Mule Creek State Prison Cycle 7 Medical Inspection Report

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Connect with us on social media Cycle 7, Mule Creek 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 6 Population-Based Metrics 9 HEDIS Results 9 Recommendations 11 Indicators 13 Access to Care 13 Diagnostic Services 19 Emergency Services 23 Health Information Management 27 Health Care Environment 33 Transfers 42 Medication Management 49 Preventive Services 57 Nursing Performance 60 Provider Performance 65 Specialized Medical Housing 71 Specialty Services 74 Administrative Operations 80 Appendix A: Methodology 83 Case Reviews 84 Compliance Testing 87 Indicator Ratings and the Overall Medical Quality Rating 88 Appendix B: Case Review Data 89 Appendix C: Compliance Sampling Methodology 93 California Correctional Health Care Services’ Response 101 Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | iv Illustrations Tables 1. MCSP Summary Table: Case Review Ratings and Policy Compliance Scores 4 2. MCSP Master Registry Data as of September 2024 7 3. MCSP Health Care Staffing Resources as of September 2024 8 4. MCSP Results Compared With State HEDIS Scores 10 5. Access to Care 16 6. Other Tests Related to Access to Care 17 7. Diagnostic Services 21 8. Health Information Management 30 9. Other Tests Related to Health Information Management 31 10. Health Care Environment 40 11. Transfers 46 12. Other Tests Related to Transfers 47 13. Medication Management 54 14. Other Tests Related to Medication Management 55 15. Preventive Services 58 16. Specialized Medical Housing 72 17. Specialty Services 77 18. Other Tests Related to Specialty Services 78 19. Administrative Operations 81 A–1. Case Review Definitions 84 B–1. MCSP Case Review Sample Sets 89 B–2. MCSP Case Review Chronic Care Diagnoses 90 B–3. MCSP Case Review Events by Program 91 B–4. MCSP Case Review Sample Summary 91 Figures A–1. Inspection Indicator Review Distribution for MCSP 83 A–2. Case Review Testing 86 A–3. Compliance Sampling Methodology 87 Photographs 1. Indoor Patient Waiting Area 33 2. Vital Signs and Blood Draw Stations Were Located Next to Each Other 34 3. Medical Supply Stored With Medications 35 4. Long-Term Storage of Staff Members’ Food in the Medical Supply Storage Room 36 5. Expired Medical Supply Dated August 2024 36 6. Medical Supply’s Manufacturer Required Storage Temperature Set Between 59°F and 77°F 37 7. Medical Supply Stored Beyond Manufacturer’s Temperature Guidelines 37 8. Insect in the Health-Care Area 38 9. Insect in the Health-Care Area 38 Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek 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: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek 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 Mule Creek State Prison (MCSP), 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 February 2024 to July 2024.4 4 Samples are obtained per case review methodology shared with stakeholders in prior cycles. The case reviews include death reviews between October 2023 and June 2024, emergency services cardiopulmonary resuscitation reviews between November 2023 and June 2024. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 3 Summary: Ratings and Scores We completed the Cycle 7 inspection of MCSP in February 2025. OIG inspectors monitored the institution’s delivery of medical care that occurred between February 2024 and July 2024. The OIG rated the case review The OIG rated the compliance component of the overall health care component of the overall health care quality at MCSP adequate. quality at MCSP adequate. OIG case review clinicians (a team of physicians and nurse consultants) reviewed 64 cases, which contained 945 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, which may occur throughout the delivery of care. After examining the medical records, our clinicians completed a follow-up on-site inspection in February 2025 to verify their initial findings. OIG physicians rated the quality of care for 25 comprehensive case reviews. Of these 25 cases, our physicians rated 24 adequate, and one inadequate. To test the institution’s policy compliance, our compliance inspectors (a team of registered nurses) monitored the institution’s compliance with its medical policies by answering a standardized set of questions that measure specific elements of health care delivery. Our compliance inspectors examined 401 patient records and 1,180 data points, and we used the data to answer 86 policy questions. In addition, we observed MCSP’s processes during an on-site inspection in September 2024. The OIG then considered the results from both case review and compliance testing, and drew overall conclusions, which we report in 12 health care indicators.5 5 The indicators for Reception Center and Prenatal and Postpartum Care did not apply to MCSP. During the OIG’s Cycle 7 inspection period, Specialized Medical Housing was not sampled or tested. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 4 We list the individual indicators and ratings applicable for this institution in Table 1 below. Table 1. MCSP Summary Table: Case Review Ratings and Policy Compliance Scores Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 5 Medical Inspection Results Deficiencies Identified During Case Review Deficiencies are medical errors that increase the risk of patient harm. Deficiencies can be minor or significant, depending on the severity of the deficiency. An adverse event occurs when the deficiency caused harm to the patient. All major health care organizations identify and track adverse events. We identify deficiencies and adverse events to highlight concerns regarding the provision of care and for the benefit of the institution’s quality improvement program to provide an impetus for improvement.6 The OIG found no adverse events at MCSP during the Cycle 7 inspection. Case Review Results OIG case reviewers (a team of physicians and nurse consultants) assessed nine of the 12 indicators applicable to MCSP. Of these nine indicators, OIG clinicians rated eight adequate and one inadequate. The OIG physicians also rated the overall adequacy of care for each of the 25 detailed case reviews they conducted. Of these 25 cases, 24 were adequate and one was inadequate. In the 945 events reviewed, we identified 196 deficiencies, 37 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 MCSP: • Patients received excellent access to providers and nurses. • Staff performed excellently in completing diagnostic tests within requested time frames. • Staff received and scanned hospital discharge reports timely. • Providers delivered excellent care for patients with urgent or emergent conditions. • Health care leadership performed well in completing clinical reviews for unscheduled emergency transports to a higher level of care. Our clinicians found the following weaknesses at MCSP: • Providers needed improvement in communicating test results to patients with complete test result notification letters. • An on-site specialist did not consistently forward their specialty reports to providers. 6 For a further discussion of an adverse event, see Table A–1. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 6 • Staff needed improvement in ensuring they timely contacted emergency medical services for emergency events. • MCSP had challenges with chronic care medications and hospital discharge medications. Compliance Testing Results Our compliance inspectors assessed nine of the 12 indicators applicable to MCSP. Of these nine indicators, our compliance inspectors rated three proficient, three adequate, and three 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. MCSP showed a high rate of policy compliance in the following areas: • Staff ensured patients received diagnostic services within ordered time frames, and providers timely reviewed and endorsed results. • Staff performed well in scanning health care services requests and community hospital discharge reports into patients’ electronic medical records. • MCSP provided patients with high-priority, medium-priority, and routine- priority specialty appointments within required time frames. In addition, providers reviewed the resulting specialist reports timely. • Nurses reviewed health care services request forms and conducted face-to- face encounters within required time frames. MCSP revealed a low rate of policy compliance in the following areas: • Staff frequently did not maintain medication continuity for chronic care patients or patients discharged from the hospital. In addition, MCSP maintained poor medication continuity for patients who transferred into the institution. • Health care staff did not consistently follow universal hand hygiene precautions during patient encounters. • Nurses did not regularly inspect emergency medical response bags. • Medical clinics stored expired medical supplies. Institution-Specific Metrics Mule Creek State Prison (MCSP) is located in Ione in Amador County. MCSP operates six clinics where staff members handle non-urgent requests for medical services, including five facility clinics and a specialty clinic. MCSP also conducts health screenings in its receiving and release clinical area (R&R), treats patients requiring urgent or emergent care in its triage and treatment area (TTA), and treats patients in need of inpatient health Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 7 services in its correctional treatment center (CTC). MCSP has been designated as an intermediate care institution. These institutions are predominantly located in or near urban areas, close to tertiary care centers and specialty care providers for the most cost- effective care. As of May 21, 2025, the department reported on its public tracker 85 percent of MCSP’s incarcerated population was fully vaccinated for COVID-19 while 57 percent of MCSP’s staff was fully vaccinated for COVID-19.7 On September 3, 2024, the Health Care Services Master Registry showed MCSP had a total population of 4,063. A breakdown of the medical risk level of the MCSP population as determined by the department is set forth in Table 2 below.8 Table 2. MCSP Master Registry Data as of September 2024 Medical Risk Level Number of Patients Percentage* High 1 783 19.3% High 2 752 18.5% Medium 1,821 44.8% Low 707 17.4% Total 4,063 100% * Percentages may not total 100% due to rounding. Source: Data for the population medical risk level were obtained from the CCHCS Master Registry dated 9-3-24. 7 For more information, see the department’s statistics on its website page titled Population COVID‑19 Tracking. 8 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: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 8 According to staffing data the OIG obtained from California Correctional Health Care Services (CCHCS), as identified in Table 3 below, MCSP had no vacant executive leadership positions, two primary care provider vacancies, 1.2 nursing supervisor vacancies, and 43.7 nursing staff vacancies. Table 3. MCSP Health Care Staffing Resources as of September 2024 Executive Primary Care Nursing Nursing Positions Leadership * Providers Supervisors Staff † Total Authorized Positions 6.0 18.0 22.7 226.7 273.4 Filled by Civil Service 6.0 16.0 21.5 184.0 227.5 Vacant 0 2.0 1.2 43.7 46.9 Percentage Filled by Civil Service 100.0% 88.9% 94.7% 81.2% 83.2% Filled by Telemedicine 0 0 0 0 0 Percentage Filled by Telemedicine 0 0 0 0 0 Filled by Registry 0 0 0 33.0 33.0 Percentage Filled by Registry 0 0 0 14.6% 12.1% Total Filled Positions 6.0 16.0 21.5 217.0 260.5 Total Percentage Filled 100.0% 88.9% 94.7% 95.7% 95.3% Appointments in Last 12 Months 0 1.0 6.0 51.3 58.3 Redirected Staff 0 0 0 0 0 Staff on Extended Leave ‡ 0 0 2.0 4.0 6.0 Adjusted Total: Filled Positions 6.0 16.0 19.5 213.0 254.5 Adjusted Total: Percentage Filled 100.0% 88.9% 85.9% 94.0% 93.1% * Executive Leadership includes the Chief Physician and Surgeon. † Nursing Staff includes the classifications of Senior Psychiatric Technician and Psychiatric Technician. ‡ In Authorized Positions. Notes: The OIG does not independently validate staffing data received from the department. Positions are based on fractional time-base equivalents. Source: Cycle 7 medical inspection preinspection questionnaire received on 9-3-24, from California Correctional Health Care Services. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek 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 MCSP’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 comparison: 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 both poor HbA1C control and colorectal cancer screening, MCSP’s results compared favorably with those found in State health plans for this measure. 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)—MCSP’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. MCSP had a 44 percent influenza immunization rate for adults 18 to 64 years old and an 80 percent influenza immunization rate for adults 65 years of age and older.9 The pneumococcal vaccination rate was 95 percent.10 Cancer Screening When compared with statewide Medi-Cal programs—California Medi-Cal, Kaiser Northern California (Medi-Cal), and Kaiser Southern California (Medi-Cal)—MCSP’s 9 The HEDIS sampling methodology requires a minimum sample of 10 patients to have a reportable result. 10 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: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 10 colorectal cancer screening rate of 88 percent was significantly higher, indicating very good performance on this measure. Table 4. MCSP Results Compared with State HEDIS Scores MCSP California California Kaiser Kaiser Cycle 7 California NorCal SoCal HEDIS Measure Results * Medi-Cal † Medi-Cal † Medi-Cal † HbA1c Screening 100% – – – Poor HbA1c Control (> 9.0%) ‡,§ 7% 33% 26% 19% HbA1c Control (< 8.0%) ‡ 84% – – – Blood Pressure Control (< 140/90) ‡ 97% – – – Eye Examinations 68% – – – Influenza – Adults (18 – 64) 44% – – – Influenza – Adults (65 +) 80% – – – Pneumococcal – Adults (65 +) 95% – – – Colorectal Cancer Screening 88% 40% 71% 71% Notes and Sources * Unless otherwise stated, data were collected in September 2024 by reviewing medical records from a sample of MCSP’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 Medi-Cal Managed Care Physical Health External Quality Review Technical Report, dated July 1, 2023 – June 30, 2024 (published April 2025); https://www.dhcs.ca.gov/dataandstats/reports/Documents/CA2023-24-Medi-Cal- Managed-Care-Physical-Health-External-Quality-Review-Technical-Report-Vol1-F1.pdf. ‡ For this indicator, the entire applicable MCSP 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: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 11 Recommendations As a result of our assessment of MCSP’s performance, we offer the following recommendations to the department: Diagnostic Services • Medical leadership should determine the root cause(s) of challenges to notifying patients of pathology test results and should implement remedial measures as appropriate. • The department should develop strategies, such as an electronic solution, to ensure providers create patient notification letters when they endorse test results and ensure patient notification letters contain all elements required by CCHCS policy. The department should implement remedial measures as appropriate. Emergency Services • The institution leadership should identify the challenges with staff not immediately activating emergency medical services for emergent patients requiring a higher level of care transfer, staff not prioritizing the automated external defibrillator (AED) placement for patients who require CPR, and custody transport teams arriving significantly after the ambulance arrives to the institution. Leadership should implement remedial measures as appropriate. Health Care Environment • Health care leadership should determine the root cause(s) for staff not following all required universal hand hygiene precautions and should implement remedial measures as appropriate. • Health care leadership should determine the root cause(s) for staff not following equipment and medical supply management protocols and should implement remedial measures as appropriate. • Nursing leadership should determine the root cause(s) for staff not ensuring the EMRBs are regularly inventoried and sealed and should implement remedial measures as appropriate. Transfers • Nursing leadership should identify strategies to ensure nursing staff document pending specialty referrals for patients transferring to other institutions in the EHRS, as per the Health Care Department Operations Manual (HCDOM), and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 12 Medication Management • Medical and nursing leadership should develop strategies to ensure chronic care, hospital discharge, and en route patients receive their medications timely and without interruption. Leadership should implement remedial measures as appropriate. • Nursing leadership should develop strategies to ensure nursing staff document patient medication refusals in medication administration records, as described in CCHCS policy and procedures, and should implement remedial measures as appropriate. Preventive Services • Health care leadership should determine the root cause(s) for challenges to timely providing immunizations to chronic care patients and should implement appropriate remedial measures. Nursing Performance • Nursing leadership should determine the challenges to ensuring nurses perform appropriate triage of sick call requests, complete and thorough face- to-face assessments, and co-consults with providers when needed. Nursing leadership should implement remedial measures as appropriate. Provider Performance • Medical leadership should determine the root cause(s) of challenges with thorough provider assessments and review of medical records and should implement remedial measures as appropriate. Specialty Services • Health care leadership should determine the root cause(s) of challenges to the timely provision of preapproved specialty appointments for transfer patients and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 13 Indicators Access to Care In this indicator, OIG inspectors evaluated the institution’s performance in providing patients with timely clinical appointments. Our inspectors reviewed scheduling and appointment timeliness for newly arrived patients, sick calls, and nurse follow-up appointments. We examined referrals to primary care providers, provider follow-ups, and specialists. Furthermore, we evaluated the follow-up appointments for patients who received specialty care or returned from an off-site hospitalization. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Proficient (89.7%) In this cycle, case review found MCSP provided very good access to care, on par with Cycle 6. The institution delivered excellent access to providers and nurses. However, we found two significant specialty appointment deficiencies, which delayed care. Considering all factors, the OIG rated the case review component of this indicator adequate. Compliance testing showed MCSP performed very well in this indicator. Providers performed excellently in timely evaluating newly transferred patients and in timely completing provider follow-up appointments for patients returning from specialty services. Staff performed fair to very well in assessing patients with chronic care conditions and patients returning from hospitalizations within required time frames. Nurses always reviewed all patient sick call requests timely and frequently completed face-to-face triages as required. Based on the overall Access to Care compliance score result, the OIG rated the compliance testing component of this indicator proficient. Case Review and Compliance Testing Results The OIG clinicians reviewed 223 provider, nursing, specialty, and off-site hospital events requiring a follow-up appointment. We identified four deficiencies related to access to care. Three pertained to timely specialty services completion, two of which were significant.11 Access to Care Providers MCSP performed very well with provider access for patients. Compliance testing showed very good access to chronic care follow-up appointments (MIT 1.001, 88.0%) and good access to nurse-to-provider sick call referrals (MIT 1.005, 85.0%). Timely provision of provider sick call follow-up appointments was excellent (MIT 1.006, 100%). Similarly, OIG clinicians found no deficiencies in timely completing provider appointments. 11 Deficiencies occurred in cases 2, 16, and 23. Specialty service access deficiencies occurred in cases 2, 16, and 23. Significant specialty service access deficiencies occurred in cases 16 and 23. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 14 Access to Clinic Nurses MCSP performed excellently in nurse access for patients. Compliance testing showed registered nurses always reviewed patients’ requests for service the same day they were received (MIT 1.003, 100%). Similarly, registered nurses almost always completed face-to- face appointments within one business day following sick call request reviews (MIT 1.004, 91.4%). OIG clinicians reviewed 58 nursing sick call requests and identified only one minor deficiency related to clinic nurse access.12 Access to Specialty Services The institution performed variably in timely completing specialty service appointments. Compliance testing showed sufficient completion rates of high-priority (MIT 14.001, 80.0%) and routine-priority (MIT 14.007, 80.0%) appointments, along with a very good completion rate of medium-priority (MIT 14.004, 86.7%) appointments. Testing further showed completing high-priority follow-up appointments with specialists needed improvement (MIT 14.003, 71.4%), but completing routine-priority follow-up appointments was very good (MIT 14.009, 87.5%), and completing medium-priority follow-up appointments was excellent (MIT 14.006, 100%). OIG clinicians found most specialty appointments occurred within requested time frames but identified two deficiencies, both of which were significant.13 The following is an example: • In case 16, the provider ordered a cardiology specialty appointment. However, the appointment occurred more than four weeks late. We discuss this further in the Specialty Services indicator. Follow-Up After Specialty Services Compliance testing showed provider appointments after specialty services always occurred within required time frames (MIT 1.008, 100%). Similarly, OIG clinicians identified no deficiencies in timely provider appointments following specialty services. Follow-Up After Hospitalization MCSP’s management of post-hospitalization follow-up appointments with the provider varied. Although compliance testing showed providers generally evaluated patients timely after hospitalization (MIT 1.007, 76.0%), OIG clinicians found excellent follow-up appointment completion with no deficiencies. Follow-Up After Urgent or Emergent Care (TTA) MCSP providers always evaluated their patients following a triage and treatment area (TTA) event as medically indicated. OIG clinicians reviewed 19 TTA events and identified no delays in provider follow-up appointments. 12 A minor deficiency related to clinic nurse access occurred in case 23. 13 Significant deficiencies occurred in cases 16 and 23. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 15 Follow-Up After Transferring Into MCSP Access to care for patients who had recently transferred into the institution was mixed. Compliance testing showed excellent access to intake appointments for newly arrived patients (MIT 1.002, 100%). In contrast, compliance testing showed completion of pre- approved specialty service appointments following transfer was poor (MIT 14.010, 45.0%). OIG clinicians found no deficiencies in the three cases reviewed for intake appointment access. We identified one minor deficiency with timely specialty service completion for a transfer patient.14 We discuss this further in the Transfers indicator. Clinician On-Site Inspection OIG clinicians spoke with MCSP’s scheduling supervisor regarding the institution’s access to care. MCSP had five main clinics: A, B, C, D, and E, each staffed with one to three providers. Clinics A, B, and C were in the main MCSP complex. Clinics D and E were located in the MCSP “Infill Complex,” situated away from the main complex. In addition to its main clinics, the institution operated a restricted housing clinic, a minimum-security facility clinic, a TTA, a correctional treatment center (CTC), and specialty clinics. The specialty clinics offered audiology, orthotics, echocardiograms, GI procedures (EGD and Colonoscopy), sleep studies, ultrasound, FibroScan, virtual speech therapy, and virtual pulmonary rehabilitation.15 The OIG clinicians observed morning huddles, which were well attended by the patient care team and staff. At the time of the on-site inspection, the scheduling supervisor reported a backlog of 342 appointments concentrated in Clinic A. Multiple staff members reported providing only urgent and emergent services in Clinic A within the two weeks preceding the on-site inspection, triggering the backlog. They cited a rise in patient violence as the reason for this adjustment. Compliance On-Site Inspection and Discussion Four of six housing units randomly tested at the time of inspection had access to health care services request forms (CDCR Form 7362) (MIT 1.101, 66.7%). In two housing units, custody officers did not have a system in place for restocking the forms. The custody officers reported reliance on medical staff to replenish the forms in the housing units. 14 A minor deficiency occurred in case 2. 15 An echocardiogram is a procedure using an ultrasound to examine and image the heart. An EGD is an esophagogastroduodenoscopy. In this procedure, the specialist uses a camera to examine the esophagus and the stomach. A FibroScan is a diagnostic imaging used to evaluate for liver scarring and fatty changes from liver disease. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek 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 22 3 0 88.0% 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 25 0 0 100% patient seen by the clinician within the required time frame? (1.002) Clinical appointments: Did a registered nurse review the patient’s request 35 0 0 100% for service the same day it was received? (1.003) Clinical appointments: Did the registered nurse complete a face-to-face visit 32 3 0 91.4% 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 17 3 15 85.0% 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 34 100% specified? (1.006) Upon the patient’s discharge from the community hospital: Did the patient 19 6 0 76.0% receive a follow-up appointment within the required time frame? (1.007) Specialty service follow-up appointments: Did the clinician follow-up visits 31 0 14 100% occur within required time frames? (1.008) * Clinical appointments: Do patients have a standardized process to obtain 4 2 0 66.7% and submit health care services request forms? (1.101) Overall percentage (MIT 1): 89.7% * 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: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek 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 N/A N/A N/A N/A required time frame? (12.003) For patients received from a county jail: Did the patient receive a history and physical by a primary care provider within seven calendar days (prior N/A N/A N/A N/A to 07/2022) or five working days (effective 07/2022)? (12.004) Was a written history and physical examination completed within the N/A N/A N/A N/A required time frame? (13.002) Did the patient receive the high-priority specialty service within 14 calendar days of the primary care provider order or the Physician 12 3 0 80.0% Request for Service? (14.001) Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care 5 2 8 71.4% provider? (14.003) Did the patient receive the medium-priority specialty service within 15-45 calendar days of the primary care provider order or the Physician Request 13 2 0 86.7% for Service? (14.004) Did the patient receive the subsequent follow-up to the medium-priority specialty service appointment as ordered by the primary care provider? 8 0 7 100% (14.006) Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician Request 12 3 0 80.0% for Service? (14.007) Did the patient receive the subsequent follow-up to the routine-priority specialty service appointment as ordered by the primary care 7 1 7 87.5% provider? (14.009) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 18 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek 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 (70.6%) Similar to Cycle 6, case review found MCSP performed satisfactorily with diagnostic services in Cycle 7. Staff provided excellent access to diagnostic services, and providers almost always endorsed test results timely. However, we also found patterns of missing or incomplete patient test result notification letters. After considering all aspects, the OIG rated the case review component of this indicator adequate. Compliance testing showed MCSP performed variably for this indicator. Staff always completed and endorsed radiology as well as laboratory tests timely. They usually reviewed and endorsed pathology results within specified time frames. However, staff needed improvement in retrieving pathology reports and in generating complete patient test result notification letters with all required elements. Based on the overall Diagnostic Services compliance score result, the OIG rated the compliance testing component of this indicator inadequate. Case Review and Compliance Testing Results The OIG clinicians reviewed 216 diagnostic-related events and identified 41 deficiencies.16 None of the deficiencies were significant, and all related to health information management. Test Completion MCSP performed perfectly in diagnostic service completion for both compliance testing and case review. Compliance testing revealed staff always completed radiology services (MIT 2.001, 100%) and laboratory services (MIT 2.004, 100%) within required time frames. OIG clinicians similarly identified no deficiencies in timely providing diagnostic services. Neither case review nor compliance testing had any STAT laboratory tests to review in their samples (MIT 2.007, N/A). 16 Deficiencies occurred in cases 10, 12–18, 21–23, 27, 29, and 30. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 20 Health Information Management As with test completion, MCSP performed excellently in diagnostic test endorsement. Compliance testing showed providers always endorsed radiology (MIT 2.002, 100%) and laboratory (MIT 2.005, 100%) results timely. Similarly, OIG clinicians found providers almost always endorsed radiology and laboratory results timely. We identified only two minor deficiencies related to providers untimely endorsing laboratory results.17 In contrast, providers needed improvement with timely notifying patients of diagnostic test results with complete letters. Compliance testing revealed MCSP’s patient notification letters of laboratory results needed improvement (MIT 2.006, 60.0%), while notification letters of radiology results was poor (MIT 2.003, 30.0%). OIG clinicians also identified 39 minor deficiencies related to sending incomplete patient test result notification letters or not sending patient test result notification letters at all.18 MCSP performed variably in managing pathology reports. Compliance testing showed staff intermittently received the final pathology reports timely (MIT 2.010, 70.0%), and providers generally reviewed and endorsed pathology reports (MIT 2.011, 75.0%) within required time frames. In contrast, compliance testing revealed providers never communicated the results of pathology studies with complete patient notification letters within specified time frames (MIT 2.012, zero). OIG clinicians also identified two minor deficiencies related to patient notification letters for pathology results.19 We also discuss this in the Health Information Management indicator. Clinician On-Site Inspection OIG clinicians met with MCSP’s correctional health services administrator II (CHSA II) and providers to discuss diagnostic procedures. The CHSA II reported having staff shortages only for radiology services during the review period and at the time of the on- site inspection. A retired annuitant had been assisting in the senior radiology technician position by working four-hour shifts, three days per week. When asked about current backlogs, the CHSA II reported no current radiology backlog. However, the CHSA II reported, due to a recent increase of violence in A Yard, laboratory services was only able to complete urgent and emergent tests, resulting in a small backlog. Generally, providers reported no issues with obtaining timely laboratory and diagnostic services. Most providers acknowledged having access to STAT laboratory tests; however, they usually opted to transfer patients to a higher level of care if the need for a STAT laboratory test arose. All clinics had their own laboratory draw areas. 17 Two minor deficiencies occurred in case 21. 18 Minor deficiencies occurred in cases 10, 12–18, 22, 23, 27, 29, and 30. 19 Minor deficiencies occurred in cases 27 and 29. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 21 Compliance Score Results Table 7. Diagnostic Services Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Was the radiology service provided within the time frame 10 0 0 100% specified in the health care provider’s order? (2.001) Radiology: Did the ordering health care provider review and endorse the 10 0 0 100% radiology report within specified time frames? (2.002) Radiology: Did the ordering health care provider communicate the results 3 7 0 30.0% of the radiology study to the patient within specified time frames? (2.003) Laboratory: Was the laboratory service provided within the time frame 10 0 0 100% specified in the health care provider’s order? (2.004) Laboratory: Did the health care provider review and endorse the laboratory 10 0 0 100% report within specified time frames? (2.005) Laboratory: Did the health care provider communicate the results of the 6 4 0 60.0% laboratory test to the patient within specified time frames? (2.006) Laboratory: Did the institution collect the STAT laboratory test and receive N/A N/A N/A N/A the results within the required time frames? (2.007) Laboratory: Did the provider acknowledge the STAT results, OR did nursing N/A N/A N/A N/A staff notify the provider within the required time frames? (2.008) Laboratory: Did the health care provider endorse the STAT laboratory N/A N/A N/A N/A results within the required time frames? (2.009) Pathology: Did the institution receive the final pathology report within the 7 3 0 70.0% required time frames? (2.010) Pathology: Did the health care provider review and endorse the pathology 6 2 2 75.0% report within specified time frames? (2.011) Pathology: Did the health care provider communicate the results of the 0 8 2 0 pathology study to the patient within specified time frames? (2.012) Overall percentage (MIT 2): 70.6% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 22 Recommendations • Medical leadership should determine the root cause(s) of challenges to notifying patients of pathology test results and should implement remedial measures as appropriate. • The department should develop strategies, such as an electronic solution, to ensure providers create patient notification letters when they endorse test results and ensure patient notification letters contain all elements required by CCHCS policy. The department should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 23 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 Inadequate Not Applicable In this cycle, case review found MCSP’s overall performance needed improvement in emergency services. Compared with Cycle 6, we identified an increase in the number of significant deficiencies this cycle. The providers performed excellent care. We found nurses generally completed good assessments and documented appropriately. In addition, medical leadership performed well with completing clinical reviews and identifying training opportunities. However, we found health care staff needed improvement in timely notifying emergency medical services (EMS) and prioritizing automated external defibrillator (AED) placement for patients who required CPR, and custody staff needed improvement in timely transporting patients to a higher level of care by.20 Factoring all the information, the OIG rated this indicator inadequate. Case Review Results We reviewed 40 urgent and emergent events and found 24 emergency care deficiencies. Of these 24 deficiencies, nine were significant.21 Emergency Medical Response OIG clinicians found MCSP needed improvement in medical emergency response. Custody and medical staff often initiated CPR without delay and administered naloxone appropriately for patients with a suspected drug overdose.22 Nurses generally performed good assessments and documented appropriately for urgent and emergent events. 20 An automated external defibrillator (AED) is a portable device used to deliver an electric shock to the heart when it detects an abnormal heart rhythm. 21 Deficiencies occurred in cases 2–6, 10, 11, and 23–26. Significant deficiencies occurred in cases 2–6, 23, and 25. 22 Naloxone is a medication used for the emergency treatment of known or suspected opioid overdose. According to the manufacturer, nasal naloxone doses can be safely administered every two to three minutes. CCHCS emergency medical training allows nurses to administer up to five nasal naloxone doses when an opioid overdose is suspected. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 24 However, OIG clinicians identified multiple concerning delays in notifying EMS, applying the AED, and custody arrival after EMS for patient transport. The following are examples. • In case 3, staff activated an emergency medical alarm for this patient with complaints of chest pain. Nurses provided emergency care and received orders to transport the patient to a higher level of care. EMS arrived at 10:58 a.m. However, the custody transport team did not arrive to the patient until 11:11 a.m., 13 minutes later, which delayed transporting the patient to the hospital. • In case 4, at 3:55 p.m., custody staff activated a medical emergency alarm for this patient, who was found unresponsive in his cell. Three minutes later, health care staff arrived to find the patient not breathing, with no pulse, and initiated CPR. After two rounds of CPR, the patient had a return of spontaneous circulation and was transferred to a higher level of care.23 However, the nurses did not apply the AED on the patient when they found him with no pulse or respirations. • In case 5, custody staff activated an emergency medical alarm and initiated CPR for this patient with a suspected drug overdose. However, staff did not contact EMS until five minutes after activating the emergency medical alarm. Similar deficiencies occurred in cases 2, 4, and 6. • In case 6, at 5:37 p.m., nursing staff responded to a medical emergency alarm for this patient, who was found hanging in his cell. Upon arrival, nursing staff found custody staff providing CPR for the patient. Nursing staff assessed the patient and provided life-saving interventions; however, they did not apply the AED until 5:42 p.m., four minutes later. • In case 26, custody staff activated an emergency medical alarm for this patient with stroke symptoms. Staff immediately initiated EMS, and the ambulance arrived to the patient at 7:42 a.m. However, the custody transport team did not arrive until 7:59 a.m., 17 minutes later, delaying patient transport to the hospital. Provider Performance MCSP providers appropriately managed patients in the TTA with urgent or emergent conditions. OIG clinicians identified no emergency provider care deficiencies. Emergency Medical Response Review Committee OIG clinicians reviewed 21 emergency events in which patients transferred to a higher level of care, including patient deaths.24 We found medical leadership overall performed well with conducting clinical reviews and identifying opportunities for improvement. However, compliance testing revealed the emergency medical response and unscheduled 23 Return of spontaneous circulation is the resumption of a sustained heart rhythm that perfuses the body after cardiac arrest. Clinically, the health care provider will check and identify a central pulse. 24 Emergency events requiring emergency transport to a higher level of care occurred in cases 1–11, 17, and 23– 26. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 25 transport event checklists were often incomplete or not completed at all (MIT 15.003, 66.7%). Clinician On-Site Inspection OIG clinicians toured the TTA located in the MCSP main facility. Two registered nurses (RNs) were staffed in the TTA each shift, with one provider assigned Monday through Friday from 7:00 a.m. to 5:00 p.m., and an on-call provider covering after hours. The TTA consisted of four rooms, including one designated for casting or splinting and another for patient observation. We interviewed the day shift nurses, who explained they responded to all medical emergency alarms alongside the licensed vocational nurses (LVNs) from the designated yards. They indicated a high volume of medical emergency alarms, reporting approximately 36 alarms in a single shift. According to the staff, this increase was due to an influx of patients with multiple medical complexities, who recently transferred in from various facilities. We also toured the TTA in the MCSP “Infill Complex” and interviewed the day shift nursing staff. Two RNs staffed each shift, and one provider covered the day shift Monday through Friday. If the provider was unavailable, the nurses would contact the patient’s primary care provider for emergency care. Staff reported handling an average of one emergency event per day and saw an average of one to two walk-in patients per day. Staff indicated the patient care team did a great job of managing the patient care population. Nursing leadership shared the primary care nurses did not respond to medical emergency alarms unless additional help was needed. They planned to implement a pilot program in the near future that would require the clinic nurses to respond to medical emergency alarms. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 26 Recommendations • The institution leadership should identify the challenges with staff not immediately activating emergency medical services for emergent patients requiring a higher level of care transfer, staff not prioritizing the automated external defibrillator (AED) placement for patients who require CPR, and custody transport teams arriving significantly after the ambulance arrives to the institution. Leadership should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek 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 Proficient (92.0%) Case review found MCSP performed satisfactorily in this indicator. Staff performed excellently with timely retrieving and processing medical records, and providers almost always timely reviewed diagnostic test results. However, we identified two deficiency patterns: an on-site specialist routinely did not forward consultation reports to the providers for review, and providers often sent incomplete patient test result notification letters or never sent the letters at all. These deficiencies were not clinically significant. Considering all factors, the OIG rated the case review component of this indicator adequate. Compliance testing showed MCSP performed very well in this indicator. Staff always scanned patient sick call requests and reviewed hospital discharge reports timely. Staff performed very well in scanning specialty and hospital discharge reports, and staff sufficiently labeled medical records and filed them in the appropriate patient files. Based on the overall Health Information Management compliance score result, the OIG rated the compliance component of this indicator proficient. Case Review and Compliance Testing Results The OIG clinicians reviewed 945 events and identified 60 deficiencies related to health information management, only one of which was significant.25 Hospital Discharge Reports MCSP staff performed well in hospital records management. Staff timely retrieved and scanned hospital discharge records into the electronic health records system (EHRS) within required time frames (MIT 4.003, 90.0%).26 OIG clinicians reviewed 17 off-site 25 Deficiencies occurred in cases 1, 3, 9, 10, 12–18, 20–23, 25–27, 29, and 30. A significant deficiency occurred in case 22. 26 EHRS is the Electronic Health Records System. The department’s electronic health record system is used for storing the patient’s medical history and health care staff communication. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 28 emergency department and hospital encounters and identified no deficiencies with MCSP staff’s management of hospital discharge reports. Specialty Reports Compliance testing showed MCSP performed satisfactorily in managing specialty reports. Staff often scanned specialty reports timely. (MIT 4.002, 86.7%) Providers frequently endorsed routine-priority (MIT 14.008, 80.0%), medium-priority (MIT 14.005, 85.7%), and high-priority (MIT 14.002, 85.7%) specialty reports within required time frames. OIG clinicians identified 16 deficiencies related to specialty report management.27 Of those 16 deficiencies, 13 pertained to an on-site specialist not forwarding reports to providers for endorsement.28 The remaining three deficiencies related to late scanning, late provider endorsement, and health information management (HIM) staff not forwarding specialty reports.29 This last HIM staff deficiency was significant. We also discuss these findings in the Specialty Services indicator. Diagnostic Reports Providers performed very well in endorsing laboratory and radiology results within specified time frames. Compliance testing showed providers always endorsed radiology (MIT 2.002, 100%) and laboratory (MIT 2.005, 100%) results timely. Similarly, OIG clinicians found providers almost always endorsed radiology and laboratory results timely. OIG clinicians identified only two minor deficiencies related to untimely provider endorsement of laboratory results.30 Neither case review nor compliance testing had any STAT laboratory tests to review in their samples (MIT 2.007, N/A). MCSP showed mixed performance in managing pathology results. Compliance testing revealed staff sometimes received final pathology reports (MIT 2.010, 70.0%), and providers usually reviewed and endorsed pathology reports (MIT 2.011, 75.0%) within required time frames. However, providers never communicated the results of pathology studies with patient notification letters within specified time frames (MIT 2.012, zero). OIG clinicians identified two minor deficiencies related to patient notification letters of pathology test results.31 Providers similarly struggled with timely patient notification with complete letters of other diagnostic test results. OIG clinicians identified 39 minor deficiencies related to missing or incomplete patient test result notification letters.32 27 Deficiencies occurred in cases 1, 3, 9, 12, 15–18, 20–22, 25, 26, and 29. 28 Deficiencies in which the on-site specialist did not forward the report to the provider for endorsement occurred in cases 1, 3, 9, 15–18, 20, 21, 25, 26, and 29. 29 Two deficiencies, one in late scanning and one in provider endorsement, each occurred in case 12. A significant HIM deficiency related to not forwarding the specialty report to the provider occurred in case 22. 30 Two minor deficiencies occurred in case 21. 31 Minor deficiencies occurred in cases 27 and 29. 32 Minor deficiencies occurred in cases 10, 12–18, 22, 23, 27, 29, and 30. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 29 We also discuss patient notification letters in the Diagnostic Services indicator. Urgent and Emergent Records OIG clinicians reviewed 41 emergency care events and found MCSP nurses and providers documented these events satisfactorily. The providers also sufficiently recorded their emergency care, including off-site telephone encounters. We identified no deficiencies. Refer to the Emergency Services indicator for additional discussion on emergency care documentation. Scanning Performance Compliance testing showed MCSP performed acceptably with scanning, labeling, and filing (MIT 4.004, 83.3%). OIG clinicians also identified only two minor deficiencies.33 Clinician On-Site Inspection OIG clinicians discussed health information management processes with MCSP’s health records technician (HRT) supervisor and correctional health services administrator (CHSA). HIM management described the process for retrieving off-site specialty reports. One of the HIM department’s main responsibilities was obtaining off-site specialty service reports within 48 hours of the specialty service appointments. Upon receiving these records, the HRT would then scan the records into EHRS and forward them to the primary care provider for review and signature. The HIM supervisors reported challenges to obtaining one local dermatology specialist’s reports timely. To track provider report endorsements, the HIM supervisors reported completing a monthly audit. They would send the results of their audit in a deficiency report to the provide, and they provided copies to the chief medical executive (CME) and each chief physician and surgeon (CP&S). Regarding staffing, the HIM supervisors reported during the review period having one vacancy for an HRT and one vacancy for an office assistant (OA). They cited the budget as a barrier to filling these positions. 33 Two minor deficiencies occurred in case 3. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek 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 15 100% health record within three calendar days of the encounter date? (4.001) Are specialty documents scanned into the patient’s electronic health record 26 4 15 86.7% within five calendar days of the encounter date? (4.002) Are community hospital discharge documents scanned into the patient’s electronic health record within three calendar days of hospital discharge? 18 2 5 90.0% (4.003) During the inspection, were medical records properly scanned, labeled, 20 4 0 83.3% 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): 92.0% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek 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 10 0 0 100% radiology report within specified time frames? (2.002) Laboratory: Did the health care provider review and endorse the laboratory 10 0 0 100% report within specified time frames? (2.005) Laboratory: Did the provider acknowledge the STAT results, OR did nursing N/A N/A N/A N/A staff notify the provider within the required time frame? (2.008) Pathology: Did the institution receive the final pathology report within the 7 3 0 70.0% required time frames? (2.010) Pathology: Did the health care provider review and endorse the pathology 6 2 2 75.0% report within specified time frames? (2.011) Pathology: Did the health care provider communicate the results of the 0 8 2 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 12 2 1 85.7% 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 12 2 1 85.7% 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 12 3 0 80.0% frame? (14.008) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 32 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek 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. Our case review clinicians do not rate this indicator. Because none of the tests in this indicator directly affected clinical patient care (it is a secondary indicator), the OIG did not consider this indicator’s rating when determining the institution’s overall quality rating. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Inadequate (60.7%) Overall, MCSP’s performance with health care environment needed improvement. Medical supply storage areas contained expired, unorganized, unidentified, or inaccurately labeled medical supplies. In addition, several clinics did not meet the requirements for essential core medical equipment and supplies. Moreover, staff did not regularly sanitize or wash their hands during patient encounters. Lastly, emergency medical response bags (EMRB) logs were missing staff verification or contained compromised medical supply packaging, and staff did not perform inventory when replacing seal tags. Based on the overall Health Care Environment compliance score result, the OIG rated this indicator inadequate. Compliance Testing Results Patient Waiting Areas We inspected only indoor waiting areas as MCSP had no outdoor waiting areas. Health care and custody staff reported 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. Indoor patient waiting area (photographed on 9-24-24). Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 34 Clinic Environment Eleven of 13 applicable 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, 84.6%). In two clinics, we observed patients being seen at the same time for vital sign checks and blood draws at the triage stations, which hindered auditory privacy (see Photo 2, below). Photo 2. Vital signs and blood draw stations were located next to each other (photographed on 9-23-24). Ten of the 13 applicable clinics we observed contained appropriate space, configuration, supplies, and equipment to allow their clinicians to perform proper clinical examinations (MIT 5.110, 76.9%). In two clinics, we observed staff left the computer screens unlocked displaying confidential medical records, leaving them accessible to unauthorized persons. In one clinic, staff did not shred confidential medical records daily. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 35 Clinic Supplies Staff in five of the 13 applicable clinics followed adequate medical supply storage and management protocols (MIT 5.107, 38.5%). We found one or more of the following deficiencies in eight clinics: unorganized, unidentified, or inaccurately labeled medical supplies; medical supplies stored with staff’s personal items, disinfectants, or medications (see Photo 3, below); long-term storage of staff’s food in the medical supply storage room (see Photo 4, next page); and expired medical supplies (see Photo 5, next page). Photo 3. Medical supply stored with medications (photographed on 9-23-24). Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 36 Photo 4. Long-term storage of staff members’ food in the medical supply storage room (photographed on 9-23-24). Photo 5. Expired medical supply dated August 2024 (photographed on 9-23-24). Seven of the 13 applicable clinics met the requirements for essential core medical equipment and supplies (MIT 5.108, 53.9%). In five clinics, MCSP staff inconsistently documented the AED performance test results within the last 30 days. In one additional clinic, one peak flow meter and associated disposable tips were missing, and staff had not completed the defibrillator performance test log documentations within the last 30 days. We examined EMRBs to determine whether they contained all essential items. We checked whether staff inspected the bags daily and inventoried them monthly. Four of the 10 EMRBs passed our test (MIT 5.111, 40.0%). We found one or more of the following deficiencies in six locations: staff did not ensure the EMRB’s compartments were sealed and intact; staff had not inventoried the EMRBs when the seal tags were replaced; Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 37 EMRBs contained medical supplies with compromised packaging; and staff inaccurately logged the EMRB daily glucometer quality control results. Medical Supply Management None of the medical supply storage areas located outside the medical clinics stored medical supplies appropriately (MIT 5.106, zero). We found medical supplies stored beyond the range of manufacturers’ temperature guidance (see Photos 6 and 7, below). Photo 7. Medical supply’s manufacturer required storage temperature set between 59°F and 77°F (photographed on 9-23-24). Photo 6. Medical supply stored beyond manufacturer’s temperature guidelines (photographed on 9-23-24). Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 38 According to the chief executive officer (CEO), health care leadership did not have any issues with the medical supply process. Health care and warehouse managers expressed no concerns about the medical supply chain or their communication process with the existing system in place. Infection Control and Sanitation Staff appropriately cleaned, sanitized, and disinfected seven of 13 applicable clinics (MIT 5.101, 53.9%). In six clinics, we found one or both of the following deficiencies: cleaning logs were not maintained or the health care area had insects (see Photos 8 and 9, below). Photo 9. Insect in the health care area (photographed on 9-24-24). Photo 8. Insect in the health care area (photographed on 9-24-24). Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 39 Staff in all clinics properly sterilized or disinfected medical equipment (MIT 5.102, 100%). We found operational sinks and hand hygiene supplies in the examination rooms in 10 of 13 applicable clinics (MIT 5.103, 76.9%). The patient restrooms in three clinics lacked antiseptic soap. We observed patient encounters in seven applicable clinics. In four clinics, clinicians did not wash their hands before examining their patients, before applying gloves, before performing blood draws, or before and after performing wound care (MIT 5.104, 42.9%). Health care staff in all clinics followed proper protocols to mitigate exposure to bloodborne pathogens and contaminated waste (MIT 5.105, 100%). Physical Infrastructure At the time of our medical inspection, 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: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 40 Compliance Score Results Table 10. Health Care Environment Scored Answer Compliance Questions Yes No N/A Yes % Infection control: Are clinical health care areas appropriately disinfected, 7 6 1 53.9% 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 13 0 1 100% warranted? (5.102) Infection control: Do clinical health care areas contain operable sinks and 10 3 1 76.9% sufficient quantities of hygiene supplies? (5.103) Infection control: Does clinical health care staff adhere to universal hand 3 4 7 42.9% hygiene precautions? (5.104) Infection control: Do clinical health care areas control exposure to blood- 13 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 5 8 1 38.5% storing bulk medical supplies? (5.107) Clinical areas: Do clinic common areas and exam rooms have essential core 7 6 1 53.9% medical equipment and supplies? (5.108) Clinical areas: Are the environments in the common clinic areas conducive 11 2 1 84.6% to providing medical services? (5.109) Clinical areas: Are the environments in the clinic exam rooms conducive to 10 3 1 76.9% 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 4 6 4 40.0% 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): 60.7% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 41 Recommendations • Health care leadership should determine the root cause(s) for staff not following all required universal hand hygiene precautions and should implement remedial measures as appropriate. • Health care leadership should determine the root cause(s) for staff not following equipment and medical supply management protocols and should implement remedial measures as appropriate. • Nursing leadership should determine the root cause(s) for staff not ensuring the EMRBs are regularly inventoried and sealed and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 42 Transfers In this indicator, OIG inspectors examined the transfer process for those patients who transferred into the institution as well as for those who transferred to other institutions. For newly arrived patients, our inspectors assessed the quality of health care screenings and the continuity of provider appointments, specialist referrals, diagnostic tests, and medications. For patients who transferred out of the institution, inspectors checked whether staff reviewed patient medical records and determined the patient’s need for medical holds. They also assessed whether staff transferred patients with their medical equipment and gave correct medications before patients left. In addition, our inspectors evaluated 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 (78.0%) Case review found MCSP performed sufficiently in the transfer process, similar to Cycle 6. Nurses performed good assessments for new patients arriving to the institution and for patients returning from the hospital. Staff scheduled nurse and provider appointments timely for newly arrived patients. For patients transferring out of MCSP, nurses ensured all essential medications and required documents were included in transfer packets. However, we identified opportunities for improvement in nursing documentation of pending specialty referrals when patients transferred to another institution. Considering all factors, the OIG rated the case review component of this indicator adequate. Compared with Cycle 6, MCSP’s overall performance improved for this indicator. MCSP needed improvement in completing initial health screening forms and ensuring medication continuity for newly transferred patients. However, the institution performed excellently in completing assessment and disposition sections of the screening process and ensuring transfer packets for departing patients included required documents and medications. Based on the overall Transfers compliance score result, the OIG rated the compliance testing component of this indicator adequate. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 43 Case Review and Compliance Testing Results OIG clinicians reviewed 43 events in 18 cases in which patients transferred into or out of the institution or returned from an off-site hospital or emergency room. We identified 11 deficiencies, three of which were significant.34 Transfers In OIG clinicians reviewed 11 events in which patients transferred into the facility from 35 other institutions. We identified two deficiencies, neither of which was significant. OIG clinicians found nurses performed very well in completing the healthcare screening form thoroughly and scheduling nurse and provider follow-up appointments timely. Compliance testing revealed nurses needed improvement in completing the initial health screening form timely and providing an explanation for questions answered “yes” on the screening form (MIT 6.001, 72.0%). However, compliance testing showed nurses always completed the assessment and disposition section of the healthcare screening form (MIT 6.002, 100%). Compliance testing showed nurses needed improvement needed with medication continuity for patients who transferred into the facility (MIT 6.003, 40.0%). The low score was mostly due to nurses not documenting identified barriers or the reason for patient refusals on the medication administration record (MAR). Compliance testing also showed staff only occasionally maintained medication continuity without interruption for patients who transferred from one housing unit to the another (MIT 7.005, 48.0%). In addition, compliance testing revealed MCSP performed poorly with ensuring patients laying over at the facility received their medications without interruption (MIT 7.006, 30.0%). The low score was mainly due to not documenting medication delivery by the next dosing interval. In contrast, OIG clinicians found staff administered medications in their cases without a disruption in medication continuity. Compliance testing showed MCSP performed excellently with ensuring a provider evaluated new patient arrivals within required time frames (MIT 1.002, 100%). However, compliance testing revealed MCSP performed poorly with scheduling preapproved specialty appointments within required time frames (MIT 14.010, 45.0%). Case review only identified one deficiency with a pending specialty appointment that was not reconciled when the patient arrived at the institution, meaning the appointment was not scheduled.36 Transfers Out Compliance testing showed MCSP performed excellently in including the required medications and corresponding transfer documents in transfer packets (MIT 6.101, 100%). While case review found nurses generally completed transfer information and administered medications prior to transfer, in three cases we identified a pattern of 34 Deficiencies occurred in cases 2, 3, 10, 23, 26, 34, and 35. Significant deficiencies occurred in cases 23 and 26. 35 Transfer-in deficiencies occurred in cases 2 and 10. 36 A specialty service appointment deficiency occurred in case 2. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 44 nurses not documenting pending specialty referrals and appointments.37 The following is an example: • In case 36, the nurse completed the preboarding transfer screening form for this patient, who was transferring out to another institution. However, the nurse did not document in EHRS the patient’s pending specialty referrals for the ear, nose, and throat specialist, the allergy specialist, or the follow-up appointment with gastroenterology specialist.38 Hospitalizations Patients returning from an off-site hospitalization or emergency room are at high risk for lapses in care quality. These patients typically experienced severe illness or injury. They require more care and place a strain on the institution’s resources. In addition, because these patients have complex medical issues, successful health information transfer is necessary for good quality care. Any transfer lapse can result in serious consequences for these patients. The OIG compliance team found MCSP performed satisfactorily in ensuring patients had timely follow-up appointments after hospitalizations or emergency room encounters (MIT 1.007, 76.0%) and performed well in retrieving and scanning hospital records (MIT 4.003, 90.0%). In addition, providers always reviewed hospital discharge documents within required time frames (MIT 4.005, 100%). OIG clinicians reviewed 13 events in which patients returned from a hospitalization or emergency room, and we found nurses performed excellently in completing thorough assessments and communicating hospital recommendations to the provider upon these patients’ returns. Compliance testing revealed MCSP performed poorly with administering medications without interruption for patients who returned from a hospitalization or emergency room encounter (MIT 7.003, 8.0%). The low score was mostly due to staff not making medications available or administering them to patients by the provider-ordered date or time. These medications included those to treat infections, high blood pressure, high cholesterol, thyroid conditions, and glaucoma.39 OIG clinicians identified three significant deficiencies related to medication continuity for patients returning after hospitalization.40 Please see the Medication Management indicator for further discussion. Clinician On-Site Inspection OIG clinicians toured both receiving and release (R&R) locations in the MCSP main facility and the MCSP “Infill Complex.” In each R&R location, the R&R was staffed with one RN on the day shift and one on the evening shift, with the TTA RN covering the night shift. We found staff knowledgeable about the transfer process. On average, the 37 Documentation deficiencies for specialty referrals and pending appointments occurred in cases 10, 35, and 36. 38 A gastroenterology specialist is a doctor who diagnosis and manages conditions of the digestive system, including the esophagus, stomach, intestines, liver, pancreas, and gallbladder. 39 Glaucoma is a condition with increased eye pressure and can cause vision loss. 40 Hospital return medication deficiencies occurred in cases 23 and 26. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 45 lower facility had 15 patients transferring into MCSP daily and five patients transferring out daily, and the upper facility had five to 10 patient transfers in and out each week. The R&R nurses were knowledgeable regarding the transfer process. The staff indicated they printed a transfer bus list a week in advance, and nurses conducted a chart review to check for any pending specialty appointments and referrals for those patients on the list. They reported notifying the receiving institution about patients with pending specialty referrals either by phone to provide a report or by sending a message via the message pool in EHRS. In addition, the nurses documented pending specialty referrals or appointments in EHRS prior to transfer. Furthermore, on the day of transfer, nurses would review charts and print out any new orders to be included in transfer packets to ensure continuity of care. Compliance On-Site Inspection and Discussion R&R nursing staff ensured all eight applicable patients transferring out of the institution had their required medications, transfer documents, and assigned durable medical equipment (MIT 6.101, 100%). Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 46 Compliance Score Results Table 11. Transfers Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution: Did nursing staff complete the initial health screening and answer all screening 18 7 0 72.0% 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 6 9 10 40.0% 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 8 0 2 100% required documents? (6.101) Overall percentage (MIT 6): 78.0% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 47 Table 12. Other Tests Related to Transfers Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution: Based on the patient’s clinical risk level during the initial health screening, was the 25 0 0 100% 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 19 6 0 76.0% 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 2 5 90.0% (4.003) For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements and did a provider 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 12 13 0 48.0% 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 9 11 0 45.0% 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: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 48 Recommendations • Nursing leadership should identify strategies to ensure nursing staff document pending specialty referrals for patients transferring to other institutions in the EHRS, as per the Health Care Department Operations Manual (HCDOM), and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 49 Medication Management In this indicator, OIG inspectors evaluated the institution’s performance in administering prescription medications on time and without interruption. The inspectors examined this process from the time a provider prescribed medication until the nurse administered the medication to the patient. In addition to examining medication administration, our compliance inspectors also tested many other processes, including medication handling, storage, error reporting, and other pharmacy processes. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Inadequate (60.1%) In this cycle, case review found MCSP’s overall performance sufficient in medication management. We found the institution performed very well with ensuring patients received their newly prescribed medications without any interruption and performed excellently with medication administration for patients who transferred into and out of the facility. However, we found MCSP continued to have challenges with medication continuity for patients on chronic care medications and medications for patients returning from the hospital. Considering all factors, the OIG rated the case review component of this indicator adequate. Compliance testing showed MCSP needed improvement in providing medication management services. MCSP performed poorly in providing patients with chronic care medications, community hospital discharge medications, and in ensuring medication continuity for patients laying over at the facility. Based on the overall Medication Management compliance score result, the OIG rated the compliance testing component of this indicator inadequate. Case Review and Compliance Testing Results We reviewed 152 events in 31 cases related to medications and found 23 medication deficiencies, nine of which were significant.41 New Medication Prescriptions OIG clinicians found MCSP performed very well with timely administering newly prescribed medications. We identified two deficiencies in two cases in which the patients received their newly prescribed medications one to two days late.42 In contrast, compliance testing revealed newly prescribed medications were not always available or administered by the provider-ordered date or time (MIT 7.002, 64.0%). Analysis of the 41 Deficiencies occurred in cases 1, 3, 9, 10, 15, 18, 21, 23–26, 29, and 30. Significant deficiencies occurred in cases 3, 15, 21, 23, 24, 26, and 29. 42 New medication deficiencies occurred in cases 1 and 25. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 50 compliance data showed patients often received their newly prescribed medications late, including medications to treat infections and high cholesterol. Chronic Medication Continuity Compliance testing revealed MCSP performed poorly with ensuring patients received their chronic care medications within required time frames (MIT 7.001, 5.6%). The low score was mostly due to the pharmacy not filling or dispensing medications timely. In addition, nursing staff did not always document a reason when patients refused to take a medication. Similarly, OIG clinicians found MCSP had many lapses in administering chronic care medications. The following are examples: • In case 3, during the month of March 2024, the patient was scheduled to receive their keep-on-person (KOP) chronic care medication for heart disease.43 However, the patient received the medication in April 2024, more than one month later. • In case 15, during the month of April 2024, the patient was due to receive their KOP chronic care diabetic medication. However, the patient only received a 15-day supply of the medication in April instead of the 30-day supply for the month. • In case 21, during the month of June 2024, the patient did not receive KOP chronic care medication, tamsulosin.44 The patient received the medication in July 2024, one month later. Hospital Discharge Medications Compliance testing showed MCSP performed poorly in medication continuity for patients who were discharged from a community hospital (MIT 7.003, 8.0%). Analysis of the compliance data showed the low score was mostly due to staff not making medications available by the provider-ordered date and time. OIG clinicians identified three significant deficiencies related to hospital discharge medications.45 The following is an example: • In case 23, the patient with a history of chronic obstructive pulmonary disease returned from the hospital with a discharge diagnosis of pneumonia. The nurse obtained a telephone order from the provider for the patient’s medications; however, the order for the rescue inhaler was entered to begin four days later, rather than the same day. Consequently, the patient did not receive the KOP rescue inhaler prior to being discharged to the housing unit. 43 KOP means “keep on person” and refers to medications that a patient can keep and self-administer according to the directions provided. 44 Tamsulosin is prescribed to treat symptoms from an enlarged prostate. 45 Hospital discharge medication deficiencies occurred in cases 23 and 26. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 51 Specialized Medical Housing Medications Both case review and compliance testing did not have any applicable samples to review for medication management during the review period. Transfer Medications Compliance testing showed MCSP performed excellently with ensuring all patients who transferred out of the facility had a five-day supply of medications (MIT 6.101, 100%). However, MCSP needed improvement with medication continuity for patients who transferred into the institution (MIT 6.003, 40.0%). Compliance testing revealed nurses did not always document identified barriers or the reason for patient refusals on the MAR. Furthermore, compliance testing showed the institution only sporadically maintained continuity for patients who transferred from one housing unit to another (MIT 7.005, 48.0%). In addition, MCSP performed poorly with ensuring patient layovers received their next medication dose at the appropriate interval (MIT 7.006, 30.0%). In contrast, OIG clinicians found MCSP performance with transfer medications was excellent. We did not identify any medication deficiencies for patients who transferred into and out of the institution. Medication Administration Compliance testing showed MCSP performed very well with administering TB medications and found nurses mostly monitored the patients taking TB medications as required (MIT 9.002, 92.3%). OIG clinicians did not identify any concerns related to TB medications. Clinician On-Site Inspection OIG clinicians toured the medication clinics on A Yard and E Yard and interviewed the LVNs. Staff informed us A Yard and E Yard each had four medication nurses on the day and evening shifts. The medication rooms were clean, spacious, and appeared well organized. The nurses were knowledgeable about the medication administration process, including processes for KOP medications as well as for patients who were non-compliant with medication. We found the A Yard medication nurses followed a structured process to ensure patients received every opportunity to obtain their KOP medications within four days before returning the medication to pharmacy. According to the nurses, they provided a medication list to custody staff for posting in the buildings and on the medication line window. If a patient did not pick up their medication on day two of the posting, the nurses would schedule the patient to come to the clinic to either pick up their medication or sign a refusal form. If a patient did not show for their scheduled appointment, the nurses would go to the patient’s cell to have the patient complete a refusal form. The medication nurses communicated any medication noncompliance issues to the providers, and the patient care team discussed the issues in the daily huddle. In addition, they scheduled any patients who were noncompliant with medications for a medication counseling appointment with the clinic RNs. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 52 The LVNs stated their additional duties included administering vaccine injections, completing preprocedural preparation forms, and performing medical first responder assignments to all medical emergency alarms. Medication Practices and Storage Controls The institution adequately stored and secured narcotic medications in all 11 applicable clinic and medication line locations (MIT 7.101, 100%). MCSP appropriately stored and secured nonnarcotic medications in three of 12 applicable clinic and medication line locations (MIT 7.102, 25.0%). In nine locations, we observed one or more of the following deficiencies: the medication storage area was unclean; the medication area lacked a clearly labeled designated area for medications to be returned to the pharmacy; medications were not securely stored as required by CCHCS policy; nurses did not maintain unissued medications in the original labeled packaging; and the treatment cart log was missing security check entries. Staff kept medications protected from physical, chemical, and temperature contamination in five of 12 applicable clinic and medication line locations (MIT 7.103, 41.7%). In seven locations, we found one or more of the following deficiencies: staff did not consistently record the room temperature; staff stored medications with personal items or disinfectants; the medication refrigerator was unsanitary; and staff did not store several medications within the manufacturers’ temperature guidelines. Staff successfully stored valid, unexpired medications in 11 of 12 applicable medication line locations (MIT 7.104, 91.7%). In one location, medication nurses did not label the multi-use medication as required by CCHCS policy, and staff did not store intravenous (IV) solutions according to manufacturers’ guidelines. 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 donning gloves or before each subsequent regloving. Staff in six of seven applicable medication preparation and administration areas demonstrated appropriate administrative controls and protocols (MIT 7.106, 85.7%). In one location, medication nurses did not describe the process they followed when reconciling newly received medication and the MAR with the corresponding physician’s order. Staff in two of seven applicable medication areas used appropriate administrative controls and protocols when distributing medications to their patients (MIT 7.107, 28.6%). In five locations, we observed one or more of the following deficiencies: medication nurses did not distribute medications to patients within required time frames; medication nurses did not always verify patients’ identification using a secondary identifier; medication nurses did not reliably observe patients while they swallowed direct observation therapy medications; medication nurses did not follow the CCHCS care guide when administering Suboxone medication; and during insulin administration, Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 53 we observed some medication nurses did not properly disinfect the medication vial’s port prior to withdrawing medication.46 Pharmacy Protocols Pharmacy staff followed general security, organization, and cleanliness management protocols in its remote and main pharmacy (MIT 7.108, 100%), and staff properly stored nonrefrigerated medications (MIT 7.109, 100%) The institution properly stored refrigerated or frozen medications in one of two pharmacies (MIT 7.110, 50.0%). In the remote pharmacy, we found an unsanitary freezer. The pharmacist-in-charge (PIC) correctly accounted for narcotic medications stored in both MCSP pharmacies (MIT 7.111, 100%). We examined 12 medication error reports and found the PIC timely and correctly processed all reports (MIT 7.112, 100%). Nonscored Tests Our compliance team interviewed patients in restrictive housing units to determine whether they had immediate access to their prescribed asthma rescue inhalers or nitroglycerin medications. Of the applicable patients interviewed, six of 10 indicated they had access to their rescue medications. Two patients reported running out of their rescue inhalers, while two other patients lost their rescue inhalers. Of the four patients, three patients had not informed any staff members, and one patient had informed medical staff one day prior. We promptly notified the CEO of this concern, and health care management immediately issued replacement rescue inhalers to the patients (MIT 7.999). 46 Suboxone is a medication containing buprenorphine and naloxone. Suboxone is used to treat opioid dependence and addiction. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 54 Compliance Score Results Table 13. Medication Management Scored Answer Compliance Questions Yes No N/A Yes % Did the patient receive all chronic care medications within the required time frames 1 17 7 5.6% or did the institution follow departmental policy for refusals or no‑shows? (7.001) Did health care staff administer, make available, or deliver new order prescription 16 9 0 64.0% medications to the patient within the required time frames? (7.002) Upon the patient’s discharge from a community hospital: Were all ordered medications administered, made available, or delivered to the patient within 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 to N/A N/A N/A N/A the patient within the required time frames? (7.004) Upon the patient’s transfer from one housing unit to another: Were medications 12 13 0 48.0% continued without interruption? (7.005) For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications administered or delivered 3 7 0 30.0% without interruption? (7.006) All clinical and medication line storage areas for narcotic medications: Does the institution employ strong medication security controls over narcotic medications 11 0 4 100% assigned to its storage areas? (7.101) All clinical and medication line storage areas for nonnarcotic medications: Does the institution properly secure and store nonnarcotic medications in the assigned 3 9 3 25.0% storage areas? (7.102) All clinical and medication line storage areas for nonnarcotic medications: Does the institution keep nonnarcotic medication storage locations free of contamination in 5 7 3 41.7% 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 11 1 3 91.7% assigned storage areas? (7.104) Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols during medication preparation and 3 4 8 42.9% medication administration processes? (7.105) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when preparing medications for 6 1 8 85.7% patients? (7.106) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when administering medications 2 5 8 28.6% to patients? (7.107) Pharmacy: Does the institution employ and follow general security, organization, and 2 0 0 100% cleanliness management protocols in its main and remote pharmacies? (7.108) Pharmacy: Does the institution’s pharmacy properly store nonrefrigerated 2 0 0 100% medications? (7.109) Pharmacy: Does the institution’s pharmacy properly store refrigerated or frozen 1 1 0 50.0% medications? (7.110) Pharmacy: Does the institution’s pharmacy properly account for narcotic 2 0 0 100% medications? (7.111) Pharmacy: Does the institution follow key medication error reporting protocols? 12 0 0 100% (7.112) Pharmacy: For Information Purposes Only: During compliance testing, did the OIG This is a nonscored test. Please see the indicator find that medication errors were properly identified and reported by the institution? (7.998) for discussion of this test. Pharmacy: For Information Purposes Only: Do patients in restricted housing units This is a nonscored test. Please see the indicator have immediate access to their KOP prescribed rescue inhalers and nitroglycerin medications? (7.999) for discussion of this test. Overall percentage (MIT 7): 60.1% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 55 Table 14. Other Tests Related to Medication Management Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution: If the patient had an existing medication order upon arrival, were medications 6 9 10 40.0% 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- 8 0 2 100% packet required documents? (6.101) Patients prescribed TB medication: Did the institution administer the 13 0 0 100% 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 12 1 0 92.3% medication? (9.002) Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient N/A N/A N/A N/A within required time frames? (13.003) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 56 Recommendations • Medical and nursing leadership should develop strategies to ensure chronic care, hospital discharge, and en route patients receive their medications timely and without interruption. Leadership should implement remedial measures as appropriate. • Nursing leadership should develop strategies to ensure nursing staff document patient medication refusals in medication administration records, as described in CCHCS policy and procedures, and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 57 Preventive Services In this indicator, OIG compliance inspectors tested whether the institution offered or provided cancer screenings, tuberculosis (TB) screenings, influenza vaccines, and other immunizations. If the department designated the institution as being at high risk for coccidioidomycosis (Valley Fever), we tested the institution’s performance in transferring out patients quickly. The OIG rated this indicator solely according to the compliance score. Our case review clinicians do not rate this indicator. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Proficient (91.1%) MCSP performed very well in preventive services. Staff performed outstandingly in administering TB medications to patients as prescribed, offering patients an influenza vaccine for the most recent influenza season, and offering colorectal cancer screening for patients ages 45 through 75. They also performed excellently in monitoring patients taking TB medications and screening patients annually for TB. However, staff needed improvement in offering required immunizations to chronic care patients. These findings are set forth in the table on the next page. Based on the overall Preventive Services compliance score result, the OIG rated this indicator proficient. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 58 Compliance Score Results Table 15. Preventive Services Scored Answer Compliance Questions Yes No N/A Yes % Patients prescribed TB medication: Did the institution administer the 13 0 0 100% 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 12 1 0 92.3% medication? (9.002) Annual TB screening: Was the patient screened for TB within the last year? 24 1 0 96.0% (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 7 5 13 58.3% patients? (9.008) Are patients at the highest risk of coccidioidomycosis (Valley Fever) N/A N/A N/A N/A infection transferred out of the facility in a timely manner? (9.009) Overall percentage (MIT 9): 91.1% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 59 Recommendations • Health care leadership should determine the root cause(s) for challenges to timely providing immunizations to chronic care patients and should implement appropriate remedial measures. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 60 Nursing Performance In this indicator, the OIG clinicians evaluated the quality of care delivered by the institution’s nurses, including registered nurses (RN), licensed vocational nurses (LVN), psychiatric technicians (PT), certified nursing assistants (CNA), and medical assistants (MA). Our clinicians evaluated nurses’ performance in making timely and appropriate assessments and interventions. We also evaluated the institution’s nurses’ documentation for accuracy and thoroughness. Clinicians reviewed nursing performance across many clinical settings and processes, including sick call, outpatient care, care coordination and management, emergency services, specialized medical housing, hospitalizations, transfers, specialty services, and medication management. The OIG assessed nursing care through case review only and performed no compliance testing for this indicator. When summarizing nursing performance, our clinicians understand that nurses perform numerous aspects of medical care. As such, specific nursing quality issues are discussed in other indicators, such as Emergency Services, Specialty Services, and Specialized Medical Housing. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Not Applicable MCSP’s overall nursing performance was sufficient. Compared with Cycle 6, MCSP had similar results this cycle. We found nurses performed good assessments and interventions for patient transfers and patients returning from hospitalizations. Although overall nursing performance was sufficient, we identified opportunities for improvement with nursing assessments and interventions in emergency care and in the outpatient clinics as discussed below. Factoring all the information, the OIG rated this indicator adequate. Case Review Results We reviewed 160 nursing encounters in 54 cases. Of the nursing encounters we reviewed, 81 occurred in the outpatient setting, and 58 were sick call requests. We identified 61 nursing performance deficiencies, seven of which were significant.47 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. 47 Deficiencies occurred in cases 1–6, 9–11, 21, 23–26, 34–42, 44–47, 50, 51, 53, 55, 57, and 58–60. Significant deficiencies occurred in cases 2, 6, 10, 23, 50, 58 and 60. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 61 OIG clinicians identified 37 outpatient nursing deficiencies, four of which were significant.48 We found nurses generally performed appropriate assessments and interventions. However, we identified opportunities for improvement with nurses completing thorough assessments, appropriately scheduling patients with symptomatic complaints, initiating co-consultations with providers when conditions warranted, and providing patient education. The following are examples: • In case 1, the nurse reviewed the patient’s sick call request with complaints of having problems going to the bathroom and stated the tissue paper was irritating him. However, the nurse triaged the complaint as asymptomatic and scheduled the patient for a nurse face-to-face assessment in 14 days instead of one business day for a symptomatic complaint. • In case 10, the nurse assessed the patient for complaints of rectal bleeding when wiping with intermittent burning discomfort. The patient also reported lifelong intermittent vomiting several times per week after eating meals. However, the nurse did not inquire about the time of symptom onset of rectal bleeding and did not co-consult with the provider to report patient symptoms. • In case 53, the nurse assessed the patient for complaints of constant right shoulder pain. However, the nurse did not provide patient education before the patient was discharged back to housing. Similar deficiencies occurred in cases 10, 21, 25, 26, 38, 47, 55, 57, and 59. • In case 60, the nurse reviewed the patient’s sick call request with symptomatic complaints of stomach cramps, vomiting, and diarrhea. The nurse did not schedule a same day evaluation for the patient’s urgent symptoms. One day later, the nurse assessed the patient who reported having abdominal discomfort, vomiting, and three to five loose stools a day for the past three days. The nurse used the nursing protocol for diarrhea and administered antidiarrheal medication. However, the nurse did not perform a complete abdominal assessment, such as listening to bowel sounds, assessing if abdomen was tender or nontender, or inquiring when the patient last vomited to include a description of the content. In addition, the nurse did not co-consult with the provider for further evaluation and a plan of care. 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. OIG clinicians found nurses mostly documented patient care appropriately. Emergency Services OIG clinicians reviewed 40 urgent and emergent events. We found nurses responded to emergency events timely, generally performed good assessments, and documented 48 Outpatient nursing deficiencies occurred in cases 1, 3, 9, 10, 21, 25, 26, 37–42, 44–47, 50, 51, 53, 55 and 57–60. Significant deficiencies occurred in cases 10, 50, 58 and 60. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 62 appropriately. However, we found staff needed improvement in a few areas, which we detail further in the Emergency Services indicator. Hospital Returns OIG clinicians reviewed 13 events involving patients returning from off-site hospitals or emergency rooms and found nurses performed excellent nursing assessments, which we detail further in the Transfers indicator. Transfers OIG clinicians reviewed nine cases involving transfer-in and transfer-out processes. The nurses performed good assessments, completed the health care screening, and initiated nurse and provider appointments within required time frames. However, we found when patients transferred out of the facility, the nurses did not always document pending specialty referrals and appointments. However, these deficiencies did not impact the overall care of the patient. Please refer to the Transfers indicator for further details. Specialized Medical Housing OIG clinicians did not have any case review samples for specialized medical housing to review during our review period. Specialty Services We reviewed 10 events in which patients returned from an off-site specialty service appointment for specialty procedures and consultations.49 Nurses performed good assessments when patients returned from off-site specialty appointments. We identified two minor deficiencies.50 One deficiency related to documentation, and in the other deficiency, the nurse did not obtain the specialist’s recommendations following the patient’s return from the appointment. Medication Management OIG clinicians reviewed 152 events involving medication management and found most nurses administered medications to patients as prescribed. However, we identified opportunities for improvement in medication continuity for patients on chronic care medications and for patients returning from the hospital. Please refer to the Medication Management indicator for additional details. Clinician On-Site Inspection OIG clinicians interviewed various nursing staff and supervisors. We attended organized and collaborative clinic huddles on A Yard and E Yard, and found staff were familiar with their patient care population. Leadership reported A Yard had the largest patient population at MCSP. The A Yard primary care team consisted of three primary care RNs (PCRNs), two providers, two 49 Specialty Service nursing encounter events occurred in cases 3, 10, 24, 25, and 26. 50 Specialty Service nursing performance deficiencies occurred in cases 1 and 3. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 63 medical assistants (MAs), and four LVNs. The A Yard nursing staff reported seeing an average of 10 to 16 patients per day. At the time of our inspection, the provider had a backlog of 147 patients, and the RN had a backlog of 100 patients, due to recent restriction of patient movement following an increase in altercations within the patient population and threats on staff. However, staff shared their plans to mitigate the backlog, including bundling appointments and scheduling weekend clinics. We interviewed the supervising registered nurse, who shared the process for auditing the quality of nursing care. The supervisor reported completing 10 sick call audits per nurse each month and conducting one-to-one training to address any deficiencies identified. The supervisor also shared some of the challenges they faced, including patient refusals of medical appointments, medications, and specialty appointments. The staff reported MCSP had implemented an incarcerated peer support specialist program. The specialist role included confirming attendance with patients who were scheduled for any medical appointments or for picking up prescribed medications. The peer support specialist would notify the nurse of any patient refusals, and the nurse would schedule a follow-up appointment and provide patient education. We interviewed nursing leadership, who reported on several quality improvement projects in progress, such as the patient disengagement project, the 9-1-1 activation project, and the Suboxone nonadherence project.51 They also shared details of an upcoming pilot project requiring the primary care nurses to respond to medical emergency alarms on the yard. At the time of our inspection, MCSP was fully staffed, except for one registry RN vacancy. The staff at MCSP expressed feeling supported by nursing leadership and reported a cohesive working relationship with custody staff. 51 The patient disengagement project addressed patients refusing medical services as well as on-site and off-site specialty appointments. To address the refusals, the institution’s leadership used the incarcerated peer support specialist program to act as a liaison between the patient and the nursing and physician care teams to help decrease refusals. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 64 Recommendations • Nursing leadership should determine the challenges to ensuring nurses perform appropriate triage of sick call requests, complete and thorough face- to-face assessments, and co-consults with providers when needed. Nursing leadership should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 65 Provider Performance In this indicator, OIG case review clinicians evaluated the quality of care delivered by the institution’s providers: physicians, physician assistants, and nurse practitioners. Our clinicians assessed the institution’s providers’ performance in evaluating, diagnosing, and managing their patients properly. We examined provider performance across several clinical settings and programs, including sick call, emergency services, outpatient care, chronic care, specialty services, intake, transfers, hospitalizations, and specialized medical housing. We assessed provider care through case review only and performed no compliance testing for this indicator. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Not Applicable Similar to Cycle 6, case review found MCSP providers continued to deliver generally acceptable care. Providers always documented nurse co-consultations and generally managed chronic conditions appropriately. They usually ordered laboratory tests, medications, and specialty consultations as medically indicated. However, providers sometimes performed incomplete assessments and inconsistently reviewed or addressed abnormal laboratory results and vital signs, which accounted for most of the severe deficiencies. After considering all aspects of care, the OIG rated this indicator adequate. Case Review Results The OIG clinicians reviewed 129 medical provider encounters and identified 40 deficiencies related to provider performance, 12 of which were significant.52 In addition, we reviewed the quality of care in 25 comprehensive case reviews. Of these 25 cases, we found 24 adequate, and one inadequate. Outpatient Assessment and Decision-Making Providers generally made appropriate assessments and sound decisions for their patients. Most of the time, they documented good histories, formulated differential diagnoses, ordered appropriate tests, provided care with the correct diagnosis, and referred patients to the proper specialists when needed. We identified 26 deficiencies related to providers’ assessments and decision-making, seven of which were significant.53 We discuss these seven significant deficiencies below. OIG clinicians identified the following significant deficiencies related to performing incomplete subjective or objective assessments: 52 Deficiencies occurred in cases 3, 9, 12, 13, 15–17, 19, 24, and 25–30. Significant deficiencies occurred in cases 3, 9, 12, 16, 26, and 27. 53 Deficiencies occurred in cases 3, 9, 12, 13, 16, 24, 25, and 27–30. Significant deficiencies occurred in cases 3, 9, 16, and 27. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 66 • In case 3, the patient complained of urinary frequency and nocturia.54 The provider prescribed prazosin for LUTS (lower urinary tract symptoms) but did not perform a prostate exam.55 • In case 27, the provider evaluated the patient at an appointment to discuss the patient’s stress test result and cardiology appointment. The provider reviewed and documented the patient’s low blood pressure, which was significantly lower than the patient’s previous two blood pressure readings. However, the provider did not perform a subjective assessment to inquire about symptomatic hypotension or perform an objective assessment. Also, in this same case, the provider later evaluated the patient at another appointment to follow up on the patient’s blood pressure. However, the provider again did not perform a subjective or objective assessment. OIG clinicians identified the following significant deficiencies related to questionable or poor decision-making, resulting from not addressing abnormal vital signs or abnormal laboratory results: • In case 3, the provider reviewed laboratory test results, which included an abnormally low ferritin test level.56 The provider sent a patient notification letter stating, “will follow up with the next chronic care visit for abnormal results.” However, the patient’s next scheduled chronic care appointment was set for four months later. In the interim, the patient submitted a sick call request to see the provider to discuss the test results. The provider did not consider scheduling a sooner appointment to discuss abnormal results with the patient. Also, in this same case, the patient was scheduled to see the provider at a follow-up appointment to discuss abnormal laboratory test results after the patient went to the emergency department at a local hospital. However, the provider did not discuss the laboratory test results with the patient. • In case 9, the provider evaluated the patient for “refusing mobility vest” and documented the patient’s elevated blood pressure. One month prior, the provider also documented an elevated blood pressure for the patient. However, the provider did not address these abnormal blood pressures or order a future recheck. • In case 16, the provider ordered an increased dosage of the patient’s diuretic, hydrochlorothiazide.57 However, the provider did not consider ordering laboratory tests to measure for potential effects of this medication on the patient’s kidney function and electrolyte levels. In addition, the provider did 54 Nocturia is excessive nighttime urination. 55 Prazosin is a medication used to treat symptoms from an enlarged prostate. 56 A ferritin test measures the amount of a blood protein that stores iron in the body. 57 Hydrochlorothiazide is a blood pressure medication used to treat blood pressure by removing fluid and salt from the body through the urine. This may result in changes in kidney function and electrolytes. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 67 not adjust the patient’s diabetic regimen, despite the Hemoglobin A1c (HbA1c) worsening from 9.1 to 10.8.58 Review of Records Providers generally reviewed medical records carefully; however, we identified seven deficiencies in which providers did not appear to have sufficient knowledge of the medical record, three of which were significant. We discuss the three significant deficiencies below:59 • In case 12, the provider evaluated the patient at an episodic care and sick call follow-up appointment. The provider documented the “Hematologist recommended to have a target INR of 2-3.”60 However, the provider did not review the MAR to see the patient had two warfarin prescriptions with two different target INR goals.61 Also, in this same case, the provider documented having reviewed a supratherapeutic INR level of 3.8.62 The provider adjusted one warfarin prescription and ordered a goal INR level of 2.5 to 3.5. However, the provider did not review the MAR, and as a result, was not aware of the second warfarin prescription with a different INR goal of 2 to 3. • In case 26, the provider signed medication orders for glaucoma eye drops, brimonidine and dorzolamide-timolol, as part of the patient’s post- hospitalization medication reconciliation. However, the provider did not confirm the medication directions and signed incorrect orders. Emergency Care Providers appropriately managed patients in the TTA with urgent or emergent conditions. OIG clinicians identified no provider care deficiencies in emergency care. We further discuss urgent and emergent patient care in the Emergency Services indicator. Chronic Care In most instances, providers appropriately managed patients’ chronic health conditions. Providers performed well in managing chronic medical conditions such as hypertension, diabetes, asthma, hepatitis C infection, and cardiovascular disease. However, we identified four deficiencies, one of which was significant, as described below:63 58 Hemoglobin A1c (HbA1c) is a blood test that measures the average plasma glucose over the previous 12 weeks. For most patients with diabetes, the HbA1c goal is 7 percent or less. https://www.cdc.gov/diabetes/diabetes-testing/prediabetes-a1c-test.html 59 Deficiencies related to reviewing records occurred in cases 12 and 26. Three significant deficiencies occurred within the two cases. 60 INR, International Normalized Ratio, is a laboratory test to measure the body’s blood clotting. This test is used to monitor the effectiveness of blood thinning medications such as warfarin. 61 Warfarin is a blood thinning medication requiring laboratory testing to monitor its effectiveness. 62 Supratherapeutic refers to a level of drug that is higher than the maximum level for treatment. 63 Deficiencies occurred in cases 15–17, and 19. A significant deficiency occurred in case 16. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 68 • In case 16, the provider evaluated the patient at a chronic care appointment and documented the patient’s blood pressure as “at goal” despite the patient’s elevated blood pressure. One day prior, the patient’s blood pressure was also elevated. However, the provider did not address these abnormal blood pressure readings or order a follow-up blood pressure appointment. In addition, the provider documented the patient’s diabetes as "Not at goal," but did not document a plan for addressing it. Specialty Services MCSP providers generally ordered appropriate specialty consultations when medically indicated. When specialists offered recommendations, the providers usually followed these recommendations appropriately and reviewed specialty reports timely. We identified only one significant deficiency related to specialty care: • In case 16, the endocrinology specialist evaluated the patient at a diabetes and hyperlipidemia follow-up appointment. The specialist recommended the patient complete laboratory work in three months and “F/U when lab back.” However, the provider did not order this follow-up appointment, and the specialist did not see the patient again during the review period. In addition, the endocrinology specialist recommended a cardiologist evaluate the patient for uncontrolled hypertension. However, the provider ordered the cardiology consultation more than five weeks later. We also discuss specialty services in the Specialty Services indicator. Documentation Quality Documentation is important because it shows the provider’s thought process during clinical decision-making. Providers almost always accurately documented encounters with patients and communication with nurses. We identified only two minor deficiencies in provider documentation.64 Patient Notification Letters After providers interpret laboratory test results, they are responsible for generating test result notification letters to inform patients of the laboratory test results and of the necessary next steps. Providers inconsistently sent notification letters to patients. When they did, the letters did not always contain the four elements required by policy: date of the test, reviewing provider’s name, whether the results were within normal limits, and whether a provider follow-up appointment is required and will be scheduled. We identified this type of deficiency in 13 of the 25 detailed cases we reviewed; however, none were significant.65 We discuss patient notification letters further in the Health Information Management indicator. 64 Minor deficiencies occurred in cases 24 and 29. 65 Minor deficiencies occurred in cases 10, 12–18, 22, 23, 27, 29, and 30. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 69 Provider Continuity Provider continuity was generally good, with most providers working on a yard for long periods of time, and in some cases, for years. Clinician On-Site Inspection OIG clinicians met with the institution’s two Chief Physician & Surgeons (CP&Ss) and providers. The CME was not present at the time of the inspection due to preplanned leave. The CP&Ss reported having two full-time employee vacancies; one vacancy was filled with a registry provider, and the other vacancy had a promising candidate. They reported having previously hired providers through “word of mouth” and having “excellent” provider staff morale. We discussed challenges to delivering care at MCSP. The CP&Ss and the providers described access to specialty care as a significant challenge. Because MCSP provided care to transgender patients, the institution needed to be able to access specialists in this field. However, these specialists had limited availability. In addition, some specialists were located a far distance away from the institution, at times necessitating patient travel of two and a half hours. We also discussed patient care with the providers, who consistently reported feeling supported by their physician supervisors. Providers stated their CP&Ss were easily accessible for questions and directly involved in their practices, as the CP&Ss sometimes evaluated patients. All the providers reported having good morale, noting their collegiality with one another and the accessibility of their CP&Ss as drivers of their job satisfaction. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 70 Recommendations • Medical leadership should determine the root cause(s) of challenges with thorough provider assessments and review of medical records and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 71 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. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Not Applicable The institution did not have any medical admissions to the specialized medical housing unit during our review or inspection period for our review. Therefore, the OIG did not assess this indicator, and instead, designated it as not applicable. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 72 Compliance Score Results Table 16. Specialized Medical Housing Scored Answer Compliance Questions Yes No N/A Yes % For OHU, CTC, and SNF: Did the registered nurse complete an initial N/A N/A N/A N/A assessment of the patient on the day of admission? (13.001) Was a written history and physical examination completed within the N/A N/A N/A N/A required time frame? (13.002) Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient N/A N/A N/A N/A within required time frames? (13.003) For specialized health care housing (CTC, SNF, hospice, OHU): Do specialized health care housing maintain an operational call N/A N/A N/A N/A system? (13.101) For specialized health care housing (CTC, SNF, hospice, OHU): Do health care staff perform patient safety checks according to institution’s local N/A N/A N/A N/A operating procedure or within the required time frames? (13.102) Overall percentage (MIT 13): N/A Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 73 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 74 Specialty Services In this indicator, OIG inspectors evaluated the quality of specialty services. The OIG clinicians focused on the institution’s performance in providing needed specialty care. Our clinicians also examined specialty appointment scheduling, providers’ specialty referrals, and medical staff’s retrieval, review, and implementation of any specialty recommendations. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Adequate (81.4%) Case review found MCSP performed satisfactorily in providing specialty services for its patients. Completion of provider follow-up appointments after specialty consultations always timely occurred. Although patients almost always received timely access to specialty appointments, we found two significant delays. In addition, while providers frequently reviewed specialty reports timely, we identified a pattern of deficiencies in which an on-site specialist did not forward consultation reports to the providers. In considering the balance of the care provided and deficiencies identified, the OIG rated the case review component of this indicator adequate. Compliance showed MCSP performed satisfactorily in this indicator. High-priority, medium-priority, and routine-priority specialty services usually occurred timely. Generally, staff received, and providers endorsed, specialty reports within required time frames. However, preapproved specialty services for newly arrived patients only intermittently occurred timely. Based on the overall Specialty Services compliance score result, the OIG rated the compliance testing component of this indicator adequate. Case Review and Compliance Testing Results OIG clinicians reviewed 115 events related to Specialty Services, including 103 specialty consultations and procedures, 10 nursing encounters, and two provider encounters. We identified 22 deficiencies in this category, three of which were significant.66 Access to Specialty Services MCSP performed variably in providing timely access to specialists. Compliance testing showed MCSP usually completed high-priority (MIT 14.001, 80.0%), medium-priority (MIT 14.004, 86.7%), and routine-priority (MIT 14.007, 80.0%) specialty appointments timely. However, staff performed poorly with ensuring preapproved specialty access within required time frames for patients who transferred into the institution (MIT 14.010, 45.0%). 66 Deficiencies occurred in cases 1, 3, 9, 12, 15–18, 20–23, 25–27, and 29. Significant deficiencies occurred in cases 16, 22, and 23. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 75 OIG clinicians identified two deficiencies with specialty care access, both of which were significant. The following is an example: • In case 23, the provider ordered the rheumatology specialty appointment.67 However, medical staff did not process the order timely, and the appointment did not occur within the review period as ordered. Provider Performance MCSP provided excellent access to providers after specialty service appointments. Compliance testing showed the institution always completed timely provider follow-up appointments (MIT 1.008, 100%). OIG clinicians similarly identified no late provider follow-up appointments. We also found providers generally ordered appropriate specialty consultations, followed specialty recommendations, and performed appropriate specialty follow-up assessments. We identified only one significant deficiency related to provider care.68 We discuss this further in the Provider Performance indicator. Nursing Performance MCSP nurses performed well in assessing patients who returned to the facility from off- site specialty appointments. OIG clinicians identified only two minor deficiencies.69 Health Information Management MCSP sufficiently managed specialty reports. Compliance testing showed staff generally received specialty reports and providers endorsed routine-priority (MIT 14.008, 80.0%), high-priority (MIT 14.002, 85.7%), and medium-priority (MIT 14.005, 85.7%) services reports within required time frames. Staff also performed very well in scanning specialty reports timely (MIT 4.002, 86.7%). OIG clinicians identified a total of 18 health information management (HIM) deficiencies, only one of which was significant as follows:70 • In case 22, HIM staff scanned the telemedicine endocrinology specialty report into EHRS. However, HIM staff did not forward the report to the provider.71 Of the remaining 17 deficiencies, 13 related to an on-site specialist not forwarding the specialty consultation reports to the providers.72 67 Rheumatology is a medical specialty involving the evaluation and management of patients with autoimmune, inflammatory, and joint conditions. 68 A significant deficiency occurred in case 16. 69 Minor deficiencies occurred in cases 1 and 3. 70 Deficiencies occurred in cases 1, 3, 9, 12, 15–18, 20–22, 25–27, and 29. A significant deficiency occurred in case 22. 71 Endocrinology is a medical specialty involving the evaluation and management of glandular and hormonal conditions, including diabetes mellitus and thyroid diseases. 72 Deficiencies in which the on-site specialist did not forward the report to the provider for endorsement occurred in cases 1, 3, 9, 15–18, 20–22, 25, 26, and 29. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 76 We also discuss this in the Health Information Management indicator. Clinician On-Site Inspection OIG clinicians discussed specialty services with the supervising registered nurses (SRNs) covering off-site specialty services, utilization management, on-site specialty services, and telemedicine specialty services. The HIM supervisors reported triaging all high- priority referrals to at least two specialty providers and following up with the specialists every other day until the soonest appointment date was secured. The specialty service SRNs also reported regularly monitoring the tracking log for appointments scheduled out of compliance. If able to switch appointments to better meet compliance dates, the specialty SRNs exchanged patient appointments as needed. They mentioned patient refusal of specialty services requiring long-distance travel as a challenge to completing some specialty consultations. We discussed difficult-to-obtain specialty services with medical staff. Some staff members reported difficulty in obtaining cosmetic and medical consultations related to gender affirming care. Other staff members cited transporting patients a long distance as a hurdle to providing these services. We also discussed the forwarding of on-site specialty reports to providers. MCSP leadership reported the on-site specialists were now expected to send their reports to the providers. The specialty service SRNs reported no staff shortages during the review period. Other SRNs covered their positions as needed. However, they tried to arrange their leave time so both were never off from work at the same time. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 77 Compliance Score Results Table 17. Specialty Services Scored Answer Compliance Questions Yes No N/A Yes % Did the patient receive the high-priority specialty service within 14 calendar days of the primary care provider order or the Physician Request for 12 3 0 80.0% 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 12 2 1 85.7% frame? (14.002) Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care provider? 5 2 8 71.4% (14.003) Did the patient receive the medium-priority specialty service within 15-45 calendar days of the primary care provider order or Physician Request for 13 2 0 86.7% Service? (14.004) Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the required time 12 2 1 85.7% frame? (14.005) Did the patient receive the subsequent follow-up to the medium-priority specialty service appointment as ordered by the primary care provider? 8 0 7 100% (14.006) Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician Request for 12 3 0 80.0% Service? (14.007) Did the institution receive and did the primary care provider review the routine-priority specialty service consultant report within the required time 12 3 0 80.0% 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? 7 1 7 87.5% (14.009) For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the sending 9 11 0 45.0% 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 19 1 0 95.0% services within required time frames? (14.011) Following the denial of a request for specialty services, was the patient 16 4 0 80.0% informed of the denial within the required time frame? (14.012) Overall percentage (MIT 14): 81.4% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 78 Table 18. Other Tests Related to Specialty Services Scored Answer Compliance Questions Yes No N/A Yes % Specialty service follow-up appointments: Did the clinician follow-up visits 31 0 14 100% occur within required time frames? (1.008) * Are specialty documents scanned into the patient’s electronic health record 26 4 15 86.7% 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: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 79 Recommendations • Health care leadership should determine the root cause(s) of challenges to the timely provision of preapproved specialty appointments for transfer patients and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 80 Administrative Operations In this indicator, OIG compliance inspectors evaluated health care administrative processes. Our inspectors examined the timeliness of the medical grievance process and checked whether the institution followed reporting requirements for adverse or sentinel events and patient deaths. Inspectors checked whether the Emergency Medical Response Review Committee (EMRRC) met and reviewed incident packages. We investigated and determined whether the institution conducted required emergency response drills. Inspectors also assessed whether the Quality Management Committee (QMC) met regularly and addressed program performance adequately. In addition, our inspectors determined whether the institution provided training and job performance reviews for its employees. We checked whether staff possessed current, valid professional licenses, certifications, and credentials. The OIG rated this indicator solely based on the compliance score. Our case review clinicians do not rate this indicator. Because none of the tests in this indicator directly affected clinical patient care (it is a secondary indicator), the OIG did not consider this indicator’s rating when determining the institution’s overall quality rating. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Adequate (79.0%) MCSP’s overall performance was satisfactory in this indicator. MCSP scored excellently in addressing patient’s medical grievances, maintaining health care staff licenses and certifications, and providing the required onboarding and clinical competency for all newly hired nursing staff. However, MCSP needed improvement in several areas. The Emergency Medical Response Review Committee (EMRRC) only intermittently completed required checklists. Medical staff did not timely complete several initial patient death reports. In addition, staff conducted medical emergency response drills with incomplete documentation. Furthermore, the nurse educator did not ensure all nurses who administer medications complete their clinical competency testing in a timely manner. Lastly, physician managers only sporadically completed probationary and annual performance appraisals timely. These findings are set forth in the table on the next page. Based on the overall Administrative Operations compliance score result, the OIG rated this indicator adequate. Compliance Testing Results Nonscored Results At MCSP, the OIG did not have any applicable adverse sentinel events requiring root cause analysis during our inspection period (MIT 15.001). We obtained CCHCS Mortality Case Review reporting data. In our inspection, for nine patients, we found no evidence in the submitted documentation that the preliminary mortality reports had been completed. These reports were overdue at the time of the OIG’s inspection (MIT 15.998). Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 81 Compliance Score Results Table 19. Administrative Operations Scored Answer Compliance Questions Yes No N/A Yes % For health care incidents requiring root cause analysis (RCA): Did the This is a nonscored test. Please refer to the institution meet RCA reporting requirements? (15.001) discussion in this indicator. Did the institution’s Quality Management Committee (QMC) meet monthly? 6 0 0 100% (15.002) For Emergency Medical Response Review Committee (EMRRC) reviewed cases: Did the EMRRC review the cases timely, and did the incident 8 4 0 66.7% 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 4 0 0 100% procedures and any applicable policies? (15.004) Did the institution conduct medical emergency response drills during each watch of the most recent quarter, and did health care and custody staff 0 3 0 0 participate in those drills? (15.101) Did the responses to medical grievances address all of the patients’ 10 0 0 100% appealed issues? (15.102) Did the medical staff review and submit initial patient death reports to the 6 3 0 66.7% CCHCS Mortality Case Review Unit on time? (15.103) Did nurse managers ensure the clinical competency of nurses who 7 3 0 70.0% administer medications? (15.104) Did physician managers complete provider clinical performance appraisals 4 13 0 23.5% timely? (15.105) Did the providers maintain valid state medical licenses? (15.106) 20 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 2 0 0 100% Automated Drug Delivery System (ADDS) licenses? (15.109) Did nurse managers ensure their newly hired nurses received the required 1 0 0 100% 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): 79.0% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 82 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 83 Appendix A: Methodology ( In designing the medical inspection program, the OIG met with stakeholders to review CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. We also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the receiver’s office, the department, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of our inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates the delivery of medical care by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population-based metrics. We rate each of the quality indicators applicable to the institution under inspection based on case reviews conducted by our clinicians or compliance tests conducted by our registered nurses. Figure A–1 below depicts the intersection of case review and compliance. Figure A–1. Inspection Indicator Review Distribution for MCSP Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 84 Case Reviews The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders, which continues in the Cycle 7 medical inspections. Below, Table A–1 provides important definitions that describe this process. Table A–1. Case Review Definitions Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 85 The OIG eliminates case review selection bias by sampling using a rigid methodology. No case reviewer selects the samples he or she reviews. Because the case reviewers are excluded from sample selection, there is no possibility of selection bias. Instead, nonclinical analysts use a standardized sampling methodology to select most of the case review samples. A randomizer is used when applicable. For most basic institutions, the OIG samples 20 comprehensive physician review cases. For institutions with larger high-risk populations, 25 cases are sampled. For the California Health Care Facility, 30 cases are sampled. Case Review Sampling Methodology We obtain a substantial amount of health care data from the inspected institution and from CCHCS. Our analysts then apply filters to identify clinically complex patients with the highest need for medical services. These filters include patients classified by CCHCS with high medical risk, patients requiring hospitalization or emergency medical services, patients arriving from a county jail, patients transferring to and from other departmental institutions, patients with uncontrolled diabetes or uncontrolled anticoagulation levels, patients requiring specialty services or who died or experienced a sentinel event (unexpected occurrences resulting in high risk of, or actual, death or serious injury), patients requiring specialized medical housing placement, patients requesting medical care through the sick call process, and patients requiring prenatal or postpartum care. After applying filters, analysts follow a predetermined protocol and select samples for clinicians to review. Our physician and nurse reviewers test the samples by performing comprehensive or focused case reviews. Case Review Testing Methodology An OIG physician, a nurse consultant, or both review each case. As the clinicians review medical records, they record pertinent interactions between the patient and the health care system. We refer to these interactions as case review events. Our clinicians also record medical errors, which we refer to as case review deficiencies. Deficiencies can be minor or significant, depending on the severity of the deficiency. If a deficiency caused serious patient harm, we classify the error as an adverse event. On the next page, Figure A–2 depicts the possibilities that can lead to these different events. After the clinician inspectors review all the cases, they analyze the deficiencies, then summarize their findings in one or more of the health care indicators in this report. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 86 Figure A–2. Case Review Testing Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 87 Compliance Testing Compliance Sampling Methodology Our analysts identify samples for both our case review inspectors and compliance inspectors. Analysts follow a detailed selection methodology. For most compliance questions, we use sample sizes of approximately 25 to 30. Figure A–3 below depicts the relationships and activities of this process. Figure A–3. Compliance Sampling Methodology Compliance Testing Methodology Our inspectors answer a set of predefined medical inspection tool (MIT) questions to determine the institution’s compliance with CCHCS policies and procedures. Our nurse inspectors assign a Yes or a No answer to each scored question. OIG headquarters nurse inspectors review medical records to obtain information, allowing them to answer most of the MIT questions. Our regional nurses visit and inspect each institution. They interview health care staff, observe medical processes, test the facilities and clinics, review employee records, logs, medical grievances, death reports, and other documents, and obtain information regarding plant infrastructure and local operating procedures. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 88 Scoring Methodology Our compliance team calculates the percentage of all Yes answers for each of the questions applicable to a particular indicator, then averages the scores. The OIG continues to rate these indicators based on the average compliance score using the following descriptors: proficient (85.0 percent or greater), adequate (between 84.9 percent and 75.0 percent), or inadequate (less than 75.0 percent). Indicator Ratings and the Overall Medical Quality Rating The OIG medical inspection unit individually examines all the case review and compliance inspection findings under each specific methodology. We analyze the case review and compliance testing results for each indicator and determine separate overall indicator ratings. After considering all the findings of each of the relevant indicators, our medical inspectors individually determine the institution’s overall case review and compliance ratings. Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 89 Appendix B: Case Review Data Table B–1. MCSP Case Review Sample Sets Sample Set Total Anticoagulation 3 Death Review/Sentinel Events 3 Diabetes 3 Emergency Services – CPR 5 Emergency Services – Non-CPR 3 High Risk 5 Hospitalization 4 Intrasystem Transfers In 3 Intrasystem Transfers Out 3 RN Sick Call 28 Specialty Services 4 64 Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 90 Table B–2. MCSP Case Review Chronic Care Diagnoses Sample Set Total Anemia 6 Anticoagulation 7 Arthritis/Degenerative Joint Disease 9 Asthma 11 Cancer 1 Cardiovascular Disease 9 Chronic Kidney Disease 8 Chronic Pain 11 Cirrhosis/End-State Liver Disease 5 COPD 7 COVID-19 6 Deep Venous Thrombosis/Pulmonary Embolism 2 Diabetes 14 Gastroesophageal Reflux Disease (GERD) 12 Hepatitis C 20 HIV 2 Hyperlipidemia 26 Hypertension 28 Mental Health 37 Seizure Disorder 2 Sleep Apnea 4 Substance Abuse 28 Thyroid Disease 2 257 Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 91 Table B–3. MCSP Case Review Events by Program Diagnosis Total Diagnostic Services 216 Emergency Care 70 Hospitalization 27 Intrasystem Transfers In 14 Intrasystem Transfers Out 11 Outpatient Care 459 Specialty Services 148 945 Table B–4. MCSP Case Review Sample Summary Sample Set Total MD Reviews Detailed 25 RN Reviews Detailed 17 RN Reviews Focused 39 Total Reviews 81 Total Unique Cases 64 Overlapping Reviews (MD & RN) 17 Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 92 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 93 Appendix C: Compliance Sampling Methodology Mule Creek 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 35 Clinic • Clinic (each clinic tested) (6 per clinic) Appointment List • Appointment date (2 – 9 months) • Randomize MIT 1.007 Returns From 25 OIG Q: 4.005 • See Health Information Management Community (Medical Records) (returns from Hospital community hospital) MIT 1.008 Specialty Services 45 OIG Q: 14.001, • See Specialty Services Follow-Up 14.004 & 14.007 MIT 1.101 Availability of 6 OIG on-site review • Randomly select one housing unit Health Care from each yard Services Request Forms Diagnostic Services MITs 2.001 – 003 Radiology 10 Radiology Logs • Appointment date (90 days – 9 months) • Randomize • Abnormal MITs 2.004 – 006 Laboratory 10 Quest • Appt. date (90 days – 9 months) • Order name (CBC, BMP, or CMPs only) • Randomize • Abnormal MITs 2.007 – 009 Laboratory STAT 0 Quest • Appt. date (90 days – 9 months) • Order name (CBC, BMP, or CMPs only) • Randomize • Abnormal MITs 2.010 – 012 Pathology 10 InterQual • Appt. date (90 days – 9 months) • Service (pathology related) • Randomize Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 94 Quality No. of Indicator Sample Category Samples Data Source Filters Health Information Management (Medical Records) MIT 4.001 Health Care Services 35 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 14 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 10 OIG inspector • R&R IP transfers with medication on-site review Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 95 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 2 OIG inspector • Identify & inspect all on-site on-site review pharmacies MIT 7.112 Medication Error 12 Medication error • All medication error reports with Reporting reports Level 4 or higher • Select total of 25 medication error reports (recent 12 months) MIT 7.999 Restricted Unit 10 On-site active • KOP rescue inhalers & nitroglycerin KOP Medications medication listing medications for IPs housed in restricted units Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 96 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 13 Maxor • Dispense date (past 9 months) • Time period on TB meds (3 months or 12 weeks) • Randomize MIT 9.003 TB Evaluation, 25 SOMS • Arrival date (at least 1 year prior to Annual Screening inspection) • Birth month • Randomize MIT 9.004 Influenza 25 SOMS • Arrival date (at least 1 year prior to Vaccinations inspection) • Randomize • Filter out IPs tested in MIT 9.008 MIT 9.005 Colorectal Cancer 25 SOMS • Arrival date (at least 1 year prior to Screening inspection) • Date of birth (45 or older) • Randomize MIT 9.006 Mammogram N/A at this SOMS • Arrival date (at least 2 yrs. prior to institution inspection) • Date of birth (age 52 – 74) • Randomize MIT 9.007 Pap Smear N/A at this SOMS • Arrival date (at least three yrs. prior to institution inspection) • Date of birth (age 24 – 53) • Randomize MIT 9.008 Chronic Care 25 OIG Q: 1.001 • Chronic care conditions (at least Vaccinations 1 condition per IP — any risk level) • Randomize • Condition must require vaccination(s) MIT 9.009 Valley Fever N/A at this Cocci transfer • Reports from past 2 – 8 months institution status report • Institution • Ineligibility date (60 days prior to inspection date) • All Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 97 Quality No. of Indicator Sample Category Samples Data Source Filters Reception Center MITs 12.001 – 007 RC N/A at this SOMS • Arrival date (2 – 8 months) institution • Arrived from (county jail, return from parole, etc.) • Randomize Specialized Medical Housing MITs 13.001 – 003 Specialized Health 0 CADDIS • Admit date (2 – 8 months) Care Housing Unit • Type of stay (no MH beds) • Length of stay (minimum of 5 days) • Rx count • Randomize MITs 13.101 – 102 Call Buttons N/A 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: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 98 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: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 99 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 17 On-site provider • All required performance evaluation Evaluation Packets evaluation files documents MIT 15.106 Provider Licenses 20 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: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 100 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7, Mule Creek State Prison | 101 California Correctional Health Care Services’ Response Office of the Inspector General, State of California Inspection Period: February 2024 – July 2024 Report Issued: October 2025 Cycle 7 Medical Inspection Report for Mule Creek State Prison OFFICE of the INSPECTOR GENERAL Amarik K. Singh Inspector General Shaun Spillane Chief Deputy Inspector General STATE of CALIFORNIA October 2025 OIG