OIG
California State Prison, Los Angeles County Medical Inspection Results Cycle 1
CALIFORNIA STATE PRISON,
LOS ANGELES COUNTY
MEDICAL INSPECTION RESULTS
BUREAU OF AUDITS AND INVESTIGATIONS
OFFICE OF THE
INSPECTOR GENERAL
DAVID R. SHAW
INSPECTOR GENERAL
STATE OF CALIFORNIA
July 2009
Contents
Executive Summary ......................................................................................… 1
Introduction …................................................................................................… 3
Background …....................................................................................… 3
About the Institution …......................................................................… 4
Objectives, Scope, and Methodology ….............................................. 4
Medical Inspection Results ….......................................................................… 7
California Prison Health Care Receivership
Corporation's Response …............................................................................. 29
Office of the Inspector General's Comments
on the Receiver's Response …....................................................................... 35
Executive Summary
An April 2001 class action lawsuit filed by inmates represented by the Prison Law Office alleged
that the state provided constitutionally inadequate medical care at California state prisons in
violation of inmates’ constitutional rights. And, in October 2005, the U.S. Northern District Court
of California declared that California’s delivery system for prison medical care was “broken
beyond repair” and still not meeting constitutional standards. As a result, the federal court imposed
a receivership to raise the delivery of medical care to constitutional standards. To evaluate and
monitor the progress of medical care delivery to inmates, the receiver requested, and the Office of
the Inspector General (OIG) agreed, to establish an objective, clinically appropriate, and metric-
oriented medical program to annually inspect the delivery of medical care at each state prison.
In April 2009, we inspected California State Prison, Los Angeles County
Overall (LAC). Our medical inspection encompassed 18 components of medical
Score delivery and comprised 142 questions. The questions are weighted based on
71.7%
their importance to the delivery of medical care to inmates. LAC received 71.7
percent of the total weighted points possible.
The following summary table lists the components we inspected in order of importance (highest to
lowest), with the institution’s score and the definitions of each inspection component. The detailed
medical inspection results, with the questions for each component, begin on page 7 of this report.
While we are committed to helping each institution achieve a higher level of medical care, it is not
our intent to determine the percentage score needed by an institution to meet constitutional
standards—that is a legal matter for the federal court to determine.
Executive Summary Table
Component Weighted Score Definition
Chronic Care 70.1% Examines how well the prison provided care and medication to inmates with
specific chronic care conditions, which are those that affect (or have the
potential to affect) an inmate's functioning and long-term prognosis for more
than six months. Our inspection tests the following chronic care conditions:
asthma, Coumadin therapy, diabetes, HIV (Human Immunodeficiency Virus),
and hypertension.
Clinical Services 65.5% Evaluates the inmate's access to primary health care services and focuses on
inmates who recently received services from any of the prison's facility or
administrative segregation unit clinics. This component evaluates sick call
processes (doctor or nurse line), medication management, and nursing.
Health Screening 68.8% Focuses on the prison's process for screening new inmates upon arrival to the
institution for health care conditions that require treatment and monitoring, as
well as ensuring inmates' continuity of care.
Specialty Services 70.3% Focuses on the prison's process for approving, denying, and scheduling services
that are outside the specialties of the prison's medical staff. Common examples
of these services include physical therapy, oncology services, podiatry
consultations, and neurology services.
Urgent Services 80.2% Addresses the care provided by the institution to inmates before and after they
were sent to a community hospital.
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Office of the Inspector General State of California
Component Weighted Score Definition
Emergency Services 84.0% Examines how well the prison responded to medical emergencies. Specifically,
we focused on “man down” or “woman down” situations. Further, questions
determine the adequacy of medical and staff responses to a “man down” or
“woman down” emergency drill.
Prenatal Care/Childbirth/Post- N/A Focuses on the prenatal and post-delivery medical care provided to pregnant
delivery inmates. Not applicable at men's institutions.
Diagnostic Services 54.0% Addresses the timeliness of radiology (x-ray) and laboratory services and
whether the prison followed up on clinically significant results.
Access to Health Care Information 72.5% Addresses the prison's effectiveness in filing, storing, and retrieving medical
records and medical-related information.
Outpatient Housing Unit N/A Determines whether the prison followed department policies and procedures
when placing inmates in the outpatient housing unit. This component also
evaluates whether the placement provided the inmate with adequate care and
whether the physician's plan addressed the placement diagnosis.
Internal Reviews 73.0% Focuses on the frequency of meetings held by the prison's Quality Management
Committee (QMC) and Emergency Response Review Committee (ERRC) and
whether key staff attended the meetings, the number of medical appeals filed,
and the prison's death review process.
Inmate Transfers 100.0% Focuses on inmates pending transfer to determine whether the sending
institution documented medication and medical conditions to assist the
receiving institution in providing continuity of care.
Clinic Operations 90.0% Addresses the general operational aspects of the prison's facility clinics.
Generally, the questions in this component relate to the overall cleanliness of
the clinics, privacy afforded to inmates during nonemergency visits, use of
priority ducats (slip of paper the inmate carries for scheduled medical
appointments), and availability of health care request forms.
Preventive Services 20.0% Focuses on inmate cancer screening and influenza immunizations.
Pharmacy Services 100.0% Addresses whether the prison's pharmacy complies with various operational
policies, such as conducting periodic inventory counts and maintaining the
currency of medications in its night lockers, keeping signature cards on file for
doctors, and having valid permits. In addition, this component also addresses
whether the pharmacy has an effective process for screening medication orders
for potential adverse reactions/interactions.
Other Services 100.0% Examines additional areas that are not captured in the other components. The
areas evaluated in this component include the prison's provision of therapeutic
diets, its handling of inmates who display poor hygiene, and the availability of
the current version of the department's Health Services Policies and Procedures.
Inmate Hunger Strikes 42.1% Examines medical staff's monitoring of inmates participating in hunger strikes.
Chemical Agent Contraindications 90.6% Addresses the prison's process of handling inmates who may be predisposed to
an adverse outcome from calculated uses of force (cell extractions) involving
Oleoresin Capsicum (OC), which is commonly referred to as "pepper spray."
For example, this might occur if the inmate has asthma.
Staffing Levels and Training 90.0% Examines the prison's medical staffing levels and training provided.
Nursing Policy 57.1% Determines whether the prison maintains written policies and procedures for
the safe and effective provision of quality nursing care. The questions in this
component also determine whether nursing staff review their duty statements
and whether supervisors periodically review the work of nurses to ensure they
properly follow established nursing protocols.
Overall Score 71.7%
Bureau of Audits and Investigations Page 2
Office of the Inspector General State of California
Introduction
Under the authority of California Penal Code section 6126, which assigns the Office of the
Inspector General (OIG) responsibility for oversight of the California Department of Corrections
and Rehabilitation, and at the request of the federal receiver, the OIG developed a comprehensive
inspection program to evaluate the delivery of medical care at each of the California Department
of Corrections and Rehabilitation’s 33 adult prisons.
In April 2009, we inspected California State Prison, Los Angeles County (LAC). Our medical
inspection encompassed 18 components of medical delivery and comprised 142 questions. To help
readers understand the medical risk associated with certain components of medical delivery—
which pose a greater risk to an inmate-patient—we developed a weighting system and assigned
points to each question. Consequently, we assigned more total points to more critical components,
such as chronic care, clinical services, and health screening. We assigned fewer total points to less
critical components, such as inmate hunger strikes, staffing levels and training, and chemical
agent contraindications. (For a detailed description of the weighting system, see Objectives,
Scope, and Methodology on the next page.)
Background
In April 2001, inmates represented by the Prison Law Office filed a class action lawsuit, known as
Plata v. Schwarzenegger. The lawsuit alleged that the state provided constitutionally inadequate
medical care at California state prisons in violation of inmates’ constitutional rights. In June 2002,
the parties entered into a Stipulation for Injunctive Relief, and the state agreed to implement over
several years comprehensive new medical care policies and procedures at all institutions.
Nevertheless, the U.S. Northern District Court of California declared in October 2005 that
California’s delivery system for prison medical care was “broken beyond repair” and still not
meeting constitutional standards. Thus, the federal court imposed a receivership to raise the
delivery of medical care to constitutional standards. In essence, the court ordered the receiver to
manage the state’s delivery of medical care and restructure day-to-day operations to develop and
sustain a system that provides constitutionally adequate medical care to inmates. The court stated
that it would remove the receiver and return control to the state once the system is stable and
provides for constitutionally adequate medical care.
To evaluate and monitor the progress of medical care delivery to inmates, the receiver requested
that the OIG establish an objective, clinically appropriate, and metric-oriented medical inspection
program. Toward that end, the Inspector General agreed to inspect annually each state prison until
the state’s delivery of medical care to inmates meets constitutional standards. We are committed to
helping each institution achieve a higher level of medical care, but it is up to the federal court to
determine the percentage score necessary for an institution to meet constitutional standards.
Bureau of Audits and Investigations Page 3
Office of the Inspector General State of California
About the Institution
The mission of LAC is to be both a reception center for short-term housing and to provide secure
long-term housing services for men who have been convicted of felonies classified as minimum,
high-medium, and maximum custody inmates. LAC provides educational and vocational
programming designed to encourage productivity, inmate responsibility, and self-improvement.
Along with four main clinics that handle non-urgent requests for medical services, LAC treats
inmates needing urgent or emergency care in its triage and treatment area (TTA). As of
July 8, 2009, the Department of Corrections and Rehabilitation reported that LAC had custody
over 4,523 inmates, with 2,010 of these inmates in LAC's reception center.
Timothy Belavich, Ph.D., who serves as the prison's acting health care manager and Paulette
Finander, M.D., the prison's chief medical officer, are responsible for LAC's entire health care
program.
Objectives, Scope, and Methodology
In designing the medical inspection program, we reviewed the California Department of
Corrections and Rehabilitation’s policies and procedures, relevant court orders, guidelines
developed by the department’s Quality Medical Assurance Team, and guidance developed by the
American Correctional Association. We also reviewed professional literature on correctional
medical care, consulted with clinical experts, and met with stakeholders from the court, the
receiver’s office, the department, and the Prison Law Office to discuss the nature and scope of the
inspection program. Based on input from these stakeholders, we developed a medical inspection
program that evaluates medical care delivery. Within each of 20 components, we created “yes” or
“no” questions designed to gauge performance.
To make the inspection results meaningful to both a medical expert and a lay reader, we worked
with clinical experts to create a weighting system that factors the relative importance of each
component compared to other components. Further, the program considers the relative importance
of each question within a component to the other questions in that component. This weighting
ensures that more critical components—such as those that pose the greatest medical risk to the
inmate-patient—are given more weight compared to those considered less serious. For example,
we assign a high number of possible points to the chronic care component because we consider
this the most serious of all the components. Conversely, we assign very few points to the hygiene
intervention component because we consider this the least serious inspection component.
Each inspection question is weighted and scored. The score is derived from the percentage of
“yes” answers for each question from all items sampled. We then multiply the percentage of “yes”
answers within a given question by the question’s weight to arrive at a score. The following
example shows how this scoring system works.
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Office of the Inspector General State of California
Example Question: Institution X
Answers Weighting Points
Yes No Yes + No Yes % Possible Received Score % N/A Unk
Is the clinical history adequate? 40 10 50 80% 20 16 80.0% 0 0
If the institution receives 40 “yes” answers and 10 “no” answers, the percentage of “yes” answers
to this question equals 80 percent. We calculate the number of points the institution would receive
by multiplying the “yes” percent of 80 by the number of possible points for this question, which is
20, to arrive at 16 points.
To arrive at the total score, we add the points received for each question and then for each
program component. Finally, we calculate the institution’s overall score by dividing the sum of the
points received by the sum of the points possible. We do not include in the institution’s overall
score the weight for questions that are not applicable or, in some cases, where a lack of
documentation would result in numerous “no” answers for one deviation from policy (unknown).
For instance, an institution may not be able to provide documentation that its emergency response
review committee met for a particular month. Therefore, when we evaluate whether meeting
minutes document monthly meetings for a particular month, the institution would receive a “no”
answer for that question. However, when we evaluate whether the meeting minutes document the
warden’s attendance at the meeting, the answer would be “unknown” so that the institution’s score
is not penalized twice for the same reason, not documenting the meeting.
To evaluate the institution’s delivery of medical care, we obtained various electronic data files
maintained by the institution for inmate medical scheduling and tracking, pharmacy, and census
data. We used these electronic data files only to identify random samples of inmates receiving or
requiring specific medical services. We then reviewed the medical file for each inmate in our
sample. We did not rely on the medical care information contained in these data files.
Our medical inspection at LAC encompassed 18 of the 20 components of medical delivery. Two
of the components were not applicable during the period inspected. In total, we reviewed 185
inmate medical files, which are referred to as unit health records. In addition, we reviewed
staffing level reports, medical appeals summaries, nursing policies and procedures, summaries of
medical drills and emergencies, minutes from Quality Management Committee and Emergency
Response Review Committee hearings, and assorted manual logs or tracking worksheets related to
medical care delivery. We also conducted a live medical emergency drill and evaluated the
adequacy of the responding staff’s actions. Finally, we interviewed medical and custody staff
members about the delivery of medical care to inmates, and we observed day-to-day medical
delivery at the institution.
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Office of the Inspector General State of California
We do not test the care provided in the licensed hospitals or correctional treatment centers because
they are subject to inspections and oversight by other regulatory agencies.
Consistent with our agreement with the receiver, our report only addresses the conditions found
related to the medical care criteria. We do not discuss the causes of noncompliance, nor do we
make specific recommendations in this report. However, if we learn of an inmate-patient who
needs immediate care, we notify the chief medical officer and request a status report. Moreover, if
we learn of significant departures from community standards, we may report such departures to
the institution’s chief medical officer or the receiver’s office. Because these matters involve
confidential medical information protected by state and federal privacy laws, specific details
related to these cases are not included in our report.
For ease of reference, following is a table of abbreviations used in the remainder of this report.
Abbreviations used in this report
AED Automatic External Defibrillator
BLS Basic Life Support
CMO Chief Medical Officer
CTC Correctional Treatment Center
CTQ Confined to Quarters
ERRC Emergency Response Review Committee
FTF Face-to-Face
GACH General Acute Care Hospital
HCM Health Care Manager
INH Isoniazid (antituberculous medication)
LVN Licensed Vocational Nurse
MOD Medical Officer of the Day
OB Obstetrician
OC Oleoresin Capsicum (pepper spray)
OHU Outpatient Housing Unit
OIG Office of the Inspector General
PCP Primary Care Provider
QMC Quality Management Committee
RN Registered Nurse
SOAPE Subjective, Objective, Assessment, Plan, Education
SRN Supervising Registered Nurse
TB Tuberculosis
TTA Triage and Treatment Area
UHR Unit Health Record
UM Utilization Management
Bureau of Audits and Investigations Page 6
Office of the Inspector General State of California
OFFICE OF THE INSPECTOR GENERAL CALIFORNIA STATE PRISON, LOS ANGELES COUNTY
Overall Score:
MEDICAL INSPECTION RESULTS
77771111....7777%%%%
04/06/2009 – 04/09/2009
Answers Weighting Points Questions Not Answered
Component Page Yes No Yes + No Yes % Points Possible Points Received Score % Not Applicable Unknown
Chronic Care 8 150 70 220 68.2% 133 93.2 70.1% 3 2
Clinical Services 9 223 107 330 67.6% 95 62.2 65.5% 57 0
Health Screening 11 221 54 275 80.4% 82 56.4 68.8% 210 5
Specialty Services 13 66 24 90 73.3% 71 49.9 70.3% 54 0
Urgent Services 14 125 37 162 77.2% 52 41.7 80.2% 35 3
Emergency Services 15 33 5 38 86.8% 53 44.5 84.0% 4 0
Diagnostic Services 17 22 22 44 50.0% 52 28.1 54.0% 20 1
Access to Health Care Information 18 5 3 8 62.5% 51 37.0 72.5% 0 0
Internal Reviews 19 30 3 33 90.9% 40 29.2 73.0% 1 0
Inmate Transfers 20 20 0 20 100.0% 30 30.0 100.0% 5 0
Clinic Operations 21 28 3 31 90.3% 33 29.7 90.0% 0 0
Preventive Services 22 5 25 30 16.7% 30 6.0 20.0% 0 0
Pharmacy Services 23 11 0 11 100.0% 29 29.0 100.0% 0 0
Other Services 24 10 0 10 100.0% 11 11.0 100.0% 1 0
Inmate Hunger Strikes 25 5 7 12 41.7% 19 8.0 42.1% 0 0
Chemical Agent Contraindications 26 9 1 10 90.0% 17 15.4 90.6% 0 0
Staffing Levels and Training 27 6 2 8 75.0% 16 14.4 90.0% 1 0
Nursing Policy 28 8 7 15 53.3% 14 8.0 57.1% 0 0
Totals 977 370 1347 72.5% 828 593.7 71.7% 391 11
Bureau of Audits and Investigations Page 7
Office of the Inspector General State of California
Answers Weighting Points
Reference
Chronic Care
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
03.076 Was the inmate's most recent chronic care visit within the time frame required 16 9 25 64.0% 10 6.4 64.0% 0 0
by the degree of control of the inmate's condition based on his or her prior
visit?
03.077 Were key elements on Forms 7419 (Chronic Care Follow-Up Visit) and 7392 19 6 25 76.0% 10 7.6 76.0% 0 0
(Primary Care Flow Sheet) filled out completely for the inmate's two most
recent visits?
03.082 Did the institution document that it provided the inmate with health care 24 1 25 96.0% 12 11.5 96.0% 0 0
education?
03.175 Did the inmate receive his or her prescribed chronic care medications during 7 17 24 29.2% 18 5.3 29.2% 1 0
the most recent three-month period or did the institution follow departmental
policy if the inmate refused to pick up or show up for his or her medications?
03.235 Is the clinical history adequate? 16 9 25 64.0% 18 11.5 64.0% 0 0
03.236 Is the focused clinical examination adequate? 20 4 24 83.3% 19 15.8 83.3% 1 0
03.237 Is the assessment adequate? 18 6 24 75.0% 19 14.3 75.0% 0 1
03.238 Is the plan adequate and consistent with the degree of control based on the 22 1 23 95.7% 19 18.2 95.7% 1 1
chronic care program intervention and follow up requirements?
03.262 Is the inmate's Problem List complete and filed accurately in the inmate's unit 8 17 25 32.0% 8 2.6 32.0% 0 0
health record (UHR)?
Components Subtotals: 150 70 220 68.2% 133 93.2 70.1% 3 2
Bureau of Audits and Investigations Page 8
Office of the Inspector General State of California
Answers Weighting Points
Reference
Clinical Services
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
01.024 RN FTF Documentation: Did the inmate's request for health care get reviewed 23 7 30 76.7% 4 3.1 76.7% 0 0
the same day it was received?
01.025 RN FTF Documentation: Did the RN complete the face-to-face (FTF) triage 25 5 30 83.3% 6 5.0 83.3% 0 0
within one (1) business day after the Form 7362 was reviewed?
01.246 Did documentation indicate that the RN reviewed all of the inmate's 25 4 29 86.2% 5 4.3 86.2% 1 0
complaints listed on Form 7362 (Health Care Services Request Form)?
01.157 RN FTF Documentation: Did the RN's subjective note address the nature and 17 12 29 58.6% 7 4.1 58.6% 1 0
history of the inmates primary complaint?
01.159 RN FTF Documentation: Did the RN's objective note include vital signs and a 16 13 29 55.2% 6 3.3 55.2% 1 0
focused physical examination, and did it adequately address the problems
noted in the subjective note?
01.244 RN FTF Documentation: Did the RN's objective note include allergies, weight, 10 19 29 34.5% 3 1.0 34.5% 1 0
current medication, and where appropriate, medication compliance?
01.158 RN FTF Documentation: Did the RN's assessment provide conclusions based 26 3 29 89.7% 6 5.4 89.7% 1 0
on subjective and objective data, were the conclusions formulated as patient
problems, and did it contain applicable nursing diagnoses?
01.162 RN FTF Documentation: Did the RN's plan include an adequate strategy to 29 0 29 100.0% 7 7.0 100.0% 1 0
address the problems identified during the FTF triage?
01.163 RN FTF Documentation: Did the RN's education/instruction adequately 25 4 29 86.2% 5 4.3 86.2% 1 0
address the problems identified during the FTF triage?
01.027 If the RN determined a referral to a primary care physician (PCP) was 7 13 20 35.0% 8 2.8 35.0% 10 0
necessary, was the inmate seen within the timelines specified by the RN during
the FTF triage?
Bureau of Audits and Investigations Page 9
Office of the Inspector General State of California
Answers Weighting Points
Reference
Clinical Services
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
01.247 Sick Call Follow-up: If the provider ordered a follow-up sick call appointment, 1 4 5 20.0% 7 1.4 20.0% 25 0
did it take place within the time frame specified?
01.124 Sick Call Medication: Did the institution administer or deliver prescription 10 20 30 33.3% 6 2.0 33.3% 0 0
medications (new orders) to the inmate within specified time frames?
15.234 Are clinic response bags audited daily and do they contain essential items? 1 1 2 50.0% 5 2.5 50.0% 0 0
21.278 Was there adequate prior management of pre-existing medical conditions that 8 2 10 80.0% 20 16.0 80.0% 15 0
contributed to the need for the TTA visit?
Components Subtotals: 223 107 330 67.6% 95 62.2 65.5% 57 0
Bureau of Audits and Investigations Page 10
Office of the Inspector General State of California
Answers Weighting Points
Reference
Health Screening
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
02.016 Did the institution complete the initial health screening on the same day the 27 3 30 90.0% 9 8.1 90.0% 0 0
inmate arrived at the institution?
02.017 If yes was answered to any of the questions on the initial health screening 6 7 13 46.2% 8 3.7 46.2% 17 0
form(s), did the RN provide an assessment and disposition on the date of
arrival?
02.018 If, during the assessment, the RN referred the inmate to a clinician, was the 0 4 4 0.0% 8 0.0 0.0% 26 0
inmate seen within the time frame?
02.021 Reception center: Did the inmate receive a complete history and physical by a 10 10 20 50.0% 5 2.5 50.0% 10 0
Nurse Practitioner, Physician Assistant, or a Physician and Surgeon within 14
calendar days of arrival?
02.211 Reception center history and physical: Is the "History of Present Illness" 4 6 10 40.0% 2 0.8 40.0% 10 0
section of Form 7206 (History and Physical Examination) complete and
appropriate to the chief complaint(s), if any?
02.212 Reception center history and physical: Are the "Past History" and "Past 17 3 20 85.0% 2 1.7 85.0% 0 0
Medical History" sections of Form 7206 (History and Physical Examination)
complete?
02.215 Reception center history and physical: Is the "Review Systems" section of 14 6 20 70.0% 2 1.4 70.0% 0 0
Form 7206 (History and Physical Examination) complete?
02.213 Reception center history and physical: Is the "Family and Social History" 15 5 20 75.0% 2 1.5 75.0% 0 0
section of Form 7206 (History and Physical Examination) complete?
02.216 Reception center history and physical: Is the "Physical Examination" section of 20 0 20 100.0% 2 2.0 100.0% 0 0
Form 7206 (History and Physical Examination) complete and appropriate to
the history and review of systems?
02.217 Reception center history and physical: Is the "Diagnosis/Impression" section of 20 0 20 100.0% 2 2.0 100.0% 0 0
Form 7206 (History and Physical Examination) appropriate to the history and
physical examination?
Bureau of Audits and Investigations Page 11
Office of the Inspector General State of California
Answers Weighting Points
Reference
Health Screening
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
02.218 Reception center history and physical: Is the "Plan of Action" section of Form 20 0 20 100.0% 2 2.0 100.0% 0 0
7206 (History and Physical Examination) appropriate to the
"Diagnosis/Impression" section of the form?
02.219 Reception center history and physical: Has required intake testing been 19 1 20 95.0% 4 3.8 95.0% 0 0
ordered?
02.020 Did the LVN/RN adequately document the tuberculin test or a review of signs 30 0 30 100.0% 6 6.0 100.0% 0 0
and symptoms if the inmate had a previous positive tuberculin test?
02.015 Was a review of symptoms completed if the inmate's tuberculin test was 4 0 4 100.0% 7 7.0 100.0% 26 0
positive, and were the results reviewed by the infection control nurse?
02.022 Reception center: If the primary care provider (PCP) indicated the inmate 0 0 0 0.0% 0 0.0 0.0% 30 0
required a special diet, did the PCP refer the inmate to a registered dietician?
02.128 If the inmate had an existing medication order upon arrival at the institution, 5 7 12 41.7% 8 3.3 41.7% 17 1
did the inmate receive the medications by the next calendar day, or did a
physician explain why the medications were not to be continued?
02.007 Non-reception center: Does the health care transfer information form indicate 7 1 8 87.5% 7 6.1 87.5% 20 2
that it was reviewed and signed by licensed health care staff within one
calendar day of the inmate's arrival at the institution?
02.014 Non-reception center: If the inmate was scheduled for a specialty appointment 0 0 0 0.0% 0 0.0 0.0% 28 2
at the sending institution, did the receiving institution schedule the appointment
within 30 days of the original appointment date?
02.111 Non-reception center: Did the inmate receive medical accommodations upon 3 1 4 75.0% 6 4.5 75.0% 26 0
arrival, if applicable?
Components Subtotals: 221 54 275 80.4% 82 56.4 68.8% 210 5
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Office of the Inspector General State of California
Answers Weighting Points
Reference
Specialty Services
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
07.037 Did the institution approve or deny the PCP's request for specialty services 20 2 22 90.9% 8 7.3 90.9% 0 0
within the specified time frames?
07.038 Did the PCP see the inmate between the date the PCP ordered the service and 2 5 7 28.6% 8 2.3 28.6% 15 0
the date the inmate received it, in accordance with specified time frames?
07.035 Did the inmate receive the specialty service within specified time frames? 11 6 17 64.7% 9 5.8 64.7% 5 0
07.090 Physical therapy services: Did the physical therapist assess the inmate and 2 0 2 100.0% 8 8.0 100.0% 20 0
document the treatment plan and treatment provided to the inmate?
07.043 Did the PCP review the consultant's report and see the inmate for a follow-up 5 9 14 35.7% 9 3.2 35.7% 8 0
appointment after the specialty services consultation within specified time
frames?
07.260 Was the institution's denial of the PCP's request for specialty services 5 0 5 100.0% 9 9.0 100.0% 0 0
consistent with the "medical necessity" requirement?
07.259 Was there adequate documentation of the reason for the denial of specialty 3 1 4 75.0% 5 3.8 75.0% 1 0
services?
07.270 Did the specialty provider provide timely findings and recommendations or did 17 0 17 100.0% 6 6.0 100.0% 5 0
an RN document that he or she called the specialty provider to ascertain the
findings and recommendations?
07.261 Is the institution scheduling high-priority (urgent) specialty services within 14 1 1 2 50.0% 9 4.5 50.0% 0 0
days?
Components Subtotals: 66 24 90 73.3% 71 49.9 70.3% 54 0
Bureau of Audits and Investigations Page 13
Office of the Inspector General State of California
Answers Weighting Points
Reference
Urgent Services
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
21.248 Upon the inmate's discharge from the community hospital, did the triage and 24 1 25 96.0% 7 6.7 96.0% 0 0
treatment area (TTA) registered nurse document that he or she reviewed the
inmate's discharge plan and completed a face-to-face assessment of the inmate?
21.250 Upon the inmate's discharge from the community hospital, did the inmate's 25 0 25 100.0% 7 7.0 100.0% 0 0
Primary Care Provider (PCP) provide orders for appropriate housing for the
inmate?
21.251 Upon the inmate's discharge from the community hospital, did the Registered 0 0 0 0.0% 0 0.0 0.0% 25 0
Nurse intervene if the inmate was housed in an area that was inappropriate for
nursing care based on the primary care provider's (PCP) housing orders?
21.249 Upon the inmate's discharge from the community hospital, did the inmate 10 15 25 40.0% 7 2.8 40.0% 0 0
receive a follow-up appointment with his or her primary care provider (PCP)
within five calendar days of discharge?
21.281 Upon the inmate's discharge from a community hospital, did the institution 9 15 24 37.5% 6 2.3 37.5% 1 0
administer or deliver all prescribed medications to the inmate within specified
time frames?
21.275 Was the documentation of the clinical care provided in the TTA adequate? 22 3 25 88.0% 10 8.8 88.0% 0 0
21.276 While the patient was in the TTA, was the clinical care rendered by the 20 3 23 87.0% 7 6.1 87.0% 0 2
attending provider adequate and timely?
21.279 For patients managed by telephone consultation alone, was the provider's 15 0 15 100.0% 8 8.0 100.0% 9 1
decision not to come to the TTA appropriate?
Components Subtotals: 125 37 162 77.2% 52 41.7 80.2% 35 3
Bureau of Audits and Investigations Page 14
Office of the Inspector General State of California
Answers Weighting Points
Reference
Emergency Services
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
08.183 Was the medical emergency responder notified of the medical emergency 4 0 4 100.0% 5 5.0 100.0% 0 0
without delay?
08.241 Did the first responder provide adequate basic life support (BLS) prior to 4 0 4 100.0% 6 6.0 100.0% 0 0
medical staff arriving?
08.184 Did the medical emergency responder arrive at the location of the medical 4 0 4 100.0% 4 4.0 100.0% 0 0
emergency within five (5) minutes of initial notification?
08.185 Did the medical emergency responder use proper equipment to address the 4 0 4 100.0% 7 7.0 100.0% 0 0
emergency and was adequate medical care provided within the scope of his or
her license?
08.242 Did licensed health care staff call 911 without unnecessary delay after a life- 3 1 4 75.0% 6 4.5 75.0% 0 0
threatening condition was identified by a licensed health care provider or peace
officer?
08.187 Did the institution provide adequate preparation for the ambulance's arrival, 4 0 4 100.0% 4 4.0 100.0% 0 0
access to the inmate, and departure?
08.186 Were both the first responder (if peace officer or licensed health care staff) and 4 0 4 100.0% 4 4.0 100.0% 0 0
the medical emergency responder basic life support (BLS) certified at the time
of the incident?
08.222 Were the findings of the institution's Emergency Response Review Committee 0 4 4 0.0% 7 0.0 0.0% 0 0
(ERRC) supported by the documentation and completed within 30 days?
15.240 Emergency Medical Response Drill: Did the responding officer activate the 1 0 1 100.0% 2 2.0 100.0% 0 0
emergency response system by providing the pertinent information to the
relevant parties, immediately and without delay?
15.255 Emergency Medical Response Drill: Did the responding officer carry and use 1 0 1 100.0% 1 1.0 100.0% 0 0
the proper equipment (protective shield or micro-mask, gloves) required by the
department?
Bureau of Audits and Investigations Page 15
Office of the Inspector General State of California
Answers Weighting Points
Reference
Emergency Services
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
15.256 Emergency Medical Response Drill: Did the responding officer properly 1 0 1 100.0% 1 1.0 100.0% 0 0
perform an assessment on the patient for responsiveness?
15.257 Emergency Medical Response Drill: Did the responding officer properly 1 0 1 100.0% 2 2.0 100.0% 0 0
perform CPR?
15.258 Emergency Medical Response Drill: Did the responding officer begin CPR 1 0 1 100.0% 2 2.0 100.0% 0 0
without unecessary delay?
15.282 Emergency Medical Response Drill: Did medical staff arrive on scene in five 0 0 0 0.0% 0 0.0 0.0% 1 0
minutes or less?
15.283 Emergency Medical Response Drill: Did the emergency medical responders 0 0 0 0.0% 0 0.0 0.0% 1 0
arrive with proper equipment (ER bag, bag-valve-mask, AED)?
15.284 Emergency Medical Response Drill: Did the responding officer provide 0 0 0 0.0% 0 0.0 0.0% 1 0
accurate information to responding medical staff?
15.285 Emergency Medical Response Drill: Did emergency medical responders 0 0 0 0.0% 0 0.0 0.0% 1 0
continue basic life support?
15.287 Emergency Medical Response Drill: Was 911 called without unnecessary 1 0 1 100.0% 2 2.0 100.0% 0 0
delay?
Components Subtotals: 33 5 38 86.8% 53 44.5 84.0% 4 0
Bureau of Audits and Investigations Page 16
Office of the Inspector General State of California
Answers Weighting Points
Reference
Diagnostic Services
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
06.049 Radiology order: Was the radiology service provided within the time frame 5 0 5 100.0% 7 7.0 100.0% 0 0
specified in the physician's order?
06.245 Radiology order: Was the diagnostic report received by the institution within 5 0 5 100.0% 8 8.0 100.0% 0 0
14 days?
06.200 Radiology order: Did the primary care provider (PCP) review the diagnostic 0 4 4 0.0% 7 0.0 0.0% 1 0
report and initiate written notice to the inmate within two (2) business days of
the date the institution received the diagnostic reports?
06.188 All laboratory orders: Was the specimen collected within the applicable time 9 1 10 90.0% 6 5.4 90.0% 0 0
frames of the physician's order?
06.191 All diagnostic services: Did the PCP document the clinically significant 1 6 7 14.3% 7 1.0 14.3% 8 0
diagnostic test results on Form 7230 (Interdisciplinary Progress Notes)?
06.263 All diagnostic services: Did the PCP adequately manage clinically significant 2 1 3 66.7% 10 6.7 66.7% 11 1
test results?
06.202 All laboratory orders: Did the PCP review the diagnostic reports and initiate 0 10 10 0.0% 7 0.0 0.0% 0 0
written notice to the inmate within two (2) business days of the date the
institution received the diagnostic reports?
Components Subtotals: 22 22 44 50.0% 52 28.1 54.0% 20 1
Bureau of Audits and Investigations Page 17
Office of the Inspector General State of California
Answers Weighting Points
Reference
Access to Health Care Information
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
19.150 Is the medical records office current with its loose filing? 0 1 1 0.0% 9 0.0 0.0% 0 0
19.169 Did medical records staff make unit health records (UHR) available to clinic 2 0 2 100.0% 15 15.0 100.0% 0 0
staff for the inmates ducated for medical appointments the next day?
19.243 Was the institution able to account for the OIG's requested UHR files? 1 0 1 100.0% 12 12.0 100.0% 0 0
19.266 Does the institution properly file inmates' medical information? 1 0 1 100.0% 5 5.0 100.0% 0 0
19.271 While reviewing unit health records (UHR) as part of the OIG's inspection, 1 0 1 100.0% 5 5.0 100.0% 0 0
were the OIGs RN and MD inspectors able to locate all relevant documentation
of health care provided to inmates?
19.272 Does the institution promptly file blood pressure logs in unit health records 0 2 2 0.0% 5 0.0 0.0% 0 0
(UHR)?
Components Subtotals: 5 3 8 62.5% 51 37.0 72.5% 0 0
Bureau of Audits and Investigations Page 18
Office of the Inspector General State of California
Answers Weighting Points
Reference
Internal Reviews
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
17.221 Did the institution complete a medical emergency response drill for each watch 0 1 1 0.0% 5 0.0 0.0% 0 0
and include participation from each medical facility during the most recent full
quarter?
17.174 Did the institution promptly process inmate medical appeals during the most 0 1 1 0.0% 5 0.0 0.0% 0 0
recent 12 months?
17.136 For each death sampled, did the institution complete the death review process? 5 0 5 100.0% 5 5.0 100.0% 0 0
17.132 Do the Emergency Response Review Committee (ERRC) meeting minutes 5 1 6 83.3% 5 4.2 83.3% 0 0
document monthly meetings for the last six (6) months?
17.138 Do the Emergency Response Review Committee (ERRC) meeting minutes 5 0 5 100.0% 5 5.0 100.0% 1 0
document the warden's (or his or her designee's) attendance?
17.118 Do the Quality Management Committee (QMC) meeting minutes document 6 0 6 100.0% 5 5.0 100.0% 0 0
monthly meetings for the last six (6) months?
17.119 Did the Quality Management Committee (QMC) report its findings to the 6 0 6 100.0% 5 5.0 100.0% 0 0
HCM/CMO each of the last six (6) meetings?
17.135 Did the last three Quality Management Committee (QMC) meeting minutes 3 0 3 100.0% 5 5.0 100.0% 0 0
reflect findings and strategies for improvement?
Components Subtotals: 30 3 33 90.9% 40 29.2 73.0% 1 0
Bureau of Audits and Investigations Page 19
Office of the Inspector General State of California
Answers Weighting Points
Reference
Inmate Transfers
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
05.108 Did Receiving and Release have the inmate's UHR and transfer envelope? 5 0 5 100.0% 7 7.0 100.0% 0 0
05.109 If the inmate was scheduled for any upcoming specialty services, were the 0 0 0 0.0% 0 0.0 0.0% 5 0
services noted on Form 7371 (Health Care Transfer Information)?
05.110 Do all appropriate forms in the transfer envelope identify all medications 5 0 5 100.0% 8 8.0 100.0% 0 0
ordered by the physician, and are the medications in the transfer envelope?
05.171 Did an RN complete all applicable sections of Form 7371 (Health Care 5 0 5 100.0% 7 7.0 100.0% 0 0
Transfer Information) based on the inmate's UHR?
05.172 Did the Health Records Department maintain a copy of the inmate's Form 7371 5 0 5 100.0% 8 8.0 100.0% 0 0
(Health Care Transfer Information) and Form 7231A (Outpatient Medication
Administration Record) when the inmate transferred?
Components Subtotals: 20 0 20 100.0% 30 30.0 100.0% 5 0
Bureau of Audits and Investigations Page 20
Office of the Inspector General State of California
Answers Weighting Points
Reference
Clinic Operations
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
14.023 Does the institution make the Form 7362 (Health Care Services Request Form) 9 0 9 100.0% 4 4.0 100.0% 0 0
available to inmates?
14.164 Are areas available to ensure privacy during RN face-to-face assessments and 3 0 3 100.0% 3 3.0 100.0% 0 0
doctors' examinations for non-emergencies?
14.166 Was the medication stored in a sealed container if food was present in the 2 0 2 100.0% 2 2.0 100.0% 0 0
clinic refrigerator?
14.131 Do medication nurses understand that medication is to be administered by the 2 0 2 100.0% 4 4.0 100.0% 0 0
same licensed staff member who prepares it and on the same day?
14.106 Does clinical staff wash their hands (either with soap or hand sanitizer) or 4 0 4 100.0% 4 4.0 100.0% 0 0
change gloves between patients?
14.033 Does the institution have an adequate process to ensure inmates who are 2 0 2 100.0% 4 4.0 100.0% 0 0
moved to a new cell still receive their medical ducats?
14.032 Does medical staff understand the institution's priority ducat process? 2 0 2 100.0% 2 2.0 100.0% 0 0
14.160 Does the institution have a process to identify, review, and address urgent 1 1 2 50.0% 4 2.0 50.0% 0 0
appointments if a doctor's line is canceled?
14.029 Does medical staff in the facility clinic know which inmates are on modified 2 0 2 100.0% 4 4.0 100.0% 0 0
program or confined to quarters (CTQ) and does staff have an adequate process
to ensure those inmates receive their medication?
14.165 Are the clinic floors, waiting room chairs, and equipment cleaned with a 1 2 3 33.3% 2 0.7 33.3% 0 0
disinfectant daily?
Components Subtotals: 28 3 31 90.3% 33 29.7 90.0% 0 0
Bureau of Audits and Investigations Page 21
Office of the Inspector General State of California
Answers Weighting Points
Reference
Preventive Services
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
10.228 Inmates prescribed INH: Did the institution properly administer the medication 1 4 5 20.0% 6 1.2 20.0% 0 0
to the inmate?
10.232 Inmates prescribed INH: Did the institution monitor the inmate monthly for the 0 5 5 0.0% 6 0.0 0.0% 0 0
most recent three months he or she was on the medication?
10.229 Inmates with TB code 34: Was the inmate evaluated for signs and symptoms of 0 5 5 0.0% 7 0.0 0.0% 0 0
TB within the previous 12 months?
10.086 All inmates age 66 or older: Did the inmate receive an influenza vaccination 4 1 5 80.0% 6 4.8 80.0% 0 0
within the previous 12 months or was the inmate's refusal documented?
10.085 Male inmates age 51 or older: Did the inmate receive a fecal occult blood test 0 10 10 0.0% 5 0.0 0.0% 0 0
(FOBT) within the previous 12 months or was the inmate's refusal
documented?
Components Subtotals: 5 25 30 16.7% 30 6.0 20.0% 0 0
Bureau of Audits and Investigations Page 22
Office of the Inspector General State of California
Answers Weighting Points
Reference
Pharmacy Services
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
13.139 Does the institution conspicuously post a valid permit in its pharmacies? 1 0 1 100.0% 2 2.0 100.0% 0 0
13.141 Does the institution properly maintain its emergency crash cart medications? 2 0 2 100.0% 2 2.0 100.0% 0 0
13.252 Does the institution properly maintain medications in its drug night locker(s)? 1 0 1 100.0% 2 2.0 100.0% 0 0
13.253 Does the institution conduct monthly inspections of its emergency cart and 3 0 3 100.0% 1 1.0 100.0% 0 0
drug night locker(s)?
13.142 Is the Pharmacist in Charge's license current? 1 0 1 100.0% 5 5.0 100.0% 0 0
13.144 Does the institution have information to ensure that medications are prescribed 1 0 1 100.0% 6 6.0 100.0% 0 0
by licensed health-care providers lawfully authorized to do so?
13.145 Does the pharmacist in charge have an effective process for screening new 1 0 1 100.0% 7 7.0 100.0% 0 0
medication orders for potential adverse reactions?
13.148 Does the pharmacist in charge monitor the quantity of medications on hand, 1 0 1 100.0% 4 4.0 100.0% 0 0
and does the pharmacy conduct an annual inventory to ensure that the quantity
of medications in the system matches the quantity of medications on hand?
Components Subtotals: 11 0 11 100.0% 29 29.0 100.0% 0 0
Bureau of Audits and Investigations Page 23
Office of the Inspector General State of California
Answers Weighting Points
Reference
Other Services
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
15.059 Did the institution properly provide therapeutic diets to inmates? 4 0 4 100.0% 4 4.0 100.0% 0 0
20.092 Hygiene Intervention: Did custody staff understand the department's policies 4 0 4 100.0% 4 4.0 100.0% 0 0
and procedures for identifying and evaluating inmates displaying inappropriate
hygiene management?
15.134 Did the institution properly respond to all active cases of TB discovered in the 0 0 0 0.0% 0 0.0 0.0% 1 0
last six months?
15.265 Is the most current version of the CDCR Health Services Policies and 2 0 2 100.0% 3 3.0 100.0% 0 0
Procedures available in the institution's law library?
Components Subtotals: 10 0 10 100.0% 11 11.0 100.0% 1 0
Bureau of Audits and Investigations Page 24
Office of the Inspector General State of California
Answers Weighting Points
Reference
Inmate Hunger Strikes
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
11.097 Did the RN conduct a face-to-face triage of the inmate within two (2) business 1 3 4 25.0% 6 1.5 25.0% 0 0
days of receipt of the Form 128-B and document the inmate's reasons for the
hunger strike, most recent recorded weight, current weight, vital signs, and
physical condition?
11.099 After the first 48 hours, did an RN or PCP complete daily assessments 2 2 4 50.0% 6 3.0 50.0% 0 0
documenting the inmate's weight, physical condition, emotional condition,
vital signs, and hydration status?
11.100 After the first 72 hours, did a physician perform a physical examination and 2 2 4 50.0% 7 3.5 50.0% 0 0
order a metabolic panel and a urinalysis of the inmate?
Components Subtotals: 5 7 12 41.7% 19 8.0 42.1% 0 0
Bureau of Audits and Investigations Page 25
Office of the Inspector General State of California
Answers Weighting Points
Reference
Chemical Agent Contraindications
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
12.062 Did the institution document that it consulted with an RN or primary care 5 0 5 100.0% 9 9.0 100.0% 0 0
provider (PCP) before a calculated use of OC?
12.064 Did the institution record how it decontaminated the inmate and did it follow 4 1 5 80.0% 8 6.4 80.0% 0 0
the decontamination policy?
Components Subtotals: 9 1 10 90.0% 17 15.4 90.6% 0 0
Bureau of Audits and Investigations Page 26
Office of the Inspector General State of California
Answers Weighting Points
Reference
Staffing Levels and Training
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
18.002 Information purposes only: Calculate the institution's average vacancy 0 0 0 0.0% 0 0.0 0.0% 1 0
percentages, the number of health care staff starting within six (6) months of
the OIG visit, and the number of health care staff hired from the registry.
The institution provided vacancy statistics within four licensed medical staffing
groups: (1) management; (2) primary care providers; (3) supervision; and (4)
rank and file nursing.
Total number of filled positions: 106.85
Total number of vacancies: 5.58
Total number of positions: 112.43
Vacancy percentage: 4.96%
Number of staff hired within last six months: 12
Total number of registry staff: 20
18.004 Did the institution have a registered nurse (RN) available on site 24 hours a 1 0 1 100.0% 4 4.0 100.0% 0 0
day, seven days a week, for emergency care?
18.005 Did the institution have a physician on site, a physician on call, or an MOD 1 0 1 100.0% 4 4.0 100.0% 0 0
available 24 hours a day, seven days a week, for the last 30 days?
18.006 Does the institution's orientation program for all newly hired nursing staff 1 0 1 100.0% 4 4.0 100.0% 0 0
include a module for sick call protocols that require face-to-face triage?
18.001 Are licensed health care staff current with their certifications and did they 3 2 5 60.0% 4 2.4 60.0% 0 0
attend required training?
Components Subtotals: 6 2 8 75.0% 16 14.4 90.0% 1 0
Bureau of Audits and Investigations Page 27
Office of the Inspector General State of California
Answers Weighting Points
Reference
Nursing Policy
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
16.231 Does the institution ensure that nursing staff review their duty statements? 3 2 5 60.0% 5 3.0 60.0% 0 0
16.154 Does the institution have written nursing policies and procedures that adhere to 5 0 5 100.0% 5 5.0 100.0% 0 0
the department's guidelines?
16.254 Does the institution's supervising registered nurse (SRN) conduct periodic 0 5 5 0.0% 4 0.0 0.0% 0 0
reviews of nursing staff?
Components Subtotals: 8 7 15 53.3% 14 8.0 57.1% 0 0
Bureau of Audits and Investigations Page 28
Office of the Inspector General State of California
California Prison Health Care
Receivership Corporation's
Response
Bureau of Audits and Investigations Page 29
Office of the Inspector General State of California
CALIFORNIA
PRISON HEALTH CARE
CEMRSHIP CORP. 1. Clark Kelso
Receiver
June 17,2009
David R. Shaw, Inspector General
Office of the Inspector General
P.O. Box 348780
Sacramento, CA 95834-8780
Dear Mr. Shaw:
The purpose of this letter is to inform you that the Office of the Receiver has reviewed the
draft report of the Office of the Inspector General's (OIG) Medical Inspection Results (MIR)
for the April 2009 inspection of California State Prison, Los Angeles County (LAC). At this
time, we would like to address the following conditions raised as a result of the MIR.
Clinical Services - Reference Numbers 01.157, 01.159, and 01.244 - Charting
According to the OIG MIR, during Face-to-Face (FTF) triage the Registered Nurse (RN) must
document the inmate patient's primary complaint, vital signs, focused physical examination,
allergies, weight, current medications, medication allergies and medication compliance. LAC
conducted training on the protocol encounter form documentation and all RN's are to receive
updates.
Clinical Services - Reference Numbers 01.027 and 01.247 - Timeframes
Health Screening -Reference Numbers 02.018 and 02.021-Timeframes
Specialty Services - Reference Number 07.038 and 07.043 - Timeframes
Urgent Services - Reference Number 21.249 - Timeframes
During the OIG medical inspection of Clinical Services, Health Screening, Specialty Services,
and Urgent Service it was noted that inmate patients were not seen within the specified
timeframes outlined in the policies and procedures. Although, LAC's providers see an
average of 15 - 18 inmate patients per day; they continue to have a backlog. Weekend clinics
have been started to address the backlog.
Clinical Services - Reference Number 01.124 - Sick Call Medications
Chronic Care - Reference Number 03.175 - Medications
According to the OIG MIR, the institution did not administer or deliver prescnptlOn
medications to the inmate within specific timeframes. LAC has recently implemented the
Maxor Guardian system. The Medication Administration Records (MARs) sampled were
those prior to and during the Maxor Guardian conversion. Furthermore, MARs were either
not filed due to an incomplete order, or identified incorrectly as a Keep on Person (KOP)
medication.
501 J Street P.O. Box 4038 Sacramento, CA 95812-4038
Tel 916.323.1923 -Fax 916.323.1257
David R. Shaw, Inspector General
June 17,2009
Page 2
Prior to the implementation, the nurse wrote the date information on the header. With the
new Maxor Guardian system MARs are pre-printed with the date and time. Training is being
provided and the process has already improved.
Clinical Services - Reference Number 15.234 - Response Bags
According to the OIG MIR, all clinic response bags are to be audited daily and should contain
essential items. LAC has recently completed training for all nursing staff regarding the policy
for checking the bag and maintaining essential items. Clinic response bags will be checked
twice daily to ensure locks are illtact and a full inventory will be conducted monthly. As part
of the new process, the Supervising Registered Nurse II will monitor the inventory sheets for
compliance.
Health Screening - Reference Numbers 02.017 and 02.211 - FornlS
During the OIG medical inspection of the Health Screening areas it was found that the "Initial
Health Screening" and "History and Physical Examination" forms were not completed
correctly. LAC is providing trainillg to the Primary Care Provider (PCP) and Nursing staff on
proper completion of the forms.
Health Screening - Reference Number 02.128 - Existing Medication Order
According to the OIG MIR, if the inmate had an existing medication order upon arrival at the
institution the inmate should receive the medications by the next calendar day. LAC will now
train the Receiving and Release medical staff to call the county facility and get a medication
information sheet when the county does not include it in the inmate file.
Health Screening - Reference Number 03.262 - Problem List
According to tIle OIG MIR, problem lists are to be completed and filed accurately in the
inmate patient's Unit Health Record (UHR). LAC medical records staff have recently been
providec;l with in-service training and are now consistently monitoring the correct placement
of the problem list in the UHR. The PCPs and nursing staff have also been provided in
service training and are now consistently completing the problem list in the Medical Clinics.
Diagnostic Services - Reference Number 06.191-Document Test Results
According to the OIG MIR, all PCP's are to docllment the clinically significant diagnostic test
results on the CDC 7230 (Interdisciplinary Progress Notes). LAC has initiated an in-service
training forum regarding the importance of documenting significant findings onto the
CDC 7230.
501 J Street P.O. Box 4038 Sacramento, CA 95812-4038
Te1916.323.1923 -Fax 916.323.1257
David R. Shaw, Inspector General
June 17,2009
Page 3
Emergency Services - Reference Number 08.222 - Committee Meetings
AccQrding to the OIG MIR, the institution's Emergency Response Review Committee's
(ERRC) findings are to be documented and completed within 30 days. LAC has assigned a
SRN - III to oversee the EERC monthly meetings and the meeting minutes now include a
mechanism for both documentation and follow-up of findings.
Preventive Services - Reference Number 10.228 - Medication
According to the OIG MIR, medical staff is to properly administer medication to the inmate.
LAC implemented a Corrective Action Plan (CAP) that ensures the Public Health Nurse will
have the Unit Health Record (UHR) present for each evaluation and review.
Preventive Services - Reference Number 10.085 - Testing
According to the OIG MIR, inmates ages 51 and older are to receive or have refused a Fecal
Occult Blood Test (FOBT). LAC utilizes both FOBT and Colonoscopy as screening for
colon cancer. Only patients having had FOBT were credited as being appropriately screened
by the OIG. Both the American Cancer Society and the U.S. Preventative Services Task
Force recommend a colonoscopy as a valid and evidence based method of colon cancer
screening. However, due to the current guidelines, providers have been directed and training
has been provided to order a FOBT on all patients for which it is medically indicated.
Inmate Hunger Strikes - Reference Number 11.097,11.09911.100 - Examination
According to the OIG MIR, there are 3 identified steps that need to occur when an inmate is
on a hunger strike: the RN is to conduct a fact-to-face triage of the inmate within two (2)
business days of the inmate patient hunger strike, after the first 48 hours an RN or PCP is to
complete daily assessments, and within 72 hours the PCP is to perform a physical
examination and request labs.
During the time of the OIG inspection it was determined that when an inmate patient was on a
hunger strike, custody was not notifying the medical staff to ensure the RN face-to-face and
daily assessments were done within specified timeframes. Consequently, medical staff was
unable to see the inmate patient within mandated timeframes. As a result, custody will
contact the Chief Medical Officer (CMO) via email once they are notified an inmate patient is
on a hunger strike. This will ensure the PCP and RN meet the specified timeframes.
Clinic Operations - Reference Number 14.160 - Cancelled Appointments
According to the OIG MIR, the institution is required to have a process to identify and
address urgent appointments if a doctor's line is cancelled. LAC has implemented a new
process. All charts corresponding to the list of scheduled patients will now be sent to the
501 J Street P.O. Box 4038 Sacramento, CA 95812-4038
Tel 916.323.1923 -Fax 916.323.1257
David R. Shaw, Inspector General
June 17, 2009
Page 4
Treatnlent and Triage Area (TTA) for review by the physician assigned to that area. Urgent
appointments will be seen the same day in the TTA.
Clinic Operations - Reference Number - 14.165 - Cleanliness
According to the OIG MIR, the clinic floors, waiting room chairs and equipment are to be
disinfected daily. LAC has recently made arrangements to use the 3rd watch porters to clean
all clinics.
Internal Reviews - Reference Number 17.221-Emergency Drills
According to the OIG MIR, the illstitution is to complete medical emergency response drills
for each watch and include participation from each medial facility during the most recent full
quarter. LAC has added a SRN - III to oversee the emergency response program drills.
Drills are ll0W held monthly on varying yards and watches.
Internal Reviews - Reference Number 17.174 - Appeals
According to the OIG MIR, the institution is to promptly process inmate appeals. In the
months prior to the OIG MIR, LAC experienced staffillg·problems in the appeals area. Those
staffing issues have been resolved and LAC is currently up-to-date on all medical appeals.
Access to Healthcare Information - Reference Number 19.150 - Loose Filing
According to the OIG MIR, the medical records department is not Cllrrent with loose filing.
LAC has noticed loose filing has significantly increased with the implementation of the
Maxor Guardian project. Currently, the medical records department has assigned certain staff
to work primarily throughout the day on loose filing.
Urgent Services - Reference Number 21.281- Documed Use
According to the OIG MIR, whell an inmate discharges from a community hospital tIle
institution is responsible to administer and deliver all prescribed medications to the inmate
within specified timeframes. Upon LAC's review of the charts lltilized during the OIG
medical inspection, TTA log book and medication profiles, the decision was made that
medications should have been pulled from the TTA Documed (a locked medical cabinet used
after hours for prescription medications). TTA staff has been re-trained in proper documed
use and proper notification of clinic staff when patients return from the community hospital.
In addition to the items identified above, the OIG draft report contains other findings with a
low reported rate of compliance. A number of findings are being addressed by statewide
initiatives or other resources designed to achieve a constitutiollal level of health care. For
those items that are not addressed by a statewide initiative, California Prison Health Care
501 J Street P.O. Box 4038 Sacramento, CA 95812-4038
Tel 916.323.1923 -Fax 916.323.1257
David R. Shaw, Inspector General
June 17, 2009
Page 5
Services (CPHCS) staff will work with the institution to develop a Corrective Action Plan
(CAP). Once a CAP is submitted and approved, CPHCS staff will monitor and follow-up on
any corrective action identified.
Tllank you for preparing the report. YOllr efforts have advanced our mutual objective of
.ensuring transparency and accountability in the CPHCS operations. Should you have any
questions or concerns, please contact Theresa Kimura-Yip, Associate Director, Medical
Policy and Program Compliance Branch at (916) 327-1205.
Sincerely,
~~Sl,M.D.
Chief Medical Officer (A)
Office oftIle Receiver
California Prison Health Care Service
cc: J. Clark Kelso, Receiver
Elaine Busll, Chief Deputy Receiver
Starr Babcock, Special Assistant to the Court
Tim Rougeux, Chief Operating Officer, Medical Services
T. Belavich, PH.D., MSHCA, Health Care Manager, LAC
P. Finander, M.D., Chief Medical Officer, LAC
Theresa Kimura-Yip, Associate Director, Medical Policy and Program Compliance Branch
Olga Durette, Health Program Manager II, Program Compliance Section
Steve Fama, Attorney, Prison Law Office
Mary Jo Bruns, Southern Regional Administrator
Elizabeth dos Santos Chen, D.O., Southern Regional Medical Director
Nancy Faszer, Deputy Inspector General In-Charge
Bernie Fernandez, Deputy Inspector General Senior
Rob Hughes,Deputy Inspector General
501 J Street P.O. Box 4038 Sacranlento, CA 95812-4038
Tel 916.323.1923 -Fax 916.323.1257
Office of the Inspector General’s Comments on the
Receiver’s Response
Preventive Services – Reference Number 10.085 – Testing
The OIG recognizes that the American Cancer Society and other bodies may recognize a
colonoscopy as an acceptable method of colon cancer screening. However, by agreement among
the stakeholders to the Plata lawsuit, including the Receiver’s office and the plaintiff’s counsel,
the medical inspection tool was developed to test compliance with specifically identified criteria.
Further, the inspection questions are only modified for a change in policy or only after
consultation with the parties to the lawsuit. This process is designed to ensure the consistency,
comparability, and transparency of the inspection process.
In this case, the parties agreed that the OIG’s testing for colon cancer screening was to be based
on departmental policy volume 4, chapter 7, section III. This policy requires that each institution
provide its male inmates at their endorsed institution age 50 or older with annual cancer
screening using a fecal occult blood test (FOBT). The OIG found that none of 10 inmates
reviewed during the inspection received an FOBT, or documented refusal of an FOBT, within
the previous 12 months. Further, given that the policy requirement is for all male inmates age 50
or older to receive an annual FOBT, the Receiver’s direction and training to order an FOBT for
all patients for which it is “medically indicated” may not ensure compliance with the current
policy.
To the extent that it is medically appropriate for the Receiver’s office to change this and other
policies, the OIG has no issue. However, until such time that policies are officially changed
including opportunity for review by the parties to the Plata lawsuit, the OIG is bound to continue
to follow the agreed upon protocols.
Bureau of Audits and Investigations Page 35
Office of the Inspector General State of California