OIG
Pelican Bay State Prison Cycle 7 Medical Inspection Report
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Cycle 7, Pelican Bay 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 20
Emergency Services 24
Health Information Management 29
Health Care Environment 35
Transfers 42
Medication Management 48
Preventive Services 55
Nursing Performance 58
Provider Performance 62
Specialized Medical Housing 68
Specialty Services 73
Administrative Operations 79
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: November 2023 – April 2024 Report Issued: July 2025
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Illustrations
Tables
1. PBSP Summary Table: Case Review Ratings and Policy Compliance Scores 4
2. PBSP Master Registry Data as of June 2024 7
3. PBSP Health Care Staffing Resources as of June 2024 8
4. PBSP Results Compared With State HEDIS Scores 10
5. Access to Care 17
6. Other Tests Related to Access to Care 18
7. Diagnostic Services 22
8. Health Information Management 32
9. Other Tests Related to Health Information Management 33
10. Health Care Environment 40
11. Transfers 45
12. Other Tests Related to Transfers 46
13. Medication Management 52
14. Other Tests Related to Medication Management 53
15. Preventive Services 56
16. Specialized Medical Housing 71
17. Specialty Services 76
18. Other Tests Related to Specialty Services 77
19. Administrative Operations 81
A–1. Case Review Definitions 84
B–1. PBSP Case Review Sample Sets 89
B–2. PBSP Case Review Chronic Care Diagnoses 90
B–3. PBSP Case Review Events by Program 91
B–4. PBSP Case Review Sample Summary 91
Figures
A–1. Inspection Indicator Review Distribution for PBSP 83
A–2. Case Review Testing 86
A–3. Compliance Sampling Methodology 87
Photographs
1. Partially Covered Outdoor Waiting Modules 35
2. Partially Covered Outdoor Waiting Modules (Detail) 36
3. Indoor Waiting Area 36
4. Long-Term Storage of Staff Members’ Food in the Medical Supply Room 37
5. Expired Medical Supplies Dated October 2023 37
6. Medical Supplies Stored With Medication 37
7. Expired Medical Supply Dated May 2022 38
Office of the Inspector General, State of California Inspection Period: November 2023 – April 2024 Report Issued: July 2025
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Introduction
Pursuant to California Penal Code section 6126 et seq., the Office of the Inspector
General (the OIG) is responsible for periodically reviewing and reporting on the delivery
of the ongoing medical care provided to incarcerated people1 in the California
Department of Corrections and Rehabilitation (the department).2
In Cycle 7, the OIG continues to apply the same assessment methodologies used in
Cycle 6, including clinical case review and compliance testing. Together, these methods
assess the institution’s medical care on both individual and system levels by providing an
accurate assessment of how the institution’s health care systems function regarding
patients with the highest medical risk, who tend to access services at the highest rate.
Through these methods, the OIG evaluates the performance of the institution in
providing sustainable, adequate care. We continue to review institutional care using
15 indicators as in prior cycles.3
Using each of these indicators, our compliance inspectors collect data in answer to
compliance- and performance-related questions as established in the medical inspection
tool (MIT). In addition, our clinicians complete document reviews of individual cases and
also perform on-site inspections, which include interviews with staff. The OIG
determines a total compliance score for each applicable indicator and considers the MIT
scores in the overall conclusion of the institution’s compliance performance.
In conducting in-depth quality-focused reviews of randomized cases, our case review
clinicians examine whether health care staff used sound medical judgment in the course
of caring for a patient. In the event we find errors, we determine whether such errors
were clinically significant or led to a significantly increased risk of harm to the patient.
At the same time, our clinicians consider whether institutional medical processes led to
identifying and correcting individual or system errors, and we examine whether the
institution’s medical system mitigated the error. The OIG rates each applicable indicator
proficient, adequate, or inadequate, and considers each rating in the overall conclusion of
the institution’s health care performance.
In contrast to Cycle 6, the OIG will provide individual clinical case review ratings and
compliance testing scores in Cycle 7, rather than aggregate all findings into a single
overall institution rating. This change will clarify the distinctions between these differing
quality measures and the results of each assessment.
1 In this report, we use the terms patient and patients to refer to incarcerated people.
2 The OIG’s medical inspections are not designed to resolve questions about the constitutionality of care, and
the OIG explicitly makes no determination regarding the constitutionality of care that the department provides
to its population.
3 In addition to our own compliance testing and case reviews, the OIG continues to offer selected Healthcare
Effectiveness Data and Information Set (HEDIS) measures for comparison purposes.
Office of the Inspector General, State of California Inspection Period: November 2023 – April 2024 Report Issued: July 2025
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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 Pelican Bay State
Prison, the institution had been delegated back to the department by the receiver.
We completed our seventh inspection of the institution, and this report presents our
assessment of the health care provided at this institution during the inspection period
from November 2023 to April 2024.4
4 Samples are obtained per case review methodology shared with stakeholders in prior cycles. The case reviews
include death reviews between August 2023 and April 2024 and emergency services cardiopulmonary
resuscitation reviews between June 2023 and April 2024.
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Summary: Ratings and Scores
We completed the Cycle 7 inspection of PBSP in October 2024. OIG inspectors monitored
the institution’s delivery of medical care that occurred between November 2023 and April
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 PBSP adequate. quality at PBSP adequate.
OIG case review clinicians (a team of physicians and nurse consultants) reviewed 55
cases, which contained 645 patient-related events. They performed quality control
reviews; their subsequent collective deliberations ensured consistency, accuracy, and
thoroughness. Our OIG clinicians acknowledged institutional structures that catch and
resolve mistakes that may occur throughout the delivery of care. After examining the
medical records, our clinicians completed a follow-up on-site inspection in October 2024
to verify their initial findings. OIG physicians rated the quality of care for 20
comprehensive case reviews. Of these 20 cases, our physicians rated one proficient, 15
adequate, and four 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 353 patient records and 1,086 data points,
and used the data to answer 90 policy questions. In addition, we observed PBSP’s
processes during an on-site inspection in June 2024.
The OIG then considered the results from both case review and compliance testing, and
drew overall conclusions, which we report in 13 health care indicators.5
5 The indicators for Reception Center and Prenatal and Postpartum Care did not apply to PBSP.
Office of the Inspector General, State of California Inspection Period: November 2023 – April 2024 Report Issued: July 2025
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We list the individual indicators and ratings applicable for this institution in Table 1 below.
Table 1. PBSP Summary Table: Case Review Ratings and Policy Compliance Scores
Office of the Inspector General, State of California Inspection Period: November 2023 – April 2024 Report Issued: July 2025
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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 PBSP during the Cycle 7 inspection.
Case Review Results
OIG case reviewers (a team of physicians and nurse consultants) assessed 10 of the 13
indicators applicable to PBSP. Of these 10 indicators, OIG clinicians rated three
proficient, seven adequate, and none inadequate. The OIG physicians also rated the
overall adequacy of care for each of the 20 detailed case reviews they conducted. Of these
20 cases, 15 were adequate, four were inadequate, and one was proficient. In the 645
events reviewed, we identified 103 deficiencies, 32 of which 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 PBSP:
• Staff provided excellent access to providers and nurses for patients after hospital
encounters, after triage and treatment area (TTA) encounters, and upon transfer
into the institution.
• Staff completed diagnostic tests for patients without any delays.
• Staff managed hospital, specialty, and TTA records for patients excellently.
• PBSP’s medication management for patients was excellent with no significant
administration lapses in new medications, hospital discharge medications,
specialized medical housing (SMH) medications, and transfer medications.
Our clinicians found the following weaknesses at PBSP:
• Providers did not manage their patients with diabetes well.
• Staff needed to improve in completing patients’ specialty appointments timely.
• Nurses needed to improve in performing complete assessments and interventions
for patients during outpatient sick call encounters and in the specialized medical
housing.
6 For a further discussion of an adverse event, see Table A–1.
Office of the Inspector General, State of California Inspection Period: November 2023 – April 2024 Report Issued: July 2025
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Compliance Testing Results
Our compliance inspectors assessed 10 of the 13 indicators applicable to PBSP. Of these
10 indicators, our compliance inspectors rated three proficient, one adequate, and six
inadequate. We tested policy compliance in Health Care Environment, Preventive
Services, and Administrative Operations as these indicators do not have a case review
component.
PBSP testing showed a high rate of policy compliance in the following areas:
• Medical staff performed outstandingly in scanning and reviewing community
hospital discharge reports and scanning requests for health care services into
patients’ electronic medical records within required time frames.
• Staff timely administered tuberculosis (TB) medications, offered influenza
vaccinations, and provided colorectal cancer screenings to all sampled patients.
• Nursing staff processed sick call request forms, performed face-to-face
evaluations, and completed nurse-to-provider referrals within required time
frames. Moreover, staff provided provider appointments excellently to newly
arrived patients and patients returning from hospitalizations.
PBSP testing revealed a low rate of policy compliance in the following areas:
• Nursing staff faltered in regularly inspecting emergency medical response bags
(EMRBs).
• Health care staff did not consistently follow hand hygiene precautions before or
after patient encounters.
• PBSP’s medical clinics contained multiple expired medical supplies.
• Staff frequently failed to maintain medication continuity for chronic care
patients, patients discharged from the hospital, and patients admitted to a
specialized medical housing unit. In addition, PBSP maintained poor medication
continuity for patients who had a temporary layover at PBSP.
Institution-Specific Metrics
Pelican Bay State Prison is located in the city of Crescent City in Del Norte County. The
institution operates as a medium-security institution housing general population
patients. CCHCS has designated PBSP as a basic care institution, providing outpatient
health care services through its clinics, which handle nonurgent requests for medical
services. Basic care institutions are located in rural areas, away from tertiary care centers
and specialty care providers whose services would likely be used frequently by higher-risk
patients. Basic care institutions can provide limited specialty medical services and
consultations for a patient population that is generally healthy. PBSP health care staff
treats patients needing urgent or emergent care in its triage and treatment area (TTA)
and cares for patients requiring inpatient health services in its correctional treatment
center (CTC).
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As of January 22, 2025, the department reports on its public tracker that 66 percent of
PBSP’s incarcerated population is fully vaccinated for COVID-19 while 43 percent of
PBSP’s staff is fully vaccinated for COVID-19.7
In June 2024, the Health Care Services Master Registry showed that PBSP had a total
population of 2,016. A breakdown of the medical risk level of the PBSP population as
determined by the department is set forth in Table 2 below.8
Table 2. PBSP Master Registry Data as of June 2024
Medical Risk Level Number of Patients Percentage*
High 1 35 1.7%
High 2 152 7.5%
Medium 984 48.8%
Low 845 41.9%
Total 2,016 100.0%
* Percentages may not total 100% due to rounding.
Source: Data for the population medical risk level were obtained from
the CCHCS Master Registry dated 6-10-24.
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.
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According to staffing data the OIG obtained from California Correctional Health Care
Services (CCHCS), as identified in Table 3 below, PBSP had 2.0 vacant executive
leadership positions, 2.0 primary care provider vacancies, 4.7 nursing supervisor
vacancies, and 57.6 nursing staff vacancies.
Table 3. PBSP Health Care Staffing Resources as of June 2024
Executive Primary Care Nursing Nursing
Positions Leadership * Providers Supervisors Staff † Total
Authorized Positions 5.0 5.0 11.7 101.6 123.3
Filled by Civil Service 4.0 2.0 7.0 43.0 56.0
Vacant 2.0 2.0 4.7 57.6 66.3
Percentage Filled by Civil Service 80.0% 40.0% 59.8% 42.3% 45.4%
Filled by Telemedicine 0 3.2 0 0 3.2
Percentage Filled by Telemedicine 0 64.0% 0 0 2.6%
Filled by Registry 0 1.0 0 46.0 47.0
Percentage Filled by Registry 0 20.0% 0 45.3% 38.1%
Total Filled Positions 4.0 6.2 7.0 89.0 106.2
Total Percentage Filled 80.0% 124.0% 59.8% 87.6% 86.1%
Appointments in Last 12 Months 0 5.0 4.0 12.0 21.0
Redirected Staff 0 0 0 0 0
Staff on Extended Leave ‡ 0 0 1.0 2.0 3.0
Adjusted Total: Filled Positions 4.0 6.2 6.0 87.0 103.2
Adjusted Total: Percentage Filled 80.0% 124.0% 51.3% 85.6% 83.7%
* 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 June 10, 2024, from California
Correctional
Health Care Services.
Office of the Inspector General, State of California Inspection Period: November 2023 – April 2024 Report Issued: July 2025
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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 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 PBSP’s performance with population-based metrics to assess the
macroscopic view of the institution’s health care delivery. Currently, only two HEDIS
measures are available for review: poor HbA1c control, which measures the percentage of
diabetic patients who have poor blood sugar control, and colorectal cancer screening
rates for patients ages 45 to 75. We list the applicable HEDIS measures in Table 4.
Comprehensive Diabetes Care
When compared with statewide Medi-Cal programs—California Medi-Cal, Kaiser
Northern California (Medi-Cal), and Kaiser Southern California (Medi-Cal)—PBSP’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. PBSP had a 43 percent influenza
immunization rate for adults 18 to 64 years old and a 73 percent influenza immunization
rate for adults 65 years of age and older.9 The pneumococcal vaccination rate was
87 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)—PBSP’s
percentage of patients with colon cancer screening rate of 68 percent was lower than for
California Kaiser NorCal and SoCal Medi-Cal but higher than for California Medi-Cal.
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.
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Table 4. PBSP Results Compared With State HEDIS Scores
PBSP 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%) ‡,§ 11% 33% 31% 22%
HbA1c Control (< 8.0%) ‡ 82% – – –
Blood Pressure Control (< 140/90) ‡ 98% – – –
Eye Examinations 44% – – –
Influenza – Adults (18 – 64) 43% – – –
Influenza – Adults (65 +) 73% – – –
Pneumococcal – Adults (65 +) 87% – – –
Colorectal Cancer Screening 68% 40% 71% 71%
Notes and Sources
* Unless otherwise stated, data were collected in June 2024 by reviewing medical records from a sample of
PBSP’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 2024;
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 PBSP 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.
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Recommendations
As a result of our assessment of PBSP’s performance, we offer the following
recommendations to the department:
Diagnostic Services
• The department should develop and implement strategies, such as an electronic
solution, to ensure providers create patient test result notification letters that
contain all elements required by CCHCS policy when they endorse test results.
Emergency Services
• Leadership should develop strategies to ensure all staff immediately activate
emergency medical services for emergent patients needing a higher level of care.
Leadership should implement remedial measures as appropriate.
• Nursing leadership should analyze the challenges to nurses performing
reassessments of emergent and urgent conditions and documenting accurate
timelines of events. 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, stocked, or sealed appropriately and should
implement remedial measures as appropriate.
Transfers
• Nursing leadership should develop strategies to ensure nursing staff completely
answer and address required initial health screening questions. Leadership
should implement remedial measures or education as appropriate.
Medication Management
• Medical and nursing leadership should determine the challenges to ensuring
chronic care patients, hospital discharge patients, and patients admitted to
specialized medical housing receive their medications timely and without
interruption. Leadership should implement remedial measures as appropriate.
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Nursing Performance
• Nursing leadership should determine the challenges to nurses performing
detailed assessments as well as providing interventions during face-to-face
patient evaluations and should implement remedial measures as appropriate.
Provider Performance
• Medical leadership should identify the root cause(s) for providers’ poor diabetes
management and should implement remedial measures as appropriate
Specialized Medical Housing
• Nursing leadership should develop strategies to ensure nursing staff in the
correctional treatment center (CTC) perform thorough patient assessments and
should implement remedial measures as appropriate.
Specialty Services
• Health care leadership should determine the challenges to the timely provision of
telemedicine specialty appointments and should implement remedial measures
as appropriate.
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Indicators
Access to Care
In this indicator, OIG inspectors evaluated the institution’s performance in providing
patients with timely clinical appointments. Our inspectors reviewed scheduling and
appointment timeliness for newly arrived patients, sick calls, and nurse follow-up
appointments. We examined referrals to primary care providers, provider follow-ups, and
specialists. Furthermore, we evaluated the follow-up appointments for patients who
received specialty care or returned from an off-site hospitalization.
Ratings and Results Overview
Case Review Rating Compliance Rating and Score
Proficient Proficient (87.4%)
Case review found PBSP provided excellent access to care. We did not find any
deficiencies in provider access for patients with specialized medical housing care, after
hospitalization care, after specialty services care, after TTA care, or upon transfer into
the institution. PBSP also offered excellent clinic nursing access. Although we found a
pattern of delayed appointments to telemedicine specialists within initial provider-
ordered time frames, patients generally received acceptable access to specialists.
Considering all aspects of care access, the OIG rated the case review component of this
indicator proficient.
Compliance testing showed PBSP performed very well in this indicator. Nurses always
timely reviewed patient sick call requests and completed face-to-face encounters. Staff
also always completed provider appointments for patients returning after
hospitalizations and frequently timely completed provider appointments for newly
transferred patients within required time frames. Staff further performed well in offering
provider appointments for chronic care patients. 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
OIG clinicians reviewed 344 provider, nursing, urgent or emergent care (TTA), specialty,
and hospital events that required the institution to generate appointments. We identified
eight deficiencies relating to Access to Care, four of which were significant.11
Access to Care Providers
PBSP ensured very good access to its providers. Compliance testing showed staff
performed well in completing timely chronic care face-to-face follow-up appointments
11 Access deficiencies occurred in cases 1, 14, 17, 18, 24, 25, 34, and 53. Significant access deficiencies occurred
in cases 1, 24, 25, and 53.
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(MIT 1.001, 84.0%) and acceptably in completing timely nurse-to-provider referral
appointments (MIT 1.005, 80.0%).
OIG clinicians found providers evaluated patients timely when referred by nurses from
their sick-call requests as well as when providers requested subsequent appointments.
We identified three minor deficiencies related to provider access in the outpatient
setting. The following are examples:
• In case 14, the provider evaluated the patient seven days late for the chronic care
appointment.
• In case 18, the provider evaluated the patient five days late for a follow-up
appointment.
• In case 34, the nurse documented a follow-up with a provider within 14 days but
did not order the appointment, so the patient was not evaluated.
Access to Specialized Medical Housing Providers
PBSP performed excellently with access to specialized medical housing providers. OIG
clinicians reviewed 65 CTC encounters and did not find any deficiencies related to
provider access. Providers evaluated the patients in specialized medical housing with
appropriate frequency, and the OIG found no delays in providers performing the initial
admission history and physical examinations for patients.
Access to Clinic Nurses
PBSP provided outstanding access to clinic nurses. Compliance testing showed nurses
always reviewed the patients’ requests for service on the same day they were received
(MIT 1.003, 100%), and all nurse face-to-face appointments occurred within one business
day after the sick call requests were reviewed (MIT 1.004, 100%). OIG clinicians reviewed
136 nursing encounters within the institution and identified no nursing access
deficiencies. Nurses timely triaged heath care requests, assessed patients, and scheduled
follow-ups with providers when medically indicated.
Access to Specialty Services
Compliance testing showed mixed performance with specialty access. Although routine-
priority specialty appointments frequently occurred timely (MIT 14.007, 86.7%), medium-
priority specialty appointments only sporadically occurred timely (MIT 14.004, 33.3%),
while high-priority specialty appointments inconsistently occurred timely (MIT 14.001,
73.3%).
During the last inspection cycle, OIG clinicians did not find any access deficiencies with
specialists; however, in Cycle 7, we identified five access deficiencies. Of these five
deficiencies, three were significant due to the duration of the delays from the original
orders. The following is an example:
• In case 1, the patient with hearing loss requested service because his newly
issued hearing aids were not working. The provider ordered a medium-priority
audiology specialty appointment; however, the appointment occurred more than
three months later, which was a two-month delay. On-site, the specialty
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supervisor stated a new nurse was in charge of this area, which may have been
the reason for the delay in scheduling.
Follow-Up After Specialty Services
Patients generally followed up with their providers after receiving high-priority specialty
services. Compliance testing showed provider appointments after specialty services
usually occurred within the required time frame (MIT 1.008, 76.7%). OIG clinicians did
not identify any access deficiencies after specialty services.
Follow-Up After Hospitalization
Providers always evaluated their patients’ hospitalizations within required time frames.
Compliance testing showed providers always timely followed up with their patients after
hospitalizations (MIT 1.007, 100%). OIG clinicians did not identify any access deficiencies
with these follow-up appointments.
Follow-Up After Urgent or Emergent Care (TTA)
PBSP providers always evaluated their patients following triage and treatment area (TTA)
encounters, as medically indicated. OIG clinicians reviewed 28 TTA events and identified
no deficiencies with access to providers after TTA encounters.
Follow-Up After Transferring Into PBSP
PBSP consistently ensured providers timely evaluated their patients when they
transferred into the institution. Intake appointments for newly arrived patients almost
always occurred within the required timeframe (MIT 1.002, 96.0%). OIG clinicians did not
find any access deficiencies with patients who transferred into the institution.
Clinician On-Site Inspection
OIG clinicians met with PBSP medical leadership, scheduling supervisors, nursing
supervisors, and specialty nurses. The nursing supervisors agreed with the deficiencies
discussed during the on-site inspection. The medical leadership reported the patient
population had increased from 1,400 to 2,100 since the beginning of 2024, which
represents a 50% increase in population. Additionally, most of these incoming patients
had already been enrolled in the enhanced outpatient program (EOP), which resulted in
increased utilization of resources.12 Many of the incoming patients were also already out
of compliance for their MAT appointments, so their arrivals instantly caused the
Dashboard to reflect that status by turning red, giving the appearance that PBSP was
significantly behind in scheduling these appointments.13 Medical leadership also stated
12 EOP is the mental health outpatient program for patients, which requires a separate patient care team,
weekly patient group and individual therapy sessions, and regular psychiatry and medication monitoring.
13 MAT is the Medication Assisted Treatment program for substance use disorder. CCHCS uses the Health
Care Services (HCS) Dashboard as a tool to provide and monitor information such as patient access timeliness,
disease management, patient outcomes, utilization of services, and cost. Organizational leaders and program
managers use it to survey key performance indicators, identify opportunities for improvement, and trend
performance over time.
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CCHCS headquarters schedulers handled the telemedicine specialties, which caused
delays and resulted in specialty appointment backlogs.
Compliance On-Site Inspection and Discussion
Three of six housing units randomly tested at the time of inspection had access to health
care services request forms (CDCR Form 7362) (MIT 1.101, 50.0%). In three housing units,
custody officers did not have a system in place for restocking the forms. According to
custody officers, they relied on medical staff to replenish the forms in the housing units.
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Cycle 7, Pelican Bay State Prison | 17
Compliance Score Results
Table 5. Access to Care
Scored Answer
Compliance Questions Yes No N/A Yes %
Chronic care follow-up appointments: Was the patient’s most recent chronic
care visit within the health care guideline’s maximum allowable interval or 21 4 0 84.0%
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 24 1 0 96.0%
patient seen by the clinician within the required time frame? (1.002)
Clinical appointments: Did a registered nurse review the patient’s request
40 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
40 0 0 100%
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
16 4 20 80.0%
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 39 100%
specified? (1.006)
Upon the patient’s discharge from the community hospital: Did the patient
5 0 0 100%
receive a follow-up appointment within the required time frame? (1.007)
Specialty service follow-up appointments: Did the clinician follow-up visits
23 7 15 76.7%
occur within required time frames? (1.008) *
Clinical appointments: Do patients have a standardized process to obtain
3 3 0 50.0%
and submit health care services request forms? (1.101)
Overall percentage (MIT 1): 87.4%
* 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.
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Cycle 7, Pelican Bay State Prison | 18
Table 6. Other Tests Related to Access to Care
Scored Answer
Compliance Questions Yes No N/A Yes %
For patients received from a county jail: If, during the assessment, the nurse
referred the patient to a provider, was the patient seen within the required N/A N/A N/A N/A
time frame? (12.003)
For patients received from a county jail: Did the patient receive a history
and physical by a primary care provider within seven calendar days (prior to N/A N/A N/A N/A
07/2022) or five working days (effective 07/2022)? (12.004)
Was a written history and physical examination completed within the
8 2 0 80.0%
required time frame? (13.002)
Did the patient receive the high-priority specialty service within 14 calendar
days of the primary care provider order or the Physician Request for 11 4 0 73.3%
Service? (14.001)
Did the patient receive the subsequent follow-up to the high-priority
specialty service appointment as ordered by the primary care 5 3 7 62.5%
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 5 10 0 33.3%
for Service? (14.004)
Did the patient receive the subsequent follow-up to the medium-priority
specialty service appointment as ordered by the primary care provider? 6 3 6 66.7%
(14.006)
Did the patient receive the routine-priority specialty service within
90 calendar days of the primary care provider order or Physician Request 13 2 0 86.7%
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 2 6 77.8%
provider? (14.009)
Source: The Office of the Inspector General medical inspection results.
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Recommendations
The OIG offers no recommendations for this indicator.
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Cycle 7, Pelican Bay State Prison | 20
Diagnostic Services
In this indicator, OIG inspectors evaluated the institution’s performance in timely
completing radiology, laboratory, and pathology tests. Our inspectors determined
whether the institution properly retrieved the resultant reports and whether providers
reviewed the results correctly. In addition, in Cycle 7, we examined the institution’s
performance in timely completing and reviewing immediate (STAT) laboratory tests.
Ratings and Results Overview
Case Review Rating Compliance Rating and Score
Adequate Adequate (75.6%)
Case review found PBSP performed very good diagnostic services, similar to its
performance in Cycle 6. PBSP offered excellent access to and timely test completion of
diagnostic studies. Staff also managed health information well as they usually retrieved
and endorsed the laboratory, radiology, and pathology results and, with few exceptions,
notified patients of their results timely. The OIG rated the case review component of this
indicator adequate.
In compliance testing, PBSP performed acceptably in this indicator. Staff performed
excellently in completing radiology services, in retrieving and endorsing pathology
reports, as well as in endorsing laboratory reports. In addition, providers satisfactorily
reviewed and endorsed radiology reports. However, staff needed improvement in
providing routine laboratory services and in generating complete patient test results
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 adequate.
Case Review and Compliance Testing Results
OIG clinicians reviewed 88 diagnostic events and identified 11 deficiencies, one of which
was significant. Of these 11 deficiencies, all related to HIM and none to completing
ordered diagnostic services.14
Test Completion
Compliance testing showed staff always completed radiology tests timely (MIT 2.001,
100%), but they needed improvement in completing laboratory tests within specified time
frames (MIT 2.004, 70.0%). OIG clinicians found PBSP performed excellently with
completing diagnostic tests, and we did not find any delays in provider-ordered
laboratory or radiographic tests.
14 Diagnostic deficiencies occurred in cases 11,15, 17, 18, 21, 22, 24, and 25. A significant deficiency occurred in
case 11.
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Cycle 7, Pelican Bay State Prison | 21
Neither case review nor compliance testing had any STAT laboratory tests in their
samples to review (MIT 2.007, N/A).
Health Information Management
PBSP performed variably with management of diagnostic test results. Compliance testing
showed staff managed health information of radiologic studies sufficiently (MIT 2.002,
80.0%) and laboratory results excellently (MIT 2.005, 100%). Staff always retrieved (MIT
2.010, 100%) and reviewed (MIT 2.011, 100%) pathology results timely, but staff never
notified patients of their results with complete test notification letters (MIT 2.012, zero).
OIG clinicians identified minor deficiencies with one report retrieval delay, four
endorsement delays, and five incomplete patient notifications. We found one significant
deficiency as follows:
• In case 11, the diabetic patient had an elevated HbA1c blood test to monitor his
sugar control.15 No providers endorsed this result, and the patient did not receive
a follow-up appointment during the review period.
Clinician On-Site Inspection
We spoke with the supervisor who oversaw the laboratory and radiology processes. The
supervisor reported PBSP had only one senior radiologic technician working during the
review period, and the unit was short-staffed with laboratory assistance until December
11, 2023. Staff offered x-ray service five days a week and CT, MRI, and ultrasound services
one day a month.16 Providers received the radiographic test results on the same day of
service and generated patient notification letters after reviewing the results. The
laboratory vendor interfaced with EHRS with the laboratory results, and providers had
five days to review and send results letters to the patients.17 At the time of the on-site
inspection in October 2024, the radiology department had a backlog of 150 to 200
imaging orders, while the laboratory did not have any backlogs of laboratory test orders.
15 Hemoglobin A1c (HbA1c) is a blood test that measures the average plasma glucose over the previous 12
weeks.
16 A CT is a computed, or computerized, tomography scan while an MRI is a magnetic resonance imaging scan.
Both create detailed images of the organs and tissues to detect diseases and abnormalities.
17 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.
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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
8 2 0 80.0%
radiology report within specified time frames? (2.002)
Radiology: Did the ordering health care provider communicate the results
8 2 0 80.0%
of the radiology study to the patient within specified time frames? (2.003)
Laboratory: Was the laboratory service provided within the time frame
7 3 0 70.0%
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
5 5 0 50.0%
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
5 0 0 100%
required time frames? (2.010)
Pathology: Did the health care provider review and endorse the pathology
5 0 0 100%
report within specified time frames? (2.011)
Pathology: Did the health care provider communicate the results of the
0 5 0 0
pathology study to the patient within specified time frames? (2.012)
Overall percentage (MIT 2): 75.6%
Source: The Office of the Inspector General medical inspection results.
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Cycle 7, Pelican Bay State Prison | 23
Recommendations
• The department should develop and implement strategies, such as an electronic
solution, to ensure providers create patient test result notification letters that
contain all elements required by CCHCS policy when they endorse test results.
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Cycle 7, Pelican Bay State Prison | 24
Emergency Services
In this indicator, OIG clinicians evaluated the quality of emergency medical care. Our
clinicians reviewed emergency medical services by examining the timeliness and
appropriateness of clinical decisions made during medical emergencies. Our evaluation
included examining the emergency medical response, cardiopulmonary resuscitation
(CPR) quality, triage and treatment area (TTA) care, provider performance, and nursing
performance. Our clinicians also evaluated the Emergency Medical Response Review
Committee’s (EMRRC) performance in identifying problems with its emergency services.
The OIG assessed the institution’s emergency services solely through case review.
Ratings and Results Overview
Case Review Rating Compliance Rating and Score
Adequate Not Applicable
Our clinicians found PBSP performed sufficiently in emergency care. Compared with
Cycle 6, the institution demonstrated similar results. The nurses generally performed
appropriate assessments and interventions, responded timely to emergency events, and
initiated CPR without delay. In addition, medical leadership conducted clinical reviews
on emergency events and generally identified training issues. However, we identified
opportunities for improvement in immediately activating emergency medical services
(EMS) and in nursing performance with reassessing and accurately documenting event
time lines, all of which are discussed below. Taking these factors into consideration, the
OIG rated this indicator adequate.
Case Review Results
We reviewed 28 urgent or emergent events and found 19 emergency care deficiencies,
four of which were significant.18
Emergency Medical Response
PBSP health care staff and custody staff responded promptly to emergencies throughout
the institution and notified TTA staff timely. However, our clinicians identified two
significant deficiencies related to a delay in contacting EMS. The following are examples:
• In case 7, staff activated a medical alarm for the patient, who was found
unconscious due to a suspected drug overdose. Staff contacted EMS eight
minutes after the alarm activation.
• In case 21, staff activated a medical alarm for a patient with a suspected seizure.
While some documentation showed staff contacted EMS at the same time the
medical alarm was activated, the TTA RN documented custody staff renotified
the watch office to request an emergent ambulance due to a delay. Subsequently,
18 Deficiencies occurred in cases 1, 4-7, 9, 17, and 20-22. Significant deficiencies occurred in cases 6, 7, and 21.
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Cycle 7, Pelican Bay State Prison | 25
staff did not contact EMS until seven minutes after the activation of the
emergency alarm.
Cardiopulmonary Resuscitation Quality
Our clinicians reviewed six cases in which staff initiated CPR.19 Nursing and custody
staff initiated CPR without delay. The nurses applied the automated external defibrillator
(AED), administered Narcan timely, and notified emergency medical services from the
scene. However, in one case we identified an opportunity for improvement:
• In case 6, staff activated a medical alarm in the B clinic for the patient, who
became unconscious after reporting complaints of nausea with dizziness. The
patient had no pulse and was not breathing. The RN initiated CPR, and the
patient regained consciousness after one round of CPR. However, when
discontinuing CPR, the RN did not reassess the patient’s oxygenation saturation
rate, mental status, or provide oxygen support for the patient despite an
abnormally low respiratory rate. Staff did not apply the oxygen to the patient
until five minutes after the discontinuation of CPR. In addition, medical
leadership did not identify this deficiency in the clinical review.
Provider Performance
PBSP providers performed well in urgent and emergent situations, as well as in after-
hours care. Providers either directly evaluated patients or were available to TTA staff by
phone in 28 emergency events during the review period. Providers satisfactorily obtained
patient histories, made appropriate triage decisions, developed supportable differential
diagnoses, and sufficiently documented in the medical records. OIG clinicians did not
find any provider deficiencies related to emergency care.
Nursing Performance
Nurses generally performed good nursing assessments and interventions. However, our
clinicians identified a pattern of nurses not always reassessing vital signs when clinically
indicated. The following are examples:
• In case 1, the RN evaluated the patient in the TTA for complaints of chest pain.
Upon arrival, the patient complained of constant, left-sided, moderate to severe
chest pain, described as pressure and sharp radiating pain to the left shoulder.
The nurse administered nitroglycerin twice.20 However, the nurse did not assess
the patient’s chest pain level after either nitroglycerin administration. In
addition, nurses routinely obtained vital signs; however, they did not record the
respiratory rate and effort from the time the patient arrived in the TTA to the
time the patient transferred to the community hospital for 46 minutes. Similar
deficiencies occurred in cases 6, 7, and 17.
19 CPR events occurred in cases 3–8.
20 Nitroglycerin is a medication that dilates blood vessels to increase blood flow to the heart.
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Cycle 7, Pelican Bay State Prison | 26
Nursing Documentation
Nurses generally performed thorough documentation for emergency events. However, we
identified seven documentation deficiencies and a pattern related to timeline
discrepancies in the sequence of events.21 The following is an example:
• In case 4, the staff activated an emergency alarm for the patient, who was found
hanging in his cell and was unresponsive. Custody initiated CPR, but the patient
ultimately died. In reviewing the timeline of events, we identified discrepancies
in documenting the times when EMS was notified and when EMS arrived.
Similar deficiencies occurred in cases 7, 9, 20 and 22.
Emergency Medical Response Review Committee
Our clinicians found medical leadership performed well with conducting clinical reviews
for all patients who transferred to a higher level of care, including patient deaths.
However, we found in six out of the 19 emergency cases reviewed, medical leadership did
not identify the same opportunities for improvement as those our clinicians identified.22
In relation, compliance testing revealed EMRRC event checklists were intermittently
incomplete (MIT 15.003, 58.3%). We discuss this further in the Administrative Operations
indicator.
Clinician On-Site Inspection
During the on-site inspection, our clinicians had the opportunity to interview the TTA
staff. PBSP had two beds in the TTA and one emergency response vehicle (ERV). The
staff reported the TTA was staffed with two RNs during the day and evening shifts and
one RN during the night shift. One RN was designated as the rover, who was assigned to
respond to all emergencies and, at times, would cover the receiving and release area
(R&R) in the mornings when no RN was available to process patients who were paroling.
The TTA had an assigned provider Monday through Friday and an on-call provider
assigned for weekend coverage.
The TTA staff shared all clinic staff were required to respond until the TTA RN rover
arrived on scene during an emergency alarm. This included the clinic RN, the licensed
vocational nurse (LVN) coordinator, the clinic medical assistant, and the medication line
LVN. Furthermore, the staff reported all clinic staff had assigned roles to perform during
emergency events. In addition, the CDCR Fire Camp personnel were available to assist
with emergency events as needed.23
The staff expressed having challenges with retaining staff because many staff were from
the registry and had arrived to PBSP from different locations; thus, they were new to the
21 Documentation deficiencies occurred in cases 4, 5, 7, 9, 20, 21 and 22.
22 Clinical reviews conducted in cases 1, 3–9, 19–22, and 24. Deficiencies occurred in cases 1, 4–7, 9 and 20.
23 The CDCR, in cooperation with the California Department of Forestry and Fire Protection (CAL FIRE) and
the Los Angeles County Fire Department (LACFD), jointly operates 35 conservation camps, commonly known
as fire camps, located in 25 counties across California. All camps are minimum-security facilities and staffed
with correctional staff. Information was obtained from https://www.cdcr.ca.gov.
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Cycle 7, Pelican Bay State Prison | 27
prison system. Nonetheless, staff expressed feeling supported by nursing leadership and
having an excellent working relationship with custody.
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Recommendations
• Leadership should develop strategies to ensure all staff immediately activate
emergency medical services for emergent patients needing a higher level of care.
Leadership should implement remedial measures as appropriate.
• Nursing leadership should analyze the challenges to nurses performing
reassessments of emergent and urgent conditions and documenting accurate
timelines of events. Leadership should implement remedial measures as
appropriate.
Office of the Inspector General, State of California Inspection Period: November 2023 – April 2024 Report Issued: July 2025
Cycle 7, Pelican Bay State Prison | 29
Health Information Management
In this indicator, OIG inspectors evaluated the flow of health information, a crucial link
in high-quality medical care delivery. Our inspectors examined whether the institution
retrieved and scanned critical health information (progress notes, diagnostic reports,
specialist reports, and hospital discharge reports) into the medical record in a timely
manner. Our inspectors also tested whether clinicians adequately reviewed and endorsed
those reports. In addition, our inspectors checked whether staff labeled and organized
documents in the medical record correctly.
Ratings and Results Overview
Case Review Rating Compliance Rating and Score
Proficient Proficient (97.7%)
Case review found PBSP performed excellently in managing health information. Staff
retrieved, endorsed, and scanned records timely. In addition, they managed hospital,
specialty, and urgent or emergent records very well. Staff also handled diagnostic
information very well. As a result, the OIG rated the case review component of this
indicator proficient.
Compliance testing showed PBSP performed outstandingly in this indicator. Staff
performed excellently in scanning patient sick call requests and specialty reports as well
as scanning and reviewing hospital discharge reports timely. Staff also performed very
well in properly scanning medical records into the correct patients’ files. Based on the
overall Health Information Management compliance score result, the OIG rated the
compliance testing component of this indicator proficient.
Case Review and Compliance Testing Results
We reviewed 645 events, including 148 hospital, diagnostic, and specialty reports, and
identified 15 deficiencies related to health information management (HIM), one of which
was significant.24
Hospital Discharge Reports
Compliance testing showed excellent performance with hospital discharge reports. PBSP
staff retrieved and scanned all hospital discharge records timely (MIT 4.003, 100%). In
addition, the hospital discharge reports included key elements, and providers reviewed
the reports timely (MIT 4.005, 100%).
24 HIM deficiencies occurred in cases 11, 15, 17, 18, 21, 22, 24, and 25. Significant deficiencies occurred in cases
11.
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OIG clinicians reviewed 26 emergency department and hospital encounters. PBSP staff
timely retrieved hospital records, scanned them into the EHRS, and reviewed them
properly. We identified only one minor deficiency as follows:
• In case 24, the patient was discharged from the hospital, and the provider
endorsed the report eight days after the receipt of the report.
Specialty Reports
Compliance testing showed PBSP staff performed variably with health information
management of routine-priority, medium-priority, and high-priority specialty reports
(MIT 14.008, 60.0%, MIT 14.005, 60.0%, and MIT 14.002, 80.0%). Nonetheless, staff almost
always scanned specialty reports into the EHRS timely (MIT 4.002, 96.7%). OIG clinicians
found staff performed well in retrieving, endorsing, and scanning specialty reports. We
identified only three minor deficiencies: two minor delays in endorsement and one
delayed echocardiogram report retrieval.25
Diagnostic Reports
Staff overall performed well with retrieving, endorsing, and scanning diagnostic records.
Compliance testing showed PBSP staff performed excellently with reviewing pathology
results (MIT 2.011, 100%) but poorly with test letter communication of these results (MIT
2.012, zero). OIG clinicians found staff usually retrieved, endorsed, and scanned
diagnostic records timely. We reviewed two pathology reports, both of which staff
handled appropriately. We also identified a total of 11 deficiencies: four with delayed
endorsement of diagnostic reports, four without patient notification letters, two with
incomplete patient notification letters, and one with delayed retrieval of the report. Only
one of these deficiencies was significant and is discussed further in the Diagnostic
Services indicator.
Neither case review nor compliance testing had any STAT laboratory tests in their
samples to review (MIT 2.007, N/A).
Urgent and Emergent Records
OIG clinicians reviewed 28 emergency care events and found PBSP nurses and providers
documented these events well. Providers sufficiently documented their emergency care,
specifically as a provider-on-call telephone consult or as a TTA in-person encounter.
Providers sufficiently their emergency care, specifically as a provider-on-call telephone
consult or as a TTA in-person encounter. OIG clinicians did not identify any deficiencies
with health information management of urgent or emergent records. The Emergency
Services indicator details additional information regarding emergency care.
Scanning Performance
PBSP’s scanning performance was overall excellent. Compliance testing showed very
good performance with scanning, labeling, and including medical records in the correct
25 An echocardiogram is a procedure using an ultrasound to examine and image the heart.
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Cycle 7, Pelican Bay State Prison | 31
patients’ files (MIT 4.004, 91.7%). OIG clinicians did not find any mislabeled or misfiled
medical documents.
Clinician On-Site Inspection
We discussed general medical records questions with HIM supervisors. They described
how a specialty clinic office technician (OT) tracked all off-site scheduled encounters on
a spreadsheet to ensure report retrieval. The utilization management (UM) RN tracked all
hospitalizations and updated the patient care team. Once the specialty RN received the
report, the RN sent the report to HIM staff, who scanned and forwarded a message
through EHRS message center to the provider for review and signature. HIM staff stated
the provider was responsible for the patient, and therefore, they did not track whether
providers sent their patient notification letters. Health Record Technician I (HRT I) and
Health Record Technician II (HRT II) staff had access to a local hospital’s electronic
medical records for printing to ensure timely record retrieval.
We discussed some of the deficiencies identified during our reviews with HIM staff. They
explained newer policies assigned a high preference to scan hospital reports as they were
retrieved, even if the records were incomplete. Staff scanned hospital radiology results,
EKGs, and specialty consultations separately using specific document labels on the
specific date these services were performed. The staff subsequently would also scan the
full hospital record using the discharge date as the date of service. This activity increased
their workload because they were required to review every hospital record and then
separate diagnostic records from consultations and discharges. We did not identify any
issues during the review period; however, this PBSP process may increase the risk for
incorrectly scanned or duplicate reports.
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Cycle 7, Pelican Bay State Prison | 32
Compliance Score Results
Table 8. Health Information Management
Scored Answer
Compliance Questions Yes No N/A Yes %
Are health care service request forms scanned into the patient’s electronic
20 0 20 100%
health record within three calendar days of the encounter date? (4.001)
Are specialty documents scanned into the patient’s electronic health record
29 1 15 96.7%
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? 5 0 0 100%
(4.003)
During the inspection, were medical records properly scanned, labeled,
22 2 0 91.7%
and included in the correct patients’ files? (4.004)
For patients discharged from a community hospital: Did the preliminary or
final hospital discharge report include key elements and did a provider 5 0 0 100%
review the report within five calendar days of discharge? (4.005)
Overall percentage (MIT 4): 97.7%
Source: The Office of the Inspector General medical inspection results.
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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
8 2 0 80.0%
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
5 0 0 100%
required time frames? (2.010)
Pathology: Did the health care provider review and endorse the pathology
5 0 0 100%
report within specified time frames? (2.011)
Pathology: Did the health care provider communicate the results of the
0 5 0 0
pathology study to the patient within specified time frames? (2.012)
Did the institution receive and did the primary care provider review the
high-priority specialty service consultant report within the required time 12 3 0 80.0%
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 9 6 0 60.0%
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 9 6 0 60.0%
frame? (14.008)
Source: The Office of the Inspector General medical inspection results.
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Recommendations
The OIG offers no recommendations for this indicator.
Office of the Inspector General, State of California Inspection Period: November 2023 – April 2024 Report Issued: July 2025
Cycle 7, Pelican Bay State Prison | 35
Health Care Environment
In this indicator, OIG compliance inspectors tested clinics’ waiting areas, infection
control, sanitation procedures, medical supplies, equipment management, and
examination rooms. Inspectors also tested clinics’ performance in maintaining auditory
and visual privacy for clinical encounters. Compliance inspectors asked the institution’s
health care administrators to comment on their facility’s infrastructure and its ability to
support health care operations. The OIG rated this indicator solely on the compliance
score. Our case review clinicians do not rate this indicator.
Because none of the tests in this indicator directly affected clinical patient care (it is a
secondary indicator), the OIG did not consider this indicator’s rating when determining
the institution’s overall quality rating.
Ratings and Results Overview
Case Review Rating Compliance Rating and Score
Not Applicable Inadequate (56.3%)
Overall, PBSP’s performance in health care environment needed improvement. Medical
supplies storage areas contained unidentified or inaccurately labeled medical supplies. In
addition, we found expired or disorganized medical supplies. Several clinics did not meet
the requirements for essential core medical equipment and supplies. Staff did not
regularly sanitize their hands during patient encounters. Emergency medical response
bags (EMRBs) contained compromised medical supply packaging and had not been
properly inventoried. Based on the overall Health Care Environment compliance score
result, the OIG rated this indicator inadequate.
Compliance Testing Results
Patient Waiting Areas
We inspected outdoor patient waiting areas,
which is used for restricted housing patients.
Health care and custody staff reported existing
waiting areas had sufficient seating capacity.
The staff reported when the indoor waiting area
was at capacity, patients waited in large outdoor
areas (see Photo 1, right) or in partially covered
individual modules (see Photo 2, next page).
We also inspected indoor waiting areas, which
is used for patients housed in other areas (see
Photo 3, next page). Health care and custody
staff reported that existing indoor waiting areas
contained sufficient seating capacity. During
Photo 1. Partially covered outdoor waiting
our inspection, we did not observe
modules (photographed on 6-18-24).
overcrowding.
Office of the Inspector General, State of California Inspection Period: November 2023 – April 2024 Report Issued: July 2025
Cycle 7, Pelican Bay State Prison | 36
Photo 2. Partially covered outdoor waiting
modules (detail) (photographed on 6-20-24).
Photo 3. Indoor waiting area
(photographed on 6-18-24).
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Cycle 7, Pelican Bay State Prison | 37
Clinic Environment
All clinic environments were sufficiently conducive to medical care; they provided
reasonable auditory privacy, appropriate waiting areas, wheelchair accessibility, and
nonexamination room workspace (MIT 5.109, 100%).
Eight of the 10 clinics we observed contained appropriate space, configuration, supplies,
and equipment to allow clinicians to perform proper clinical examinations (MIT 5.110,
80.0%). In one clinic, the examination room had unsecured confidential medical records.
In another clinic, the examination room lacked visual privacy for conducting clinical
examinations.
Clinic Supplies
Only two of the 10 clinics followed
adequate medical supply storage and
management protocols (MIT 5.107, 20.0%).
We found one or more of the following
deficiencies in eight clinics: compromised
sterile medical supply packaging; long-
term storage of staff’s food in the medical
supply storage room (see Photo 4, right);
expired medical supplies (see Photo 5,
below); unorganized, unidentified, or
inaccurately labeled medical supplies;
medical supplies stored with medication
(see Photo 6, below right); and cleaning
Photo 4. Long-term storage of staff members' food in the
materials stored with medical supplies. medical supply room (photographed on 6-18-24).
Photo 5. Expired medical supplies dated October 2023
(photographed on 6-20-24).
Photo 6. Medical supplies stored with
medication (photographed on 6-20-24).
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Cycle 7, Pelican Bay State Prison | 38
Six of the 10 clinics met requirements for essential core medical equipment and supplies
(MIT 5.108, 40.0%). In four clinics we found one or more of the following deficiencies:
missing disposable paper for the examination table; missing an established, identified
Snellen chart distance line on the wall or the floor; a nonfunctional otoscope; and several
inaccurate or incomplete clinic glucometer quality control logs. We also found staff did
not consistently complete 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. Only one
of the nine applicable EMRBs passed our test (MIT 5.111, 11.1%). We found one or more
of the following deficiencies with eight EMRBs: staff had not inventoried the EMRB
when the seal tags were replaced; EMRB contained compromised medical supply
packaging; and EMRB glucometer quality control logs were either inaccurate or
incomplete.
Medical Supply Management
None of the medical supply storage areas
located outside the medical clinics stored
medical supplies adequately (MIT 5.106, zero).
We found expired medical supplies in the
medical warehouse (see Photo 7).
According to the CEO, PBSP leadership did
not have any concerns about the medical
supplies process. Health care managers and
medical warehouse managers expressed no
concerns about the medical supply chain or
their communication process.
Infection Control and Sanitation
Staff appropriately, cleaned, sanitized, and
disinfected eight of 10 clinics (MIT 5.101,
80.0%). In one clinic, we found a damaged and
unsanitary clinic floor, while in another clinic,
Photo 7. Expired medical supply dated May 2022
we found an unsanitary cabinet under the
(phtotographed on 6-19-24).
clinic sink.
Staff in all clinics properly sterilized or disinfected medical equipment (MIT 5.102, 100%).
We found operating sinks and hand hygiene supplies in the examination rooms in six of
10 clinics (MIT 5.103, 60.0%). In four clinics, the patient restrooms lacked antiseptic soap
or disposable hand towels.
We observed patient encounters in seven clinics. In five clinics, clinicians did not wash
their hands before applying gloves or before each subsequent regloving (MIT 5.104,
28.6%).
Health care staff in all clinics followed proper protocols to mitigate exposure to blood-
borne pathogens and contaminated waste (MIT 5.105, 100%).
Office of the Inspector General, State of California Inspection Period: November 2023 – April 2024 Report Issued: July 2025
Cycle 7, Pelican Bay State Prison | 39
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).
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Cycle 7, Pelican Bay 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,
8 2 0 80.0%
cleaned, and sanitary? (5.101)
Infection control: Do clinical health care areas ensure that reusable invasive
and noninvasive medical equipment is properly sterilized or disinfected as 10 0 0 100%
warranted? (5.102)
Infection control: Do clinical health care areas contain operable sinks and
6 4 0 60.0%
sufficient quantities of hygiene supplies? (5.103)
Infection control: Does clinical health care staff adhere to universal hand
2 5 3 28.6%
hygiene precautions? (5.104)
Infection control: Do clinical health care areas control exposure to blood-
10 0 0 100%
borne pathogens and contaminated waste? (5.105)
Warehouse, conex, and other nonclinic storage areas: Does the medical
supply management process adequately support the needs of the medical 0 1 0 0
health care program? (5.106)
Clinical areas: Does each clinic follow adequate protocols for managing and
2 8 0 20.0%
storing bulk medical supplies? (5.107)
Clinical areas: Do clinic common areas and exam rooms have essential core
4 6 0 40.0%
medical equipment and supplies? (5.108)
Clinical areas: Are the environments in the common clinic areas conducive
10 0 0 100%
to providing medical services? (5.109)
Clinical areas: Are the environments in the clinic exam rooms conducive to
8 2 0 80.0%
providing medical services? (5.110)
Clinical areas: Are emergency medical response bags and emergency crash
carts inspected and inventoried within required time frames, and do they 1 8 1 11.1%
contain essential items? (5.111)
Does the institution’s health care management believe that all clinical areas
This is a nonscored test. Please see the
have physical plant infrastructures that are sufficient to provide adequate
indicator for discussion of this test.
health care services? (5.999)
Overall percentage (MIT 5): 56.3%
Source: The Office of the Inspector General medical inspection results.
Office of the Inspector General, State of California Inspection Period: November 2023 – April 2024 Report Issued: July 2025
Cycle 7, Pelican Bay 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, stocked, or sealed appropriately and should
implement remedial measures as appropriate.
Office of the Inspector General, State of California Inspection Period: November 2023 – April 2024 Report Issued: July 2025
Cycle 7, Pelican Bay State Prison | 42
Transfers
In this indicator, OIG inspectors examined the transfer process for those patients who
transferred into the institution as well as for those who transferred to other institutions.
For newly arrived patients, our inspectors assessed the quality of health care screenings
and the continuity of provider appointments, specialist referrals, diagnostic tests, and
medications. For patients who transferred out of the institution, inspectors checked
whether staff reviewed patient medical records and determined the patient’s need for
medical holds. They also assessed whether staff transferred patients with their medical
equipment and gave correct medications before patients left. In addition, our inspectors
evaluated the performance of staff in communicating vital health transfer information,
such as preexisting health conditions, pending appointments, tests, and specialty
referrals; and inspectors confirmed whether staff sent complete medication transfer
packages to receiving institutions. For patients who returned from off-site hospitals or
emergency rooms, inspectors reviewed whether staff appropriately implemented
recommended treatment plans, administered necessary medications, and scheduled
appropriate follow-up appointments.
Ratings and Results Overview
Case Review Rating Compliance Rating and Score
Adequate Inadequate (73.6%)
PBSP overall performed well in the transfer process. Compared with Cycle 6, the
institution processed more events, but the number of deficiencies remained similar. The
nurses completed the initial health screening form and scheduled provider appointments
timely. Furthermore, the nurses performed excellently with providing medication
continuity and ensuring medications were placed in the transfer packet for patients who
transferred out. Although PBSP performed well in the transfer process, we found
opportunities for improvement in nursing assessments when patients returned from an
off-site hospitalization or emergency room. Considering all factors, the OIG rated the
case review component of this indicator adequate.
Compliance testing showed mixed results with the transfer process. The institution
showed outstanding performance in ensuring transfer packets for departing patients
included required documents and medications. PBSP performed satisfactorily in ensuring
medication continuity for newly transferred patients. However, the institution faltered in
completing initial health screening forms. Based on the overall Transfers compliance
score result, the OIG rated the compliance testing component of this indicator
inadequate.
Office of the Inspector General, State of California Inspection Period: November 2023 – April 2024 Report Issued: July 2025
Cycle 7, Pelican Bay State Prison | 43
Case Review and Compliance Testing Results
We reviewed 51 events in 21 cases in which patients transferred into or out of the
institution or returned from an off-site hospital or emergency room. We identified 10
deficiencies, one of which was significant.26
Transfers In
Our clinicians found PBSP’s R&R nurses performed very well with evaluating the
transfer-in patients and requested nurse and provider appointments within required time
frames. We reviewed 15 transfer-in events and identified only two minor deficiencies
related to documentation.27
Our clinicians found the nurses completed the initial health screening form and
scheduled provider appointments timely. One RN was designated as the rover, who was
assigned to respond to all emergencies and at times, would cover the receiving and
release area (R&R) in the mornings when no RN was available to process patients who
were paroling. In contrast, compliance testing revealed nurses rarely completed the
initial health screening form within required time frames (MIT 6.001, 16.0%). However,
compliance testing showed nurses performed excellently with completing the assessment
and disposition section of the form (MIT 6.002, 100%).
Compliance testing showed PBSP performed excellently with ensuring new patient
arrivals were evaluated by a provider within the required time frame (MIT 1.002, 96.0%).
However, compliance testing revealed patients who had transferred in with pending
specialty appointments were inconsistently seen within required time frames, and
sometimes the appointments did not occur at all (MIT, 14.010, 42.9%).
Compliance testing showed PBSP showed satisfactory performance with ensuring
medication continuity for new patient arrivals (MIT 6.003, 78.6%) and patients
transferring within the facility most often received their medications without any
interruptions (MIT 7.005, 84.0%). However, compliance testing also revealed the
institution needed to improve with medication continuity for patient layovers (MIT 7.006,
33.3%). Specifically, in analyzing compliance data, we found only three applicable case
samples, two of which were noncompliant with medications. In contrast, our clinicians
found new patient arrivals received their medications timely.
Transfers Out
Our clinicians found PBSP performed well with the transfer-out process. We reviewed 10
transfer-out events and identified two minor deficiencies.28 Nurses almost always
completed the transfer information, administered medications prior to transfer, and
ensured medications were placed in the transfer packet. Compliance testing showed
PBSP performed excellently with ensuring transfer packets included the required
medications and required transfer documents (MIT 6.101, 100%).
26 Deficiencies occurred in cases 1, 17, 21, 22, 24, 28, 31, and 53. Significant deficiencies occurred in case 24.
27 Documentation deficiencies occurred in cases 17 and 28.
28 Transfer-out deficiencies occurred in cases 31 and 53.
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Cycle 7, Pelican Bay State Prison | 44
Hospitalizations
Patients returning from an off-site hospitalization or emergency room are at high risk for
lapses in care quality. These patients typically experience severe illness or injury. They
require more care and place a strain on the institution’s resources. In addition, because
these patients in general 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.
Compliance testing showed PBSP performed excellently in providing follow-up
appointments within required time frames for patients returning from off-site
hospitalizations (MIT 1.007, 100%) and revealed staff always scanned discharge
documents into the patients’ medical records within three calendar days of hospital
discharge (MIT 4.003, 100%). Compliance testing also indicated providers always
reviewed hospital reports within five calendar days (MIT 4.005, 100%). Our clinicians
reached similar results.
Nursing generally performed appropriate nursing assessments and interventions.
However, our clinicians identified three deficiencies related to incomplete nursing
assessments upon the patient’s hospital return.29 The following is an example:
• In case 53, the nurse evaluated the patient upon returning from the hospital who
complained of severe back pain with radiating pain down the left leg to the heel.
However, the nurse did not obtain a full set of vital signs.
Compliance testing revealed PBSP performed poorly in medication continuity for
patients who returned from off-site hospitalizations (MIT 7.003, 25.0%). The low score
was mostly due to medications not being made available or administered to the patient by
the ordering provider’s administration date and time. Our clinicians did not find any
medication-related deficiencies.
Clinician On-Site Inspection
Our clinicians toured the R&R and had the opportunity to interview the RN registry
nurse, who was covering behind the regular R&R nurse. The staffing in R&R consisted of
one RN each shift. The nurse shared they assessed a weekly average of 25 patients
transferring in and five to 10 patients transferring out. The nurse explained how they
reconciled medications for patient transfers and the process for communicating pending
specialty appointments. The nurse expressed feeling supported by nursing leadership and
having a cohesive relationship with custody staff.
Compliance On-Site Inspection and Discussion
R&R nursing staff ensured all nine applicable patients transferring out of the institution
had the required medications, transfer documents, and assigned durable medical
equipment (MIT 6.101, 100%).
29 Incomplete nursing assessments occurred in cases 1, 22, and 53.
Office of the Inspector General, State of California Inspection Period: November 2023 – April 2024 Report Issued: July 2025
Cycle 7, Pelican Bay State Prison | 45
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 4 21 0 16.0%
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 11 3 11 78.6%
administered or delivered without interruption? (6.003)
For patients transferred out of the facility: Do medication transfer packages
include required medications along with the corresponding transfer packet 9 0 1 100%
required documents? (6.101)
Overall percentage (MIT 6): 73.6%
Source: The Office of the Inspector General medical inspection results.
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Cycle 7, Pelican Bay State Prison | 46
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 24 1 0 96.0%
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 5 0 0 100%
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? 5 0 0 100%
(4.003)
For patients discharged from a community hospital: Did the preliminary or
final hospital discharge report include key elements and did a provider 5 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 1 3 1 25.0%
within required time frames? (7.003)
Upon the patient’s transfer from one housing unit to another: Were
21 4 0 84.0%
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 1 2 0 33.3%
administered or delivered without interruption? (7.006)
For endorsed patients received from another CDCR institution: If the patient
was approved for a specialty services appointment at the sending
6 8 2 42.9%
institution, was the appointment scheduled at the receiving institution
within the required time frames? (14.010)
Source: The Office of the Inspector General medical inspection results.
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Cycle 7, Pelican Bay State Prison | 47
Recommendations
• Nursing leadership should develop strategies to ensure nursing staff completely
answer and address required initial health screening questions. Leadership
should implement remedial measures or education as appropriate.
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Cycle 7, Pelican Bay State Prison | 48
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
Proficient Inadequate (68.4%)
Our clinicians found PBSP performed excellently in medication management. Compared
with Cycle 6, the institution had similar results. PBSP ensured patients almost always
received their medications without interruption with new medication prescriptions,
chronic care medications, hospital discharge medications, specialized medical housing
medications. PBSP ensured patients almost always received their medications without
interruption with new medication prescriptions, chronic care medications, hospital
discharge medications, and specialized medical housing medications. Factoring in all the
information, OIG rated the case review component of this indicator proficient.
Compliance testing showed PBSP needed to improve in medication management. PBSP
scored low in providing patients with chronic care medications, community hospital
discharge medications, and ensuring medication continuity for patients laying over at
PBSP. 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 126 events in 26 cases related to medications and found one medication
deficiency, which was significant.30
New Medication Prescriptions
Compliance testing showed PBSP performed satisfactorily with ensuring new
medications were made available and administered timely (MIT 7.002, 80.0%). In contrast,
our clinicians found PBSP always ensured new medications were delivered and
administered timely, and we did not identify any deficiencies related to new medication
prescriptions.
30 A significant deficiency occurred in case 15.
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Cycle 7, Pelican Bay State Prison | 49
Chronic Medication Continuity
Compliance testing revealed PBSP needed to improve with ensuring chronic care
medications were administered timely (MIT 7.001, 50.0%) In analyzing the compliance
data, we found the low scores were due to the pharmacy having not filled and dispensed
the medication timely, which included medications for blood pressure, cholesterol, and
diabetes. In contrast, our clinicians found PBSP performed well with administering
chronic care medications without interruption. We only identified one significant
deficiency in one case wherein the patient did not receive his cardiac chronic care
medication for the month of January 2024; however, the provider discontinued the
medication the following month.31 When we discussed this deficiency with the institution
leadership, they agreed with the deficiency finding.
Hospital Discharge Medications
Compliance testing revealed the institution performed poorly in medication continuity
for patients who returned from off-site hospitalizations (MIT 7.003, 25.0%). In contrast,
our clinicians found PBSP performed excellently with timely administering hospital
discharge medications. Please refer to the Transfers indicator for additional details.
Specialized Medical Housing Medications
Our clinicians found PBSP performed excellently with ensuring all medications were
administered timely for patients admitted to the specialized medical housing unit. In
contrast, compliance testing revealed staff needed to improve in medication continuity
for new patient admissions (MIT 13.003, 33.3%). In analyzing the compliance data, the low
score was mostly due to medications, which included those for seizures, chronic pain,
and chest pain, not having been made available by the ordering provider’s prescribed
administration times.
Transfer Medications
Our clinicians found PBSP performed excellently with ensuring medications were
administered without any interruptions for patient transfers into and out of the facility.
Compliance testing showed satisfactory performance with medication continuity for new
patient arrivals (MIT 6.003, 78.6%) and found patient transfers within the facility mostly
received their medications without any interruptions (MIT 7.005, 84.0%). However,
compliance testing showed the institution needed to improve with medication continuity
for patient layovers at the institution (MIT 7.006, 33.3%). Please see the Transfers
indicator for further details.
Both compliance testing and case review found PBSP performed perfectly in ensuring all
patients who transferred out of the facility had a five-day supply of medications (MIT
6.101, 100%).
Medication Administration
Compliance testing showed staff performed excellently with ensuring TB medications
were prescribed as ordered (MIT 9.001, 100%) and found staff appropriately monitored
31 A significant deficiency for chronic care medication occurred in case 15.
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Cycle 7, Pelican Bay State Prison | 50
most patients who were taking TB medications (MIT 9.002, 76.0%).
Clinician On-Site Inspection
During the on-site visit, our clinicians toured the medical clinic on the B Yard and
interviewed the LVNs. The staff shared they were staffed with one LVN per shift and had
an LVN who floated to assist when needed. The medication administration area was
clean, spacious, and appeared well organized. The LVNs were knowledgeable about the
medication KOP process and the medication transfer process. The LVNs expressed they
were not always able to attend morning huddles due to conflicting times with medication
lines. However, the medication LVN communicated any medications issues that needed
to be addressed to the LVN coordinator to report during the huddle, and the medication
LVN also sent a message to the provider. On the weekends, the medication LVN reported
any medication concerns to the TTA RN rover and the on-call provider.
Nurses reported the staff worked well together as a team. They also expressed they felt
supported by nursing leadership and had a good working relationship with custody staff.
Medication Practices and Storage Controls
The institution adequately stored and secured narcotic medications in seven of nine
applicable clinic and medication line locations (MIT 7.101, 77.8%). In one location, nurses
did not describe the appropriate narcotic medication discrepancy reporting process. In
the other location, narcotic medications were not properly and securely stored as
required by CCHCS policy.
PBSP appropriately stored and secured nonnarcotic medications in four of 10 applicable
clinic and medication line locations (MIT 7.102, 40.0%). In six locations, we observed one
or more of the following deficiencies: nurses did not follow the process in place to return
medications with expired pharmacy labels to the pharmacy; the medication area lacked a
clearly labeled designated area for medications that were to be returned to the pharmacy;
nurses did not maintain unissued medication in its original labeled packaging; the
medication storage cart was unsanitary; and medications were not properly and securely
stored as required by CCHCS policy.
Staff kept medications protected from physical, chemical, and temperature
contamination in six of the 10 applicable clinic and medication line locations (MIT 7.103,
60.0%). In three locations, staff did not consistently record room or refrigerator
temperatures. In one location, the medication refrigerator was unsanitary.
Staff successfully stored valid, unexpired medications in eight of the 10 applicable
medication line locations (MIT 7.104, 80.0%). In two locations, nurses did not label
multiple-use medication as required by CCHCS policy.
Nurses exercised proper hand hygiene and contamination control protocols in two of six
applicable locations (MIT 7.105, 33.3%). In four locations, nurses neglected to wash or
sanitize their hands when required. These occurrences included before preparing and
administering medications, or before each subsequent regloving.
Staff in five of six applicable medication preparation and administration areas
demonstrated appropriate administrative controls and protocols (MIT 7.106, 83.3%). In
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Cycle 7, Pelican Bay State Prison | 51
one location, medication nurses did not describe the process they followed when
reconciling newly received medication and the medication administration record (MAR)
against the corresponding physician’s order.
Staff in one of six applicable medication areas used appropriate administrative controls
and protocols when distributing medications to their patients (MIT 7.107, 16.7%). In five
locations, we observed one or more of the following deficiencies: medication nurses did
not always verify patient’s identification using a secondary identifier; medication nurses
did not reliably observe patients while they swallowed direct observation therapy
medications; and some medication nurses did not properly disinfect the vial’s port prior
to withdrawing medication.
Pharmacy Protocols
PBSP always followed general security, organization, and cleanliness management
protocols for nonrefrigerated and refrigerated medications stored in its pharmacy (MIT
7.108, 7.109, and 7.110, 100%).
The pharmacist-in-charge (PIC) always correctly accounted for narcotic medications
stored in PBSP’s pharmacy (MIT 7.111, 100%).
We examined 11 medication error reports and found the PIC also always timely and
correctly processed all reports (MIT 7.112, 100%).
Nonscored Tests
In addition to testing the institution’s self-reported medication errors, our inspectors
also followed up on any significant medication errors found during compliance testing.
We did not score this test; we provide these results for informational purposes only. At
PBSP, the OIG did not find any applicable medication errors (MIT 7.998).
The OIG interviewed patients in restricted housing units to determine whether they had
immediate access to their prescribed asthma rescue inhalers or nitroglycerin
medications. Six of 10 applicable patients interviewed indicated they had access to their
rescue medications. Four patients stated the rescue inhaler was taken away and placed in
their property when they transferred to the restricted housing unit. We promptly notified
the CEO of this concern, and health care management immediately issued replacement
rescue inhalers to the patients (MIT 7.999).
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Cycle 7, Pelican Bay State Prison | 52
Compliance Score Results
Table 13. Medication Management
Scored Answer
Compliance Questions Yes No N/A Yes %
Did the patient receive all chronic care medications within the required time frames
10 10 5 50.0%
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
20 5 0 80.0%
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 1 3 1 25.0%
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
21 4 0 84.0%
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 1 2 0 33.3%
delivered without interruption? (7.006)
All clinical and medication line storage areas for narcotic medications: Does the
institution employ strong medication security controls over narcotic medications 7 2 2 77.8%
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 4 6 1 40.0%
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 6 4 1 60.0%
the assigned storage areas? (7.103)
All clinical and medication line storage areas for nonnarcotic medications: Does the
institution safely store nonnarcotic medications that have yet to expire in the 8 2 1 80.0%
assigned storage areas? (7.104)
Medication preparation and administration areas: Do nursing staff employ and
follow hand hygiene contamination control protocols during medication 2 4 5 33.3%
preparation and medication administration processes? (7.105)
Medication preparation and administration areas: Does the institution employ
appropriate administrative controls and protocols when preparing medications for 5 1 5 83.3%
patients? (7.106)
Medication preparation and administration areas: Does the institution employ
appropriate administrative controls and protocols when administering medications 1 5 5 16.7%
to patients? (7.107)
Pharmacy: Does the institution employ and follow general security, organization,
1 0 0 100%
and cleanliness management protocols in its main and remote pharmacies? (7.108)
Pharmacy: Does the institution’s pharmacy properly store nonrefrigerated
1 0 0 100%
medications? (7.109)
Pharmacy: Does the institution’s pharmacy properly store refrigerated or frozen
1 0 0 100%
medications? (7.110)
Pharmacy: Does the institution’s pharmacy properly account for narcotic
1 0 0 100%
medications? (7.111)
Pharmacy: Does the institution follow key medication error reporting protocols?
11 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): 68.4%
Source: The Office of the Inspector General medical inspection results.
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Table 14. Other Tests Related to Medication Management
Scored Answer
Compliance Questions Yes No N/A Yes %
For endorsed patients received from another CDCR institution: If the patient
had an existing medication order upon arrival, were medications 11 3 11 78.6%
administered or delivered without interruption? (6.003)
For patients transferred out of the facility: Do medication transfer packages
include required medications along with the corresponding transfer-packet 9 0 1 100%
required documents? (6.101)
Patients prescribed TB medication: Did the institution administer the
25 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 19 6 0 76.0%
medication? (9.002)
Upon the patient’s admission to specialized medical housing: Were all
medications ordered, made available, and administered to the patient 3 6 1 33.3%
within required time frames? (13.003)
Source: The Office of the Inspector General medical inspection results.
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Recommendations
• Medical and nursing leadership should determine the challenges to ensuring
chronic care patients, hospital discharge patients, and patients admitted to
specialized medical housing receive their medications timely and without
interruption. Leadership should implement remedial measures as appropriate.
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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 (87.9%)
PBSP performed very well in preventive services. Staff performed excellently in
administering TB medications to patients as prescribed, offering patients an influenza
vaccination for the most recent influenza season, and offering colorectal cancer screening
for patients from ages 45 through 75. Staff performed satisfactorily in monitoring
patients on TB medications and in screening patients annually for TB. However, the
institution 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.
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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
25 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 19 6 0 76.0%
medication? (9.002)
Annual TB screening: Was the patient screened for TB within the last year?
20 5 0 80.0%
(9.003)
Were all patients offered an influenza vaccination for the most recent
25 0 0 100%
influenza season? (9.004)
All patients from the age of 45 through the age of 75: Was the patient
25 0 0 100%
offered colorectal cancer screening? (9.005)
Female patients from the age of 50 through the age of 74: Was the patient
N/A N/A N/A N/A
offered a mammogram in compliance with policy? (9.006)
Female patients from the age of 21 through the age of 65: Was patient
N/A N/A N/A N/A
offered a pap smear in compliance with policy? (9.007)
Are required immunizations being offered for chronic care patients? (9.008) 10 4 11 71.4%
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): 87.9%
Source: The Office of the Inspector General medical inspection results.
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Recommendations
The OIG offers no recommendations for this indicator.
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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
Our clinicians found nursing performance was sufficient in this indicator. Compared
with Cycle 6, the institution showed improvement with significantly fewer deficiencies.
Nurses performed very well in the transfer process and in administering medications.
Although nursing performance was satisfactory overall, our inspection continued to
indicate opportunities for improvement in nursing assessments, interventions, and
documentation, which we discuss below. Factoring in all the information, the OIG rated
this indicator adequate.
Case Review Results
We reviewed 164 nursing encounters in 50 cases. Of the nursing encounters we reviewed,
69 occurred in the outpatient setting and 55 were sick call requests. We identified 46
nursing performance deficiencies, five of which were significant.32
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. A comprehensive assessment allows nurses to gather essential information
about their patients and develop appropriate interventions.
32 Deficiencies occurred in cases 1, 2, 4-7, 9, 14, 15, 17, 20-22, 28, 31, 35-39, 45, 47, 53, and 55. Significant
deficiencies occurred in cases 2, 6, 14, and 39.
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Our clinicians identified 16 outpatient deficiencies, four of which were significant.33
Nurses generally performed good assessments and interventions, triaged sick call
requests appropriately, and evaluated patients timely. However, our clinicians found
opportunities for improvement with incomplete nursing sick call assessments, initiating
a co-consultation with the provider when conditions warranted, and initiating a provider
follow-up appointment based on the plan of care findings. The following are examples:
• In case 14, on several occasions the diabetic patient had abnormal blood sugar
readings. However, nurses did not inquire about signs and symptoms or notify
the provider to report the critical blood sugar level results.
• In case 21, the nurse evaluated the diabetic patient for complaints of left-foot
numbness radiating to all five toes. However, the nurse did not subjectively
assess the time of symptom onset and did not schedule a provider follow-up
appointment for further evaluation. Instead, the nurse advised the patient to
return to the clinic if symptoms worsened.
• In case 47, the nurse evaluated the patient for complaints of head pain and a
request for pain medication after the removal of a cyst on the forehead. However,
the nurse did not assess the surgical wound to document signs and symptoms of
infection, such as whether any redness, swelling, or drainage was present.
Outpatient Nursing Documentation
Complete and accurate nursing documentation is an essential component of patient care.
Without proper documentation, health care staff can overlook changes in patients’
conditions. Nurses mostly documented care appropriately. Our clinicians identified three
deficiencies related to incomplete nursing assessment documentation.34 However, these
deficiencies did not impact the overall care of the patients.
Emergency Services
We reviewed 28 urgent or emergent events. Nurses responded promptly to emergent
events and generally performed appropriate assessments and interventions. However, we
identified opportunities for improvement in nursing reassessments and in documenting
event time lines, which we detail further in the Emergency Services indicator.
Hospital Returns
We reviewed 26 events involving returns from off-site hospitals or emergency room
encounters. Nurses generally performed appropriate nursing assessments, which we
detailed further in the Transfers indicator.
Transfers
We reviewed 25 cases involving transfer-in and transfer-out processes. PBSP nurses
overall performed well in completing the initial health care screening, scheduling
33 Outpatient deficiencies occurred in cases 1, 2, 14, 15, 21, 35, 36, 37, 38, 39, 45, and 47. Significant deficiencies
occurred in cases 2, 14, and 39.
34 Documentation deficiencies occurred in cases 15, 27, and 37.
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provider follow-up appointments, and ensuring all transfer-out requirements were met.
Please refer to the Transfers indicator for further details.
Specialized Medical Housing
We reviewed six cases with a total of 55 events. Nurses overall performed timely
assessments, evaluated the patients frequently, and mostly documented patient care
appropriately. Although the nurses overall performed good patient care, we found at
times nursing assessments were incomplete. For more specific details, please refer to the
Specialized Medical Housing indicator.
Specialty Services
We reviewed four cases in which patients returned from off-site specialty services
appointments or consultations. Nursing overall performed well in this indicator. Our
clinicians did not identify any deficiencies.
Medication Management
OIG clinicians reviewed 126 events involving medication management and found most
nurses performed excellently in administering patient medications as prescribed. Our
clinicians only identified one significant deficiency. Please refer to the Medication
Management indicator for additional details.
Clinician On-Site Inspection
Our clinicians spoke with nursing supervisors and nurses in the TTA, CTC, R&R,
outpatient clinics, and medication areas. We attended the morning huddle on the B Yard
and found the huddle was well organized and demonstrated collaborative teamwork. Staff
was familiar with their patient population, and addressed all patient concerns. The care
team consisted of a telehealth primary care provider (PCP), a primary care RN, a medical
assistant, and an LVN coordinator.
The B Clinic RN reported seeing an average of eight patients per day. At the time of our
inspection, the nurse had three patients scheduled, and no backlog existed. Our clinicians
interviewed the LVN coordinator, who shared her duties consisted of managing patient
registries for annual screenings for various conditions, vaccinations, blood pressure
checks, dressing changes, and issuing durable medical equipment.
Our clinicians had the opportunity to interview the chief nurse executive (CNE), who had
significant experience working at PBSP. The CNE shared having two performance
improvement projects in progress for specialty services and for urine toxicology
laboratory drug screening for the medication-assisted treatment (MAT) program. The
CNE reported the primary challenge was staffing retention, specifically in how it affected
maintaining consistency with training and adherence to policies and procedures.
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Recommendations
• Nursing leadership should determine the challenges to nurses performing
detailed assessments as well as providing interventions during face-to-face
patient evaluations and should implement remedial measures as appropriate.
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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
PBSP providers delivered good care during this cycle. While COVID-19 affected provider
performance in Cycle 6, it did not significantly affect provider care delivery during the
review period in Cycle 7. We found providers performed well with assessment and
decision-making, review of records, emergency care, specialty services, documentation
quality, and provider care. They had room for improvement in chronic care, and we
identified a pattern of providers not appropriately managing their diabetic patients’
blood sugar levels. Considering all aspects, the OIG rated this indicator adequate.
Case Review Results
OIG clinicians reviewed 123 medical provider encounters and identified 24 deficiencies,
18 of which were significant.35 In addition, we examined the quality of care in 20
comprehensive case reviews. Of these 20 cases, we found one proficient, 15 adequate, and
four inadequate.
Outpatient Assessment and Decision-Making
Providers generally made good assessments and sound decisions. They took pertinent
histories, formed differential diagnoses, offered appropriate tests, provided proper
workups for patients, and referred for specialty care when medically indicated. However,
the OIG clinicians identified some deficiencies, the following of which are examples:
• In case 8, the patient requested to stop taking his MAT medication.36 Based on
evidence in the EHRS, OIG clinicians determined the provider appointment with
the patient to discuss the MAT medication occurred. However, the provider did
not document a progress note and did not follow up with the patient. This was
35 Provider deficiencies occurred in cases 8, 9, 10, 11, 12, 13, 14, 15, 16, 18, 20, 21, 23, 24, and 25. Significant
deficiencies occurred in cases 8, 10, 11, 12, 13, 14, 16, 18, 20, 21, 24, and 25.
36 MAT is the Medication Assisted Treatment program for substance use disorder.
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important because this event was the only provider interaction in the review
period before the patient died.
• In case 14, the patient complained of urinary hesitancy; however, the provider did
not evaluate the patient’s prostate as a cause.37
• In case 20, the nurse notified the provider about the patient having a persistent
cough for two months. The provider should have ordered an in-person evaluation
but did not. The patient was eventually seen by another provider more than a
month later after the patient submitted another sick-call request for the cough.
Review of Records
Providers need to review several different types of records to properly deliver care. They
review patient medical charts for medications, diagnostics, specialty appointments,
emergency care, and hospitalizations. Providers generally reviewed medical records
carefully. However, providers did not review vital signs appropriately in two encounters
as detailed below:
• In case 14, the diabetic patient was admitted to the hospital with euglycemic
diabetic ketoacidosis.38 As part of the work-up, the patient underwent a CT scan
of the abdomen and pelvis, which showed an adrenal nodule.39 The patient also
had elevation in GAD-65 autoantibodies.40 Although the provider endorsed these
results, the provider did not thoroughly address the findings.
• In case 21, the patient with diabetes and seizures did not have a chronic care
appointment for more than a year. The provider evaluated the patient during
episodic appointments and did not schedule a chronic care appointment to
address the patient’s chronic care conditions.
Emergency Care
Providers made appropriate triage decisions when patients arrived at the TTA for
emergency treatment. Providers were available for consultation with TTA staff via
telephone when outside normal office hours. They usually triaged patients appropriately
and sent them for a higher level of care when needed. OIG clinicians did not identify any
provider deficiencies related to emergency care.
37 Urinary hesitancy is a condition with difficulty starting or maintaining a urine stream. For a male patient, an
enlarged prostate can cause urinary hesitancy.
38 Euglycemic diabetic ketoacidosis is a serious complication of diabetes with normal to near-normal blood
glucose levels, metabolic acidosis, and elevated ketone levels.
39 An adrenal nodule is an abnormal growth in the adrenal gland. The adrenal gland is a small, triangular
shaped gland located on the top of the kidneys. It produces hormones to regulate blood pressure, metabolism,
and stress response.
40 GAD-65 autoantibodies are detected in blood tests. An autoantibody is a substance made by the body that
targets against the body’s own cells, tissues, or organs. Elevated levels indicate autoimmune disease.
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Chronic Care
While providers managed most chronic conditions well, they showed room for
improvement with managing diabetes. OIG clinicians identified 12 deficiencies in the
seven cases related to diabetes care. The following deficiencies are examples:
• In case 10, the provider evaluated the diabetic patient at a chronic care follow-up
appointment. However, the provider did not consider ordering a moderate
intensity statin for this patient with an elevated LDL cholesterol.41
• In case 11, the provider evaluated the patient who had diabetes, hypertension,
and hyperlipidemia at a chronic care appointment. The provider cloned various
parts of the provider’s progress note and did not consider starting the patient on
GLP-1 medication to control the patient’s worsening blood sugar level.42
• In case 12, the provider evaluated the patient who had uncontrolled diabetes at a
chronic care appointment. The patient had received his last insulin adjustment
three months prior, and his blood sugars levels were worsening. Despite the
patient feeling well at the time of the appointment and not wanting his insulin
adjusted, the provider should have scheduled a follow-up earlier than 180 days
later. In addition, a few days after the appointment, the patient’s diabetic
laboratory test showed his sugars had risen further, and the provider sent a letter
noting a new appointment had been scheduled for him; however, this
appointment did not occur.
• In case 13, the patient received a blood test showing his blood sugar levels were
worsening, revealing the HbA1c count had increased from 7.2 percent to 12.9
percent.43 The provider did not order a follow-up appointment with the patient to
address the elevated blood test.
• In case 14, the patient had poorly controlled diabetes. The provider mismanaged
the diabetes medication treatment by increasing empagliflozin and stopping a
large dose of long-acting insulin.44 This action would not be sufficient to control
the diabetes. When the HbA1c result showed worsening control, the provider did
not consider restarting the insulin or prescribing short-term fingerstick
monitoring of sugars. The provider also did not ascertain whether the patient’s
dietary habits or physical activity level had been contributing to the worsening
blood sugar levels and did not address the patient’s low blood pressure during the
appointment. Overall, the provider did not adjust any therapies or interact with
the patient over a three-month period.
• In case 16, the provider evaluated the diabetic patient at a chronic care
appointment and did not order an eye examination to evaluate for diabetic
41 A statin is a cholesterol reducing medication. LDL cholesterol is a low-density lipoprotein and an elevated
level is a risk factor for heart disease.
42 Glucagon-like peptide 1 (GLP-1) is a medication used to reduce sugar levels.
43 Hemoglobin A1c 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
44 Empagliflozin is a medication used to treat diabetes by blocking the reabsorption of sugar in the kidneys,
resulting in more glucose excretion through urine and reduced blood sugar levels.
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retinopathy or perform a monofilament test to evaluate for neuropathy.45 Both of
these were last performed over a year prior.
Specialized Medical Housing
Providers appropriately and timely completed admission history and physical
examinations for patients. Providers evaluated patients at clinically appropriate intervals
and delivered acceptable care.
Specialty Services
PBSP providers generally referred patients for specialty consultations when needed. OIG
clinicians identified some provider performance deficiencies related to specialty services.
The following are examples:
• In case 14, the diabetic patient complained of left-eye vision changes described
as “black smoke.”46 The provider requested a routine-priority optometry
appointment instead of an earlier appointment.
• In case 24, the neurologist evaluated the patient, who was on two antiseizure
medications. The neurologist recommended the patient continue taking these
medications, check the medication level with a laboratory test, and order an
electroencephalogram.47 However, the provider did not order the laboratory test
to measure the medication level.
We also discuss provider specialty performance in the Specialty Services indicator.
Documentation Quality
Generally, providers documented progress notes appropriately. We identified a few errors
in documentation as follows:
• In case 9, the provider evaluated the patient and reviewed the patient’s urine
toxicology test showing methamphetamines, marijuana, and fentanyl; however,
the provider documented, “illicit substances were not found.”
• In case 14, the provider documented the wrong date on the progress note.
• In case 15, the provider documented the patient was taking a different dose of
suboxone than the dose the patient was actually taking.
45 Diabetic retinopathy is a complication of diabetes affecting the eyes resulting from damage to blood vessels
in the retina. The retina is the layer of cells in back of the eye that senses light and sends signals to the brain. A
monofilament test is a test using a small strand of nylon to check for loss of sensation in the foot.
46 The visual complaints of “black smoke” may be indicative of a serious emergency medical condition such as
retinal detachment where the eye retina pulls away from the back of the eye, resulting in blindness.
47 An electroencephalogram test measures the electrical activity in the brain.
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Provider Continuity
PBSP offered good provider continuity to the patients. OIG clinicians did not find any
problems with provider continuity during the review period.
Clinician On-Site Inspection
At the on-site inspection, we received a report that PBSP was in a unique position; PBSP
had neither a permanent chief medical executive (CME) as the CME had retired in
February 2024, nor a permanent chief physician and surgeon (CP&S) as the CP&S had
transferred to another institution. We spoke with the regional health executive (RHE)
who was managing PBSP’s providers in the interim. During our period of inspection,
PBSP had one State physician, one advanced practitioner, and one registry provider on-
site. The institution was also served by four telemedicine primary care providers
remotely, along with two dual position providers.48
The RHE described the staffing and leadership shortages at the institution, which had
been compounded by the prison population’s increase of about 50 percent. The increased
patient load consisted of predominantly Level 2 enhanced outpatient individuals, who
used more medical and custodial resources. A large proportion of the new patients
arrived with appointments already out of compliance, which created an instant provider
appointment backlog that numbered more than 300 during the summer months.49
We spoke with the various providers who reported not having medical leadership was
detrimental to their morale. According to providers, the loss of their long-time CME in
February, reassignments to different yards a few months ago, and increased workloads
due to new patients with more complaints made the process of caring for patients more
difficult.
48 Dual position providers worked at another institution for the access extra four hours per day.
49 This occurred after the review period and before the OIG case review on-site inspection.
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Recommendations
• Medical leadership should identify the root cause(s) for providers’ poor diabetes
management and should implement remedial measures as appropriate.
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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. At the time of our inspection, PBSP’s specialized medical housing consisted of a
correctional treatment center (CTC).
Ratings and Results Overview
Case Review Rating Compliance Rating and Score
Adequate Inadequate (73.3%)
Our clinicians found PBSP performed sufficiently in this indicator. Compared with Cycle
6, the institution showed improvement with significantly fewer deficiencies during Cycle
7. Providers delivered excellent care and made appropriate medical decisions. Nursing
generally performed good assessments and interventions, completed admission
assessments timely, co-consulted with the provider, and administered medications
timely. Although nursing overall provided good care, we identified opportunities for
improvement with completing thorough nursing assessments. Factoring in all the
information, OIG rated this case review component of this indicator adequate.
Compliance testing showed mixed performance in this indicator. Staff frequently
completed admission assessments and history and physical (H&P) examinations timely.
However, the institution needed significant improvement in ensuring medication
continuity for patients admitted into the specialized medical housing unit. Based on the
overall Specialized Medical Housing compliance score result, the OIG rated the
compliance testing component of this indicator inadequate.
Case Review and Compliance Testing Results
We reviewed 55 CTC events, including 26 provider events and 29 nursing events. Due to
the frequency of nursing and provider contacts in the specialized medical housing, we
bundle up to two weeks of patient care into a single event. We identified 12 deficiencies,
none of which were significant.50
Provider Performance
Providers performed excellently in the specialized medical housing. We reviewed six
CTC cases. Providers assessed patients and made good decisions, referred patients to
specialists as needed, and reviewed other care events. They always completed their
50 Deficiencies occurred in cases 2, 22, 24, 53, 54, and 55.
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history and physical examinations timely upon admission into the CTC and performed
their rounds for patients at appropriate intervals. OIG clinicians reviewed 26 provider
encounters and did not find any deficiencies.
Compliance testing showed providers generally completed admission history and
physical examinations timely (MIT 13.002, 80.0%).
Nursing Performance
Compliance testing showed nurses frequently completed an initial assessment of patients
at the time of admission (MIT 13.001, 80.0%).
Our case review found nurses generally performed appropriate assessments and
interventions. Nurses also completed the initial admission assessment within required
time frames. However, we identified a pattern in three cases showing incomplete nursing
assessments.51 The following are examples:
• In case 2, during the period from of March 1, 2024, through April 19, 2024, the
patient often complained of bilateral knee pain. However, the nurses did not
always assess the pain scale level, the quality of pain, or follow-up with a
corresponding pain assessment.
• In case 22, the patient with a peripherally inserted central catheter (PICC) line
was admitted to the CTC for antibiotic therapy.52 However, the nurses frequently
did not assess the PICC line site or obtain external measurements to include arm
circumference.
Medication Administration
Our clinicians found PBSP ensured all new patient admissions received their medications
without interruption. In contrast, compliance testing revealed staff needed significant
improvement in timely administering medication for new patient admissions (MIT
13.003, 33.3%). Please see the Medication Management indicator for further discussion.
Clinician On-Site Inspection
Our clinicians interviewed the CTC nursing supervisor and CTC staff. The CTC had 10
medical beds, 10 mental health crisis beds, one seclusion room, and two negative pressure
rooms. The CTC staffing consists of two RNs on each shift as well as a psychiatric
technician and an LVN during the day and the evening shifts. The CTC has an assigned
provider Monday through Friday and an on-call provider assigned for weekend coverage.
At the time of our on-site inspection, the patient census was 16.
The nursing supervisor shared the CTC held staff huddles each shift during which staff
discussed patient care issues. Furthermore, the supervisor discussed the various nursing
audits they had conducted to assess the quality of nursing care. Some of the challenges
the CTC faced included staffing retention and the new enhanced outpatient program
51 Patterns of incomplete nursing assessments occurred in cases 2, 22, and 53.
52 A peripherally inserted central catheter provides intravenous access to administer fluids and medication.
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(EOP) that had begun in February 2024, which had created an influx of new patients who
had many health challenges.
The CTC staff reported they felt supported by nursing leadership and had an excellent
working relationship with custody staff.
Compliance On-Site Inspection and Discussion
At the time of the OIG’s on-site inspection, the CTC had a functional call light
communication system (MIT 13.101, 100%).
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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
8 2 0 80.0%
assessment of the patient on the day of admission? (13.001)
Was a written history and physical examination completed within the
8 2 0 80.0%
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 3 6 1 33.3%
within required time frames? (13.003)
For specialized health care housing (CTC, SNF, hospice, OHU): Do
specialized health care housing maintain an operational call 1 0 0 100%
system? (13.101)
For specialized health care housing (CTC, SNF, hospice, OHU): Do health
care staff perform patient safety checks according to institution’s local 0 0 1 N/A
operating procedure or within the required time frames? (13.102)
Overall percentage (MIT 13): 73.3%
Source: The Office of the Inspector General medical inspection results.
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Recommendations
• Nursing leadership should develop strategies to ensure nursing staff in the CTC
perform thorough patient assessments and should implement remedial measures
as appropriate.
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Specialty Services
In this indicator, OIG inspectors evaluated the quality of specialty services. The OIG
clinicians focused on the institution’s performance in providing needed specialty care.
Our clinicians also examined specialty appointment scheduling, providers’ specialty
referrals, and medical staff’s retrieval, review, and implementation of any specialty
recommendations.
Ratings and Results Overview
Case Review Rating Compliance Rating and Score
Adequate Inadequate (68.2%)
Case review found PBSP delivered very good specialty services for its patients. Providers
referred patients when medically indicated and often endorsed specialty reports timely.
Nurses always assessed patients who returned from off-site specialists and assisted with
relaying recommendations during telemedicine specialty encounters. Medical records
staff generally retrieved reports timely, sent reports to providers, and scanned them into
the EHRS appropriately. However, we found access to specialists needed to improve; we
identified delays in access to telemedicine specialists. The OIG rated the case review
component of this indicator adequate.
Compliance testing showed a mixed performance in this indicator. Access to off-site
specialists’ ranged from very good to needing significant improvement. Preapproved
specialty services for newly arrived patients sporadically occurred within required time
frames. In addition, performance in retrieving specialty reports and prompt provider
endorsements varied. Based on the overall Specialty Services compliance score result, the
OIG rated the compliance component of this indicator inadequate.
Case Review and Compliance Testing Results
OIG clinicians reviewed 51 events related to specialty services: 34 specialty consultations
and procedures, nine nursing encounters related to patient returns from outside or
telemedicine specialty visits, and six provider encounters. We identified eight
deficiencies in this category, four of which were significant.53
Access to Specialty Services
PBSP’s performance was variable with access to specialty services. Compliance testing
showed mixed performance with specialty access as routine-priority specialty
appointments frequently occurred timely (MIT 14.007, 86.7%), high-priority specialty
appointments inconsistently occurred timely (MIT 14.001, 73.3%), and medium-priority
specialty appointments only sporadically occurred timely (MIT 14.004, 33.3%). Continuity
of specialty services after transfer into the facility was poor (MIT 14.010, 42.9%). OIG
53 Deficiencies occurred in cases 1, 17, 18, 24, 25, and 53. Significant deficiencies occurred in cases 1, 24, 25, and
53.
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clinicians found acceptable access to specialty services. During the last inspection cycle,
we did not find any access deficiencies with specialists; however, in this cycle, we found
four access deficiencies, three of which were significant due to the delay duration from
the original order. The following are two examples:
• In case 24, the patient had multiple abnormalities throughout both lungs
showing on radiology imaging, suggesting sarcoidosis.54 The provider ordered a
medium-priority pulmonology specialty appointment; however, this appointment
occurred with a two-month delay. On-site, the specialty supervisor stated the
delays were due to CCHCS headquarters scheduling of telemedicine specialty
appointments, along with the patient’s multiple hospitalizations and CTC
admissions causing the opening and closing of the patient’s medical chart, which
together resulted in the discontinuation of the appointment order.
• In case 53, the patient complained of intense back pain and had laboratory tests
showing elevated markers of inflammation and anemia, all of which prompted
the provider to be concerned about spinal cord infection. The provider ordered
an urgent neurosurgery specialty referral, which should have occurred within two
weeks; however, the referral was scheduled one month later and was then
ultimately canceled and rescheduled several months later. On-site, the specialty
supervisor stated the CCHCS headquarters schedulers were responsible for the
timely arranging of telemedicine specialty appointments.
Provider Performance
Providers appropriately ordered specialty consults within the proper time frames. When
specialists evaluated patients with high-priority referrals, the provider always followed
up with the patients within five days of the referral. Additionally, the providers almost
always reviewed specialty reports timely. We found only one provider performance
deficiency related to inaccurate documentation as follows:
• In case 25, the provider evaluated the patient at a chronic care appointment and
documented the patient had not seen the kidney specialist for over two years.
However, the kidney specialist evaluated the patient two months prior and the
provider had already endorsed the kidney specialist’s report.
Compliance testing showed providers or nurses generally assessed patients timely after
specialty services (MIT 1.008, 76.7%).
Nursing Performance
PBSP nurses performed excellently with specialty services. Nurses assessed patients
returning from off-site appointments in the TTA and messaged providers as necessary.
Nurses also supported telemedicine specialists and relayed recommendations to
providers when orders were needed for medications or further appointments. OIG
clinicians did not find any nursing deficiencies in specialty care.
54 Sarcoidosis is an inflammatory condition affecting the lungs, skin, lymph nodes, and other parts of the body.
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Health Information Management
PBSP medical records staff generally retrieved specialty reports timely and forwarded
them to providers for endorsement. Compliance testing showed mixed performance with
health information management of routine-, medium-, and high-priority specialty reports
(MIT 14.008, 60.0%, MIT 14.005, 60.0%, and MIT 14.002, 80.0%). However, medical records
staff almost always scanned specialty reports into the EHRS timely (MIT 4.002, 96.7%).
OIG clinicians only found one delay in retrieving an echocardiogram. We found timely
provider endorsements with two exceptions; however, both delays were two days or less.
Clinician On-Site Inspection
OIG clinicians spoke with PBSP medical leadership, specialty supervisors, and providers
about specialty care. Medical leadership reported telemedicine specialties were handled
by CCHCS headquarters schedulers, which caused delays and resulted in specialty
appointment backlogs. Leadership was unsure if the delays were due to not having
enough telemedicine specialty contractors to provide services or to the increased
statewide specialty usage. Supervisors stated they had no on-site PBSP staffing shortages
related to managing specialty services. They described retrieval of the reports for off-site
specialty processes and how these reports were sent to providers for endorsements. We
also spoke to the on-site nurse and the on-site optometrist. The optometrist stated the
process was to document directly into the EHRS, so providers could view the report
afterward. The optometrist notified the provider if and when providers needed to
generate orders.
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Compliance Score Results
Table 17. Specialty Services
Scored Answer
Compliance Questions Yes No N/A Yes %
Did the patient receive the high-priority specialty service within 14 calendar
days of the primary care provider order or the Physician Request for 11 4 0 73.3%
Service? (14.001)
Did the institution receive and did the primary care provider review the
high-priority specialty service consultant report within the required time 12 3 0 80.0%
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 3 7 62.5%
(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 5 10 0 33.3%
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 9 6 0 60.0%
frame? (14.005)
Did the patient receive the subsequent follow-up to the medium-priority
specialty service appointment as ordered by the primary care provider? 6 3 6 66.7%
(14.006)
Did the patient receive the routine-priority specialty service within 90
calendar days of the primary care provider order or Physician Request for 13 2 0 86.7%
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 9 6 0 60.0%
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 2 6 77.8%
(14.009)
For endorsed patients received from another CDCR institution: If the patient
was approved for a specialty services appointment at the sending
6 8 2 42.9%
institution, was the appointment scheduled at the receiving institution
within the required time frames? (14.010)
Did the institution deny the primary care provider’s request for specialty
20 0 0 100%
services within required time frames? (14.011)
Following the denial of a request for specialty services, was the patient
15 5 0 75.0%
informed of the denial within the required time frame? (14.012)
Overall percentage (MIT 14): 68.2%
Source: The Office of the Inspector General medical inspection results.
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Table 18. Other Tests Related to Specialty Services
Scored Answer
Compliance Questions Yes No N/A Yes %
Specialty service follow-up appointments: Did the clinician follow-up visits
23 7 15 76.7%
occur within required time frames? (1.008) *
Are specialty documents scanned into the patient’s electronic health record
29 1 15 96.7%
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.
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Recommendations
• Health care leadership should determine the challenges to the timely provision of
telemedicine specialty appointments and should implement remedial measures
as appropriate.
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Administrative Operations
In this indicator, OIG compliance inspectors evaluated health care administrative
processes. Our inspectors examined the timeliness of the medical grievance process and
checked whether the institution followed reporting requirements for adverse or sentinel
events and patient deaths. Inspectors checked whether the Emergency Medical Response
Review Committee (EMRRC) met and reviewed incident packages. We investigated and
determined whether the institution conducted required emergency response drills.
Inspectors also assessed whether the Quality Management Committee (QMC) met
regularly and addressed program performance adequately. In addition, our inspectors
determined whether the institution provided training and job performance reviews for its
employees. We checked whether staff possessed current, valid professional licenses,
certifications, and credentials. The OIG rated this indicator solely based on the
compliance score. Our case review clinicians do not rate this indicator.
Because none of the tests in this indicator directly affected clinical patient care (it is a
secondary indicator), the OIG did not consider this indicator’s rating when determining
the institution’s overall quality rating.
Ratings and Results Overview
Case Review Rating Compliance Rating and Score
Not Applicable Inadequate (66.0%)
PBSP’s performance was mixed in this indicator. While PBSP scored excellently in some
applicable tests, it needed improvement in multiple areas. The Emergency Medical
Response Review Committee (EMRRC) only sometimes completed the required
checklists. Staff did not conduct a live medical emergency response drill or the drill was
conducted with incomplete documentation and missing required emergency response
drill forms. Staff also did not conduct two live emergency response drills for the most
recent quarter. Physician managers did not complete annual performance appraisals
timely, and they did not have a local process to monitor the providers’ timely renewal of
emergency response certifications prior to expiration. The nurse educator did not ensure
all newly hired nurses received the required onboarding training and only intermittently
ensured nurses who administer medications timely complete their annual competency
testing. 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
inadequate.
Compliance Testing Results
Nonscored Results
At PBSP, 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 four
patients, we found no evidence in the submitted documentation the preliminary mortality
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reports had been completed. These reports were overdue at the time of OIG’s inspection
(MIT 15.998).
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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
7 5 0 58.3%
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
4 0 0 100%
CCHCS Mortality Case Review Unit on time? (15.103)
Did nurse managers ensure the clinical competency of nurses who
5 5 0 50.0%
administer medications? (15.104)
Did physician managers complete provider clinical performance appraisals
0 2 0 0
timely? (15.105)
Did the providers maintain valid state medical licenses? (15.106) 16 0 0 100%
Did the staff maintain valid Cardiopulmonary Resuscitation (CPR), Basic Life
Support (BLS), and Advanced Cardiac Life Support (ACLS) certifications? 1 1 1 50.0%
(15.107)
Did the nurses and the pharmacist-in-charge (PIC) maintain valid
professional licenses and certifications, and did the pharmacy maintain a 6 0 1 100%
valid correctional pharmacy license? (15.108)
Did the pharmacy and the providers maintain valid Drug Enforcement
Agency (DEA) registration certificates, and did the pharmacy maintain valid 1 0 0 100%
Automated Drug Delivery System (ADDS) licenses? (15.109)
Did nurse managers ensure their newly hired nurses received the required
0 1 0 0
onboarding and clinical competency training? (15.110)
Did the CCHCS Death Review Committee process death review reports
This is a nonscored test. Please refer to the
timely? Effective 05/2022: Did the Headquarters Mortality Case Review
discussion in this indicator.
process mortality review reports timely? (15.998)
What was the institution’s health care staffing at the time of the OIG medical This is a nonscored test. Please refer to Table 3
inspection? (15.999) for CCHCS-provided staffing information.
Overall percentage (MIT 15): 66.0%
Source: The Office of the Inspector General medical inspection results.
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Recommendations
The OIG offers no recommendations for this indicator.
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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 PBSP
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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
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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.
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Figure A–2. Case Review Testing
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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.
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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.
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Appendix B: Case Review Data
Table B–1. PBSP Case Review Sample Sets
Sample Set Total
CTC/OHU 3
Death Review/Sentinel Events 2
Diabetes 5
Emergency Services – CPR 5
Emergency Services – Non-CPR 2
High Risk 4
Hospitalization 4
Intrasystem Transfers In 3
Intrasystem Transfers Out 3
RN Sick Call 21
Specialty Services 3
55
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Table B–2. PBSP Case Review Chronic Care Diagnoses
Sample Set Total
Anemia 2
Arthritis/Degenerative Joint Disease 7
Asthma 7
Cancer 1
Cardiovascular Disease 1
Chronic Kidney Disease 6
Chronic Pain 7
Cirrhosis/ End Stage Liver Disease 3
COPD 1
COVID-19 1
Diabetes 11
GERD 5
Hepatitis C 19
Hyperlipidemia 11
Hypertension 17
Mental Health 16
Rheumatological Disease 3
Seizure Disorder 3
Sleep Apnea 1
Substance Abuse 26
Thyroid Disease 1
149
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Table B–3. PBSP Case Review Events by Program
Diagnosis Total
Diagnostic Services 94
Emergency Care 72
Hospitalization 29
Intrasystem Transfers In 15
Intrasystem Transfers Out 10
Outpatient Care 309
Specialized Medical Housing 65
Specialty Services 51
645
Table B–4. PBSP Case Review Sample Summary
Sample Set Total
MD Reviews Detailed 20
MD Reviews Focused 2
RN Reviews Detailed 13
RN Reviews Focused 42
Total Reviews 77
Total Unique Cases 55
Overlapping Reviews (MD & RN) 22
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Appendix C: Compliance Sampling Methodology
Pelican Bay 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 40 Clinic • Clinic (each clinic tested)
(6 per clinic) Appointment List • Appointment date (2 – 9 months)
• Randomize
MIT 1.007 Returns From 5 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 5 InterQual • Appt. date (90 days – 9 months)
• Service (pathology-related)
• Randomize
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Quality No. of
Indicator Sample Category Samples Data Source Filters
Health Information Management (Medical Records)
MIT 4.001 Health Care Services 40 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 5 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 5 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 10 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
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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 5 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 3 SOMS • Date of transfer (2– 8 months)
• Sending institution (another
departmental facility)
• Randomize
• NA/DOT meds
MITs 7.101 – 103 Medication Storage Varies OIG inspector • Identify and inspect clinical & med
Areas by test on-site review line areas that store medications
MITs 7.104 – 107 Medication Varies OIG inspector • Identify and inspect on-site clinical
Preparation and by test on-site review areas that prepare and administer
Administration Areas medications
MITs 7.108 – 111 Pharmacy 1 OIG inspector • Identify & inspect all on-site
on-site review pharmacies
MIT 7.112 Medication Error 11 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
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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 25 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: November 2023 – April 2024 Report Issued: July 2025
Cycle 7, Pelican Bay 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 10 CADDIS • Admit date (2 – 8 months)
Care Housing Unit • Type of stay (no MH beds)
• Length of stay (minimum of 5 days)
• Rx count
• Randomize
MITs 13.101 – 102 Call Buttons All OIG inspector • Specialized Health Care Housing
on-site review • Review by location
Specialty Services
MITs 14.001 – 003 High-Priority 15 Specialty Services • Approval date (3 – 9 months)
Initial and Follow-Up Appointments • Remove consult to audiology,
RFS chemotherapy, dietary, Hep C, HIV,
orthotics, gynecology, consult to
public health/Specialty RN, dialysis,
ECG 12-Lead (EKG), mammogram,
occupational therapy,
ophthalmology, optometry, oral
surgery, physical therapy, physiatry,
podiatry, radiology, follow-up
wound care / addiction medication,
narcotic treatment program, and
transgender services
• Randomize
MITs 14.004 – 006 Medium-Priority 15 Specialty Services • Approval date (3 – 9 months)
Initial and Follow-Up Appointments • Remove consult to audiology,
RFS chemotherapy, dietary, Hep C, HIV,
orthotics, gynecology, consult to
public health/Specialty RN, dialysis,
ECG 12-Lead (EKG), mammogram,
occupational therapy,
ophthalmology, optometry, oral
surgery, physical therapy, physiatry,
podiatry, radiology, follow-up
wound care/addiction medication,
narcotic treatment program, and
transgender services
• Randomize
Office of the Inspector General, State of California Inspection Period: November 2023 – April 2024 Report Issued: July 2025
Cycle 7, Pelican Bay 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 16 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: November 2023 – April 2024 Report Issued: July 2025
Cycle 7, Pelican Bay State Prison | 99
Quality No. of
Indicator Sample Category Samples Data Source Filters
Administrative Operations (continued)
MIT 15.103 Death Reports 4 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 2 On-site provider • All required performance evaluation
Evaluation Packets evaluation files documents
MIT 15.106 Provider Licenses 16 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 4 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: November 2023 – April 2024 Report Issued: July 2025
Cycle 7, Pelican Bay State Prison | 100
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Office of the Inspector General, State of California Inspection Period: November 2023 – April 2024 Report Issued: July 2025
Cycle 7, Pelican Bay State Prison | 101
California Correctional Health Care Services’
Response
Office of the Inspector General, State of California Inspection Period: November 2023 – April 2024 Report Issued: July 2025
Cycle 7
Medical Inspection Report
for
Pelican Bay State Prison
OFFICE of the
INSPECTOR GENERAL
Amarik K. Singh
Inspector General
Shaun Spillane
Chief Deputy Inspector General
STATE of CALIFORNIA
July 2025
OIG