OIG
Salinas Valley State Prison Cycle 7 Medical Inspection Report
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Cycle 7, Salinas Valley State Prison | iii
Contents
Illustrations iv
Introduction 1
Summary: Ratings and Scores 3
Medical Inspection Results 5
Deficiencies Identified During Case Review 5
Case Review Results 5
Compliance Testing Results 5
Institution-Specific Metrics 6
Population-Based Metrics 9
HEDIS Results 9
Recommendations 11
Indicators 13
Access to Care 13
Diagnostic Services 20
Emergency Services 24
Health Information Management 28
Health Care Environment 34
Transfers 42
Medication Management 48
Preventive Services 56
Nursing Performance 59
Provider Performance 64
Specialized Medical Housing 69
Specialty Services 74
Administrative Operations 80
Appendix A: Methodology 83
Case Reviews 84
Compliance Testing 87
Indicator Ratings and the Overall Medical Quality Rating 88
Appendix B: Case Review Data 89
Appendix C: Compliance Sampling Methodology 93
California Correctional Health Care Services’ Response 101
Office of the Inspector General, State of California Inspection Period: January 2023 – June 2023 Report Issued: February 2025
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Illustrations
Tables
1. SVSP Summary Table: Case Review Ratings and Policy Compliance
Scores 4
2. SVSP Master Registry Data as of August 2023 7
3. SVSP Health Care Staffing Resources as of August 2023 8
4. SVSP Results Compared With State HEDIS Scores 10
5. Access to Care 17
6. Other Tests Related to Access to Care 18
7. Diagnostic Services 22
8. Health Information Management 31
9. Other Tests Related to Health Information Management 32
10. Health Care Environment 40
11. Transfers 45
12. Other Tests Related to Transfers 46
13. Medication Management 53
14. Other Tests Related to Medication Management 54
15. Preventive Services 57
16. Specialized Medical Housing 72
17. Specialized Services 77
18. Other Tests Related to Specialized Services 78
19. Administrative Operations 81
A–1. Case Review Definitions 84
B–1. SVSP Case Review Sample Sets 89
B–2. SVSP Case Review Chronic Care Diagnoses 90
B–3. SVSP Case Review Events by Program 91
B–4. SVSP Case Review Sample Summary 91
Figures
A–1. Inspection Indicator Review Distribution for SVSP 83
A–2. Case Review Testing 86
A–3. Compliance Sampling Methodology 87
Photographs
1. Patient Waiting Area 34
2. Patient Individual Waiting Modules 35
3. Expired Medical Supply Dated February 2021 35
4. Expired Medical Supply Dated May 5, 2022 36
5. Inaccurately Labeled and Disorganized Medical Supplies 36
6. Snellen Reading Chart Missing Marked Distance Line; Chart Was a
Printout 37
7. IV Solution Accumulated Condensation 37
8. Insect in the Clinic's Medication Room 38
9. Expired Chemical Test Strip Dated April 2023 39
Office of the Inspector General, State of California Inspection Period: January 2023 – June 2023 Report Issued: February 2025
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Introduction
Pursuant to California Penal Code section 6126 et seq., the Office of the Inspector
General (the OIG) is responsible for periodically reviewing and reporting on the delivery
of the ongoing medical care provided to incarcerated people1 in the California
Department of Corrections and Rehabilitation (the department).2
In Cycle 7, the OIG continues to apply the same assessment methodologies used in
Cycle 6, including clinical case review and compliance testing. Together, these methods
assess the institution’s medical care on both individual and system levels by providing an
accurate assessment of how the institution’s health care systems function regarding
patients with the highest medical risk, who tend to access services at the highest rate.
Through these methods, the OIG evaluates the performance of the institution in
providing sustainable, adequate care. We continue to review institutional care using
15 indicators as in prior cycles.3
Using each of these indicators, our compliance inspectors collect data in answer to
compliance- and performance-related questions as established in the medical inspection
tool (MIT). In addition, our clinicians complete document reviews of individual cases and
also perform on-site inspections, which include interviews with staff. The OIG
determines a total compliance score for each applicable indicator and considers the MIT
scores in the overall conclusion of the institution’s compliance performance.
In conducting in-depth quality-focused reviews of randomized cases, our case review
clinicians examine whether health care staff used sound medical judgment in the course
of caring for a patient. In the event we find errors, we determine whether such errors
were clinically significant or led to a significantly increased risk of harm to the patient.
At the same time, our clinicians consider whether institutional medical processes led to
identifying and correcting individual or system errors, and we examine whether the
institution’s medical system mitigated the error. The OIG rates each applicable indicator
proficient, adequate, or inadequate, and considers each rating in the overall conclusion of
the institution’s health care performance.
In contrast to Cycle 6, the OIG will provide individual clinical case review ratings and
compliance testing scores in Cycle 7, rather than aggregate all findings into a single
overall institution rating. This change will clarify the distinctions between these differing
quality measures and the results of each assessment.
1 In this report, we use the terms patient and patients to refer to incarcerated people.
2 The OIG’s medical inspections are not designed to resolve questions about the constitutionality of care, and
the OIG explicitly makes no determination regarding the constitutionality of care the department provides to
its population.
3 In addition to our own compliance testing and case reviews, the OIG continues to offer selected Healthcare
Effectiveness Data and Information Set (HEDIS) measures for comparison purposes.
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As we did during Cycle 6, our office continues to inspect both those institutions
remaining under federal receivership and those delegated back to the department. The
penal code provides no difference in the standards used for assessing a delegated
institution versus an institution not yet delegated. At the time of the Cycle 7 inspection
of Salinas Valley State Prison, the institution had not been delegated back to the
department by the receiver.
We completed our seventh inspection of the institution, and this report presents our
assessment of the health care provided at this institution during the inspection period
from January 2023 to June 2023.4
4 Samples are obtained per case review methodology shared with stakeholders in prior cycles. The case reviews
include death reviews between May 2022 and February 2023, and transfer reviews between October 2022 and
April 2023.
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Summary: Ratings and Scores
We completed the Cycle 7 inspection of SVSP in November 2023. OIG inspectors
monitored the institution’s delivery of medical care that occurred between January 2023
and June 2023.
The OIG rated the case review The OIG rated the compliance
component of the overall health care component of the overall health care
quality at SVSP adequate. quality at SVSP inadequate.
The OIG clinicians (a team of physicians and nurse consultants) reviewed 48 unique
cases, which contained 1,123 patient-related events. They performed quality control
reviews; their subsequent collective deliberations ensured consistency, accuracy, and
thoroughness. Our OIG clinicians acknowledged institutional structures that catch and
resolve mistakes that may occur throughout the delivery of care. After examining the
medical records, our clinicians completed a follow-up on-site inspection in
November 2023 to verify their initial findings. The OIG physicians rated the quality of
care for 20 comprehensive case reviews. Of these 20 cases, our physicians rated
18 adequate and two inadequate.
To test the institution’s policy compliance, our compliance inspectors (a team of
registered nurses) monitored the institution’s compliance with its medical policies by
answering a standardized set of questions that measure specific elements of health care
delivery. Our compliance inspectors examined 369 patient records and 1,147 data points
and used the data to answer 93 policy questions. In addition, we observed SVSP’s
processes during an on-site inspection in August 2023.
The OIG then considered the results from both case review and compliance testing, and
drew overall conclusions, which we report in 13 health care indicators.5
5 The indicators for Reception Center and Prenatal and Postpartum Care did not apply to SVSP.
Office of the Inspector General, State of California Inspection Period: January 2023 – June 2023 Report Issued: February 2025
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We list the individual indicators and ratings applicable for this institution in Table 1 below.
Table 1. SVSP Summary Table: Case Review Ratings and Policy Compliance Scores
Office of the Inspector General, State of California Inspection Period: January 2023 – June 2023 Report Issued: February 2025
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Medical Inspection Results
Deficiencies Identified During Case Review
Deficiencies are medical errors that increase the risk of patient harm. Deficiencies can be
minor or significant, depending on the severity of the deficiency. An adverse event occurs
when the deficiency caused harm to the patient. All major health care organizations
identify and track adverse events. We identify deficiencies and adverse events to
highlight concerns regarding the provision of care and for the benefit of the institution’s
quality improvement program to provide an impetus for improvement.6
The OIG found no adverse event at SVSP during the Cycle 7 inspection.
Case Review Results
OIG case reviewers (a team of physicians and nurse consultants) assessed 10 of the 13
indicators applicable to SVSP. Of these 10 indicators, OIG clinicians rated 10 adequate.
The OIG physicians also rated the overall adequacy of care for each of the 20 detailed
case reviews they conducted. Of these 20 cases, 18 were adequate, and two were
inadequate. In the 1,123 events reviewed, we found 239 deficiencies, 46 of which OIG
clinicians considered to be of such magnitude that, if left unaddressed, would likely
contribute to patient harm.
Our clinicians found the following strengths at SVSP:
• Compared to Cycle 6, providers improved their medical record review,
decision-making, follow through with treatment plans, and continuity of
care.
• SVSP delivered excellent provider and nurse access.
Our clinicians found the following weaknesses at SVSP:
• SVSP needed improvement with specialty access, which has been ongoing
from Cycle 6.
• SVSP needed improvement in timely completing diagnostic studies.
Compliance Testing Results
Our compliance inspectors assessed 10 of the 13 indicators applicable to SVSP. Of these
10 indicators, our compliance inspectors rated two proficient, and eight inadequate. We
tested policy compliance in Health Care Environment, Preventive Services, and
Administrative Operations as these indicators do not have a case review component.
6 For a further discussion of an adverse event, see Table A–1.
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SVSP showed a high rate of policy compliance in the following areas:
• Staff performed well in scanning initial health care screening forms,
community hospital discharge reports, specialty service reports, and requests
for health care services into patients’ electronic medical records within
required time frames.
• Nurses processed sick call request forms, performed face-to-face evaluations,
and completed nurse-to-provider referrals within required time frames.
• Providers evaluated patients returning from outside community hospitals or
specialty service appointments within required time frames. Moreover,
patients were referred within required time frames to their providers upon
arrival at the institution.
SVSP showed a low rate of policy compliance in the following areas:
• SVSP’s clinical areas had multiple expired medical supplies.
• Health care staff did not consistently follow hand hygiene precautions before
or after patient encounters.
• Nursing staff did not regularly inspect emergency response bags.
• Staff often did not maintain medication continuity for chronic care patients,
patients discharged from the hospital, and patients admitted to a specialized
medical housing unit. In addition, SVSP had poor medication continuity for
patients who transferred into the institution, transferred within the
institution, or had a temporary layover at SVSP.
• SVSP did not consistently provide routine and STAT laboratory services
within specified time frames.
• Providers often did not communicate results of diagnostic services timely.
Most patient letters communicating these results were missing the date of
the diagnostic service, the date of the results, and whether the results were
within normal limits.
Institution-Specific Metrics
Located five miles north of Soledad, on a 300-acre site in Monterey County, Salinas Valley
State Prison (SVSP) has been designed to house Level 1, Level 3 and Level 4 patients. The
institution ran clinics in which staff members handled nonurgent requests for medical
care. Patients requiring urgent or emergent care were seen in the institution’s triage and
treatment area (TTA). SVSP also had a licensed correctional treatment center (CTC) for
providing inpatient care. SVSP has been designated by California Correctional Health
Care Services (CCHCS) as a basic care institution. Basic care facilities are typically located
in rural areas, away from tertiary care centers and specialty care providers whose services
would likely be used frequently by patients at higher medical risk.
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As of July 18, 2024, the department reports on its public tracker that 78 percent of SVSP’s
incarcerated population is fully vaccinated for COVID-19 while 65 percent of SVSP’s staff
is fully vaccinated for COVID-19.7
In August 2023, the Health Care Services Master Registry showed SVSP had a total
population of 2,910. A breakdown of the medical risk level of the SVSP population as
determined by the department is set forth in Table 2 below.8
Table 2. SVSP Master Registry Data as of August 2023
Medical Risk Level Number of Patients Percentage*
High 1 224 7.7%
High 2 338 11.6%
Medium 1,467 50.4%
Low 881 30.3%
Total 2,910 100.0%
* Percentages may not total 100% due to rounding.
Source: Data for the population medical risk level were obtained from
the CCHCS Master Registry dated 08-14-2023
7 For more information, see the department’s statistics on its website page titled Population COVID-19
Tracking.
8 For a definition of medical risk, see CCHCS HCDOM 1.2.14, Appendix 1.9.
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According to staffing data the OIG obtained from CCHCS, as identified in Table 3 below,
SVSP had 3.0 vacant executive leadership positions, 8.0 primary care provider vacancies,
5.5 nursing supervisor vacancies, and 179.8 nursing staff vacancies.
Table 3. SVSP Health Care Staffing Resources as of August 2023
Executive Primary Care Nursing Nursing
Positions Leadership * Providers Supervisors Staff † Total
Authorized Positions 6.0 13.0 41.5 339.1 399.6
Filled by Civil Service 5.0 5.0 36.0 159.3 205.3
Vacant 3.0 8.0 5.5 179.8 196.3
Percentage Filled by Civil Service 83.3% 38.5% 86.7% 47.0% 51.4%
Filled by Telemedicine 0 2.0 0 0 2.0
Percentage Filled by Telemedicine 0 15.4% 0 0 0.5%
Filled by Registry 0 4.0 0 110.0 114.0
Percentage Filled by Registry 0 30.8% 0 32.4% 28.5%
Total Filled Positions 5.0 11.0 36.0 269.3 321.3
Total Percentage Filled 83.3% 84.6% 86.7% 79.4% 80.4%
Appointments in Last 12 Months 0 2.0 0 21.0 23.0
Redirected Staff 0 0 0 0 0
Staff on Extended Leave ‡ 0 0 3.0 20.0 23.0
Adjusted Total: Filled Positions 5.0 11.0 33.0 249.3 298.3
Adjusted Total: Percentage Filled 83.3% 84.6% 79.5% 73.5% 74.6%
* Executive Leadership includes the Chief Physician and Surgeon.
† Nursing Staff includes the classifications of Senior Psychiatric Technician and Psychiatric Technician.
‡ In Authorized Positions.
Notes: The OIG does not independently validate staffing data received from the department. Positions are based on
fractional time-base equivalents.
Source: Cycle 7 medical inspection preinspection questionnaire received on August 14, 2023, from California Correctional
Health Care Services.
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Population-Based Metrics
In addition to our own compliance testing and case reviews, as noted above, the OIG
presents selected measures from the Healthcare Effectiveness Data and Information Set
(HEDIS) for comparison purposes. The HEDIS is a set of standardized quantitative
performance measures designed by the National Committee for Quality Assurance to
ensure the public has the data it needs to compare the performance of health care plans.
Because the Veterans Administration no longer publishes its individual HEDIS scores,
we removed them from our comparison for Cycle 7. Likewise, Kaiser (commercial plan)
no longer publishes HEDIS scores. However, through the California Department of
Health Care Services’ Medi‑Cal Managed Care Technical Report, the OIG obtained
California Medi-Cal and Kaiser Medi-Cal HEDIS scores to use in conducting our
analysis, and we present them here for comparison.
HEDIS Results
We considered SVSP’s performance with population-based metrics to assess the
macroscopic view of the institution’s health care delivery. Currently, only two HEDIS
measures are available for review: poor HbA1c control, which measures the percentage of
diabetic patients who have poor blood sugar control, and colorectal cancer screening
rates for patients ages 45 to 75. For poor HBA1c control, SVSP’s results compared
favorably with those found in State health plans for this measure. We list the applicable
HEDIS measures in Table 4.
Comprehensive Diabetes Care
When compared with statewide Medi-Cal programs—California Medi-Cal, Kaiser
Northern California (Medi-Cal), and Kaiser Southern California (Medi-Cal)—SVSP’s
percentage of patients with poor HbA1c control was significantly lower, indicating very
good performance on this measure.
Immunizations
Statewide comparative data were not available for immunization measures; however, we
include these data for informational purposes. SVSP had a 33 percent influenza
immunization rate for adults 18 to 64 years old and a 50 percent influenza immunization
rate for adults 65 years of age and older.9 The pneumococcal vaccination rate was
90 percent.10
9 The HEDIS sampling methodology requires a minimum sample of 10 patients to have a reportable result.
10 The pneumococcal vaccines administered are the 13, 15, and 20 valent pneumococcal vaccines (PCV13,
PCV15, and PCV20), or 23 valent pneumococcal vaccine (PPSV23), depending on the patient’s medical
conditions. For the adult population, the influenza or pneumococcal vaccine may have been administered at a
different institution other than where the patient was currently housed during the inspection period.
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Cancer Screening
When compared with statewide Medi-Cal programs, SVSP’s colorectal cancer screening
rate of 68 percent was equal to or slightly lower than Kaiser Northern California (Medi-
Cal) and Kaiser Southern California (Medi-Cal), respectively
Table 4. SVSP Results Compared With State HEDIS Scores
SVSP California California
Kaiser Kaiser
Cycle 7 California NorCal SoCal
HEDIS Measure Results * Medi-Cal † Medi-Cal † Medi-Cal †
HbA1c Screening 91% – – –
Poor HbA1c Control (> 9.0%) ‡,§ 14% 36% 31% 22%
HbA1c Control (< 8.0%) ‡ 79% – – –
Blood Pressure Control (< 140/90) ‡ 88% – – –
Eye Examinations 57% – – –
Influenza – Adults (18 – 64) 33% – – –
Influenza – Adults (65 +) 50% – – –
Pneumococcal – Adults (65 +) 90% – – –
Colorectal Cancer Screening 68% 37% 68% 70%
Notes and Sources
* Unless otherwise stated, data were collected in August 2023 by reviewing medical records from a sample of
SVSP’s population of applicable patients. These random statistical sample sizes were based on a 95 percent
confidence level with a 15 percent maximum margin of error.
† HEDIS Medi-Cal data were obtained from the California Department of Health Care Services publication
Medi-Cal Managed Care External Quality Review Technical Report, dated July 1, 2022–June 30, 2023
(published March–April 2024); https://www.dhcs.ca.gov/dataandstats/reports/Documents/Medi-Cal-Managed-
Care-Technical-Report-Volume-1.pdf.
‡ For this indicator, the entire applicable SVSP population was tested.
§ For this measure only, a lower score is better.
Source: Institution information provided by the California Department of Corrections and Rehabilitation.
Health care plan data were obtained from the CCHCS Master Registry.
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Recommendations
As a result of our assessment of SVSP’s performance, we offer the following
recommendations to the department:
Diagnostic Services
• The department should develop strategies to ensure providers generate
letters communicating test results to their patients and the letters include all
elements as required by CCHCS policy.
• Medical leadership should determine the root cause(s) of challenges to timely
collecting, receiving, and notifying providers of STAT laboratory results and
implement remedial measures as appropriate.
Emergency Services
• Nursing leadership should determine the root cause(s) of challenges
preventing staff from completing thorough assessments and accurate
documentation after an emergent event and should implement remedial
measures as indicated.
• Executive leadership should determine the root cause(s) of challenges to
completing thorough reviews of urgent and emergent events in which
patients transfer to the community hospital and should implement remedial
measures as indicated.
Health Care Environment
• Medical and nursing leadership should analyze the root cause(s) for staff not
following all required universal hand hygiene precautions and should
implement remedial measures as appropriate.
• Executive leadership should analyze the root cause(s) for staff not following
equipment and medical supply management protocols and should implement
remedial measures as appropriate.
• Nursing leadership should determine the root cause(s) for staff not ensuring
the EMRBs are regularly inventoried and sealed or not properly completing
the monthly logs and should implement remedial measures as appropriate.
Transfers
• Nursing leadership should identify the root cause(s) for R&R nurses not
completing the initial health screening, including answering all questions
and documenting an explanation for each “yes” answer, not documenting a
complete set of vital signs as part of the patient’s initial health screening
assessment, and not completing the initial health screening form prior to a
patient being placed in housing. Nursing leadership should implement
remedial measures as appropriate.
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• Nursing leadership should identify the challenges to ensuring newly arrived
patients receive medications without interruption and implement remedial
measures as appropriate.
Medication Management
• Medical and nursing leadership should determine the challenges to ensuring
chronic care, hospital discharge, and en route patients receive their
medications timely and without interruption; leadership should implement
remedial measures as appropriate.
• Nursing leadership should determine the root cause(s) for nursing staff not
documenting patient refusals and no shows in the medical administration
record, as described in CCHCS policy and procedures, and leadership should
implement remedial measures as appropriate.
Preventive Services
• Nursing leadership should analyze the challenges to ensuring nursing staff
monitor and document patients receiving TB medications according to
CCHCS guidelines and should implement remedial measures as appropriate.
• Nursing leadership should analyze the challenges to ensuring nursing staff
perform the annual TB screening during the patient’s birth month and
should implement remedial measures as appropriate.
• Medical leadership should analyze the challenges related to the timely
provision of preventive vaccines to chronic care patients and should
implement remedial measures as appropriate.
Nursing Performance
• Nursing leadership should analyze the challenges to nurses performing
thorough assessments during face-to-face patient evaluations and should
implement remedial measures as indicated.
Specialty Services
• Medical leadership should determine the root cause(s) of challenges to the
timely provision of specialty appointments, including preapproved specialty
appointments for transfer-in patients, and should implement remedial
measures as appropriate.
• The department should consider developing and implementing measures to
ensure the institution timely receives the specialty reports and providers
timely review these reports.
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Indicators
Access to Care
In this indicator, OIG inspectors evaluated the institution’s performance in providing
patients with timely clinical appointments. Our inspectors reviewed scheduling and
appointment timeliness for newly arrived patients, sick calls, and nurse follow-up
appointments. We examined referrals to primary care providers, provider follow-ups, and
specialists. Furthermore, we evaluated the follow-up appointments for patients who
received specialty care or returned from an off-site hospitalization.
Ratings and Results Overview
Case Review Rating Compliance Rating and Score
Adequate Proficient (86.7%)
SVSP’s performance improved in case review compared to its performance in Cycle 6.
SVSP facilitated excellent access to providers and nurses, follow-up appointments after
specialty appointments, and follow-up appointments after hospital discharge. However,
SVSP needed improvement with access to specialty services. The OIG rated the case
review component of this indicator adequate.
SVSP’s performance in compliance testing continued to improve in Cycle 7. Providers
showed good performance in timely evaluating newly transferred patients, patients after
their return from specialist appointments and hospitalizations, and patients with chronic
care conditions. Nurses timely reviewed all patient sick call requests and frequently
completed face-to-face triage. However, SVSP did not maintain a good process to ensure
housing units adequately stored requests for health care services forms. Based on the
overall compliance score result, the OIG rated the compliance component of this
indicator proficient.
Case Review and Compliance Testing Results
OIG clinicians reviewed 522 provider, nursing, urgent or emergent care (TTA), specialty,
and hospital events that may have required the institution to generate appointments. We
identified 26 deficiencies relating to Access to Care, six of which were significant.11 Of
the 20 minor deficiencies, 12 involved delays in obtaining diagnostic studies. Four of the
six significant deficiencies were due to specialty appointment scheduling delays.
Access to Care Providers
Access to clinic providers is an integral part of patient care in health care delivery. Case
review found SVSP performed excellently in access to care providers. We reviewed 135
outpatient provider events and found no deficiencies with the timeliness of outpatient
provider appointments ordered by the provider or referred by nurses.
11 Access to care deficiencies occurred in cases 8, 15–19, 21, 23–25, and 47. Significant deficiencies occurred in
cases 16, 18, 23, and 24.
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In contrast, compliance testing showed intermittent access to chronic care follow-up
appointments (MIT 1.001, 72.0%); however, nursing-to-provider sick call referrals
frequently occurred (MIT 1.005, 91.7%).
Access to Specialized Medical Housing Providers
SVSP provided very good access to CTC providers. OIG clinicians reviewed 49 CTC
provider encounters and only found two access deficiencies, which occurred in the same
case:
• In case 23, the CTC provider did not evaluate the patient within policy time
frames.
Access to Clinic Nurses
SVSP performed excellently with access to nurse sick calls and provider-to-nurse
referrals. Compliance testing showed nurses always reviewed patients’ requests for
service the same day they were received (MIT 1.003, 100%), and nurse appointments often
occurred within one business day after review of a sick call request (MIT 1.004, 93.3%).
Our clinicians assessed 148 nursing events in the outpatient and CTC setting, as well as
seven nursing sick call requests in five cases. We found no deficiencies with access to
nurses.
Access to Specialty Services
SVSP’s performance was mixed with referrals to specialty services. Compliance testing
showed room for improvement with completion rates for high-priority (MIT 14.001,
66.7%) and medium-priority (MIT 14.004, 66.7%) appointments, but SVSP had a very good
completion rate for routine-priority appointments (MIT 14.007, 86.7%). Specialist follow-
up appointment completion also varied with high-priority (MIT 14.003, 90.0%), medium-
priority (14.006, 71.4%), and routine-priority (MIT 14.009, 60.0%) appointments. Case
review clinicians found most specialty appointments occurred within requested time
frames; however, we identified eight deficiencies due to delays. The following are two
examples:
• In case 23, the patient had a lung nodule suspicious for cancer. The provider
ordered a high-priority request for a lung specialist. However, staff scheduled
the appointment more than one month later, which was a delay of over
twenty days.
• In case 24, the patient had kidney stones that were not resolving with
conservative treatment. The provider ordered a urology telemedicine
appointment to occur within 24 days, but staff scheduled the appointment
more than six weeks late.
Follow-Up After Specialty Services
Compliance testing revealed provider appointments after specialty services frequently
occurred within the required time frame (MIT 1.008, 83.3%). The OIG clinicians reviewed
81 off-site or telemedicine specialty consultations or procedures and found only three
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deficiencies in which the provider appointment after specialty services was not
scheduled. The following are examples:
• In case 18, the patient had a high-priority oncology specialist consultation
for leukemia but did not have a follow-up appointment with the provider
afterward. The provider eventually saw the patient about two months later
for a chronic care appointment.
• In case 21, on two separate occasions, staff did not order a provider follow-up
appointment within five days after a high-priority off-site procedure or
specialist consultation.
Follow-Up After Hospitalization
SVSP performed excellently and always ensured providers evaluated patients after
hospitalizations. Case review did not find any deficiencies in this area.
Follow-Up After Urgent or Emergent Care (TTA)
Providers always evaluated their patients following a triage and treatment area (TTA)
event as requested. OIG clinicians reviewed 48 TTA events and identified no delays in
provider follow-up appointments.
Follow-Up After Transferring Into SVSP
Access to care for patients who had recently transferred into the institution was
satisfactory. Compliance testing showed acceptable access to intake appointments for
newly arrived patients (MIT 1.002, 84.0%). Case reviewers did not find any deficiencies in
this area; however, we only reviewed three cases in which patients transferred from
another institution.
Clinician On-Site Inspection
Our case review clinicians spoke with SVSP’s executive leadership, medical and nursing
leadership, and schedulers regarding the institution’s access to care. They explained
diagnostic services were delayed due to an interim process in which patients who refused
laboratory tests were given additional opportunities to complete the tests. This is
discussed further in the Diagnostics Services indicator. They also explained how
specialty consultations had occurred late due to the insufficient availability of specialty
services and appointments in the surrounding region for the medical complexity of their
patients. Specifically, despite its designation as a “basic” institution, SVSP has a diverse
and substantial population of patients requiring medical oversight, including the
psychiatric inpatient and other outpatient mental health care programs, a large disabled
population, a large transgender population, a large addiction treatment program, and an
extraordinarily high percentage of high risk patients.12 Due to the impact of these factors,
12 Institutions designated as “basic” are generally expected to have a high risk medical population of
approximately 5%. At nearly 20%, SVSP’s high risk population is essentially four times the expected ratio.
However, this institution is still assigned a medical staffing package consistent with its basic designation.
Office of the Inspector General, State of California Inspection Period: January 2023 – June 2023 Report Issued: February 2025
Cycle 7, Salinas Valley State Prison | 16
even with telemedicine specialty services, SVSP experienced difficulty scheduling
specialty consultations within desired time frames.
Compliance On-Site Inspection and Discussion
Four of six housing units randomly tested at the time of inspection had access to the
Health Care Services Request Form (CDCR 7362) (MIT 1.101, 66.7%). In two housing
units, custody officers did not have a system in place for restocking CDCR 7362. The
custody officers reported reliance on medical staff to replenish the CDCR 7362 in the
housing units.
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Cycle 7, Salinas Valley State Prison | 17
Compliance Score Results
Table 5. Access to Care
Scored Answer
Compliance Questions Yes No N/A Yes %
Chronic care follow-up appointments: Was the patient’s most recent chronic
care visit within the health care guideline’s maximum allowable interval or 19 6 0 76.0%
within the ordered time frame, whichever is shorter? (1.001)
For endorsed patients received from another CDCR institution: Based on
the patient’s clinical risk level during the initial health screening, was the 21 4 0 84.0%
patient seen by the clinician within the required time frame? (1.002)
Clinical appointments: Did a registered nurse review the patient’s request
30 0 0 100%
for service the same day it was received? (1.003)
Clinical appointments: Did the registered nurse complete a face-to-face visit
28 2 0 93.3%
within one business day after the CDCR Form 7362 was reviewed? (1.004)
Clinical appointments: If the registered nurse determined a referral to a
primary care provider was necessary, was the patient seen within the
11 1 18 91.7%
maximum allowable time or the ordered time frame, whichever is the
shorter? (1.005)
Sick call follow-up appointments: If the primary care provider ordered a
follow-up sick call appointment, did it take place within the time frame 2 0 28 100%
specified? (1.006)
Upon the patient’s discharge from the community hospital: Did the patient
22 3 0 88.0%
receive a follow-up appointment within the required time frame? (1.007)
Specialty service follow-up appointments: Did the clinician follow-up visits
34 8 3 81.0%
occur within required time frames? (1.008) *
Clinical appointments: Do patients have a standardized process to obtain
4 2 0 66.7%
and submit health care services request forms? (1.101)
Overall percentage (MIT 1): 86.7%
* CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician follow-up visits
following specialty services. As a result, we tested MIT 1.008 only for high-priority specialty services or when staff ordered
follow-ups. The OIG continued to test the clinical appropriateness of specialty follow-ups through its case review testing.
Source: The Office of the Inspector General medical inspection results.
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Cycle 7, Salinas Valley State Prison | 18
Table 6. Other Tests Related to Access to Care
Scored Answer
Compliance Questions Yes No N/A Yes %
For patients received from a county jail: If, during the assessment, the
nurse referred the patient to a provider, was the patient seen within the N/A N/A N/A N/A
required time frame? (12.003)
For patients received from a county jail: Did the patient receive a history
and physical by a primary care provider within seven calendar days (prior N/A N/A N/A N/A
to 07/2022) or five working days (effective 07/2022)? (12.004)
Was a written history and physical examination completed within the
5 2 0 71.4%
required time frame? (13.002)
Did the patient receive the high-priority specialty service within
14 calendar days of the primary care provider order or the Physician 10 5 0 66.7%
Request for Service? (14.001)
Did the patient receive the subsequent follow-up to the high-priority
specialty service appointment as ordered by the primary care 9 1 5 90.0%
provider? (14.003)
Did the patient receive the medium-priority specialty service within 15-45
calendar days of the primary care provider order or the Physician Request 10 5 0 66.7%
for Service? (14.004)
Did the patient receive the subsequent follow-up to the medium-priority
specialty service appointment as ordered by the primary care provider? 5 2 8 71.4%
(14.006)
Did the patient receive the routine-priority specialty service within
90 calendar days of the primary care provider order or Physician Request 13 2 0 86.7%
for Service? (14.007)
Did the patient receive the subsequent follow-up to the routine-priority
specialty service appointment as ordered by the primary care 3 2 10 60.0%
provider? (14.009)
Source: The Office of the Inspector General medical inspection results.
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Cycle 7, Salinas Valley State Prison | 19
Recommendations
The OIG offers no recommendations for this indicator.
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Cycle 7, Salinas Valley State Prison | 20
Diagnostic Services
In this indicator, OIG inspectors evaluated the institution’s performance in timely
completing radiology, laboratory, and pathology tests. Our inspectors determined
whether the institution properly retrieved the resultant reports and whether providers
reviewed the results correctly. In addition, in Cycle 7, we examined the institution’s
performance in timely completing and reviewing immediate (STAT) laboratory tests.
Ratings and Results Overview
Case Review Rating Compliance Rating and Score
Adequate Inadequate (60.0%)
Case review found SVSP performed acceptably with diagnostic services, similar to Cycle
6. We found more test completion delays of one to two days in comparison to the last
cycle. Providers almost always endorsed test results timely; however, they often did not
generate complete patient test result notification letters. Although the number of these
letter deficiencies were high, they did not significantly increase the risk of harm to the
patients. Overall, the OIG rated the case review component of this indicator adequate.
SVSP’s overall compliance testing scores needed improvement for this indicator. Staff
performed exceptionally in timely completing radiology tests, frequently retrieved
pathology reports timely, and often timely reviewed radiology and laboratory results.
However, staff only sometimes completed routine-priority laboratory tests within the
required time frames, and never completed STAT tests within the required time frames.
Providers almost always promptly endorsed diagnostic results but inconsistently
generated patient test result letters with all required elements. Based on the overall
compliance score result, the OIG rated the compliance component of this indicator
inadequate.
Case Review and Compliance Testing Results
We reviewed 161 diagnostic events and found 40 deficiencies, two of which were
significant.13 Of the 40 deficiencies, 12 related to delays in obtaining labs and 27 related
to incomplete patient notification letters.
Test Completion
Compliance testing showed mixed performance in test completion. Completion of X-rays
was perfect (MIT 2.001, 100%) and completion of laboratory tests was satisfactory (MIT
2.004, 80.0%); however, completion of STAT laboratory tests was very poor (MIT 2.007,
zero).
13 Diagnostic deficiencies occurred in cases 2, 8, 13–15, 17–19, and 23–25. Significant diagnostics deficiencies
occurred in cases 13 and 24.
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Cycle 7, Salinas Valley State Prison | 21
With case review, SVSP’s test completion performance was acceptable. Case review
clinicians found 11 deficiencies related to completion delays in routine diagnostics and
one delay with a STAT laboratory test. Most of the delays in test completion were not
significant and did not increase the risk of harm.
• In case 24, the provider ordered a STAT urine test to be completed on the same day.
However, this specimen was collected two days later.
Health Information Management
In compliance testing, providers always reviewed X-rays timely (MIT 2.002, 100%) and
often reviewed laboratory tests timely (MIT 2.005, 90.0%). Providers always endorsed
STAT laboratory tests (MIT 2.009, 100%); however, patient notification of STAT
laboratory test results never occurred timely (MIT 2.008, zero). With pathology tests, staff
often retrieved the results (MIT 2.010, 80.0%) and providers often reviewed the results
timely (MIT 2.011, 80.0%); however, providers rarely sent proper patient notification
letters (MIT 2.012, 10.0%).
With case review, SVSP staff retrieved laboratory and diagnostic results promptly and
sent them to providers for review. Case review clinicians identified one deficiency in
which providers did not timely endorse the result, and 25 deficiencies where patient
notification letters were either incomplete or not generated. The clinicians reviewed
these deficiencies in the context of the type of diagnostic test and the severity of not
reporting the results to the patient. These deficiencies did not require any changes to
treatment plans and had minimal impact or risk of harm to the patient.
Clinician On-Site Inspection
The case review clinicians discussed deficiencies with laboratory supervisors. The
supervisors stated the delays in test completion were due to a temporary policy in which,
if patients refused a diagnostic study, the laboratory staff would return the next day and
offer to perform the diagnostic study again. This gave the patients an opportunity to have
the diagnostic study performed without having to go through the refusal process and
obtain a new order. Because patients at SVSP refused frequently, diagnostics were
delayed, and the laboratory staff felt overwhelmed. Leadership stated this was no longer
the policy at SVSP.
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Compliance Score Results
Table 7. Diagnostic Services
Scored Answer
Compliance Questions Yes No N/A Yes %
Radiology: Was the radiology service provided within the time frame
10 0 0 100%
specified in the health care provider’s order? (2.001)
Radiology: Did the ordering health care provider review and endorse the
10 0 0 100%
radiology report within specified time frames? (2.002)
Radiology: Did the ordering health care provider communicate the results
7 3 0 70.0%
of the radiology study to the patient within specified time frames? (2.003)
Laboratory: Was the laboratory service provided within the time frame
6 4 0 60.0%
specified in the health care provider’s order? (2.004)
Laboratory: Did the health care provider review and endorse the laboratory
9 1 0 90.0%
report within specified time frames? (2.005)
Laboratory: Did the health care provider communicate the results of the
3 7 0 30.0%
laboratory test to the patient within specified time frames? (2.006)
Laboratory: Did the institution collect the STAT laboratory test and receive
0 6 0 0
the results within the required time frames? (2.007)
Laboratory: Did the provider acknowledge the STAT results, OR did nursing
0 6 0 0
staff notify the provider within the required time frames? (2.008)
Laboratory: Did the health care provider endorse the STAT laboratory
6 0 0 100%
results within the required time frames? (2.009)
Pathology: Did the institution receive the final pathology report within the
8 2 0 80.0%
required time frames? (2.010)
Pathology: Did the health care provider review and endorse the pathology
8 2 0 80.0%
report within specified time frames? (2.011)
Pathology: Did the health care provider communicate the results of the
1 9 0 10.0%
pathology study to the patient within specified time frames? (2.012)
Overall percentage (MIT 2): 60.0%
Source: The Office of the Inspector General medical inspection results.
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Cycle 7, Salinas Valley State Prison | 23
Recommendations
• The department should develop strategies to ensure providers generate
letters communicating test results to their patients and the letters include all
elements as required by CCHCS policy.
• Medical leadership should determine the root cause(s) of challenges to timely
collecting, receiving, and notifying providers of STAT laboratory results and
implement remedial measures as appropriate.
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Emergency Services
In this indicator, OIG clinicians evaluated the quality of emergency medical care. Our
clinicians reviewed emergency medical services by examining the timeliness and
appropriateness of clinical decisions made during medical emergencies. Our evaluation
included examining the emergency medical response, cardiopulmonary resuscitation
(CPR) quality, triage and treatment area (TTA) care, provider performance, and nursing
performance. Our clinicians also evaluated the Emergency Medical Response Review
Committee’s (EMRRC) performance in identifying problems with its emergency services.
The OIG assessed emergency services through case review only and performed no
compliance testing for this indicator.
Ratings and Results Overview
Case Review Rating Compliance Rating and Score
Adequate Not Applicable
SVSP performed satisfactorily in emergency services. Compared to Cycle 6, SVSP staff
improved in initiating CPR, notifying emergency medical services (EMS), and
administering oxygen. Nurses and providers performed adequate evaluations for patients
and delivered appropriate interventions. The EMRRC generally identified deficiencies
with emergency services and training needs; however, the clinicians found opportunities
for improvement in identifying deficiencies regarding reassessment and documentation.
Considering all factors, the OIG rated this indicator adequate.
Case Review Results
Our clinicians reviewed 65 urgent or emergent events and found 53 emergency care
deficiencies.14 Of these 53 deficiencies, four were significant.15 Of the 53 deficiencies,
32 deficiencies were contained in two cases for patients who had multiple complaints of
chest pain.
Emergency Medical Response
Generally, SVSP provided good emergency care. Our clinicians reviewed five cases in
which patients required CPR.16 Custody staff initiated CPR without delay, administered
Narcan, and notified emergency medical services (EMS) and the TTA staff. Health care
staff almost always responded to medical emergencies throughout the institution without
delay. We identified one deficiency of delayed response. Additionally, our clinicians
identified opportunities for improvement in documentation of time lines and the flow
14 Of the 65 urgent or emergent events, 41 events occurred in cases 1 and 2.
15 Deficiencies occurred in cases 1–8, 19–22, and 47. Significant deficiencies occurred in cases 1, 2, 20, and 22.
16 CPR events occurred in cases 3–5, 7, and 9.
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Cycle 7, Salinas Valley State Prison | 25
rate of oxygen administered to patients. We identified five deficiencies related to these
areas, none of which were significant. 17
Provider Performance
SVSP providers performed excellently in urgent and emergent situations as well as with
after-hours care. They made appropriate triage decisions and diagnoses. Of the 65 TTA
events, we reviewed 60 TTA events in which providers were present or consulted and
found no provider deficiencies.
Nursing Performance
Medical first responders and TTA nurses mostly performed good assessments,
intervened, and notified providers as needed. Our clinicians identified opportunities for
improvement in the areas of nursing assessment and intervention. The following are
examples:
• In cases 1, 2, and 8, staff evaluated patients in the TTA for urgent symptoms.
However, the TTA nurses did not perform reassessments or reassess vital
signs prior to the patient’s release to the housing unit.
• In case 1, the patient received urgent care for chest pain. The nurse assessed
the patient and received orders to transfer the patient emergently to a higher
level of care by ambulance. However, the nurse delayed contacting EMS for
34 minutes due to miscommunication.
• In case 20, the TTA nurse responded to a patient with pale, cool skin after a
witnessed fall. Upon arrival at the patient’s location, the TTA nurse assessed
the patient with increased respirations; however, the nurse did not promptly
take a complete set of vital signs or perform an objective assessment to
determine if immediate intervention and 9-1-1 activation was required.
Instead, the TTA nurse transferred the patient to the TTA for further
assessment and observation. While the patient was observed in the TTA, the
nurse assessed the patient with critically low blood pressure and a rapid
respiratory rate. The patient required immediate fluid resuscitation to
provide life saving measures; however, the nurse did not make multiple
intravenous (IV) attempts or initiate intraosseous (IO) access after the initial
IV was unsuccessful.18
Nursing Documentation
Nurses in the TTA usually performed thorough documentation for emergent events.
Although documentation was lacking for time line of events and medication
administration, these deficiencies did not affect overall patient care. 19
17 CPR event deficiencies occurred in cases 3–5, and 7.
18 Interosseous access involves inserting a catheter into bone to provide immediate medication or fluids.
19 Deficiencies occurred in case 1–3, 6, 7, 21, and 22.
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Emergency Medical Response Review Committee
The EMRRC is required to audit all unscheduled transports to a higher level of care to
evaluate staff performance, documentation, and policy adherence as well as to identify
training issues. Our clinicians reviewed 28 events and identified 10 deficiencies.20 SVSP’s
EMRRC met monthly, usually identified deficiencies, and provided staff training.
However, we identified a trend in which the committee did not always identify
deficiencies regarding reassessment and documentation.
Compliance testing showed the institution rarely performed reviews within required time
frames (MIT 15.003, 8.3%). Compliance inspectors found additional errors including
incomplete checklists and missing entries, and the chief medical executive (CME) and
chief nurse executive (CNE) or designees did not perform a clinical review.
Clinician On-Site Inspection
Our clinicians toured the TTA during our on-site inspection. The TTA had two bays: one
was used for emergent or urgent patients; the other was shared by the off-site return
nurse and specialty clinics.
TTA nursing staff reported nursing staff respond to medical alarms in the outpatient
environment. Nursing staff in CTC and PIP respond to medical emergencies in the
inpatient setting and notify TTA nursing staff if additional medical help is needed.21
SVSP staff reported the institution participated in a pilot program where patients
received two doses of intranasal Narcan for emergency use on two yards. In addition,
when custody responded to a medical alarm and found a patient unresponsive from a
suspected overdose, the custody sergeant would administer Narcan doses until the arrival
of healthcare staff.
20 Deficiencies occurred in cases 1, 2, 4, 7, and 19.
21 PIP is the Psychiatric Inpatient Program.
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Cycle 7, Salinas Valley State Prison | 27
Recommendations
• Nursing leadership should determine the root cause(s) of challenges
preventing staff from completing thorough assessments and accurate
documentation after an emergent event and should implement remedial
measures as indicated.
• Executive leadership should determine the root cause(s) of
challenges to completing thorough reviews of urgent and emergent
events in which patients transfer to the community hospital and
should implement remedial measures as indicated.
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Health Information Management
In this indicator, OIG inspectors evaluated the flow of health information, a crucial link
in high-quality medical care delivery. Our inspectors examined whether the institution
retrieved and scanned critical health information (progress notes, diagnostic reports,
specialist reports, and hospital discharge reports) into the medical record in a timely
manner. Our inspectors also tested whether clinicians adequately reviewed and endorsed
those reports. In addition, our inspectors checked whether staff labeled and organized
documents in the medical record correctly.
Ratings and Results Overview
Case Review Rating Compliance Rating and Score
Adequate Proficient (89.3%)
Case review found SVSP’s performance for this indicator was similar to Cycle 6. Staff
often timely retrieved and scanned hospital discharge records, diagnostic results, and
urgent and emergent reports. However, we found room for improvement with specialty
report retrieval and in obtaining provider endorsements timely. About half the
deficiencies we identified resulted from incomplete or missing patient notification
letters. The OIG rated the case review component of this indicator adequate.
Compliance testing showed SVSP performed excellently in this indicator. Staff always
timely scanned patients’ requests for medical care and retrieved hospital discharge
documents. They also showed good performance in scanning specialty reports and
ensuring medical records were labeled and filed in the appropriate patient files. Based on
the overall compliance score result, the OIG rated the compliance component of this
indicator proficient.
Case Review and Compliance Testing Results
We reviewed 1,123 events and found 48 deficiencies related to health information
management. Of these 48 deficiencies, four were significant.22 The significant
deficiencies with health information management related to delays, not retrieving
specialty reports, and not scanning one wound culture result into the EHRS.23
Hospital Discharge Reports
Case review clinicians reviewed 61 off-site emergency discharge department and hospital
encounters. SVSP staff generally retrieved hospital records, scanned them into the EHRS,
22 HIM deficiencies occurred in cases 1, 2, 10, 13–15, 17, 18, 20, 21, 23–25, 32, 34–37, and 47. Significant HIM
deficiencies occurred in cases 10, 13, 14, and 15.
23 EHRS is the Electronic Health Records System. The department’s electronic health record system is used for
storing the patient’s medical history and health care staff communication.
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Cycle 7, Salinas Valley State Prison | 29
and reviewed them properly. We identified two delays with provider endorsement of
records, one hospital record that was incorrectly scanned, and the deficiency below.
• In case 13, the patient was hospitalized with soft tissue infection of his left
leg. SVSP staff did not retrieve or scan the wound culture results.
Staff always scanned hospital reports into the EHRS (MIT 4.003, 100%) and frequently
retrieved and scanned hospital discharge records (MIT 4.005, 88.0%).
Specialty Reports
Although improved from last cycle, SVSP still had some difficulty with managing
specialty reports. We found four deficiencies with retrieving and scanning reports as well
as three endorsement delays. The following are examples:
• In case 10, the otolaryngologist evaluated the patient, but the staff retrieved this
specialist’s report 12 days later.
• In case 14, the podiatrist evaluated the patient, but staff did not retrieve and scan the
specialist’s report into the EHRS.
• In case 15, the gastroenterologist evaluated the patient, but the staff did not retrieve and
scan this specialist’s report into the EHRS until notified by the OIG.
Diagnostic Reports
SVSP staff’s handling of diagnostic reports was good. We reviewed 160 diagnostic events
and identified 26 deficiencies related to health information management (HIM) and
handling of diagnostic reports: two deficiencies related to late provider endorsements
and 24 related to incomplete patient notification letters. All these deficiencies were
minor and did not significantly increase the risk of harm to the patient.
Compliance performance was mixed for diagnostic reports. Staff did not timely complete
STAT laboratory testing (MIT 2.007, zero) and did not notify providers of STAT results
(MIT 2.008, zero). Providers rarely generated pathology notification letters (MIT 2.012,
10.0%); however, providers often reviewed and endorsed pathology results (MIT 2.011,
80.0%).
Urgent and Emergent Records
OIG clinicians reviewed 149 emergency care events and found SVSP nurses and providers
recorded these events well. The providers also recorded their emergency care sufficiently,
including off-site telephone encounters, and we did not identify any deficiencies with
providers in the emergent setting. However, we identified problems with the
electrocardiogram (EKG) machines not being calibrated to reflect the accurate time. The
Emergency Services indicator provides additional details.
Scanning Performance
Case review found SVSP performed well with scanning and labeling of records. We did
not identify any deficiencies with the scanning accuracy of the records we reviewed. Last
cycle, SVSP had deficiencies with missing refusal forms, but this was not an issue in
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Cycle 7, Salinas Valley State Prison | 30
Cycle 7. Compliance testing showed borderline performance with scanning documents
(MIT 4.004, 75.0%).
Clinician On-Site Inspection
We discussed health information management processes with SVSP supervisors. They
described how medical records staff coordinate with off-site specialty nurses to obtain
off-site specialty reports. They verbalized some specialists do not complete their
consultations reports timely.
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Cycle 7, Salinas Valley State Prison | 31
Compliance Score Results
Table 8. Health Information Management
Scored Answer
Compliance Questions Yes No N/A Yes %
Are health care service request forms scanned into the patient’s electronic
20 0 10 100%
health record within three calendar days of the encounter date? (4.001)
Are specialty documents scanned into the patient’s electronic health record
25 5 15 83.3%
within five calendar days of the encounter date? (4.002)
Are community hospital discharge documents scanned into the patient’s
electronic health record within three calendar days of hospital discharge? 20 0 5 100%
(4.003)
During the inspection, were medical records properly scanned, labeled,
18 6 0 75.0%
and included in the correct patients’ files? (4.004)
For patients discharged from a community hospital: Did the preliminary or
final hospital discharge report include key elements and did a provider 22 3 0 88.0%
review the report within five calendar days of discharge? (4.005)
Overall percentage (MIT 4): 89.3%
Source: The Office of the Inspector General medical inspection results.
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Table 9. Other Tests Related to Health Information Management
Scored Answer
Compliance Questions Yes No N/A Yes %
Radiology: Did the ordering health care provider review and endorse the
10 0 0 100%
radiology report within specified time frames? (2.002)
Laboratory: Did the health care provider review and endorse the laboratory
9 1 0 90.0%
report within specified time frames? (2.005)
Laboratory: Did the provider acknowledge the STAT results, OR did nursing
0 6 0 0
staff notify the provider within the required time frame? (2.008)
Pathology: Did the institution receive the final pathology report within the
8 2 0 80.0%
required time frames? (2.010)
Pathology: Did the health care provider review and endorse the pathology
8 2 0 80.0%
report within specified time frames? (2.011)
Pathology: Did the health care provider communicate the results of the
1 9 0 10.0%
pathology study to the patient within specified time frames? (2.012)
Did the institution receive and did the primary care provider review the
high-priority specialty service consultant report within the required time 14 1 0 93.3%
frame? (14.002)
Did the institution receive and did the primary care provider review the
medium-priority specialty service consultant report within the required time 8 6 1 57.1%
frame? (14.005)
Did the institution receive and did the primary care provider review the
routine-priority specialty service consultant report within the required time 8 5 2 61.5%
frame? (14.008)
Source: The Office of the Inspector General medical inspection results.
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Recommendations
The OIG offers no recommendations for this indicator.
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Cycle 7, Salinas Valley State Prison | 34
Health Care Environment
In this indicator, OIG compliance inspectors tested clinics’ waiting areas, infection
control, sanitation procedures, medical supplies, equipment management, and
examination rooms. Inspectors also tested clinics’ performance in maintaining auditory
and visual privacy for clinical encounters. Compliance inspectors asked the institution’s
health care administrators to comment on their facility’s infrastructure and its ability to
support health care operations. The OIG rated this indicator solely on the compliance
score. Our case review clinicians do not rate this indicator.
Because none of the tests in this indicator directly affected clinical patient care (it is a
secondary indicator), the OIG did not consider this indicator’s rating when determining
the institution’s overall compliance rating.
Ratings and Results Overview
Case Review Rating Compliance Rating and Score
Not Applicable Inadequate (55.7%)
In this cycle, multiple aspects of SVSP’s health care environment were poor: medical
supplies storage areas inside of the clinics contained expired medical supplies; several
areas of the examination rooms were unsanitary; emergency medical response bag
(EMRB) logs were missing staff verification or inventory was not performed; several
clinics did not meet the requirements for essential core medical equipment and supplies;
and staff did not regularly sanitize their hands before or after examining patients. Based
on the overall compliance score result, the OIG rated this indicator inadequate.
Compliance Testing Results
Patient Waiting Areas
We inspected patient waiting areas.
Health care and custody staff reported the
existing waiting areas contained
sufficient seating capacity. Dependent on
the population, patients were either
placed in the clinic waiting area or held in
individual modules (see Photo 1, right,
and Photo 2, next page). During our
inspection, we did not observe
overcrowding in any of the clinics’ patient
waiting areas.
Photo 1. Patient waiting area
(photographed on 8-30-23).
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Cycle 7, Salinas Valley State Prison | 35
Photo 2. Patient individual waiting modules
(photographed on 8-31-23).
Clinic Environment
All nine clinic environments were sufficiently conducive for medical care. They provided
reasonable auditory privacy, appropriate waiting areas, wheelchair accessibility, and
nonexamination room workspace (MIT 5.109, 100%).
Of the nine clinics we observed, eight contained
appropriate space, configuration, supplies, and
equipment to allow their clinicians to perform proper
clinical examinations (MIT 5.110, 88.9%). In one clinic,
the examination room lacked visual privacy for
conducting clinical examinations. In addition, we
observed the clinical staff kept the examination room
door open and discussed the plan of care for a patient by
the doorway with a different patient inside the
examination room, which hindered auditory privacy.
Clinic Supplies
Only three of the nine clinics followed adequate medical
supply storage and management protocols (MIT 5.107,
33.3%). We found one or more of the following
deficiencies in six clinics: expired medical supplies (see
Photo 3, right and Photo 4, next page); unorganized,
compromised, unlabeled, or inaccurately labeled
medical supplies (see Photo 5, next page); cleaning
materials stored with medical supplies; and staff
members’ personal food stored long term in the medical
supply storage cart. Photo 3. Expired medical supply dated
February 2021 (photographed on 8-29-23).
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Cycle 7, Salinas Valley State Prison | 36
Photo 4. Expired medical supply dated May 5, 2022
(photographed on 8-29-23).
Photo 5. Inaccurately labeled and disorganized
medical supplies (photographed 8-30-23).
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Only two of the nine clinics met requirements for
essential core medical equipment and supplies
(MIT 5.108, 22.2%). Seven clinics lacked medical
supplies or had nonfunctional equipment. The
missing items included examination table paper, an
oto-ophthalmoscope, and tips for the otoscope. The
staff had not properly calibrated an automated vital
signs machine and a nebulization unit. Several
clinics contained nonfunctional oto-
ophthalmoscopes or nonfunctional overhead lights.
We found the Snellen reading chart did not have a
corresponding distance line marked on the floor or
wall and the chart utilized was a printout (see
Photo 6, left). In addition, staff had not completed
the AED or defibrillator performance test log
documentation within the last 30 days.
Furthermore, the clinic daily glucometer quality
control logs were either inaccurate or incomplete.
We examined emergency medical response bags
(EMRBs) to determine whether they contained all
Photo 6. Snellen reading chart did not have a essential items. We checked whether staff
corresponding distance line marked on the floor or inspected the bags daily and inventoried them
wall, and the chart used was a printout
monthly. Four of the seven applicable EMRBs
(photographed on 8-30-23).
passed our test (MIT 5.111, 57.1%). In three EMRBs
we found one or more of the following deficiencies:
staff did not ensure the EMRB’s compartments were sealed
and intact or staff had not inventoried the EMRBs when the
seal tags were replaced.
Medical Supply Management
None of the medical supply storage areas located outside
the medical clinics stored medical supplies adequately (MIT
5.106, zero). The warehouse manager did not maintain a
temperature log for medical supplies with manufacturer
temperature guidelines stored in the medical warehouse.
Although intravenous (IV) solutions stored were within the
recommended temperature at the time of our inspection, we
found several solutions had accumulated condensation (see
Photo 7, right).
According to the chief executive officer (CEO), the
institution did not have any concerns about the medical
supply process. Health care managers and medical
warehouse managers expressed no concerns about the
medical supply chain or their communication process with
Photo 7. IV solution accumulated condensation
the existing system.
(photographed on 8-29-23).
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Cycle 7, Salinas Valley State Prison | 38
Infection Control and Sanitation
Infection control and sanitation staff
appropriately, cleaned, sanitized, and
disinfected seven of nine clinics (MIT 5.101,
77.8%). In two clinics, cleaning logs were not
maintained. In addition, in one of the two
clinics, we found an insect in the clinic’s
medication room (see Photo 8, right).
Staff in seven of nine clinics (MIT 5.102, 77.8%)
properly sterilized or disinfected medical
equipment. In two clinics, we found one or more
of the following deficiencies: staff did not date
stamp the packaging of sterilized medical
equipment; staff did not have a good
Photo 8. Insect in the clinic's medication room
understanding of the sterilization cleaning
(photographed on 8-30-23).
protocols and the institution’s local operating
procedures; and the previously sterilized
reusable invasive medical equipment label did
not correctly change color to verify successful sterilization.
We found operating sinks and hand hygiene supplies in the examination rooms in five of
nine clinics (MIT 5.103, 55.6%). In four clinics, the patient restroom lacked antiseptic
soap or disposable hand towels.
We observed patient encounters in seven clinics. In all seven clinics, clinicians did not
wash their hands before or after examining their patients, before applying gloves, after
performing blood draws, after performing blood draw services, or during re-gloving while
performing wound care services (MIT 5.104, zero).
Health care staff in all clinics followed proper protocols to mitigate exposure to
bloodborne pathogens and contaminated waste (MIT 5.105, 100%).
In addition to the above findings, our compliance inspectors observed the following
notable findings in the clinic during their on-site inspection:
• We found an expired chemical testing strip used to make sure chemicals
intended for disinfection were within the correct concentration levels (see Photo
9, next page).
• The clinic at D-2 had a non-functional patient restroom. We promptly notified
the staff of this concern, and assigned custody staff immediately submitted a
work order and had it approved by the yard’s sergeant.
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Cycle 7, Salinas Valley State Prison | 39
Photo 9. Expired chemical test strip dated
April 2023 (photographed on 8-31-23).
Physical Infrastructure
At the time of our medical inspection, the institution’s administrative team reported no
ongoing health care facility improvement program construction projects. The
institution’s health care management and plant operations manager reported all clinical
area infrastructures were in good working order (MIT 5.999).
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Compliance Score Results
Table 10. Health Care Environment
Scored Answer
Compliance Questions Yes No N/A Yes %
Infection control: Are clinical health care areas appropriately disinfected,
7 2 1 77.8%
cleaned, and sanitary? (5.101)
Infection control: Do clinical health care areas ensure that reusable invasive
and noninvasive medical equipment is properly sterilized or disinfected as 7 2 1 77.8%
warranted? (5.102)
Infection control: Do clinical health care areas contain operable sinks and
5 4 1 55.6%
sufficient quantities of hygiene supplies? (5.103)
Infection control: Does clinical health care staff adhere to universal hand
0 7 3 0
hygiene precautions? (5.104)
Infection control: Do clinical health care areas control exposure to blood-
9 0 1 100%
borne pathogens and contaminated waste? (5.105)
Warehouse, conex, and other nonclinic storage areas: Does the medical
supply management process adequately support the needs of the medical 0 1 0 0
health care program? (5.106)
Clinical areas: Does each clinic follow adequate protocols for managing and
3 6 1 33.3%
storing bulk medical supplies? (5.107)
Clinical areas: Do clinic common areas and exam rooms have essential core
2 7 1 22.2%
medical equipment and supplies? (5.108)
Clinical areas: Are the environments in the common clinic areas conducive
9 0 1 100%
to providing medical services? (5.109)
Clinical areas: Are the environments in the clinic exam rooms conducive to
8 1 1 88.9%
providing medical services? (5.110)
Clinical areas: Are emergency medical response bags and emergency crash
carts inspected and inventoried within required time frames, and do they 4 3 3 57.1%
contain essential items? (5.111)
Does the institution’s health care management believe that all clinical areas
This is a nonscored test. Please see the
have physical plant infrastructures that are sufficient to provide adequate
indicator for discussion of this test.
health care services? (5.999)
Overall percentage (MIT 5): 55.7%
Source: The Office of the Inspector General medical inspection results.
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Cycle 7, Salinas Valley State Prison | 41
Recommendations
• Medical and nursing leadership should analyze the root cause(s) for staff not
following all required universal hand hygiene precautions and should
implement remedial measures as appropriate.
• Executive leadership should analyze the root cause(s) for staff not following
equipment and medical supply management protocols and should implement
remedial measures as appropriate.
• Nursing leadership should determine the root cause(s) for staff not ensuring
the EMRBs are regularly inventoried and sealed or not properly completing
the monthly logs and should implement remedial measures as appropriate.
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Transfers
In this indicator, OIG inspectors examined the transfer process for those patients who
transferred into the institution as well as for those who transferred to other institutions.
For newly arrived patients, our inspectors assessed the quality of health care screenings
and the continuity of provider appointments, specialist referrals, diagnostic tests, and
medications. For patients who transferred out of the institution, inspectors checked
whether staff reviewed patient medical records and determined the patient’s need for
medical holds. They also assessed whether staff transferred patients with their medical
equipment and gave correct medications before patients left. In addition, our inspectors
evaluated the performance of staff in communicating vital health transfer information,
such as preexisting health conditions, pending appointments, tests, and specialty
referrals; and inspectors confirmed whether staff sent complete medication transfer
packages to receiving institutions. For patients who returned from off-site hospitals or
emergency rooms, inspectors reviewed whether staff appropriately implemented
recommended treatment plans, administered necessary medications, and scheduled
appropriate follow-up appointments.
Ratings and Results Overview
Case Review Rating Compliance Rating and Score
Adequate Inadequate (73.6%)
In case review, SVSP performed satisfactorily in the transfer process. Compared to Cycle
6, nurses improved in nursing assessment for patients returning from the community
hospital or emergency rooms. For patients transferring in and out of the institution, case
review found nursing assessments were good; however, nurses did not perform COVID-
19 point-of-care testing prior to patients transferring out of SVSP. Providers evaluated
patients timely for newly arrived patients. In contrast, SVSP did not perform well in the
transfer-out process. We identified opportunities for improvement in transfer screenings,
COVID-19 screenings, and medication continuity. Factoring all the information, the OIG
rated the case review component of this indicator adequate.
Compliance testing showed mixed results for the transfers indicator. SVSP scored low in
completing initial health screening forms and ensuring medication continuity for newly
transferred patients. In contrast, the institution performed very well in completing the
assessment and disposition sections of the screening process. The institution also
showed good performance in ensuring transfer packets for departing patients included
the required documents and medications. Based on the overall compliance score result,
the OIG rated the compliance component of this indicator inadequate.
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Case Review and Compliance Testing Results
We reviewed 73 events in 21 cases in which patients transferred into or out of the
institution or returned from an off-site hospital or emergency room. We identified 17
deficiencies, six of which were significant.24
Transfers In
The transfer-in process was very good. Compliance testing showed receiving and release
(R&R) nurses always completed the assessment and disposition section of the forms (MIT
6.002, 100%); however, the nurses frequently did not thoroughly complete the screening
(MIT 6.001, 56.0%). This included nursing staff completing the initial health screening
form after the patient was transferred to the housing unit, not documenting an
explanation to questions answered with a “yes,” or not documenting patients’ weight.
Our clinicians reviewed three transfer-in cases and found nurses performed very well
completing assessments and ordering the initial provider appointments within required
time frames. We identified one minor deficiency in nursing documentation.
Compliance testing showed SVSP performed well with ensuring newly arrived patients
saw a provider within the required time frames (MIT 1.002, 84.0%). Our clinicians did not
identify any deficiencies with the timeliness of provider appointments for newly arrived
patients.
Case review and compliance testing had mixed results for medication continuity for
transfer-in patients (MIT 6.003, 55.0%). Our case review clinicians did not identify any
concerns with medication continuity. Analysis of the compliance data showed patients
received keep-on-person (KOP) medications up to one day late, medication was not
delivered to the patient by the ordered administration date, and nurses did not always
document completely.
Case review and compliance testing had mixed results for timely scheduling specialty
appointments. Compliance testing showed SVSP performed poorly in scheduling pre-
approved specialty appointments for patients who transferred into the institution (MIT
14.010, 35.0%). Analysis of the compliance scores show SVSP did not schedule patients for
specialty appointments timely; the appointments occurred between one and 141 days late.
Our case review clinicians did not identify any concerns with specialty appointments.
Transfers Out
The transfer-out process needed improvement. Our clinicians reviewed three cases and
found five deficiencies, three of which were significant.25 In two cases, the R&R nurses
did not perform a COVID-19 point-of-care test to rule out COVID-19. Compliance
testing showed R&R nurses ensured five of six patients transferring out of the institution
had the required medications, transfer documents, and assigned durable medical
equipment (DME) (MIT 6.101, 83.3%). For one patient, the transfer packet included a
24 Deficiencies occurred in cases 1, 8, 13, 15, 20, 21, 24, 26, 29-31, and 47. Significant deficiencies occurred in
cases 13, 20, 21, 29, and 31.
25 Transfer-out deficiencies occurred in case 29, 30, and 31. Significant deficiencies occurred in cases 29 and 31.
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Cycle 7, Salinas Valley State Prison | 44
medication with an expired pharmacy label. Our clinicians identified one deficiency
regarding a lapse in medication continuity for patients transferring out of the institution:
• In case 31, the patient transferred out of the institution without medications
prescribed for hypertension and gastric reflux disease.
Hospitalizations
Patients returning from an off-site hospitalization or emergency room are at high risk for
lapses in care quality. These patients typically have experienced severe illness or injury.
They require more care and place a strain on the institution’s resources. In addition,
because these patients have complex medical issues, successful health information
transfer is necessary for good quality care. Any transfer lapse can result in serious
consequences for these patients.
For hospital returns, SVSP’s performance resulted in different findings for case review
and compliance testing. OIG clinicians reviewed 63 events in 15 cases in which patients
returned from a hospitalization or emergency room evaluation and identified 11
deficiencies, three of which were significant.26 Of the significant deficiencies identified,
none related to nursing performance as the nurses performed excellent assessments.
In contrast, SVSP performed poorly in medication continuity for patients who returned
to the institution after discharge from the hospital (MIT 7.003, 36.0%). Our clinicians also
identified one minor deficiency related to medication continuity.27
Compliance testing showed SVSP performed well in timely provider follow-up
appointments (MIT 1.007, 88.0%), staff always scanned hospital discharge documents into
the patient’s electronic health record (MIT 4.003, 100%), and providers often reviewed the
hospital discharge report timely (MIT 4.005, 88.0%). Our clinicians found most documents
scans were timely. We found four deficiencies, which are addressed in the Health
Information Management indicator.28
SVSP provider performance with hospital returns will be discussed further in the
Provider Performance indicator. Case review clinicians found three deficiencies where
the provider did not follow hospital recommendations and medications.
Clinician On-Site Inspection
During the on-site inspection, our clinicians interviewed the R&R nurse, who was
familiar with the transfer process and did not report any issues with supplies, equipment,
or pharmacy. The R&R nurse reported SVSP receives 60 to 70 new arrivals per week.
When patients arrive at the institution, the R&R nurse must wait until the care team
panels are assigned in EHRS before documenting on the initial screening form. When
patients transferred to the institution or returned from a hospitalization, the nurses
reconciled medication orders and the providers reconciled remaining orders and DME.
26 Deficiencies occurred in cases 1, 8, 13, 15, 20, 21, 24, and 47. Significant deficiencies occurred in cases 13, 20
and 21.
27 Deficiencies occurred in case 20.
28 Deficiencies occurred in cases 1, 13, 20, and 47. A significant deficiency occurred in case 13.
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Compliance Score Results
Table 11. Transfers
Scored Answer
Compliance Questions Yes No N/A Yes %
For endorsed patients received from another CDCR institution: Did nursing
staff complete the initial health screening and answer all screening 14 11 0 56.0%
questions within the required time frame? (6.001)
For endorsed patients received from another CDCR institution: When
required, did the RN complete the assessment and disposition section of
the initial health screening form; refer the patient to the TTA if TB signs and 25 0 0 100%
symptoms were present; and sign and date the form on the same day staff
completed the health screening? (6.002)
For endorsed patients received from another CDCR institution: If the
patient had an existing medication order upon arrival, were medications 11 9 5 55.0%
administered or delivered without interruption? (6.003)
For patients transferred out of the facility: Do medication transfer packages
include required medications along with the corresponding transfer packet 5 1 2 83.3%
required documents? (6.101)
Overall percentage (MIT 6): 73.6%
Source: The Office of the Inspector General medical inspection results.
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Table 12. Other Tests Related to Transfers
Scored Answer
Compliance Questions Yes No N/A Yes %
For endorsed patients received from another CDCR institution: Based on
the patient’s clinical risk level during the initial health screening, was the 21 4 0 84.0%
patient seen by the clinician within the required time frame? (1.002)
Upon the patient’s discharge from the community hospital: Did the patient
receive a follow-up appointment with a primary care provider within the 22 3 0 88.0%
required time frame? (1.007)
Are community hospital discharge documents scanned into the patient’s
electronic health record within three calendar days of hospital discharge? 20 0 5 100%
(4.003)
For patients discharged from a community hospital: Did the preliminary or
final hospital discharge report include key elements and did a provider 22 3 0 88.0%
review the report within five calendar days of discharge? (4.005)
Upon the patient’s discharge from a community hospital: Were all ordered
medications administered, made available, or delivered to the patient 9 16 0 36.0%
within required time frames? (7.003)
Upon the patient’s transfer from one housing unit to another: Were
14 11 0 56.0%
medications continued without interruption? (7.005)
For patients en route who lay over at the institution: If the temporarily
housed patient had an existing medication order, were medications 4 6 0 40.0%
administered or delivered without interruption? (7.006)
For endorsed patients received from another CDCR institution: If the
patient was approved for a specialty services appointment at the sending
7 13 0 35.0%
institution, was the appointment scheduled at the receiving institution
within the required time frames? (14.010)
Source: The Office of the Inspector General medical inspection results.
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Recommendations
• Nursing leadership should identify the root cause(s) for R&R nurses not
completing the initial health screening, including answering all questions
and documenting an explanation for each “yes” answer, not documenting a
complete set of vital signs as part of the patient’s initial health screening
assessment, and not completing the initial health screening form prior to a
patient being placed in housing. Nursing leadership should implement
remedial measures as appropriate.
• Nursing leadership should identify the challenges to ensuring newly arrived
patients receive medications without interruption and implement remedial
measures as appropriate.
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Medication Management
In this indicator, OIG inspectors evaluated the institution’s performance in
administering prescription medications on time and without interruption. The inspectors
examined this process from the time a provider prescribed medication until the nurse
administered the medication to the patient. In this indicator, the OIG strongly
considered the compliance test results, which tested medication processes to a much
greater degree than case review testing. In addition to examining medication
administration, our compliance inspectors also tested many other processes, including
medication handling, storage, error reporting, and other pharmacy processes.
Ratings and Results Overview
Case Review Rating Compliance Rating and Score
Adequate Inadequate (62.5%)
Case reviewers found SVSP performed sufficiently in medication management. Staff
adequately ensured patients received their medications timely during the transfer-in and
transfer-out processes as well as for new medication prescriptions, chronic care
medications, and hospital discharge medications. While SVSP improved overall in
specialized medical housing (SMH) continuity of medications as compared to Cycle 6, our
clinicians still identified a trend in SMH medication lapses. Considering all factors, the
OIG rated the case review component of this indicator adequate.
Compliance testing showed SVSP needed improvement with this indicator. SVSP scored
low in providing patients with chronic care medications, newly prescribed medications as
ordered, community hospital discharge medications, and medications for patients
temporarily housed at the institution. SVSP also scored low in medication continuity for
patients transferring within the institution. Based on the overall compliance score result,
the OIG rated the compliance component of this indicator inadequate.
Case Review and Compliance Testing Results
We reviewed 125 events in 27 cases related to medications and found 20 medication
deficiencies, four of which were significant.29
New Medication Prescriptions
For new medication availability, compliance testing showed the institution’s
performance needed improvement. Compliance testing revealed SVSP intermittently
made available, administered, or delivered medications within the required time frame
(MIT 7.002, 52.0%). In contrast our case review clinicians found staff almost always
administered newly prescribed medications timely. Our clinicians found three
29 Deficiencies occurred in cases 8, 10, 12, 16, 18, 20–23, 31, and 48. Significant deficiencies occurred in cases 10,
16, and 31.
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deficiencies for newly prescribed medications, one of which was significant.30 The
following is an example:
• In case 16, the provider ordered a dosage increase for medication to treat the
patient’s hypertension. The patient received the new blood pressure
medication one month late and, on that day, received two 30-day supplies of
the medication.
Chronic Medication Continuity
Compliance testing showed patients’ chronic care medications were only occasionally
available within the required time frames (MIT 7.001, 25.0%). Our clinicians found nine
cases with lapses in chronic care medication continuity.31 Below is an example:
• In case 2, the patient received KOP nitroglycerin medication twice within a
seven-day period. In addition, the patient did not receive an automatic refill
of the scheduled medication to treat to a prostate condition in February 2023.
Hospital Discharge Medications
Compliance testing showed patients returning from hospitals or emergency rooms
sporadically received their medications within the required time frames (MIT 7.003,
36.0%). Analysis of the compliance data showed nursing staff either did not administer
medications or did not document the patient’s reason for the refusal or for not presenting
to the medication line. In contrast, our case review clinicians found staff almost always
administered medications timely. We found one deficiency involving a lapse in continuity
of chronic care medication, which was not significant. Please refer to the Transfers
indicator for additional details.
Specialized Medical Housing Medications
Case review and compliance testing had mixed results. Compliance testing showed SVSP
needed improvement managing medications in the SMH (MIT 13.003, 14.3%). Although
patients received their medications as ordered, the low score was due to the pharmacy
not filling and dispensing the medication timely, and to nursing staff not documenting
reasons for refusal. Case reviewers identified six deficiencies, none of which were
significant.32
Transfer Medications
Case review showed better results for transfer medications compared with the findings
from compliance testing. Compliance testing showed SVSP needed improvement in
medication continuity for patients arriving to the institution (MIT 6.003, 55.0%) and with
medication continuity when patients transferred from yard to yard (MIT 7.005, 56.0%).
30 Deficiencies occurred in cases 16, and 18. A significant deficiency occurred in case 16.
31 Patients did not receive timely chronic care medications in cases 8, 10, 12, 16, 18, 20, 21, 29, and 48.
Significant deficiencies occurred in cases 10 and 16, and 22.
32 Deficiencies occurred in cases 8, 23, and 48.
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Our case review clinicians did not identify any deficiencies related to medication
continuity for patients who transferred into the institution.
Compliance testing showed SVSP frequently ensured patients who transferred out of the
institution received a five-day supply of medications (MIT 6.101, 83.3%). Our clinicians
identified only one significant deficiency that we further discuss in the Transfers
indicator.
In compliance testing, patients who were temporarily housed at the facility occasionally
received their medications without interruption (MIT 7.006, 40.0%). Our clinicians did not
review any cases where patients were temporarily housed at SVSP.
Medication Administration
SVSP performed very well in ensuring continuity of tuberculosis (TB) medications (MIT
9.001, 100%). However, the institution poorly monitored patients on TB medications (MIT
9.002, 50.0%). Our clinicians did not have any case review samples with events related to
TB medications.
Clinician On-Site Inspection
Our clinicians attended various huddles where medical staff discussed expired
medications, medication noncompliance, and out-of-compliant TB medication. In one
huddle, the provider addressed the expiring medications.
We interviewed several medication nurses, and found they were familiar with
medication-related processes such as KOP medications, patient refusals, and the transfer
process. Licensed vocational nursing (LVN) staff reported patients have four days to pick
up KOP medication. If the patient does not pick up the medication on the fourth day, the
medication nurse will document on the medication administration record (MAR) the
patient was a “no show/no barrier.” For patients who were not at the institution during
the scheduled medication administration time due to off-site appointments or
hospitalizations, the nurses would document in the MAR “out to medical” and document
in the comments “no show/no barrier.”
Nurses reported the institution’s involvement in a pilot program in two yards for KOP
Narcan where each patient has access to two doses of Narcan and can request refills as
needed.
Medication nurses reported they believed nursing morale was fair; they could
communicate concerns to their supervisors and had a good rapport with custody staff.
Medication Practices and Storage Controls
The institution adequately stored and secured narcotic medications in all of nine
applicable clinic and medication line locations (MIT 7.101, 100%).
SVSP appropriately stored and secured nonnarcotic medications in four of 11 applicable
clinic and medication line locations (MIT 7.102, 36.4%). In five locations, nurses did not
maintain unissued medication in its original labeled packaging. In the remaining two
locations, treatment cart logs were missing daily security check entries.
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Staff kept medications protected from physical, chemical, and temperature
contamination in six of the 11 applicable clinic and medication line locations (MIT 7.103,
54.6%). In five locations, we found one or more of the following deficiencies: staff did not
consistently record the room temperature; staff did not store internal and external
medications separately; staff stored medications with disinfectants; and the medication
refrigerator was unsanitary.
Staff successfully stored valid, unexpired medications in 10 of the 11 applicable
medication line locations (MIT 7.104, 90.9%). In one location, nurses did not label multi-
use medications as required by CCHCS policy.
Nurses exercised proper hand hygiene and contamination control protocols in three of
seven applicable locations (MIT 7.105, 42.9%). In four locations, some nurses neglected to
wash or sanitize their hands before each subsequent regloving or change gloves when the
gloves were compromised.
Staff in all of seven applicable medication preparation and administration areas showed
appropriate administrative controls and protocols when preparing medications for
patients (MIT 7.106, 100%).
In contrast, staff in only two of seven applicable medication areas used appropriate
administrative controls and protocols when distributing medications to their patients
(MIT 7.107, 28.6%). In five locations, we observed one or more of the following
deficiencies: medication nurses did not distribute medications to patients within the
required time frame; medication nurses did not consistently observe patients while they
swallowed direct observation therapy medications; and during insulin administration, we
observed some medication nurses did not properly disinfect the vial’s port prior to
withdrawing medication.
Pharmacy Protocols
SVSP always followed general security, organization, and cleanliness management
protocols for nonrefrigerated and refrigerated medications stored in its pharmacy (MIT
7.108, 7.109, and 7.110, 100%).
The pharmacist-in-charge (PIC) did not thoroughly review monthly inventories of
controlled substances in the institution’s clinic and medication storage locations.
Specifically, the PIC or nurse present at the time of the medication area inspection did
not correctly complete the medication area inspection checklists (CDCR form 7477). This
error resulted in a score of zero for this test (MIT 7.111, zero).
We examined seven pharmacy-related medication error reports. The PIC timely and
correctly processed all reports (MIT 7.112, 100%).
Nonscored Tests
In addition to testing the institution’s self-reported medication errors, our inspectors
also followed up on any significant medication errors found during compliance testing.
We did not score this test; we provide these results for informational purposes only. At
SVSP, the OIG did not find any applicable medication errors (MIT 7.998).
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The OIG interviewed patients in restricted housing units to determine whether they had
immediate access to their prescribed asthma rescue inhalers or nitroglycerin
medications. Of 20 applicable patients interviewed, 13 indicated they had access to their
rescue medications. Two patients stated they did not receive their medication upon
transfer to the unit or institution. Two patients reported they ran out of their medication
but did not ask for a refill. Two patients reported they did not have their prescribed
rescue medication. The remaining patient’s medication was expired at the time of our
inspection. We promptly notified the CEO of this concern, and health care management
obtained new refusal documentation for one patient and immediately issued replacement
rescue inhalers to the other patients (MIT 7.999).
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Compliance Score Results
Table 13. Medication Management
Scored Answer
Compliance Questions Yes No N/A Yes %
Did the patient receive all chronic care medications within the required time frames
4 12 9 25.0%
or did the institution follow departmental policy for refusals or no‑shows? (7.001)
Did health care staff administer, make available, or deliver new order prescription
13 12 0 52.0%
medications to the patient within the required time frames? (7.002)
Upon the patient’s discharge from a community hospital: Were all ordered
medications administered, made available, or delivered to the patient within 9 16 0 36.0%
required time frames? (7.003)
For patients received from a county jail: Were all medications ordered by the
institution’s reception center provider administered, made available, or delivered to N/A N/A N/A N/A
the patient within the required time frames? (7.004)
Upon the patient’s transfer from one housing unit to another: Were medications
14 11 0 56.0%
continued without interruption? (7.005)
For patients en route who lay over at the institution: If the temporarily housed
patient had an existing medication order, were medications administered or 4 6 0 40.0%
delivered without interruption? (7.006)
All clinical and medication line storage areas for narcotic medications: Does the
institution employ strong medication security controls over narcotic medications 9 0 3 100%
assigned to its storage areas? (7.101)
All clinical and medication line storage areas for nonnarcotic medications: Does the
institution properly secure and store nonnarcotic medications in the assigned 4 7 1 36.4%
storage areas? (7.102)
All clinical and medication line storage areas for nonnarcotic medications: Does the
institution keep nonnarcotic medication storage locations free of contamination in 6 5 1 54.6%
the assigned storage areas? (7.103)
All clinical and medication line storage areas for nonnarcotic medications: Does the
institution safely store nonnarcotic medications that have yet to expire in the 10 1 1 90.9%
assigned storage areas? (7.104)
Medication preparation and administration areas: Do nursing staff employ and
follow hand hygiene contamination control protocols during medication 3 4 5 42.9%
preparation and medication administration processes? (7.105)
Medication preparation and administration areas: Does the institution employ
appropriate administrative controls and protocols when preparing medications for 7 0 5 100%
patients? (7.106)
Medication preparation and administration areas: Does the institution employ
appropriate administrative controls and protocols when administering medications 2 5 5 28.6%
to patients? (7.107)
Pharmacy: Does the institution employ and follow general security, organization,
1 0 0 100%
and cleanliness management protocols in its main and remote pharmacies? (7.108)
Pharmacy: Does the institution’s pharmacy properly store nonrefrigerated
1 0 0 100%
medications? (7.109)
Pharmacy: Does the institution’s pharmacy properly store refrigerated or frozen
1 0 0 100%
medications? (7.110)
Pharmacy: Does the institution’s pharmacy properly account for narcotic
0 1 0 0
medications? (7.111)
Pharmacy: Does the institution follow key medication error reporting protocols?
7 0 0 100%
(7.112)
Pharmacy: For Information Purposes Only: During compliance testing, did the OIG This is a nonscored test. Please see the indicator
find that medication errors were properly identified and reported by the institution?
(7.998) for discussion of this test.
Pharmacy: For Information Purposes Only: Do patients in restricted housing units This is a nonscored test. Please see the indicator
have immediate access to their KOP prescribed rescue inhalers and nitroglycerin
medications? (7.999) for discussion of this test.
Overall percentage (MIT 7): 62.5%
Source: The Office of the Inspector General medical inspection results.
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Table 14. Other Tests Related to Medication Management
Scored Answer
Compliance Questions Yes No N/A Yes %
For endorsed patients received from another CDCR institution: If the
patient had an existing medication order upon arrival, were medications 11 9 5 55.0%
administered or delivered without interruption? (6.003)
For patients transferred out of the facility: Do medication transfer packages
include required medications along with the corresponding transfer- 5 1 2 83.3%
packet required documents? (6.101)
Patients prescribed TB medication: Did the institution administer the
8 0 0 100%
medication to the patient as prescribed? (9.001)
Patients prescribed TB medication: Did the institution monitor the patient
per policy for the most recent three months he or she was on the 4 4 0 50.0%
medication? (9.002)
Upon the patient’s admission to specialized medical housing: Were all
medications ordered, made available, and administered to the patient 1 6 0 14.3%
within required time frames? (13.003)
Source: The Office of the Inspector General medical inspection results.
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Recommendations
• Medical and nursing leadership should determine the challenges to ensuring
chronic care, hospital discharge, and en route patients receive their
medications timely and without interruption; leadership should implement
remedial measures as appropriate.
• Nursing leadership should determine the root cause(s) for nursing staff not
documenting patient refusals and no shows in the medical administration
record, as described in CCHCS policy and procedures, and leadership should
implement remedial measures as appropriate.
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Preventive Services
In this indicator, OIG compliance inspectors tested whether the institution offered or
provided cancer screenings, tuberculosis (TB) screenings, influenza vaccines, and other
immunizations. If the department designated the institution as being at high risk for
coccidioidomycosis (Valley Fever), we tested the institution’s performance in transferring
out patients quickly. The OIG rated this indicator solely according to the compliance
score. Our case review clinicians do not rate this indicator.
Ratings and Results Overview
Case Review Rating Compliance Rating and Score
Not Applicable Inadequate (69.3%)
SVSP had a mixed performance in preventive services. Staff performed well in
administering TB medications, offering patients an influenza vaccine for the most recent
influenza season, and offering colorectal cancer screening for patients from ages 45
through 75. However, SVSP did not always administer TB medications, monitor patients
taking prescribed TB medications or offer required immunizations to chronic care
patients. Based on the overall compliance score result, the OIG rated this indicator
inadequate.
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Compliance Score Results
Table 15. Preventive Services
Scored Answer
Compliance Questions Yes No N/A Yes %
Patients prescribed TB medication: Did the institution administer the
8 0 0 100%
medication to the patient as prescribed? (9.001)
Patients prescribed TB medication: Did the institution monitor the patient
per policy for the most recent three months he or she was on the 4 4 0 50.0%
medication? (9.002)
Annual TB screening: Was the patient screened for TB within the last year?
14 11 0 56.0%
(9.003)
Were all patients offered an influenza vaccination for the most recent
25 0 0 100%
influenza season? (9.004)
All patients from the age of 45 through the age of 75: Was the patient
23 2 0 92.0%
offered colorectal cancer screening? (9.005)
Female patients from the age of 50 through the age of 74: Was the patient
N/A N/A N/A N/A
offered a mammogram in compliance with policy? (9.006)
Female patients from the age of 21 through the age of 65: Was patient
N/A N/A N/A N/A
offered a pap smear in compliance with policy? (9.007)
Are required immunizations being offered for chronic care patients? (9.008) 3 14 8 17.7%
Are patients at the highest risk of coccidioidomycosis (Valley Fever)
N/A N/A N/A N/A
infection transferred out of the facility in a timely manner? (9.009)
Overall percentage (MIT 9): 69.3%
Source: The Office of the Inspector General medical inspection results.
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Recommendations
• Nursing leadership should analyze the challenges to ensuring nursing staff
monitor and document patients receiving TB medications according to
CCHCS guidelines and should implement remedial measures as appropriate.
• Nursing leadership should analyze the challenges to ensuring nursing staff
perform the annual TB screening during the patient’s birth month and
should implement remedial measures as appropriate.
• Medical leadership should analyze the challenges related to the timely
provision of preventive vaccines to chronic care patients and should
implement remedial measures as appropriate.
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Nursing Performance
In this indicator, the OIG clinicians evaluated the quality of care delivered by the
institution’s nurses, including registered nurses (RN), licensed vocational nurses (LVN),
psychiatric technicians (PT), certified nursing assistants (CNA), and medical assistants
(MA). Our clinicians evaluated nurses’ performance in making timely and appropriate
assessments and interventions. We also evaluated the institution’s nurses’ documentation
for accuracy and thoroughness. Clinicians reviewed nursing performance across many
clinical settings and processes, including sick call, outpatient care, care coordination and
management, emergency services, specialized medical housing, hospitalizations,
transfers, specialty services, and medication management. The OIG assessed nursing care
through case review only and performed no compliance testing for this indicator.
When summarizing nursing performance, our clinicians understand nurses perform
numerous aspects of medical care. As such, specific nursing quality issues are discussed
in other indicators, such as Emergency Services, Specialty Services, and Specialized
Medical Housing.
Ratings and Results Overview
Case Review Rating Compliance Rating and Score
Adequate Not Applicable
SVSP nurses provided sufficient nursing care. Nurses generally performed good
assessments and interventions; however, the clinicians identified opportunities for
improvement with nursing assessment in the outpatient clinics, specialized medical
housing, and emergency services. Considering all factors, the OIG rated this indicator
adequate.
Case Review Results
We reviewed 294 nursing encounters in 45 cases.33 Of the nursing encounters we
reviewed, 83 occurred in the outpatient setting and 48 were sick call requests. We
identified 82 nursing performance deficiencies, 14 of which were significant.34
Outpatient Nursing Assessment and Interventions
A critical component of nursing care is the quality of nursing assessment, which includes
both subjective (patient interviews) and objective (observation and examination)
elements. A comprehensive assessment allows nurses to gather essential information
about their patients and to develop appropriate interventions.
33 Nursing encounters occurred in cases 1–9, 11, 13, and 15–48.
34 Deficiencies occurred in cases 1–8, 15–17, 19–22, 24–26, 29–32, 35, 36, 38, 39, and 45–48. Significant
deficiencies occurred in cases 1, 15, 16, 20, 21, 25, 29, and 31.
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Our clinicians identified 31 outpatient nursing performance deficiencies, 10 of which
were significant.35 Nurses generally provided appropriate nursing assessments and
interventions. However, our clinicians identified opportunities for improvement in sick
call triage. The following are examples of outpatient deficiencies:
• In case 15, the nurse triaged the patient’s sick call complaints for severe
headaches, fatigue, dizziness, and abdominal pain. However, the nurse did
not evaluate the patient the same day for urgent symptoms. Instead, the
nurse scheduled the patient to be seen the next business day.
• In case 16, the nurse evaluated the patient for symptoms of chest congestion,
coughing up mucus, and a scratchy throat. The nurse did not inquire if the
patient had a productive cough and did not assess the sputum color, amount,
or consistency. Secondly, the patient presented with an abnormally elevated
blood pressure, but the nurse did not recheck the patient’s blood pressure
prior to discharging the patient to the housing unit or notifying the provider
of the abnormal reading. Lastly, the nurse did not perform a COVID-19
point-of-care test for the patient with acute respiratory symptoms.
• In case 21, the nurse triaged the patient’s sick call as non-symptomatic for
complaint of dramatic weight loss and a request to be placed back on a
nutritional liquid supplement. The nurse scheduled an LVN follow-up
appointment in 14 days; however, the nurse should have triaged this sick call
as symptomatic and scheduled the patient for a RN face-to-face assessment
the following business day.
Outpatient Nursing Documentation
Complete and accurate nursing documentation is an essential component of patient care.
Without proper documentation, health care staff can overlook changes in patients’
conditions. Nursing staff generally documented care appropriately.
Case Management
OIG clinicians reviewed four events in two cases in which patients were evaluated by a
care manager.36 We did not identify deficiencies in chronic care management.
Wound Care
Our clinicians reviewed six events in four cases in which nurses provided wound care.
Nurses performed appropriate assessments and wound care. Our clinicians did not
identify any deficiencies.
35 Deficiencies occurred in cases 1, 2, 15–17, 20–22, 24, 25, 32, 35, 36, 38, 39, and 45–46. Significant deficiencies
occurred in cases 1, 15, 16, 20, 21, and 25.
36 The RN care manager assessed patients in cases 1, 16, and 24.
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Emergency Services
We reviewed 65 urgent or emergent events. Nurses responded promptly to emergent
events. However, their assessments, interventions, and documentation showed room for
improvement, which we detail further in the Emergency Services indicator.
Hospital Returns
We reviewed 63 events involving patients returning from off-site hospitals or emergency
rooms. The nurses performed excellent nursing assessments. Our clinicians did not
identify any nursing deficiencies. Please refer to the Transfers indicator for further
details.
Transfers
We reviewed six cases involving the transfer-in and transfer-out processes. Nurses
performed appropriately for the transfer-in process. However, we identified opportunities
for improvement in assessments and interventions for the transfer-out process. Please
refer to the Transfers indicator for further details.
Specialized Medical Housing
We reviewed five cases with a total of 66 nursing events, including five events in which
nurses provided emergency care.37 Nurses performed appropriate assessments. For more
specific details, please refer to the Specialized Medical Housing indicator.
Specialty Services
We reviewed 27 events in 11 cases in which patients returned from off-site specialty
appointments.38 Our clinicians identified two nursing performance deficiencies, neither
of which was significant.39 Nurses frequently performed appropriate assessments and
interventions. Please refer to the Specialty Services indicator for additional details.
Medication Management
OIG clinicians examined 125 events involving medication management and found most
nurses administered patients’ medications as prescribed. Please refer to the Medication
Management indicator for additional details.
Clinician On-Site Inspection
During the clinician on-site inspection, we interviewed SVSP nursing leadership and
nursing staff. We interviewed nursing staff in the outpatient clinics, medication areas,
TTA, R&R, CTC and the PIP. At the time of our inspection, the institution did not have
any backlog with nursing appointments.
37 Nurses provided urgent or emergent care in the Specialized Medical Housing in cases 8, 19, and 47.
38 Nursing performed assessments for patients returning from off-site specialty appointments in cases 1, 2, 8,
11, 16, 17, 19, 21, 22, 24, and 25.
39 Deficiencies occurred in cases 8 and 17.
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The CNE reported nursing leadership had hired two Directors of Nursing. The CNE
expressed gratitude for the support SVSP received from the regional nurse consultant
from CCHCS. The regional consultant performed audits of the sick call process and
worked closely with nursing leadership to improve nursing triage of sick calls,
assessments, interventions, and documentation.
Our clinicians also attended SVSP’s nursing subcommittee. Nursing leadership discussed
the sick call process, corrective action plans in place, and barriers to patient care.
Nursing leadership addressed our findings, acknowledged opportunities for quality
improvement, and immediately implemented corrective action based on OIG findings.
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Recommendations
• Nursing leadership should analyze the challenges to nurses performing
thorough assessments during face-to-face patient evaluations and should
implement remedial measures as indicated.
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Provider Performance
In this indicator, OIG case review clinicians evaluated the quality of care delivered by the
institution’s providers: physicians, physician assistants, and nurse practitioners. Our
clinicians assessed the institution’s providers’ performance in evaluating, diagnosing,
and managing their patients properly. We examined provider performance across several
clinical settings and programs, including sick call, emergency services, outpatient care,
chronic care, specialty services, intake, transfers, hospitalizations, and specialized
medical housing. We assessed provider care through case review only and performed no
compliance testing for this indicator.
Ratings and Results Overview
Case Review Rating Compliance Rating and Score
Adequate Not Applicable
SVSP providers delivered generally acceptable care, which is an improvement from
Cycle 6. Providers improved their reviews of records and improved on following through
with stated treatment plans. However, we found opportunities for continued
improvement with assessments, decision making, review of records, and chronic care
management. The OIG clinicians did not find any continuity of care issues in the cases
we reviewed this cycle. Some of the improvement can be attributed to increasing the
number of available providers to deliver care. Considering all aspects, the OIG rated this
indicator adequate.
Case Review Results
Providers delivered satisfactory care during the review period. OIG clinicians reviewed
198 medical provider encounters and identified 36 deficiencies, 15 of which were
significant.40 In addition, our clinicians examined the quality of care in 20 comprehensive
case reviews. Of these 20 cases, we found 18 adequate and two inadequate.
In our case reviews, we found SVSP patients often required many mental health services,
refused appointments and services, behaved aggressively, and were noncompliant with
medical care. We considered the providers’ performance in this context.
Assessment and Decision-Making
Providers, overall, conducted acceptable evaluations and made sound decisions. Provider
evaluation and decision-making are the most important aspects of provider care.
Determining diagnoses and treatments is nearly impossible without obtaining a proper
history of the patients’ complaints or medical conditions. Equally important for providers
is examining specific areas of the body with relevance to suspected medical issues. This
40 Provider deficiencies occurred in case 8, 10–12, 14–17, 20–25, and 47. Significant deficiencies occurred in
cases 11, 16, 20–24, and 47.
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allows providers to determine possible diagnoses and treatment plans. The providers
performed satisfactorily in this area. However, we found opportunities for improvement.
• In case 8, the CTC provider reviewed laboratory test results indicating low
white blood cells and low sodium levels but did not evaluate for possible
causes.
• In case 21, on more than one occasion, the provider evaluated the patient,
who had chronic obstructive lung disease with low oxygen levels. The
provider did not obtain vital signs or thoroughly review the patient’s medical
record to be aware the patient was still on prednisone, a medication used for
chronic obstructive lung disease.
• In case 23, instead of evaluating the patient in person, the provider only
performed a chart review for this CTC patient, who had a CTC rounding
event due. The patient required an assessment for his uncontrolled diabetes
and recurrent diarrhea.
• In case 24, the provider evaluated the patient, who complained of dizziness,
palpitations, and chest pressure with activity; however, the provider did not
order a Holter monitor or cardiac stress test to evaluate the cause of the
symptoms.
Review of Records
Providers generally reviewed medical records carefully with some exceptions. Case
review clinicians found five deficiencies with record reviews. The following are examples:
• In case 14, the provider evaluated the patient for follow-up and documented
elevated blood pressure. The provider did not review the medication
administration record to be aware the patient had not picked up his
lisinopril, a blood pressure medication, that month.
• In case 16, the provider evaluated a patient for passing out and considered
arrhythmia as a possible cause but did not order an electrocardiogram, a
simple office test to evaluate electrical activity of the heart.
• In case 20, the patient returned from the hospital with diabetic ketoacidosis
with low blood pressure.41 However, the provider did not review records
carefully to reconcile laboratory orders or hospital recommendations to
repeat the echocardiogram or follow up with a cardiologist.42
41 Diabetic ketoacidosis is a diabetic complication in which the patient’s body produces excess blood acids
called ketones. This condition can be life-threatening and requires the patient to be hospitalized for treatment.
42 An echocardiogram is a procedure using an ultrasound to examine and image the heart.
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Emergency Care
Providers appropriately managed patients in the TTA with urgent and emergent
conditions. They triaged patients and sent them out to the hospital when necessary. We
did not find any provider performance deficiencies with emergency care.
Chronic Care
Providers needed to improve their handling of hypertension and diabetes. We found five
deficiencies related to elevated blood pressure in five cases.43 Sometimes the providers
ignored the vital signs; in other instances, they did not follow up with the patient after
making medication adjustments. The diabetes care deficiencies pertained to lack of
review of blood sugar records, lack of review of laboratory test intervals, and lack of
therapeutic adjustments.44 The following are examples of deficiencies related to diabetes
and blood pressure management:
• In case 11, the provider did not review the diabetic patient’s elevated blood
sugar to be aware the patient was three times the normal range in the week
prior to the appointment and did not discuss the patient’s repeated refusals
of his diabetes medication.
• In case 20, the provider had an encounter with the patient, who was
diagnosed with diabetic ketoacidosis. The provider did not order the diabetes
monitoring test (hemoglobin A1c).
• In case 22, the patient started a blood pressure medication due to elevated
blood pressure. At the provider follow-up appointment, the provider did not
manage the patient’s blood pressure. He did not document a blood pressure
reading and did not order a follow-up appointment to determine whether the
medication needed further adjustments.
• In case 23, the provider evaluated the patient for diabetes several times but
did not adjust the patient’s therapy to improve compliance and diabetes
control.
Specialty Services
SVSP appropriately referred patients for specialty care, when needed. Case review
clinicians reviewed 79 specialty encounters and found only three instances where
providers did not follow recommendations. We discuss providers’ specialty services
performance further in the Specialty Services indicator. The following is an example:
• In case 11, the provider evaluated the patient and recommended follow-up
with a podiatry consultation. The patient was diagnosed with “diabetic foot,”
but the provider did not review the patient’s recent elevated blood sugar
levels and did not discuss the patient’s recurrent refusals of diabetic
medications.
43 Blood pressure deficiencies occurred in cases 12, 14, 16, and 22.
44 Deficiencies involving diabetic care occurred in cases 11, 20, and 23.
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Patient Notification Letters
Providers did not always send patient notification letters to patients. When they did, the
letters did not always contain the four elements required by policy. Case review clinicians
found 24 deficiencies in this area.45
Provider Continuity
SVSP offered good provider continuity, which was a marked improvement when
compared with last cycle. Case review clinicians did not find any deficiencies from lack of
provider continuity.
Clinician On-Site Inspection
We spoke with providers and medical leadership about the provider performance
deficiencies. The providers voiced the rationale for their decisions. They had good
working relationships with nursing staff and custody officers. Medical leadership was
approachable and able to assist with their issues.
Medical leadership stated they had more staffing than they previously had during Cycle 6.
They voiced concern about SVSP being staffed as a “basic” institution but having a
substantial and diverse population of patients requiring significant medical care as would
be more expected of an “intermediate” institution. They expressed appreciation for
having more full-time providers available, noting they performed better and experienced
fewer continuity issues.
45 These deficiencies occurred in cases 2, 14, 15, 17, 18, 24, and 25.
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Recommendations
The OIG offers no recommendations for this indicator.
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Specialized Medical Housing
In this indicator, OIG inspectors evaluated the quality of care in the specialized medical
housing units. We evaluated the performance of the medical staff in assessing,
monitoring, and intervening for medically complex patients requiring close medical
supervision. Our inspectors also evaluated the timeliness and quality of provider and
nursing intake assessments and care plans. We assessed staff members’ performance in
responding promptly when patients’ conditions deteriorated and looked for good
communication when staff consulted with one another while providing continuity of
care. Our clinicians also interpreted relevant compliance results and incorporated them
into this indicator. At the time of our inspection, SVSP’s specialized medical housing
consisted of a correctional treatment center (CTC) and psychiatric inpatient program
(PIP).
Ratings and Results Overview
Case Review Rating Compliance Rating and Score
Adequate Inadequate (67.9%)
Overall, SVSP delivered fair medical care in the CTC. Nursing staff performed thorough
admission assessments. Our clinicians found the nurses evaluated patients every shift but
needed improvement on assessments and documentation during rounding. We found
providers delivered sufficient care. Taking all factors into consideration, the OIG rated
the case review component of this indicator adequate.
Compliance testing showed mixed performance in this indicator. Although staff
sometimes completed timely admission assessments and history with physical
examinations, staff needed improvement in medication administration. Based on the
overall compliance score result, the OIG rated the compliance component of this
indicator inadequate.
Case Review and Compliance Testing Results
OIG clinicians reviewed 49 provider events and 66 nursing events in five cases.46 Due to
the frequency of nursing and provider contacts in the specialized medical housing, we
bundle up to two weeks of patient care into a single event. We identified 40 deficiencies,
eight of which were significant.47
Provider Performance
Case review clinicians reviewed 49 specialized medical housing (SMH) events; each
event may have encompassed care lasting up to a month at a time. We identified 15
provider deficiencies in three cases; most of the deficiencies were in case 23. The
provider did not accurately document diabetes management changes on multiple
46 Specialized medical housing events occurred in cases 8, 19, 23, 47, and 48.
47 Deficiencies occurred in cases 8, 19, 23, 47 and 48. Significant deficiencies occurred in cases 19, 23, and 47.
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occasions. The provider also did not round on the patient appropriately. While the
care in case 23 was poor, overall provider care in the CTC was acceptable. Our
clinicians did not identify any deficiencies with the timeliness of provider admission
history and physicals; however, compliance testing revealed providers intermittently
completed timely admission history and physicals (MIT 13.002, 71.4%).
• In case 23, the patient had uncontrolled diabetes throughout the review
period. The provider did not adjust the patient’s diabetes regimen at times.
• In case 47, the patient reported to the CTC nurse about complaints of chest
pain. The CTC nurse contacted the CTC provider, and the provider evaluated
the patient about 30 minutes later. The provider only commented on
shoulder pain from a fall and did not document any discussion on the
patient’s chest pain.
Nursing Performance
In the inpatient setting, nurses identifying changes in patients’ conditions is crucial.
Changes in a patient’s condition may require immediate assessments, urgent evaluations,
immediate contact with the provider, or EMS activation.
Our clinicians evaluated urgent or emergent care in the CTC and PIP, transfers to the
community emergency department for further evaluation, hospital return assessments,
and nursing care continuity. We reviewed six events in three cases where patients
transferred to a higher level of care for evaluation. We identified three deficiencies, none
of which were significant.48
SMH nurses provided adequate care. They performed rounds each shift, ensured patient
safety, and provided good emergency care. Compliance testing concluded patients
admitted to the CTC and PIP often received timely initial health assessments (MIT
13.001, 85.7%). Our clinicians found nurses frequently performed complete initial
assessments; however, we identified nursing deficiencies in assessments and
documentation.
In both CTC and PIP, nurses intermittently did not perform complete patient
assessments. We also found, when nurses identified abnormal findings, they sometimes
did not reassess their patients thoroughly or provide needed interventions. The following
are examples:
• In case 19, the patient was readmitted to the PIP in March 2023, after a
hospitalization for head injury and schizophrenia. Nurses frequently did not
perform neurological assessments. In addition, nurses documented elevated
pulse but did not reassess the patient’s pulse or notify the provider of the
abnormal findings.
• In case 48, the bedridden patient was readmitted to the CTC in March 2023,
after discharging from the hospital with a blood infection and pneumonia.
The patient had multiple contractures and had tube feedings for nutrition.
The CTC nurses frequently did not perform thorough assessments to
48Deficiencies occurred in cases 8 and 19.
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monitor for risk of choking or monitor the patient’s weight for adequate
intake, and the nurses did not perform appropriate pre- and post-
assessments for tube feedings.
At the time of on-site inspection, the CTC had a functional call light communication
system (MIT 13.101, 100%).
Medication Administration
Compliance testing showed newly admitted patients to the CTC only sporadically
received their medications within the required time frames (MIT 13.003, 14.3%). Analysis
of the compliance data showed the pharmacy did not dispense or deliver medication
timely, staff did not administer medications from the licensed correctional clinic (LCC)
by the provider’s ordering date and time, and nursing staff did not document the reason
for refusal in the patient’s medication record. In contrast, our clinicians did not identify a
lapse of medication continuity for newly admitted patients to the CTC or the PIP.
However, our clinicians found lapses in medication continuity for patients during their
stay in the CTC and PIP.49 The following are examples:
• In case 8, the patient with a history of thyroid disease missed four days of
thyroid medication in January 2023.
• In case 23, the diabetic patient did not receive one dose of insulin and one
pill of diabetic medication in June 2023.
Clinician On-Site Inspection
Our clinicians toured the CTC, observed the CTC huddle, and interviewed nursing and
supervisory staff. At the time of our on-site inspection, the CTC had 12 medical beds
occupied. The CTC had 24-hour nursing staff. We interviewed the supervising registered
nurse (SRN), who reported performing monthly audits and annual reviews. Providers
were available on-site from 7 a.m. to 3 p.m. After hours, the nurses contacted the on-call
provider and obtained verbal orders for medications. The providers reconciled the
remaining orders when they arrived at the institution the next business day.
49 Deficiencies occurred in cases 8, 23, and 48.
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Compliance Score Results
Table 16. Specialized Medical Housing
Scored Answer
Compliance Questions Yes No N/A Yes %
For OHU, CTC, and SNF: Did the registered nurse complete an initial
6 1 0 85.7%
assessment of the patient on the day of admission? (13.001)
Was a written history and physical examination completed within the
5 2 0 71.4%
required time frame? (13.002)
Upon the patient’s admission to specialized medical housing: Were all
medications ordered, made available, and administered to the patient 1 6 0 14.3%
within required time frames? (13.003)
For specialized health care housing (CTC, SNF, hospice, OHU): Do
specialized health care housing maintain an operational call 1 0 0 100%
system? (13.101)
For specialized health care housing (CTC, SNF, hospice, OHU): Do health
care staff perform patient safety checks according to institution’s local 0 0 1 N/A
operating procedure or within the required time frames? (13.102)
Overall percentage (MIT 13): 67.9%
Source: The Office of the Inspector General medical inspection results.
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Recommendations
The OIG offers no recommendations for this indicator.
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Specialty Services
In this indicator, OIG inspectors evaluated the quality of specialty services. The OIG
clinicians focused on the institution’s performance in providing needed specialty care.
Our clinicians also examined specialty appointment scheduling, providers’ specialty
referrals, and medical staff’s retrieval, review, and implementation of any specialty
recommendations.
Ratings and Results Overview
Case Review Rating Compliance Rating and Score
Adequate Inadequate (73.2%)
In case review, SVSP provided acceptable specialty services for their patients. Both
provider performance and nursing performance related to specialty care were very good.
The institution managed specialty health information acceptably. Compared with Cycle
6, SVSP improved with access to specialty services and information management. The
OIG rated the case review component of this indicator adequate.
Compliance testing showed mixed performance in this indicator. Providers generated
appropriate referrals, and staff timely scheduled follow-up specialty appointments.
However, access to specialists ranged from excellent to poor, depending on the
appointment priority. Preapproved specialty referrals for newly arrived patients
occasionally occurred within the recommended time frames. In addition, retrieval of
specialty reports and prompt provider endorsements both needed improvements. Based
on the overall compliance score result, the OIG rated the compliance component of this
indicator inadequate.
Case Review and Compliance Testing Results
We reviewed 154 events related to specialty services; 81 were specialty consultations and
procedures. We found 21 deficiencies in this category, seven of which were significant.50
Despite its remote location, SVSP has a large proportion of patients who are medically
complex and require more specialty care. Due to these circumstances, access to
specialists was affected. We considered SVSP’s specialty service performance in this
context.
Access to Specialty Services
SVSP provided suboptimal access to specialists. Compliance testing showed variable
access depending on the priority. Specialty referrals for routine-priority appointments
were very good (MIT 14.007, 86.7%), while referrals for medium- and high-priority
50 Specialty deficiencies occurred in cases 8, 10, 11, 14,–18, 21, 23–25, and case 47. Significant deficiencies
occurred in cases 10, 14–16, 18, 23, and 24.
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appointments needed improvement (MIT 14.004, 66.7% and MIT 14.001, 66.7%).
Continuity of specialty services after transfer was poor (MIT 14.010, 35.0%).
Case reviewers found SVSP had room for improvement in access to specialty services.
Our clinicians identified eight deficiencies related to delays in access to specialists or
follow-up appointments with the SVSP providers after specialty appointments, three of
which were significant. The following are examples:
• In case 23, the provider requested a high-priority pulmonology appointment
for a nodule suspicious for cancer. This appointment occurred one month
late.
• In case 24, the provider ordered a urology appointment for kidney stones to
occur by a specified date. This appointment was delayed by six weeks.
Provider Performance
SVSP providers ordered specialty consultations within proper time frames. Compliance
testing showed providers and nurses generally evaluated patients within five days of a
specialty consultation (MIT 1.008, 81.0%). The providers also followed up with patients
after high-priority referrals most of the time. Case reviewers found only one deficiency,
in case 18, where the provider did not evaluate the patient after a high-priority oncology
encounter. Providers generally followed specialists’ recommendations; however, we
found two instances where they did not. The following is an example:
• In case 10, the provider reviewed the specialist’s recommendation to keep the
cholesterol level below 70 but did not follow this recommendation.
Nursing Performance
SVSP nursing performance with specialty services was very good. Nurses evaluated
patients returning from off-site appointments and messaged providers for the necessary
medication and specialty orders. We found one instance where the nurse messaged the
primary provider instead of the on-call provider, which resulted in a delay in obtaining
the specialist’s recommended medication.
Health Information Management
SVSP had some difficulty managing health information of specialty reports. Case
reviewers found three deficiencies with endorsements, two deficiencies with retrieving
reports, and two deficiencies with scanning specialty reports into the EHRS. Compliance
testing showed mixed performances. Please see the Health Information Management
indicator for further details.
Clinician On-Site Inspection
We discussed specialty services in SVSP with supervisors in nursing, medical, and
specialty services. The supervisors conveyed, because the institution has so many
missions (differing incarcerated populations) affecting healthcare and lack sufficient
proximate specialists to serve the high number and variety of health care needs, SVSP has
experienced difficulty obtaining specialty consultations within the required time frames.
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Leadership similarly reported the many missions and lack of specialists caused delays in
scheduling of specialty consultations.
Specialty supervisors also explained, once a request for service (RFS) was approved, the
institution prioritized telemedicine consultations unless otherwise documented in the
RFS.51 This was how the institution tried to expand the available specialty pool for
patients at SVSP. They also stated the TTA RN processed patients when they returned
from off-site specialty appointments. If the patients needed new medication orders, the
TTA RN would message the on-call provider to obtain the necessary orders. The RN
directed follow-up orders or other further RFSs to the primary providers responsible for
the patient. The nurses who support the specialists on site at the institution reviewed the
telemedicine specialty recommendations. The on-site nurses were responsible for
messaging the provider for all necessary orders.
51 The request for service (RFS) is a referral order for a specialty consultation.
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Compliance Score Results
Table 17. Specialized Services
Scored Answer
Compliance Questions Yes No N/A Yes %
Did the patient receive the high-priority specialty service within 14 calendar
days of the primary care provider order or the Physician Request for 10 5 0 66.7%
Service? (14.001)
Did the institution receive and did the primary care provider review the
high-priority specialty service consultant report within the required time 14 1 0 93.3%
frame? (14.002)
Did the patient receive the subsequent follow-up to the high-priority
specialty service appointment as ordered by the primary care provider? 9 1 5 90.0%
(14.003)
Did the patient receive the medium-priority specialty service within 15-45
calendar days of the primary care provider order or Physician Request for 10 5 0 66.7%
Service? (14.004)
Did the institution receive and did the primary care provider review the
medium-priority specialty service consultant report within the required time 8 6 1 57.1%
frame? (14.005)
Did the patient receive the subsequent follow-up to the medium-priority
specialty service appointment as ordered by the primary care provider? 5 2 8 71.4%
(14.006)
Did the patient receive the routine-priority specialty service within 90
calendar days of the primary care provider order or Physician Request for 13 2 0 86.7%
Service? (14.007)
Did the institution receive and did the primary care provider review the
routine-priority specialty service consultant report within the required time 8 5 2 61.5%
frame? (14.008)
Did the patient receive the subsequent follow-up to the routine-priority
specialty service appointment as ordered by the primary care provider? 3 2 10 60.0%
(14.009)
For endorsed patients received from another CDCR institution: If the patient
was approved for a specialty services appointment at the sending
7 13 0 35.0%
institution, was the appointment scheduled at the receiving institution
within the required time frames? (14.010)
Did the institution deny the primary care provider’s request for specialty
20 0 0 100%
services within required time frames? (14.011)
Following the denial of a request for specialty services, was the patient
18 2 0 90.0%
informed of the denial within the required time frame? (14.012)
Overall percentage (MIT 14): 73.2%
Source: The Office of the Inspector General medical inspection results.
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Table 18. Other Tests Related to Specialized Services
Scored Answer
Compliance Questions Yes No N/A Yes %
Specialty service follow-up appointments: Did the clinician follow-up visits
34 8 3 81.0%
occur within required time frames? (1.008) *
Are specialty documents scanned into the patient’s electronic health record
25 5 15 83.3%
within five calendar days of the encounter date? (4.002)
* CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician follow-up visits
following specialty services. As a result, we tested MIT 1.008 only for high-priority specialty services or when staff ordered
follow-ups. The OIG continued to test the clinical appropriateness of specialty follow-ups through its case review testing.
Source: The Office of the Inspector General medical inspection results.
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Recommendations
• Medical leadership should determine the root cause(s) of challenges to the
timely provision of specialty appointments, including preapproved specialty
appointments for transfer-in patients, and should implement remedial
measures as appropriate.
• The department should consider developing and implementing measures to
ensure the institution timely receives the specialty reports and providers
timely review these reports.
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Administrative Operations
In this indicator, OIG compliance inspectors evaluated health care administrative
processes. Our inspectors examined the timeliness of the medical grievance process and
checked whether the institution followed reporting requirements for adverse or sentinel
events and patient deaths. Inspectors checked whether the Emergency Medical Response
Review Committee (EMRRC) met and reviewed incident packages. We investigated and
determined whether the institution conducted required emergency response drills.
Inspectors also assessed whether the Quality Management Committee (QMC) met
regularly and addressed program performance adequately. In addition, our inspectors
determined whether the institution provided training and job performance reviews for its
employees. We checked whether staff possessed current, valid professional licenses,
certifications, and credentials. The OIG rated this indicator solely based on the
compliance score. Our case review clinicians do not rate this indicator.
Because none of the tests in this indicator directly affected clinical patient care (it is a
secondary indicator), the OIG did not consider this indicator’s rating when determining
the institution’s overall compliance rating.
Ratings and Results Overview
Case Review Rating Compliance Rating and Score
Not Applicable Inadequate (68.8%)
SVSP’s performance was mixed in this indicator. While SVSP scored well in some
applicable tests, performance needed improvement in several areas. The EMMRC did not
always complete the required checklists and review the cases within required time
frames. The institution conducted medical emergency response drills with incomplete
documentation of required emergency response drill forms. Physician managers did not
always complete annual performance appraisals timely. The nurse educator did not
ensure a newly hired nurse received the required onboarding training timely. These
findings are set forth in the table on the next page. Based on the overall compliance score
result, the OIG rated this indicator inadequate.
Compliance Testing Scores
Nonscored Results
At SVSP, the OIG did not find any applicable adverse sentinel events required root cause
analysis during our inspection period. (MIT 15.001). We obtained CCHCS Mortality Case
Review reporting data. Ten patient deaths occurred during our review period. The OIG
inspectors found no evidence the regional and institutional physician and nurse
executives received, accepted, or rejected the preliminary mortality reports timely. The
reports were also overdue at the time of OIG’s inspection (MIT 15.998).
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Compliance Score Results
Table 19. Administrative Operations
Scored Answer
Compliance Questions Yes No N/A Yes %
For health care incidents requiring root cause analysis (RCA): Did the This is a nonscored test. Please refer to the
institution meet RCA reporting requirements? (15.001) discussion in this indicator.
Did the institution’s Quality Management Committee (QMC) meet monthly?
5 1 0 83.3%
(15.002)
For Emergency Medical Response Review Committee (EMRRC) reviewed
cases: Did the EMRRC review the cases timely, and did the incident
1 11 0 8.3%
packages the committee reviewed include the required documents?
(15.003)
For institutions with licensed care facilities: Did the Local Governing Body
(LGB) or its equivalent meet quarterly and discuss local operating 4 0 0 100%
procedures and any applicable policies? (15.004)
Did the institution conduct medical emergency response drills during each
watch of the most recent quarter, and did health care and custody staff 0 3 0 0
participate in those drills? (15.101)
Did the responses to medical grievances address all of the patients’
10 0 0 100%
appealed issues? (15.102)
Did the medical staff review and submit initial patient death reports to the
8 2 0 80.0%
CCHCS Mortality Case Review Unit on time? (15.103)
Did nurse managers ensure the clinical competency of nurses who
9 1 0 90.0%
administer medications? (15.104)
Did physician managers complete provider clinical performance appraisals
2 4 1 33.3%
timely? (15.105)
Did the providers maintain valid state medical licenses? (15.106) 15 0 0 100%
Did the staff maintain valid Cardiopulmonary Resuscitation (CPR), Basic Life
Support (BLS), and Advanced Cardiac Life Support (ACLS) certifications? 2 0 1 100%
(15.107)
Did the nurses and the pharmacist-in-charge (PIC) maintain valid
professional licenses and certifications, and did the pharmacy maintain a 6 0 1 100%
valid correctional pharmacy license? (15.108)
Did the pharmacy and the providers maintain valid Drug Enforcement
Agency (DEA) registration certificates, and did the pharmacy maintain valid 1 0 0 100%
Automated Drug Delivery System (ADDS) licenses? (15.109)
Did nurse managers ensure their newly hired nurses received the required
0 1 0 0
onboarding and clinical competency training? (15.110)
Did the CCHCS Death Review Committee process death review reports
This is a nonscored test. Please refer to the
timely? Effective 05/2022: Did the Headquarters Mortality Case Review
discussion in this indicator.
process mortality review reports timely? (15.998)
What was the institution’s health care staffing at the time of the OIG medical This is a nonscored test. Please refer to Table 3
inspection? (15.999) for CCHCS-provided staffing information.
Overall percentage (MIT 15): 68.8%
Source: The Office of the Inspector General medical inspection results.
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Recommendations
The OIG offers no recommendations for this indicator.
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Appendix A: Methodology
In designing the medical inspection program, the OIG met with stakeholders to review
CCHCS policies and procedures, relevant court orders, and guidance developed by the
American Correctional Association. We also reviewed professional literature on
correctional medical care; reviewed standardized performance measures used by the
health care industry; consulted with clinical experts; and met with stakeholders from the
court, the receiver’s office, the department, the Office of the Attorney General, and the
Prison Law Office to discuss the nature and scope of our inspection program. With input
from these stakeholders, the OIG developed a medical inspection program that evaluates
the delivery of medical care by combining clinical case reviews of patient files, objective
tests of compliance with policies and procedures, and an analysis of outcomes for certain
population-based metrics.
We rate each of the quality indicators applicable to the institution under inspection based
on case reviews conducted by our clinicians or compliance tests conducted by our
registered nurses. Figure A–1 below depicts the intersection of case review and
compliance.
Figure A–1. Inspection Indicator Review Distribution for SVSP
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Case Reviews
The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of
its stakeholders, which continues in the Cycle 7 medical inspections. Below, Table A–1
provides important definitions that describe this process.
Table A–1. Case Review Definitions
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The OIG eliminates case review selection bias by sampling using a rigid methodology.
No case reviewer selects the samples he or she reviews. Because the case reviewers are
excluded from sample selection, there is no possibility of selection bias. Instead,
nonclinical analysts use a standardized sampling methodology to select most of the case
review samples. A randomizer is used when applicable.
For most basic institutions, the OIG samples 20 comprehensive physician review cases.
For institutions with larger high-risk populations, 25 cases are sampled. For the
California Health Care Facility, 30 cases are sampled.
Case Review Sampling Methodology
We obtain a substantial amount of health care data from the inspected institution and
from CCHCS. Our analysts then apply filters to identify clinically complex patients with
the highest need for medical services. These filters include patients classified by CCHCS
with high medical risk, patients requiring hospitalization or emergency medical services,
patients arriving from a county jail, patients transferring to and from other departmental
institutions, patients with uncontrolled diabetes or uncontrolled anticoagulation levels,
patients requiring specialty services or who died or experienced a sentinel event
(unexpected occurrences resulting in high risk of, or actual, death or serious injury),
patients requiring specialized medical housing placement, patients requesting medical
care through the sick call process, and patients requiring prenatal or postpartum care.
After applying filters, analysts follow a predetermined protocol and select samples for
clinicians to review. Our physician and nurse reviewers test the samples by performing
comprehensive or focused case reviews.
Case Review Testing Methodology
An OIG physician, a nurse consultant, or both review each case. As the clinicians review
medical records, they record pertinent interactions between the patient and the health
care system. We refer to these interactions as case review events. Our clinicians also
record medical errors, which we refer to as case review deficiencies.
Deficiencies can be minor or significant, depending on the severity of the deficiency. If a
deficiency caused serious patient harm, we classify the error as an adverse event. On the
next page, Figure A–2 depicts the possibilities that can lead to these different events.
After the clinician inspectors review all the cases, they analyze the deficiencies, then
summarize their findings in one or more of the health care indicators in this report.
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Figure A–2. Case Review Testing
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Compliance Testing
Compliance Sampling Methodology
Our analysts identify samples for both our case review inspectors and compliance
inspectors. Analysts follow a detailed selection methodology. For most compliance
questions, we use sample sizes of approximately 25 to 30. Figure A–3 below depicts the
relationships and activities of this process.
Figure A–3. Compliance Sampling Methodology
Compliance Testing Methodology
Our inspectors answer a set of predefined medical inspection tool (MIT) questions to
determine the institution’s compliance with CCHCS policies and procedures. Our nurse
inspectors assign a Yes or a No answer to each scored question.
OIG headquarters nurse inspectors review medical records to obtain information,
allowing them to answer most of the MIT questions. Our regional nurses visit and
inspect each institution. They interview health care staff, observe medical processes, test
the facilities and clinics, review employee records, logs, medical grievances, death
reports, and other documents, and obtain information regarding plant infrastructure and
local operating procedures.
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Scoring Methodology
Our compliance team calculates the percentage of all Yes answers for each of the
questions applicable to a particular indicator, then averages the scores. The OIG
continues to rate these indicators based on the average compliance score using the
following descriptors: proficient (85.0 percent or greater), adequate (between 84.9 percent
and 75.0 percent), or inadequate (less than 75.0 percent).
Indicator Ratings and the Overall Medical
Quality Rating
The OIG medical inspection unit individually examines all the case review and
compliance inspection findings under each specific methodology. We analyze the case
review and compliance testing results for each indicator and determine separate overall
indicator ratings. After considering all the findings of each of the relevant indicators, our
medical inspectors individually determine the institution’s overall case review and
compliance ratings.
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Appendix B: Case Review Data
Table B–1. SVSP Case Review Sample Sets
Sample Set Total
Anticoagulation 1
CTC/OHU 2
Death Review/Sentinel Events 2
Diabetes 4
Emergency Services – CPR 5
Emergency Services – Non-CPR 2
High Risk 4
Hospitalization 4
Intrasystem Transfers In 3
Intrasystem Transfers Out 3
RN Sick Call 15
Specialty Services 3
48
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Table B–2. SVSP Case Review Chronic Care Diagnoses
Sample Set Total
Anemia 6
Anticoagulation 5
Arthritis/Degenerative Joint Disease 3
Asthma 14
Cancer 4
Cardiovascular Disease 4
Chronic Kidney Disease 1
Chronic Pain 10
Cirrhosis/ End Stage Liver Disease 2
COPD 2
COVID-19 1
Deep Venous Thrombosis/ Pulmonary Embolism 2
Diabetes 10
GERD 15
HIV 1
Hepatitis C 12
Hyperlipidemia 13
Hypertension 24
Mental Health 21
Migraine 1
Seizure Disorder 9
Sleep Apnea 1
Substance Abuse 21
Thyroid Disease 3
185
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Table B–3. SVSP Case Review Events by Program
Diagnosis Total
Diagnostic Services 160
Emergency Care 148
Hospitalization 69
Intrasystem Transfers In 5
Intrasystem Transfers Out 5
Outpatient Care 420
Specialized Medical Housing 162
Specialty Services 154
1,123
Table B–4. SVSP Case Review Sample Summary
Sample Set Total
MD Reviews Detailed 20
MD Reviews Focused 2
RN Reviews Detailed 10
RN Reviews Focused 26
Total Reviews 58
Total Unique Cases 48
Overlapping Reviews (MD & RN) 10
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Appendix C: Compliance Sampling Methodology
Salinas Valley State Prison
Quality No. of
Indicator Sample Category Samples Data Source Filters
Access to Care
MIT 1.001 Chronic Care 25 Master Registry • Chronic care conditions (at least one
Patients condition per patient — any risk level)
• Randomize
MIT 1.002 Nursing Referrals 25 OIG Q: 6.001 • See Transfers
MITs 1.003 – 006 Nursing Sick Call 30 Clinic • Clinic (each clinic tested)
(6 per clinic) Appointment List • Appointment date (2 – 9 months)
• Randomize
MIT 1.007 Returns From 25 OIG Q: 4.005 • See Health Information Management
Community (Medical Records) (returns from
Hospital community hospital)
MIT 1.008 Specialty Services 45 OIG Q: 14.001, • See Specialty Services
Follow-Up 14.004 & 14.007
MIT 1.101 Availability of 6 OIG on-site review • Randomly select one housing unit
Health Care from each yard
Services Request
Forms
Diagnostic Services
MITs 2.001 – 003 Radiology 10 Radiology Logs • Appointment date
(90 days – 9 months)
• Randomize
• Abnormal
MITs 2.004 – 006 Laboratory 10 Quest • Appt. date (90 days – 9 months)
• Order name (CBC, BMP, or CMPs only)
• Randomize
• Abnormal
MITs 2.007 – 009 Laboratory STAT 6 Quest • Appt. date (90 days – 9 months)
• Order name (CBC, BMP, or CMPs only)
• Randomize
• Abnormal
MITs 2.010 – 012 Pathology 10 InterQual • Appt. date (90 days – 9 months)
• Service (pathology-related)
• Randomize
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Quality No. of
Indicator Sample Category Samples Data Source Filters
Health Information Management (Medical Records)
MIT 4.001 Health Care Services 30 OIG Qs: 1.004 • Nondictated documents
Request Forms • First 20 IPs for MIT 1.004
MIT 4.002 Specialty Documents 45 OIG Qs: 14.002, • Specialty documents
14.005 & 14.008 • First 10 IPs for each question
MIT 4.003 Hospital Discharge 25 OIG Q: 4.005 • Community hospital discharge
Documents documents
• First 20 IPs selected
MIT 4.004 Scanning Accuracy 24 Documents for • Any misfiled or mislabeled document
any tested identified during
incarcerated OIG compliance review
person (24 or more = No)
MIT 4.005 Returns From 25 CADDIS off-site • Date (2 – 8 months)
Community Hospital admissions • Most recent 6 months provided
(within date range)
• Rx count
• Discharge date
• Randomize
Health Care Environment
MITs 5.101 – 105 Clinical Areas 10 OIG inspector • Identify and inspect all on-site clinical
MITs 5.107 – 111 on-site review areas
Transfers
MITs 6.001 – 003 Intrasystem Transfers 25 SOMS • Arrival date (3 – 9 months)
• Arrived from (another departmental
facility)
• Rx count
• Randomize
MIT 6.101 Transfers Out 6 OIG inspector • R&R IP transfers with medication
on-site review
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Quality No. of
Indicator Sample Category Samples Data Source Filters
Pharmacy and Medication Management
MIT 7.001 Chronic Care 25 OIG Q: 1.001 • See Access to Care
Medication • At least one condition per patient —
any risk level
• Randomize
MIT 7.002 New Medication 25 Master Registry • Rx count
Orders • Randomize
• Ensure no duplication of IPs tested in
MIT 7.001
MIT 7.003 Returns From 25 OIG Q: 4.005 • See Health Information Management
Community Hospital (Medical Records) (returns from
community hospital)
MIT 7.004 RC Arrivals — N/A at this OIG Q: 12.001 • See Reception Center
Medication Orders institution
MIT 7.005 Intrafacility Moves 25 MAPIP transfer • Date of transfer (2 – 8 months)
data • To location/from location (yard to
yard and to/from ASU)
• Remove any to/from MHCB
• NA/DOT meds (and risk level)
• Randomize
MIT 7.006 En Route 10 SOMS • Date of transfer (2– 8 months)
• Sending institution (another
departmental facility)
• Randomize
• NA/DOT meds
MITs 7.101 – 103 Medication Storage Varies by OIG inspector • Identify and inspect clinical & med
Areas test on-site review line areas that store medications
MITs 7.104 – 107 Medication Varies by OIG inspector • Identify and inspect on-site clinical
Preparation and test on-site review areas that prepare and administer
Administration Areas medications
MITs 7.108 – 111 Pharmacy 1 OIG inspector • Identify & inspect all on-site
on-site review pharmacies
MIT 7.112 Medication Error 7 Medication error • All medication error reports with
Reporting reports Level 4 or higher
• Select total of 25 medication error
reports (recent 12 months)
MIT 7.999 Restricted Unit 20 On-site active • KOP rescue inhalers & nitroglycerin
KOP Medications medication medications for IPs housed in
listing restricted units
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Quality No. of
Indicator Sample Category Samples Data Source Filters
Prenatal and Postpartum Care
MITs 8.001 – 007 Recent Deliveries N/A at this OB Roster • Delivery date (2 – 12 months)
institution • Most recent deliveries (within date
range)
Pregnant Arrivals N/A at this OB Roster • Arrival date (2 – 12 months)
institution • Earliest arrivals (within date range)
Preventive Services
MITs 9.001 – 002 TB Medications 8 Maxor • Dispense date (past 9 months)
• Time period on TB meds (3 months
or 12 weeks)
• Randomize
MIT 9.003 TB Evaluation, 25 SOMS • Arrival date (at least 1 year prior to
Annual Screening inspection)
• Birth month
• Randomize
MIT 9.004 Influenza 25 SOMS • Arrival date (at least 1 year prior to
Vaccinations inspection)
• Randomize
• Filter out IPs tested in MIT 9.008
MIT 9.005 Colorectal Cancer 25 SOMS • Arrival date (at least 1 year prior to
Screening inspection)
• Date of birth (45 or older)
• Randomize
MIT 9.006 Mammogram N/A at this SOMS • Arrival date (at least 2 yrs. prior to
institution inspection)
• Date of birth (age 52 – 74)
• Randomize
MIT 9.007 Pap Smear N/A at this SOMS • Arrival date (at least three yrs. prior to
institution inspection)
• Date of birth (age 24 – 53)
• Randomize
MIT 9.008 Chronic Care 25 OIG Q: 1.001 • Chronic care conditions (at least
Vaccinations 1 condition per IP — any risk level)
• Randomize
• Condition must require vaccination(s)
MIT 9.009 Valley Fever Cocci transfer • Reports from past 2 – 8 months
N/A at this
institution status report • Institution
• Ineligibility date (60 days prior to
inspection date)
• All
Office of the Inspector General, State of California Inspection Period: January 2023 – June 2023 Report Issued: February 2025
Cycle 7, Salinas Valley State Prison | 97
Quality No. of
Indicator Sample Category Samples Data Source Filters
Reception Center
MITs 12.001 – 007 RC N/A at this SOMS • Arrival date (2 – 8 months)
institution • Arrived from (county jail, return from
parole, etc.)
• Randomize
Specialized Medical Housing
MITs 13.001 – 003 Specialized Health 7 CADDIS • Admit date (2 – 8 months)
Care Housing Unit • Type of stay (no MH beds)
• Length of stay (minimum of 5 days)
• Rx count
• Randomize
MITs 13.101 – 102 Call Buttons All OIG inspector • Specialized Health Care Housing
on-site review • Review by location
Specialty Services
MITs 14.001 – 003 High-Priority 15 Specialty Services • Approval date (3 – 9 months)
Initial and Follow-Up Appointments • Remove consult to audiology,
RFS chemotherapy, dietary, Hep C, HIV,
orthotics, gynecology, consult to
public health/Specialty RN, dialysis,
ECG 12-Lead (EKG), mammogram,
occupational therapy, ophthalmology,
optometry, oral surgery, physical
therapy, physiatry, podiatry, radiology,
follow-up wound care / addiction
medication, narcotic treatment
program, and transgender services
• Randomize
MITs 14.004 – 006 Medium-Priority 15 Specialty Services • Approval date (3 – 9 months)
Initial and Follow-Up Appointments • Remove consult to audiology,
RFS chemotherapy, dietary, Hep C, HIV,
orthotics, gynecology, consult to
public health/Specialty RN, dialysis,
ECG 12-Lead (EKG), mammogram,
occupational therapy, ophthalmology,
optometry, oral surgery, physical
therapy, physiatry, podiatry, radiology,
follow-up wound care/addiction
medication, narcotic treatment
program, and transgender services
• Randomize
Office of the Inspector General, State of California Inspection Period: January 2023 – June 2023 Report Issued: February 2025
Cycle 7, Salinas Valley State Prison | 98
Quality No. of
Indicator Sample Category Samples Data Source Filters
Specialty Services (continued)
MITs 14.007 – 009 Routine-Priority 15 Specialty Services • Approval date (3 – 9 months)
Initial and Follow-Up Appointments • Remove consult to audiology,
RFS chemotherapy, dietary, Hep C, HIV,
orthotics, gynecology, consult to
public health/Specialty RN, dialysis,
ECG 12-Lead (EKG), mammogram,
occupational therapy, ophthalmology,
optometry, oral surgery, physical
therapy, physiatry, podiatry, radiology,
follow-up wound care/addiction
medication, narcotic treatment
program, and transgender services
• Randomize
MIT 14.010 Specialty Services 20 Specialty Services • Arrived from (other departmental
Arrivals Arrivals institution)
• Date of transfer (3 – 9 months)
• Randomize
MITs 14.011 – 012 Denials 20 InterQual • Review date (3 – 9 months)
• Randomize
N/A IUMC/MAR • Meeting date (9 months)
Meeting Minutes • Denial upheld
• Randomize
Administrative Operations
MIT 15.001 Adverse/sentinel 0 Adverse/sentinel • Adverse/Sentinel events
events events report (2 – 8 months)
MIT 15.002 QMC Meetings 6 Quality • Meeting minutes (12 months)
Management
Committee
meeting minutes
MIT 15.003 EMRRC 12 EMRRC meeting • Monthly meeting minutes
minutes (6 months)
MIT 15.004 LGB 4 LGB meeting • Quarterly meeting minutes
minutes (12 months)
MIT 15.101 Medical Emergency 3 On-site summary • Most recent full quarter
Response Drills reports & • Each watch
documentation for
ER drills
MIT 15.102 Institutional Level 10 On-site list of • Medical grievances closed
Medical Grievances grievances/closed (6 months)
grievance files
MIT 15.103 Death Reports 10 Institution-list of • Most recent 10 deaths
deaths in prior • Initial death reports
12 months
Office of the Inspector General, State of California Inspection Period: January 2023 – June 2023 Report Issued: February 2025
Cycle 7, Salinas Valley State Prison | 99
Quality No. of
Indicator Sample Category Samples Data Source Filters
Administrative Operations (continued)
MIT 15.104 Nursing Staff 10 On-site nursing • On duty one or more years
Validations education files • Nurse administers medications
• Randomize
MIT 15.105 Provider Annual 6 On-site provider • All required performance evaluation
Evaluation Packets evaluation files documents
MIT 15.106 Provider Licenses 15 Current provider • Review all
listing (at start of
inspection)
MIT 15.107 Medical Emergency All On-site certification • All staff
Response tracking logs • Providers (ACLS)
Certifications • Nursing (BLS/CPR)
• Custody (CPR/BLS)
MIT 15.108 Nursing Staff and All On-site tracking • All required licenses and
Pharmacist in Charge system, logs, or certifications
Professional Licenses employee files
and Certifications
MIT 15.109 Pharmacy and All On-site listing of • All DEA registrations
Providers’ Drug provider DEA
Enforcement Agency registration #s &
(DEA) Registrations pharmacy
registration
document
MIT 15.110 Nursing Staff New All Nursing staff • New employees (hired within last
Employee training logs 12 months)
Orientations
MIT 15.998 CCHCS Mortality 10 OIG summary log: • Between 35 business days &
Case Review deaths 12 months prior
• California Correctional Health Care
Services mortality reviews
Office of the Inspector General, State of California Inspection Period: January 2023 – June 2023 Report Issued: February 2025
Cycle 7, Salinas Valley State Prison | 100
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Office of the Inspector General, State of California Inspection Period: January 2023 – June 2023 Report Issued: February 2025
Cycle 7, Salinas Valley State Prison | 101
California Correctional Health Care Services’
Response
February 3, 2025
Amarik Singh, Inspector General
Office of the Inspector General
10111 Old Placerville Road, Suite 110
Sacramento, CA 95827
Dear Ms. Singh:
California Correctional Health Care Services has reviewed the draft Medical Inspection Report
for Salinas Valley State Prisonconducted by the Office of the Inspector General from January
2023to June 2023. Thank you for preparing the report. While CCHCS disagrees with the findings
for the compliance portion of the OIG Inspection for Salinas Valley State Prison, we understand
that the OIG is forming a workgroup to revise the Medical Inspection Tool to reduce or eliminate
subjectivity and complex, compound questions that make it difficult for CCHCS to determine
areas of policy non-compliance. CCHCS looks forward to participating in such efforts and urges
the OIG to begin the process as soon as possible.
If you have any questions or concerns, please contact me at (916) 691-3747.
Sincerely,
DeAnna Gouldy
Deputy Director
Policy and Risk Management Services
California Correctional Health Care Services
cc: Diana Toche, D.D.S., Undersecretary, Health Care Services, CDCR
Clark Kelso, Receiver
Jeff Macomber, Secretary, CDCR
Directors, CCHCS
Roscoe Barrow, Chief Counsel, CCHCS Office of Legal Affairs
Renee Kanan, M.D., Deputy Director, Medical Services, CCHCS
Barbara Barney-Knox, R.N., Deputy Director, Nursing Services, CCHCS
Annette Lambert, Deputy Director, Quality Management, CCHCS
Robin Hart, Associate Director, Risk Management Branch, CCHCS
Regional Executives, Region II, CCHCS
Chief Executive Officer, SVSP
Heather Pool, Chief Assistant Inspector General, OIG
Doreen Pagaran, R.N., Nurse Consultant Program Review, OIG
Amanda Elhardt, Report Coordinator, OIG
P.O. Box 588500
Elk Grove, CA 95758
Office of the Inspector General, State of California Inspection Period: January 2023 – June 2023 Report Issued: February 2025
Cycle 7
Medical Inspection Report
for
Salinas Valley State Prison
OFFICE of the
INSPECTOR GENERAL
Amarik K. Singh
Inspector General
STATE of CALIFORNIA
February 2025
OIG