70 Clinician On-Site Inspection OIG clinicians discussed specialty services with the supervising registered nurse (SRN) and the management of specialty reports with the health information management (HIM) supervisors. The SRN reported not having an on-site nurse since early 2024. As a result, all other specialty staff assisted as needed. The SRN detailed backlogs with off-site and on-site services. HDSP had specialty services backlogs for off-site gastroenterology, electrodiagnostic tests (nerve conduction and electromyography), and on-site optometry.71 To keep track of specialty appointments, the off-site specialty nurse maintained a request for service (RFS) tracking log.72 For telemedicine specialty appointments, the nurse communicated with the telemedicine scheduler at CCHCS Headquarters upon receiving an RFS. 67 A minor deficiency occurred in case 20. 68 A minor deficiency occurred in case 10. 69 Minor deficiencies occurred in cases 20 and 24. 70 A minor deficiency occurred in case 25. 71 Electromyography evaluates the electrical activity of muscles and nerves. 72 The request for service (RFS) is a referral order for a specialty consultation. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 77 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 11 4 0 73.3% 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 14 1 0 93.3% frame? (14.002) Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care provider? 5 2 8 71.4% (14.003) Did the patient receive the medium-priority specialty service within 15-45 calendar days of the primary care provider order or Physician Request for 12 3 0 80.0% Service? (14.004) Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the required time 10 5 0 66.7% frame? (14.005) Did the patient receive the subsequent follow-up to the medium-priority specialty service appointment as ordered by the primary care provider? 8 0 7 100% (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 12 3 0 80.0% 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 10 5 0 66.7% 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? 3 2 10 60.0% (14.009) For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the sending 6 8 0 42.9% 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 12 1 0 92.3% services within required time frames? (14.011) Following the denial of a request for specialty services, was the patient 10 3 0 76.9% informed of the denial within the required time frame? (14.012) Overall percentage (MIT 14): 75.3% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 78 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 23 14 8 62.2% occur within required time frames? (1.008) * Are specialty documents scanned into the patient’s electronic health record 30 0 15 100% 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: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 79 Recommendations • Health care leadership should ascertain the challenges to the timely receipt and provider review of specialty reports and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 80 Administrative Operations In this indicator, OIG compliance inspectors evaluated health care administrative processes. Our inspectors examined the timeliness of the medical grievance process and checked whether the institution followed reporting requirements for adverse or sentinel events and patient deaths. Inspectors checked whether the Emergency Medical Response Review Committee (EMRRC) met and reviewed incident packages. We investigated and determined whether the institution conducted required emergency response drills. Inspectors also assessed whether the Quality Management Committee (QMC) met regularly and addressed program performance adequately. In addition, our inspectors determined whether the institution provided training and job performance reviews for its employees. We checked whether staff possessed current, valid professional licenses, certifications, and credentials. The OIG rated this indicator solely based on the compliance score. Our case review clinicians do not rate this indicator. Because none of the tests in this indicator directly affected clinical patient care (it is a secondary indicator), the OIG did not consider this indicator’s rating when determining the institution’s overall quality rating. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Inadequate (60.2%) HDSP’s performance was mixed in this indicator. While HDSP scored well in some applicable tests, it needed improvement in several areas. The EMMRC occasionally completed required checklists or reviewed cases within required time frames. Meeting minutes from the local governing body were missing approval documentation. In addition, the institution conducted medical emergency response drills with incomplete documentation, missing required emergency response drill forms, or without participation of custody staff. Physician managers did not complete an annual performance appraisal in a timely manner. Lastly, the nurse educator did not ensure all newly hired nurses received their required onboarding training timely. 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 HDSP, the OIG did not have any applicable adverse sentinel events requiring root cause analysis during our inspection period (MIT 15.001). We obtained CCHCS Mortality Case Review reporting data. In our inspection, for seven applicable patients, we found no evidence in the submitted documentation that the preliminary mortality reports had been completed. These reports were overdue at the time of the OIG’s inspection (MIT 15.998). Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 81 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 0 4 0 0 procedures and any applicable policies? (15.004) Did the institution conduct medical emergency response drills during each watch of the most recent quarter, and did health care and custody staff 0 3 0 0 participate in those drills? (15.101) Did the responses to medical grievances address all of the patients’ 10 0 0 100% appealed issues? (15.102) Did the medical staff review and submit initial patient death reports to the 7 1 0 87.5% CCHCS Mortality Case Review Unit on time? (15.103) Did nurse managers ensure the clinical competency of nurses who 7 3 0 70.0% administer medications? (15.104) Did physician managers complete provider clinical performance appraisals 0 1 0 0 timely? (15.105) Did the providers maintain valid state medical licenses? (15.106) 17 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): 60.2% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 82 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 83 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 HDSP Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 84 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: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 85 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: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 86 Figure A–2. Case Review Testing Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 87 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: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 88 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: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 89 Appendix B: Case Review Data Table B–1. HDSP Case Review Sample Sets Sample Set Total Anticoagulation 1 Death Review/Sentinel Events 2 Diabetes 3 Emergency Services – CPR 5 Emergency Services – Non-CPR 2 High Risk 4 Hospitalization 4 Intrasystem Transfers In 3 Intrasystem Transfers Out 3 RN Sick Call 18 Specialty Services 4 49 Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 90 Table B–2. HDSP Case Review Chronic Care Diagnoses Sample Set Total Anemia 1 Anticoagulation 1 Arthritis/Degenerative Joint Disease 2 Asthma 4 Cancer 2 Cardiovascular Disease 4 Chronic Kidney Disease 5 Chronic Pain 7 Cirrhosis/End Stage Liver Disease 2 Coccidioidomycosis 1 COPD 1 COVID-19 2 Deep Venous Thrombosis/Pulmonary Embolism 1 Diabetes 9 Gastroesophageal Reflux Disease 9 Hepatitis C 12 Hyperlipidemia 15 Hypertension 18 Mental Health 15 Seizure Disorder 1 Sleep Apnea 2 Substance Abuse 26 Thyroid Disease 3 143 Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 91 Table B–3. HDSP Case Review Events by Program Diagnosis Total Diagnostic Services 142 Emergency Care 64 Hospitalization 17 Intrasystem Transfers In 10 Intrasystem Transfers Out 6 Outpatient Care 431 Specialty Services 122 792 Table B–4. HDSP Case Review Sample Summary Sample Set Total MD Reviews Detailed 20 MD Reviews Focused 5 RN Reviews Detailed 12 RN Reviews Focused 35 Total Reviews 72 Total Unique Cases 49 Overlapping Reviews (MD & RN) 23 Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 92 Appendix C: Compliance Sampling Methodology High Desert State Prison Quality No. of Indicator Sample Category Samples Data Source Filters Access to Care MIT 1.001 Chronic Care 25 Master Registry • Chronic care conditions (at least one Patients condition per patient — any risk level) • Randomize MIT 1.002 Nursing Referrals 25 OIG Q: 6.001 • See Transfers MITs 1.003 – 006 Nursing Sick Call 30 Clinic • Clinic (each clinic tested) (6 per clinic) Appointment List • Appointment date (2 – 9 months) • Randomize MIT 1.007 Returns From 21 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: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 93 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 21 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 21 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 11 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 6 OIG inspector • R&R IP transfers with medication on-site review Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 94 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 21 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 6 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 13 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 7 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: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 95 Quality No. of Indicator Sample Category Samples Data Source Filters Prenatal and Postpartum Care MITs 8.001 – 007 Recent Deliveries N/A at this OB Roster • Delivery date (2 – 12 months) institution • Most recent deliveries (within date range) Pregnant Arrivals N/A at this OB Roster • Arrival date (2 – 12 months) institution • Earliest arrivals (within date range) Preventive Services MITs 9.001 – 002 TB Medications 12 Maxor • Dispense date (past 9 months) • Time period on TB meds (3 months or 12 weeks) • Randomize MIT 9.003 TB Evaluation, 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: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 96 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 0 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: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 97 Quality No. of Indicator Sample Category Samples Data Source Filters Specialty Services (continued) MITs 14.007 – 009 Routine-Priority 15 Specialty Services • Approval date (3 – 9 months) Initial and Follow-Up Appointments • Remove consult to audiology, RFS chemotherapy, dietary, Hep C, HIV, orthotics, gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, physiatry, podiatry, radiology, follow-up wound care/addiction medication, narcotic treatment program, and transgender services • Randomize MIT 14.010 Specialty Services 14 Specialty Services • Arrived from (other departmental Arrivals Arrivals institution) • Date of transfer (3 – 9 months) • Randomize MITs 14.011 – 012 Denials 13 InterQual • Review date (3 – 9 months) • Randomize N/A IUMC/MAR • Meeting date (9 months) Meeting Minutes • Denial upheld • Randomize Administrative Operations MIT 15.001 Adverse/sentinel 0 Adverse/sentinel • Adverse/Sentinel events events events report (2 – 8 months) MIT 15.002 QMC Meetings 6 Quality • Meeting minutes (12 months) Management Committee meeting minutes MIT 15.003 EMRRC 12 EMRRC meeting • Monthly meeting minutes minutes (6 months) MIT 15.004 LGB 4 LGB meeting • Quarterly meeting minutes minutes (12 months) MIT 15.101 Medical Emergency 3 On-site summary • Most recent full quarter Response Drills reports & • Each watch documentation for ER drills MIT 15.102 Institutional Level 10 On-site list of • Medical grievances closed Medical Grievances grievances/closed (6 months) grievance files Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 98 Quality Sample Category No. of Data Source Filters Indicator Samples 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 1 On-site provider • All required performance evaluation Evaluation Packets evaluation files documents MIT 15.106 Provider Licenses 17 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: September 2023 – February 2024 Report Issued: June 2025 Cycle 7, High Desert State Prison | 99 California Correctional Health Care Services’ Response Office of the Inspector General, State of California Inspection Period: September 2023 – February 2024 Report Issued: June 2025 Cycle 7 Medical Inspection Report for High Desert State Prison OFFICE of the INSPECTOR GENERAL Amarik K. Singh Inspector General Shaun Spillane Chief Deputy Inspector General STATE of CALIFORNIA June 2025 OIG