California State Prison, Sacramento Medical Inspection Results Cycle 1

CALIFORNIA STATE PRISON, SACRAMENTO MEDICAL INSPECTION RESULTS BUREAU OF AUDITS AND INVESTIGATIONS OFFICE OF THE INSPECTOR GENERAL DAVID R. SHAW INSPECTOR GENERAL STATE OF CALIFORNIA NOVEMBER 2008 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.............................................................24 Office of the Inspector General’s Comments on the Receiver’s Response............................................................26 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 September 2008, we inspected California State Prison, Sacramento (CSP Overall Sacramento). Our medical inspection encompassed 20 components of medical Score delivery and comprised 145 questions. The questions are weighted based on 65.2% their importance to the delivery of medical care to inmates. CSP Sacramento received 65.2 percent of the total weighted points possible. The following summary table lists the 20 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 62.7% 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 67.0% 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 76.4% 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 47.4% 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 82.5% Addresses the care provided by the institution to inmates before and after they were sent to a community hospital. Bureau of Audits and Investigations Page 1 Office of the Inspector General State of California Component Weighted Definition Score Emergency Services 47.5% 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/Childbirth/Post- N/A Focuses on the prenatal and post-delivery medical care provided to pregnant delivery inmates. Not applicable at men’s institutions. Diagnostic Services 68.1% Addresses the timeliness of radiology (x-ray) and laboratory services and whether the prison followed up on clinically significant results. Access to Health Care Information 39.2% Addresses the prison’s effectiveness in filing, storing, and retrieving medical records and medical-related information. Outpatient Housing Unit 75.6% Determines whether the prison followed department policies and procedures when placing inmates in the outpatient housing unit. This component also evaluates whether the placement provided the inmate with adequate care and whether the physician’s plan addressed the placement diagnosis. Internal Reviews 70.4% 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 75.3% 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 91.0% Addresses the general operational aspects of the prison’s facility clinics. Generally, the questions in this component relate to the overall cleanliness of the clinics, privacy afforded to inmates during nonemergency visits, use of priority ducats (slip of paper the inmate carries for scheduled medical appointments), and availability of health care request forms. Preventive Services 32.1% Focuses on inmate cancer screening and influenza immunizations. Pharmacy Services 74.5% 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 90.6% 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 10.5% Examines medical staff’s monitoring of inmates participating in hunger strikes. Chemical Agent Contraindications 100% Addresses the prison’s process of handling inmates who may be predisposed to an adverse outcome from calculated uses of force (cell extractions) involving Oleoresin Capsicum (OC), which is commonly referred to as “pepper spray.” For example, this might occur if the inmate has asthma. Staffing Levels and Training 95.0% Examines the prison’s medical staffing levels and training provided. Nursing Policy 78.6% 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 65.2% Bureau of Audits and Investigations Page 2 Office of the Inspector General State of California Introduction Under the authority of California Penal Code section 6126, which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation, and at the request of the federal receiver, the OIG developed a comprehensive inspection program to evaluate the delivery of medical care at each of the California Department of Corrections and Rehabilitation’s 33 adult prisons. In September 2008, we inspected California State Prison, Sacramento (CSP Sacramento). Our medical inspection encompassed 20 components of medical delivery and comprised 145 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, now known as Plata v. Schwarzenegger. The lawsuit alleged that the state provided constitutionally inadequate medical care at California state prisons in violation of inmates’ constitutional rights. In June 2002, the parties entered into a Stipulation for Injunctive Relief, and the state agreed to implement over several years comprehensive new medical care policies and procedures at all institutions. Nevertheless, the U.S. Northern District Court of California declared in October 2005 that California’s delivery system for prison medical care was “broken beyond repair” and still not meeting constitutional standards. Thus, the federal court imposed a receivership to raise the delivery of medical care to constitutional standards. In essence, the court ordered the receiver to manage the state’s delivery of medical care and restructure day-to-day operations to develop and sustain a system that provides constitutionally adequate medical care to inmates. The court stated that it would remove the receiver and return control to the state once the system is stable and provides for constitutionally adequate medical care. To evaluate and monitor the progress of medical care delivery to inmates, the receiver requested that the OIG establish an objective, clinically appropriate, and metric-oriented medical inspection program. Toward that end, the Inspector General agreed to inspect annually each state prison until the state’s delivery of medical care to inmates meets constitutional standards. We are committed to helping each institution achieve a higher level of medical care, but it is up to the federal court to determine the percentage score necessary for an institution to meet constitutional standards. Bureau of Audits and Investigations Page 3 Office of the Inspector General State of California About the Institution CSP Sacramento, which opened in 1986, is located adjacent to Folsom State Prison. When it first opened in 1986, the institution was administered by the warden of Folsom State Prison and called New Folsom. In 1992, the institution’s name was changed to California State Prison, Sacramento, and since then has been administered as a separate prison with its own warden. CSP Sacramento houses maximum security inmates serving long sentences or inmates that have been management problems at other institutions. The institution also serves as a medical hub for Northern California with a psychiatric services unit, an enhanced outpatient program, and an enhanced outpatient administrative segregation unit. Along with several clinics that handle non- urgent requests for medical services, CSP Sacramento treats inmates needing urgent or emergency care in its three triage and treatment areas (TTA). Further, the institution has an outpatient housing unit and a state-licensed correctional treatment center. As of September 17, 2008, the California Department of Corrections and Rehabilitation reported that CSP Sacramento housed 3,026 male inmates. Jasdeep Bal, M.D., who serves as both the institution’s health care manager and chief medical officer, is responsible for CSP Sacramento’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 nursing policy 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. Bureau of Audits and Investigations Page 4 Office of the Inspector General State of California Example Question: Institution X Answers Weighting Points N/A Unk Yes No Yes + No Yes % Possible Received Is the clinical history adequate? 40 10 50 80% 20 16 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. In total, we reviewed 175 inmate medical files, which are referred to as unit health records. In addition, we reviewed staffing level reports, medical appeals summaries, nursing protocols, 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 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 quality management committee. Because these Bureau of Audits and Investigations Page 5 Office of the Inspector General State of California 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 CDCR California Department of Corrections and Rehabilitation CMO Chief Medical Officer CPR Cardio-Pulmonary Resuscitation CTC Correctional Treatment Center CTQ Confined to Quarters ER Emergency Room ERRC Emergency Response Review Committee FOBT Fecal Occult Blood Test FTF Face-to-Face GACH General Acute Care Hospital HCM Health Care Manager HIV Human Immunodeficiency Virus INH Isoniazid (antituberculous medication) LVN Licensed Vocational Nurse MD Medical Doctor MOD Medical Officer of the Day OB Obstetrician OC Oleoresin Capsicum (pepper spray) OHU Outpatient Housing Unit OIG Office of the Inspector General PCP Primary Care Provider QMC Quality Management Committee RN Registered Nurse SOAPE Subjective, Objective, Assessment, Plan, Education SRN Supervising Registered Nurse TB Tuberculosis TTA Triage and Treatment Area UHR Unit Health Record UM Utilization Management Bureau of Audits and Investigations Page 6 Office of the Inspector General State of California OFFICE OF THE INSPECTOR GENERAL CALIFORNIA STATE PRISON, SACRAMENTO Overall Score: MEDICAL INSPECTION RESULTS 65.2% 9/22/2008 - 9/25/2008 Answers Weighting Points Questions Not Answered Component Page Yes No Yes + No Yes % Points Possible Points Received Score % Not Applicable Unknown Chronic Care 8 121 77 198 61.1% 133 83.4 62.7% 4 3 Clinical Services 8 210 61 271 77.5% 95 63.6 67.0% 51 0 Health Screening 10 78 17 95 82.1% 59 45.1 76.4% 80 5 Specialty Services 11 38 51 89 42.7% 71 33.7 47.4% 28 2 Urgent Services 12 82 23 105 78.1% 59 48.7 82.5% 49 6 Emergency Services 13 20 18 38 52.6% 59 28.0 47.5% 2 3 Diagnostic Services 14 38 17 55 69.1% 52 35.4 68.1% 10 0 Access to Health Care Information 15 4 4 8 50.0% 51 20.0 39.2% 0 0 Outpatient Housing Unit 16 62 20 82 75.6% 48 36.3 75.6% 2 2 Internal Reviews 17 29 4 33 87.9% 40 28.2 70.4% 0 1 Inmate Transfers 18 15 6 21 71.4% 38 28.6 75.3% 4 0 Clinic Operations 18 26 3 29 89.7% 29 26.4 91.0% 1 0 Preventive Services 19 9 16 25 36.0% 24 7.7 32.1% 1 0 Pharmacy Services 20 9 8 17 52.9% 29 21.6 74.5% 0 0 Other Services 21 8 1 9 88.9% 16 14.5 90.6% 1 0 Inmate Hunger Strikes 21 1 8 9 11.1% 19 2.0 10.5% 0 0 Chemical Agent Contraindications 21 15 0 15 100.0% 17 17.0 100.0% 5 0 Staffing Levels and Training 22 7 1 8 87.5% 16 15.2 95.0% 1 0 Nursing Policy 23 12 3 15 80.0% 14 11.0 78.6% 0 0 Totals 784 338 1122 69.9% 869 566.3 65.2% 239 22 Bureau of Audits and Investigations Page 7 Office of the Inspector General State of California Answers Weighting Points Reference Number Chronic Care 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 22 3 25 88.0% 10 8.8 88.0% 0 0 required 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) 1 24 25 4.0% 10 0.4 4.0% 0 0 and 7392 (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 16 9 25 64.0% 12 7.7 64.0% 0 0 care education? 03.175 Did the inmate receive his or her prescribed chronic care medications 11 13 24 45.8% 18 8.3 45.8% 0 1 during 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? 12 8 20 60.0% 18 10.8 60.0% 0 0 03.236 Is the focused clinical examination adequate? 17 3 20 85.0% 19 16.2 85.0% 0 0 03.237 Is the assessment adequate? 11 4 15 73.3% 19 13.9 73.3% 4 1 03.238 Is the plan adequate and consistent with the degree of control based 11 8 19 57.9% 19 11.0 57.9% 0 1 on the chronic care program intervention and follow up requirements? 03.262 Is the inmate's Problem List complete and filed accurately in the 20 5 25 80.0% 8 6.4 80.0% 0 0 inmate's unit health record (UHR)? Component Subtotals: 121 77 198 61.1% 133 83.4 62.7% 4 3 Answers Weighting Points Reference Number Clinical Services 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 24 1 25 96.0% 4 3.8 96.0% 0 0 reviewed the same day it was received? Bureau of Audits and Investigations Page 8 Office of the Inspector General State of California Answers Weighting Points Reference Number Clinical Services Yes No Yes + No Yes % Possible Received Score % N/A Unk 01.027 If the RN determined a referral to a primary care physician (PCP) 5 12 17 29.4% 8 2.4 29.4% 8 0 was 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 1 3 4 25.0% 7 1.8 25.0% 21 0 appointment, did it take place within the time frame specified? 01.124 Sick Call Medication: Did the institution administer or deliver 5 18 23 21.7% 6 1.3 21.7% 2 0 prescription medications (new orders) to the inmate within specified time frames? 01.025 RN FTF Documentation: Did the RN complete the face-to-face 19 6 25 76.0% 6 4.6 76.0% 0 0 (FTF) triage 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 23 2 25 92.0% 5 4.6 92.0% 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 22 2 24 91.7% 7 6.4 91.7% 1 0 nature and history of the inmates primary complaint? 01.159 RN FTF Documentation: Did the RN's objective note include vital 21 2 23 91.3% 6 5.5 91.3% 2 0 signs and a 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 22 2 24 91.7% 3 2.8 91.7% 1 0 allergies, weight, current medication, and where appropriate, medication compliance? 01.158 RN FTF Documentation: Did the RN's assessment provide 21 1 22 95.5% 6 5.7 95.5% 3 0 conclusions based 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 22 2 24 91.7% 7 6.4 91.7% 1 0 strategy to address the problems identified during the FTF triage? Bureau of Audits and Investigations Page 9 Office of the Inspector General State of California Answers Weighting Points Reference Number Clinical Services Yes No Yes + No Yes % Possible Received Score % N/A Unk 01.163 RN FTF Documentation: Did the RN's education/instruction 17 5 22 77.3% 5 3.9 77.3% 3 0 adequately address the problems identified during the FTF triage? 15.234 Are clinic response bags audited daily and do they contain essential 0 2 2 0.0% 5 0.0 0.0% 0 0 items? 21.278 Was there adequate prior management of pre-existing medical 8 3 11 72.7% 20 14.5 72.7% 9 0 conditions that contributed to the need for the TTA visit? Component Subtotals: 210 61 271 77.5% 95 63.6 67.0% 51 0 Answers Weighting Points Reference Number Health Screening Yes No Yes + No Yes % Possible Received Score % N/A Unk 02.016 Did the institution complete the initial health screening on the same 20 0 20 100.0% 9 9.0 100.0% 0 0 day the inmate arrived at the institution? 02.020 Did the LVN/RN adequately document the tuberculin test or a review 18 2 20 90.0% 6 5.4 90.0% 0 0 of signs 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 1 0 1 100.0% 7 7.0 100.0% 17 2 was 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 4 8 12 33.3% 8 2.7 33.3% 8 0 institution, 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 19 0 19 100.0% 7 7.0 100.0% 0 1 indicate 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 0 0 0 0.0% 0 0.0 0.0% 19 1 appointment at the sending institution, did the receiving institution schedule the appointment within 30 days of the original appointment date? Bureau of Audits and Investigations Page 10 Office of the Inspector General State of California Answers Weighting Points Reference Number Health Screening Yes No Yes + No Yes % Possible Received Score % N/A Unk 02.111 Non-reception center: Did the inmate receive medical 2 1 3 66.7% 6 4.0 66.7% 16 1 accommodations upon arrival, if applicable? 02.017 If yes was answered to any of the questions on the initial health 12 0 12 100.0% 8 8.0 100.0% 8 0 screening 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, 2 6 8 25.0% 8 2.0 25.0% 12 0 was the inmate seen within the time frame? Component Subtotals: 78 17 95 82.1% 59 45.1 76.4% 80 5 Answers Weighting Points Reference Number Specialty Services 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 10 12 22 45.5% 8 3.6 45.5% 0 0 services within the specified time frames? 07.038 Did the PCP see the inmate between the date the PCP ordered the 1 12 13 7.7% 8 0.6 7.7% 4 0 service and the date the inmate received it, in accordance with specified time frames? 07.035 Did the inmate receive the specialty service within specified time 8 9 17 47.1% 9 4.2 47.1% 0 0 frames? 07.090 Physical therapy services: Did the physical therapist assess the 2 0 2 100.0% 8 8.0 100.0% 15 0 inmate and 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 2 7 9 22.2% 9 2.0 22.2% 7 1 follow-up 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 4 0 4 100.0% 9 9.0 100.0% 0 1 consistent with the "medical necessity" requirement? 07.259 Was there adequate documentation of the reason for the denial of 3 2 5 60.0% 5 3.0 60.0% 0 0 specialty services? Bureau of Audits and Investigations Page 11 Office of the Inspector General State of California Answers Weighting Points Reference Number Specialty Services Yes No Yes + No Yes % Possible Received Score % N/A Unk 07.270 Did the specialty provider provide timely findings and 8 7 15 53.3% 6 3.2 53.3% 2 0 recommendations or did 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 0 2 2 0.0% 9 0.0 0.0% 0 0 within 14 days? Component Subtotals: 38 51 89 42.7% 71 33.7 47.4% 28 2 Answers Weighting Points Reference Number Urgent Services Yes No Yes + No Yes % Possible Received Score % N/A Unk 21.248 Upon the inmate's discharge from the community hospital, did the 15 4 19 78.9% 7 5.5 78.9% 1 0 triage and 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 8 3 11 72.7% 7 5.1 72.7% 9 0 inmate's 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 4 0 4 100.0% 7 7.0 100.0% 15 1 registered 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 12 8 20 60.0% 7 4.2 60.0% 0 0 inmate 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 11 0 11 100.0% 6 6.0 100.0% 6 3 institution administer or deliver all prescribed medications to the inmate within specified time frames? 21.275 Was the TTA documentation adequate for evaluating the clinical care 13 7 20 65.0% 10 6.5 65.0% 0 0 provided? 21.276 While the patient was in the TTA, was the clinical care rendered by 10 1 11 90.9% 7 6.4 90.9% 8 1 the attending provider adequate and timely? Bureau of Audits and Investigations Page 12 Office of the Inspector General State of California Answers Weighting Points Reference Number Urgent Services Yes No Yes + No Yes % Possible Received Score % N/A Unk 21.279 For patients managed by telephone consultation alone, was the 9 0 9 100.0% 8 8.0 100.0% 10 1 provider's decision not to come to the TTA appropriate? Component Subtotals: 82 23 105 78.1% 59 48.7 82.5% 49 6 Answers Weighting Points Reference Number Emergency Services Yes No Yes + No Yes % Possible Received Score % N/A Unk 08.183 Was the medical emergency responder notified of the medical 4 0 4 100.0% 5 5.0 100.0% 0 0 emergency without delay? 08.241 Did the first responder provide adequate basic life support (BLS) 0 3 3 0.0% 6 0.0 0.0% 1 0 prior to medical staff arriving? 08.184 Did the medical emergency responder arrive at the location of the 4 0 4 100.0% 4 4.0 100.0% 0 0 medical emergency within five (5) minutes of initial notification? 08.185 Did the medical emergency responder use proper equipment to 1 1 2 50.0% 7 3.5 50.0% 1 1 address the 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 2 2 4 50.0% 6 3.0 50.0% 0 0 after a life-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 1 1 2 50.0% 4 2.0 50.0% 0 2 arrival, access to the inmate, and departure? 08.186 Were both the first responder (if peace officer or licensed health care 4 0 4 100.0% 4 4.0 100.0% 0 0 staff) and 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 2 2 4 50.0% 7 3.5 50.0% 0 0 Committee (ERRC) supported by the documentation and completed within 30 days? 15.256 Emergency Medical Response Drill: Did the responding officer 0 1 1 0.0% 1 0.0 0.0% 0 0 properly perform an assessment on the patient for responsiveness? Bureau of Audits and Investigations Page 13 Office of the Inspector General State of California Answers Weighting Points Reference Number Emergency Services Yes No Yes + No Yes % Possible Received Score % N/A Unk 15.257 Emergency Medical Response Drill: Did the responding officer 0 1 1 0.0% 2 0.0 0.0% 0 0 properly perform CPR? 15.258 Emergency Medical Response Drill: Did the responding officer 0 1 1 0.0% 2 0.0 0.0% 0 0 begin CPR without unecessary delay? 15.282 Emergency Medical Response Drill: Did medical staff arrive on 0 1 1 0.0% 2 0.0 0.0% 0 0 scene in five minutes or less? 15.283 Emergency Medical Response Drill: Did the emergency medical 0 1 1 0.0% 1 0.0 0.0% 0 0 responders arrive with proper equipment (ER bag, bag-valve-mask, AED)? 15.284 Emergency Medical Response Drill: Did the responding officer 0 1 1 0.0% 1 0.0 0.0% 0 0 provide accurate information to responding medical staff? 15.285 Emergency Medical Response Drill: Did emergency medical 1 0 1 100.0% 1 1.0 100.0% 0 0 responders continue basic life support? 15.286 Emergency Medical Response Drill: Did medical staff continue with 0 1 1 0.0% 1 0.0 0.0% 0 0 CPR without transporting the patient until the arrival of ambulance personnel? If the patient was transported, was this decision justified? 15.287 Emergency Medical Response Drill: Was 911 called without 0 1 1 0.0% 2 0.0 0.0% 0 0 unnecessary delay? 15.240 Emergency Medical Response Drill: Did the responding officer 1 0 1 100.0% 2 2.0 100.0% 0 0 activate the 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 0 1 1 0.0% 1 0.0 0.0% 0 0 carry and use the proper equipment (protective shield or micro-mask, gloves) required by the department? Component Subtotals: 20 18 38 52.6% 59 28.0 47.5% 2 3 Answers Weighting Points Reference Number Diagnostic Services Yes No Yes + No Yes % Possible Received Score % N/A Unk Bureau of Audits and Investigations Page 14 Office of the Inspector General State of California Answers Weighting Points Reference Number Diagnostic Services Yes No Yes + No Yes % Possible Received Score % N/A Unk 06.049 Radiology order: Was the radiology service provided within the time 5 0 5 100.0% 7 7.0 100.0% 0 0 frame specified in the physician's order? 06.245 Radiology order: Was the diagnostic report received by the 4 1 5 80.0% 8 6.4 80.0% 0 0 institution within 14 days? 06.200 Radiology order: Did the primary care provider (PCP) review the 0 5 5 0.0% 7 0.0 0.0% 0 0 diagnostic 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 9 1 10 90.0% 6 5.4 90.0% 0 0 applicable time frames of the physician's order? 06.191 All diagnostic services: Did the PCP document the clinically 7 2 9 77.8% 7 5.4 77.8% 6 0 significant diagnostic test results on Form 7230 (Interdisciplinary Progress Notes)? 06.263 All diagnostic services: Did the PCP adequately manage clinically 10 1 11 90.9% 10 9.1 90.9% 4 0 significant test results? 06.202 All laboratory orders: Did the PCP review the diagnostic reports and 3 7 10 30.0% 7 2.1 30.0% 0 0 initiate written notice to the inmate within two (2) business days of the date the institution received the diagnostic reports? Component Subtotals: 38 17 55 69.1% 52 35.4 68.1% 10 0 Answers Weighting Points Reference Number Access to Health Care Information 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 The institution's main medical records area had approximately 24 3/4 inches of loose filing. 19.169 Did medical records staff make unit health records (UHR) available 2 0 2 100.0% 15 15.0 100.0% 0 0 to clinic staff for the inmates ducated for medical appointments the next day? Bureau of Audits and Investigations Page 15 Office of the Inspector General State of California Answers Weighting Points Reference Number Access to Health Care Information Yes No Yes + No Yes % Possible Received Score % N/A Unk 19.243 Was the institution able to account for the OIG's requested UHR 0 1 1 0.0% 12 0.0 0.0% 0 0 files? 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 0 1 1 0.0% 5 0.0 0.0% 0 0 inspection, were the OIG's 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 2 0 2 100.0% 5 5.0 100.0% 0 0 records (UHR)? Component Subtotals: 4 4 8 50.0% 51 20.0 39.2% 0 0 Answers Weighting Points Reference Number Outpatient Housing Unit Yes No Yes + No Yes % Possible Received Score % N/A Unk 04.052 Did the RN complete an initial assessment of the inmate on the day 9 1 10 90.0% 5 4.5 90.0% 0 0 of placement? 04.051 Did the primary care provider (PCP) evaluate the inmate within one 9 1 10 90.0% 5 4.5 90.0% 0 0 calendar day after placement? 04.053 While the inmate was placed in the OHU, did the PCP complete the 3 7 10 30.0% 4 1.2 30.0% 0 0 Subjective, Objective, Assessment, Plan and Education (SOAPE) at a minimum of every 14 days? 04.054 Did the utilization management (UM) nurse assess the inmate within 0 8 8 0.0% 4 0.0 0.0% 2 0 one week of the inmate's placement and every 30 days thereafter? 04.112 Was the PCP's initial evaluation adequate for the problem(s) 9 2 11 81.8% 5 4.1 81.8% 0 0 requiring OHU placement? 04.230 Was the PCP's initial assessment (or diagnoses) appropriate for the 10 0 10 100.0% 5 5.0 100.0% 0 1 findings in the initial evaluation? 04.056 Did the PCP's plan adequately address the initial assessment? 10 0 10 100.0% 5 5.0 100.0% 0 1 Bureau of Audits and Investigations Page 16 Office of the Inspector General State of California Answers Weighting Points Reference Number Outpatient Housing Unit Yes No Yes + No Yes % Possible Received Score % N/A Unk 04.208 Was the level of care available in the OHU appropriate to the 11 0 11 100.0% 9 9.0 100.0% 0 0 patient's clinical presentation? 15.103 In the outpatient housing unit (OHU), are patient call buttons 0 1 1 0.0% 3 0.0 0.0% 0 0 operational or does medical staff make rounds every 30 minutes? 15.225 Does the OHU use disinfectant daily in common patient areas? 1 0 1 100.0% 3 3.0 100.0% 0 0 Component Subtotals: 62 20 82 75.6% 48 36.3 75.6% 2 2 Answers Weighting Points Reference Number Internal Reviews Yes No Yes + No Yes % Possible Received Score % N/A Unk 17.221 Did the institution complete a medical emergency response drill for 0 1 1 0.0% 5 0.0 0.0% 0 0 each watch and include participation from each medical facility during the most recent full quarter? 17.174 Did the institution promptly process inmate medical appeals during 0 1 1 0.0% 5 0.0 0.0% 0 0 the most recent 12 months? 17.136 For each death sampled, did the institution complete the death review 4 1 5 80.0% 5 4.0 80.0% 0 0 process? 17.132 Do the Emergency Response Review Committee (ERRC) meeting 5 1 6 83.3% 5 4.2 83.3% 0 0 minutes document monthly meetings for the last six (6) months? 17.138 Do the Emergency Response Review Committee (ERRC) meeting 5 0 5 100.0% 5 5.0 100.0% 0 1 minutes document the warden's (or his or her designee's) attendance? 17.118 Do the Quality Management Committee (QMC) meeting minutes 6 0 6 100.0% 5 5.0 100.0% 0 0 document monthly meetings for the last six (6) months? 17.119 Did the Quality Management Committee (QMC) report its findings to 6 0 6 100.0% 5 5.0 100.0% 0 0 the HCM/CMO each of the last six (6) meetings? 17.135 Did the last three Quality Management Committee (QMC) meeting 3 0 3 100.0% 5 5.0 100.0% 0 0 minutes reflect findings and strategies for improvement? Component Subtotals: 29 4 33 87.9% 40 28.2 70.4% 0 1 Bureau of Audits and Investigations Page 17 Office of the Inspector General State of California Answers Weighting Points Reference Number Inmate Transfers Yes No Yes + No Yes % Possible Received Score % N/A Unk 05.108 Did Receiving and Release have the inmate's UHR and transfer 5 0 5 100.0% 7 7.0 100.0% 0 0 envelope? 05.109 If the inmate was scheduled for any upcoming specialty services, 1 0 1 100.0% 8 8.0 100.0% 4 0 were the services noted on Form 7371 (Health Care Transfer Information)? 05.110 Do all appropriate forms in the transfer envelope identify all 5 0 5 100.0% 8 8.0 100.0% 0 0 medications ordered by the physician, and are the medications in the transfer envelope? 05.171 Did an RN complete all applicable sections of Form 7371 (Health 4 1 5 80.0% 7 5.6 80.0% 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 0 5 5 0.0% 8 0.0 0.0% 0 0 Form 7371 (Health Care Transfer Information) and Form 7231A (Outpatient Medication Administration Record) when the inmate transferred? Component Subtotals: 15 6 21 71.4% 38 28.6 75.3% 4 0 Answers Weighting Points Reference Number Clinic Operations Yes No Yes + No Yes % Possible Received Score % N/A Unk 14.023 Does the institution make the Form 7362 (Health Care Services 7 0 7 100.0% 4 4.0 100.0% 0 0 Request Form) available to inmates? 14.165 Are the clinic floors, waiting room chairs, and equipment cleaned 3 0 3 100.0% 2 2.0 100.0% 0 0 with a disinfectant daily? 14.164 Are areas available to ensure privacy during RN face-to-face 4 1 5 80.0% 3 2.4 80.0% 0 0 assessments and doctors' examinations for non-emergencies? 14.166 Was the medication stored in a sealed container if food was present 2 0 2 100.0% 2 2.0 100.0% 0 0 in the clinic refrigerator? 14.131 Do medication nurses understand that medication is to be 2 0 2 100.0% 4 4.0 100.0% 0 0 administered by the same licensed staff member who prepares it and on the same day? Bureau of Audits and Investigations Page 18 Office of the Inspector General State of California Answers Weighting Points Reference Number Clinic Operations Yes No Yes + No Yes % Possible Received Score % N/A Unk 14.106 Does clinical staff wash their hands (either with soap or hand 2 2 4 50.0% 4 2.0 50.0% 0 0 sanitizer) or change gloves between patients? 14.033 Does the institution have an adequate process to ensure inmates who 2 0 2 100.0% 4 4.0 100.0% 0 0 are 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 2 0 2 100.0% 4 4.0 100.0% 0 0 urgent appointments if a doctor's line is canceled? 14.029 Does medical staff in the facility clinic know which inmates are on 0 0 0 0.0% 0 0.0 0.0% 1 0 modified program or confined to quarters (CTQ) and does staff have an adequate process to ensure those inmates receive their medication? Component Subtotals: 26 3 29 89.7% 29 26.4 91.0% 1 0 Answers Weighting Points Reference Number Preventive Services Yes No Yes + No Yes % Possible Received Score % N/A Unk 10.228 Inmates prescribed INH: Did the institution properly administer the 2 3 5 40.0% 6 2.4 40.0% 0 0 medication to the inmate? 10.232 Inmates prescribed INH: Did the institution monitor the inmate 0 5 5 0.0% 6 0.0 0.0% 0 0 monthly for the 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 2 3 5 40.0% 7 2.8 40.0% 0 0 symptoms of TB within the previous 12 months? 10.086 All inmates age 66 or older: Did the inmate receive an influenza 0 0 0 0.0% 0 0.0 0.0% 1 0 vaccination within the previous 12 months or was the inmate's refusal documented? Of the two inmates at the institution age 66 or older, only one record was available. Since the results of a single sample item can be misleading, we did not complete this test. Bureau of Audits and Investigations Page 19 Office of the Inspector General State of California Answers Weighting Points Reference Number Preventive Services Yes No Yes + No Yes % Possible Received Score % N/A Unk 10.085 Male inmates age 51 or older: Did the inmate receive a fecal occult 5 5 10 50.0% 5 2.5 50.0% 0 0 blood test (FOBT) within the previous 12 months or was the inmate's refusal documented? Component Subtotals: 9 16 25 36.0% 24 7.7 32.1% 1 0 Answers Weighting Points Reference Number Pharmacy Services Yes No Yes + No Yes % Possible Received Score % N/A Unk 13.139 Does the institution conspicuously post a valid permit in its 1 0 1 100.0% 2 2.0 100.0% 0 0 pharmacies? 13.141 Does the institution properly maintain its emergency crash cart 4 1 5 80.0% 2 1.6 80.0% 0 0 medications? 13.252 Does the institution properly maintain medications in its drug night 1 0 1 100.0% 2 2.0 100.0% 0 0 locker(s)? 13.253 Does the institution conduct monthly inspections of its emergency 0 6 6 0.0% 1 0.0 0.0% 0 0 cart and 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 pharmacist in charge maintain a valid signature card that 0 1 1 0.0% 6 0.0 0.0% 0 0 contains the required information for all primary care providers (PCP)? 13.145 Does the pharmacist in charge have an effective process for screening 1 0 1 100.0% 7 7.0 100.0% 0 0 new medication orders for potential adverse reactions? 13.148 Does the pharmacist in charge monitor the quantity of medications on 1 0 1 100.0% 4 4.0 100.0% 0 0 hand, 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? Component Subtotals: 9 8 17 52.9% 29 21.6 74.5% 0 0 Bureau of Audits and Investigations Page 20 Office of the Inspector General State of California Answers Weighting Points Reference Number Other Services Yes No Yes + No Yes % Possible Received Score % N/A Unk 15.059 Did the institution properly provide therapeutic diets to inmates? 2 0 2 100.0% 4 4.0 100.0% 0 0 15.058 If the institution does not offer therapeutic diets, does staff follow the 0 0 0 0.0% 0 0.0 0.0% 1 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 1 0 1 100.0% 5 5.0 100.0% 0 0 discovered in the last six months? 15.265 Is the most current version of the CDCR Health Services Policies and 1 1 2 50.0% 3 1.5 50.0% 0 0 Procedures available in the institution's law library? 20.092 Hygiene Intervention: Did custody staff understand the department's 4 0 4 100.0% 4 4.0 100.0% 0 0 policies and procedures for identifying and evaluating inmates displaying inappropriate hygiene management? Component Subtotals: 8 1 9 88.9% 16 14.5 90.6% 1 0 Answers Weighting Points Reference Number Inmate Hunger Strikes 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) 1 2 3 33.3% 6 2.0 33.3% 0 0 business 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 0 3 3 0.0% 6 0.0 0.0% 0 0 assessments 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 0 3 3 0.0% 7 0.0 0.0% 0 0 examination and order a metabolic panel and a urinalysis of the inmate? Component Subtotals: 1 8 9 11.1% 19 2.0 10.5% 0 0 Answers Weighting Points Reference Number Chemical Agent Contraindications Yes No Yes + No Yes % Possible Received Score % N/A Unk Bureau of Audits and Investigations Page 21 Office of the Inspector General State of California Answers Weighting Points Reference Number Chemical Agent Contraindications 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 5 0 5 100.0% 9 9.0 100.0% 5 0 care provider (PCP) before a calculated use of OC? 12.064 Did the institution record how it decontaminated the inmate and did it 10 0 10 100.0% 8 8.0 100.0% 0 0 follow the decontamination policy? Component Subtotals: 15 0 15 100.0% 17 17.0 100.0% 5 0 Answers Weighting Points Reference Number Staffing Levels and Training Yes No Yes + No Yes % Possible Received Score % N/A Unk 18.002 Information purposes only: Calculate the institution's average 0 0 0 0.0% 0 0.0 0.0% 1 0 vacancy 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: 84.5 Total number of vacancies: 0 Total number of positions: 84.5 Vacancy percentage: 0% Number of staff hired within last six months: 11 (13%) Total number of registry staff: 49 18.004 Did the institution have a registered nurse (RN) available on site 24 1 0 1 100.0% 4 4.0 100.0% 0 0 hours a day, seven days a week, for emergency care? 18.005 Did the institution have a physician on site, a physician on call, or an 1 0 1 100.0% 4 4.0 100.0% 0 0 MOD 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 1 0 1 100.0% 4 4.0 100.0% 0 0 staff 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 4 1 5 80.0% 4 3.2 80.0% 0 0 they attend required training? Bureau of Audits and Investigations Page 22 Office of the Inspector General State of California Answers Weighting Points Reference Number Staffing Levels and Training Yes No Yes + No Yes % Possible Received Score % N/A Unk Component Subtotals: 7 1 8 87.5% 16 15.2 95.0% 1 0 Answers Weighting Points Reference Number Nursing Policy Yes No Yes + No Yes % Possible Received Score % N/A Unk 16.231 Does the institution ensure that nursing staff review their duty 2 3 5 40.0% 5 2.0 40.0% 0 0 statements? 16.154 Does the institution have written nursing policies and procedures that 5 0 5 100.0% 5 5.0 100.0% 0 0 adhere to the department's guidelines? 16.254 Does the institution's supervising registered nurse (SRN) conduct 5 0 5 100.0% 4 4.0 100.0% 0 0 periodic reviews of nursing staff? Component Subtotals: 12 3 15 80.0% 14 11.0 78.6% 0 0 Bureau of Audits and Investigations Page 23 Office of the Inspector General State of California California Prison Health Care Receivership Corporation’s Response Bureau of Audits and Investigations Page 24 Office of the Inspector General State of California Bureau of Audits and Investigations Page 25 Office of the Inspector General State of California Office of the Inspector General’s Comments on the Receiver’s Response The response from the receiver’s office states, “In the future, the OIG should provide the supporting data as part of the draft report so that relevant comments could be possible. At this time it is premature for the Receiver’s Office to object or agree with the results of the MIR [medical inspection results] as we have not had an opportunity to conduct a review of the specific records and data used to reach your determinations.” In fact, consistent with the protocols jointly established with the receiver’s office during the pilot phase of the inspection program, the Office of the Inspector General provided the supporting data to the health care manager at California State Prison, Sacramento. In addition, the Office of the Inspector General provided the receiver’s office with a copy of the draft report and the transmittal letter to the health care manager, which indicated that the supporting data had been provided to the receiver’s medical staff at the institution. Therefore, in light of the sequence of events, the receiver’s office was provided the opportunity to review the specific records and data that we used to reach our conclusions. We appreciate the desire of the receiver’s office to review the supplemental information, and we will provide this information directly to the receiver’s office in the future. Bureau of Audits and Investigations Page 26 Office of the Inspector General State of California