Kern Valley State Prison Cycle 7 Medical Inspection Report

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Connect with us on social media Cycle 7, Kern Valley 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 6 Institution-Specific Metrics 7 Population-Based Metrics 9 HEDIS Results 9 Recommendations 11 Indicators 13 Access to Care 13 Diagnostic Services 19 Emergency Services 24 Health Information Management 27 Health Care Environment 33 Transfers 41 Medication Management 47 Preventive Services 55 Nursing Performance 58 Provider Performance 62 Specialized Medical Housing 66 Specialty Services 71 Administrative Operations 77 Appendix A: Methodology 81 Case Reviews 82 Compliance Testing 85 Indicator Ratings and the Overall Medical Quality Rating 86 Appendix B: Case Review Data 87 Appendix C: Compliance Sampling Methodology 91 California Correctional Health Care Services’ Response 99 Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | iv Illustrations Tables 1. KVSP Summary Table: Case Review Ratings and Policy Compliance Scores 4 2. KVSP Master Registry Data as of December 2023 7 3. KVSP Health Care Staffing Resources as of December 2023 8 4. KVSP Results Compared With State HEDIS Scores 10 5. Access to Care 16 6. Other Tests Related to Access to Care 17 7. Diagnostic Services 22 8. Health Information Management 30 9. Other Tests Related to Health Information Management 31 10. Health Care Environment 39 11. Transfers 44 12. Other Tests Related to Transfers 45 13. Medication Management 52 14. Other Tests Related to Medication Management 53 15. Preventive Services 56 16. Specialized Medical Housing 69 17. Specialty Services 74 18. Other Tests Related to Specialty Services 75 19. Administrative Operations 78 A–1. Case Review Definitions 82 B–1. KVSP Case Review Sample Sets 87 B–2. KVSP Case Review Chronic Care Diagnoses 88 B–3. KVSP Case Review Events by Program 89 B–4. KVSP Case Review Sample Summary 89 Figures A–1. Inspection Indicator Review Distribution for KVSP 81 A–2. Case Review Testing 84 A–3. Compliance Sampling Methodology 85 Photographs 1. Clinic Waiting Area 33 2. Long-Term Storage of Staff Members’ Food Stored in the Medical Supply Storage Room 34 3. Expired Medical Supply Dated June 2021 34 4. Expired Medical Supply Dated January 31, 2023 35 5. Expired Medical Supply Dated July 12, 2023 36 6. Medical Supply With Manufacturer’s Temperature Guideline 36 7. Unsanitary Stretcher 37 8. Unsanitary Emergency Medical Response Vehicle 37 Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley 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 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: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley 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 Kern Valley State Prison, the institution had been delegated back to the department by the receiver. We completed our seventh inspection of the institution, and this report presents our assessment of the health care provided at this institution during the inspection period from April 2023 to September 2023.4 4 Samples are obtained per case review methodology shared with stakeholders in prior cycles. The case reviews include death reviews between January 2023 and September 2023. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 3 Summary: Ratings and Scores We completed the Cycle 7 inspection of Kern Valley State Prison (KVSP) in March 2024. OIG inspectors monitored the institution’s delivery of medical care that occurred between April 2023 and September 2023. The OIG rated the case review The OIG rated the compliance component of the overall health care component of the overall health care quality at KVSP adequate. quality at KVSP inadequate. OIG case review clinicians (a team of physicians and nurse consultants) reviewed 50 cases, which contained 808 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 March 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 all 20 adequate. 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 380 patient records and 1,145 data points and used the data to answer 93 policy questions. In addition, we observed KVSP’s processes during an on-site inspection in December 2023. The OIG then considered the results from both case review and compliance testing, and drew overall conclusions, which we report in 13 health care indicators.5 5 The indicators for Reception Center and Prenatal and Postpartum Care did not apply to KVSP. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 4 We list the individual indicators and ratings applicable for this institution in Table 1 below. Table 1. KVSP Summary Table: Case Review Ratings and Policy Compliance Scores Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 5 Medical Inspection Results Deficiencies Identified During Case Review Deficiencies are medical errors that increase the risk of patient harm. Deficiencies can be minor or significant, depending on the severity of the deficiency. An adverse event occurs when the deficiency caused harm to the patient. All major health care organizations identify and track adverse events. We identify deficiencies and adverse events to highlight concerns regarding the provision of care and for the benefit of the institution’s quality improvement program to provide an impetus for improvement.6 The OIG did not find any adverse events at KVSP during the Cycle 7 inspection. Case Review Results OIG case reviewers (a team of physicians and nurse consultants) assessed 10 of the 13 indicators applicable to KVSP. Of these 10 indicators, OIG clinicians rated nine adequate and one proficient. The OIG physicians also rated the overall adequacy of care for each of the 20 detailed case reviews they conducted. Of these 20 cases, all 20 were adequate. In the 808 events reviewed, we identified 119 deficiencies, 23 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 KVSP: • Most outpatient appointments with providers, including appointments with providers after hospitalizations, specialty consultations, or TTA events, occurred timely. Most nursing appointments also occurred timely. • Providers delivered generally good care, made appropriate assessments and decisions, managed chronic medical conditions effectively, and thoroughly reviewed medical records. • Nurses frequently performed good assessments, reviewed the specialists’ recommendations, and communicated those results to the provider when patients returned from off-site specialty appointments. • Nurses performed good screenings and referred patients appropriately to providers when patients transferred into the institution. Our clinicians found the following weaknesses at KVSP: • Staff performed poorly with medication continuity for patients transferring into the institution. 6 For a further discussion of an adverse event, see Table A–1. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 6 • Specialized medical housing patients sporadically received their medications timely, specifically when medications were not available and not renewed prior to expiration. Compliance Testing Results Our compliance inspectors assessed 10 of the 13 indicators applicable to KVSP. Of these 10 indicators, our compliance inspectors rated six adequate and four inadequate. We solely tested policy compliance in Health Care Environment, Preventive Services, and Administrative Operations as these indicators do not have a case review component. KVSP showed a high rate of policy compliance in the following areas: • Nursing staff processed sick call request forms, performed face-to-face evaluations, and completed nurse-to-provider referrals within required time frames. In addition, KVSP housing units contained adequate supplies of health care services request forms. • Patients returning from outside community hospitals or specialty services appointments saw their primary care providers within the specified time frames. • Staff timely scanned health care services request forms, specialists’ reports, and community hospital discharge reports into patients’ electronic medical records. • Staff performed well in offering immunizations and providing preventative services for patients, such as influenza vaccinations, annual testing for tuberculosis (TB), and colorectal cancer screenings. KVSP showed a low rate of policy compliance in the following areas: • The medical warehouse and clinics had multiple expired medical supplies. • Nursing staff did not regularly inspect emergency response bags and treatment carts. • Health care staff only occasionally followed hand hygiene precautions before or after patient encounters. • Staff frequently failed to maintain medication continuity for chronic care patients, patients discharged from the hospital, and patients admitted to a specialized medical housing unit. In addition, KVSP maintained poor medication continuity for patients who transferred into the institution, transferred within the institution, or had a temporary layover at KVSP. • Staff did not consistently provide STAT laboratory services within required time frames. • Providers often did not generate complete patient notification letters communicating the results of diagnostic services. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 7 Institution-Specific Metrics Located in Delano, Kern County, Kern Valley State Prison (KVSP) is a Level IV (maximum-security) facility consisting of four semiautonomous 180-bed facilities and two standalone administrative segregation units. KVSP operates several medical clinics where staff handle nonurgent requests for medical services. The institution also treats patients who need urgent or emergent care in its triage and treatment area (TTA) and patients who require inpatient care in their correctional treatment center (CTC). The institution screens patients in its receiving and release location (R&R) and provides specialized clinical services in its specialty service/telemedicine clinic. KVSP has been designated by CDCR as a basic care institution as its location is rural, far from tertiary care centers and specialty care providers whose services would likely be used frequently by higher-risk patients.7 As of February 7, 2025, the department reports on its public tracker that 76 percent of KVSP’s incarcerated population is fully vaccinated for COVID-19 while 63 percent of KVSP’s staff is fully vaccinated for COVID-19.8 In December 2023, the Health Care Services Master Registry showed that KVSP had a total population of 2,945. A breakdown of the medical risk level of the KVSP population as determined by the department is set forth in Table 2 below.9 Table 2. KVSP Master Registry Data as of December 2023 Medical Risk Level Number of Patients Percentage* High 1 116 3.9% High 2 233 7.9% Medium 1,436 48.8% Low 1,160 39.4% Total 2,945 100.0% * Percentages may not total 100% due to rounding. Source: Data for the population medical risk level were obtained from the CCHCS Master Registry dated 12/04/2023. 7 Notably, institutions designated as “basic” are generally expected to have a total high risk medical population of approximately 5%. At nearly 12%, KVSP’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: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 8 According to staffing data the OIG obtained from California Correctional Health Care Services (CCHCS), as identified in Table 3 below, KVSP had zero vacant executive leadership positions, 2.6 primary care provider vacancies, 0.2 nursing supervisor vacancies, and 13.1 nursing staff vacancies. Table 3. KVSP Health Care Staffing Resources as of December 2023 Executive Primary Care Nursing Nursing Positions Leadership * Providers Supervisors Staff † Total Authorized Positions 5.0 7.5 12.2 112.4 137.1 Filled by Civil Service 5.0 4.9 12.0 99.0 120.9 Vacant 0 2.6 0.2 13.1 15.9 Percentage Filled by Civil Service 100% 65.3% 98.4% 88.1% 88.2% Filled by Telemedicine 0 2.6 0 0 2.6 Percentage Filled by Telemedicine 0 34.7% 0 0 1.9% Filled by Registry 0 0 0 26.0 26.0 Percentage Filled by Registry 0 0 0 23.1% 19.0% Total Filled Positions 5.0 7.5 12.0 125.0 149.5 Total Percentage Filled 100% 100% 98.4% 111.2% 100% Appointments in Last 12 Months 1.0 0 3.0 25.0 29.0 Redirected Staff 0 0 0 0 0 Staff on Extended Leave ‡ 0 0 2.0 6.0 8.0 Adjusted Total: Filled Positions 5.0 7.5 10.0 119.0 141.5 Adjusted Total: Percentage Filled 100% 100% 82.0% 105.9% 103.2% * 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 December 4, 2023, from California Correctional Health Care Services. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley 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 KVSP’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. For poor HbA1c control, KVSP’s results compared favorably with those found in State health plans. 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) — KVSP’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. KVSP had a 33 percent influenza immunization rate for adults 18 to 64 years old and a 76 percent influenza immunization rate for adults 65 years of age and older.10 The pneumococcal vaccination rate was 86 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) — KVSP’s 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: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 10 colorectal cancer screening rate of 81 percent was significantly higher, indicating very good performance on this measure. Table 4. KVSP Results Compared With State HEDIS Scores KVSP California California Kaiser Kaiser Cycle 7 California NorCal SoCal HEDIS Measure Results * Medi-Cal † Medi-Cal † Medi-Cal † HbA1c Screening 97% – – – Poor HbA1c Control (> 9.0%) ‡,§ 8% 36% 31% 22% HbA1c Control (< 8.0%) ‡ 84% – – – Blood Pressure Control (< 140/90) ‡ 84% – – – Eye Examinations 45% – – – Influenza – Adults (18 – 64) 33% – – – Influenza – Adults (65 +) 76% – – – Pneumococcal – Adults (65 +) 86% – – – Colorectal Cancer Screening 81% 37% 68% 70% Notes and Sources * Unless otherwise stated, data were collected in December 2023 by reviewing medical records from a sample of KVSP’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 KVSP 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: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 11 Recommendations As a result of our assessment of KVSP’s performance, we offer the following recommendations to the department: Diagnostic Services • The department should develop strategies, such as a statewide electronic solution, to ensure providers generate letters communicating test results to their patients and the letters include all elements as required by CCHCS policy. • Medical leadership should determine the root cause(s) of challenges related to timely collecting, receiving, and notifying STAT laboratory test results and should implement remedial measures as appropriate. Health Care Environment • Nursing leadership should determine the root cause(s) of staff neglecting to ensure clinic examination rooms contain essential core medical equipment, and staff failing to follow equipment and medical supply management protocols, and should take necessary remedial measures. • Medical and nursing leadership should analyze the root cause(s) for staff not following all required universal hand hygiene precautions and should implement remedial measures as appropriate. • Nursing leadership should determine the root cause(s) for staff neglecting to ensure the EMRBs are regularly inventoried and sealed and should implement remedial measures as appropriate. Transfers • Healthcare leadership should identify the challenges to maintaining medication continuity for patients transferring into the institution without their medications and 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 ensure staff document administrating medications in the EHRS, as described in CCHCS policy and procedures. • Nursing leadership should consider developing and implementing strategies to ensure nursing staff properly document patient refusals in the MAR, as described in CCHCS policy and procedures. • Healthcare leadership should identify challenges related to issuing and renewing medications timely in specialized medical housing and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 12 Preventive Services • Nursing leadership should analyze the challenges to ensuring nursing staff administer and monitor patients receiving TB medications according to CCHCS guidelines and should implement remedial measures as appropriate. • Medical leadership should analyze the challenges related to untimely providing required immunizations to chronic care patients and should implement remedial measures as appropriate. Specialty Services • Medical leadership should ascertain the challenges related to timely retrieving and endorsing specialty reports and should implement remedial measures as appropriate. • Medical leadership should ascertain causes related to untimely providing or scheduling patients’ specialty service appointments and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 13 Indicators Access to Care In this indicator, OIG inspectors evaluated the institution’s performance in providing patients with timely clinical appointments. Our inspectors reviewed scheduling and appointment timeliness for newly arrived patients, sick calls, and nurse follow-up appointments. We examined referrals to primary care providers, provider follow-ups, and specialists. Furthermore, we evaluated the follow-up appointments for patients who received specialty care or returned from an off-site hospitalization. Ratings and Results Overview Case Review Rating Compliance Rating and Score Proficient Adequate (82.2%) Case review found KVSP performed excellently in providing access to care. Almost all provider appointments, including outpatient, and after hospitalization, specialty, and TTA events occurred timely. We also found all nursing appointments occurred timely. Factoring in all aspects of care, the OIG rated the case review component of this indicator proficient. KVSP’s performance in compliance testing was mixed for access to care. Access to providers was very good for newly transferred patients and for patients who returned to KVSP after hospitalization or specialty services appointments. Nurses frequently reviewed patient sick call requests. However, staff needed improvement in completing chronic care provider appointments. Based on the overall compliance score result, the OIG rated the compliance component of this indicator adequate. Case Review and Compliance Testing Results OIG clinicians reviewed 403 provider, nursing, urgent or emergent care (TTA), specialty, and hospital events requiring the institution to generate appointments. We identified only four deficiencies related to access to care, three of which were significant.12 Access to Care Providers Compliance testing revealed KVSP completed less than half of chronic care follow-up appointments timely (MIT 1.001, 48.0%). However, the institution generally completed nurse-to-provider appointments and always completed provider-ordered sick call follow- up appointments timely (MIT 1.005, 75.0% and MIT 1.006, 100%). OIG clinicians reviewed 59 clinic provider appointments and identified one deficiency as follows: 12 Deficiencies occurred in cases 10, 15, 24, and 25. Significant deficiencies occurred in cases 10, 15, and 25. Notably, the very low number of deficiencies is particularly impressive in light of the significantly larger high- risk medical population KVSP must attend to as compared with most institutions designated “basic.” Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 14 • In case 24, a nurse assessed the patient for dizziness and ordered a provider appointment to occur within 14 days; however, the appointment occurred in 27 days. Access to Specialized Medical Housing Providers KVSP’s specialized medical housing consisted of a correctional treatment center (CTC). In compliance testing and case review, KVSP performed well with access to CTC providers. Compliance testing showed providers always timely completed the admission history and physical examinations for patients admitted to the CTC (MIT 13.002, 100%). The OIG clinicians reviewed 34 provider encounters and did not identify deficiencies related to CTC provider access. Access to Clinic Nurses Compliance testing showed nurses almost always reviewed nurse sick call requests on the same day they were received (MIT 1.003, 93.3%). Nurses also often completed face-to-face encounters within the required one business day (MIT 1.004, 86.2%). OIG clinicians reviewed 66 nursing encounters and did not identify deficiencies related to clinic nurse access. Access to Specialty Services Compliance testing showed nearly all initial high-priority (MIT 14.001, 93.3%), most initial medium-priority (MIT 14.004, 80.0%), and most initial routine-priority (MIT 14.007, 80.0%) specialty appointments occurred within required time frames. KVSP’s performance in access to follow-up specialty appointments was not as good. Compliance testing revealed only approximately two thirds of follow-up high-priority (MIT 14.003, 60.0%), medium-priority (MIT 14.006, 66.7%), and routine-priority (MIT 14.009, 71.4%) specialty appointments occurred within required time frames. OIG clinicians reviewed 72 specialty events and identified three deficiencies related to 13 specialty appointments. We discuss these deficiencies in the Specialty Services indicator. Follow-Up After Specialty Services Compliance testing showed provider follow-up appointments after specialty services frequently occurred within required time frames (MIT 1.008, 90.9%). OIG clinicians did not identify any missed or delayed provider appointments. Follow-Up After Hospitalization Compliance testing showed provider appointments after hospitalization generally occurred within required time frames (MIT 1.007, 80.0%). OIG clinicians reviewed 27 hospital returns and did not identify any missed or delayed appointments. 13 Deficiencies occurred in cases 10, 15, and 25. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 15 Follow-Up After Urgent or Emergent Care (TTA) Providers always evaluated their patients following a TTA event as medically indicated. The OIG clinicians reviewed 49 TTA events and did not identify any deficiencies. Follow-Up After Transferring Into KVSP Compliance testing showed provider appointments for newly arrived patients usually occurred timely (MIT 1.002, 82.6%). Case review evaluated six transfer-in events and did not identify any missed or delayed provider appointments. Clinician On-Site Inspection Our case review clinicians spoke with KVSP’s medical leadership, nursing leadership, and scheduling supervisors regarding the institution’s access to care. We were informed KVSP has four main clinics: A, B, C, and D. Each clinic was staffed with one provider and an office technician who attended the morning huddles and scheduled provider appointments by compliance dates. Each provider evaluated about 12 patients per day. At the time of the on-site inspection, KVSP showed OIG clinicians the appointment backlog tracker for all clinics, which indicated a backlog of only one provider appointment. Compliance On-Site Inspection Five of six housing units randomly tested at the time of inspection had access to the health care services request form (CDCR Form 7362) (MIT 1.101, 83.3%). In one housing unit, custody officers did not have a system in place for restocking the forms. The custody officers reported relying on medical staff to replenish the forms in the housing unit. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 16 Compliance Score Results Table 5. Access to Care Scored Answer Compliance Questions Yes No N/A Yes % Chronic care follow-up appointments: Was the patient’s most recent chronic care visit within the health care guideline’s maximum allowable interval or 12 13 0 48.0% 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 19 4 2 82.6% patient seen by the clinician within the required time frame? (1.002) Clinical appointments: Did a registered nurse review the patient’s request 28 2 0 93.3% for service the same day it was received? (1.003) Clinical appointments: Did the registered nurse complete a face-to-face visit 25 4 1 86.2% 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 9 3 18 75.0% maximum allowable time or the ordered time frame, whichever is the shorter? (1.005) Sick call follow-up appointments: If the primary care provider ordered a follow-up sick call appointment, did it take place within the time frame 1 0 29 100% specified? (1.006) Upon the patient’s discharge from the community hospital: Did the patient 20 5 0 80.0% receive a follow-up appointment within the required time frame? (1.007) Specialty service follow-up appointments: Did the clinician follow-up visits 30 3 12 90.9% occur within required time frames? (1.008) * Clinical appointments: Do patients have a standardized process to obtain 5 1 0 83.3% and submit health care services request forms? (1.101) Overall percentage (MIT 1): 82.2% * 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: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 17 Table 6. Other Tests Related to Access to Care Scored Answer Compliance Questions Yes No N/A Yes % For patients received from a county jail: If, during the assessment, the nurse referred the patient to a provider, was the patient seen within the required N/A N/A N/A N/A time frame? (12.003) For patients received from a county jail: Did the patient receive a history and physical by a primary care provider within seven calendar days (prior to N/A N/A N/A N/A 07/2022) or five working days (effective 07/2022)? (12.004) Was a written history and physical examination completed within the 10 0 0 100% required time frame? (13.002) Did the patient receive the high-priority specialty service within 14 calendar days of the primary care provider order or the Physician Request for 14 1 0 93.3% Service? (14.001) Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care 6 4 5 60.0% 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? 6 3 6 66.7% (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 5 2 8 71.4% provider? (14.009) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 18 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 19 Diagnostic Services In this indicator, OIG inspectors evaluated the institution’s performance in timely completing radiology, laboratory, and pathology tests. Our inspectors determined whether the institution properly retrieved the resultant reports and whether providers reviewed the results correctly. In addition, in Cycle 7, we examined the institution’s performance in timely completing and reviewing immediate (STAT) laboratory tests. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Inadequate (61.5%) Case review found KVSP performed satisfactorily in this indicator. Staff completed all radiology tests and most laboratory tests within specified time frames. The providers inconsistently generated complete patient test result notification letters; however, these deficiencies did not significantly increase the risk of harm to patients. Taking all factors into consideration, the OIG rated the case review component of this indicator adequate. KVSP scored low overall in compliance testing for this indicator. Staff performed well in completing radiology and laboratory tests as well as in retrieving pathology testing results. However, staff performed poorly in completing STAT laboratory tests. Providers generally endorsed diagnostic results but rarely generated 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 The OIG clinicians reviewed 136 diagnostic events and identified 18 deficiencies. Of the 18 deficiencies, 16 related to health information management and two related to test completion.14 Test Completion Compliance testing showed staff usually completed radiology tests within specified time frames (MIT 2.001, 80.0%). OIG clinicians reviewed 13 radiology tests and did not identify any missed or delayed test completions. Compliance testing also showed staff generally completed laboratory tests within specified time frames (MIT 2.004, 80.0%). OIG clinicians reviewed 116 laboratory tests and identified two deficiencies related to untimely test completion.15 The following is an example: 14 Diagnostic deficiencies occurred in cases 1, 2, 6, 9–12, 15, 16, 24, 46, and 47. 15 Deficiencies occurred in cases 2 and 24. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 20 • In case 2, a provider ordered a urine toxicology test to be done on the following day. However, the test was completed five days late. Compliance testing revealed staff performed only half of STAT laboratory tests within required time frames (MIT 2.007, 50.0%). In their case samples, OIG clinicians did not have any STAT laboratory tests, but had a STAT chest X-ray and two STAT electrocardiograms. KVSP staff completed these timely. Health Information Management Compliance testing showed providers sometimes endorsed radiology reports and frequently endorsed laboratory reports timely (MIT 2.002, 70.0% and MIT 2.005, 90.0%). The providers also often endorsed pathology reports (MIT 2.011, 80.0%) and always endorsed STAT laboratory results timely (MIT 2.009, 100%). Case review also found providers endorsed all diagnostic results timely. We did not identify any deficiencies related to test endorsements. In compliance testing, staff only occasionally notified providers of STAT laboratory results within required time frames (MIT 2.008, 28.6%) but generally retrieved pathology reports on time (MIT 2.010, 80.0%). Compliance testing revealed providers only sporadically sent patient test result notification letters within required time frames for radiology tests (MIT 2.003, 20.0%), laboratory tests (MIT 2.006, 30.0%), and pathology tests (MIT 2.012, 30.0%). OIG clinicians identified four deficiencies in which providers did not send letters notifying patients of laboratory test results and one deficiency in which the provider did not send a letter notifying the patient of radiology test results. We also identified 11 examples of patient test result notification letters missing at least one of the required elements. The following are examples: • In case 1, a provider notified a patient of laboratory test results with a letter, but the letter did not include all required elements such as whether the test results were within normal limits. • In case 10, a provider endorsed laboratory test results, including an elevated hemoglobin A1c level, but did not send the required patient notification letter.16 • In case 46, a provider endorsed an x-ray report of the patient’s right hand, but did not send the required patient result notification letter. Clinician On-Site Inspection The laboratory supervisor reported KVSP had four full-time phlebotomists who collected blood samples for laboratory tests at the four main clinics, and an x-ray technician who performed general x-rays on site. KVSP also had on-site ultrasound, CT, and MRI imaging available through mobile imaging services once a month.17 The laboratory 16 Hemoglobin A1c is a blood test that measures the average blood glucose level over the previous 12 weeks. 17 A CT scan is a computed, or computerized, tomography imaging scan. An MRI is a magnetic resonance imaging scan. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 21 supervisor detailed the process for STAT blood tests, stating the four-hour window for results began when the specimen was picked up by a contracted vendor. Laboratory staff then called the vendor for results approximately two hours later and every hour thereafter until results were reported. Laboratory personnel were expected to relay this information to a TTA registered nurse (RN), who would then call the provider with the STAT laboratory test results. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 22 Compliance Score Results Table 7. Diagnostic Services Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Was the radiology service provided within the time frame 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 7 3 0 70.0% radiology report within specified time frames? (2.002) Radiology: Did the ordering health care provider communicate the results 2 8 0 20.0% of the radiology study to the patient within specified time frames? (2.003) Laboratory: Was the laboratory service provided within the time frame 8 2 0 80.0% specified in the health care provider’s order? (2.004) Laboratory: Did the health care provider review and endorse the laboratory 9 1 0 90.0% report within specified time frames? (2.005) Laboratory: Did the health care provider communicate the results of the 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 4 4 0 50.0% the results within the required time frames? (2.007) Laboratory: Did the provider acknowledge the STAT results, OR did nursing 2 5 1 28.6% staff notify the provider within the required time frames? (2.008) Laboratory: Did the health care provider endorse the STAT laboratory 7 0 1 100% results within the required time frames? (2.009) Pathology: Did the institution receive the final pathology report within the 8 2 0 80.0% required time frames? (2.010) Pathology: Did the health care provider review and endorse the pathology 8 2 0 80.0% report within specified time frames? (2.011) Pathology: Did the health care provider communicate the results of the 3 7 0 30.0% pathology study to the patient within specified time frames? (2.012) Overall percentage (MIT 2): 61.5% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 23 Recommendations • The department should develop strategies, such as a statewide electronic solution, to ensure providers generate letters communicating test results to their patients and the letters include all elements as required by CCHCS policy. • Medical leadership should determine the root cause(s) of challenges related to timely collecting, receiving, and notifying STAT laboratory test results and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 24 Emergency Services In this indicator, OIG clinicians evaluated the quality of emergency medical care. Our clinicians reviewed emergency medical services by examining the timeliness and appropriateness of clinical decisions made during medical emergencies. Our evaluation included examining the emergency medical response, cardiopulmonary resuscitation (CPR) quality, triage and treatment area (TTA) care, provider performance, and nursing performance. Our clinicians also evaluated the Emergency Medical Response Review Committee’s (EMRRC) performance in identifying problems with its emergency services. The OIG assessed the institution’s emergency services solely through case review. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Not Applicable OIG clinicians found KVSP generally provided sufficient emergency care. Compared with Cycle 6, KVSP’s performance in emergency services improved. Providers delivered good care, and nurses provided good interventions as well as sufficient assessments and documentation. The EMRRC performed clinical reviews and identified most of their staff members’ deficiencies. Overall, the OIG rated this indicator adequate. Case Review Results We reviewed 49 urgent or emergent events and identified 15 emergency care deficiencies. Of these deficiencies, three were significant.18 Emergency Medical Response KVSP staff responded promptly to emergencies throughout the institution. They initiated CPR, activated emergency medical services (EMS), and notified TTA staff timely. Provider Performance KVSP providers performed well in urgent and emergent situations. Most providers made appropriate decisions, transferred patients to a community hospital when necessary, and documented events as clinically indicated. However, we identified one deficiency as follows: • In case 2, a provider evaluated a patient with chest pain and ordered sublingual nitroglycerine, suspecting coronary artery syndrome.19 However, 18 Deficiencies occurred in cases 1–5, 7, 8, and 50. Significant deficiencies occurred in cases 1, 2, and 8. 19 Nitroglycerin is a medication that dilates blood vessels to increase blood flow to the heart. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 25 the provider ordered the patient be transferred to community hospital via BLS instead of ACLS transport.20 Nursing Performance KVSP nurses generally provided appropriate nursing assessments and good interventions. Nurses recognized when opioid overdoses occurred and implemented the nursing overdose protocol. However, we identified a pattern of deficiencies for incomplete nursing assessments. The following cases are examples: • In case 1, the patient complained of chest pain radiating to the left shoulder and right-sided weakness. The patient reported taking a vasodilator (nitroglycerin). However, the nurse did not reassess the patient’s pain to determine whether additional doses of nitroglycerin needed to be given. In addition, the nurse did not assess the patient’s extremities for tone and sensation. • In case 8, the patient complained of heartburn and nausea. A licensed vocational nurse (LVN) was the first medical responder. The LVN obtained vital signs and documented a plan to send the patient to the RN clinic for further evaluation. However, we found no evidence an RN evaluated the patient. Nursing Documentation Nursing documentation was sufficient. However, we identified a pattern of deficiencies related to nurses not documenting medication administration times on the medication administration record (MAR). We also identified timeline discrepancies related to sequences of events. Emergency Medical Response Review Committee OIG clinicians found KVSP performed clinical reviews for all patients who transferred to a higher level of care and self-identified most of their staff members’ deficiencies. Compliance testing showed the EMRRC checklist was only sporadically completed timely and thoroughly (MIT 15.003, 16.7%). This is discussed further in the Administrative Operations indicator. Clinical On-Site Inspection OIG clinicians toured the TTA during our on-site inspection. The institution had three medical beds and sufficient space to provide emergency care. One designated provider was available during regular business hours; otherwise, providers were assigned on an on-call basis and were available by telephone. The nurses reported the TTA had two RNs on the night shift and three RNs on the morning and afternoon shifts. Although they did not have an official position for the third RN, leadership assigned the third RN as a floating position due to the increased patient care workload and increase in patients 20 BLS is basic life support while ACLS is advanced cardiac life support. ACLS transport is critical care transport for patients who need emergency care and a high level of medical monitoring, such as patients who have cardiac symptoms. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 26 returning from off-site appointments. Nurses also reported having a good rapport and collaborative working relationship with custody staff and leadership. We met with nursing leadership to discuss some of our case review findings. Leadership reported providing training to staff. They also shared some of their training materials and tools for quality improvement. For example, they had a first medical responder timeline tool for the scriber or writer, which also served as a prompt for tasks that needed to be completed. Leadership also presented training on TTA-required documentation for higher level of care send-outs, off-site returns, and TTA walk-ins. Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 27 Health Information Management In this indicator, OIG inspectors evaluated the flow of health information, a crucial link in high-quality medical care delivery. Our inspectors examined whether the institution retrieved and scanned critical health information (progress notes, diagnostic reports, specialist reports, and hospital discharge reports) into the medical record in a timely manner. Our inspectors also tested whether clinicians adequately reviewed and endorsed those reports. In addition, our inspectors checked whether staff labeled and organized documents in the medical record correctly. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Adequate (77.1%) Case review found KVSP performed well in health information management. Medical staff retrieved all hospital records and most specialty reports within required time frames. However, we found a large number of incomplete or missing patient notification letters, as well as rare scanning errors or illegible nurse names. Taking all factors into consideration, the OIG rated the case review component of this indicator adequate. KVSP’s compliance testing performance was satisfactory. Staff always scanned patient health care request forms. They also retrieved most hospital records and specialty reports within required time frames. However, staff performed poorly in scanning, labeling, and filing medical documents into the appropriate patient file. Based on the overall compliance score result, the OIG rated the compliance component of this indicator adequate. Case Review and Compliance Testing Results OIG clinicians reviewed 808 events and identified 25 deficiencies related to health information management. None of these deficiencies were significant.21 Hospital Discharge Reports Compliance testing revealed staff usually retrieved hospital records timely (MIT 4.003, 85.7%). In addition, hospital discharge reports always included key elements and providers always endorsed all discharge summaries timely (MIT 4.005, 100%). OIG clinicians reviewed 27 off-site emergency department or hospital encounters and found KVSP staff retrieved all discharge summaries timely. However, we identified one late endorsement as described below: 21 Deficiencies occurred in cases 1, 6, 8–12, 15, 16, 24, 26, 28, 46, and 47. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 28 • In case 8, the provider endorsed a hospital discharge summary eight days after the report was scanned into the EHRS. Specialty Reports Compliance testing showed staff generally retrieved and scanned specialty reports within required time frames (MIT 4.002, 83.3%); however, staff needed significant improvement in timely retrieving or endorsing high-priority (MIT 14.002, 73.3%), medium-priority (MIT 14.005, 46.7%), and routine-priority specialty reports (MIT 14.008, 50.0%). OIG clinicians reviewed 72 specialty appointments and identified the following deficiency: • In case 11, the medical staff scanned an endocrinology report three days late. We also identified one report that no provider endorsed, and two reports that the providers endorsed late. The following are examples: • In case 12, the provider did not endorse a cardiac stress test report. • In case 46, the provider endorsed an orthopedic report 11 days after the report was scanned into the EHRS. Diagnostic Reports Compliance testing showed KVSP providers always timely endorsed STAT laboratory results (MIT 2.009, 100%) and most pathology reports (MIT 2.011, 80.0%) within required time frames. Providers often endorsed laboratory results (MIT 2.005, 90.0%) but needed improvement in endorsing radiology results (MIT 2.002, 70.0%) within required time frames. OIG clinicians did not identify any deficiencies related to diagnostic test endorsement but identified a pattern of 16 deficiencies involving incomplete or missing patient test result notification letters, none of which were significant. Please refer to the Diagnostic Services indicator for additional information. Urgent and Emergent Records OIG clinicians reviewed 49 emergency care events and found some documentation deficiencies. Nevertheless, both nurses and providers recorded these events adequately. Please see the Emergency Services indicator for more information. Scanning Performance Compliance testing showed staff always scanned patient health care request forms timely (MIT 4.001, 100%), but only sporadically scanned, labeled, or filed medical documents properly (MIT 4.004, 16.7%). OIG clinicians identified two minor deficiencies related to mislabeled or misfiled medical documents as discussed below: Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 29 • In case 15, a specialist consultation report was scanned into the wrong patient’s EHRS. • In case 26, a specialized medical housing provider progress note was mislabeled as an outpatient progress note. Legibility OIG clinicians found most handwritten nursing assessments of sick call requests were legible; however, we identified two deficiencies related to illegible nurses’ names.22 Clinician On-Site Inspection OIG clinicians discussed health information management processes with the KVSP health information management supervisor, who stated the institution had a tracking process for specialty consultations and hospital records to ensure those documents were retrieved timely. We also discussed the numerous incomplete patient notification letters with the chief physician and surgeon (CP&S), who stated an expectation for the providers to review their inboxes daily and generate patient notification letters when indicated. KVSP developed a patient notification letter template that included all required elements, such as the date of the test, whether the test result was within normal limits, and whether a follow-up appointment was required. 22 Deficiencies occurred in cases 11 and 28. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 30 Compliance Score Results Table 8. Health Information Management Scored Answer Compliance Questions Yes No N/A Yes % Are health care service request forms scanned into the patient’s electronic 20 0 10 100% health record within three calendar days of the encounter date? (4.001) Are specialty documents scanned into the patient’s electronic health record 25 5 15 83.3% within five calendar days of the encounter date? (4.002) Are community hospital discharge documents scanned into the patient’s electronic health record within three calendar days of hospital discharge? 18 3 4 85.7% (4.003) During the inspection, were medical records properly scanned, labeled, 4 20 0 16.7% 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 25 0 0 100% review the report within five calendar days of discharge? (4.005) Overall percentage (MIT 4): 77.1% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 31 Table 9. Other Tests Related to Health Information Management Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Did the ordering health care provider review and endorse the 7 3 0 70.0% radiology report within specified time frames? (2.002) Laboratory: Did the health care provider review and endorse the laboratory 9 1 0 90.0% report within specified time frames? (2.005) Laboratory: Did the provider acknowledge the STAT results, OR did nursing 2 5 1 28.6% staff notify the provider within the required time frame? (2.008) Pathology: Did the institution receive the final pathology report within the 8 2 0 80.0% required time frames? (2.010) Pathology: Did the health care provider review and endorse the pathology 8 2 0 80.0% report within specified time frames? (2.011) Pathology: Did the health care provider communicate the results of the 3 7 0 30.0% 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 11 4 0 73.3% 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 7 8 0 46.7% 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 7 7 1 50.0% frame? (14.008) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 32 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 33 Health Care Environment In this indicator, OIG compliance inspectors tested clinics’ waiting areas, infection control, sanitation procedures, medical supplies, equipment management, and examination rooms. Inspectors also tested clinics’ performance in maintaining auditory and visual privacy for clinical encounters. Compliance inspectors asked the institution’s health care administrators to comment on their facility’s infrastructure and its ability to support health care operations. The OIG rated this indicator solely on the compliance score. Case review does not rate this indicator. Because none of the tests in this indicator directly affected clinical patient care (it is a secondary indicator), the OIG did not consider this indicator’s rating when determining the institution’s overall compliance rating and score. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Inadequate (50.1%) Overall, KVSP performed poorly with respect to its health care environment. In this cycle, multiple aspects of KVSP’s health care environment needed improvement: medical supply storage areas inside and outside the clinics contained expired medical supplies; several areas of the examination rooms were unsanitary; EMRB logs were missing staff verification or staff did not perform inventory when changing seal tags; several clinics did not meet the requirements for essential core medical equipment and supplies; and staff did not properly wash their hands throughout patient encounters. Based on the overall compliance score result, the OIG rated this indicator inadequate. Compliance Testing Results Waiting Areas We inspected only indoor waiting areas, as KVSP had no outdoor waiting areas. Health care and custody staff reported the existing waiting areas contained sufficient seating capacity (see Photo 1). During our inspection, we did not observe overcrowding in any of the clinics’ indoor waiting areas. Photo 1. Clinic waiting area (photographed on 12-19-23). Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 34 Clinic Environment All clinic environments were sufficiently conducive for medical care; they provided reasonable auditory privacy, appropriate waiting areas, wheelchair accessibility, and nonexamination room workspace (MIT 5.109, 100%). Eight of the 10 applicable clinics we observed contained appropriate space, configuration, supplies, and equipment to allow clinicians to provide proper medical services (MIT 5.110, 80.0%). In one clinic, the examination room had unsecured confidential medical records. In the other remaining clinic, the sink cabinet was in disrepair. Clinic Supplies Only four of the 11 clinics followed adequate medical supply storage and management protocols (MIT 5.107, 36.4%). We found one or more of the following deficiencies in seven clinics: compromised sterile medical supply packaging; long-term storage of staff members’ food in the medical supply storage room (see Photo 2, right); expired medical supplies (see Photo 3, below, and Photo 4, next page); unorganized, unidentified, or inaccurately labeled medical supplies; and cleaning materials stored with medical supplies. Photo 2. Long-term storage of staff members’ food stored in the medical supply storage room (photographed on 12-19-23). Photo 3. Expired medical supply dated June 2021 (photographed on 12-19-23). Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 35 Photo 4. Expired medical supply dated January 31, 2023 (photographed on 12-21-23). Three of the 11 clinics met requirements for essential core medical equipment and supplies (MIT 5.108, 27.3%). The remaining eight clinics lacked medical supplies or contained nonfunctional equipment. The missing items included a nebulization unit, oto- ophthalmoscope, and disposable examination table paper. The nonfunctional equipment included the Snellen eye chart at an improper distance and a nonfunctional oto- ophthalmoscope. We also found staff either did not complete performance checks of the automated external defibrillator or did not complete the defibrillator performance test log documentations within the last 30 days. In addition, several clinic daily glucometer quality control logs were incomplete. We examined EMRBs to determine whether they contained all essential items. We checked whether staff inspected the bags daily and inventoried them monthly. Only one of the nine EMRBs passed our test (MIT 5.111, 11.1%). We found one or more of the following deficiencies with eight EMRBs: staff failed to ensure EMRB compartments were sealed and intact, and staff had not inventoried the EMRBs when the seal tags were replaced. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 36 Medical Supply Management None of the medical supply storage areas located outside the medical clinics contained medical supplies stored adequately (MIT 5.106, zero). We found expired medical supplies (see Photo 5, right). In addition, the warehouse manager did not maintain a temperature log for medical supplies with manufacturer temperature guidelines stored in the medical warehouse. (see Photo 6, below). According to the chief executive officer (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 Photo 5. Expired medical supply dated July 12, 2023 their communication process. (photographed on 12-21-23). Photo 6. Medical supply with manufacturer’s temperature guideline (photographed on 12-19-23). Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 37 Infection Control and Sanitation Staff appropriately cleaned, sanitized, and disinfected four of 10 applicable clinics (MIT 5.101, 40.0%). In six clinics, either cleaning logs were incomplete, or we found one or more of the following items to be unsanitary: a stretcher (see Photo 7, right), a cabinet under the sink, cabinet drawers, a suction machine, and an emergency medical response vehicle (see Photo 8, below). Photo 7. Unsanitary stretcher (photographed on 12-20-23). Photo 8. Unsanitary emergency medical response vehicle (photographed on 12-20-23). Staff in seven of 10 applicable clinics properly sterilized or disinfected medical equipment (MIT 5.102, 70.0%). In one clinic, staff did not remove and replace the examination table disposable paper between patient encounters. In another clinic, staff did not mention disinfecting the examination table as part of their daily start-up protocol. In the remaining clinic, staff did not ensure reusable invasive medical equipment was kept sterile. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 38 We found operational sinks and hand hygiene supplies in the examination rooms in seven of 10 applicable clinics (MIT 5.103, 70.0%). The patient restrooms in three clinics lacked either antiseptic soap or disposable hand towels. We observed patient encounters in six clinics. In five clinics, staff did not wash their hands before or after examining their patients (MIT 5.104, 16.7%). Health care staff in all clinics followed proper protocols to mitigate exposure to blood- borne pathogens and contaminated waste (MIT 5.105, 100%). Physical Infrastructure At the time of our medical inspection, the institution’s administrative team reported no ongoing health care facility improvement program construction projects. The institution’s health care management and plant operations manager reported all clinical area infrastructures were in good working order (MIT 5.999). Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 39 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, 4 6 1 40.0% cleaned, and sanitary? (5.101) Infection control: Do clinical health care areas ensure that reusable invasive and noninvasive medical equipment is properly sterilized or disinfected as 7 3 1 70.0% warranted? (5.102) Infection control: Do clinical health care areas contain operable sinks and 7 3 1 70.0% sufficient quantities of hygiene supplies? (5.103) Infection control: Does clinical health care staff adhere to universal hand 1 5 5 16.7% hygiene precautions? (5.104) Infection control: Do clinical health care areas control exposure to blood- 10 0 1 100% borne pathogens and contaminated waste? (5.105) Warehouse, conex, and other nonclinic storage areas: Does the medical supply management process adequately support the needs of the medical 0 1 0 0 health care program? (5.106) Clinical areas: Does each clinic follow adequate protocols for managing and 4 7 0 36.4% storing bulk medical supplies? (5.107) Clinical areas: Do clinic common areas and exam rooms have essential core 3 8 0 27.3% medical equipment and supplies? (5.108) Clinical areas: Are the environments in the common clinic areas conducive 9 0 2 100% to providing medical services? (5.109) Clinical areas: Are the environments in the clinic exam rooms conducive to 8 2 1 80.0% providing medical services? (5.110) Clinical areas: Are emergency medical response bags and emergency crash carts inspected and inventoried within required time frames, and do they 1 8 2 11.1% 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): 50.1% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 40 Recommendations • Nursing leadership should determine the root cause(s) of staff neglecting to ensure clinic examination rooms contain essential core medical equipment, and staff failing to follow equipment and medical supply management protocols, and should take necessary remedial measures. • Medical and nursing leadership should analyze the root cause(s) for staff not following all required universal hand hygiene precautions and should implement remedial measures as appropriate. • Nursing leadership should determine the root cause(s) for staff neglecting to ensure the EMRBs are regularly inventoried and sealed and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 41 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 staff performance in communicating vital health transfer information, such as preexisting health conditions, pending appointments, tests, and specialty referrals. Inspectors further 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 Adequate (75.5%) OIG clinicians found KVSP performed sufficiently in the transfer process. Nurses screened patients appropriately. When patients returned from the hospital or emergency rooms they received good care. Nurses performed good assessments, and the provider follow-up appointments occurred timely. However, KVSP did not maintain medication continuity when patients transferred into the institution. The OIG rated the case review component of this indicator adequate. Compared with Cycle 6, KVSP’s overall compliance performance greatly improved for this indicator. KVSP performed excellently in completing the assessment and disposition section of the screening process. However, KVSP still needed improvement in completing the initial health screening forms and in ensuring medication continuity for patients newly transferring into the institution. Based on the overall compliance score result, the OIG rated the compliance testing component of this indicator adequate. Case Review and Compliance Testing Results We reviewed 75 events in 24 cases in which patients transferred into or out of the institution, or returned from an off-site hospital or emergency room. We identified 10 deficiencies, none of which were significant.23 23 Deficiencies occurred in cases 6, 8, 12, 18, 20, 22, 23, and 26. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 42 Transfers In OIG clinicians reviewed 11 events and identified two deficiencies, neither of which was significant. Compliance testing showed nurses did not complete the initial health screening forms thoroughly (MIT 6.001, 28.0%). In contrast, nurses performed excellently in addressing signs and symptoms when screening for tuberculosis (MIT 6.002, 100%). OIG clinicians found nurses screened patients appropriately. Compliance testing showed KVSP needed improvement in ensuring patients received their medications timely (MIT 6.003, 73.9%). OIG clinicians found poor medication continuity when patients transferred into KVSP. The following two cases showed room for improvement: • In case 6, on 5/17/23, the patient transferred in without his KOP gastrointestinal medications. The medications were reordered to be reissued the same day of arrival. However, the patient never received the medications during the review period. • In case 18, on 7/21/23, the patient, with a history of arthritis, transferred in without his pain medication. The medication was reordered to be reissued the same day of arrival; however, the patient received the medication seven days late. Compliance testing showed providers saw newly arrived patients within required time frames (MIT 1.002, 82.6%). OIG clinicians found all patients were seen timely. Compliance testing showed KVSP performed poorly in providing timely preapproved specialty services appointments when patients transferred into the institution (MIT 14.010, 30.0%). OIG clinicians did not review any applicable transfer-in cases. Transfers Out OIG clinicians reviewed six events and identified three deficiencies, none of which were significant. We found nurses generally screened patients appropriately, completed the interfacility transfer information, and ensured all patients had their medical equipment. KVSP generally transferred patients with a five-day supply of medications. At the time of the on-site inspection, compliance reviewed one transfer packet. The transfer packet included all medications and required documents (MIT 6.101, 100%). Hospitalizations Patients returning from an off-site hospitalization or emergency room are at high risk for lapses in care quality. These patients typically have 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. OIG clinicians reviewed 58 events and identified five deficiencies, none of which were significant. The nurses performed good assessments, reviewed the hospital’s recommendations, and notified the providers in most cases. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 43 Compliance testing showed staff frequently scanned hospital discharge documents within required time frames (MIT 4.003, 85.7%), and providers reviewed all documents timely (MIT, 4.005, 100%). OIG clinicians found most documents were scanned within required time frames, and providers reviewed all documents timely. Compliance testing showed poor medication continuity for patients returning from hospitalizations (MIT 7.003, 8.0%). In contrast, OIG clinicians found the patients in their cases who returned from hospitals and emergency rooms generally received their medications timely. Compliance testing showed KVSP provided timely follow-up appointments for patients returning from hospitals and emergency rooms (MIT 1.007, 80.0%). OIG clinicians found all follow-up appointments for these patients in their cases occurred timely. Clinician On-Site Inspection The R&R nurse was knowledgeable about the transfer process. The R&R area was staffed with one nurse on each shift. We were informed, on average, 10 patients per day transferred out of KVSP. A few days before our on-site inspection, 77 patients had transferred into KVSP from Corcoran State Prison. The nurse reported extra nurses were assigned to the R&R to help with the large influx of patients. The nurse also reported nursing morale was good and rapport with nursing leadership and custody staff was positive. Compliance Testing Results Compliance On-Site Inspection and Discussion R&R nursing staff ensured all patients transferring out of the institution had the required medications, transfer documents, and assigned durable medical equipment (DME) (MIT 6.101, 100%). Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 44 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 7 18 0 28.0% questions within the required time frame? (6.001) For endorsed patients received from another CDCR institution: When required, did the RN complete the assessment and disposition section of the initial health screening form; refer the patient to the TTA if TB signs and 25 0 0 100% symptoms were present; and sign and date the form on the same day staff completed the health screening? (6.002) For endorsed patients received from another CDCR institution: If the patient had an existing medication order upon arrival, were medications 17 6 2 73.9% 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 1 0 0 100% required documents? (6.101) Overall percentage (MIT 6): 75.5% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 45 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 19 4 2 82.6% 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 20 5 0 80.0% 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? 18 3 4 85.7% (4.003) For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements and did a provider 25 0 0 100% 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 2 23 0 8.0% within required time frames? (7.003) Upon the patient’s transfer from one housing unit to another: Were 18 7 0 72.0% 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 3 7 0 30.0% administered or delivered without interruption? (7.006) For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the sending 6 14 0 30.0% institution, was the appointment scheduled at the receiving institution within the required time frames? (14.010) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 46 Recommendations • Healthcare leadership should identify the challenges to maintaining medication continuity for patients transferring into the institution without their medications and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 47 Medication Management In this indicator, OIG inspectors evaluated the institution’s performance in administering prescription medications on time and without interruption. The inspectors examined this process from the time a provider prescribed medication until the nurse administered the medication to the patient. When rating this indicator, the OIG strongly considered the compliance test results, which tested medication processes to a much greater degree than case review testing. In addition to examining medication administration, our compliance inspectors also tested many other processes, including medication handling, storage, error reporting, and other pharmacy processes. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Inadequate (56.9%) Overall, OIG clinicians found KVSP performed sufficiently in medication management. They managed medications well for patients with new prescriptions as well as for patients returning from the hospital or emergency rooms. KVSP showed room for improvement in medication management for transfer-in patients and patients in specialized medical housing. The OIG rated the case review component of this indicator adequate. Compliance testing showed KVSP needed improvement in this indicator. KVSP received low scores in providing patients with chronic care medications, newly prescribed medications, and community hospital discharge medications. KVSP also received low scores in providing medications for patients temporarily housed at the institution as well as in medication continuity for patients transferring within the institution. 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 100 events in 27 cases related to medications and identified 28 medication deficiencies, six of which were significant.24 New Medication Prescriptions Compliance testing showed new medications were not always available or administered timely (MIT 7.002, 60.0%). Our clinicians identified five deficiencies, one of which was significant. The following is an example: 24 Deficiencies occurred in cases 1, 2, 6, 7, 10–12, 15, 18, 22, 23, 25, 26, 47, and 54. Significate deficiencies occurred in cases 10, 12, 15, 23, and 26. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 48 • In case 10, the patient had a leg wound. The provider ordered an antibiotic to start the next day. However, the patient received the new medication one day late. Chronic Medication Continuity Compliance testing showed patients only sporadically received their chronic care medications within required time frames (MIT 7.001, 18.8%). OIG clinicians identified 12 deficiencies, three of which were significant. The following cases are examples: • In case 12, the patient had a history of high blood pressure and high cholesterol. The patient did not receive his blood pressure and cholesterol medications for one month, resulting in a lapse in medication continuity. • In case 15, the patient had a history of a knee infection. He was prescribed medication he must continuously take for the rest of his life (suppressive antibiotic therapy). However, the medication expired before it was renewed, resulting in a lapse of medication continuity. Hospital Discharge Medications Compliance testing showed patients who returned from off-site hospitals or emergency rooms rarely received their medications within required time frames (MIT 7.003, 8.0%). OIG clinicians identified one minor deficiency. Specialized Medical Housing Medications Compliance testing showed staff only occasionally administered medications timely when patients were admitted to the CTC (MIT 13.003, 40.0%). Our clinicians identified six deficiencies, one of which was significant. The following cases showed room for improvement: • In case 26, the patient complained of a cough. The chest X-ray showed abnormal findings in the lung area. The provider ordered an antibiotic to start the same day. However, the patient received the medication one day late. The nurse documented the medication was not available. • Also in case 26, the patient had a history of high blood pressure. The patient’s blood pressure medications expired prior to being renewed. Subsequently, the patient did not receive the medication for two days. • In case 54, the patient did not receive his mental health medication for one day. The nurse documented the medication was not available. Transfer Medications Compliance testing showed KVSP staff needed to improve in providing patients their medications within required time frames when the patients initially transfer into the institution (MIT 6.003, 73.9%). OIG clinicians found poor medication continuity when patients transferred into the institution; however, patients generally transferred out with their medications. Please refer to the Transfers indicator for further details. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 49 Medication Administration Compliance testing showed nurses intermittently administered tuberculosis (TB) medications as prescribed (MIT 9.001, 62.5%). Further analysis showed the low score resulted from nursing staff not documenting patients’ reasons for not coming to the medication line. In addition, the nurses only sporadically monitored patients taking TB medications (MIT 9.002, 25.0%). In contrast, OIG clinicians found nurses administered these medications properly. Clinician On-Site Inspection Our clinicians interviewed medication nurses and found they were knowledgeable about the medication process. Nurses attended clinic huddles and notified providers about expiring medications. Nurses generally reported nursing morale was good. They also reported having a good rapport with custody staff. We also met with the pharmacist and nursing leadership to discuss some of our findings. The pharmacist reported KVSP had 125 medications available on their licensed correctional clinic list versus 25 medications available on the statewide list.25 This was due to a higher number of the population designated for the enhanced outpatient program as well as to patient drug usage and infection rates at KVSP. The pharmacist reported they could also fill prescriptions at the large chain pharmacies within the community through the pharmacy benefit manager program. For example, if the provider ordered a medication on the weekend that was not available at the institution, the nursing supervisor could take the prescription to the community pharmacy and present the medication coverage card, allowing the community pharmacy to fill order. Nursing leadership presented the training materials they provided to the medication nurses. This training material provided instruction for when to chart “medication not given” versus “medication not done.” Specifically, leadership directed medication nurses to document “not given” when the nurse intended to give the medication as prescribed, but the task was not completed due to patient symptoms or patient request (e.g., low blood pressure or the patient refused). Alternatively, leadership instructed nurses to document “not done” when the patient was not present to receive the medication (e.g., the patient was out to a medical appointment, or a refill was not requested). Compliance Testing Results Medication Practices and Storage Controls The institution adequately stored and secured narcotic medications in all 10 applicable clinic and medication line locations (MIT 7.101, 100%). KVSP appropriately stored and secured nonnarcotic medications in six of 10 applicable clinic and medication line locations (MIT 7.102, 60.0%). In four locations, we observed one or more of the following deficiencies: the medication cart was disorganized and unsanitary; the medication storage cabinet was unclean; the medication area did not have 25 Licensed correctional clinic (LCC) stock refers to stock medications that are not patient-specific, which the pharmacy provides for the medical staff to administer. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 50 a system in place to separate returned medications previously in a patient’s possession from other medications to be returned to the pharmacy; and nurses did not maintain unissued medication in its original labeled packaging. Staff did not keep medications protected from physical, chemical, and temperature contamination in all 10 applicable clinic and medication line locations (MIT 7.103, zero). In all 10 locations, we identified one or more of the following deficiencies: staff did not store internal and external medications separately; the medication refrigerator was unsanitary; and although room temperature was monitored and maintained by pharmacy using a data logger, nursing staff did not record the room temperature as required by CCHCS policy. Staff successfully stored valid, unexpired medications in nine of the 10 applicable medication line locations (MIT 7.104, 90.0%). In one location, nurses did not label the multiple-use medication as required by CCHCS policy. Nurses exercised proper hand hygiene and contamination control protocols in three of seven applicable locations (MIT 7.105, 42.9%). In four locations, some nurses neglected to wash or sanitize their hands before preparing medications or before each subsequent regloving. Staff in four of seven applicable medication preparation and administration areas demonstrated appropriate administrative controls and protocols (MIT 7.106, 57.1%). In three locations, medication nurses did not describe the process they followed when reconciling a newly received medication and the MAR against the corresponding physician’s order. Staff in five of seven applicable medication areas used appropriate administrative controls and protocols when distributing medications to patients (MIT 7.107, 71.4%). In two locations, we observed one or more of the following deficiencies: medication nurses did not always verify a patient’s identification using a secondary identifier; medication nurses did not reliably observe patients while they swallowed direct observation therapy medications; nurses verified the patient’s blood sugar level reading verbally rather than from the glucometer device as required prior to administering insulin medication; and medication nurses did not follow the CCHCS care guide when administering Suboxone medication. Pharmacy Protocols KVSP followed all general security, organization, and cleanliness management protocols for nonrefrigerated and refrigerated medications stored in its pharmacy (MIT 7.108, 7.109, and 7.110, 100%). The pharmacist-in-charge (PIC) did not thoroughly review monthly inventories of controlled substances in the institution’s clinic and medication storage locations. Specifically, the nurse and the pharmacist present at the time of the medication area inspection did not correctly complete several medication area inspection checklists (CDCR Form 7477). These errors resulted in a score of zero for this test (MIT 7.111). At the time of our on-site inspection, the PIC reported no pharmacy-related errors had occurred in the previous 12 months (MIT 7.112, N/A). Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 51 Nonscored Tests In addition to testing the institution’s self-reported medication errors, our inspectors 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 KVSP, the OIG did not find any applicable medication errors (MIT 7.998). The OIG interviewed patients in restricted housing units to determine whether they had immediate access to their prescribed asthma rescue inhalers or nitroglycerin medications. All 20 applicable patients interviewed indicated they had access to their rescue medications (MIT 7.999). Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 52 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 or did the institution follow departmental policy for refusals or no‑shows? 3 13 9 18.8% (7.001) Did health care staff administer, make available, or deliver new order 15 10 0 60.0% prescription 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 2 23 0 8.0% 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 N/A N/A N/A N/A to the patient within the required time frames? (7.004) Upon the patient’s transfer from one housing unit to another: Were medications 18 7 0 72.0% 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 3 7 0 30.0% delivered 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 6 4 1 60.0% storage areas? (7.102) All clinical and medication line storage areas for nonnarcotic medications: Does the institution keep nonnarcotic medication storage locations free of 0 10 1 0 contamination in the assigned storage areas? (7.103) All clinical and medication line storage areas for nonnarcotic medications: Does the institution safely store nonnarcotic medications that have yet to expire in the 9 1 1 90.0% assigned storage areas? (7.104) Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols during medication 3 4 4 42.9% preparation and medication administration processes? (7.105) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when preparing medications 4 3 4 57.1% for patients? (7.106) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when administering 5 2 4 71.4% medications to patients? (7.107) Pharmacy: Does the institution employ and follow general security, organization, and cleanliness management protocols in its main and remote pharmacies? 1 0 0 100% (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 0 1 0 0 medications? (7.111) Pharmacy: Does the institution follow key medication error reporting protocols? N/A N/A N/A N/A (7.112) Pharmacy: For Information Purposes Only: During compliance testing, did the This is a nonscored test. Please see the indicator for OIG find that medication errors were properly identified and reported by the discussion of this test. institution? (7.998) Pharmacy: For Information Purposes Only: Do patients in restricted housing units This is a nonscored test. Please see the indicator for have immediate access to their KOP prescribed rescue inhalers and nitroglycerin discussion of this test. medications? (7.999) Overall percentage (MIT 7): 56.9% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 53 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 17 6 2 73.9% 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 1 0 0 100% required documents? (6.101) Patients prescribed TB medication: Did the institution administer the 5 3 0 62.5% medication to the patient as prescribed? (9.001) Patients prescribed TB medication: Did the institution monitor the patient per policy for the most recent three months he or she was on the 2 6 0 25.0% medication? (9.002) Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient 4 6 0 40.0% within required time frames? (13.003) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 54 Recommendations • The institution should consider developing and implementing measures to ensure staff timely make available and administer medications to patients, and ensure staff document administrating medications in the EHRS, as described in CCHCS policy and procedures. • Nursing leadership should consider developing and implementing strategies to ensure nursing staff properly document patient refusals in the MAR, as described in CCHCS policy and procedures. • Healthcare leadership should identify challenges related to issuing and renewing medications timely in specialized medical housing and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 55 Preventive Services In this indicator, OIG compliance inspectors tested whether the institution offered or provided cancer screenings, tuberculosis (TB) screenings, influenza vaccines, and other immunizations. If the department designated the institution as being at high risk for coccidioidomycosis (Valley Fever), we tested the institution’s performance in transferring out patients quickly. The OIG rated this indicator solely according to the compliance score. Our case review clinicians do not rate this indicator. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Adequate (76.0%) KVSP had a mixed performance in preventive services. Staff performed well in screening patients annually for TB, offering patients an influenza vaccine for the most recent influenza season, offering colorectal cancer screenings for patients from ages 45 through 75, and transferring out patients who are at the highest risk for coccidioidomycosis. However, staff performed poorly in administering and monitoring patients on TB medications, and offering required immunizations to chronic care patients. These findings are set forth in the table on the next page. Based on the overall compliance score result, the OIG rated this indicator adequate. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 56 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 5 3 0 62.5% medication to the patient as prescribed? (9.001) Patients prescribed TB medication: Did the institution monitor the patient per policy for the most recent three months he or she was on the 2 6 0 25.0% 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) 9 5 11 64.3% Are patients at the highest risk of coccidioidomycosis (Valley Fever) 6 0 0 100% infection transferred out of the facility in a timely manner? (9.009) Overall percentage (MIT 9): 76.0% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 57 Recommendations • Nursing leadership should analyze the challenges to ensuring nursing staff administer and monitor patients receiving TB medications according to CCHCS guidelines and should implement remedial measures as appropriate. • Medical leadership should analyze the challenges related to untimely providing required immunizations to chronic care patients and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 58 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 KVSP’s overall nursing care was satisfactory, which was comparable with Cycle 6. Specifically, nurses provided good care in the following areas: hospitalization, transfers- in, and specialty services. Nurses provided sufficient care in the following areas: services for emergency, outpatient, transfers-out, and specialized medical housing. Considering all factors, the OIG rated this indicator adequate. Case Review Results We reviewed 202 nursing encounters in 50 cases. Of the nursing encounters we reviewed, 66 occurred in the outpatient setting, and 41 were sick call requests. We identified 48 nursing performance deficiencies, 10 of which were significant.26 Outpatient Nursing Assessment and Interventions A critical component of nursing care is the quality of nursing assessment, which includes both subjective (patient interviews) and objective (observation and examination) elements. Nurses generally performed appropriate assessments and interventions. We identified 22 outpatient nursing deficiencies, six of which were significant.27 26 Deficiencies occurred in cases 1–5, 7, 8, 12–14, 20, 22–30, 32–34, 37, 41, 42, 50, and 54. Significant deficiencies occurred in cases 1, 8, 13, 24, 26, 30, 33, 34, and 42. 27 Deficiencies occurred in cases 1, 2, 13, 14, 23–25, 27–30, 32–34, 37, 41, and 42. Significant deficiencies occurred in cases 13, 24, 30, 33, 34, and 42. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 59 Nursing Sick Call Nurses triaged most sick call requests appropriately and generally provided appropriate nursing assessments and interventions. We identified a pattern of deficiencies related to incomplete nursing assessments and nurses not ordering needed provider follow-up appointments. The following cases are examples: • In case 13, the patient complained of throat pain, sweating, and allergies. The sick call nurse documented the appointment was completed. However, the record contained no evidence the nurse assessed the patient. • In case 30, the patient complained of two ingrown toenails that were causing him pain. He requested to have the toenails removed. The sick call nurse did not assess the patient’s pain severity. In addition, the nurse documented the plan was to follow up with the provider in 14 days. However, the nurse did not order the appointment. Consequently, the patient was not evaluated by the provider. • In case 42, the patient complained of headaches after eating and weakness. Although the patient denied experiencing pain during the encounter, the sick call nurse did not inquire about the location of the headaches. The nurse documented the plan was to follow up with the provider in 14 days. However, the nurse did not order the appointment. Consequently, the patient was not evaluated by the provider. 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. Nurses generally documented care appropriately. However, the following cases showed room for improvement: • In case 23, the patient had a hand wound. Though the nurses performed daily wound care for seven days, the nurses often did not document the appearance of the wound. • In case 27, the patient complained of ear pain. The nurse documented the patient had swelling of and drainage from the ear. However, the nurse did not document the color of the drainage. Emergency Services We reviewed 49 urgent or emergent events. The nurses performed sufficient assessments and documentation as well as good interventions, which we further detail in the Emergency Services indicator. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 60 Hospital Returns We reviewed 13 cases that involved returns from off-site hospitals or emergency rooms. The nurses performed good assessments, interventions, and documentation. Please refer to the Transfer indicator for further details. Transfers We reviewed six cases involving the transfer-in process. The nurses performed good assessment, interventions, and documentation. We also reviewed three cases involving the transfer-out processes. The nurses performed sufficient screenings and documentation. Please refer to the Transfers indicator for further details. Specialized Medical Housing We reviewed 27 nursing encounters. The nurses performed sufficient assessments and interventions. For more specific details, please refer to the Specialized Medical Housing indicator. Specialty Services We reviewed 11 cases in which patients returned from an off-site specialty appointment. The nurses performed good assessments, reviewed the specialists’ findings and recommendations, and communicated those results to the providers. The Specialty Services indicator provides further details. Medication Management OIG clinicians reviewed 100 events involving medication management and found all nurses administered patient medications as prescribed. Please refer to the Medication Management indicator for additional details. Clinician On-Site Inspection OIG clinicians toured the outpatient clinics, specialty services, medication areas, TTA, CTC, and R&R. We attended organized huddles. Patient care teams were familiar with their patient populations, and nurses were knowledgeable about processes in their respective areas. Nursing staff generally reported nursing morale was good. In addition, they described having good rapport with nursing leadership and custody staff. We met with nursing leadership to discuss some of our case review findings. They agreed with most findings and were very organized and prepared for our discussion. They provided us with numerous training documents they had distributed to their staff to implement quality improvement processes. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 61 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 62 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 Case review found KVSP providers generally delivered good care. Providers mostly made appropriate assessments and decisions, and managed chronic medical conditions effectively. Providers needed to improve with reviewing the MAR and with documentation. Considering all factors, the OIG rated this indicator adequate. Case Review Results OIG clinicians reviewed 103 medical provider encounters and identified nine deficiencies, three of which were significant.28 In addition, we examined the quality of care in 20 comprehensive case reviews and found all 20 cases adequate. Outpatient Assessment and Decision-Making Providers generally made appropriate assessments and sound medical plans for their patients. They diagnosed medical conditions correctly, ordered appropriate tests, and coordinated effective treatment plans for their patients. Case review clinicians identified one deficiency related to poor assessment. • In case 15, a provider evaluated a patient with diarrhea, stool incontinence, and bloody stool but did not perform an abdominal examination. Outpatient Review of Records Providers performed well in reviewing the MAR and in renewing their patients’ medications timely. For patients returning from hospitalizations, providers performed satisfactorily in reviewing medical records and addressing the hospitalists’ 28 Deficiencies occurred in cases 1, 2, 15, 23–25, 45, and 47. Significant deficiencies occurred in cases 1, 2, and 24. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 63 recommendations. We identified two deficiencies related to poor review of medical records as follows: • In case 24, the provider reordered an antiarrhythmic medication for the patient; however, the provider did not review the MAR and, therefore, did not recognize the patient had refused the antiarrhythmic medication.29 • In case 45, the patient was prescribed two antibiotics for a left-hand infection; however, the provider did not review the MAR and, therefore, did not recognize the patient had refused most of the antibiotics. Emergency Care Providers generally made appropriate triage decisions and treatment plans for patients receiving emergency care in the TTA. In addition, providers always documented progress notes for TTA events. The OIG identified one deficiency related to poor provider 30 performance, which we discuss in the Emergency Services indicator. Chronic Care Providers performed well in managing chronic medical conditions such as hypertension, diabetes, asthma, hepatitis C infection, and cardiovascular disease. For patients with diabetes, the providers regularly monitored the patients’ blood glucose levels and adjusted diabetic medications as medically indicated. For patients with cardiovascular disease, the providers generally prescribed antiplatelet and cholesterol-lowering medications to reduce the risk of heart attack or stroke. Specialized Medical Housing Providers delivered good care while completing rounds at clinically appropriate intervals, performed good assessments, and made sound decisions for patients in the specialized medical housing. Our clinician identified one deficiency, which is discussed in the Specialized Medical Housing indicator. Specialty Services Providers appropriately referred and reviewed specialty reports in a timely manner. The providers also often timely addressed most of the specialists’ recommendations. However, we identified one significant deficiency as follows: • In case 1, the provider reviewed the neurologist’s report, but did not address the specialist’s recommendation to reduce the antiplatelet medication dosage by half. 29 An antiarrhythmic medication can prevent and treat abnormal heart rhythms. 30 A deficiency occurred in case 2. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 64 Outpatient Documentation Quality Providers generally documented outpatient encounters on the same day of the encounter. Case review identified three deficiencies related to documentation quality. The following are two examples: • In case 23, the provider evaluated the patient after a recent hospitalization for a right-arm infection but did not document a progress note. • In case 47, the provider evaluated the patient after a recent orthopedic consultation for a right-hand fracture but did not document having reviewed the orthopedic recommendations. Patient Notification Letter Providers performed poorly in relaying diagnostic test results to their patients with notification letters. Providers often did not send complete patient test result notification letters or did not send them at all. We discuss these deficiencies in the Diagnostic Services indicator. Provider Continuity Generally, the institution offered good provider continuity for patient care. Clinician On-Site Inspection Medical leadership reported KVSP had eight full-time providers with one and a half vacancies. The providers were enthusiastic about their work and generally satisfied with nursing, diagnostic, and specialty services. We attended morning huddles for clinics A and C, at each of which the patient care teams discussed specialty appointments with recommendations, patients’ glucose logs, hospital returns, and medication refusals. Nurses informed providers of the scheduled clinic appointments, expiring medications, and new patients arriving from other institutions. In our case reviews, we found 97 patient refusals. We discussed the numerous refusals of medications, provider appointments, and specialty appointments with the KVSP CEO, who expressed concern with shot callers preventing other inmates from attending these appointments and receiving medications such as Suboxone to treat opioid addiction.31 In addition, OIG clinicians also interviewed a provider, who documented in the progress note the patient refused follow-up appointments due to safety concerns. Specifically, the provider explained the patient felt safer remaining in his cell than potentially risking a physical altercation to obtain his medication. 31 A shot caller is term used to name an incarcerated person who is often a gang member and has significant influence over others within an institution. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 65 Recommendations The OIG offers no specific recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 66 Specialized Medical Housing In this indicator, OIG inspectors evaluated the quality of care in the specialized medical housing units. We evaluated the performance of the medical staff in assessing, monitoring, and intervening for medically complex patients requiring close medical supervision. Our inspectors also evaluated the timeliness and quality of provider and nursing intake assessments and care plans. We assessed staff members’ performance in responding promptly when patients’ conditions deteriorated and looked for good communication when staff consulted with one another while providing continuity of care. Our clinicians also interpreted relevant compliance results and incorporated them into this indicator. At the time of our inspection, KVSP’s specialized medical housing consisted of a correctional treatment center (CTC). Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Adequate (77.5%) OIG clinicians found KVSP performed sufficiently in the CTC. Compared with Cycle 6, we identified fewer and less significant clinical deficiencies. The providers delivered good care, and the nurses provided sufficient care. However, medication management in specialized medical housing showed room for improvement. The OIG rated the case review component of this indicator adequate. Compliance testing showed mixed performance in this indicator. Staff frequently completed history and physical examinations in specialized medical housing. However, staff needed improvement in timely completing admission assessments and administering medications. Based on the overall compliance score result, the OIG rated this indicator adequate. Case Review and Compliance Testing Results We reviewed 77 CTC events that included 34 provider events and 27 nursing events. Due to the frequency of nursing and provider contacts in the specialized medical housing, we bundled up to two weeks of patient care into a single event. We identified 20 deficiencies, three of which were significant.32 Provider Performance Compliance testing showed providers always completed admission history and physical examinations timely (MIT 13.002, 100%). OIG clinicians found providers delivered good care, as they completed rounds at clinically appropriate intervals, performed good assessments, made sound decisions, and addressed specialists’ recommendations. We identified one deficiency as follows: 32 Deficiencies occurred in cases 25, 26, and 54. Significant deficiencies occurred in case 26. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 67 • In case 25, the provider reviewed three laboratory tests that showed low blood counts suggestive for anemia; however, the provider did not further evaluate for the low blood count. Nursing Performance Compliance testing showed CTC nurses intermittently completed admission assessments within required time frames (MIT 13.001, 70.0%). OIG clinicians found CTC nurses conducted rounds appropriately and generally provided sufficient care. However, we identified a pattern of deficiencies for incomplete nursing assessments and documentation. The following cases are examples: • In case 26, the patient was diagnosed with pneumonia and a urinary tract infection while in the CTC. Nurses frequently did not assess the patient’s lung sounds or his usage of the incentive spirometer (a hand-held device to improve lung function). In addition, nurses frequently did not assess the color and clarity of the patient’s urine. Furthermore, nurses frequently did not document the patient’s liquid nutritional supplement (LNS) intake. • In case 54, the patient had a history of Crohn’s disease (inflammatory bowel disorder) and was admitted to the CTC. Nurses did not weigh the patient. In addition, nurses did not document the patient’s LNS intake. Medication Administration Compliance testing showed patients admitted to the CTC only sporadically received their medications timely (MIT 13.003, 40.0%). OIG clinicians similarly found opportunities for improvement in this area. Specifically, we identified a pattern of deficiencies related to medications not being available and medications not being renewed before expiration, resulting in missed doses. We discuss these deficiencies further in the Medication Management indicator. Clinician On-Site Inspection The CTC had 10 medical beds and eight negative pressure rooms.33 At the time of our on- site inspection, the center was full. The CTC was staffed with a designated provider, RNs, an LVN, a psychiatric technician, and a nursing assistant. The supervising registered nurse (SRN) reported the night shift SRNs performed chart audits. We met with nursing leadership to discuss some of our case review findings. Leadership provided documentation showing the SRNs had already trained staff on the issues related to our findings. They also shared some of their training materials and tools for quality improvement, including proper documentation for intravenous tubing changes for patients with peripherally inserted central catheters.34 33 A negative pressure room has lower air pressure than the surrounding areas. This helps prevent spread of airborne infectious microorganisms. 34 A peripherally inserted central catheter (PICC) provides intravenous access to administer fluids and medication. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 68 Compliance On-Site Inspection At the time of on-site inspection, the CTC had a functional call light communication system (MIT 13.101, 100%). Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 69 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 7 3 0 70.0% assessment of the patient on the day of admission? (13.001) Was a written history and physical examination completed within the 10 0 0 100% required time frame? (13.002) Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient 4 6 0 40.0% within required time frames? (13.003) For specialized health care housing (CTC, SNF, hospice, OHU): Do specialized health care housing maintain an operational call 1 0 0 100% system? (13.101) For specialized health care housing (CTC, SNF, hospice, OHU): Do health care staff perform patient safety checks according to institution’s local 0 0 1 N/A operating procedure or within the required time frames? (13.102) Overall percentage (MIT 13): 77.5% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 70 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 71 Specialty Services In this indicator, OIG inspectors evaluated the quality of specialty services. The OIG clinicians focused on the institution’s performance in providing needed specialty care. Our clinicians also examined specialty appointment scheduling, providers’ specialty referrals, and medical staff’s retrieval, review, and implementation of any specialty recommendations. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Inadequate (68.8%) Case review found KVSP performed well in providing specialty services. Providers referred patients to specialists appropriately, and staff timely scheduled follow-up appointments. Most specialty appointments occurred as ordered. Staff also retrieved and scanned almost all specialty reports timely; however, we found occasional missing or late endorsements. Factoring in all aspects, the OIG rated the case review component of this indicator adequate. Compliance testing showed mixed performance in specialty services. Access to specialists ranged from excellent to poor, depending on the appointment priority. Preapproved specialty referrals for newly arrived patients sporadically occurred within recommended time frames. In addition, retrieval of specialty reports and prompt provider endorsements both needed improvement. Based on the overall compliance score result, the OIG rated this indicator inadequate. Case Review and Compliance Testing Results OIG clinicians reviewed 103 events related to specialty services, including 72 specialty consultations. We identified nine deficiencies in this category, four of which were significant.35 Access to Specialty Services Compliance testing showed most initial high-priority, medium-priority, and routine- priority specialty appointments occurred timely (MIT 14.001, 93.3%, MIT 14.004, 80.0%, and MIT 14.007, 80.0%). However, the institution needed improvement in timely completing follow-up specialty appointments (MIT 14.003, 60.0%, MIT 14.006, 66.7%, and MIT 14.009, 71.4%). For patients transferring to KVSP with preapproved specialty requests, compliance testing showed the specialty appointments only sporadically occurred timely (MIT 14.010, 30.0%). 35 Deficiencies occurred in cases 1, 10–12, 15, 25, 46, and 47. Significant deficiencies occurred in cases 1, 10, 15, and 25. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 72 Case review found most specialty appointments occurred within required time frames, but identified three significant deficiencies as follows: • In case 10, a MAT provider ordered a follow-up appointment for the patient to occur in 14 days; however, the appointment did not occur.36 • In case 15, a provider ordered the recommended follow-up appointment for the patient with a neurosurgeon to occur within one week; however, the appointment occurred six weeks late. • In case 25, a provider ordered an appointment for the patient with an infectious disease specialist within 16 days; however, the appointment occurred in 90 days. Provider Performance Overall, KVSP’s provider performance was good. Compliance testing showed providers frequently evaluated patients in follow-up appointments after specialty consultations within required time frames (MIT 1.008, 90.9%). Case review found KVSP providers performed well in appropriately referring patients to specialists and in addressing specialists’ recommendations with one exception, which is discussed in the Provider Performance indicator.37 We found providers followed MAT treatment protocols, and we did not identify any deficiencies. Nursing Performance Overall, KVSP’s nursing performance in specialty care was sufficient. TTA nurses appropriately assessed patients after they returned from specialty appointments. TTA and specialty nurses were generally careful to document accurately and order provider follow-up appointments within recommended time frames. Case review did not identify any deficiencies related to nursing performance. Health Information Management Compliance testing showed KVSP staff often retrieved and scanned specialty reports within five days of the specialty encounter date (MIT 4.002, 83.3%). However, staff inconsistently retrieved or reviewed high-priority (MIT 14.002, 73.3%), medium-priority (MIT 14.005, 46.7%), and routine-priority (MIT 14.008, 50.0%) specialty reports within the required time frames. Case review found most specialty reports were retrieved, scanned, and endorsed timely. However, we identified one late scanned report, two late endorsed reports, and one nonendorsed report. We discuss these deficiencies in the Health Information Management indicator. 36 MAT is the Medication Assisted Treatment program for substance use disorder. 37 The deficiency occurred in case 1. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 73 Clinician On-Site Inspection OIG clinicians discussed specialty referral management processes with KVSP medical and nursing leadership, specialty service nurses, and utilization management nurses. Staff reported they used a tracking tool to schedule specialty appointments and retrieve specialists’ reports. Specialty services nurses expressed difficulty in obtaining dermatology and neurosurgery appointments. They also stated the biggest challenge was the numerous patient refusals of specialty appointments. These refusals required medical staff to frequently reschedule specialty appointments. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 74 Compliance Score Results Table 17. Specialty Services Scored Answer Compliance Questions Yes No N/A Yes % Did the patient receive the high-priority specialty service within 14 calendar days of the primary care provider order or the Physician Request for 14 1 0 93.3% Service? (14.001) Did the institution receive and did the primary care provider review the high-priority specialty service consultant report within the required time 11 4 0 73.3% 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? 6 4 5 60.0% (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 7 8 0 46.7% 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? 6 3 6 66.7% (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 7 7 1 50.0% frame? (14.008) Did the patient receive the subsequent follow-up to the routine-priority specialty service appointment as ordered by the primary care provider? 5 2 8 71.4% (14.009) For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the sending 6 14 0 30.0% institution, was the appointment scheduled at the receiving institution within the required time frames? (14.010) Did the institution deny the primary care provider’s request for specialty 20 0 0 100% services within required time frames? (14.011) Following the denial of a request for specialty services, was the patient 14 5 1 73.7% informed of the denial within the required time frame? (14.012) Overall percentage (MIT 14): 68.8% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 75 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 30 3 12 90.9% occur within required time frames? (1.008) * Are specialty documents scanned into the patient’s electronic health record 25 5 15 83.3% within five calendar days of the encounter date? (4.002) * CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician follow-up visits following specialty services. As a result, we tested MIT 1.008 only for high-priority specialty services or when staff ordered follow-ups. The OIG continued to test the clinical appropriateness of specialty follow-ups through its case review testing. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 76 Recommendations • Medical leadership should ascertain the challenges related to timely retrieving and endorsing specialty reports and should implement remedial measures as appropriate. • Medical leadership should ascertain causes related to untimely providing or scheduling patients’ specialty service appointments and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 77 Administrative Operations In this indicator, OIG compliance inspectors evaluated health care administrative processes. Our inspectors examined the timeliness of the medical grievance process and checked whether the institution followed reporting requirements for adverse or sentinel events and patient deaths. Inspectors checked whether the Emergency Medical Response Review Committee (EMRRC) met and reviewed incident packages. We investigated and determined whether the institution conducted required emergency response drills. Inspectors also assessed whether the Quality Management Committee (QMC) met regularly and addressed program performance adequately. In addition, our inspectors determined whether the institution provided training and job performance reviews for its employees. We checked whether staff possessed current, valid professional licenses, certifications, and credentials. The OIG rated this indicator solely based on the compliance score. Case review does not rate this indicator. Because none of the tests in this indicator directly affected clinical patient care (it is a secondary indicator), the OIG did not consider this indicator’s rating when determining the institution’s overall compliance rating and score. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Adequate (78.8%) KVSP’s overall performance was satisfactory in administrative operations. Although KVSP scored excellently in most applicable tests, it needed improvement in several areas. The Emergency Medical Response Review Committee (EMRRC) rarely completed the required checklists and rarely completed incident reviews. In addition, staff conducted medical emergency response drills with incomplete and inconsistent documentation. Last, the nursing educator did not ensure all newly hired nurses received the required onboarding training. These findings are set forth in the table on the next page. Based on the overall compliance score result, the OIG rated this indicator adequate. Compliance Testing Results Nonscored Results At KVSP, the OIG did not find 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 nine patients, we found no evidence in the submitted documentation that any preliminary mortality reports had been completed. All nine reports were overdue at the time of the OIG’s inspection (MIT 15.998). Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 78 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 2 10 0 16.7% 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 3 1 0 75.0% 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 1 2 0 33.3% 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 9 0 0 100% CCHCS Mortality Case Review Unit on time? (15.103) Did nurse managers ensure the clinical competency of nurses who 10 0 0 100% administer medications? (15.104) Did physician managers complete provider clinical performance appraisals 5 0 0 100% timely? (15.105) Did the providers maintain valid state medical licenses? (15.106) 7 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): 78.8% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 79 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 80 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 81 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 KVSP Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 82 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: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 83 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: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 84 Figure A–2. Case Review Testing Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 85 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: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 86 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: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 87 Appendix B: Case Review Data Table B–1. KVSP Case Review Sample Sets Sample Set Total CTC 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 5 50 Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 88 Table B–2. KVSP Case Review Chronic Care Diagnoses Sample Set Total Anemia 5 Anticoagulation 1 Arthritis/Degenerative Joint Disease 5 Asthma 6 Cardiovascular Disease 3 Chronic Kidney Disease 1 Chronic Pain 17 Cirrhosis/End-Stage Liver Disease 2 Coccidioidomycosis 2 Deep Venous Thrombosis/Pulmonary Embolism 1 Diabetes 7 Gastroesophageal Reflux Disease 3 Hepatitis C 25 Hyperlipidemia 12 Hypertension 15 Mental Health 24 Migraine Headaches 4 Rheumatological Disease 1 Seizure Disorder 5 Sleep Apnea 2 Substance Abuse 30 Thyroid Disease 1 172 Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 89 Table B–3. KVSP Case Review Events by Program Diagnosis Total Diagnostic Services 167 Emergency Care 79 Hospitalization 58 Intrasystem Transfers In 11 Intrasystem Transfers Out 6 Outpatient Care 281 Specialized Medical Housing 77 Specialty Services 129 808 Table B–4. KVSP Case Review Sample Summary Sample Set Total MD Reviews Detailed 20 MD Reviews Focused 1 RN Reviews Detailed 11 RN Reviews Focused 30 Total Reviews 62 Total Unique Cases 50 Overlapping Reviews (MD & RN) 12 Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 90 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 91 Appendix C: Compliance Sampling Methodology Kern Valley 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 25 OIG Q: 4.005 • See Health Information Management Community (Medical Records) (returns from Hospital community hospital) MIT 1.008 Specialty Services 45 OIG Q: 14.001, • See Specialty Services Follow-Up 14.004 & 14.007 MIT 1.101 Availability of 6 OIG on-site review • Randomly select one housing unit Health Care from each yard Services Request Forms Diagnostic Services MITs 2.001 – 003 Radiology 10 Radiology Logs • Appointment date (90 days – 9 months) • Randomize • Abnormal MITs 2.004 – 006 Laboratory 10 Quest • Appt. date (90 days – 9 months) • Order name (CBC, BMP, or CMPs only) • Randomize • Abnormal MITs 2.007 – 009 Laboratory STAT 8 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: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 92 Quality No. of Indicator Sample Category Samples Data Source Filters Health Information Management (Medical Records) MIT 4.001 Health Care Services 30 OIG Qs: 1.004 • Nondictated documents Request Forms • First 20 IPs for MIT 1.004 MIT 4.002 Specialty Documents 45 OIG Qs: 14.002, • Specialty documents 14.005 & 14.008 • First 10 IPs for each question MIT 4.003 Hospital Discharge 25 OIG Q: 4.005 • Community hospital discharge Documents documents • First 20 IPs selected MIT 4.004 Scanning Accuracy 24 Documents for • Any misfiled or mislabeled document any tested identified during incarcerated OIG compliance review person (24 or more = No) MIT 4.005 Returns From 25 CADDIS off-site • Date (2 – 8 months) Community Hospital admissions • Most recent 6 months provided (within date range) • Rx count • Discharge date • Randomize Health Care Environment MITs 5.101 – 105 Clinical Areas 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 1 OIG inspector • R&R IP transfers with medication on-site review Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 93 Quality No. of Indicator Sample Category Samples Data Source Filters Pharmacy and Medication Management MIT 7.001 Chronic Care 25 OIG Q: 1.001 • See Access to Care Medication • At least one condition per patient — any risk level • Randomize MIT 7.002 New Medication 25 Master Registry • Rx count Orders • Randomize • Ensure no duplication of IPs tested in MIT 7.001 MIT 7.003 Returns From 25 OIG Q: 4.005 • See Health Information Management Community Hospital (Medical Records) (returns from community hospital) MIT 7.004 RC Arrivals — N/A at this OIG Q: 12.001 • See Reception Center Medication Orders institution MIT 7.005 Intrafacility Moves 25 MAPIP transfer • Date of transfer (2 – 8 months) data • To location/from location (yard to yard and to/from ASU) • Remove any to/from MHCB • NA/DOT meds (and risk level) • Randomize MIT 7.006 En Route 10 SOMS • Date of transfer (2– 8 months) • Sending institution (another departmental facility) • Randomize • NA/DOT meds MITs 7.101 – 103 Medication Storage Varies OIG inspector • Identify and inspect clinical & med Areas by test on-site review line areas that store medications MITs 7.104 – 107 Medication Varies OIG inspector • Identify and inspect on-site clinical Preparation and by test on-site review areas that prepare and administer Administration Areas medications MITs 7.108 – 111 Pharmacy 1 OIG inspector • Identify & inspect all on-site on-site review pharmacies MIT 7.112 Medication Error 0 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 20 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: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 94 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 8 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 6 Cocci transfer • Reports from past 2 – 8 months status report • Institution • Ineligibility date (60 days prior to inspection date) • All Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 95 Quality No. of Indicator Sample Category Samples Data Source Filters Reception Center MITs 12.001 – 007 RC N/A at this SOMS • Arrival date (2 – 8 months) institution • Arrived from (county jail, return from parole, etc.) • Randomize Specialized Medical Housing MITs 13.001 – 003 Specialized Health 10 CADDIS • Admit date (2 – 8 months) Care Housing Unit • Type of stay (no MH beds) • Length of stay (minimum of 5 days) • Rx count • Randomize MITs 13.101 – 102 Call Buttons All OIG inspector • Specialized Health Care Housing on-site review • Review by location Specialty Services MITs 14.001 – 003 High-Priority 15 Specialty Services • Approval date (3 – 9 months) Initial and Follow-Up Appointments • Remove consult to audiology, RFS chemotherapy, dietary, Hep C, HIV, orthotics, gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, physiatry, podiatry, radiology, follow-up wound care / addiction medication, narcotic treatment program, and transgender services • Randomize MITs 14.004 – 006 Medium-Priority 15 Specialty Services • Approval date (3 – 9 months) Initial and Follow-Up Appointments • Remove consult to audiology, RFS chemotherapy, dietary, Hep C, HIV, orthotics, gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, physiatry, podiatry, radiology, follow-up wound care/addiction medication, narcotic treatment program, and transgender services • Randomize Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 96 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 20 Specialty Services • Arrived from (other departmental Arrivals Arrivals institution) • Date of transfer (3 – 9 months) • Randomize MITs 14.011 – 012 Denials 20 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: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 97 Quality No. of Indicator Sample Category Samples Data Source Filters Administrative Operations (continued) MIT 15.103 Death Reports 9 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 5 On-site provider • All required performance evaluation Evaluation Packets evaluation files documents MIT 15.106 Provider Licenses 7 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 9 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: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 98 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7, Kern Valley State Prison | 99 California Correctional Health Care Services’ Response Office of the Inspector General, State of California Inspection Period: April 2023 – September 2023 Report Issued: May 2025 Cycle 7 Medical Inspection Report for Kern Valley State Prison OFFICE of the INSPECTOR GENERAL Amarik K. Singh Inspector General Shaun Spillane Chief Deputy Inspector General STATE of CALIFORNIA May 2025 OIG