OIG
Pleasant Valley State Prison Medical Inspection Results Cycle 1
PLEASANT VALLEY STATE PRISON
MEDICAL INSPECTION RESULTS
BUREAU OF AUDITS AND INVESTIGATIONS
OFFICE OF THE
INSPECTOR GENERAL
DAVID R. SHAW
INSPECTOR GENERAL
STATE OF CALIFORNIA
August 2009
Contents
Executive Summary .................................................................................… 1
Introduction …...........................................................................................… 3
Background …...............................................................................… 3
About the Institution ….................................................................… 4
Objectives, Scope, and Methodology …......................................... 4
Medical Inspection Results …..................................................................… 7
California Prison Health Care Receivership
Corporation's Response …........................................................................ 28
Executive Summary
An April 2001 class action lawsuit filed by inmates represented by the Prison Law Office alleged
that the state provided constitutionally inadequate medical care at California state prisons in
violation of inmates’ constitutional rights. And, in October 2005, the U.S. Northern District Court of
California declared that California’s delivery system for prison medical care was “broken beyond
repair” and still not meeting constitutional standards. As a result, the federal court imposed a
receivership to raise the delivery of medical care to constitutional standards. To evaluate and
monitor the progress of medical care delivery to inmates, the receiver requested, and the Office of
the Inspector General (OIG) agreed, to establish an objective, clinically appropriate, and metric-
oriented medical program to annually inspect the delivery of medical care at each state prison.
In April 2009, we inspected Pleasant Valley State Prison (PVSP). Our medical
Overall inspection encompassed 18 components of medical delivery and comprised
Score 133 questions. The questions are weighted based on their importance to the
64.5% delivery of medical care to inmates. PVSP received 64.5 percent of the total
weighted points possible.
The following summary table lists the components we inspected in order of importance (highest to
lowest), with the institution’s score and the definitions of each inspection component. The detailed
medical inspection results, with the questions for each component, begin on page 7 of this report.
While we are committed to helping each institution achieve a higher level of medical care, it is not
our intent to determine the percentage score needed by an institution to meet constitutional standards
—that is a legal matter for the federal court to determine.
Executive Summary Table
Component Weighted Definition
Score
Chronic Care 56.9% Examines how well the prison provided care and medication to inmates with specific
chronic care conditions, which are those that affect (or have the potential to affect) an
inmate's functioning and long-term prognosis for more than six months. Our inspection
tests the following chronic care conditions: asthma, Coumadin therapy, diabetes, HIV
(Human Immunodeficiency Virus), and hypertension.
Clinical Services 46.7% Evaluates the inmate's access to primary health care services and focuses on inmates who
recently received services from any of the prison's facility or administrative segregation
unit clinics. This component evaluates sick call processes (doctor or nurse line), medication
management, and nursing.
Health Screening 67.1% Focuses on the prison's process for screening new inmates upon arrival to the institution for
health care conditions that require treatment and monitoring, as well as ensuring inmates'
continuity of care.
Specialty Services 60.6% Focuses on the prison's process for approving, denying, and scheduling services that are
outside the specialties of the prison's medical staff. Common examples of these services
include physical therapy, oncology services, podiatry consultations, and neurology services.
Urgent Services 80.5% Addresses the care provided by the institution to inmates before and after they were sent to
a community hospital.
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Office of the Inspector General State of California
Component Weighted Definition
Score
Emergency Services 82.8% Examines how well the prison responded to medical emergencies. Specifically, we focused
on "man down" or "woman down" situations. Further, questions determine the adequacy of
medical and staff response to a "man down" or "woman down" emergency drill.
Prenatal Care/ N/A Focuses on the prenatal and post-delivery medical care provided to pregnant inmates. Not
Childbirth/Post-delivery applicable at men's institutions.
Diagnostic Services 64.6% Addresses the timeliness of radiology (x-ray) and laboratory services and whether the
prison followed up on clinically significant results.
Access to Health Care 62.7% Addresses the prison's effectiveness in filing, storing, and retrieving medical records and
Information medical-related information.
Outpatient Housing N/A Determines whether the prison followed department policies and procedures when placing
Unit inmates in the outpatient housing unit. This component also evaluates whether the
placement provided the inmate with adequate care and whether the physician's plan
addressed the placement diagnosis.
Internal Reviews 70.5% Focuses on the frequency of meetings held by the prison's Quality Management Committee
(QMC) and Emergency Response Review Committee (ERRC) and whether key staff
attended the meetings, the number of medical appeals filed, and the prison's death review
process.
Inmate Transfers 76.0% Focuses on inmates pending transfer to determine whether the sending institution
documented medication and medical conditions to assist the receiving institution in
providing continuity of care.
Clinic Operations 92.7% Addresses the general operational aspects of the prison's facility clinics. Generally, the
questions in this component relate to the overall cleanliness of the clinics, privacy afforded
to inmates during nonemergency visits, use of priority ducats (slip of paper the inmate
carries for scheduled medical appointments), and availability of health care request forms.
Preventive Services 27.3% Focuses on inmate cancer screening and influenza immunizations.
Pharmacy Services 72.4% Addresses whether the prison's pharmacy complies with various operational policies, such
as conducting periodic inventory counts and maintaining the currency of medications in its
night lockers, keeping signature cards on file for doctors, and having valid permits. In
addition, this component also addresses whether the pharmacy has an effective process for
screening medication orders for potential adverse reactions/interactions.
Other Services 70.0% Examines additional areas that are not captured in the other components. The areas
evaluated in this component include the prison's provision of therapeutic diets, its handling
of inmates who display poor hygiene, and the availability of the current version of the
department's Health Services Policies and Procedures.
Inmate Hunger Strikes 36.8% Examines medical staff's monitoring of inmates participating in hunger strikes.
Chemical Agent 66.3% Addresses the prison's process of handling inmates who may be predisposed to an adverse
Contraindications outcome from calculated uses of force (cell extractions) involving Oleoresin Capsicum
(OC), which is commonly referred to as "pepper spray." For example, this might occur if
the inmate has asthma.
Staffing Levels and 80.0% Examines the prison's medical staffing levels and training provided.
Training
Nursing Policy 100.0% Determines whether the prison maintains written policies and procedures for the safe and
effective provision of quality nursing care. The questions in this component also determine
whether nursing staff review their duty statements and whether supervisors periodically
review the work of nurses to ensure they properly follow established nursing protocols.
Overall Score 64.5%
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Office of the Inspector General State of California
Introduction
Under the authority of California Penal Code section 6126, which assigns the Office of the Inspector
General (OIG) responsibility for oversight of the California Department of Corrections and
Rehabilitation, and at the request of the federal receiver, the OIG developed a comprehensive
inspection program to evaluate the delivery of medical care at each of the California Department of
Corrections and Rehabilitation’s 33 adult prisons.
In April 2009, we inspected Pleasant Valley State Prison (PVSP). Our medical inspection encompassed
18 components of medical delivery and comprised 133 questions. To help readers understand the
medical risk associated with certain components of medical delivery—which pose a greater risk to an
inmate-patient—we developed a weighting system and assigned points to each question.
Consequently, we assigned more total points to more critical components, such as chronic care,
clinical services, and health screening. We assigned fewer total points to less critical components, such
as inmate hunger strikes, staffing levels and training, and chemical agent contraindications. (For a
detailed description of the weighting system, see Objectives, Scope, and Methodology on the next
page.)
Background
In April 2001, inmates represented by the Prison Law Office filed a class action lawsuit, known as
Plata v. Schwarzenegger. The lawsuit alleged that the state provided constitutionally inadequate
medical care at California state prisons in violation of inmates’ constitutional rights. In June 2002, the
parties entered into a Stipulation for Injunctive Relief, and the state agreed to implement over several
years comprehensive new medical care policies and procedures at all institutions.
Nevertheless, the U.S. Northern District Court of California declared in October 2005 that California’s
delivery system for prison medical care was “broken beyond repair” and still not meeting
constitutional standards. Thus, the federal court imposed a receivership to raise the delivery of medical
care to constitutional standards. In essence, the court ordered the receiver to manage the state’s
delivery of medical care and restructure day-to-day operations to develop and sustain a system that
provides constitutionally adequate medical care to inmates. The court stated that it would remove the
receiver and return control to the state once the system is stable and provides for constitutionally
adequate medical care.
To evaluate and monitor the progress of medical care delivery to inmates, the receiver requested that
the OIG establish an objective, clinically appropriate, and metric-oriented medical inspection program.
Toward that end, the Inspector General agreed to inspect annually each state prison until the state’s
delivery of medical care to inmates meets constitutional standards. We are committed to helping each
institution achieve a higher level of medical care, but it is up to the federal court to determine the
percentage score necessary for an institution to meet constitutional standards.
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Office of the Inspector General State of California
About the Institution
The primary mission of Pleasant Valley State Prison is to provide long-term housing and services for
minimum, medium, and maximum custody inmates. As of July 22, 2009, the California Department of
Corrections and Rehabilitation reported that PVSP had custody over 4,884 male inmates. The
institution provides academic classes, vocational instruction, and work programs to help inmates
become more productive. PVSP is made up of one smaller facility for minimum security inmates and
four large facilities for inmates requiring a higher security level. Each of these four facilities houses a
medical clinic where staff handle non-urgent requests for medical services. PVSP also treats inmates
needing urgent or emergency care in its triage and treatment area (TTA). According to information
provided by the institution, PVSP's vacancy rate among licensed medical managers, primary care
providers, supervisors, and rank and file nurses was 28.5 percent.
Felix Igbinosa, M.D., who serves as the prison's chief medical officer and acting health care manager,
is responsible for PVSP's entire health care program.
Objectives, Scope, and Methodology
In designing the medical inspection program, we reviewed the California Department of Corrections
and Rehabilitation’s policies and procedures, relevant court orders, guidelines developed by the
department’s Quality Medical Assurance Team, and guidance developed by the American Correctional
Association. We also reviewed professional literature on correctional medical care, consulted with
clinical experts, and met with stakeholders from the court, the receiver’s office, the department, and
the Prison Law Office to discuss the nature and scope of the inspection program. Based on input from
these stakeholders, we developed a medical inspection program that evaluates medical care delivery.
Within each of 20 components, we created “yes” or “no” questions designed to gauge performance.
To make the inspection results meaningful to both a medical expert and a lay reader, we worked with
clinical experts to create a weighting system that factors the relative importance of each component
compared to other components. Further, the program considers the relative importance of each
question within a component to the other questions in that component. This weighting ensures that
more critical components—such as those that pose the greatest medical risk to the inmate-patient—are
given more weight compared to those considered less serious. For example, we assign a high number
of possible points to the chronic care component because we consider this the most serious of all the
components. Conversely, we assign very few points to the hygiene intervention component because we
consider this the least serious inspection component.
Each inspection question is weighted and scored. The score is derived from the percentage of “yes”
answers for each question from all items sampled. We then multiply the percentage of “yes” answers
within a given question by the question’s weight to arrive at a score. The following example shows
how this scoring system works.
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Office of the Inspector General State of California
Example Question: Institution X
Answers Weighting Points
Yes No Yes + No Yes % Possible Received Score % N/A Unk
Is the clinical history adequate? 40 10 50 80% 20 16 80.0% 0 0
If the institution receives 40 “yes” answers and 10 “no” answers, the percentage of “yes” answers to
this question equals 80 percent. We calculate the number of points the institution would receive by
multiplying the “yes” percent of 80 by the number of possible points for this question, which is 20, to
arrive at 16 points.
To arrive at the total score, we add the points received for each question and then for each program
component. Finally, we calculate the institution’s overall score by dividing the sum of the points
received by the sum of the points possible. We do not include in the institution’s overall score the
weight for questions that are not applicable or, in some cases, where a lack of documentation would
result in numerous “no” answers for one deviation from policy (unknown). For instance, an institution
may not be able to provide documentation that its emergency response review committee met for a
particular month. Therefore, when we evaluate whether meeting minutes document monthly meetings
for a particular month, the institution would receive a “no” answer for that question. However, when
we evaluate whether the meeting minutes document the warden’s attendance at the meeting, the
answer would be “unknown” so that the institution’s score is not penalized twice for the same reason,
not documenting the meeting.
To evaluate the institution’s delivery of medical care, we obtained various electronic data files
maintained by the institution for inmate medical scheduling and tracking, pharmacy, and census data.
We used these electronic data files only to identify random samples of inmates receiving or requiring
specific medical services. We then reviewed the medical file for each inmate in our sample. We did not
rely on the medical care information contained in these data files.
Our medical inspection at PVSP encompassed 18 of the 20 components of medical delivery. Two of
the components were not applicable during the period inspected. In total, we reviewed 178 inmate
medical files, which are referred to as unit health records. In addition, we reviewed staffing level
reports, medical appeals summaries, nursing policies and procedures, summaries of medical drills and
emergencies, minutes from Quality Management Committee and Emergency Response Review
Committee hearings, and assorted manual logs or tracking worksheets related to medical care delivery.
We also conducted a live medical emergency drill and evaluated the adequacy of the responding staff’s
actions. Finally, we interviewed medical and custody staff members about the delivery of medical care
to inmates, and we observed day-to-day medical delivery at the institution.
We do not test the care provided in the licensed hospitals or correctional treatment centers because
they are subject to inspections and oversight by other regulatory agencies. Consistent with our
agreement with the receiver, our report only addresses the conditions found related to the medical care
criteria. We do not discuss the causes of noncompliance, nor do we make specific recommendations in
this report. However, if we learn of an inmate-patient who needs immediate care, we notify the chief
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Office of the Inspector General State of California
medical officer and request a status report. Moreover, if we learn of significant departures from
community standards, we may report such departures to the institution’s chief medical officer or the
receiver’s office. Because these matters involve confidential medical information protected by state
and federal privacy laws, specific details related to these cases are not included in our report.
For ease of reference, following is a table of abbreviations used in the remainder of this report.
Abbreviations used in this report
AED Automatic External Defibrillator
BLS Basic Life Support
CMO Chief Medical Officer
CTC Correctional Treatment Center
CTQ Confined to Quarters
ERRC Emergency Response Review Committee
FTF Face-to-Face
GACH General Acute Care Hospital
HCM Health Care Manager
INH Isoniazid (antituberculous medication)
LVN Licensed Vocational Nurse
MOD Medical Officer of the Day
OB Obstetrician
OC Oleoresin Capsicum (pepper spray)
OHU Outpatient Housing Unit
OIG Office of the Inspector General
PCP Primary Care Provider
QMC Quality Management Committee
RN Registered Nurse
SOAPE Subjective, Objective, Assessment, Plan, Education
SRN Supervising Registered Nurse
TB Tuberculosis
TTA Triage and Treatment Area
UHR Unit Health Record
UM Utilization Management
Bureau of Audits and Investigations Page 6
Office of the Inspector General State of California
OFFICE OF THE INSPECTOR GENERAL PLEASANT VALLEY STATE PRISON
Overall Score:
MEDICAL INSPECTION RESULTS
64.5%
04/27/2009 – 04/30/2009
Answers Weighting Points Questions Not Answered
Component Page Yes No Yes + No Yes % Points Possible Points Received Score % Not Applicable Unknown
Chronic Care 8 120 90 210 57.1% 133 75.7 56.9% 2 13
Clinical Services 9 166 178 344 48.3% 95 44.4 46.7% 40 3
Health Screening 11 63 25 88 71.6% 52 34.9 67.1% 90 2
Specialty Services 12 60 32 92 65.2% 71 43.0 60.6% 50 2
Urgent Services 13 113 40 153 73.9% 59 47.5 80.5% 45 2
Emergency Services 14 35 5 40 87.5% 58 48.0 82.8% 7 3
Diagnostic Services 16 35 21 56 62.5% 52 33.6 64.6% 7 2
Access to Health Care Information 17 4 4 8 50.0% 51 32.0 62.7% 0 0
Internal Reviews 18 30 4 34 88.2% 40 28.2 70.5% 0 0
Inmate Transfers 19 15 5 20 75.0% 30 22.8 76.0% 5 0
Clinic Operations 20 25 3 28 89.3% 33 30.6 92.7% 0 0
Preventive Services 21 6 29 35 17.1% 30 8.2 27.3% 0 0
Pharmacy Services 22 9 2 11 81.8% 29 21.0 72.4% 0 0
Other Services 23 6 1 7 85.7% 10 7.0 70.0% 2 0
Inmate Hunger Strikes 24 1 2 3 33.3% 19 7.0 36.8% 0 0
Chemical Agent Contraindications 25 2 1 3 66.7% 8 5.3 66.3% 3 0
Staffing Levels and Training 26 4 4 8 50.0% 16 12.8 80.0% 1 0
Nursing Policy 27 15 0 15 100.0% 14 14.0 100.0% 0 0
Totals 709 446 1,155 61.4% 800 516 64.5% 252 27
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Office of the Inspector General State of California
Answers Weighting Points
Reference
Chronic Care
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
03.076 Was the inmate's most recent chronic care visit within the time frame required 18 7 25 72.0% 10 7.2 72.0% 0 0
by the degree of control of the inmate's condition based on his or her prior
visit?
03.077 Were key elements on Forms 7419 (Chronic Care Follow-Up Visit) and 7392 6 19 25 24.0% 10 2.4 24.0% 0 0
(Primary Care Flow Sheet) filled out completely for the inmate's two most
recent visits?
03.082 Did the institution document that it provided the inmate with health care 15 10 25 60.0% 12 7.2 60.0% 0 0
education?
03.175 Did the inmate receive his or her prescribed chronic care medications during 1 23 24 4.2% 18 0.8 4.2% 1 0
the most recent three-month period or did the institution follow departmental
policy if the inmate refused to pick up or show up for his or her medications?
03.235 Is the clinical history adequate? 11 14 25 44.0% 18 7.9 44.0% 0 0
03.236 Is the focused clinical examination adequate? 18 7 25 72.0% 19 13.7 72.0% 0 0
03.237 Is the assessment adequate? 12 7 19 63.2% 19 12.0 63.2% 1 5
03.238 Is the plan adequate and consistent with the degree of control based on the 15 2 17 88.2% 19 16.8 88.2% 0 8
chronic care program intervention and follow up requirements?
03.262 Is the inmate's Problem List complete and filed accurately in the inmate's unit 24 1 25 96.0% 8 7.7 96.0% 0 0
health record (UHR)?
Components Subtotals: 120 90 210 57.1% 133 75.7 56.9% 2 13
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Office of the Inspector General State of California
Answers Weighting Points
Reference
Clinical Services
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
01.024 RN FTF Documentation: Did the inmate's request for health care get reviewed 26 4 30 86.7% 4 3.5 86.7% 0 0
the same day it was received?
01.025 RN FTF Documentation: Did the RN complete the face-to-face (FTF) triage 10 20 30 33.3% 6 2.0 33.3% 0 0
within one (1) business day after the Form 7362 was reviewed?
01.246 Did documentation indicate that the RN reviewed all of the inmate's 20 10 30 66.7% 5 3.3 66.7% 0 0
complaints listed on Form 7362 (Health Care Services Request Form)?
01.157 RN FTF Documentation: Did the RN's subjective note address the nature and 15 15 30 50.0% 7 3.5 50.0% 0 0
history of the inmates primary complaint?
01.159 RN FTF Documentation: Did the RN's objective note include vital signs and a 16 14 30 53.3% 6 3.2 53.3% 0 0
focused physical examination, and did it adequately address the problems
noted in the subjective note?
01.244 RN FTF Documentation: Did the RN's objective note include allergies, weight, 10 20 30 33.3% 3 1.0 33.3% 0 0
current medication, and where appropriate, medication compliance?
01.158 RN FTF Documentation: Did the RN's assessment provide conclusions based 10 20 30 33.3% 6 2.0 33.3% 0 0
on subjective and objective data, were the conclusions formulated as patient
problems, and did it contain applicable nursing diagnoses?
01.162 RN FTF Documentation: Did the RN's plan include an adequate strategy to 19 11 30 63.3% 7 4.4 63.3% 0 0
address the problems identified during the FTF triage?
01.163 RN FTF Documentation: Did the RN's education/instruction adequately 17 13 30 56.7% 5 2.8 56.7% 0 0
address the problems identified during the FTF triage?
01.027 If the RN determined a referral to a primary care physician (PCP) was 9 10 19 47.4% 8 3.8 47.4% 11 0
necessary, was the inmate seen within the timelines specified by the RN during
the FTF triage?
01.247 Sick Call Follow-up: If the provider ordered a follow-up sick call appointment, 4 7 11 36.4% 7 2.5 36.4% 18 1
did it take place within the time frame specified?
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Office of the Inspector General State of California
Answers Weighting Points
Reference
Clinical Services
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
01.124 Sick Call Medication: Did the institution administer or deliver prescription 3 24 27 11.1% 6 0.7 11.1% 3 0
medications (new orders) to the inmate within specified time frames?
15.234 Are clinic response bags audited daily and do they contain essential items? 2 0 2 100.0% 5 5.0 100.0% 0 0
21.278 Was there adequate prior management of pre-existing medical conditions that 5 10 15 33.3% 20 6.7 33.3% 8 2
contributed to the need for the TTA visit?
Components Subtotals: 166 178 344 48.3% 95 44.4 46.7% 40 3
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Office of the Inspector General State of California
Answers Weighting Points
Reference
Health Screening
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
02.016 Did the institution complete the initial health screening on the same day the 13 7 20 65.0% 9 5.9 65.0% 0 0
inmate arrived at the institution?
02.017 If yes was answered to any of the questions on the initial health screening 7 3 10 70.0% 8 5.6 70.0% 10 0
form(s), did the RN provide an assessment and disposition on the date of
arrival?
02.018 If, during the assessment, the RN referred the inmate to a clinician, was the 5 2 7 71.4% 8 5.7 71.4% 13 0
inmate seen within the time frame?
02.020 Did the LVN/RN adequately document the tuberculin test or a review of signs 17 3 20 85.0% 6 5.1 85.0% 0 0
and symptoms if the inmate had a previous positive tuberculin test?
02.015 Was a review of symptoms completed if the inmate's tuberculin test was 0 0 0 0.0% 0 0.0 0.0% 20 0
positive, and were the results reviewed by the infection control nurse?
02.128 If the inmate had an existing medication order upon arrival at the institution, 0 9 9 0.0% 8 0.0 0.0% 10 1
did the inmate receive the medications by the next calendar day, or did a
physician explain why the medications were not to be continued?
02.007 Non-reception center: Does the health care transfer information form indicate 18 1 19 94.7% 7 6.6 94.7% 0 1
that it was reviewed and signed by licensed health care staff within one
calendar day of the inmate's arrival at the institution?
02.014 Non-reception center: If the inmate was scheduled for a specialty appointment 0 0 0 0.0% 0 0.0 0.0% 20 0
at the sending institution, did the receiving institution schedule the appointment
within 30 days of the original appointment date?
02.111 Non-reception center: Did the inmate receive medical accommodations upon 3 0 3 100.0% 6 6.0 100.0% 17 0
arrival, if applicable?
Components Subtotals: 63 25 88 71.6% 52 34.9 67.1% 90 2
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Office of the Inspector General State of California
Answers Weighting Points
Reference
Specialty Services
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
07.037 Did the institution approve or deny the PCP's request for specialty services 19 3 22 86.4% 8 6.9 86.4% 0 0
within the specified time frames?
07.038 Did the PCP see the inmate between the date the PCP ordered the service and 1 11 12 8.3% 8 0.7 8.3% 9 1
the date the inmate received it, in accordance with specified time frames?
07.035 Did the inmate receive the specialty service within specified time frames? 11 5 16 68.8% 9 6.2 68.8% 5 1
07.090 Physical therapy services: Did the physical therapist assess the inmate and 2 0 2 100.0% 8 8.0 100.0% 20 0
document the treatment plan and treatment provided to the inmate?
07.043 Did the PCP review the consultant's report and see the inmate for a follow-up 5 9 14 35.7% 9 3.2 35.7% 8 0
appointment after the specialty services consultation within specified time
frames?
07.260 Was the institution's denial of the PCP's request for specialty services 5 0 5 100.0% 9 9.0 100.0% 0 0
consistent with the "medical necessity" requirement?
07.259 Was there adequate documentation of the reason for the denial of specialty 3 2 5 60.0% 5 3.0 60.0% 0 0
services?
07.270 Did the specialty provider provide timely findings and recommendations or did 14 0 14 100.0% 6 6.0 100.0% 8 0
an RN document that he or she called the specialty provider to ascertain the
findings and recommendations?
07.261 Is the institution scheduling high-priority (urgent) specialty services within 14 0 2 2 0.0% 9 0.0 0.0% 0 0
days?
Components Subtotals: 60 32 92 65.2% 71 43.0 60.6% 50 2
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Office of the Inspector General State of California
Answers Weighting Points
Reference
Urgent Services
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
21.248 Upon the inmate's discharge from the community hospital, did the triage and 22 3 25 88.0% 7 6.2 88.0% 0 0
treatment area (TTA) registered nurse document that he or she reviewed the
inmate's discharge plan and completed a face-to-face assessment of the inmate?
21.250 Upon the inmate's discharge from the community hospital, did the inmate's 24 1 25 96.0% 7 6.7 96.0% 0 0
Primary Care Provider (PCP) provide orders for appropriate housing for the
inmate?
21.251 Upon the inmate's discharge from the community hospital, did the Registered 1 0 1 100.0% 7 7.0 100.0% 24 0
Nurse intervene if the inmate was housed in an area that was inappropriate for
nursing care based on the primary care provider's (PCP) housing orders?
21.249 Upon the inmate's discharge from the community hospital, did the inmate 14 10 24 58.3% 7 4.1 58.3% 1 0
receive a follow-up appointment with his or her primary care provider (PCP)
within five calendar days of discharge?
21.281 Upon the inmate's discharge from a community hospital, did the institution 3 20 23 13.0% 6 0.8 13.0% 2 0
administer or deliver all prescribed medications to the inmate within specified
time frames?
21.275 Was the documentation of the clinical care provided in the TTA adequate? 20 5 25 80.0% 10 8.0 80.0% 0 0
21.276 While the patient was in the TTA, was the clinical care rendered by the 23 1 24 95.8% 7 6.7 95.8% 0 1
attending provider adequate and timely?
21.279 For patients managed by telephone consultation alone, was the provider's 6 0 6 100.0% 8 8.0 100.0% 18 1
decision not to come to the TTA appropriate?
Components Subtotals: 113 40 153 73.9% 59 47.5 80.5% 45 2
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Office of the Inspector General State of California
Answers Weighting Points
Reference
Emergency Services
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
08.183 Was the medical emergency responder notified of the medical emergency 3 0 3 100.0% 5 5.0 100.0% 1 1
without delay?
08.241 Did the first responder provide adequate basic life support (BLS) prior to 4 0 4 100.0% 6 6.0 100.0% 0 1
medical staff arriving?
08.184 Did the medical emergency responder arrive at the location of the medical 3 1 4 75.0% 4 3.0 75.0% 0 1
emergency within five (5) minutes of initial notification?
08.185 Did the medical emergency responder use proper equipment to address the 5 0 5 100.0% 7 7.0 100.0% 0 0
emergency and was adequate medical care provided within the scope of his or
her license?
08.242 Did licensed health care staff call 911 without unnecessary delay after a life- 3 0 3 100.0% 6 6.0 100.0% 2 0
threatening condition was identified by a licensed health care provider or peace
officer?
08.187 Did the institution provide adequate preparation for the ambulance's arrival, 3 0 3 100.0% 4 4.0 100.0% 2 0
access to the inmate, and departure?
08.186 Were both the first responder (if peace officer or licensed health care staff) and 5 0 5 100.0% 4 4.0 100.0% 0 0
the medical emergency responder basic life support (BLS) certified at the time
of the incident?
08.222 Were the findings of the institution's Emergency Response Review Committee 0 3 3 0.0% 7 0.0 0.0% 2 0
(ERRC) supported by the documentation and completed within 30 days?
15.240 Emergency Medical Response Drill: Did the responding officer activate the 1 0 1 100.0% 2 2.0 100.0% 0 0
emergency response system by providing the pertinent information to the
relevant parties, immediately and without delay?
15.255 Emergency Medical Response Drill: Did the responding officer carry and use 1 0 1 100.0% 1 1.0 100.0% 0 0
the proper equipment (protective shield or micro-mask, gloves) required by the
department?
Bureau of Audits and Investigations Page 14
Office of the Inspector General State of California
Answers Weighting Points
Reference
Emergency Services
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
15.256 Emergency Medical Response Drill: Did the responding officer properly 1 0 1 100.0% 1 1.0 100.0% 0 0
perform an assessment on the patient for responsiveness?
15.257 Emergency Medical Response Drill: Did the responding officer properly 1 0 1 100.0% 2 2.0 100.0% 0 0
perform CPR?
15.258 Emergency Medical Response Drill: Did the responding officer begin CPR 1 0 1 100.0% 2 2.0 100.0% 0 0
without unecessary delay?
15.282 Emergency Medical Response Drill: Did medical staff arrive on scene in five 1 0 1 100.0% 2 2.0 100.0% 0 0
minutes or less?
15.283 Emergency Medical Response Drill: Did the emergency medical responders 1 0 1 100.0% 1 1.0 100.0% 0 0
arrive with proper equipment (ER bag, bag-valve-mask, AED)?
15.284 Emergency Medical Response Drill: Did the responding officer provide 1 0 1 100.0% 1 1.0 100.0% 0 0
accurate information to responding medical staff?
15.285 Emergency Medical Response Drill: Did emergency medical responders 1 0 1 100.0% 1 1.0 100.0% 0 0
continue basic life support?
15.287 Emergency Medical Response Drill: Was 911 called without unnecessary 0 1 1 0.0% 2 0.0 0.0% 0 0
delay?
Components Subtotals: 35 5 40 87.5% 58 48.0 82.8% 7 3
Bureau of Audits and Investigations Page 15
Office of the Inspector General State of California
Answers Weighting Points
Reference
Diagnostic Services
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
06.049 Radiology order: Was the radiology service provided within the time frame 4 1 5 80.0% 7 5.6 80.0% 0 0
specified in the physician's order?
06.245 Radiology order: Was the diagnostic report received by the institution within 5 0 5 100.0% 8 8.0 100.0% 0 0
14 days?
06.200 Radiology order: Did the primary care provider (PCP) review the diagnostic 0 5 5 0.0% 7 0.0 0.0% 0 0
report and initiate written notice to the inmate within two (2) business days of
the date the institution received the diagnostic reports?
06.188 All laboratory orders: Was the specimen collected within the applicable time 7 3 10 70.0% 6 4.2 70.0% 0 0
frames of the physician's order?
06.191 All diagnostic services: Did the PCP document the clinically significant 8 3 11 72.7% 7 5.1 72.7% 4 0
diagnostic test results on Form 7230 (Interdisciplinary Progress Notes)?
06.263 All diagnostic services: Did the PCP adequately manage clinically significant 10 0 10 100.0% 10 10.0 100.0% 3 2
test results?
06.202 All laboratory orders: Did the PCP review the diagnostic reports and initiate 1 9 10 10.0% 7 0.7 10.0% 0 0
written notice to the inmate within two (2) business days of the date the
institution received the diagnostic reports?
Components Subtotals: 35 21 56 62.5% 52 33.6 64.6% 7 2
Bureau of Audits and Investigations Page 16
Office of the Inspector General State of California
Answers Weighting Points
Reference
Access to Health Care Information
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
19.150 Is the medical records office current with its loose filing? 0 1 1 0.0% 9 0.0 0.0% 0 0
19.169 Did medical records staff make unit health records (UHR) available to clinic 2 0 2 100.0% 15 15.0 100.0% 0 0
staff for the inmates ducated for medical appointments the next day?
19.243 Was the institution able to account for the OIG's requested UHR files? 1 0 1 100.0% 12 12.0 100.0% 0 0
19.266 Does the institution properly file inmates' medical information? 0 1 1 0.0% 5 0.0 0.0% 0 0
19.271 While reviewing unit health records (UHR) as part of the OIG's inspection, 1 0 1 100.0% 5 5.0 100.0% 0 0
were the OIGs RN and MD inspectors able to locate all relevant documentation
of health care provided to inmates?
19.272 Does the institution promptly file blood pressure logs in unit health records 0 2 2 0.0% 5 0.0 0.0% 0 0
(UHR)?
Components Subtotals: 4 4 8 50.0% 51 32.0 62.7% 0 0
Bureau of Audits and Investigations Page 17
Office of the Inspector General State of California
Answers Weighting Points
Reference
Internal Reviews
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
17.221 Did the institution complete a medical emergency response drill for each watch 0 1 1 0.0% 5 0.0 0.0% 0 0
and include participation from each medical facility during the most recent full
quarter?
17.174 Did the institution promptly process inmate medical appeals during the most 0 1 1 0.0% 5 0.0 0.0% 0 0
recent 12 months?
17.136 For each death sampled, did the institution complete the death review process? 4 1 5 80.0% 5 4.0 80.0% 0 0
17.132 Do the Emergency Response Review Committee (ERRC) meeting minutes 6 0 6 100.0% 5 5.0 100.0% 0 0
document monthly meetings for the last six (6) months?
17.138 Do the Emergency Response Review Committee (ERRC) meeting minutes 5 1 6 83.3% 5 4.2 83.3% 0 0
document the warden's (or his or her designee's) attendance?
17.118 Do the Quality Management Committee (QMC) meeting minutes document 6 0 6 100.0% 5 5.0 100.0% 0 0
monthly meetings for the last six (6) months?
17.119 Did the Quality Management Committee (QMC) report its findings to the 6 0 6 100.0% 5 5.0 100.0% 0 0
HCM/CMO each of the last six (6) meetings?
17.135 Did the last three Quality Management Committee (QMC) meeting minutes 3 0 3 100.0% 5 5.0 100.0% 0 0
reflect findings and strategies for improvement?
Components Subtotals: 30 4 34 88.2% 40 28.2 70.5% 0 0
Bureau of Audits and Investigations Page 18
Office of the Inspector General State of California
Answers Weighting Points
Reference
Inmate Transfers
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
05.108 Did Receiving and Release have the inmate's UHR and transfer envelope? 5 0 5 100.0% 7 7.0 100.0% 0 0
05.109 If the inmate was scheduled for any upcoming specialty services, were the 0 0 0 0.0% 0 0.0 0.0% 5 0
services noted on Form 7371 (Health Care Transfer Information)?
05.110 Do all appropriate forms in the transfer envelope identify all medications 4 1 5 80.0% 8 6.4 80.0% 0 0
ordered by the physician, and are the medications in the transfer envelope?
05.171 Did an RN accurately complete all applicable sections of Form 7371 (Health 1 4 5 20.0% 7 1.4 20.0% 0 0
Care Transfer Information) based on the inmate's UHR?
05.172 Did the Health Records Department maintain a copy of the inmate's Form 7371 5 0 5 100.0% 8 8.0 100.0% 0 0
(Health Care Transfer Information) and Form 7231A (Outpatient Medication
Administration Record) when the inmate transferred?
Components Subtotals: 15 5 20 75.0% 30 22.8 76.0% 5 0
Bureau of Audits and Investigations Page 19
Office of the Inspector General State of California
Answers Weighting Points
Reference
Clinic Operations
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
14.023 Does the institution make the Form 7362 (Health Care Services Request Form) 5 1 6 83.3% 4 3.3 83.3% 0 0
available to inmates?
14.164 Are areas available to ensure privacy during RN face-to-face assessments and 3 0 3 100.0% 3 3.0 100.0% 0 0
doctors' examinations for non-emergencies?
14.166 Was the medication stored in a sealed container if food was present in the 2 0 2 100.0% 2 2.0 100.0% 0 0
clinic refrigerator?
14.131 Do medication nurses understand that medication is to be administered by the 2 0 2 100.0% 4 4.0 100.0% 0 0
same licensed staff member who prepares it and on the same day?
14.106 Does clinical staff wash their hands (either with soap or hand sanitizer) or 3 1 4 75.0% 4 3.0 75.0% 0 0
change gloves between patients?
14.033 Does the institution have an adequate process to ensure inmates who are 2 0 2 100.0% 4 4.0 100.0% 0 0
moved to a new cell still receive their medical ducats?
14.032 Does medical staff understand the institution's priority ducat process? 2 0 2 100.0% 2 2.0 100.0% 0 0
14.160 Does the institution have a process to identify, review, and address urgent 2 0 2 100.0% 4 4.0 100.0% 0 0
appointments if a doctor's line is canceled?
14.029 Does medical staff in the facility clinic know which inmates are on modified 2 0 2 100.0% 4 4.0 100.0% 0 0
program or confined to quarters (CTQ) and does staff have an adequate process
to ensure those inmates receive their medication?
14.165 Are the clinic floors, waiting room chairs, and equipment cleaned with a 2 1 3 66.7% 2 1.3 66.7% 0 0
disinfectant daily?
Components Subtotals: 25 3 28 89.3% 33 30.6 92.7% 0 0
Bureau of Audits and Investigations Page 20
Office of the Inspector General State of California
Answers Weighting Points
Reference
Preventive Services
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
10.228 Inmates prescribed INH: Did the institution properly administer the medication 1 4 5 20.0% 6 1.2 20.00% 0 0
to the inmate?
10.232 Inmates prescribed INH: Did the institution monitor the inmate monthly for the 0 5 5 0.0% 6 0.0 0.0% 0 0
most recent three months he or she was on the medication?
10.229 Inmates with TB code 34: Was the inmate evaluated for signs and symptoms of 5 0 5 100.0% 7 7.0 100.0% 0 0
TB within the previous 12 months?
10.086 All inmates age 66 or older: Did the inmate receive an influenza vaccination 0 10 10 0.0% 6 0.0 0.0% 0 0
within the previous 12 months or was the inmate's refusal documented?
10.085 Male inmates age 51 or older: Did the inmate receive a fecal occult blood test 0 10 10 0.0% 5 0.0 0.0% 0 0
(FOBT) within the previous 12 months or was the inmate's refusal
documented?
Components Subtotals: 6 29 35 17.1% 30 8.2 27.3% 0 0
Bureau of Audits and Investigations Page 21
Office of the Inspector General State of California
Answers Weighting Points
Reference
Pharmacy Services
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
13.139 Does the institution conspicuously post a valid permit in its pharmacies? 1 0 1 100.0% 2 2.0 100.0% 0 0
13.141 Does the institution properly maintain its emergency crash cart medications? 2 0 2 100.0% 2 2.0 100.0% 0 0
13.252 Does the institution properly maintain medications in its drug night locker(s)? 0 1 1 0.0% 2 0.0 0.0% 0 0
13.253 Does the institution conduct monthly inspections of its emergency cart and 3 0 3 100.0% 1 1.0 100.0% 0 0
drug night locker(s)?
13.142 Is the Pharmacist in Charge's license current? 1 0 1 100.0% 5 5.0 100.0% 0 0
13.144 Does the institution have information to ensure that medications are prescribed 0 1 1 0.0% 6 0.0 0.0% 0 0
by licensed health-care providers lawfully authorized to do so?
13.145 Does the pharmacist in charge have an effective process for screening new 1 0 1 100.0% 7 7.0 100.0% 0 0
medication orders for potential adverse reactions?
13.148 Does the pharmacist in charge monitor the quantity of medications on hand, 1 0 1 100.0% 4 4.0 100.0% 0 0
and does the pharmacy conduct an annual inventory to ensure that the quantity
of medications in the system matches the quantity of medications on hand?
Components Subtotals: 9 2 11 81.8% 29 21.0 72.4% 0 0
Bureau of Audits and Investigations Page 22
Office of the Inspector General State of California
Answers Weighting Points
Reference
Other Services
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
15.059 Did the institution properly provide therapeutic diets to inmates? 0 0 0 0.0% 0 0.0 0.0% 1 0
20.092 Hygiene Intervention: Did custody staff understand the department's policies 4 0 4 100.0% 4 4.0 100.0% 0 0
and procedures for identifying and evaluating inmates displaying inappropriate
hygiene management?
15.058 If the institution does not offer therapeutic diets, does staff know the 0 1 1 0.0% 3 0.0 0.0% 0 0
department's procedures for transferring inmates who are determined to require
a therapeutic diet?
15.134 Did the institution properly respond to all active cases of TB discovered in the 0 0 0 0.0% 0 0.0 0.0% 1 0
last six months?
15.265 Is the most current version of the CDCR Health Services Policies and 2 0 2 100.0% 3 3.0 100.0% 0 0
Procedures available in the institution's law library?
Components Subtotals: 6 1 7 85.7% 10 7.0 70.0% 2 0
Bureau of Audits and Investigations Page 23
Office of the Inspector General State of California
Answers Weighting Points
Reference
Inmate Hunger Strikes
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
11.097 Did the RN conduct a face-to-face triage of the inmate within two (2) business 0 1 1 0.0% 6 0.0 0.0% 0 0
days of receipt of the Form 128-B and document the inmate's reasons for the
hunger strike, most recent recorded weight, current weight, vital signs, and
physical condition?
11.099 After the first 48 hours, did an RN or PCP complete daily assessments 0 1 1 0.0% 6 0.0 0.0% 0 0
documenting the inmate's weight, physical condition, emotional condition,
vital signs, and hydration status?
11.100 After the first 72 hours, did a physician perform a physical examination and 1 0 1 100.0% 7 7.0 100.0% 0 0
order a metabolic panel and a urinalysis of the inmate?
Components Subtotals: 1 2 3 33.3% 19 7.0 36.8% 0 0
Bureau of Audits and Investigations Page 24
Office of the Inspector General State of California
Answers Weighting Points
Reference
Chemical Agent Contraindications
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
12.062 Did the institution document that it consulted with an RN or primary care 0 0 0 0.0% 0 0.0 0.0% 3 0
provider (PCP) before a calculated use of OC?
12.064 Did the institution record how it decontaminated the inmate and did it follow 2 1 3 66.7% 8 5.3 66.7% 0 0
the decontamination policy?
Components Subtotals: 2 1 3 66.7% 8 5.3 66.3% 3 0
Bureau of Audits and Investigations Page 25
Office of the Inspector General State of California
Answers Weighting Points
Reference
Staffing Levels and Training
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
18.002 Information purposes only: Calculate the institution's average vacancy 0 0 0 0.0% 0 0.0 0.0% 1 0
percentages, the number of health care staff starting within six (6) months of
the OIG visit, and the number of health care staff hired from the registry.
The institution provided vacancy statistics within four licensed medical staffing
groups: (1) management; (2) primary care providers; (3) supervision; and (4)
rank and file nursing.
Total number of filled positions: 67
Total number of vacancies: 26.71
Total number of positions: 93.71
Vacancy percentage: 28.50%
Number of staff hired within last six months: 14
Total number of registry staff: 67
18.004 Did the institution have a registered nurse (RN) available on site 24 hours a 1 0 1 100.0% 4 4.0 100.0% 0 0
day, seven days a week, for emergency care?
18.005 Did the institution have a physician on site, a physician on call, or an MOD 1 0 1 100.0% 4 4.0 100.0% 0 0
available 24 hours a day, seven days a week, for the last 30 days?
18.006 Does the institution's orientation program for all newly hired nursing staff 1 0 1 100.0% 4 4.0 100.0% 0 0
include a module for sick call protocols that require face-to-face triage?
18.001 Are licensed health care staff current with their certifications and did they 1 4 5 20.0% 4 0.8 20.0% 0 0
attend required training?
Components Subtotals: 4 4 8 50.0% 16 12.8 80.0% 1 0
Bureau of Audits and Investigations Page 26
Office of the Inspector General State of California
Answers Weighting Points
Reference
Nursing Policy
Number Yes No Yes + No Yes % Possible Received Score % N/A Unk
16.231 Does the institution ensure that nursing staff review their duty statements? 5 0 5 100.0% 5 5.0 100.0% 0 0
16.154 Does the institution have written nursing policies and procedures that adhere to 5 0 5 100.0% 5 5.0 100.0% 0 0
the department's guidelines?
16.254 Does the institution's supervising registered nurse (SRN) conduct periodic 5 0 5 100.0% 4 4.0 100.0% 0 0
reviews of nursing staff?
Components Subtotals: 15 0 15 100.0% 14 14.0 100.0% 0 0
Bureau of Audits and Investigations Page 27
Office of the Inspector General State of California
California Prison Health Care
Receivership Corporation's
Response
Bureau of Audits and Investigations Page 28
Office of the Inspector General State of California
STATE OF CALIFORNIA J. Clark Kelso, Receiver
PRISON HEALTH CARE SERVICES
July 9, 2009
David R. Shaw, Inspector General
Office ofthe Inspector General
P.O. Box 348780
Sacramento, CA 95834-8780
Dear Mr. Shaw,
The purpose of this letter is to inform you that the Office of the Receiver has reviewed the draft
report of the Office of the Inspector General's (OIG) Medical Inspection Results (MIR) for the
April 2009 inspection of Pleasant Valley State Prison (PVSP). At this time, we would like to
address the following conditions raised as a result ofthe MIR.
Chronic Care-Reference Numbers -03.077, 03.082 and 03.235
The OIG found the key elements on Form 7419 (Chronic Care Follow-up Visit) and Form 7392
(Primary Care Flow Sheet) were not filled out completely. PVSP continues to experience high
turn-over of Primary Care Providers (PCP) as a result of heavy usage of registry staff to fill vacant
state positions. Every effort is made to ensure that all PCPs (Including Registry) receive orientation
and mentoring. PVSP will continue to utilize the peer review process to aid in the development of
providers. Training is on-going for the PCPs for accurate and thorough completion of appropriate
CDCRForms.
Chronic Care -Reference Number 03.175
Urgent Services - Reference Number 21.281
The OIG found the institution did not administer or deliver prescription medications to the
patient-inmates within specified timeframes outlined in the Policy and Procedure (P&P). The
Medication Administration Record (MAR) and Prescription Data reviewed during the course of the
OIG inspection were reviewed by PVSP personnel for additional information. The nurse educator is
scheduling continued training for all nursing staff to address MAR documentation. Pursuant to
policy, all Keep on Person (KOP) MARs are to be dated and signed by the patient-inmate upon
receipt of his medication(s). Direct Observation Therapy (DOT) MARs are to be used pursuant to
policy and nursing staff shall appropriately document refusals on the back of the MAR. In addition,
the Medication Licensed Vocational Nurse (LVN) shall complete the CDC 7225-Refusal of
Examination and/or Treatment and have the patient-inmate sign. PVSP shall continue to utilize a
weekly medication audit tool to verify the accuracy and completion of the MAR. The weekly
medication audit tool will also verify refusals and no shows.
P.O. Box 4038. Sacramento, CA 95812-4038
David R. Shaw, Inspector General
July 13, 2009
Page 2
Clinical Services -Reference Numbers 01.025
The OIG found the Registered Nurse (RN) did not complete the Face-to-Face (FTF) triage within
one business day after Form 7362 was reviewed. RN shortages and lack of available confidential
consulting rooms in the medical clinics contributed to tIle delay in RN FTF triage. With the recent
activation of the Health Care Access Unit, additional custody positions were created for medical
escorting and medical clinic coverage. In addition, with the recent implementation of the Primary
Care Model, the RNs and Office Technicians (OT) CaIl verify tinleliness of the 7362's in the daily
huddle. In-service training has been initiated and PVSP plans for ongoing training in completing the
7362s, addressing the patient-inmates complaint, and problems identified during FTF triage.
Clinical Services -Reference Numbers 01.157, 01.158, 01.163
The OIG found that during FTF triage, the RN did not consistently document the patient-inmate's
primary complaint, vital signs, focused physical examination, allergies, weigllt, current medication,
medication allergies and medication compliance. In addition, the RN assessment should provide
conclusions, education and instruction based on subjective and objective data. PVSP is providing
in-service training to address specific areas and plan for ongoing training in completing the 7362s.
Clinical Services -Reference Numbers 01.027, 01.247
The OIG found that patient-inmates were not seen within the specified timeframes outlined in the
P&P. The nledical sclledulers make every effort to schedule patient-inmates as ordered. However,
inadequate clinical space and provider shortages continue to limit efforts to schedule all
patient-inmates witllin the specified timeframes. Since the implementation of the Primary Care
Model, the medical schedulers, providers, and RNs meet daily in the huddle to discuss ways to
enSlrre patient-inmates are seen within the appropriate timeframes.
Clinical Services -Reference Number 01.124
The OIG found the institution did not administer or deliver prescription medications to the
patient-inmates within the specified tinleframes outlined in the P&P. PVSP was experiencing a
high volume of nursing staff turnover. Due to the nursing staffing issues, many of the vacancies
were filled with registry personnel. In addition to the nursing staffing issues, the lack of available
medical space hindered their ability to adnlinister or deliver prescriptiollS witllin tIle required
timeframes. At this time, the Medical Sub-Committee has chartered two Quality Improvement
Teams (QITs) to address the timeliness of medication refills and administration. PVSP will
continue to provide medication delivery training and education.
David R. Shaw, Inspector General
July 13, 2009
Page 3
Urgent Services -Reference Number 21.278
PVSP continues to struggle with PCP shortages and inadequate clinical space. Vacant state
positions are filled witll registry providers causing a high turnover rate. Due to the instability of
PCPs, continuity of care is oftel1 compromised. PVSP recently implemented the Primary Care
Model and the Primary Care Teams are attending their daily huddles to address chronic care issues,
continuity of care, specialty appointments, TTA Visits, Hospital Discharges, etc. PVSP will
continue to use quality improvement tools including peer review, death review, grand r0U11ds, high
risk review and Medication Administration Review Committee (MARC) meetings to monitor the
quality and quantity of care patient-inmates are receiving.
Health Screening -Reference Number 02.128
The OIG found that medications were not delivered within the specified timeframes for
patient-inmates that arrived through Receiving and Release (R&R). PurSUaIlt to Operations
Procedure 101-Medication Management, all patient-inmate medications are to be honored through
R&R lmtil the patient-inmate is seen by his PCP at the initial evaluation. Due to the implementation
of the Guardian Program (Official Roll-Out Date: 1/20/09) at PVSP, the institution llas experienced
delays in meeting tIle 24-hour reqllirenlent. The Medical Sub-Committee has chartered two QITs to
address the timeliness ofmedication refills and administration.
Specialty Services -Reference Numbers 07.038, 07.043
The OIG found the patient-inmates were not seen within the specified timeframes outlined in the
P&P. At the time of the OIG Audit, PVSP was operating at 56% of position·-authority
(including Registry Staf!). Due to the PCP shortages, many of the facilities experienced backlogs.
With the introduction of the InterQual System, ·PVSP has seen a reduction in the nlmlber of
approved Referral for Services (RFS). 111 addition, the Health Care Access Unit was recently
activated at PVSP thus providing additional resources for the nledical department. With the recent
implementation of the Primary Care Model, all On-Site Specialty Appointments, Off-Site Specialty
Appointments, TTA Visits and Hospital Discharges are discussed the following morning in the
daily huddle. PVSP will continue to make every effort to ensure patient-inmates are seen within the
required timeframes.
Specialty Services -Reference Nuntbers 07.259
The OIG found the institution did not adequately document the reason for the denial of specialty
services. Prior to the inlplementation of InterQual, PVSP kept records of cases reviewed by MARC,
but did not keep lengthy details of the denials. With the June 2009 implementation of InterQual,
there is a specific process that clearly explains why a specialty service is denied. InterQual criteria
are applied to all RFS at PVSP.
David R. Shaw, Inspector General
July 13, 2009
Page 4
Emergency Services -Reference Number 08.222
The OIG fowld the institutions Emergency Response Review Committee (ERRC) findings were not
supported by the documelltation and were not completed within 30 days. The ERRC was meeting
every 30 days (as was done in prior practice) to revi~w cases from prior months. PVSP will adjust
the calendar to ensure cases are reviewed wit~n 30 days ofthe incident date.
Emergency Services -Reference Nunlber 15.287
The OIG .found the institution did not initiate a simulated 911 call during an emergency medical
response drill as reqllired by policy. In-service training will be conducted regarding Operations
Procedure 115-Urgellt/Emergent Response and will address the appropriate criteria and guidelines
for calling 911.
Diagnostic Services -Reference Number 06.200 and 06.202
The OIG found the institution did not review diagnostic reports for Radiology and Laboratory
orders and initiate written notice to tIle patient-inmate within the specified timeframes as outlined in
the P&P. PVSP has implemented a new tracking and PCP review system. Radiology and
Laboratory personnel are currently delivering reports to the medical records department. An OT in
medical records is responsible for completing the CDC 7393-Notification of Diagnostic Results.
The CDC 7393, radiology and laboratory reports, are placed in a designated area by Yard. The PCP
for every yard is required to stop by medical records each morning to review the diagnostic results
and sign off on the CDC 7393. Upon completion of the CDC 7393, medical records staff sends a
copy to the patient-inmate and sclledulers. The original CDC 7393, radiology, and laboratory report
is filed in the Unit Health Record (UHR).
Access to Health Care Infornlation -Reference Number 19.150
The OIG found the Medical Records Office was not current with its loose filing. With the
implemelltation of the Guardiatl Program (Phannacy), the amount of loose filing has increased by
300%. Medical Records staff continues to work overtime in an attempt to reduce the backlog of
loose filing.
Internal Reviews -Reference Number 17.221
The OIG found the institution did not complete the required fonns as outlined in the P&P. PVSP
follows Chapter 12-Al, subsection IV of the Enlergency Medical Response Program Policy and
Procedures (2008) which includes participation of llealthcare staff and custody during medical
emergency response drills. As noted, a Medical Emergency Response Drill for each watch was
conducted dlrriIlg the nlost recent quarter. Although tIle drills were conducted, the appropriate
documentation was not completed as required in Chapter 12-Al. PVSP shall conduct additional
David R. Shaw, Inspector General
July 13, 2009
Page 5
in-service training with staff to ensure compliance with the Emergency Medical Response Program
Policy.
Inmate Transfers -Reference Number 05.171
The OIG found the instiultion did not accurately conlplete all applicable sections of Form 7371
(Health Care Transfer Form) based on the UHR. Ill-service training shall be provided to ensure
accuracy in completing all applicable sections ofthe CDC 7371.
Preventive Senrice -Referellce Number 10.228
The OIG found the instiultion did not properly administer the prescribed INH medication to the
patient-inmate. In-Service training will continue to be provided to nursillg staff on proper
medication adnlinistratioll.
Preventive Senrices -Reference Number 10.232
The OIG found the institution did not properly monitor the patient-inmates monthly as outlined in
the P&P. In-service training shall be provided to the medical staff to ensure patient-inmates are
monitored monthly when prescribed INH therapy.
Pharmacy Senrices -Reference Number 13.252
The OIG found expired medications in the night drug locker. The phamlacy staff continues to
complete regular audits ofthe drug night locker. The Pharmacist in Charge or designee shall double
check tIle audits ofthe drug night lockers to ensure acclrracy and accountability.
Inmate Hunger Strike -Reference Numbers 11.097, 11.099
The OIG found the institution did not conduct FTF triage within two business days or document the
reason for the hunger strike. Also, the patient-inmate's, weight, physical condition, emotional
condition, vital signs and hydration status were not documented. The Nurse Instructor provided
in-service training regarding hunger-strike protocol and the SRNs shall ensure all staff members are
trained and the hunger strike protocol is followed.
Staffmg Levels and Training -Reference Number 18.001
The OIG found the institution staff had not completed New Employee Orientation (NEO) or Health
Care New Employee Orientation (HCNEO). PVSP managers will ensure all state employees attend
NEO or HCNEO as a COlldition ofemployment.
David R. Shaw, Inspector General
July 13, 2009
Page 6
In addition to the items idel1tified above, the OIG draft report contains other findings with a low
reported rate of compliance. A number of findings are being addressed by statewide initiatives or
other resources designed to achieve a constitutional level of health care. For those items that are not
addressed by a statewide initiative, California Prison Health Care Services (CPHCS) staffwill work
with the institution to develop a Corrective Action Plan (CAP). Once a CAP is submitted and
approved, CPHCS staffwill monitor and follow-up on any corrective action identified.
Thank you for preparing the report. YOlIT efforts have advanced our mutual objective of ensuring
transparency and accountability in the CPHCS operations. Should you have any questions or
concerns, please contact Theresa Kimura-Yip, Associate Director, Medical Policy and Program
Compliance Branch at (916) 327-1205.
Sincerely,
Brenda Epperly-Ellis, irector
Policy, Planning and Evaluation Programs
California Prison Health Care Services
cc: J. Clark Kelso, Receiver
Elaine Busll, ClliefDeputy, Office ofthe Receiver
Starr Babcock, Special Assistant to the Court
Felix Igbinosa, Health Care Manager, Pleasant Valley State Prison
Felix Igbinosa, ChiefMedical Officer, Pleasant Valley State Prison
Theresa KinllITa-Yip, Associate Director, Medical Policy and Program Compliance Branch
Olga Durette, Health Program Manager II, Program Compliance Section
Steve Fama, Attorney, Prison Law Office
Gabriela Maleszewski, Central Regional Administrator
John Zweifler, M.D., Central Regional Medical Director
Nancy Faszer, Deputy Inspector General In-Charge
Bernie Fernandez, Depllty Inspector General Senior
Rob Huglles, Deputy Inspector General
Dwight Winslow, M.D., ChiefMedical Officer (A), Califonlia Prison Health Care Services
Larry Schmidt, Central Regional ChiefNurse Executive