Pleasant Valley State Prison Cycle 7 Medical Inspection Report

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Connect with us on social media Cycle 7, Pleasant Valley State Prison | iii Contents Illustrations iv Introduction 1 Summary: Ratings and Scores 3 Medical Inspection Results 5 Deficiencies Identified During Case Review 5 Case Review Results 5 Compliance Testing Results 6 Institution-Specific Metrics 6 Population-Based Metrics 9 HEDIS Results 9 Recommendations 11 Indicators 13 Access to Care 13 Diagnostic Services 20 Emergency Services 25 Health Information Management 29 Health Care Environment 35 Transfers 43 Medication Management 49 Preventive Services 56 Nursing Performance 59 Provider Performance 64 Specialized Medical Housing 69 Specialty Services 72 Administrative Operations 78 Appendix A: Methodology 81 Case Reviews 82 Compliance Testing 85 Indicator Ratings and the Overall Medical Quality Rating 86 Appendix B: Case Review Data 87 Appendix C: Compliance Sampling Methodology 91 California Correctional Health Care Services’ Response 99 Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | iv Illustrations Tables 1. PVSP Summary Table: Case Review Ratings and Policy Compliance Scores 4 2. PVSP Master Registry Data as of August 2024 7 3. PVSP Health Care Staffing Resources as of August 2024 8 4. PVSP Results Compared With State HEDIS Scores 10 5. Access to Care 17 6. Other Tests Related to Access to Care 18 7. Diagnostic Services 23 8. Health Information Management 32 9. Other Tests Related to Health Information Management 33 10. Health Care Environment 41 11. Transfers 46 12. Other Tests Related to Transfers 47 13. Medication Management 53 14. Other Tests Related to Medication Management 54 15. Preventive Services 57 16. Specialized Medical Housing 70 17. Specialty Services 75 18. Other Tests Related to Specialty Services 76 19. Administrative Operations 79 A–1. Case Review Definitions 82 B–1. PVSP Case Review Sample Sets 87 B–2. PVSP Case Review Chronic Care Diagnoses 88 B–3. PVSP Case Review Events by Program 89 B–4. PVSP Case Review Sample Summary 89 Figures A–1. Inspection Indicator Review Distribution for PVSP 81 A–2. Case Review Testing 84 A–3. Compliance Sampling Methodology 85 Photographs 1. Indoor Patient Waiting Area 35 2. Individual Waiting Modules 36 3. Expired Medical Supply Dated March 2015 36 4. Expired Medical Supply Dated February 2024 37 5. Snellen Chart Was Not Mounted on the Wall at the Time of Inspection 37 6. Compromised EMRB Medical Supply 38 7. Compromised EMRB Medical Supply 38 8. Expired Medical Supply Dated March 2024 38 9. Damaged Clinic Floor That Cannot Be Properly Sanitized 39 10. Damaged Ceiling That Cannot Be Properly Sanitized 39 Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 1 Introduction Pursuant to California Penal Code section 6126 et seq., the Office of the Inspector General (the OIG) is responsible for periodically reviewing and reporting on the delivery of the ongoing medical care provided to incarcerated people1 in the California Department of Corrections and Rehabilitation (the department).2 In Cycle 7, the OIG continues to apply the same assessment methodologies used in Cycle 6, including clinical case review and compliance testing. Together, these methods assess the institution’s medical care on both individual and system levels by providing an accurate assessment of how the institution’s health care systems function regarding patients with the highest medical risk, who tend to access services at the highest rate. Through these methods, the OIG evaluates the performance of the institution in providing sustainable, adequate care. We continue to review institutional care using 15 indicators as in prior cycles.3 Using each of these indicators, our compliance inspectors collect data in answer to compliance- and performance-related questions as established in the medical inspection tool (MIT). In addition, our clinicians complete document reviews of individual cases and also perform on-site inspections, which include interviews with staff. The OIG determines a total compliance score for each applicable indicator and considers MIT scores in the overall conclusion of the institution’s compliance performance. In conducting in-depth, quality-focused reviews of randomized cases, our case review clinicians examine whether health care staff used sound medical judgment in the course of caring for a patient. In the event we find errors, we determine whether such errors were clinically significant or led to a significantly increased risk of harm to the patient. At the same time, our clinicians consider whether institutional medical processes led to identifying and correcting individual or system errors, and we examine whether the institution’s medical system mitigated the error. The OIG rates each applicable indicator proficient, adequate, or inadequate, and considers each rating in the overall conclusion of the institution’s health care performance. In contrast to Cycle 6, the OIG will provide individual clinical case review ratings and compliance testing scores in Cycle 7 rather than aggregate all findings into a single overall institution rating. This change will clarify the distinctions between these differing quality measures and the results of each assessment. 1 In this report, we use the terms patient and patients to refer to incarcerated people. 2 The OIG’s medical inspections are not designed to resolve questions about the constitutionality of care, and the OIG explicitly makes no determination regarding the constitutionality of care the department provides to its population. 3 In addition to our own compliance testing and case reviews, the OIG continues to offer selected Healthcare Effectiveness Data and Information Set (HEDIS) measures for comparison purposes. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 2 As we did during Cycle 6, our office continues to inspect both those institutions remaining under federal receivership and those delegated back to the department. There is no difference in the standards used for assessing a delegated institution versus an institution not yet delegated. At the time of the Cycle 7 inspection of Pleasant Valley State Prison, the institution had been delegated back to the department by the receiver. We completed our seventh inspection of the institution, and this report presents our assessment of the health care provided at this institution during the inspection period from January 2024 to June 2024.4 4 Samples are obtained per case review methodology and shared with stakeholders in prior cycles. The case reviews include death reviews between July 2023 and June 2024 and transfer reviews between June 2023 and June 2024. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 3 Summary: Ratings and Scores We completed the Cycle 7 inspection of PVSP in January 2025. OIG inspectors monitored the institution’s delivery of medical care that occurred between January 2024 and June 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 PVSP adequate. quality at PVSP adequate. OIG case review clinicians (a team of physicians and nurse consultants) reviewed 46 cases, which contained 577 patient-related events. They performed quality control reviews; their subsequent collective deliberations ensured consistency, accuracy, and thoroughness. Our OIG clinicians acknowledged institutional structures that catch and resolve mistakes, which may occur throughout the delivery of care. After examining the medical records, our clinicians completed a follow-up on-site inspection in January 2025 to verify their initial findings. OIG physicians rated the quality of care for 20 comprehensive case reviews. Of these 20 cases, our physicians rated 19 adequate and one inadequate. To test the institution’s policy compliance, our compliance inspectors (a team of registered nurses) monitored the institution’s compliance with its medical policies by answering a standardized set of questions that measure specific elements of health care delivery. Our compliance inspectors examined 373 patient records and 1,069 data points, and used the data to answer 85 policy questions. In addition, we observed PVSP’s processes during an on-site inspection in August 2024. The OIG then considered the results from both case review and compliance testing, and drew overall conclusions, which we report in 12 health care indicators.5 5 The indicators for Specialized Medical Housing, Reception Center, and Prenatal and Postpartum Care did not apply to PVSP. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 4 We list the individual indicators and ratings applicable for this institution in Table 1 below. Table 1. PVSP Summary Table: Case Review Ratings and Policy Compliance Scores Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 5 Medical Inspection Results Deficiencies Identified During Case Review Deficiencies are medical errors that increase the risk of patient harm. Deficiencies can be minor or significant, depending on the severity of the deficiency. An adverse event occurs when the deficiency caused harm to the patient. All major health care organizations identify and track adverse events. We identify deficiencies and adverse events to highlight concerns regarding the provision of care and for the benefit of the institution’s quality-improvement program to provide an impetus for improvement.6 The OIG found no adverse events at PVSP during the Cycle 7 inspection. Case Review Results OIG case reviewers (a team of physicians and nurse consultants) assessed nine of the 12 indicators applicable to PVSP. Of these nine indicators, OIG clinicians rated one proficient and eight adequate. OIG physicians also rated the overall adequacy of care for each of the 20 detailed case reviews they conducted. Of these 20 cases, 19 were adequate and one was inadequate. In the 577 events reviewed, we identified 142 deficiencies, 26 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 PVSP: • Staff provided excellent access to nursing, provider, and initial specialty referral appointments. • Staff frequently completed diagnostic tests and STAT radiology studies timely. • Staff performed well in emergency response care and assessments. • Staff delivered very good care for patients transferring in or out of the institution. Our clinicians found the following weaknesses at PVSP: • Providers needed improvement in communicating diagnostic test results to patients with complete patient test-results letters and timely endorsement of specialty service reports. • Staff did not consistently retrieve emergency room or hospital documents timely. 6 For a further discussion of an adverse event, see Table A–1. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 6 • Providers did not consistently follow specialists’ recommendations and did not document the medical rationale for not doing so. Compliance Testing Results Our compliance inspectors assessed nine of the 12 indicators applicable to PVSP. Of these nine indicators, our compliance inspectors rated two proficient, four adequate, and three inadequate. We solely tested policy compliance in Health Care Environment, Preventive Services, and Administrative Operations because these indicators do not have a case review component. PVSP showed a high rate of policy compliance in the following areas: • Staff performed well in scanning requests for health care services and community hospital discharge reports into patients’ electronic medical records. • Staff ensured patients received diagnostic services within ordered time frames, and providers timely reviewed and endorsed results. • Staff performed very well in providing preventive services for their patients such as influenza vaccination and colorectal cancer screenings. In addition, staff frequently administered tuberculosis (TB) medications to patients as prescribed, offered immunizations to chronic-care patients, and performed TB screening. • Patients returning from outside community hospitals or specialty service appointments were evaluated by their primary care providers within specified time frames. Moreover, patients were often timely evaluated their providers upon arrival at the institution. PVSP revealed a low rate of policy compliance in the following areas: • PVSP’s medical warehouse and clinical areas had multiple expired medical supplies. • Nurses did not regularly inspect emergency medical response bags. • Health care staff did not consistently follow universal hand-hygiene precautions during patient encounters. • Staff frequently did not maintain medication continuity for chronic-care patients and patients discharged from the hospital. Institution-Specific Metrics Pleasant Valley State Prison (PVSP) is located in Coalinga, in Fresno County. The institution houses general-population, minimum- to maximum-custody patients. PVSP operates medical clinics where staff handle nonurgent requests for medical services. PVSP also conducts screenings in its receiving and release clinical area and treats patients needing urgent or emergency care in its triage and treatment area. The Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 7 institution primarily provides medical care for patients designated as low to medium medical risk; however, it does have a very small population of patients classified as high medical risk. California Correctional Health Care Services (CCHCS) has designated PVSP as a basic health care institution; an institution located in a rural area away from tertiary care centers and specialty-care providers whose services would likely be used frequently by higher-risk patients. PVSP’s geographical location is in the western San Joaquin Valley, and the institution is one of two California prisons designated as a restricted area for patients who are at high risk for contracting coccidioidomycosis (commonly known as Valley Fever).7 As of April 25, 2025, the department reports on its public tracker that 48 percent of PVSP’s incarcerated population is fully vaccinated for COVID-19 while 55 percent of PVSP’s staff is fully vaccinated for COVID-19.8 On August 2024, the Health Care Services Master Registry showed PVSP had a total population of 2,447. A breakdown of the medical risk level of PVSP’s population as determined by the department is set forth in Table 2 below.9 Table 2. PVSP Master Registry Data as of August 2024 Medical Risk Level Number of Patients Percentage* High 1 0 0 High 2 9 0.4% Medium 845 34.5% Low 1,593 65.1% Total 2,447 100% * Percentages may not total 100% due to rounding. Source: Data for the population medical risk level were obtained from the CCHCS Master Registry dated 8-19-24. 7 Coccidioidomycosis is also known as Valley Fever. It is a fungal infection that enters the body through inhalation of spores found in the soil in certain parts of the Southwestern United States. This infection can affect the lungs, skin, joints, bone, and brain. 8 For more information, see the department’s statistics on its website page titled Population COVID-19 Tracking. 9 For a definition of medical risk, see CCHCS HCDOM 1.2.14, Appendix 1.9. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 8 According to staffing data the OIG obtained from California Correctional Health Care Services (CCHCS), as identified in Table 3 below, PVSP had no vacant executive leadership positions, 0.5 primary care provider vacancies, 1.2 nursing supervisor vacancies, and 5.1 nursing staff vacancies. Table 3. PVSP Health Care Staffing Resources as of August 2024 Executive Primary Care Nursing Nursing Positions Leadership * Providers Supervisors Staff † Total Authorized Positions 5.0 6.5 10.7 86.8 109.0 Filled by Civil Service 5.0 6.0 9.5 81.6 102.1 Vacant 0 0.5 1.2 5.1 6.8 Percentage Filled by Civil Service 100% 92.3% 88.8% 94.0% 93.7% Filled by Telemedicine 0 0 0 0 0 Percentage Filled by Telemedicine 0 0 0 0 0 Filled by Registry 0 0 0 0 0 Percentage Filled by Registry 0 0 0 0 0 Total Filled Positions 5.0 6.0 9.5 81.6 102.1 Total Percentage Filled 100% 92.3% 88.8% 94.0% 93.7% Appointments in Last 12 Months 1.0 1.0 0.5 10.6 13.1 Redirected Staff 0 0 0 0 0 Staff on Extended Leave ‡ 0 0 1.0 9.0 10.0 Adjusted Total: Filled Positions 5.0 6.0 8.5 72.6 92.1 Adjusted Total: Percentage Filled 100% 92.3% 79.4% 83.6% 84.5% * 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 8-12-24, from California Correctional Health Care Services. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 9 Population-Based Metrics In addition to our own compliance testing and case reviews, as noted above, the OIG presents selected measures from the Healthcare Effectiveness Data and Information Set (HEDIS) for comparison purposes. The HEDIS is a set of standardized quantitative performance measures designed by the National Committee for Quality Assurance to ensure that the public has the data it needs to compare the performance of health care plans. Because the Veterans Administration no longer publishes its individual HEDIS scores, we removed them from our comparison for Cycle 7. Likewise, Kaiser (commercial plan) no longer publishes HEDIS scores. However, through the California Department of Health Care Services’ Medi‑Cal Managed Care Technical Report, the OIG obtained California Medi-Cal and Kaiser Medi-Cal HEDIS scores to use in conducting our analysis, and we present them here for comparison. HEDIS Results We considered PVSP’s performance with population-based metrics to assess the macroscopic view of the institution’s health care delivery. Currently, only two HEDIS measures are available for comparison: poor HbA1c control, which measures the percentage of diabetic patients who have poor blood sugar control, and the colorectal cancer screening rate 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)—PVSP’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. PVSP had a 36 percent influenza immunization rate for adults 18 to 64 years old.10 Cancer Screening When compared with statewide Medi-Cal programs—California Medi-Cal, Kaiser Northern California (Medi-Cal), and Kaiser Southern California (Medi-Cal)—PVSP’s colorectal cancer rate was 74 percent, indicating better performance on this measure. 10 The HEDIS sampling methodology requires a minimum sample of 10 patients to have a reportable result. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 10 Table 4. PVSP Results Compared With State HEDIS Scores PVSP California California Kaiser Kaiser Cycle 7 California NorCal SoCal HEDIS Measure Results * Medi-Cal † Medi-Cal † Medi-Cal † HbA1c Screening N/A – – – Poor HbA1c Control (> 9.0%) ‡,§ 7% 33% 31% 22% HbA1c Control (< 8.0%) ‡ 93% – – – Blood Pressure Control (< 140/90) ‡ 100% – – – Eye Examinations N/A – – – Influenza – Adults (18 – 64) 36% – – – Influenza – Adults (65 +) N/A – – – Pneumococcal – Adults (65 +) N/A – – – Colorectal Cancer Screening 74% 40% 71% 71% Notes and Sources * Unless otherwise stated, data were collected in August 2024 by reviewing medical records from a sample of PVSP’s population of applicable patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. † HEDIS Medi-Cal data were obtained from the California Department of Health Care Services publication Medi-Cal Managed Care External Quality Review Technical Report, dated July 1, 2023 – June 30, 2024 (published April 2025); https://www.dhcs.ca.gov/dataandstats/reports/Documents/CA2023-24-Medi-Cal- Managed-Care-Physical-Health-External-Quality-Review-Technical-Report-Vol1-F1.pdf. ‡ For this indicator, the entire applicable PVSP population was tested. § For this measure only, a lower score is better. Source: Institution information provided by the California Department of Corrections and Rehabilitation. Health care plan data were obtained from the CCHCS Master Registry. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 11 Recommendations As a result of our assessment of PVSP’s performance, we offer the following recommendations to the department: Access to Care • Nursing leadership should determine the root causes(s) of the untimely review of sick-call requests and should implement appropriate remedial measures. Diagnostic Services • Medical leadership should determine the root cause(s) of the challenges to providers timely creating patient test result letters with all elements required by CCHCS policy. Medical 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 appropriate remedial measures. • Health care leadership should determine the root cause(s) for staff not following equipment and medical-supply-management protocols and should implement appropriate remedial measures. • Nursing leadership should determine the root cause(s) for staff not ensuring EMRBs are regularly and properly inventoried, stocked, or sealed and should implement appropriate remedial measures. 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 analyze challenges in ensuring chronic care medications, newly prescribed medications, and hospital discharge medications are made available and administered without interruption and should implement appropriate remedial measures. Provider Performance • Medical leadership should determine the root cause(s) of providers not following specialists’ recommendations or not documenting the medical Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 12 reasoning for not following recommendations and should implement appropriate remedial measures. Specialty Services • Health care leadership should identify challenges in the untimely receipt and provider review of specialty reports and implement appropriate remedial measures. • Health care leadership should determine the root cause(s) of untimely specialty appointments, including preapproved specialty appointments for transfer-in patients, and implement appropriate remedial measures. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 13 Indicators Access to Care In this indicator, OIG inspectors evaluated the institution’s performance in providing patients with timely clinical appointments. Our inspectors reviewed scheduling and appointment timeliness for newly arrived patients, sick calls, and nurse follow-up appointments. We examined referrals to primary care providers, provider follow-ups, and specialists. Furthermore, we evaluated follow-up appointments for patients who received specialty care or returned from an off-site hospitalization. Ratings and Results Overview Case Review Rating Compliance Rating and Score Proficient Adequate (80.4%) As in Cycle 6, case review found PVSP provided excellent access to care in Cycle 7. Appointments with clinic providers and sick-call nurses occurred timely. PVSP generally offered good access to specialists and to PVSP providers after specialty encounters. Patients also received timely follow-up appointments after hospitalizations or emergency services. After reviewing all aspects of access to care, the OIG rated the case review component of this indicator proficient. Compliance testing showed PVSP performed satisfactorily overall in this indicator. Nurses always completed face-to-face encounters and follow-up sick-call appointments timely. PVSP performed very well in delivering provider follow-up appointments within required time frames for patients transferring into the institution, patients returning from hospitalization, and patients returning from specialty services. PVSP also performed well in delivering timely chronic-care follow-up appointments for patients. However, compliance testing resulted in low scores in the timeliness of nurses’ review of patient sick-call requests. Based on the overall Access to Care compliance score result, the OIG rated the compliance testing component of this indicator adequate. Case Review and Compliance Testing Results OIG clinicians reviewed 127 provider, nursing, urgent or emergent care (TTA), specialty, and hospital events requiring the institution to generate appointments. We identified three deficiencies relating to Access to Care, one of which was significant.11 Access to Care Providers PVSP provided excellent access to clinic providers. Compliance testing showed chronic- care follow-up appointments generally occurred within the specified time frame (MIT 1.001, 84.0%). Appointments resulting from referrals from nurses to providers also frequently occurred timely (MIT 1.005, 91.7%), while follow-up appointments with providers after sick-call encounters always occurred timely (MIT 1.006, 100%). Similarly, 11 Deficiencies occurred in cases 8, 18, and 22. A significant deficiency occurred in case 22. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 14 OIG clinicians found outstanding access to clinic providers. We reviewed 59 provider encounters and identified only one minor deficiency: • In case 8, clinic staff bundled three follow-up appointment orders and completed all three orders after a provider encounter. However, the provider entered two of the orders just the previous day, with future end dates of 14 days and 30 days respectively. By bundling the orders, staff removed future appointments from the queue, thereby affecting the patient’s intended future follow up. Access to Specialized Medical Housing Providers During the review period, the specialized medical housing unit was closed. Access to Clinic Nurses PVSP’s performance in providing access to sick-call nurses was mixed. While compliance testing revealed nurses needed improvement in reviewing sick-call requests timely (MIT 1.003, 60.0%), nurses always performed face-to-face assessments within one business day (MIT 1.004, 100%). OIG clinicians reviewed 36 nursing encounters and identified no deficiencies in access to care. Access to Specialty Services PVSP performed variably in providing access to specialty services. Compliance testing showed access to routine-priority appointments was excellent (MIT 14.007, 93.3%). Most medium-priority (MIT 14.004, 86.7%) and high-priority appointments (MIT 14.001, 80.0%) also occurred as ordered. High-priority follow-up appointments mostly occurred timely (MIT 14.003, 87.5%); medium-priority appointments only sometimes occurred timely (MIT 14.006, 57.1%); and routine-priority appointments generally occurred timely (MIT 14.009, 75.0%). OIG clinicians reviewed 19 specialty encounters and identified only one significant deficiency as follows: • In case 22, an orthopedic surgeon evaluated the patient after collarbone surgery. At that time, another orthopedic specialty referral for a new finger fracture was pending. However, staff “completed” all orthopedic orders in the EHRS. This action required the provider to submit a second request for services (RFS) with the orthopedic specialist for the finger fracture, thereby delaying the orthopedic consultation.12 Follow-Up After Specialty Services PVSP performed very well in scheduling provider appointments after specialty encounters. Compliance testing showed nearly all follow-up appointments occurred within the required time frame (MIT 1.008, 92.9%). OIG clinicians did not identify any deficiencies in this area. 12 A request for service (RFS) is a referral order for a specialty consultation. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 15 Follow-Up After Hospitalization PVSP provided very good access to care for recently hospitalized patients. Compliance testing showed providers frequently evaluated patients within the required time frame (MIT 1.007, 90.5%). OIG clinicians reviewed eight hospital returns and identified only one delayed provider appointment: • In case 18, a triage and treatment area (TTA) registered nurse contacted the on- call provider when the patient returned from the hospital in significant pain. The provider requested a follow-up with a provider the next day. However, this appointment did not occur until three days later. Follow-Up After Urgent or Emergent Care (TTA) Patients received timely follow-up with a provider after a triage-and-treatment-area encounter when medically indicated. OIG clinicians did not identify any deficiencies. Follow-Up After Transferring Into PVSP Patients who had recently transferred into PVSP received very good access to PVSP’s providers. Compliance testing showed providers evaluated most patients within the required time frame (MIT 1.002, 88.0%). OIG clinicians reviewed three cases involving newly arrived patients and did not identify any missed or delayed provider appointments. Clinician On-Site Inspection OIG clinicians met with PVSP health care access leadership, providers, nurses, and other staff. Staff reported PVSP had four main yards: A, B, C, and D. Each yard had its own medical clinic and one or two assigned providers. Most clinic providers worked four 10-hour days per week, with approximately 15 patients scheduled per day, and two to seven nursing co-consultations. PVSP also utilized one telemedicine provider. In addition, PVSP operated a TTA, an on-site procedure clinic, an evening clinic, and a restricted housing unit. Staff reported its specialized medical housing unit, the correctional treatment center, had been closed for many years and remained closed during our inspection. Leadership, providers, and nurses at PVSP expressed challenges in caring for gang- affiliated patients. Although medical staff were generally unaware of the specific affiliations, custody staff took precautions to separate certain patients to maintain safety for patients, staff, and the institution as a whole. PVSP also altered clinic operations in some yards. For example, in C Yard, Monday and Wednesday afternoons were reserved for patients from a specific gang. For medical care at other times, staff evaluated patients associated with that gang in the TTA instead of at the clinic. Compliance On-Site Inspection and Discussion Only one of six housing units randomly tested at the time of inspection had access to the proper health care services request forms (CDCR Form 7362) (MIT 1.101, 16.7%). In four housing units, custody officers did not have a system in place for restocking the forms. Custody officers reported reliance on medical staff to replenish the forms in the housing units. In one housing unit, custody officers reported providing a scanned version of the Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 16 form saved on the desktop computer and making more copies of the printed version. Staff provide a copy of the form rather than procuring forms from the medical warehouse or custody program offices. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley 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 22 3 0 88.0% patient seen by the clinician within the required time frame? (1.002) Clinical appointments: Did a registered nurse review the patient’s request 18 12 0 60.0% for service the same day it was received? (1.003) Clinical appointments: Did the registered nurse complete a face-to-face visit 18 0 12 100% 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 11 1 18 91.7% 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 5 0 25 100% specified? (1.006) Upon the patient’s discharge from the community hospital: Did the patient 19 2 0 90.5% receive a follow-up appointment within the required time frame? (1.007) Specialty service follow-up appointments: Did the clinician follow-up visits 39 3 3 92.9% occur within required time frames? (1.008) * Clinical appointments: Do patients have a standardized process to obtain 1 5 0 16.7% and submit health care services request forms? (1.101) Overall percentage (MIT 1): 80.4% * 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. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley 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 N/A N/A N/A N/A required time frame? (13.002) Did the patient receive the high-priority specialty service within 14 calendar days of the primary care provider order or the Physician Request for 12 3 0 80.0% Service? (14.001) Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care 7 1 7 87.5% 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 13 2 0 86.7% for Service? (14.004) Did the patient receive the subsequent follow-up to the medium-priority specialty service appointment as ordered by the primary care provider? 4 3 8 57.1% (14.006) Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician Request 14 1 0 93.3% 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 6 2 7 75.0% provider? (14.009) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 19 Recommendations • Nursing leadership should determine the root causes(s) of the untimely review of sick-call requests and should implement appropriate remedial measures. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley 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 (83.3%) Overall, case review found PVSP performed well in delivering diagnostic services. Staff frequently completed diagnostic tests and STAT radiology studies timely. In addition, providers often endorsed test results within specified time frames. However, similar to Cycle 6, providers often either did not send test result notification letters or sent incomplete test result notification letters to patients. After reviewing all aspects, the OIG rated the case review component of this indicator adequate. In Cycle 7, PVSP’s overall compliance testing score improved for this indicator. Staff performed very well to excellently in completing diagnostic services and retrieving results in a timely manner. Providers also nearly always reviewed and endorsed diagnostic test results within required time frames. However, providers performed variably in delivering complete test result notification letters to patients. Based on the overall Diagnostic Services compliance score result, the OIG rated the compliance component of this indicator adequate. Case Review and Compliance Testing Results OIG clinicians reviewed 114 diagnostic events and identified 57 deficiencies, one of which was significant. Of these 57 deficiencies, four related to test completion and 53 related to health information management.13 For health information management, we consider test reports that were never retrieved or reviewed to be as severe a problem as tests that were never performed. We discuss this further in the Health Information Management indicator. Test Completion PVSP performed very well in completing diagnostic tests. Compliance testing showed staff completed all radiology services (MIT 2.001, 100%) and nearly all laboratory services 13 Deficiencies occurred in cases 1, 2, 8, 9, 12-15, 17, and 19-23. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 21 (MIT 2.004, 90.0%) within requested time frames. OIG clinicians identified four minor deficiencies related to laboratory test completion.14 Compliance testing did not have any STAT laboratory tests in their samples (MIT 2.007, N/A). OIG clinicians reviewed five STAT radiology studies, all of which were completed timely.15 Health Information Management PVSP performed variably with managing diagnostic test results. Compliance testing showed providers almost always endorsed laboratory test results (MIT 2.005, 90.0%) and always endorsed radiology studies (MIT 2.002, 100%) timely. Staff always received pathology reports (MIT 2.010, 100%) within required time frames, and providers always endorsed them (MIT 2.011, 100%) timely. OIG clinicians reviewed 114 diagnostic events and identified six late provider endorsements, none of which were significant.16 However, we identified one significant deficiency involving late retrieval of a pathology report.17 We discuss this deficiency further in the Health Information Management indicator. Providers performed variably in communicating diagnostic test results to patients by completing complete notification letters. Compliance testing showed providers often timely sent laboratory result letters (MIT 2.006, 90.0%) and radiology result letters (MIT 2.003, 80.0%), but they never informed patients with complete notification letters for pathology results (MIT 2.012, zero) within the required time frames. OIG clinicians identified 41 minor deficiencies with missing or incomplete patient test result notification letters.18 The following are examples: • In case 2, a provider endorsed laboratory test results six days late and did not send the patient a test results letter. • In case 14, a provider endorsed receipt of a pathology report. However, the provider did not send the patient a test results letter. • In case 15, a provider endorsed a chest X-ray report but did not send the patient a results letter. • In case 19, a provider sent the patient a test results letter. However, the letter did not state whether the results were normal or abnormal. • In case 22, a provider sent the patient a test results letter. However, the letter did not include the date of the test or whether a follow-up appointment was needed. OIG clinicians also identified three misfiled documents.19 14 Deficiencies occurred in cases 1, 2, and 13. 15 STAT radiology studies occurred in cases 2, 8, 9, 18, and 22. 16 Late provider endorsements occurred in cases 2, 14, and 19. 17 A significant deficiency occurred in case 13. 18 Deficiencies occurred in cases 2, 8, 9, 12-15, 17, and 19-22. 19 Staff misfiled a heart rhythm strip in case 1 and misfiled two EKGs in case 21. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 22 Clinician On-Site Inspection OIG clinicians met with the diagnostic supervisor and staff members. Laboratory staff at PVSP consisted of a senior laboratory technician and two laboratory assistants. Staff reported PVSP did not perform STAT laboratory testing due to the time delay associated with PVSP’s rural location. STAT laboratory specimens were processed in the Los Angeles area, making STAT testing impractical. Therefore, staff reported sending patients who needed STAT laboratory testing to a local hospital. On the other hand, staff provided STAT radiology services for plain film studies. A regional senior radiology technician who worked at PVSP reported a single radiology technician managed on-site radiology service orders. He mentioned PVSP staff communicated well and worked together to deliver proper care to patients. PVSP also offered ultrasound, CT, and MRI imaging services once per month.20 20 A CT is a computed, or computerized, tomography scan while an MRI is a magnetic resonance imaging scan. Both create detailed images of organs and tissues to detect diseases and abnormalities. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 23 Compliance Score Results Table 7. Diagnostic Services Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Was the radiology service provided within the time frame 10 0 0 100% specified in the health care provider’s order? (2.001) Radiology: Did the ordering health care provider review and endorse the 10 0 0 100% radiology report within specified time frames? (2.002) Radiology: Did the ordering health care provider communicate the results 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 9 1 0 90.0% specified in the health care provider’s order? (2.004) Laboratory: Did the health care provider review and endorse the laboratory 9 1 0 90.0% report within specified time frames? (2.005) Laboratory: Did the health care provider communicate the results of the 9 1 0 90.0% 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 10 0 0 100% required time frames? (2.010) Pathology: Did the health care provider review and endorse the pathology 10 0 0 100% report within specified time frames? (2.011) Pathology: Did the health care provider communicate the results of the 0 10 0 0 pathology study to the patient within specified time frames? (2.012) Overall percentage (MIT 2): 83.3% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 24 Recommendations • Medical leadership should determine the root cause(s) of the challenges to providers timely creating patient test result letters with all elements required by CCHCS policy. Medical leadership should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 25 Emergency Services In this indicator, OIG clinicians evaluated the quality of emergency medical care. Our clinicians reviewed emergency medical services by examining the timeliness and appropriateness of clinical decisions made during medical emergencies. Our evaluation included examining the emergency medical response, cardiopulmonary resuscitation (CPR) quality, triage and treatment area (TTA) care, provider performance, and nursing performance. Our clinicians also evaluated the Emergency Medical Response Review Committee’s (EMRRC) performance in identifying problems with its emergency services. The OIG assessed the institution’s emergency services mainly through case review. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Not Applicable As in Cycle 6, PVSP performed well in providing emergency services. TTA nurses and first medical responders frequently completed thorough assessments and documentation, and they provided appropriate interventions. TTA providers were available for consultation with nurses when necessary and collaborated with nurses in making sound treatment decisions. The OIG rated the case review component of this indicator adequate. Case Review Results We reviewed 15 urgent and emergent events and found 11 emergency services deficiencies. Of these 11 deficiencies, five were significant.21 Emergency Medical Response Overall, PVSP showed good performance for emergency medical response. First medical responders arrived promptly and communicated with TTA staff as required. First medical responders also frequently completed thorough documentation. For patients who required CPR, custody staff initiated CPR immediately. Staff administered Narcan rapidly for patients who were suspected of an opioid drug overdose.22 We reviewed eight events requiring first medical responders. PVSP staff often activated emergency medical services (EMS) timely. The following cases involved delays in initiating 9-1-1: 21 Deficiencies occurred in cases 1, 3, 6, 9, 17, and 21. Significant deficiencies occurred in cases 6, 9, and 17. Of the 11 deficiencies, three related to nursing performance, four related to patient-care environment, two related to provider performance, and two related to health information management. 22 Narcan is a medication used for the emergency treatment of known or suspected opioid overdose. According to the manufacturer, nasal naloxone doses can be safely administered every two to three minutes. CCHCS emergency medical training allows nurses to administer five nasal naloxone doses when an opioid overdose is suspected. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 26 • In case 6, on June 15, 2024, staff initiated a medical emergency alarm at 2:20 p.m. for an unconscious patient, who required CPR. Staff did not initiate 9-1-1 until 2:14 p.m., four minutes later. • In case 17, on March 19, 2024, at 4:47 a.m., custody staff activated a medical emergency for an unresponsive patient, who was suspected of a drug overdose. PVSP staff initiated 9-1-1 at 4:54 a.m., seven minutes later. During our on-site inspection, nursing administration agreed with the above deficiencies and provided staff training. Provider Performance Providers performed very well in urgent and emergent situations and after-hours care. They generally made appropriate decisions and completed documentation, including phone-call encounters. However, OIG clinicians identified two minor deficiencies related to providers’ delivery of emergency care.23 Nursing Performance TTA nurses performed well during urgent and emergent events. They generally completed thorough assessments, provided appropriate interventions, and communicated with the provider as required. TTA nurses initiated nursing protocols and provided medical care. They initiated peripheral IV insertions, administered oxygen and Narcan, and reassessed their patients frequently.24 Case 5 is an example in which nursing and custody staff provided particularly good emergency care to an unresponsive patient with facial trauma. Nursing Documentation TTA nurses generally performed good documentation. Timelines were mostly thorough and accurate. The few documentation deficiencies we identified did not affect overall patient care. We did not identify any patterns of deficiencies. Emergency Medical Response Review Committee Review of the emergency medical response review committee (EMRRC) yielded conflicting results. Our clinicians reviewed 12 emergency medical response and unscheduled transport event checklists and found EMRRC met monthly and reviewed emergency response care within required time frames. The nursing and medical leadership and or designees performed the clinical reviews, frequently identified training issues, and provided staff training. Compliance findings indicated the opposite results. Emergency medical response and unscheduled transport event checklists were frequently incomplete, and the institution did not review cases within the required time frame (MIT 15.003, 33.3%). 23 Deficiencies occurred in cases 1 and 21. 24 A peripheral intravenous (IV) is a thin flexible tube inserted into a vein to deliver fluids, medication, or other treatments directly into the bloodstream. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 27 Clinician On-Site Inspection During our on-site inspection, OIG clinicians inspected the TTA and interviewed TTA nursing staff and the supervising registered nurse. The TTA had three beds and was staffed with two registered nurses on each shift except for the night shift. An additional registered nurse was assigned to the night shift due to the closure of the correctional treatment center. The TTA had an assigned provider and a list of on-call providers for after hours and weekends. The TTA has three emergency vehicles to respond to medical emergencies throughout the institution. One of the vehicles is used regularly, and two are on standby. Nurses reported all three vehicles were in working order. In addition, TTA staff informed us the medical warehouse repairs equipment quickly when needed, the pharmacy provides needed medications timely, and staff have no issues obtaining supplies to provide nursing care. Nursing staff shared that, during business hours, clinic RNs, LVNs, and medical assistants (MAs) respond to medical emergencies in their assigned yards. MAs are utilized as scribes, and TTA nursing staff respond to medical emergencies when yard staff requests. After hours, the TTA nurse responds to medical emergencies throughout the institution. Furthermore, nurses informed us they have monthly emergency drills, which include tabletop scenarios. TTA nurses were knowledgeable about the process for patients returning from outside medical appointments. They communicate information to specialty nurses via the electronic health records system (EHRS) and call the provider for urgent recommendations.25 Both TTA nurses and the supervising registered nurse reported they have a good relationship with custody staff and the institution’s administration. They also reported the nursing morale at PVSP is inconsistent. 25 EHRS is the electronic health records system. The department’s electronic health record system is used for storing the patient’s medical history and health care staff communication. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 28 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 29 Health Information Management In this indicator, OIG inspectors evaluated the flow of health information, a crucial link in high-quality medical care delivery. Our inspectors examined whether the institution retrieved and scanned critical health information (progress notes, diagnostic reports, specialist reports, and hospital-discharge reports) into the medical record in a timely manner. Our inspectors also tested whether clinicians adequately reviewed and endorsed those reports. In addition, our inspectors checked whether staff labeled and organized documents in the medical record correctly. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Proficient (86.7%) Case review found PVSP performed adequately in this indicator. Staff documented emergency events well. They retrieved and scanned diagnostic and specialty reports timely on most occasions. However, we found examples of missing emergency- department records and either late or delayed receipt of specialty and test reports. Providers often created patient test result notification letters with missing information or did not create a letter at all. However, these factors did not significantly impact patient care. After considering all factors, the OIG rated the case review component of this indicator adequate. Compliance testing showed PVSP performed well in health information management. Staff performed excellently in timely retrieving and scanning hospital records, and in timely scanning patient health care service request forms. Staff also generally scanned specialty documents timely. In addition, they usually properly scanned, correctly labeled, and included medical records into the correct patient 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 OIG clinicians reviewed 577 events and identified 63 deficiencies related to health information management. Of these 63 deficiencies, five were significant.26 Hospital Discharge Reports PVSP’s management of hospital records was mixed. Compliance showed PVSP staff almost always scanned hospital records within the required time frame (MIT 4.003, 95.0%). Likewise, the hospital discharge reports contained the required key elements, and the providers almost always endorsed hospital records within the required time frame (MIT 4.005, 95.2%). However, OIG clinicians reviewed eight hospital and emergency- 26 Deficiencies occurred in cases 1, 2, 8, 9, 12-17, and 19-23. Significant deficiencies occurred in cases 9, 13, and 22. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 30 department events and identified four retrieval deficiencies, three of which were significant.27 The following are examples: • In case 9, the patient was evaluated in the emergency department twice. However, PVSP staff did not retrieve the emergency department report and scan it into the EHRS either time. • In case 22, the patient was evaluated in the emergency department for right- shoulder pain. However, PVSP staff did not retrieve the emergency department report and scan it into the EHRS. Specialty Reports PVSP did not perform well in managing specialty reports. Compliance testing revealed the timeliness of scanning specialty reports needed improvement (MIT 4.002, 73.3%). Staff also needed improvement in timely receiving and endorsing high-priority (MIT 14.002, 69.2%), medium-priority (MIT 14.005, 60.0%), and routine-priority (MIT 14.008, 64.3%) specialty reports. OIG clinicians reviewed 30 specialty reports and identified four deficiencies, one of which was significant:28 • In case 22, the patient had right-clavicle (collarbone) surgery. However, PVSP staff did not retrieve and scan the dictated surgical report into the EHRS. Diagnostic Reports PVSP staff frequently managed diagnostic reports timely. Compliance testing showed providers often endorsed laboratory results (MIT 2.005, 90.0%) and always endorsed radiology results (MIT 2.002, 100%) timely. Staff also always retrieved pathology results (MIT 2.010, 100%), and providers always endorsed them (MIT 2.011, 100%), within required time frames. Although OIG clinicians found PVSP staff usually handled diagnostic reports well, we identified one significant deficiency involving the late retrieval of a serious pathology result: • In case 13, a provider removed a skin lesion from the patient’s chest. Staff sent the specimen for further analysis. The pathology result was returned with the diagnosis of melanoma, a dangerous form of skin cancer. However, PVSP staff did not retrieve this report until more than a month later, at the request of a provider. Compliance testing showed providers usually sent patient notification letters for laboratory results (MIT 2.006, 90.0%) and radiology results (MIT 2.003, 80.0%) within the recommended time frames yet struggled to do the same for pathology results (MIT 2.012, zero). OIG clinicians identified 41 deficiencies involving incomplete or missing patient test result notification letters.29 Please refer to the Diagnostics Services indicator for more information. 27 Deficiencies occurred in cases 9, 16, and 22. Significant deficiencies occurred in cases 9 and 22. 28 Deficiencies occurred in cases 9 and 22. A significant deficiency occurred in case 22. 29 Deficiencies occurred in cases 2, 8, 9, 12-15, 17, and 19-22. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 31 Urgent and Emergent Records OIG clinicians reviewed 15 emergency care events and found PVSP nurses recorded these events well. Providers also documented their emergency care sufficiently, including on- call telephone encounters. We found no significant deficiencies. The Emergency Services indicator provides additional details. Scanning Performance Staff performed sufficiently in properly scanning and labeling medical reports as well as including them in the correct patients’ files (MIT 4.004, 75.0%). OIG clinicians identified eight minor deficiencies related to scanning.30 Clinician On-Site Inspection OIG clinicians discussed health information management (HIM) processes with the health record technician supervisor (HRT II) and staff. The HRT II reported the HIM staff and triage and treatment area (TTA) nurses maintained a shared log for tracking patients returning from off-site specialty appointments or hospital encounters. When a patient returned to PVSP, TTA nurses obtained any documents sent with the patient and called the off-site facility for any missing documents. HIM staff also kept a separate log with patient names and information, and staff reviewed it daily. HIM staff retrieved any pending reports, including pathology reports and final hospital summaries. The HRT II discussed implementing a more thorough tracking system and performing random audits to ensure retrieval of all documents. 30 Deficiencies occurred in cases 1, 9, and 21-23. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 32 Compliance Score Results Table 8. Health Information Management Scored Answer Compliance Questions Yes No N/A Yes % Are health care service request forms scanned into the patient’s electronic 19 1 10 95.0% health record within three calendar days of the encounter date? (4.001) Are specialty documents scanned into the patient’s electronic health record 22 8 15 73.3% within five calendar days of the encounter date? (4.002) Are community hospital discharge documents scanned into the patient’s electronic health record within three calendar days of hospital discharge? 19 1 1 95.0% (4.003) During the inspection, were medical records properly scanned, labeled, 18 6 0 75.0% 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 20 1 0 95.2% review the report within five calendar days of discharge? (4.005) Overall percentage (MIT 4): 86.7% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 33 Table 9. Other Tests Related to Health Information Management Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Did the ordering health care provider review and endorse the 10 0 0 100% radiology report within specified time frames? (2.002) Laboratory: Did the health care provider review and endorse the laboratory 9 1 0 90.0% report within specified time frames? (2.005) Laboratory: Did the provider acknowledge the STAT results, OR did nursing N/A N/A N/A N/A staff notify the provider within the required time frame? (2.008) Pathology: Did the institution receive the final pathology report within the 10 0 0 100% required time frames? (2.010) Pathology: Did the health care provider review and endorse the pathology 10 0 0 100% report within specified time frames? (2.011) Pathology: Did the health care provider communicate the results of the 0 10 0 0 pathology study to the patient within specified time frames? (2.012) Did the institution receive and did the primary care provider review the high-priority specialty service consultant report within the required time 9 4 2 69.2% 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 5 1 64.3% frame? (14.008) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 34 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley 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 (41.4%) Overall, PVSP performed poorly with respect to its health care environment. Medical supply storage areas contained expired, unidentified, or inaccurately labeled medical supplies as well as unorganized medical supplies. In addition, several clinics did not meet the requirements for essential core medical equipment and supplies. Staff did not regularly sanitize or wash their hands during patient encounters. Lastly, emergency medical response bag (EMRB) logs contained compromised medical supply packaging, were missing staff verification, or inventory was not performed when seal tags were replaced. Based on the overall Health Care Environment compliance score result, the OIG rated this indicator inadequate. Compliance Testing Results Patient Waiting Areas We inspected only indoor waiting areas because PVSP had no outdoor waiting areas. Health care and custody staff reported the existing waiting areas contained sufficient seating capacity. Patients waited either in the clinic waiting area or in individual modules (see Photo 1, right, and Photo 2, next page). During our inspection, we did not observe overcrowding in any of the clinics’ indoor waiting areas. Photo 1. Indoor patient waiting area (photographed on 8-28- 24). Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 36 Photo 2. Individual waiting modules (photographed on 8-27-24). Clinic Environment All clinic environments were sufficiently conducive for medical care. They provided reasonable auditory privacy, appropriate waiting areas, wheelchair accessibility, and nonexamination room workspace (MIT 5.109, 100%). Of the nine applicable clinics we inspected, six contained appropriate space, configuration, supplies, and equipment to allow clinicians to perform proper clinical examinations (MIT 5.110, 66.7%). In two clinics, examination rooms had unsecured confidential medical records. In one clinic, the examination room had a torn examination chair vinyl cover. Clinic Supplies None of the nine clinics followed adequate medical supply storage and management protocols (MIT 5.107, zero). We found one or more of the following deficiencies in all clinics: expired or compromised medical supplies (see Photo 3, right, and Photo 4, next page); unorganized, unidentified, or inaccurately labeled medical supplies; and medical supplies stored with staff’s personal items or disinfectants. Photo 3. Expired medical supply dated March 2015 (photographed on 8-27-24). Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 37 Photo 4. Expired medical supply dated February 2024 (photographed on 8-28-24). Only one of the nine clinics met the requirements for essential core medical equipment and supplies (MIT 5.108, 11.1%). We found one or more of the following deficiencies in eight clinics: examination rooms were missing a nebulization unit, lubricating jelly, an oto-ophthalmoscope, tongue depressors, or a medication refrigerator. We also found several nonfunctional oto-ophthalmoscopes and an incomplete glucometer quality- control log. In addition, Snellen eye charts either did not have a corresponding distance line on the floor or wall, were not placed an accurate distance away from the line or were not mounted on the wall (see Photo 5, below). Lastly, staff also had not properly calibrated several nebulization units or an automated external defibrillator (AED) and had not completed an AED or defibrillator performance test within the last 30 days. Photo 5. Snellen chart was not mounted on the wall at the time of inspection (photographed on 8-27-24). Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 38 We examined emergency medical response bags (EMRBs) to determine whether they contained all essential items. We checked whether staff inspected the bags daily and inventoried them monthly. None of the seven EMRBs passed our test (MIT 5.111, zero). We found one or more of the following deficiencies with all seven EMRBs: staff did not ensure the EMRBs’ compartments were sealed and intact; staff’s EMRB log documentation was inaccurate; staff had not inventoried the EMRBs when the seal tags were replaced; staff did not log EMRBs’ daily glucometer quality- control results; and staff inaccurately logged the EMRB glucometer Photo 7. Compromised EMRB medical control-solution range supply (photographed on 8-28-24). when performing daily glucometer quality control. Moreover, EMRBs contained compromised Photo 6. Compromised EMRB medical supply medical supply packaging (see Photos 6, left and 7, right). (photographed on 8-28-24). Medical Supply Management None of the medical supply storage areas located outside the medical clinics sufficiently stored medical supplies (MIT 5.106, zero). We found expired medical supplies (see Photo 8, right). According to the chief executive officer (CEO), health care leadership did not have any issues with the medical supply process. Health care and warehouse managers expressed no concerns about the medical supply chain or Photo 8. Expired medical supply dated March 2024 their communication process with (photographed on 8-28-24). the existing system in place. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 39 Infection Control and Sanitation Staff appropriately cleaned, sanitized, and disinfected five of nine clinics (MIT 5.101, 55.6%). In four clinics, we found one or more of the following deficiencies: cleaning logs were not maintained; the examination room sink, clinic floor, cabinet under the sink, drawers, or supply cabinet were unsanitary; and a clinic floor and ceiling were damaged and could not be thoroughly sanitized (see Photo 9, left, and Photo 10, below). Photo 9. Damaged clinic floor that cannot be thoroughly sanitized (photographed on 8-27-24). Staff in four of nine clinics (MIT 5.102, 44.4%) properly sterilized or disinfected medical equipment. In three clinics, staff did not mention disinfecting the examination table Photo 10. Damaged ceiling that cannot be thoroughly sanitized (photographed on 8-27-24). as part of their daily start-up protocol. In one clinic, staff did not remove and replace examination table paper between patient encounters. We found operating sinks and hand-hygiene supplies in examination rooms in five of nine clinics (MIT 5.103, 55.6%). In four clinics, patient restrooms lacked antiseptic soap and disposable hand towels. In one of the four clinics, the staff restroom lacked antiseptic soap. We observed patient encounters in six clinics. In four clinics, clinicians did not wash their hands before examining their patients (MIT 5.104, 33.3%). Health care staff in eight of nine clinics followed proper protocols to mitigate exposure to bloodborne pathogens and contaminated waste (MIT 5.105, 88.9%). In one clinic, nursing staff did not describe the appropriate process of disinfecting medical equipment after coming into contact with biohazardous waste. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 40 Physical Infrastructure We gathered information to determine whether the institution’s physical infrastructure was maintained in a manner that supported health care management’s ability to provide timely and adequate health care. Health care managers did not have concerns about the facility’s infrastructure or its effect on staff’s ability to provide adequate health care. At the time of the inspection, the institution had one infrastructure project completed for which it received temporary utilization approval, two completed projects pending utilization approval, and one project underway, all of which management staff felt would improve the delivery of care at PVSP: • Project SP 3.3: TTA renovation began in May 2022. PVSP management reported the State Fire Marshall granted temporary utilization. • Project SP 3.2: Physical therapy treatment room renovation began in November 2022. Although renovation was completed, PVSP management reported utilization was still pending the State Fire Marshall’s clearance. • Project SP 3.4: Medical staff area renovation began in November 2022. Although renovation was completed, PVSP management reported the utilization was still pending the State Fire Marshall’s clearance. • Project SP 3.2.3: Specialty examination room renovation began in November 2019 and was scheduled to be completed by December 2024. PVSP reported utilization will require the State Fire Marshall’s clearance upon completion. The CEO did not believe pending clearances from the State Fire Marshall hindered the institution’s ability to provide good patient care (MIT 5.999). Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 41 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, 5 4 0 55.6% 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 4 5 0 44.4% warranted? (5.102) Infection control: Do clinical health care areas contain operable sinks and 5 4 0 55.6% sufficient quantities of hygiene supplies? (5.103) Infection control: Does clinical health care staff adhere to universal hand 2 4 3 33.3% hygiene precautions? (5.104) Infection control: Do clinical health care areas control exposure to blood- 8 1 0 88.9% 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 0 9 0 0 storing bulk medical supplies? (5.107) Clinical areas: Do clinic common areas and exam rooms have essential core 1 8 0 11.1% medical equipment and supplies? (5.108) Clinical areas: Are the environments in the common clinic areas conducive 9 0 0 100% to providing medical services? (5.109) Clinical areas: Are the environments in the clinic exam rooms conducive to 6 3 0 66.7% 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 0 7 2 0 contain essential items? (5.111) Does the institution’s health care management believe that all clinical areas This is a nonscored test. Please see the have physical plant infrastructures that are sufficient to provide adequate indicator for discussion of this test. health care services? (5.999) Overall percentage (MIT 5): 41.4% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 42 Recommendations • Health care leadership should determine the root cause(s) for staff not following all required universal hand-hygiene precautions and should implement appropriate remedial measures. • Health care leadership should determine the root cause(s) for staff not following equipment and medical-supply-management protocols and should implement appropriate remedial measures. • Nursing leadership should determine the root cause(s) for staff not ensuring EMRBs are regularly and properly inventoried, stocked, or sealed and should implement appropriate remedial measures. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 43 Transfers In this indicator, OIG inspectors examined the transfer process for those patients who transferred into the institution as well as for those who transferred to other institutions. For newly arrived patients, our inspectors assessed the quality of health care screenings and the continuity of provider appointments, specialist referrals, diagnostic tests, and medications. For patients who transferred out of the institution, inspectors checked whether staff reviewed patient medical records and determined the patient’s need for medical holds. They also assessed whether staff transferred patients with their medical equipment and gave correct medications before patients left. In addition, our inspectors evaluated staff performance in communicating vital health transfer information such as preexisting health conditions, pending appointments, tests, and specialty referrals. Inspectors further confirmed whether staff sent complete medication transfer packages to receiving institutions. For patients who returned from off-site hospitals or emergency rooms, inspectors reviewed whether staff appropriately implemented recommended treatment plans, administered necessary medications, and scheduled appropriate follow- up appointments. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Adequate (83.0%) PVSP performed very well for this indicator. Receiving and release (R&R) nurses thoroughly completed initial health screenings, ensured medication continuity, and scheduled nurse and provider follow-up appointments as required. During the transfer- out process, nurses frequently ensured all requirements were met. PVSP also had very good performance for hospital returns. Nurses completed good assessments, and the institution provided continuity of hospital-recommended medications. Considering all factors, the OIG rated the case review component of this indicator adequate. Compared with Cycle 6, PVSP’s overall compliance performance greatly improved for this indicator. The institution performed excellently in completing the assessment and disposition section of the screening process and ensuring medication continuity for newly transferred patients. In contrast, nursing staff performed poorly in thoroughly completing initial health screening forms. Based on the overall Transfers compliance score result, the OIG rated the compliance component of this indicator adequate. Case Review and Compliance Testing Results OIG clinicians reviewed 18 events in 13 cases in which patients transferred into or out of the institution or returned from an off-site hospital or emergency room. We identified four deficiencies, two of which were significant.31 31 Deficiencies occurred in cases 16, 18, 22, and 26. Significant deficiencies occurred in cases 22 and 26. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 44 Transfers In PVSP performed excellently for case review. OIG clinicians reviewed four events in which patients transferred into the facility from other institutions and did not identify any deficiencies. R&R nurses completed thorough initial health screenings, scheduled required nurse and provider follow-up appointments, and educated patients as required. Similarly, compliance testing showed R&R nurses always completed the assessment and disposition section of the initial health screening form (MIT 6.002, 100%). However, compliance testing also showed R&R nurses only occasionally completed initial health screenings thoroughly (MIT 6.001, 32.0%). The low score mostly resulted from nurses’ failures to document an explanation when patients answered “yes” to the question asking whether they are under a doctor’s care and being seen and scheduled for medical reasons, or whether they have pending medical appointments. Case review and compliance analyses also reached similar results for medication continuity. R&R nurses always ensured patients received their ordered medications upon arriving at PVSP (MIT 6.003, 100%). PVSP further performed excellently in administering medications timely for patients who transferred from yard to yard within the facility as well as patients who were housed at PVSP en route to another facility (MIT 7.005, 100% and MIT 7.006, 100%). Compliance testing showed, when patients arrived at PVSP, providers usually evaluated them within the required time frame (MIT 1.002, 88.0%). However, specialty-services appointments for patients who arrived at PVSP only intermittently occurred within the required time frame (MIT 14.010, 57.9%). We analyzed compliance testing results and identified two primary reasons appointments did not occur: patients did not timely refuse specialty services, and staff did not schedule appointments timely. Transfers Out R&R nurses frequently ensured all transfer requirements were met. Our clinicians reviewed six transfer-out events in four cases and found one significant deficiency as follows: • In case 26, the patient transferred out of PVSP to another institution. Although the R&R nurse documented, “Transfer packet given to custody,” the electronic health records system contained no evidence the staff met all transfer requirements. We found no documentation for the following transfer requirements: medical and mental health clearance, the patient summary, and whether the patient was on a medical hold or a hold was even needed. Hospitalizations Patients returning from an off-site hospitalization or emergency room are at high risk for lapses in care quality. These patients typically experienced severe illness or injury. They require more care and place a strain on the institution’s resources. Moreover, because these patients have complex medical issues, the successful transfer of health information is necessary for high-quality care. Any transfer lapse can result in serious consequences for these patients. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 45 Our clinicians reviewed five events in four cases in which patients returned from off-site hospitalizations or emergency room encounters. We identified three deficiencies, one of which was significant and is further discussed in the Health Information Management indicator.32 None of the deficiencies related to nursing performance. Case review found PVSP nurses performed excellently with patient hospital returns. We did not identify any deficiencies in nursing performance. When patients returned from the hospital, nurses assessed patients, reviewed hospital documents, scheduled provider follow-up appointments, and communicated with the provider as required. Patients frequently received provider follow-up appointments within the required time frames (MIT 1.007, 90.5%). Furthermore, providers often reviewed hospital discharge documents within the required time frames (MIT 4.005, 95.2%). Case review identified two deficiencies related to obtaining hospital documents. PVSP staff almost always scanned hospital or emergency room summary reports into the EHRS and made them available timely (MIT 4.003, 95.0%). Please refer to the Health Information Management indicator for further details. Hospital medication continuity results differed between case review and compliance testing. Case review did not identify any deficiencies in the timeliness of patients’ receipts of hospital discharge medications. Compliance testing, however, revealed poor performance in this test (MIT 7.003, 41.2%). Please refer to the Medication Management indicator for further details. Clinician On-Site Inspection While on site, we interviewed R&R staff. R&R staffing consists of one registered nurse on each shift. The R&R nurse was knowledgeable about transfer processes and reported R&R staff have no issues obtaining access to the pharmacy, supplies, or equipment needed to perform their functions. The nurse informed us, when the Enhanced Outpatient Program (EOP) building opened, the R&R received 40 to 50 patients daily.33 At that time of the onsite inspection, the number of patients arriving daily at PVSP varied from one to 33 patients, and the number of patients transferring out of PVSP daily varied from one to 13 patients. The nursing staff found custody staff helpful and the administration supportive. According to nursing staff, nursing morale at the institution was inconsistent. Compliance On-Site Inspection and Discussion R&R nursing staff ensured both patients we tested, who were transferring out of the institution, had required medications, transfer documents, and assigned durable medical equipment (DME) (MIT 6.101, 100%). 32 Hospitalization deficiencies occurred in cases 16, 18, and 22. A significant deficiency occurred in case 22. 33 The Enhanced Outpatient Program (EOP) provides care to patients with mental health disorders who would benefit from the structure of a therapeutic environment that is less restrictive than inpatient settings. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 46 Compliance Score Results Table 11. Transfers Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution: Did nursing staff complete the initial health screening and answer all screening 8 17 0 32.0% 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 10 0 15 100% 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 2 0 0 100% required documents? (6.101) Overall percentage (MIT 6): 83.0% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 47 Table 12. Other Tests Related to Transfers Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution: Based on the patient’s clinical risk level during the initial health screening, was the 22 3 0 88.0% 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 19 2 0 90.5% required time frame? (1.007) Are community hospital discharge documents scanned into the patient’s electronic health record within three calendar days of hospital discharge? 19 1 1 95.0% (4.003) For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements and did a provider 20 1 0 95.2% 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 7 10 4 41.2% within required time frames? (7.003) Upon the patient’s transfer from one housing unit to another: Were 25 0 0 100% medications continued without interruption? (7.005) For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications 3 0 0 100% 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 11 8 0 57.9% institution, was the appointment scheduled at the receiving institution within the required time frames? (14.010) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 48 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. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 49 Medication Management In this indicator, OIG inspectors evaluated the institution’s performance in administering prescription medications on time and without interruption. 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 tested many other processes, including medication handling, storage, error reporting, and other pharmacy processes. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Inadequate (74.6%) For this cycle, case review results showed PVSP had very good performance for medication management. As in Cycle 6, we found very few medication deficiencies. Considering all factors, the OIG rated the case review component of this indicator adequate. In compliance testing, PVSP had a mixed performance for this indicator. The institution’s staff performed exceptionally well in medication continuity for patients transferring within the institution and for patients temporarily housed at PVSP. The pharmacy also performed excellently in employing general security and storing medications in its main pharmacy. Conversely, the institution needed significant improvement in timely providing chronic care medications, newly prescribed medication orders, and hospital discharge medications. 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 121 events in 23 cases related to medications and found five medication deficiencies, two of which were significant.34 New Medication Prescription Case review results showed PVSP performed very well with new medication prescriptions. Patients frequently received their newly ordered medications timely. Of the five deficiencies we identified, the following two were significant: • In case 15, on June 5, 2024, the provider ordered a new keep-on-person (KOP) antibiotic to be administered for five days.35 The first dose was due on 34 Deficiencies occurred in cases 7-10 and 15. Significant deficiencies occurred in cases 9 and 15. 35 “Keep on person” refers to medications that a patient can keep and self-administer according to the directions provided. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 50 June 6, 2024. The patient received his newly ordered antibiotic one day late, on June 7, 2024. • In case 9, between April 17, 2024, and April 25, 2024, the diabetic patient did not receive antiseptic solution and Epsom salt to soak his feet for wound care after a surgery for an ingrown toenail. Compliance testing, on the other hand, found patients only intermittently received their newly ordered medications timely (MIT 7.002, 68.0%.) Many new medications were either unavailable or were not administered timely. Chronic Medication Continuity Case review and compliance results differed. Case review did not identify any significant deficiencies. However, compliance testing revealed the majority of patients did not receive their chronic-care medications within required time frames (MIT 7.001, 47.4%). Hospital-Discharge Medications Compliance testing indicated PVSP only occasionally ensured patients received their medications once they returned from an off-site hospitalization or emergency room encounter (MIT 7.003, 41.2%). The pharmacy did not make medications available, and staff did not administer medications as ordered. Examples include antibiotics and stomach medications. In contrast, clinicians found PVSP performed excellently in ensuring patients received medications timely upon return from the hospital to the institution. Specialized Medical Housing Medications The specialized medical housing unit was closed during our review period. Transfer Medications Both case review and compliance testing showed PVSP performed excellently in providing transfer medications. Case review did not identify any medication deficiencies for patients transferring into or out of the institution. Compliance testing yielded similar excellent results. Patients arriving at PVSP always received their medications without interruption (MIT 6.003, 100%). For those patients who transferred out of PVSP, nursing staff always ensured the transfer packets included required medications and documents (MIT 6.101, 100%). PVSP nursing staff always provided medications without delay to patients who transferred from yard to yard within the facility and to those patients who were en route to other institutions (MIT 7.005, 100% and MIT 7.006, 100%). Medication Administration Nurses frequently administered tuberculosis (TB) medications as ordered (MIT 9.001, 92.0%). However, they only intermittently monitored patients on TB medications (MIT 9.002, 64.0%). Nurses did not always perform weekly or monthly monitoring of patients or address patients’ symptoms. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 51 Clinician On-Site Inspection We interviewed the pharmacist and medication nurses during our on-site inspection. Nurses were knowledgeable about their processes for KOP medications, for patients transferring to another institution, and for patients transferring within the institution. We inspected Clinics A and C. Staffing in these clinics consists of one medication nurse on the morning shift and one on the evening shift. The medication nurse attended and participated in morning huddles in both clinics. Team members discussed topics such as medication refusals, expiring medications, and medication noncompliance. During clinic hours, medication nurses also serve as first medical responders for their assigned yards. Emergency medical response bags and radios are available to them. Nurses reported nursing morale varies. They also stated they promptly receive medication supplies from the pharmacy. Nurses reported good working relationships with custody staff and stated administrative staff are supportive. Medication Practices and Storage Controls The institution adequately stored and secured narcotic medications in seven of eight applicable clinic and medication-line locations (MIT 7.101, 87.5%). In one location, nurses did not describe the appropriate narcotic medication discrepancy reporting process. PVSP appropriately stored and secured nonnarcotic medications in six of eight applicable clinic and medication-line locations (MIT 7.102, 75.0%). In one location, the medication area had medications with an expired pharmacy label, which were to be returned to the pharmacy. In another location, the treatment cart log was missing daily security check entries. Staff kept medications protected from physical, chemical, and temperature contamination in three of the eight applicable clinic and medication-line locations (MIT 7.103, 37.5%). In three locations, staff did not store internal and external medications separately. In one location, staff stored medications with personal food items. In one location, the medication refrigerator was unsanitary. Staff successfully stored valid, unexpired medications in seven of the eight applicable medication-line locations (MIT 7.104, 87.5%). In one location, nurses did not label multiuse medication as required by California Correctional Health Care Services’ policy. Nurses exercised proper hand-hygiene and contamination-control protocols in two of six applicable locations (MIT 7.105, 33.3%). Most nurses neglected to wash or sanitize their hands before each subsequent regloving. Staff in four of six applicable medication preparation and administration areas demonstrated appropriate administrative controls and protocols (MIT 7.106, 66.7%). In two locations, medication nurses did not describe the process they followed when reconciling newly received medication with information documented in the medication administration record and with the corresponding physician’s order. Staff in three of six applicable medication areas used appropriate administrative controls and protocols when distributing medications to their patients (MIT 7.107, 50.0%). In three locations, we observed one or more of the following deficiencies: medication nurses did Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 52 not distribute medications to patients within the required time frame; medication nurses did not always verify patients’ identifications using a secondary identifier; medication nurses did not reliably observe patients while they swallowed directly-observed-therapy medications;36 and medication nurses did not follow California Correctional Health Care Services’ care guide when administering Suboxone medication. Pharmacy Protocols Pharmacy staff followed general security, organization, and cleanliness-management protocols in its pharmacy (MIT 7.108, 100%). Staff properly stored nonrefrigerated (MIT 7.109, 100%), refrigerated, and frozen medications in its pharmacy (MIT 7.110, 100%). The pharmacist-in-charge (PIC) correctly accounted for narcotic medications stored in PVSP’s pharmacy (MIT 7.111, 100%). At the time of our on-site inspection, the PIC reported no pharmacy-related errors have occurred in the past 12 months (MIT 7.112, N/A). 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 PVSP, the OIG did not find any applicable medication errors (MIT 7.998, N/A). The OIG interviewed patients in isolation units to determine whether they had immediate access to their prescribed asthma rescue inhalers or nitroglycerin medications. All 10 applicable patients interviewed indicated they had access to their rescue medications (MIT 7.999, 100%). 36 Directly observed therapy refers to dose-by-dose administration of medications by licensed health care staff (RN, LVN or PT) using the highest level of observation of ingestion of medication administered to the patient. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 53 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 9 10 6 47.4% 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 17 8 0 68.0% 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 7 10 4 41.2% 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 25 0 0 100% continued without interruption? (7.005) For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications administered or delivered 3 0 0 100% 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 1 2 87.5% assigned to its storage areas? (7.101) All clinical and medication line storage areas for nonnarcotic medications: Does the institution properly secure and store nonnarcotic medications in the assigned 6 2 2 75.0% 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 3 5 2 37.5% 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 7 1 2 87.5% assigned storage areas? (7.104) Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols during medication preparation and 2 4 4 33.3% medication administration processes? (7.105) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when preparing medications for 4 2 4 66.7% patients? (7.106) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when administering medications 3 3 4 50.0% to patients? (7.107) Pharmacy: Does the institution employ and follow general security, organization, and 1 0 0 100% cleanliness management protocols in its main and remote pharmacies? (7.108) Pharmacy: Does the institution’s pharmacy properly store nonrefrigerated 1 0 0 100% medications? (7.109) Pharmacy: Does the institution’s pharmacy properly store refrigerated or frozen 1 0 0 100% medications? (7.110) Pharmacy: Does the institution’s pharmacy properly account for narcotic 1 0 0 100% medications? (7.111) Pharmacy: Does the institution follow key medication error reporting protocols? 0 0 1 N/A (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): 74.6% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 54 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 10 0 15 100% 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 2 0 0 100% required documents? (6.101) Patients prescribed TB medication: Did the institution administer the 23 2 0 92.0% 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 16 9 0 64.0% medication? (9.002) Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient N/A N/A N/A N/A within required time frames? (13.003) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 55 Recommendations • Medical and nursing leadership should analyze challenges in ensuring chronic care medications, newly prescribed medications, and hospital discharge medications are made available and administered without interruption and should implement appropriate remedial measures. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 56 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 patients out 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 (89.3%) PVSP performed very well in this indicator. Staff performed excellently in offering patients an influenza vaccine for the most recent influenza season, offering colorectal cancer screening for patients from ages 45 through 75, and transferring out patients who are at high risk of coccidioidomycosis (Valley Fever) infection. Staff also performed very well in administering TB medications to patients as prescribed and offering required immunizations to chronic care patients. Moreover, staff performed satisfactorily in screening patients annually for TB. However, they needed improvement in monitoring patients taking prescribed TB medications. These findings are set forth in the table on the next page. Based on the overall Preventive Services compliance score result, the OIG rated this indicator proficient. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 57 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 23 2 0 92.0% 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 16 9 0 64.0% medication? (9.002) Annual TB screening: Was the patient screened for TB within the last year? 21 4 0 84.0% (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 24 1 0 96.0% 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) 8 1 16 88.9% Are patients at the highest risk of coccidioidomycosis (Valley Fever) 25 0 0 100% infection transferred out of the facility in a timely manner? (9.009) Overall percentage (MIT 9): 89.3% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 58 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 59 Nursing Performance In this indicator, 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 Overall, PVSP nurses delivered good nursing care, as in Cycle 6. Nurses generally performed good nursing assessments, interventions, and documentation. However, as in Cycle 6, nursing assessments in the outpatient setting showed room for improvement. The OIG rated the case review component of this indicator adequate. Case Review Results We reviewed 104 nursing encounters in 36 cases, and we identified 18 deficiencies in nursing performance, three of which were significant.37 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. Although outpatient clinic nurses performed very well overall, we found missing components of patient assessments in a few cases.38 Nurses triaged sick calls and evaluated patients timely, generally completed thorough patient assessments, and 37 Deficiencies occurred in cases 1, 3, 6, 17, 19, 21, 22, 26, 32, 34, 35, 38, and 42-46. Significant deficiencies occurred in cases 21, 26, and 32. 38 Missing components of patient assessments occurred in cases 1, 19, 21, 34, 35, 38, 42, 43, and 45. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 60 provided interventions as required. Of the 104 nursing encounters, 71 occurred in the outpatient setting, 46 of which were sick-call requests. Our clinicians identified 14 outpatient nursing-performance deficiencies, two of which were significant.39 The significant deficiencies are as follows: • In case 21, from January 25, 2024, to January 28, 2024, nurses performed surveillance rounds for possible infectious diarrhea. During rounding encounters, nurses did not always take a full set of vital signs. Moreover, nurses did not always notify the on-call provider of changes in the patient’s status. • In case 32, on May 5, 2024, the sick-call nurse assessed the patient for an allergic reaction. The nurse documented receiving orders from the provider to administer Benadryl 25 mg injection once and administer calamine lotion. However, the on-call provider documented a plan for Benadryl 50 mg injection, Zyrtec, Pepcid, calamine lotion, and a provider follow-up in three to five days. The nurse entered an order for Benadryl 25 mg instead of 50 mg injection. Consequently, the nurse administered Benadryl 25 mg injection instead of the correct dose ordered by the provider. Secondly, the nurse did not enter the orders for Zyrtec, Pepcid, or calamine lotion as ordered by the provider, and the medication administration record contained no documentation of these orders. The nurse did document administering Zyrtec in the nursing progress note. However, nursing documentation did not indicate the nurse administered Pepcid or calamine lotion. Lastly, the nurse scheduled a provider follow-up within 14 days instead of following the provider’s recommendation of three to five days. 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. Outpatient clinic nurses frequently preformed very good documentation.40 Nurses documented required information regarding sick calls, patient assessments, and communication with providers. Case Management Our clinicians reviewed nine events related to case management and did not identify any deficiencies.41 Case managers’ duties include annual hepatitis C virus follow ups, wound evaluations, and initial whole-care-person appointments.42 Nurses review medications and laboratory results for patients with chronic health conditions. They also educate patients on their chronic disease and encourage compliance with medical care. 39 Deficiencies occurred in cases 1, 19, 21, 22, 32, 34, 35, 38, and 42-46. Significant deficiencies occurred in cases 21 and 32. 40 Outpatient nursing documentation deficiencies occurred in cases 21, 22, and 44. 41 Care managers assessed patients in cases 6, 7, 12-14, and 19. 42 Hepatitis C virus (HCV) is a virus that infects the liver and can scar the liver, cause liver dysfunction, and increases risk for liver cancer. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 61 Wound Care Nurses showed very good performance for wound care. We reviewed four cases involving wound care orders.43 The nurses assessed patients’ wounds and provided wound care as ordered. Emergency Services Overall, nurses performed well in providing emergent or urgent care for patients. Nurses generally completed thorough patient assessments, provided appropriate interventions, and thoroughly documented patient encounters. We reviewed 15 urgent or emergent events. Please refer to the Emergency Services indicator for further details. Hospital Returns We reviewed five events in which patients returned from off-site hospitalizations or emergency room encounters. Nurses assessed patients thoroughly, reviewed hospital documents, and communicated with providers as needed. For additional details please refer to the Transfers indicator. Transfers R&R nurses always completed initial health screenings and frequently ensured transfer- out requirements were met. We reviewed 10 events involving transfer-in and transfer-out processes. Please refer to the Transfers indicator for further details. Specialized Medical Housing The specialized medical housing unit was closed during our review period. Specialty Services We reviewed four events in which patients returned to the facility from off-site specialty appointments. Nurses performed good assessments, reviewed specialty documents, and scheduled provider follow-up appointments as required. Medication Management OIG clinicians analyzed 121 events involving medication management and found nurses administered patients’ medications as prescribed. Please refer to the Medication Management indicator for additional details. Clinician On-Site Inspection During our on-site inspection, we interviewed various nursing staff throughout the institution, which included RNs, LVNs, supervising registered nurses (SRNs), and nursing leadership. We found nursing staff members were knowledgeable about 43 Wound care occurred in cases 12, 15, 16, and 18. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 62 processes in their assigned areas. We attended well-organized clinic huddles, which had good staff participation. Clinic nurses were familiar with their patient population. Staff in each clinic we inspected had an RN appointment backlog of three or less. Nursing staff in Clinic A informed us they have 15 to 25 scheduled patient appointments daily with an average of 10 additional and one walk-in appointment daily. The Clinic C nurse reported an average of 12 scheduled patient appointments daily with up to seven appointments added daily. Clinic C does not have daily walk-in appointments. A LVN is assigned as the care coordinator in each clinic. The care coordinator duties include administering vaccines, reviewing patient registries, providing patient education, and responding to emergencies. Clinic staff reported no issues accessing supplies, equipment, or the pharmacy. We also interviewed the chief nurse executive (CNE), who informed us the current nursing quality-improvement projects include maintaining hand hygiene and keeping the medication room doors closed. The CNE reported observing a 75 percent improvement rate in keeping medication room doors closed. Another project includes assessing medication management documentation. Nurses do not always document why a medication was not administered. Medication staff received training, and documentation has shown improvement. A new process-improvement project includes nurse-led therapeutic groups for enhanced outpatient program patients. The CNE reported recruiting staff for SRN and public health nurse positions has been challenging. The CNE informed us nursing morale at the institution is fair. The shared governance process promotes open communication among staff, encourages staff input on processes, and increases nursing morale. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 63 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 64 Provider Performance In this indicator, OIG case review clinicians evaluated the quality of care delivered by the institution’s providers: physicians, physician assistants, and nurse practitioners. Our clinicians assessed the institution’s providers’ performance in evaluating, diagnosing, and managing their patients properly. We examined provider performance across several clinical settings and programs, including sick call, emergency services, outpatient care, chronic care, specialty services, intake, transfers, hospitalizations, and specialized medical housing. We assessed provider care through case review only and performed no compliance testing for this indicator. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Not Applicable Case review found PVSP providers generally delivered good patient care. Providers mostly managed a variety of acute and chronic conditions effectively while reviewing records timely. However, we found some lapses in assessment, documentation, and following specialists’ recommendations. After considering all aspects of care, the OIG rated this indicator adequate. Case Review Results OIG clinicians reviewed 90 medical provider encounters and identified 43 deficiencies, 12 of which were significant.44 In addition, OIG clinicians examined the quality of care in 20 comprehensive case reviews. Of these 20 cases, we found 19 adequate and one inadequate. Outpatient Assessment and Decision-Making Providers usually made appropriate assessments and sound decisions for their patients. They usually documented relevant physical examinations and addressed abnormal vital signs. For the most part, they accurately diagnosed medical conditions, ordered pertinent tests and medications, and coordinated effective treatment plans. However, OIG clinicians identified 21 assessment and decision-making deficiencies, four of which were significant: • In case 8, a provider endorsed laboratory results but did not review all laboratory result comments, which stated additional testing was indicated. As a result, the provider did not order additional testing, and the patient did not receive proper treatment for his condition. • Also in case 8, a provider evaluated the patient at a follow-up appointment for coccidiomycosis. The provider allowed the patient’s medication to expire without 44 Deficiencies occurred in cases 1, 2, 8, 9, 11-13, and 15-23. Significant deficiencies occurred in cases 8, 9, 21, and 22. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 65 documenting objective evidence the patient’s coccidiomycosis infection had resolved. The provider had also misinterpreted the patient’s latest coccidiomycosis result as negative, when in fact, additional testing was recommended. Furthermore, the provider did not order a follow-up chest x-ray to reevaluate the previous abnormal findings and did not order an appointment to reassess the patient’s status. • In case 21, a provider ordered contact precautions and surveillance rounds on the patient with possible infectious diarrhea. However, the provider did not specify what type of surveillance the nurses were to perform, did not include parameters for abnormal vital signs, and did not specify when to contact the physician on- call. • Also in case 21, a provider decreased the patient’s medication, mesalamine, for the patient’s ulcerative colitis.45 However, the patient’s specialist did not recommend this decrease, and the provider did not document the rationale for this change. Review of Records Overall, providers mostly reviewed medical records carefully. OIG clinicians identified no significant deficiencies related to the review of hospital records, off-site specialty reports, or medications. Emergency Care Providers made appropriate triage decisions and treatment plans for patients in the triage and treatment area (TTA). Providers were also available for consultation with TTA nursing staff. OIG clinicians identified two minor deficiencies related to emergency care.46 The following is an example: • In case 1, a provider responded to a patient emergency but did not document a provider progress note. Chronic Care In most instances, providers appropriately managed the patient’s chronic health conditions such as hypertension, diabetes, asthma, hepatitis C infection, and cardiovascular disease. For the most part, providers were competent in treating coccidiomycosis and effectively managed patients who were on medication-assisted treatment (MAT).47 Deficiencies related to coccidiomycosis management are discussed above in the Outpatient Assessment and Decision-Making subsection of this indicator. 45 Mesalamine is a medication used to reduce inflammation. Ulcerative colitis is a chronic bowel disease with inflammation and ulcers in the intestines. 46 Deficiencies occurred in cases 1 and 21. 47 MAT is the medication-assisted treatment program for substance use disorder. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 66 Specialized Medical Housing PVSP’s specialized medical housing unit was closed at the time of our case review and inspection. Specialty Services Most PVSP providers referred patients to specialists appropriately. However, OIG clinicians identified eight deficiencies involving missing or late referrals from providers, which are further discussed in the Specialty Services indicator. The following are examples: • In case 22, a provider ordered a follow-up appointment instead of submitting a Request for Service (RFS) to orthopedic surgery. As a result, the patient’s orthopedic evaluation was delayed. • Also in case 22, a provider ordered an orthopedic evaluation of the patient’s fractured finger. However, the provider ordered a follow-up appointment instead of submitting an RFS. The provider also did not order an orthopedic evaluation of the patient’s knee symptoms. Both actions further delayed the patient’s access to orthopedics. OIG clinicians also found most providers addressed specialists’ recommendations. However, we identified the examples below in which the provider did not follow the specialist’s recommendation: • In case 9, a provider evaluated a diabetic patient after a podiatry appointment. The podiatrist had removed all five toenails on the patient’s left foot and had recommended a follow-up appointment in three to four weeks. However, the provider ordered a follow-up appointment in 61 days. • Also in case 9, a provider ordered a podiatry follow-up appointment seven to eight weeks from the last podiatry appointment. However, the specialist had recommended a follow-up evaluation in two to four weeks. • Again, in case 9, a provider reordered a podiatry follow-up appointment nine to 10 weeks from the last podiatry appointment. However, the specialist had recommended a follow-up evaluation in two to four weeks. • In case 21, a provider evaluated the patient after a gastroenterology consultation. The specialist recommended a slow, four-week reduction of the steroid medication. However, the provider did not order this medication. • In case 22, a provider evaluated the patient after an orthopedic postoperative appointment. The patient had reported altered sensation of the right hand to the surgeon, who had recommended a separate referral to orthopedics to assess that specific complaint. However, the provider did not inquire about these new symptoms and did not submit an request for services for a new orthopedic evaluation. • Also in case 22, a provider assessed the patient after an orthopedic follow-up appointment for a clavicle fracture and surgery. The orthopedic provider Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 67 recommended new referrals to orthopedic surgery for the patient’s finger fracture and cubital tunnel symptoms.48 However, the provider did not order either evaluation. Documentation Quality Providers generally documented patient encounters and nursing communications timely. However, we identified six minor deficiencies in which the provider did not update the patient’s problem list and four deficiencies related to minor errors in documentation. The following are examples: • In case 1, a provider sent the patient a results letter for a newly positive hepatitis C laboratory result, erroneously stating the result was normal and no follow-up appointment was required. • In case 8, throughout the review period, the provider did not update the patient’s diagnoses of coccidiomycosis, dyslipidemia, type 2 diabetes mellitus, or chronic migraine headaches on the patient’s active problem list in the EHRS. • In case 9, a provider evaluated the patient after a podiatrist removed toenails from the patient’s left foot. The patient complained of left calf pain to the provider. However, the provider documented examining the patient’s right calf. The provider then ordered a hospital evaluation for the patient to rule out a clot in the left lower leg. This type of documentation inconsistency can lead to missed diagnoses. Provider Continuity PVSP offered good provider continuity. The patient care team scheduled patients with their primary clinic provider whenever possible. Providers covered for each other’s patients when needed. Clinician On-Site Inspection OIG clinicians met with PVSP medical leadership and providers. They reported stable and consistent staffing. The chief medical executive has held his position for almost 10 years, and several providers have worked at PVSP for 15 years. Two providers were nurses at PVSP before becoming nurse practitioners and chose to remain at PVSP. Nurse practitioners and the physician assistant reported working four 10-hour days, with one physician assistant also working in the evening clinic voluntarily. All providers, including the chief physician and surgeon, shared on-call duties, and providers were paired for cross-coverage of in-basket responsibilities. PVSP did not utilize any registry providers, and no provider vacancies existed at the time of our inspection. The providers expressed respect for leadership and indicated morale at PVSP is high. 48 The cubital tunnel is a space in the elbow in which the ulnar nerve is located. The narrowing or compression of this space causes pressure on the ulnar nerve, thereby affecting sensation and strength. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 68 Recommendations • Medical leadership should determine the root cause(s) of providers not following specialists’ recommendations or not documenting the medical reasoning for not following recommendations and should implement appropriate remedial measures. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 69 Specialized Medical Housing In this indicator, OIG inspectors evaluate the quality of care in specialized medical housing units. We evaluate the performance of medical staff in assessing, monitoring, and intervening for medically complex patients requiring close medical supervision. Our inspectors also evaluate the timeliness and quality of provider and nursing intake assessments and care plans. We assess staff members’ performance in responding promptly when patients’ conditions deteriorate and look for good communication when staff consult with one another while providing continuity of care. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Not Applicable Because information was unavailable for the inspection period due to the closure, the OIG did not assess this indicator, and instead, designated this indicator as not applicable. Case Review and Compliance Testing Results Compliance On-Site Inspection and Discussion At the time of our inspection, PVSP’s specialized medical housing unit was closed. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 70 Compliance Score Results Table 16. Specialized Medical Housing Scored Answer Compliance Questions Yes No N/A Yes % For OHU, CTC, and SNF: Did the registered nurse complete an initial N/A N/A N/A N/A assessment of the patient on the day of admission? (13.001) Was a written history and physical examination completed within the N/A N/A N/A N/A required time frame? (13.002) Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient N/A N/A N/A N/A within required time frames? (13.003) For specialized health care housing (CTC, SNF, hospice, OHU): Do specialized health care housing maintain an operational call N/A N/A N/A N/A system? (13.101) For specialized health care housing (CTC, SNF, hospice, OHU): Do health care staff perform patient safety checks according to institution’s local N/A N/A N/A N/A operating procedure or within the required time frames? (13.102) Overall percentage (MIT 13): N/A Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 71 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 72 Specialty Services In this indicator, OIG inspectors evaluated the quality of specialty services. OIG clinicians focused on the institution’s performance in providing needed specialty care. Our clinicians also examined specialty appointment scheduling, providers’ specialty referrals, and medical staff’s retrieval, review, and implementation of any specialty recommendations. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Adequate (77.6%) Case review found PVSP performed satisfactorily in providing specialty services. Patients generally received timely specialty consultations, and PVSP staff managed specialty appointments acceptably. Nurses performed well in caring for patients after specialty appointments. Providers generally referred patients appropriately; however, some providers did not follow specialists’ recommendations. Taking all these factors into account, the OIG rated the case review component of this indicator adequate. PVSP’s performance varied in compliance testing for this indicator. Depending on the priority of the specialty service, timely completion of specialty services ranged from needing improvement to excellent. However, Preapproved specialty services for newly arrived patients only intermittently occurred within required time frames. In addition, performance in timely retrieving specialty reports with prompt provider endorsements needed improvement. Based on the overall Specialty Services compliance score result, the OIG rated the compliance testing component of this indicator adequate. Case Review and Compliance Testing Results OIG clinicians reviewed 29 events related to specialty services, including 15 specialty consultations. We identified six deficiencies in this category, two of which were significant.49 Access to Specialty Services PVSP’s access to specialists for initial specialty referrals was generally good. Compliance testing showed most high-priority (MIT 14.001, 80.0%) and medium-priority (MIT 14.004, 86.7%) specialty referrals occurred timely, while routine-priority (MIT 14.007, 93.3%) specialty referrals almost always occurred timely. Similarly, OIG clinicians identified only one deficiency related to obtaining an initial specialty appointment.50 We discuss this significant deficiency further in the Access to Care indicator. 49 Deficiencies occurred in cases 8, 9, and 22. A significant deficiency occurred in case 22. 50 The deficiency occurred in case 22. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 73 Compliance testing showed access to specialists for follow-up appointments was mixed. High-priority follow-up (MIT 14.003, 87.5%) and routine-priority follow-up (MIT 14.009, 75.0%) specialty appointments usually occurred timely, but medium-priority (MIT 14.006, 57.1%) specialty appointments only sometimes occurred timely. OIG clinicians did not identify any deficiencies related to late or missed follow-up specialty appointments. Preapproved specialty access for newly arrived patients needed improvement. Compliance testing revealed these specialty appointments only intermittently occurred timely (MIT 14.010, 57.9%). OIG clinicians did not identify any deficiencies related to preapproved specialty access for newly arrived patients. Provider Performance Although OIG clinicians found most providers appropriately referred patients to specialists, we identified eight instances related to missed or late specialty referrals.51 We also found several examples in which the provider did not follow through with the specialist’s recommendations.52 We discuss these deficiencies further in the Provider Performance indicator. Nursing Performance PVSP nurses performed well in assessing patients who returned to the facility from off- site specialty appointments. OIG clinicians did not identify any nursing performance deficiencies as nurses performed good assessments, reviewed specialty documents, and notified providers as medically indicated. Nurses also scheduled provider follow-up appointments and obtained orders for urgent medications as needed. Health Information Management Staff did not perform well in managing specialty reports. Compliance testing revealed retrieval of specialty documents needed improvement (MIT 4.002, 73.3%). In addition, staff did not receive, and providers did not regularly endorse, high-priority (MIT 14.002, 69.2%), medium-priority (MIT 14.005, 60.0%), or routine-priority (MIT 14.008, 64.3%) specialty reports timely. OIG clinicians identified four deficiencies, only one of which was significant. The significant deficiency related to a missing surgical report, while the three minor deficiencies involved misfiled or mislabeled documents. We discuss the significant deficiency further in the Health Information Management indicator. Clinician On-Site Inspection OIG clinicians discussed specialty services with PVSP specialty nurses, utilization management nurses, and providers. Staff reported PVSP provided on-site specialty services for audiology, optometry, orthotics and prosthetics, sleep studies, and virtual physical therapy. Although various telemedicine specialties were available, staff reported occasional challenges in scheduling appointments for urology and orthopedics specialties, along with sleep studies. When a specialist requested a follow-up appointment within an ordered time frame, PVSP staff called to schedule the appointment. Staff stated consistent communication with specialists’ staff usually helped 51 Deficiencies occurred in cases 2, 9, and 22. Significant deficiencies occurred in cases 9 and 22. 52 Deficiencies occurred in cases 21 and 22. Significant deficiencies occurred in both cases. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 74 to maintain compliance with scheduling. However, occasionally, the specialist’s office would state no appointments were available for the requested time frame. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 75 Compliance Score Results Table 17. Specialty Services Scored Answer Compliance Questions Yes No N/A Yes % Did the patient receive the high-priority specialty service within 14 calendar days of the primary care provider order or the Physician Request for 12 3 0 80.0% Service? (14.001) Did the institution receive and did the primary care provider review the high-priority specialty service consultant report within the required time 9 4 2 69.2% 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? 7 1 7 87.5% (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 13 2 0 86.7% Service? (14.004) Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the required time 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? 4 3 8 57.1% (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 14 1 0 93.3% 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 5 1 64.3% 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? 6 2 7 75.0% (14.009) For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the sending 11 8 0 57.9% 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 16 0 0 100% services within required time frames? (14.011) Following the denial of a request for specialty services, was the patient 15 0 1 100% informed of the denial within the required time frame? (14.012) Overall percentage (MIT 14): 77.6% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 76 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 39 3 3 92.9% occur within required time frames? (1.008) * Are specialty documents scanned into the patient’s electronic health record 22 8 15 73.3% within five calendar days of the encounter date? (4.002) * CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician follow-up visits following specialty services. As a result, we tested MIT 1.008 only for high-priority specialty services or when staff ordered follow-ups. The OIG continued to test the clinical appropriateness of specialty follow-ups through its case review testing. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 77 Recommendations • Health care leadership should identify challenges in the untimely receipt and provider review of specialty reports and implement appropriate remedial measures. • Health care leadership should determine the root cause(s) of untimely specialty appointments, including preapproved specialty appointments for transfer-in patients, and implement appropriate remedial measures. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 78 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 (73.6%) PVSP’s performance was mixed in this indicator. While PVSP scored well in some applicable tests, it needed improvement in several areas. EMRRC sporadically completed required checklists or reviewed cases within required time frames. In addition, staff conducted medical emergency response drills with incomplete documentation and missing required emergency response drill forms. Physician managers only occasionally completed annual performance appraisals in a timely manner. Lastly, the nurse educator needed improvement in ensuring all nurses who administer medication complete their annual competency testing in a timely manner. 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 PVSP, 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 five patients, we found no evidence in the submitted documentation that preliminary mortality reports had been completed. These reports were overdue at the time of the OIG’s inspection (MIT 15.998). Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 79 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 4 8 0 33.3% 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 N/A N/A N/A N/A 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 1 0 80.0% 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 1 4 0 20.0% timely? (15.105) Did the providers maintain valid state medical licenses? (15.106) 9 0 0 100% Did the staff maintain valid Cardiopulmonary Resuscitation (CPR), Basic Life Support (BLS), and Advanced Cardiac Life Support (ACLS) certifications? 2 0 1 100% (15.107) Did the nurses and the pharmacist-in-charge (PIC) maintain valid professional licenses and certifications, and did the pharmacy maintain a 6 0 1 100% valid correctional pharmacy license? (15.108) Did the pharmacy and the providers maintain valid Drug Enforcement Agency (DEA) registration certificates, and did the pharmacy maintain valid 1 0 0 100% Automated Drug Delivery System (ADDS) licenses? (15.109) Did nurse managers ensure their newly hired nurses received the required 1 0 0 100% onboarding and clinical competency training? (15.110) Did the CCHCS Death Review Committee process death review reports This is a nonscored test. Please refer to the timely? Effective 05/2022: Did the Headquarters Mortality Case Review discussion in this indicator. process mortality review reports timely? (15.998) What was the institution’s health care staffing at the time of the OIG medical This is a nonscored test. Please refer to Table 3 inspection? (15.999) for CCHCS-provided staffing information. Overall percentage (MIT 15): 73.6% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 80 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 81 Appendix A: Methodology In designing the medical inspection program, the OIG met with stakeholders to review CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. We also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the receiver’s office, the department, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of our inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates the delivery of medical care by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population-based metrics. We rate each of the quality indicators applicable to the institution under inspection based on case reviews conducted by our clinicians or compliance tests conducted by our registered nurses. Figure A–1 below depicts the intersection of case review and compliance. Figure A–1. Inspection Indicator Review Distribution for PVSP Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 82 Case Reviews The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders, which continues in the Cycle 7 medical inspections. Below, Table A–1 provides important definitions that describe this process. Table A–1. Case Review Definitions Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 83 The OIG eliminates case review selection bias by sampling using a rigid methodology. No case reviewer selects the samples he or she reviews. Because 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 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 clinician inspectors review all the cases, they analyze the deficiencies, then summarize their findings in one or more of the health care indicators in this report. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 84 Figure A–2. Case Review Testing Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 85 Compliance Testing Compliance Sampling Methodology Our analysts identify samples for both our case review inspectors and compliance inspectors. Analysts follow a detailed selection methodology. For most compliance questions, we use sample sizes of approximately 25 to 30. Figure A–3 below depicts the relationships and activities of this process. Figure A–3. Compliance Sampling Methodology Compliance Testing Methodology Our inspectors answer a set of predefined medical inspection tool (MIT) questions to determine the institution’s compliance with CCHCS policies and procedures. Our nurse inspectors assign a Yes or a No answer to each scored question. OIG headquarters nurse inspectors review medical records to obtain information, allowing them to answer most of the MIT questions. Our regional nurses visit and inspect each institution. They interview health care staff, observe medical processes, test facilities and clinics, review employee records, logs, medical grievances, death reports, and other documents, and obtain information regarding plant infrastructure and local operating procedures. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 86 Scoring Methodology Our compliance team calculates the percentage of all Yes answers for each of the questions applicable to a particular indicator, then averages the scores. The OIG continues to rate these indicators based on the average compliance score using the following descriptors: proficient (85.0 percent or greater), adequate (between 84.9 percent and 75.0 percent), or inadequate (less than 75.0 percent). Indicator Ratings and the Overall Medical Quality Rating The OIG medical inspection unit individually examines all the case review and compliance inspection findings under each specific methodology. We analyze the case review and compliance testing results for each indicator and determine separate overall indicator ratings. After considering all findings of each of the relevant indicators, our medical inspectors individually determine the institution’s overall case review and compliance ratings. Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 87 Appendix B: Case Review Data Table B–1. PVSP Case Review Sample Sets Sample Set Total Death Review/Sentinel Events 2 Diabetes 4 Emergency Services – CPR 3 Emergency Services – Non-CPR 2 High Risk 4 Hospitalization 4 Intrasystem Transfers In 2 Intrasystem Transfers Out 3 RN Sick Call 18 Specialty Services 4 46 Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 88 Table B–2. PVSP Case Review Chronic Care Diagnoses Sample Set Total Anemia 2 Arthritis/Degenerative Joint Disease 4 Asthma 3 Chronic Pain 5 Cirrhosis/End-State Liver Disease 2 Coccidioidomycosis (Valley Fever) 8 Diabetes 4 Gastroesophageal Reflux Disease (GERD) 5 Hepatitis C 15 Hyperlipidemia 13 Hypertension 9 Mental Health 18 Migraine Headaches 1 Seizure Disorder 2 Substance Abuse 22 Thyroid Disease 3 116 Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 89 Table B–3. PVSP Case Review Events by Program Diagnosis Total Diagnostic Services 146 Emergency Care 30 Hospitalization 13 Intrasystem Transfers In 4 Intrasystem Transfers Out 6 Outpatient Care 333 Specialty Services 45 577 Table B–4. PVSP Case Review Sample Summary Sample Set Total MD Reviews Detailed 20 MD Reviews Focused 0 RN Reviews Detailed 12 RN Reviews Focused 25 Total Reviews 57 Total Unique Cases 46 Overlapping Reviews (MD & RN) 11 Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 90 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 91 Appendix C: Compliance Sampling Methodology Pleasant Valley State Prison Quality No. of Indicator Sample Category Samples Data Source Filters Access to Care MIT 1.001 Chronic Care 25 Master Registry • Chronic care conditions (at least one Patients condition per patient — any risk level) • Randomize MIT 1.002 Nursing Referrals 25 OIG Q: 6.001 • See Transfers MITs 1.003 – 006 Nursing Sick Call 30 Clinic • Clinic (each clinic tested) (6 per clinic) Appointment List • Appointment date (2 – 9 months) • Randomize MIT 1.007 Returns From 21 OIG Q: 4.005 • See Health Information Management Community (Medical Records) (returns from Hospital community hospital) MIT 1.008 Specialty Services 45 OIG Q: 14.001, • See Specialty Services Follow-Up 14.004 & 14.007 MIT 1.101 Availability of 6 OIG on-site review • Randomly select one housing unit Health Care from each yard Services Request Forms Diagnostic Services MITs 2.001 – 003 Radiology 10 Radiology Logs • Appointment date (90 days – 9 months) • Randomize • Abnormal MITs 2.004 – 006 Laboratory 10 Quest • Appt. date (90 days – 9 months) • Order name (CBC, BMP, or CMPs only) • Randomize • Abnormal MITs 2.007 – 009 Laboratory STAT 0 Quest • Appt. date (90 days – 9 months) • Order name (CBC, BMP, or CMPs only) • Randomize • Abnormal MITs 2.010 – 012 Pathology 10 InterQual • Appt. date (90 days – 9 months) • Service (pathology related) • Randomize Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 92 Quality No. of Indicator Sample Category Samples Data Source Filters Health Information Management (Medical Records) MIT 4.001 Health Care Services 30 OIG Qs: 1.004 • Nondictated documents Request Forms • First 20 IPs for MIT 1.004 MIT 4.002 Specialty Documents 45 OIG Qs: 14.002, • Specialty documents 14.005 & 14.008 • First 10 IPs for each question MIT 4.003 Hospital Discharge 21 OIG Q: 4.005 • Community hospital discharge Documents documents • First 20 IPs selected MIT 4.004 Scanning Accuracy 24 Documents for • Any misfiled or mislabeled document any tested identified during incarcerated OIG compliance review person (24 or more = No) MIT 4.005 Returns From 21 CADDIS off-site • Date (2 – 8 months) Community Hospital admissions • Most recent 6 months provided (within date range) • Rx count • Discharge date • Randomize Health Care Environment MITs 5.101 – 105 Clinical Areas 9 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 2 OIG inspector • R&R IP transfers with medication on-site review Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 93 Quality No. of Indicator Sample Category Samples Data Source Filters Pharmacy and Medication Management MIT 7.001 Chronic Care 25 OIG Q: 1.001 • See Access to Care Medication • At least one condition per patient — any risk level • Randomize MIT 7.002 New Medication 25 Master Registry • Rx count Orders • Randomize • Ensure no duplication of IPs tested in MIT 7.001 MIT 7.003 Returns From 21 OIG Q: 4.005 • See Health Information Management Community Hospital (Medical Records) (returns from community hospital) MIT 7.004 RC Arrivals — N/A at this OIG Q: 12.001 • See Reception Center Medication Orders institution MIT 7.005 Intrafacility Moves 25 MAPIP transfer • Date of transfer (2 – 8 months) data • To location/from location (yard to yard and to/from ASU) • Remove any to/from MHCB • NA/DOT meds (and risk level) • Randomize MIT 7.006 En Route 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 1 Medication error • All medication error reports with Reporting reports Level 4 or higher • Select total of 25 medication error reports (recent 12 months) MIT 7.999 Restricted Unit 10 On-site active • KOP rescue inhalers & nitroglycerin KOP Medications medication listing medications for IPs housed in restricted units Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 94 Quality No. of Indicator Sample Category Samples Data Source Filters Prenatal and Postpartum Care MITs 8.001 – 007 Recent Deliveries N/A at this OB Roster • Delivery date (2 – 12 months) institution • Most recent deliveries (within date range) Pregnant Arrivals N/A at this OB Roster • Arrival date (2 – 12 months) institution • Earliest arrivals (within date range) Preventive Services MITs 9.001 – 002 TB Medications 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 25 Cocci transfer • Reports from past 2 – 8 months status report • Institution • Ineligibility date (60 days prior to inspection date) • All Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 95 Quality No. of Indicator Sample Category Samples Data Source Filters Reception Center MITs 12.001 – 007 RC N/A at this SOMS • Arrival date (2 – 8 months) institution • Arrived from (county jail, return from parole, etc.) • Randomize Specialized Medical Housing MITs 13.001 – 003 Specialized Health N/A at this CADDIS • Admit date (2 – 8 months) Care Housing Unit institution • Type of stay (no MH beds) • Length of stay (minimum of 5 days) • Rx count • Randomize MITs 13.101 – 102 Call Buttons N/A at this OIG inspector • Specialized Health Care Housing institution 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: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 96 Quality No. of Indicator Sample Category Samples Data Source Filters Specialty Services (continued) MITs 14.007 – 009 Routine-Priority 15 Specialty Services • Approval date (3 – 9 months) Initial and Follow-Up Appointments • Remove consult to audiology, RFS chemotherapy, dietary, Hep C, HIV, orthotics, gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, physiatry, podiatry, radiology, follow-up wound care/addiction medication, narcotic treatment program, and transgender services • Randomize MIT 14.010 Specialty Services 19 Specialty Services • Arrived from (other departmental Arrivals Arrivals institution) • Date of transfer (3 – 9 months) • Randomize MITs 14.011 – 012 Denials 16 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 N/A at this LGB meeting • Quarterly meeting minutes institution 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: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 97 Quality No. of Indicator Sample Category Samples Data Source Filters Administrative Operations (continued) MIT 15.103 Death Reports 5 Institution-list of • Most recent 10 deaths deaths in prior Initial death reports 12 months MIT 15.104 Nursing Staff 10 On-site nursing • On duty one or more years Validations education files • Nurse administers medications • Randomize MIT 15.105 Provider Annual 5 On-site provider • All required performance evaluation Evaluation Packets evaluation files documents MIT 15.106 Provider Licenses 9 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 5 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: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 98 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7, Pleasant Valley State Prison | 99 California Correctional Health Care Services’ Response Office of the Inspector General, State of California Inspection Period: January 2024 – June 2024 Report Issued: September 2025 Cycle 7 Medical Inspection Report for Pleasant Valley State Prison OFFICE of the INSPECTOR GENERAL Amarik K. Singh Inspector General Shaun Spillane Chief Deputy Inspector General STATE of CALIFORNIA September 2025 OIG