Sierra Conservation Center Cycle 7 Medical Inspection Report

Electronic copies of reports published by the Office of the Inspector General are available free in portable document format (PDF) on our website. We also offer an online subscription service. For information on how to subscribe, visit www.oig.ca.gov. For questions concerning the contents of this report, please contact Shaun Spillane, Public Information Officer, at 916-288-4212. Connect with us on social media Cycle 7, Sierra Conservation Center | iii Contents Illustrations iv Introduction 1 Summary: Ratings and Scores 3 Medical Inspection Results 5 Deficiencies Identified During Case Review 5 Case Review Results 5 Compliance Testing Results 6 Institution-Specific Metrics 6 Population-Based Metrics 9 HEDIS Results 9 Recommendations 11 Indicators 14 Access to Care 14 Diagnostic Services 22 Emergency Services 27 Health Information Management 33 Health Care Environment 40 Transfers 46 Medication Management 54 Preventive Services 62 Nursing Performance 65 Provider Performance 72 Specialized Medical Housing 80 Specialty Services 83 Administrative Operations 90 Appendix A: Methodology 93 Case Reviews 94 Compliance Testing 97 Indicator Ratings and the Overall Medical Quality Rating 98 Appendix B: Case Review Data 99 Appendix C: Compliance Sampling Methodology 103 California Correctional Health Care Services’ Response 111 Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | iv Illustrations Tables 1. SCC Summary Table: Case Review Ratings and Policy Compliance Scores 4 2. SCC Master Registry Data as of October 2024 7 3. SCC Health Care Staffing Resources as of October 2024 8 4. SCC Results Compared With State HEDIS Scores 10 5. Access to Care 19 6. Other Tests Related to Access to Care 20 7. Diagnostic Services 25 8. Health Information Management 37 9. Other Tests Related to Health Information Management 38 10. Health Care Environment 44 11. Transfers 51 12. Other Tests Related to Transfers 52 13. Medication Management 59 14. Other Tests Related to Medication Management 60 15. Preventive Services 63 16. Specialized Medical Housing 81 17. Specialty Services 87 18. Other Tests Related to Specialty Services 88 19. Administrative Operations 91 A–1. Case Review Definitions 94 B–1. SCC Case Review Sample Sets 99 B–2. SCC Case Review Chronic Care Diagnoses 100 B–3. SCC Case Review Events by Program 101 B–4. SCC Case Review Sample Summary 101 Figures A–1. Inspection Indicator Review Distribution for SCC 93 A–2. Case Review Testing 96 A–3. Compliance Sampling Methodology 97 Photographs 1. Indoor Waiting Area 40 2. Individual Waiting Modules 41 3. Expired Medical Supply Dated January 31, 2024 41 4. Long-Term Storage of Staff’s Food in the Medical Supply Storage Area 42 5. Staff’s Personal Items and Food Stored With Medical Supplies 42 Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 1 Introduction Pursuant to California Penal Code section 6126 et seq., the Office of the Inspector General (the OIG) is responsible for periodically reviewing and reporting on the delivery of the ongoing medical care provided to incarcerated people1 in the California Department of Corrections and Rehabilitation (the department).2 In Cycle 7, the OIG continues to apply the same assessment methodologies used in Cycle 6, including clinical case review and compliance testing. Together, these methods assess the institution’s medical care on both individual and system levels by providing an accurate assessment of how the institution’s health care systems function regarding patients with the highest medical risk, who tend to access services at the highest rate. Through these methods, the OIG evaluates the institution’s performance 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 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. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 2 As we did during Cycle 6, our office continues to inspect both those institutions remaining under federal receivership and those delegated back to the department. There is no difference in the standards used for assessing a delegated institution versus an institution not yet delegated. At the time of the Cycle 7 inspection of Sierra Conservation Center (SCC), the institution had been delegated back to the department by the receiver. We completed our seventh inspection of the institution, and this report presents our assessment of the health care provided at this institution during the inspection period from March 2024 to August 2024.4 4 Samples are obtained per case review methodology shared with stakeholders in prior cycles. The case reviews include death reviews between August 2023 and February 2024. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 3 Summary: Ratings and Scores We completed the Cycle 7 inspection of Sierra Conservation Center (SCC) in March 2025. OIG inspectors monitored the institution’s delivery of medical care that occurred between March 2024 and August 2024. The OIG rated the case review The OIG rated the compliance component of the overall health care component of the overall health care quality at SCC inadequate. quality at SCC inadequate. OIG case review clinicians (a team of physicians and nurse consultants) reviewed 40 cases, which contained 724 patient-related events. They performed quality control reviews; their subsequent collective deliberations ensured consistency, accuracy, and thoroughness. Our clinicians acknowledged institutional structures that catch and resolve mistakes throughout the delivery of care. After examining the medical records, our clinicians completed a follow up on-site inspection in March 2025, to verify their initial findings. OIG physicians rated the quality of care for 20 comprehensive case reviews. Of these 20 cases, our physicians rated 11 adequate and nine 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 351 patient records and 1,003 data points and used the data to answer 84 policy questions. We also observed SCC’s processes during an on-site inspection in October 2024. The OIG then considered the results from both case review and compliance testing and drew overall conclusions, which we report in 12 health care indicators.5 5 The indicators for Reception Center and Prenatal and Postpartum Care did not apply to SCC. During the OIG’s Cycle 7 inspection period, Specialized Medical Housing was not sampled or tested. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 4 We list the individual indicators and ratings applicable for this institution in Table 1 below. Table 1. SCC Summary Table: Case Review Ratings and Policy Compliance Scores Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 5 Medical Inspection Results Deficiencies Identified During Case Review Deficiencies are medical errors that increase the risk of patient harm. Deficiencies can be minor or significant, depending on the severity of the deficiency. An adverse event occurs when the deficiency caused harm to the patient. All major health care organizations identify and track adverse events. We identify deficiencies and adverse events to highlight concerns regarding the provision of care and for the benefit of the institution’s quality improvement program to provide an impetus for improvement.6 The OIG found no adverse events at SCC during the Cycle 7 inspection. Case Review Results OIG case reviewers (a team of physicians and nurse consultants) assessed nine of the 12 indicators applicable to SCC. Of these nine indicators, OIG clinicians rated none proficient, five adequate, and four inadequate. OIG physicians also rated the overall adequacy of care for each of the 20 detailed case reviews they conducted. Of these 20 cases, 11 were adequate and nine were inadequate. In reviewing the 724 events, we identified 303 deficiencies, 85 of which we considered to be of such magnitude that, if left unaddressed, would likely contribute to patient harm. Our clinicians found the following strengths at SCC: • Patients received good access to providers and nurses. • Staff responded to emergencies promptly. • Staff performed well in timely completing laboratory and radiology tests. • Nurses performed well with administering prescribed medications to on-site SCC patients. Our clinicians found the following weaknesses at SCC: • Nurses needed to improve in performing complete assessments, interventions, and documentation for clinic, emergency care, and transfer patients. • Providers needed improvement in poor assessment and decision-making, particularly with more complex patients. • Providers did not consistently communicate results to patients with complete test result notification letters. • The morning huddles process, through which medical staff share patient information and prepare for the day’s upcoming medical encounters, revealed 6 For further discussion of an adverse event, see Table A–1. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 6 the patient care teams were unprepared and not fully knowledgeable of their patients. Compliance Testing Results Our compliance inspectors assessed nine of the 12 indicators applicable to SCC. Of these nine indicators, our compliance inspectors rated none proficient, four adequate, and five inadequate. We solely tested policy compliance in Health Care Environment, Preventive Services, and Administrative Operations because these indicators do not have a case review component. SCC showed a high rate of policy compliance in the following areas: • SCC staff often ensured patients received diagnostic services within ordered time frames, and providers timely reviewed and endorsed results. • Staff performed very well in providing preventive services for patients, such as influenza vaccination and colorectal cancer screenings. In addition, staff always offered tuberculosis (TB) medications and almost always timely monitored patients taking TB medications. • Primary care providers usually evaluated their patients returning from outside community hospitals and new patient arrivals within required time frames. SCC showed a low rate of policy compliance in the following areas: • SCC staff frequently did not maintain medication continuity for chronic-care patients, patients discharged from the hospital, patients transferring in, or patients who had a layover at SCC. • Health care staff did not consistently follow universal hand hygiene precautions during patient encounters. • Providers did not often communicate results of diagnostic services timely with complete test result notification letters. Most patient letters communicating these results were missing the date of the diagnostic service, the date of the results, or whether the results were within normal limits. • Staff did not provide chronic-care and specialty-services provider follow-up appointments within required time frames. Institution-Specific Metrics Sierra Conservation Center (SCC), located near Jamestown in Tuolumne County, was opened in 1965. SCC provides housing, rehabilitative programs, and services for minimum- and medium-custody incarcerated persons. It is one of the only two prisons in the state responsible for the training and placement of incarcerated men in the conservation camp program. SCC administers 20 male camps located from Central California to the California– Mexico border. SCC houses incarcerated persons who are designated as low-to-medium medical risk. These incarcerated persons have infrequent care needs that are mostly managed at local community hospitals or through transfer from a camp back to the main SCC Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 7 facility for a higher level of care. The institution operates five medical clinics where medical personnel handle nonurgent requests for medical services. SCC conducts screenings in its receiving and release clinical area, treats patients who need urgent or emergent care in its triage and treatment area, and treats patients requiring outpatient health services and assistance with activities of daily living in the outpatient housing unit. SCC’s outpatient housing unit was closed at the time of our review. California Correctional Health Care Services has designated SCC as a basic care institution. Basic care institutions are located in rural areas, away from tertiary care centers and specialty care providers whose services would likely be used by higher-risk patients. Basic care institutions provide limited, specialty medical services and consultation for a generally healthy patient population. As of June 6, 2025, the department reported on its public tracker 45 percent of SCC’s incarcerated population was fully vaccinated for COVID-19, while 53 percent of SCC’s staff was fully vaccinated for COVID-19.7 On October 1, 2024, the Health Care Services Master Registry showed SCC had a total population of 4,029. A breakdown of the medical risk level of SCC’s population as determined by the department is set forth in Table 2 below.8 Table 2. SCC Master Registry Data as of October 2024 Medical Risk Level Number of Patients Percentage* High 1 18 0.4% High 2 42 1.0% Medium 532 13.2% Low 3,437 85.3% Total 4,029 100.0% * Percentages may not total 100% due to rounding. Source: Data for the population medical risk level were obtained from the CCHCS Master Registry dated 10-1-24. 7 For more information, see the department’s statistics on its website page titled Population COVID‑19 Tracking. 8 For a definition of medical risk, see CCHCS HCDOM 1.2.14, Appendix 1.9. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 8 According to staffing data the OIG obtained from California Correctional Health Care Services (CCHCS), as identified in Table 3 below, SCC had one vacant executive leadership position, 2.1 primary care provider vacancies, 2.7 nursing supervisor vacancies, and 9.5 nursing staff vacancies. Table 3. SCC Health Care Staffing Resources as of October 2024 Executive Primary Care Nursing Nursing Positions Leadership * Providers Supervisors Staff † Total Authorized Positions 5.0 6.5 10.7 57.1 79.3 Filled by Civil Service 4.0 4.4 8.0 47.6 64.0 Vacant 1.0 2.1 2.7 9.5 15.3 Percentage Filled by Civil Service 80.0% 67.7% 74.8% 83.4% 80.7% Filled by Telemedicine 0 0 0 0 0 Percentage Filled by Telemedicine 0 0 0 0 0 Filled by Registry 0 0 0 0 0 Percentage Filled by Registry 0 0 0 0 0 Total Filled Positions 4.0 4.4 8.0 47.6 64.0 Total Percentage Filled 80.0% 67.7% 74.8% 83.4% 80.7% Appointments in Last 12 Months 1.0 0 2.0 7.4 10.4 Redirected Staff 0 0 0 0 0 Staff on Extended Leave ‡ 0 0 0 2.0 2.0 Adjusted Total: Filled Positions 4.0 4.4 8.0 45.6 62.0 Adjusted Total: Percentage Filled 80.0% 67.7% 74.8% 79.9% 78.2% * 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 10-1-24, from California Correctional Health Care Services. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 9 Population-Based Metrics In addition to our own compliance testing and case reviews, as noted above, the OIG presents selected measures from the Healthcare Effectiveness Data and Information Set (HEDIS) for comparison purposes. The HEDIS is a set of standardized quantitative performance measures designed by the National Committee for Quality Assurance to ensure 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 SCC’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 comparative review: poor HbA1c control, which measures the percentage of diabetic patients who have poor blood sugar control, and colorectal cancer screening rates for patients ages 45 to 75. We list the applicable HEDIS measures in Table 4. Comprehensive Diabetes Care When compared with statewide Medi-Cal programs—California Medi-Cal, Kaiser Northern California (Medi-Cal), and Kaiser Southern California (Medi-Cal)—SCC’s percentage of patients with poor HbA1c control was significantly lower at nine percent, 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. SCC had a 40 percent influenza immunization rate for adults 18 to 64 years old and an 83 percent influenza immunization rate for adults 65 years of age and older.9 The pneumococcal vaccination rate was 92 percent.10 Cancer Screening When compared with statewide Medi-Cal programs—California Medi-Cal, Kaiser Northern California (Medi-Cal), and Kaiser Southern California (Medi-Cal)—SCC’s percentage of patients with colon cancer screening rate of 66 percent was higher than California Medi-Cal but lower than California Kaiser NorCal and SoCal Medi-Cal. 9 The HEDIS sampling methodology requires a minimum sample of 10 patients to have a reportable result. 10 The pneumococcal vaccines administered are the 13, 15, and 20 valent pneumococcal vaccines (PCV13, PCV15, and PCV20), or 23 valent pneumococcal vaccine (PPSV23), depending on the patient’s medical conditions. For the adult population, the influenza or pneumococcal vaccine may have been administered at a different institution other than where the patient was housed during the inspection period. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 10 Table 4. SCC Results Compared With State HEDIS Scores SCC California California Kaiser Kaiser Cycle 7 California NorCal SoCal HEDIS Measure Results * Medi-Cal † Medi-Cal † Medi-Cal † HbA1c Screening 100% – – – Poor HbA1c Control (> 9.0%) ‡,§ 9% 33% 26% 19% HbA1c Control (< 8.0%) ‡ 84% – – – Blood Pressure Control (< 140/90) ‡ 97% – – – Eye Examinations 84% – – – Influenza – Adults (18 – 64) 40% – – – Influenza – Adults (65 +) 83% – – – Pneumococcal – Adults (65 +) 92% – – – Colorectal Cancer Screening 66% 40% 71% 71% Notes and Sources * Unless otherwise stated, data were collected in October 2024 by reviewing medical records from a sample of SCC’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 Physical Health External Quality Review Technical Report, dated July 1, 2023 – June 30, 2024 (published April 2025); https://www.dhcs.ca.gov/dataandstats/reports/Documents/CA2023-24- Medi-Cal-Managed-Care-Physical-Health-External-Quality-Review-Technical-Report-Vol1-F1.pdf. ‡ For this indicator, the entire applicable SCC population was tested. § For this measure only, a lower score is better. Source: Institution information provided by the California Department of Corrections and Rehabilitation. Health care plan data were obtained from the CCHCS Master Registry. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 11 Recommendations As a result of our assessment of SCC’s performance, we offer the following recommendations to the department: Access to Care • Nursing leadership should determine the root cause(s) of poor nurse triage of health care services request forms (CDCR 7362) and implement remedial measures as appropriate. • Health care leadership should determine the root cause(s) of untimely provider appointments for chronic care and provider follow-up appointments after specialty services and implement remedial measures as appropriate. • Health care leadership should develop and implement strategies to improve the morning huddle process for the patient care teams. Diagnostic Services • Medical leadership should continue to study the implementation of their proposed system improvements in patient letters and make any corrective adjustments needed to ensure the new process is effective and improves the rate of complete and clear communication to the patients. Emergency Services • Nursing leadership should develop strategies to ensure supervising registered nurses (SRNs) complete thorough audits of all events that include emergency medical responses and should implement remedial measures as appropriate. • Nursing and medical leadership should develop strategies to ensure nursing and provider clinical reviews identify all opportunities for improvement in provider and nurse performance and should implement remedial measures as appropriate. • Medical leadership should develop strategies to ensure providers order appropriate patient transportation to a higher level of care for emergent events and should implement remedial measures as appropriate. • The institution should consider replacing vital signs equipment with models capable of synchronizing data with the electronic health record system (EHRS).11 11 EHRS is the Electronic Health Records System. The department’s electronic health record system is used for storing the patient’s medical history. The health care staff use the system to communicate. This record stays with the patient throughout the patient’s time in department’s correctional system. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 12 Health Information Management • Health care leadership should identify challenge(s) in the untimely receipt and scanning of hospital as well as specialty reports and should implement appropriate remedial measures. Health Care Environment • Medical and nursing leadership should determine the root cause(s) for staff not following all required universal hand hygiene precautions and should implement remedial measures as appropriate. • Executive leadership should determine the root cause(s) for staff not following equipment and medical supply management protocols and should implement remedial measures as appropriate. • Nursing leadership should determine the root cause(s) for staff not ensuring EMRBs are regularly and properly inventoried, stocked, or sealed and should implement appropriate remedial measures. Transfers • Nursing leadership should develop and implement strategies, such as internal staff auditing, to ensure assessments are complete and thorough for patients who transfer in, transfer out, or return from the hospital or emergency room. • Medical and nursing leadership should develop and implement a process between nursing and providers to ensure they promptly review all hospital discharge recommendations and timely place orders. Medication Management • SCC leadership should develop and implement measures to ensure the fire camp patients receive all medications without delay and ensure pharmacy staff communicate with nurses when medications are returned to the institution. Leadership should implement remedial measures as appropriate. • SCC leadership should determine the challenges to providing medication continuity for patients with chronic care medications, newly ordered medications, transfer-in medications, and community hospital discharge medications. Leadership should implement remedial measures as appropriate. Preventative Services • Health care leadership should determine the root cause(s) for challenges to timely providing immunizations to chronic care patients and should implement appropriate remedial measures. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 13 Nursing Performance • Nursing leadership should identify the challenges preventing SCC nurses from performing complete assessments and interventions and should implement remedial measures as appropriate. • Nursing leadership should develop and implement strategies, such as sick call audits, to ensure supervisors evaluate the nursing triage process to confirm the nurses properly assess patients’ requests and schedule patients with urgent or emergent symptoms in an appropriate time frame. Leadership should implement remedial measures as appropriate. • SCC nursing and medical leadership should develop strategies to ensure primary care huddles are thorough and comprehensive, and the care teams address all pending or unresolved items. Leadership should implement remedial measures as appropriate and educate all medical staff on proper huddle expectations. Provider Performance • Medical leadership should identify the root cause(s) for poor provider care of medically complex patients and should implement remedial measures as appropriate. • Medical leadership should develop and implement strategies to ensure patients receive specialty services within priority time frames appropriate to their medical conditions. Specialty Services • Health care leadership should determine the root cause(s) of untimely preapproved specialty appointments for transfer-in patients and implement appropriate remedial measures. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 14 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 Inadequate (73.2%) In Cycle 7, case review found SCC provided acceptable access to care, as in Cycle 6. After staff ordered appointments, they often occurred timely. Chronic-care appointments for patients housed at SCC also occurred timely. In addition, hospital and triage and treatment area (TTA) follow-ups as well as clinic appointments also occurred timely, once ordered. We found providers sometimes ordered inappropriate specialty-referral priorities; however, this did not significantly hinder access to specialty services. Although nurses performed poorly in triaging sick calls, if an appointment was ordered, it usually occurred timely. Considering all factors, the OIG rated the case review component of this indicator adequate. Compliance showed SCC performed variably for this indicator. Staff performed excellently in timely reviewing patient sick calls and often completed nurse face-to-face appointments within the required time frame. Providers almost always timely completed appointments for patients returning after hospitalizations and for newly transferred patients. However, staff needed significant improvement in timely completing provider appointments for chronic care patients and for patients returning after specialty services appointments. Based on the overall Access to Care compliance score result, the OIG rated the compliance component of this indicator inadequate. Case Review and Compliance Testing Results OIG clinicians reviewed 185 provider, nursing, urgent or emergent care (TTA), specialty, and hospital events that required the institution to generate appointments. We identified 14 deficiencies directly relating to Access to Care, seven of which were significant.12 Access to Care Providers SCC’s performance was mixed for access to providers. Compliance testing showed poor performance with timely completion of provider chronic care follow-up appointments (MIT 1.001, 48.0%) but excellent performance with timely completion of nursing to primary care provider referrals (MIT 1.005, 100%). 12 Access to care deficiencies occurred in cases 1, 8, 11-12, 14-16, 20-21, 23, and 34. Significant deficiencies occurred in cases 12, 14-15, 21, and 34 Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 15 OIG clinicians identified six deficiencies in provider access, only one of which was significant as follows:13 • In case 34, the sick call RN evaluated the patient and documented a plan to refer the patient to a provider within 14 days; however, the RN did not order this appointment within this timeframe. Access to Clinic Nurses Ensuring nurses timely receive, review, and triage patient sick calls is critical. SCC’s performance varied in access to clinic nurses. Compliance testing showed nurses performed excellently in triaging sick calls (MIT 1.003, 100%), and sufficiently in completing face-to- face assessments (MIT 1.004, 81.3%). However, OIG clinicians found poor nursing access. We reviewed 50 nursing sick call requests in 21 cases and identified 11 nursing performance deficiencies in which SCC nurses did not appropriately triage sick calls or order needed follow-up appointments, delaying medical care. Six of the 11 deficiencies were significant.14 In two deficiencies, nurses triaged health care services request forms and ordered appointments correctly; however, staff did not schedule the appointments within compliance time frames. The following deficiency was significant: • In case 15, the RN reviewed a sick call request from the patient for possible side effects from Lasix, a diuretic medication. His symptoms included excessive urination, incontinence, and penile pain. The nurse documented the patient should be seen; however, a nurse did not assess the patient and his symptoms worsened, resulting in his transfer to the hospital three days later. The remaining nine deficiencies related to poor nursing triage of medical requests for services, five of which were significant. This led to the patients not being assessed by nurses despite their medical need for care. We discuss further in the Nursing Performance indicator. Access to Specialty Services Access to specialty services was good overall. Compliance testing revealed an excellent completion rate of high-priority (MIT 14.001, 93.3%) and routine-priority (MIT 14.007, 93.3%) specialty service appointments. In addition, medium-priority specialty appointments frequently occurred timely (MIT 14.004, 80.0%). OIG clinicians identified a pattern of SCC providers ordering referrals for specialty services with medically inappropriate time frame priorities; however, once providers ordered the referrals, the referrals often occurred timely. We found six deficiencies, five of which were clinically significant.15 We discuss the referral pattern further in the Provider Performance and Specialty Services indicators. 13 Provider access deficiencies occurred in cases 8, 12, 16, 20, 23, and 34. A significant deficiency occurred in case 34. 14 Nurse sick call events occurred in cases 1-2, 10-15, 18, and 30-41. Deficiencies occurred in cases 2, 10-12, 14-15, and 18. Significant deficiencies occurred in cases 2, 11,15, and 18. 15 Deficiencies occurred in cases 1, 12, 14, and 21. Significant deficiencies occurred in cases 12, 14, and 21. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 16 Follow-Up After Specialty Services Compliance testing revealed SCC needed improvement in timely provider follow-up appointments after specialty services (MIT 1.008, 69.1%). OIG clinicians identified four deficiencies in which providers did not timely evaluate patients for scheduled specialty services follow-up appointments. Only one appointment was high priority, and none were significant.16 All four appointments were “completed” in the medical record as though the patient had been seen; however, none of the appointments occurred. Follow-Up After Hospitalization Compliance testing showed providers frequently followed up with their patients after hospitalizations (MIT 1.007, 92.0%) within the required time frames. OIG clinicians did not identify any access deficiencies with the provider follow-up appointments. Follow-Up After Urgent or Emergent Care (TTA) SCC providers generally evaluated their patients following a TTA event as medically indicated. OIG clinicians reviewed 19 TTA events in which patients returned to the housing units. Of those 19 TTA events, 11 primary care provider follow-up appointments occurred between five and 14 days late. We identified no provider follow-up appointment deficiencies. Follow-Up After Transferring into the SCC Staff timely evaluated their patients after they transferred into SCC. Compliance testing showed excellent access to clinicians for newly arrived patients (MIT 1.002, 95.0%). OIG clinicians did not find any transfer-in nursing or provider access deficiencies. Clinician On-Site Inspection OIG clinicians spoke with SCC’s medical leadership, nursing leadership, and schedulers regarding patients’ access to care. We also attended the morning huddles. Leadership reported SCC had no specialized medical housing, but had three main on-site clinics designated A, B, and C. SCC is the primary medical hub for 31 fire camps throughout the state, which are owned and operated by CalFire. Due to the closure of California Correctional Center, SCC received 15 northern camps from November to December 2022. The fire camps house approximately 1,600 incarcerated persons at various locations throughout the state. Leadership stated the incarcerated persons at the fire camps are assigned to medical care at one of two hubs, depending on their location: California Institute for Men (CIM) via telemedicine for southern fire camp patients, or SCC. For routine medical care, the patients are transported by custody from their camps to the closest medical hub, either CIM or SCC. There, they are seen by providers, nursing staff, and laboratory staff, either in person or via telemedicine. Transport occurs in custody vans that can hold only eight incarcerated persons, limiting the number of patients who can be seen at one time at each location. 16 Follow-up provider deficiencies related to providers occurred in cases 12, 20, and 23. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 17 Leadership stated firefighters in the fire camps must meet certain criteria for “vigorous duty.” Incarcerated camp support personnel must also meet full-duty criteria and be rated at no more than medium medical risk. Some firefighters or camp support patients do require periodic medical appointments, laboratories, and chronic medication administration. Medical leadership stated chronic care appointment frequency is determined by the chronic care registry and appointments are grouped by location in a rotational method. Leadership reported the health care requests for services (Form 7362s) are available in fire camps and described the sick call process. Completed 7362s are picked up weekly at fire camps, instead of daily as is the practice in an institutional setting. Most of these are non- symptomatic. An SCC RN triages the 7362s delivered to SCC on the weekly bus and routes them to the appropriate department. SCC considers the day SCC receives the 7362 as the date the patient completed the 7362, even if the patient submitted the 7362 six days prior. With this process, the fire camp patients may not receive timely RN triage of their medical requests, or do not receive the medical privacy of the 7362 lock boxes as at SCC. MERT activations can occur anywhere in the state, and a designated number of medical personnel, firefighters, and camp support personnel must immediately deploy to the disaster area.17 SCC providers and nurses support the activation for maximum seven-day shifts. If disaster support is required longer than seven days, additional medical staff will undertake the next seven-day shift. This continues until the disaster ends. This may affect provider availability at SCC, during the peak fire season. Providers stated they use satellite for internet access while deployed so they can continue to support their patient panel at SCC, as well as obtain camper histories in the event of an emergency. We discuss MERT further in the Nursing Performance indicator. OIG clinicians identified one provider who was responsible for “completing” specialty follow- up appointments without evaluating the patient in person. At the on-site inspection, this provider mentioned this was due to a process-knowledge deficit and received corrective training prior to our inspection. We observed morning huddles on all yards. The morning huddles are intended to function as a daily meeting between all care staff to discuss, coordinate, and prioritize patient needs, including medication renewals, overnight emergencies or events, and newly arrived patients. Morning huddles also generally strategize resolutions for nursing, provider, and specialty appointments that have past compliance deadlines. Appropriate staff attended the SCC huddles; however, the huddle members did not exchange critical patient care information. Instead, medical assistants or LVNs facilitated the huddles using a huddle report, which involved them simply calling out a section of the huddle report, such as “medication renewals,” then announcing only the number of patients listed under that section. The huddle members did not discuss important information about any of the patients or any medication details, and the SCC providers asked no questions. When OIG clinicians requested further details on some of the patients, we found the staff members running the huddles were not familiar with the patients, their medical issues, or the medical significance of their entries on the daily huddle report. In the six huddles, we witnessed staff were unprepared and unfamiliar with their patients. 17 MERT stands for Medical Expedition Response Team, which is a specialized unit of medical personnel that responds to medical emergencies during natural disasters or highly hazardous disasters. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 18 Compliance Testing Results None of the four housing units randomly tested at the time of inspection had access to health care services request forms (CDCR 7362) (MIT 1.101, zero). In four housing units, custody officers did not have a system in place for restocking the forms. Custody officers reported they either relied on medical staff to replenish these forms in the housing units or printed a copy from their own computers, which meant they did not use the required triplicate forms. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 19 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 12 13 0 48.0% 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 19 1 5 95.0% patient seen by the clinician within the required time frame? (1.002) Clinical appointments: Did a registered nurse review the patient’s request 32 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 26 6 0 81.3% 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 15 0 17 100% 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 0 0 32 N/A specified? (1.006) Upon the patient’s discharge from the community hospital: Did the patient 23 2 0 92.0% receive a follow-up appointment within the required time frame? (1.007) Specialty service follow-up appointments: Did the clinician follow-up visits 29 13 3 69.1% occur within required time frames? (1.008) * Clinical appointments: Do patients have a standardized process to obtain 0 4 0 0 and submit health care services request forms? (1.101) Overall percentage (MIT 1): 73.2% * CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician follow-up visits following specialty services. As a result, we tested MIT 1.008 only for high-priority specialty services or when staff ordered follow-ups. The OIG continued to test the clinical appropriateness of specialty follow-ups through its case review testing. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 20 Table 6. Other Tests Related to Access to Care Scored Answer Compliance Questions Yes No N/A Yes % For patients received from a county jail: If, during the assessment, the nurse referred the patient to a provider, was the patient seen within the required N/A N/A N/A N/A time frame? (12.003) For patients received from a county jail: Did the patient receive a history and physical by a primary care provider within seven calendar days (prior to N/A N/A N/A N/A 07/2022) or five working days (effective 07/2022)? (12.004) Was a written history and physical examination completed within the N/A N/A N/A N/A required time frame? (13.002) Did the patient receive the high-priority specialty service within 14 calendar days of the primary care provider order or the Physician Request for 14 1 0 93.3% Service? (14.001) Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care 8 1 6 88.9% 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 12 3 0 80.0% 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? 7 0 8 100% (14.006) Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician Request 14 1 0 93.3% for Service? (14.007) Did the patient receive the subsequent follow-up to the routine-priority specialty service appointment as ordered by the primary care 9 1 5 90.0% provider? (14.009) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 21 Recommendations • Nursing leadership should determine the root cause(s) of poor nurse triage of health care services request forms (CDCR 7362) and implement remedial measures as appropriate. • Health care leadership should determine the root cause(s) of untimely provider appointments for chronic care and provider follow-up appointments after specialty services and implement remedial measures as appropriate. • Health care leadership should develop and implement strategies to improve the morning huddle process for the patient care teams. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 22 Diagnostic Services In this indicator, OIG inspectors evaluated the institution’s performance in timely completing radiology, laboratory, and pathology tests. Our inspectors determined whether the institution properly retrieved the resultant reports and whether providers reviewed the results correctly. In addition, in Cycle 7, we examined the institution’s performance in timely completing and reviewing immediate (STAT) laboratory tests. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Adequate (75.8%) In this cycle, case review found SCC performed satisfactorily in diagnostic services, consistent with Cycle 6. Staff timely completed diagnostic services both for on-site and camp patients. Radiology staff also completed these tests within ordered timelines. However, we identified deficiencies in patient notification letter generation and missing off-site pathology reports. After considering all factors, the OIG rated the case review component of this indicator adequate. SCC’s performance in compliance testing was mixed in this indicator. Staff generally completed diagnostic services timely. Providers also performed excellently in reviewing and endorsing diagnostic test results within the required time frames. In contrast, providers needed improvement in generating complete patient test result notification letters with all required elements. Based on the overall Diagnostic Services compliance score result, the OIG rated the compliance component of this indicator adequate. Case Review and Compliance Testing Results OIG clinicians reviewed 114 diagnostic events and identified 33 deficiencies, one of which was significant. Of these 33 deficiencies, 30 related to health information management. Of the remaining three deficiencies, two related to not sending patient test result notification letters and one related to a nurse not consulting with providers about an abnormal test result. We found no deficiencies related to incomplete or delayed diagnostic tests.18 Test Completion Compliance testing found SCC performed very well in completing radiology services (MIT 2.001, 90.0%) and sufficiently in completing laboratory tests (MIT 2.004, 80.0%). OIG clinicians found no deficiencies with laboratory or radiology test completion. Neither case review nor compliance testing had any STAT laboratory tests in their samples to review (MIT 2.007, NA). 18 Deficiencies occurred in cases 1, 9-10, 12-15, 18, and 20-23. The significant deficiency occurred in case 12. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 23 Please see the Clinician On-Site Inspection section below for further discussion on diagnostic studies. Health Information Management SCC providers reviewed and endorsed laboratory and radiology studies well; however, communicating results with complete test result notification letters to the patients was poor. Compliance testing showed providers performed excellently in the timely review of radiology reports, laboratory results, and pathology results (MIT 2.002, 100%, MIT 2.005, 100%, and MIT 2.011, 100%.). Staff also performed well with retrieving pathology reports within required time frames (MIT 2.010, 80.0%). However, providers performed poorly in communicating with complete patient test result notification letters for radiology results (MIT 2.003, 40.0%), laboratory results (MIT 2.006, 62.5%), and pathology results (MIT 2.012, 30.0%). OIG clinicians reviewed 114 diagnostic events, none of which contained STAT test or on-site biopsies with pathology. We identified 33 deficiencies, 32 of which related to omitted elements in patient results letters or missing patient results letters.19 We identified one significant deficiency as follows: • In case 12, the patient’s normal EKG was scanned into the patient’s medical record; however, another patient’s abnormal EKG was also erroneously included. OIG clinicians identified deficiencies with missing off-site pathology reports which we discuss in more detail in the Health Information Management indicator. Clinician On-Site Inspection OIG clinicians met with diagnostic, HIM, and medical leadership as well as staff to discuss diagnostic services. Medical leadership reported STAT laboratory tests were not available at SCC or at fire camps; therefore, none were ordered. If STAT laboratory tests were needed, patients would have to be sent to the local hospital for further evaluation. Diagnostic leadership reported having on-site x-ray services, and specialty CT, MRI, and ultrasound imaging services.20 Staff completed x-rays on-site for patients housed at SCC as well as for non-emergent fire camp patients as needed. An imaging vendor provided mobile CTs, MRIs, ultrasounds, and FibroScans for SCC.21 The CTs and MRIs were usually completed monthly, and the imaging schedule was available one year in advance. Diagnostics leadership and the laboratory assistants scheduled the on-site and fire camp patient laboratory tests. They reported most new SCC patients arrive in A and B yards, where medical staff draw additional screening laboratory tests to complement the initial intake screening laboratory tests drawn at the reception center. From those yards, medical staff 19 Diagnostic HIM deficiencies occurred in cases 1, 9-10, 12, 15, 18, and 21-23. The significant deficiency occurred in case 12. 20 A CT is a computed, or computerized, tomography scan while an MRI is a magnetic resonance imaging scan. Both create detailed images of the organs and tissues to detect diseases and abnormalities. 21 A FibroScan is a diagnostic imaging scan used to evaluate for liver scarring and fatty changes from liver disease. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 24 evaluate and approve some patients to go to one of the 31 fire camps locations throughout California. Leadership reported the approximately 1,600 fire camp incarcerated persons may be deployed at any time to support CalFire emergencies such as fire, snow removal, or sand bagging efforts anywhere in the state. For instance, leadership mentioned approximately 1,000 incarcerated persons were deployed earlier this year to southern California to assist in the fires that occurred there, requiring rescheduling of tests. Leadership stated the fire camps may affect timely completion of laboratory tests. Medical hubs are set up across the state to accommodate the most distant fire camp patients. Most incarcerated persons assigned to the fire camps are low risk medical, requiring less frequent laboratory blood draws than higher medical risk patients, but laboratory studies are sometimes necessary. Laboratory technicians stated they travel to two fire camp hubs per week for scheduled laboratory draws. Transport from the fire camps to the hubs is limited to eight incarcerated persons due to the custody transport van passenger capacity. Leadership stated providing timely radiology services for fire camp patients may also be a challenge for several reasons. Due to the distance between most fire camps and SCC, fire camp patients scheduled for imaging usually must stay at SCC at least overnight. Medical leadership mentioned fire camp patients will frequently refuse imaging studies because of the yard politics and high risk of violence. When a new patient or returning fire camp patient arrives at SCC, informal incarcerated yard leadership requires the patient to make “payment” or physically fight to protect themselves. Leadership and staff reported most fire camp patients would choose to avoid the required overnight stay to complete the studies, even if refusing the imaging creates a high medical risk. As discussed further below in the Specialty Services indicator, medical leadership stated they are piloting a program where distant fire camp patients can temporarily house at a closer fire camp, then transport to SCC only for the day of testing, rather than housing at SCC overnight. The Chief Physician and Surgeon (CP&S) demonstrated a new patient diagnostic results notification letter system that included all CCHCS required components in the letters. According to leadership, this system may reduce the number of diagnostic HIM deficiencies related to incomplete patient notification letters. Upon provider endorsement, the system will generate standardized result letters for the 30 most common laboratory tests. Providers can still generate personalized responses; however, they reported this will create additional letters, which may cause patient confusion. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 25 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 9 1 0 90.0% 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 4 6 0 40.0% of the radiology study to the patient within specified time frames? (2.003) Laboratory: Was the laboratory service provided within the time frame 8 2 0 80.0% specified in the health care provider’s order? (2.004) Laboratory: Did the health care provider review and endorse the laboratory 10 0 0 100% report within specified time frames? (2.005) Laboratory: Did the health care provider communicate the results of the 5 3 2 62.5% laboratory test to the patient within specified time frames? (2.006) Laboratory: Did the institution collect the STAT laboratory test and receive N/A N/A N/A N/A the results within the required time frames? (2.007) Laboratory: Did the provider acknowledge the STAT results, OR did nursing N/A N/A N/A N/A staff notify the provider within the required time frames? (2.008) Laboratory: Did the health care provider endorse the STAT laboratory N/A N/A N/A N/A results within the required time frames? (2.009) Pathology: Did the institution receive the final pathology report within the 8 2 0 80.0% required time frames? (2.010) Pathology: Did the health care provider review and endorse the pathology 10 0 0 100% report within specified time frames? (2.011) Pathology: Did the health care provider communicate the results of the 3 7 0 30.0% pathology study to the patient within specified time frames? (2.012) Overall percentage (MIT 2): 75.8% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 26 Recommendations • Medical leadership should continue to study the implementation of their proposed system improvements in patient letters and make any corrective adjustments needed to ensure the new process is effective and improves the rate of complete and clear communication to the patients. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 27 Emergency Services In this indicator, OIG clinicians evaluated the quality of emergency medical care. Our clinicians reviewed emergency medical services by examining the timeliness and appropriateness of clinical decisions made during medical emergencies. Our evaluation included examining the emergency medical response, cardiopulmonary resuscitation (CPR) quality, triage and treatment area (TTA) care, provider performance, and nursing performance. Our clinicians also evaluated the Emergency Medical Response Review Committee’s (EMRRC) performance in identifying problems with its emergency services. The OIG assessed the institution’s emergency services solely through case review. Ratings and Results Overview Case Review Rating Compliance Rating and Score Inadequate Not Applicable In this cycle, case review found SCC performed poorly with emergency services. Compared with Cycle 6, we identified more overall deficiencies as well as more significant deficiencies. Although emergency medical response times were generally prompt, and medical responders usually requested emergency medical services quickly, nurses often did not thoroughly assess symptoms or initiate appropriate interventions. SCC providers also completed poor patient assessments, missed documentation, and initiated insufficient or inappropriate plans of care. Additionally, while SCC conducted clinical reviews when patients had unscheduled higher level of care transfers, the medical and nursing leadership did not identify opportunities for improvement for their staff. Overall, SCC had systemic issues in their emergency provider and nursing care and did not have sufficient mechanisms in place to identify and address individual and system deficits. Taking all factors into consideration, the OIG rated this indicator inadequate. Case Review Results We reviewed 40 urgent and emergent events and found 58 emergency care deficiencies. Of these 58 deficiencies, 18 were significant.22 Emergency Medical Response SCC performed excellently with emergency medical response times. We reviewed 29 emergency medical events in which custody staff and nurses responded.23 We found custody and medical staff responded promptly to emergencies throughout the institution and initiated emergency medical services (EMS) promptly; however, one opportunity for improvement is detailed below: • In case 13, the patient exhibited signs of a stroke. The medical staff thought EMS had been requested; however, after waiting 42 minutes, EMS still had not 22 Deficiencies occurred in case 2-4, 6, 11-13, 15, 17, 18, 20, 21, and 23. Significant deficiencies occurred in cases 2- 4, 6, 13, 15, 17, and 20. 23 Emergency medical responses occurred in cases 1-4, 6, 12-15, 17, 18, and 20. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 28 arrived. Subsequently, a TTA nurse initiated a new request, which prompted EMS’s response to SCC. Cardiopulmonary Resuscitation Quality During this period, we reviewed two cases in which staff initiated CPR.24 In both cases, custody staff initiated CPR, nurses responded promptly, and staff timely requested EMS; however, nurses did not provide sufficient interventions. Two examples are below: • In case 3, SCC custody and nursing staff performed CPR for eight minutes and attached an automated external defibrillator (AED), which delivered a shock.25 Nursing staff also administered two doses of naloxone.26 The patient had a return of spontaneous circulation (ROSC) but remained unresponsive.27 The nurse did not administer additional doses of naloxone for the unconscious patient with suspected opioid overdose, as per nursing protocol. • In case 4, the nurse documented the patient had shallow respirations and was only breathing four times per minute; however, the nurse did not continue providing positive pressure ventilation.28 Instead, the nurse provided only two rescue breaths and then applied a non-rebreather mask, which did not provide adequate oxygenation. Provider Performance OIG clinicians identified 21 provider performance deficiencies, seven of which were significant.29 Thirteen deficiencies related to poor provider assessment and decision making. Deficiencies included providers not documenting progress notes to include their assessments or patients’ plans of care. Additionally, nurses consulted providers about patients, but providers sometimes did not document this communication. The following are examples: • In case 15, a provider evaluated the patient, who had a history of atrial fibrillation and heart failure, for shortness of breath with exertion.30 The provider did not check the patient’s oxygen saturation with exertion. Furthermore, the provider did not consider other possible reasons for the patient’s shortness of breath. Instead, the provider concluded the patient was stable and discharged him to his housing unit. The patient’s condition worsened 24 CPR occurred in cases 3 and 4. 25 An automated external defibrillator (AED) is a portable device used to deliver an electric shock to the heart when it detects an abnormal heart rhythm. 26 Naloxone is a medication used for emergency treatment of known or suspected opioid overdose. According to the manufacturer, nasal naloxone doses can be safely administered every two to three minutes. CCHCS emergency medical training allows nurses to administer five nasal naloxone doses when an opioid overdose is suspected. 27 Return of spontaneous circulation (ROSC) is the resumption of a sustained heart rhythm that perfuses the body after cardiac arrest. Clinically, when ROSC occurs, the health care provider will check for a central arterial pulse. 28 Positive pressure ventilation is a method to deliver pressurized air or oxygen into the lungs for patients who cannot breathe on their own. 29 Deficiencies occurred in cases 2, 11, 12, 15, 17, 18, 20, 21, and 23. Significant deficiencies occurred in cases 2, 15, 17, and 20. 30 Atrial fibrillation is a medical condition in which the heart chamber contracts abnormally, which can be life-threatening and require treatment. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 29 and three days later, a different provider evaluated the patient for shortness of breath. The second provider again did not perform a thorough examination and did not pursue further testing. Instead, the provider discharged the patient back to his housing unit. The patient continued to worsen and four days later, complained of rectal bleeding, severe shortness of breath, and chest pain. Subsequently, the patient was transferred to a community hospital, where he was admitted and received a blood transfusion. • In case 17, the provider evaluated the patient, who complained of abdominal pain, nausea, and vomiting for several days. The provider ordered the patient be transported to a community hospital for further evaluation; however, the provider did not order ambulance transportation. Instead, the provider ordered custody staff transport the patient via state vehicle, which was inappropriate for the patient’s clinical condition. • In case 20, a nurse consulted a provider regarding a patient with a traumatic hand injury. The provider did not document a progress note and did not order an x-ray to occur on the same day. Instead, the provider ordered the x-ray to occur within 14 days and did not order a follow-up with the patient. • In case 23, a nurse consulted a provider about the patient, who recently had surgery. The provider ordered a new medication but did not document a progress note. We identified a similar pattern of providers not documenting pertinent nurse co-consultations with clinically relevant information in the EHRS in cases 2, 12, 17, 18, and 20. Nursing Performance SCC nurses had mixed performance in providing emergency services. Nurses responded promptly to medical emergencies and usually consulted a provider when warranted. However, when patients’ symptoms required a thorough nursing assessment, the nurses often did not fully assess the symptoms or initiate necessary interventions. The following are examples: • In case 2, the patient had cardiac risk factors and complained of chest pain. TTA nurses identified the patient had a severely low heart rate; however, nurses administered nitroglycerin, which could have caused the patient’s heart rate to further decrease.31 Additionally, the nurse initiated the chest pain nursing protocol but delayed administering aspirin for 20 minutes.32 • In case 15, the patient had a history of heart failure and had recently returned to SCC after hemorrhoid surgery. Nurses responded to the patient’s complaints for difficulty breathing and pain. The nurses documented the patient’s respiratory rate was slightly high at 24 breaths per minute. Also, the nurses documented the patient had swelling in both legs, a delayed capillary refill, and irregular labored 31 Nitroglycerin is a medication that dilates blood vessels to increase blood flow to the heart. 32 Aspirin has a blood-thinning effect and can be used to treat certain heart disease. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 30 breathing with diminished lung sounds.33 However, the nurse did not reassess these abnormal findings before discharging the patient. Nursing Documentation OIG clinicians found SCC nurses rarely documented details of the information relayed to and received from providers. Moreover, on occasion, nurses inconsistently documented timelines, interventions, and their patients’ clinical presentations. The following are examples: • In case 3, the first medical responder licensed vocational nurse (LVN) arrived at the patient’s location as CPR was in progress. The LVN documented oxygen delivery via non-rebreather mask; however, the TTA RN documented oxygen was delivered via a bag-valve mask.34 • In case 12, this patient transferred to a community emergency room for evaluation of rectal bleeding and symptomatic anemia. The TTA RN documented the patient had shortness of breath and was lightheaded, but the provider on call did not document being notified of these symptoms. In contrast, the provider documented the patient was not short of breath, had no additional bleeding, and had no lightheadedness. Emergency Medical Response Review Committee Compliance testing showed the Emergency Medical Response Review Committee at SCC frequently did not review emergency events timely, did not review events at all, or did not fully complete the incident package (MIT 15.003, 33.3%). OIG clinicians found, when patients transferred to a higher level of care, supervising registered nurses (SRNs) always completed the Emergency Response and Unscheduled Transport Event Checklist form, and designated nursing and medical leadership also conducted clinical reviews. However, OIG clinicians reviewed 19 events that warranted clinical reviews and identified opportunities for improvement in 13 events. SCC’s clinical reviews only identified one of the 13 opportunities for improvement.35 The following cases provide examples: • In case 15, on two separate events, the patient was transferred to a community emergency room for evaluation of shortness of breath. In these events, we identified opportunities for improvement for both the nursing and provider interventions; however, SCC nursing and medical leadership did not identify any of these same opportunities during their clinical reviews. • In case 17, nursing and medical leadership conducted a clinical review for the patient, who transferred to a community emergency room for abdominal pain and tenderness. SCC did not identify opportunities for improvement for nurses in monitoring the patient’s vital signs and severity of abdominal pain. Moreover, the review did not identify the concern that an SCC provider ordered custody 33 Delayed capillary refill means it takes longer than usual for the blood to return to the skin in the fingers or toes after pressing on them. This can be a sign of poor blood flow and may lead to further complications. 34 A non-rebreather mask is an oxygen mask that delivers high concentrations of oxygen and is used when a person can breathe on their own but needs a lot of oxygen quicky. A bag valve mask (BVM), also known as an ambu bag, is a hand-held device used to provide rescue breathing when someone is not breathing on their own. 35 SCC’s nursing and medical leadership did not identify opportunities for improvement in cases 2, 3, 4, 6, 12, 13, 15, 17, and 18. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 31 staff to transport the patient to the community emergency room via a state vehicle despite the patient’s condition warranting EMS monitoring and ambulance transportation. Clinician On-Site Inspection At SCC, the TTA is located in the A/B facility. The TTA has three examination room bays and a nursing station. Collectively, the bays had a defibrillator, EKG machine, scale, treatment carts, gurneys, and vital sign monitors. Unfortunately, the nurses could not document into the EHRS at the point of service because of poor computer battery life and mobile workstations that did not have computers. Subsequently, we learned the nurses must return to the nursing station to chart all information into their patients’ medical records. Additionally, SCC’s vital sign machines do not automatically record to the corresponding patient record. Instead, nurses must manually enter all vital signs before the machine is powered off, or the data will be automatically deleted. We learned, on the morning and afternoon shifts, two RNs staff the TTA, and the medication administration LVNs serve as the first medical responders (FMR). On the evening shift, one TTA RN is the FMR for A/B facility and one TTA RN remains in the C facility medical clinic to facilitate prompt emergency response. Although a TTA RN always responds to medical alarms, we learned they do so on foot with an emergency response bag, which could take longer to arrive to the patient. In some cases, when requested, SCC’s local fire department responded via ambulance. During business days and hours, an on-site medical provider is assigned to assist the TTA; outside of these hours, an on-call provider is available via telephone. During OIG clinicians’ interviews with the TTA RNs, we learned, in addition to responding to institutional alarms, the TTA RNs assessed patients returning from off-site specialist appointments, community hospitals, and emergency room encounters. An additional responsibility for the TTA RN included triaging medical concerns received from the fire camps. The nurses explained, when fire camp patients required immediate care, custody staff would activate EMS or transport patients to a local emergency room. The nursing staff indicated they documented all communication with the fire camps in a call log created in Microsoft Excel on the institutional computer shared drive. The Chief Nurse Executive (CNE) shared with the OIG clinicians the SRNs reviewed each patient encounter only if it resulted in a higher level of care transfer. The CNE indicated institutional medical alarms that did not result in a higher level of care were not subject to this formal review process. Additionally, nursing leadership did not conduct clinical reviews for TTA nursing encounters. The CNE planned this year to initiate a formal review process for these encounters. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 32 Recommendations • Nursing leadership should develop strategies to ensure supervising registered nurses (SRNs) complete thorough audits of all events that include emergency medical responses and should implement remedial measures as appropriate. • Nursing and medical leadership should develop strategies to ensure nursing and provider clinical reviews identify all opportunities for improvement in provider and nurse performance and should implement remedial measures as appropriate. • Medical leadership should develop strategies to ensure providers order appropriate patient transportation to a higher level of care for emergent events and should implement remedial measures as appropriate. • The institution should consider replacing vital signs equipment with models capable of synchronizing data with the electronic health record system (EHRS). Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 33 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 Inadequate (72.6%) Case review found SCC performed acceptably in health information management. Staff usually retrieved and scanned, and providers generally endorsed, diagnostic results timely. However, we identified some incomplete hospital records, missing off-site pathology reports, and errors regarding specialty service consultation reports. Considering all factors, the OIG rated the case review component of this indicator adequate. Compliance testing showed SCC needed improvement in this indicator. Staff did always scan patient sick call requests timely, and they mostly retrieved and scanned hospital records and specialty reports within the required time frames. However, SCC needed improvement in timely obtaining and endorsing hospital reports as well as properly scanning and labeling medical records into the correct patient files. Based on the overall Health Information Management compliance score result, the OIG rated the compliance component of this indicator inadequate. Case Review and Compliance Testing Results We reviewed 728 events and found 51 deficiencies related to health information management. Of these 51 deficiencies, eight were significant.36 Hospital Discharge Reports Compliance testing showed SCC staff performed sufficiently in retrieving and scanning hospital discharge records into the EHRS within the required time frames (MIT 4.003, 75.0%). However, staff needed improvement in obtaining hospital discharge reports with key elements and reviewing them timely (MIT 4.005, 52.0%). OIG clinicians reviewed 26 off-site emergency department and hospital encounters. SCC usually retrieved and scanned hospital records into the EHRS, and providers endorsed them 36 Deficiencies occurred in cases 1-2, 9-15, 18, and 20-23. Significant deficiencies occurred in cases 2, 11-12, 15, 17, and 21. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 34 timely. However, OIG clinicians identified five deficiencies with discharge and hospital record retrieval, three of which were significant as follows:37 • In case 2, when the provider evaluated the patient four days after hospital discharge for emergency small bowel resection, the record contained no hospital documentation from either of the hospitals involved in the patient’s care during this event. Because of this missing information, the provider was unable to adequately assess and treat the patient at the follow-up appointment. Staff scanned the hospital records two days late. • In case 12, while hospitalized, the patient had a flexible sigmoidoscopy with biopsies completed for uncontrolled ulcerative colitis and severe anemia.38 SCC staff retrieved the biopsy results nearly one month late. This increased the patient’s risk for delayed diagnosis and treatment. • In case 17, the patient had surgery to remove two intestinal segments, which were sent to the hospital laboratory for analysis; however, HIM staff never obtained the pathology report on the specimens. This increased the patient’s risk for a missed diagnosis and treatment. Specialty Reports Compliance testing showed SCC performed satisfactorily in timely receiving and endorsing medium-priority reports (MIT 14.005, 76.9%). In contrast, SCC needed improvement in scanning of specialty documents within required time frames (MIT 4.002, 73.3%). SCC also needed improvement in timely receiving and endorsing high-priority specialty reports (MIT 14.002, 73.3%) and performed poorly in timely receiving and endorsing routine-priority reports (MIT 14.008, 53.3%). OIG clinicians reviewed 74 specialty consultation reports and identified 15 deficiencies, three of which were significant.39 Eight deficiencies related to misfiled or mislabeled specialty documents, five deficiencies related to specialty reports scanned late into the EHRS, and two deficiencies related to late or missing provider endorsements. The following are significant deficiencies: • In case 12, SCC staff scanned a parathyroid gland scan result into the EHRS nearly one month late.40 This delay was significant because the results of this test were necessary for the ENT specialist to review to decide on surgical treatment.41 • In case 15, after a virtual physical therapy appointment, the LVN messaged the provider stating the appointment occurred and to follow up on the specialist’s 37 HIM hospital deficiencies occurred in cases 2, 12, 15, and 17. 38 Flexible sigmoidoscopy is a procedure using a flexible lighted tube to visualize inside the rectum and lower large intestines. Ulcerative colitis is a disease with chronic inflammation and ulcers in the intestines. 39 Deficiencies occurred in cases 12-15 and 20-22. Significant deficiencies occurred in cases 12, 15, and 21. 40 The parathyroid gland is located in the neck and regulates calcium, phosphorous, and vitamin D levels. 41 An ENT specialist is an Ear Nose and Throat specialist. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 35 recommendations; however, staff scanned the physical therapy report over five months later. • In case 21, an ENT specialist collected neck wound cultures on the patient’s recurrent neck abscesses. The results showed bacteria with multiple drug resistances. SSC staff obtained the results eight days late and then included them as part of another hospital record. This may have affected the patient’s treatment plan and outcome. OIG clinicians found, once reports were scanned, providers often endorsed them within required time frames. Diagnostic Reports SCC’s performance in managing diagnostic reports was mixed. Compliance showed providers always timely endorsed radiology, laboratory, and pathology results within specified time frames (MIT 2.002, 100%, MIT 2.005, 100%, and MIT 2.011, 100%). Staff often received pathology reports timely (MIT 2.010, 80.0%); however, providers only sporadically communicated pathology results to patients with complete notification letters (MIT 2.012, 30.0%) within specified time frames. OIG clinicians found providers endorsed diagnostic studies timely and often communicated the results to patients with notification letters; however, the notification letters frequently lacked all CCHCS required components. OIG clinicians also found HIM staff did not always timely retrieve the pathology reports for procedures completed offsite. Neither case review nor compliance testing had any STAT laboratory tests in their samples to review (MIT 2.007, N/A). Please refer to the Diagnostic Services indicator for further details. Urgent and Emergent Records OIG clinicians reviewed 40 emergency care events and found SCC nurses and providers usually documented these events adequately. We identified six provider performance deficiencies for missing or incomplete emergency documentation, two of which were significant.42 We discuss nursing and provider performance deficiencies further in the Emergency Services, Nursing Performance and Provider Performance indicators. Scanning Performance SCC’s performance in scanning varied. Compliance testing showed staff always scanned health care services request forms into the EHRS within required time frames (MIT 4.001, 100%) and performed satisfactorily in scanning community hospital discharge documents (MIT 4.003, 75.0%). However, SCC needed improvement in properly scanning, labelling, and including medical records in the correct patients’ files (MIT 4.004, 62.5%). OIG clinicians reviewed over 39 encounters requiring HIM to scan, label, and file records. We identified 42 Urgent and Emergent provider HIM deficiencies occurred in cases 2, 12, 15, 17 and 23. Two significant deficiencies occurred in case 2. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 36 nine deficiencies, only one of which was significant.43 We also discuss these in the Diagnostic Services and Specialty Services indicators. Clinician On-Site Inspection We discussed health information management processes with SCC HIM leadership, medical leadership, office technicians, nurses, providers, and ancillary staff. HIM leadership reported only having approximately 50 percent of the allotted health records technicians during the review period. Recruitment efforts were ongoing; however, they had received very little interest in the positions. One reason given for recruitment difficulties was no clear promotional path past Health Records Technician II. After a long recruitment process, one additional staff was hired in December 2024. HIM leadership reported they historically audit each other’s work; however, due to short staffing, this was not possible. Leadership stated this may have contributed to the filing and labelling errors found in our review and stated the auditing process would be reimplemented since the additional December staff hire. HIM leadership stated HIM is responsible for obtaining off-site specialty, hospital, emergency, and imaging documents. They reported having direct electronic access to one outside facility with two more in process. HIM expressed having experienced difficultly obtaining outside records from facilities without direct electronic access. For those facilities, HIM must fax and email requests for records, then follow up with phone calls. Telemedicine nurses are responsible for obtaining telemedicine specialty reports that HIM scan upon receipt. On August 19, 2024, HIM received access to the MedWeb database system for retrieving missing telemedicine specialty reports. HIM, diagnostics, medical leadership, and staff stated, in July 2024, CCHCS headquarters implemented an improved pathology report retrieval process. Leadership reported HIM or diagnostic staff were previously responsible for identifying and retrieving outstanding pathology reports. The new pathology report retrieval process requires providers to order retrieval of outstanding pathology reports after their review of specialty, hospital, or on-site records. HIM will then obtain, scan, and forward the report to the provider for review and endorsement. Staff reported the providers supporting the three northern fire camp hubs may have little or no internet connectivity during fire camp on-site clinics. This may limit access to real-time updated information in the EHRS. 43 General scanning deficiencies occurred in cases 12-15, and 20-21. A significant deficiency occurred in case 12. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 37 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 12 100% health record within three calendar days of the encounter date? (4.001) Are specialty documents scanned into the patient’s electronic health record 22 8 15 73.3% within five calendar days of the encounter date? (4.002) Are community hospital discharge documents scanned into the patient’s electronic health record within three calendar days of hospital discharge? 15 5 5 75.0% (4.003) During the inspection, were medical records properly scanned, labeled, 15 9 0 62.5% 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 13 12 0 52.0% review the report within five calendar days of discharge? (4.005) Overall percentage (MIT 4): 72.6% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 38 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 10 0 0 100% report within specified time frames? (2.005) Laboratory: Did the provider acknowledge the STAT results, OR did nursing N/A N/A N/A N/A staff notify the provider within the required time frame? (2.008) Pathology: Did the institution receive the final pathology report within the 8 2 0 80.0% required time frames? (2.010) Pathology: Did the health care provider review and endorse the pathology 10 0 0 100% report within specified time frames? (2.011) Pathology: Did the health care provider communicate the results of the 3 7 0 30.0% 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 11 4 0 73.3% 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 10 3 2 76.9% 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 7 0 53.3% frame? (14.008) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 39 Recommendations • Health care leadership should identify challenge(s) in the untimely receipt and scanning of hospital as well as specialty reports and should implement appropriate remedial measures. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 40 Health Care Environment In this indicator, OIG compliance inspectors tested clinics’ waiting areas, infection control, sanitation procedures, medical supplies, equipment management, and examination rooms. Inspectors also tested clinics’ performance in maintaining auditory and visual privacy for clinical encounters. Compliance inspectors asked the institution’s health care administrators to comment on their facility’s infrastructure and its ability to support health care operations. The OIG rated this indicator solely on the compliance score. Our case review clinicians do not rate this indicator. Because none of the tests in this indicator directly affected clinical patient care (it is a secondary indicator), the OIG did not consider this indicator’s rating when determining the institution’s overall quality rating. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Adequate (75.0%) Overall, SCC performed acceptably with respect to its health care environment. Staff always appropriately cleaned, sterilized, and disinfected all clinical areas or medical equipment. Staff also excellently stored medical supplies in the medical warehouse. However, SCC needed improvement in several areas. Medical supplies storage areas in the clinics contained disorganized, unidentified, or inaccurately labeled medical supplies. Some clinics did not meet the requirements for essential core medical equipment and supplies In addition, staff did not always document the automated external defibrillator (AED) performance test results within the last 30 days and did not regularly sanitize or wash their hands during patient encounters. Furthermore, emergency medical response bags (EMRBs) contained compromised medical supply packaging or had not been properly inventoried. Based on the overall Health Care Environment compliance score result, the OIG rated this indicator adequate. Compliance Testing Results Waiting Areas We inspected only indoor waiting areas as SCC had no outdoor waiting areas. Health care and custody staff reported existing waiting areas contained sufficient seating capacity (see Photo 1, right). Patients waited either in the clinic waiting area or in individual modules (see Photo 2, below). During Photo 1. Indoor waiting area (photographed on 10-22-24). Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 41 Photo 2. Individual waiting modules (photographed on 10-22-24). our inspection, we did not observe overcrowding in any of the clinics’ indoor waiting areas. Clinic Environment All clinic environments were sufficiently conducive for medical care; they provided reasonable auditory privacy, appropriate waiting areas, wheelchair accessibility, and nonexamination room workspace (MIT 5.109, 100%). Six of the eight applicable clinics we observed contained appropriate space, configuration, supplies, and equipment to allow clinicians to perform proper clinical examinations (MIT 5.110, 75.0%). In two clinics, examination rooms had unsecured confidential medical records. Clinic Supplies Only two of the eight clinics followed adequate medical supply storage and management protocols (MIT 5.107, 25.0%). We found one or more of the following deficiencies in six clinics: expired medical supplies (see Photo 3, right); unorganized, unidentified, or inaccurately labeled medical supplies; cleaning materials stored with Photo 3. Expired medical supply dated January 31, 2024 (photographed on 10-22-24). Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 42 medical supplies; medications stored with medical supplies; long-term storage of staff members’ food in the medical supply storage area (see Photo 4, left); and staff members’ personal items and food stored with medical supplies (see Photo 5, below). Photo 4. Long-term storage of staff’s food in the medical supply storage area (photographed on 10-22-24). Four of the eight clinics met the requirements for essential core medical equipment and supplies (MIT 5.108, 50.0%). We found one or Photo 5. Staff’s personal items and food stored both of the following deficiencies in four with medical supplies (photographed on 10-22-24). clinics: staff did not always document the automated external defibrillator (AED) performance test results within the last 30 days, or 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 essential items. We checked whether staff inspected the bags daily and inventoried them monthly. Three of the five EMRBs passed our test (MIT 5.111, 60.0%). In one location, the EMRB stored a compromised medical supply. In another clinic, staff did not log EMRB daily glucometer quality control results. Medical Supply Management SCC staff performed excellently in storing clinic medical supplies in the medical supply storage areas outside the clinics (MIT 5.106, 100%). According to the chief executive officer (CEO), health care leadership did not have any issues with the medical supply process. Health care and warehouse managers expressed no concerns about the medical supply chain or their communication process with the existing system in place. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 43 Infection Control and Sanitation Staff appropriately cleaned, sterilized, and disinfected all clinics (MIT 5.101, 100%). Additionally, staff in all seven applicable clinics properly sterilized or disinfected medical equipment (MIT 5.102, 100%). We found operating sinks and hand hygiene supplies in the examination rooms in six of eight clinics (MIT 5.103, 75.0%). In two clinics, the patient restrooms lacked antiseptic soap and disposable hand towels. We observed patient encounters in five clinics. In three clinics, clinicians did not wash their hands before examining their patients, before applying gloves, before performing blood draws, or before each subsequent re-gloving (MIT 5.104, 40.0%). Health care staff in all clinics followed proper protocols to mitigate exposure to bloodborne pathogens and contaminated waste (MIT 5.105, 100%). Physical Infrastructure At the time of our medical inspection, SCC’s administrative team reported no ongoing health care facility improvement program construction projects. The health care management and plant operations manager reported all clinical area infrastructures were in good working order (MIT 5.999). Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 44 Compliance Score Results Table 10. Health Care Environment Scored Answer Compliance Questions Yes No N/A Yes % Infection control: Are clinical health care areas appropriately disinfected, 8 0 0 100% 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 0 1 100% warranted? (5.102) Infection control: Do clinical health care areas contain operable sinks and 6 2 0 75.0% sufficient quantities of hygiene supplies? (5.103) Infection control: Does clinical health care staff adhere to universal hand 2 3 3 40.0% hygiene precautions? (5.104) Infection control: Do clinical health care areas control exposure to blood- 8 0 0 100% borne pathogens and contaminated waste? (5.105) Warehouse, conex, and other nonclinic storage areas: Does the medical supply management process adequately support the needs of the medical 1 0 0 100% health care program? (5.106) Clinical areas: Does each clinic follow adequate protocols for managing and 2 6 0 25.0% storing bulk medical supplies? (5.107) Clinical areas: Do clinic common areas and exam rooms have essential core 4 4 0 50.0% medical equipment and supplies? (5.108) Clinical areas: Are the environments in the common clinic areas conducive 8 0 0 100% to providing medical services? (5.109) Clinical areas: Are the environments in the clinic exam rooms conducive to 6 2 0 75.0% providing medical services? (5.110) Clinical areas: Are emergency medical response bags and emergency crash carts inspected and inventoried within required time frames, and do they 3 2 3 60.0% contain essential items? (5.111) Does the institution’s health care management believe that all clinical areas This is a nonscored test. Please see the have physical plant infrastructures that are sufficient to provide adequate indicator for discussion of this test. health care services? (5.999) Overall percentage (MIT 5): 75.0% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 45 Recommendations • Medical and nursing leadership should determine the root cause(s) for staff not following all required universal hand hygiene precautions and should implement remedial measures as appropriate. • Executive leadership should determine the root cause(s) for staff not following equipment and medical supply management protocols and should implement remedial measures as appropriate. • Nursing leadership should determine the root cause(s) for staff not ensuring EMRBs are regularly and properly inventoried, stocked, or sealed and should implement appropriate remedial measures. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 46 Transfers In this indicator, OIG inspectors examined the transfer process for those patients who transferred into the institution as well as for those who transferred to other institutions. For newly arrived patients, our inspectors assessed the quality of health care screenings and the continuity of provider appointments, specialist referrals, diagnostic tests, and medications. For patients who transferred out of the institution, inspectors checked whether staff reviewed patient medical records and determined the patient’s need for medical holds. They also assessed whether staff transferred patients with their medical equipment and gave correct medications before patients left. In addition, our inspectors evaluated staff performance in communicating vital health transfer information, such as preexisting health conditions, pending appointments, tests, and specialty referrals. Inspectors further confirmed whether staff sent complete medication transfer packages to receiving institutions. For patients who returned from off-site hospitals or emergency rooms, inspectors reviewed whether staff appropriately implemented recommended treatment plans, administered necessary medications, and scheduled appropriate follow-up appointments. Ratings and Results Overview Case Review Rating Compliance Rating and Score Inadequate Inadequate (74.5%) Overall, case review found SCC provided poor transfer services. Compared with Cycle 6, we found more deficiencies overall and more significant deficiencies, the majority of which occurred when patients returned from a community hospital or emergency room. SCC nurses and providers frequently did not ensure medication continuity. Additionally, nurses did not provide complete assessments and appropriate plans of care as their patients’ conditions warranted. SCC also needed improvement in obtaining hospital records and promptly scanning records into their patients’ electronic health records. When patients arrived at SCC, we identified additional opportunities for improvement in nursing documentation. The lack of documentation impacted our ability to assess the quality of patient care. Additionally, when patients transferred from SCC, nurses frequently did not assess their patients on the day of transfer and did not consistently communicate necessary information to the receiving institution. Considering all factors, the OIG rated the case review component of this indicator inadequate. Compliance testing showed SCC had a mixed performance in this indicator. The institution performed excellently in completing the assessment and disposition sections of the screening process and ensuring transfer packets for departing patients included all required documents and medications. In contrast, the institution scored low in completing initial health screening forms. The institution also needed improvement in medication continuity for newly transferred patients. Based on the overall Transfers compliance score result, the OIG rated the compliance testing component of this indicator inadequate. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 47 Case Review and Compliance Testing Results OIG clinicians reviewed 48 events in 16 cases in which patients transferred into or out of the institution or returned from an off-site hospital or emergency room.44 We identified 30 deficiencies, 10 of which were significant.45 Transfers In SCC showed mixed performance in the transfer-in process. SCC performed excellently in ensuring providers evaluated patients timely upon arriving to the institution (MIT 1.002, 95.0%). The compliance team also found receiving and release (R&R) nurses always completed the assessment and disposition section of the screening form (MIT 6.002, 100%). However, the compliance team found SCC performed poorly in thoroughly completing the initial health screening form within the required time frame (MIT 6.001, 48.0%). Of the 13 samples tested, five were due to the R&R nurses not thoroughly completing the initial health screening form. The other eight were due to the Strategic Offender Management System (SOMS) date and time stamp indicating the nursing staff completed the initial health screening after the patient transferred to their assigned housing units; under current policy, the nurse is required to assess patients before they transfer to a housing unit.46 Compliance testing also found, in two of the four eligible samples, newly arrived patients received medications one day late (MIT 6.003, 50.0%). Furthermore, when patients arrived for layover at SCC, compliance testing indicated opportunities for improvement in medication continuity (MIT 7.006, 75.0%). OIG clinicians reviewed nine events in five cases for patients who transferred into SCC from other institutions. We identified six deficiencies, one of which were significant.47 Most nursing deficiencies related to insufficiently documenting their assessment findings and patients’ plans of care. Additionally, on two occasions, R&R nurses did not document either whether the patient arrived with the keep-on-person (KOP) medications or whether they issued patients their prescribed KOP medications.48 On another occasion, a patient arrived with a pending specialist referral; the provider extended the compliance date but did not document the rationale for this decision. Further examples of transfer deficiencies are listed below: • In case 18, the patient had a feeding tube and an abdominal incision with 24 staples. The nurses did not ensure feeding tube patency and did not document the tube length. Furthermore, a nurse documented consulting a provider but did not document details of this communication, such as wound and feeding tube 44 The events occurred in cases 1, 2, 6, 12-18, and 24-29. 45 Deficiencies occurred in cases 2, 6, 12-15, 17, 18, and 24-29. Significant deficiencies occurred in cases 2, 6, 12, 13, 15, 17, 18, and 28. 46 The Strategic Offender Management System (SOMS) refers to a comprehensive framework or technology-driven platform used by law enforcement, correctional services, and criminal justice agencies to manage offenders throughout their interaction with the criminal justice system. This includes tracking, monitoring, assessing, and rehabilitating offenders with the goal of improving public safety, reducing recidivism, and ensuring effective use of resources. 47 Deficiencies occurred in cases 18, 24, 25, and 26. A significant deficiencies occurred in case 18. 48 KOP means “keep-on-person” and refers to medications that a patient can keep and self-administer according to the directions provided. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 48 care. Additionally, the nurse did not educate the patient on wound care and infection prevention measures. • In case 24, the patient transferred to SCC and was prescribed a rescue inhaler. The nurse did not assess whether the patient had the rescue inhaler on his person. Transfers Out Our clinician team found opportunities for improvement in SCC’s transfer-out process. OIG clinicians reviewed six transfer-out events within three cases and identified four deficiencies, two of which were significant.49 In two of the three cases, nurses did not evaluate their patients on the day of transfer. Also, for two of the three transferred patients, SCC did not perform a handoff to ensure continuity of specialist care. Lastly, in one of three cases, nurses did not administer required medications on the day of transfer and did not notify the receiving institution or central pharmacy staff the patient had missing essential medications. The following is an example: • In case 28, the patient transferred out of SCC. On the day of transfer, the nurse did not evaluate this patient, did not obtain the patient’s vital signs, and did not document which specific transfer requirements were met. Hospitalizations Patients returning from an off-site hospitalization or emergency room are at high risk for lapses in care quality. These patients typically experienced severe illness or injury. They require more care and place a strain on the institution’s resources. 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. SCC’s performance varied in the return process for hospitalizations and emergency room encounters. Compliance testing showed staff usually completed follow-up appointments within required time frames for patients returning from hospitalizations and emergency room encounters (MIT 1.007, 92.0%). However, both case review and compliance found opportunities for improvement in ensuring staff received and scanned hospital records into the patients’ medical records promptly (MIT 4.003, 75.0%). Compliance testing also found providers only sometimes reviewed and endorsed documents in a timely manner (MIT 4.005, 52.0%). Hospital Discharge OIG clinicians found opportunities for improvement when patients returned from a community hospital or emergency room. Deficiencies occurred when nurses did not communicate the hospital provider’s medication recommendations to SCC providers. We identified additional deficiencies in which providers or nurses initiated incorrect medication doses and did not timely reconcile medications, resulting in lapses in medication continuity. On two other occasions, nurses did not issue keep-on-person rescue inhalers. Compliance testing showed SCC performed poorly in ensuring staff made medication timely available as well as delivered or administered medications to patients within the required time frames 49 Transfer out deficiencies occurred in cases 27, 28, and 29. Significant deficiencies occurred in case 28. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 49 (MIT 7.003, 21.1%). Additional information can be found in the Medication Management indicator. OIG clinicians reviewed 33 events in 10 cases in which patients returned from off-site hospitalizations or emergency room encounters. We identified 20 deficiencies, seven of which were significant.50 The following are examples: • In case 6, the nurse assessed this patient, who returned from a fire camp, after an emergency room encounter with a diagnosis of Influenza A (requiring quarantine). The patient complained of moderately severe throat pain, had an elevated pulse rate and a moderately low oxygen saturation reading, and exhibited abnormal lung sounds upon auscultation. The community hospital emergency room discharge recommendations indicated the patient should take a full course of an antibiotic for four days and have an albuterol inhaler to use “at least” four times daily. Though the nurse correctly documented the patient did not arrive with medications, the nurse did not issue an albuterol inhaler. Moreover, the nurse incorrectly initiated the order to use the inhaler “as needed,” instead of directing the patient to use the inhaler four times per day as recommended. • In case 15, the nurse assessed the patient after a hospital admission for congestive heart failure, acute respiratory failure, and atrial flutter.51 During the hospital admission, the patient was found to have fluid overload and required diuresis to remove the fluid; however, the nurse did not obtain the patient’s weight and did not document the rationale for not issuing the newly recommended rescue inhaler. Clinician On-Site Inspection SCC’s R&R department was staffed with an RN on each shift, excluding weekends and holidays. The R&R nurse indicated an average of 300 patients arrived at SCC and 360 patients departed monthly. The R&R nurse explained, on Thursdays, custody staff emailed R&R nurses a list of persons scheduled to transfer from SCC. The R&R nurses would review each patient’s medical record for pending orders, including orders that would prevent patients from transferring. The nurse also indicated the R&R nurses tried to assess the patients the day before their scheduled transfer date to assess vital signs, screen for infectious disease symptoms, and reconcile prescribed KOP medications and durable medical equipment (DME). The nurse also indicated sometimes they collected patient’s KOP medications, and other times they allowed patients to keep medications when doses would be due prior to the transfer. The nurse shared, when patients were missing medications, the R&R nurses would inform the receiving institution by email, and the patients were instructed to submit a sick call request to obtain their missing medications at the new institution. Additionally, the nurse indicated they would consult with a provider when a patient’s essential medications were missing. 50 Patients returned from a hospitalization or emergency room encounters occurred in cases 1, 2, 6, 12-18. Deficiencies occurred in cases 2, 6, 12-15, 17, and 18. A significant deficiency occurred in cases 2, 6, 12, 13, 15, and 17. 51 Atrial flutter is a type of abnormal heart rhythm where the heart beats too fast. This fast heart rhythm can lead to symptoms of palpitations, fatigue or dizziness. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 50 The CNE indicated, when patients transferred out from SCC, R&R nurses were only expected to review the patients’ active orders; the nurses were not expected to perform a chart review. The CNE also indicated the nursing supervisors were not expected to formally evaluate the R&R nurses’ performance. Instead, they performed random R&R audits; however, SCC could not provide documentation of these audits. The CNE explained she did not review the context of this information and indicated she planned to implement a formal audit to assess nursing quality for the transfer-out process. Compliance On-Site Inspection and Discussion R&R nursing staff ensured all seven applicable patients transferring out of the institution had their required medications, transfer documents, and assigned DME (MIT 6.101, 100%). Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 51 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 12 13 0 48.0% 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 17 0 8 100% 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 2 2 21 50.0% 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 7 0 3 100% required documents? (6.101) Overall percentage (MIT 6): 74.5% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 52 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 19 1 5 95.0% 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 23 2 0 92.0% 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? 15 5 5 75.0% (4.003) For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements and did a provider 13 12 0 52.0% 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 4 15 6 21.1% within required time frames? (7.003) Upon the patient’s transfer from one housing unit to another: Were 25 0 0 100% medications continued without interruption? (7.005) For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications 3 1 0 75.0% 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 8 5 0 61.5% institution, was the appointment scheduled at the receiving institution within the required time frames? (14.010) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 53 Recommendations • Nursing leadership should develop and implement strategies, such as internal staff auditing, to ensure assessments are complete and thorough for patients who transfer in, transfer out, or return from the hospital or emergency room. • Medical and nursing leadership should develop and implement a process between nursing and providers to ensure they promptly review all hospital discharge recommendations and timely place orders. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 54 Medication Management In this indicator, OIG inspectors evaluated the institution’s performance in administering prescription medications on time and without interruption. The inspectors examined this process from the time a provider prescribed medication until the nurse administered the medication to the patient. In addition to examining medication administration, our compliance inspectors also tested many other processes, including medication handling, storage, error reporting, and other pharmacy processes. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Inadequate (59.9%) In this cycle, case review found SCC usually provided sufficient medication management to the patients housed at SCC; however, the clinicians’ case review samples did not include patients assigned to fire camp areas. Consequently, the case review results were entirely determined from patients housed at SCC. Although the case review process occasionally identified opportunities for improvement in chronic care medication continuity, the OIG clinicians found nurses performed well with issuing and administering prescribed medications to patients. Compared with Cycle 6, we identified fewer overall deficiencies. Considering all factors, the OIG rated the case review component of this indicator adequate. Compliance testing showed SCC needed improvement in providing medication management services. SCC performed poorly in providing patients with chronic care medications, newly ordered medications, transfer-in medications, and community hospital discharge medications. Compliance testing also identified opportunities for improvement in ensuring medication continuity for patients laying over at SCC. Based on the overall Medication Management compliance score result, the OIG rated the compliance testing component of this indicator inadequate. Case Review and Compliance Testing Results We reviewed 112 events in 26 cases related to medications and found 19 medication deficiencies, seven of which were significant.52 New Medication Prescriptions Compliance testing revealed newly prescribed medications were either not available or not timely administered (MIT 7.002, 44.0%). In contrast, case review found only two cases in which newly prescribed medications were not issued or administered to patients as ordered. An example is detailed below: 52 Deficiencies occurred in cases 8, 11-15, 17, 18, and 23. Significant deficiencies occurred in cases 8, 11, 12, 13, and 15. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 55 • In case 8, the patient was to begin new dosages of two medications for diabetes; however, the patient never received those medications as ordered, and the medication dosage was adjusted again a few weeks later. Chronic Medication Continuity Compliance testing revealed medications were only occasionally available and issued to patients within the required time frames (MIT 7.001, 18.8%). OIG clinicians found four cases in which patients did not timely receive chronic care medications or did not receive them at all.53 An example is listed below. • In case 11, medication continuity was interrupted when the patient did not receive a one-month supply of chronic care blood pressure medication in the month of April. Hospital Discharge Medications OIG clinicians found opportunities for improvement in medication continuity when patients returned from a community hospital or emergency room. Please refer to the Transfers indicator for additional details. Compliance testing showed SCC performed poorly in ensuring staff administered, made available, and delivered medications to patients within the required time frames (MIT 7.003, 21.1%). Transfer Medications Compliance testing showed SCC performed excellently in ensuring patients who transferred from yard to yard received their medications timely (MIT 7.005, 100%), and patients leaving the institution had appropriate medications in their transfer envelopes (MIT 6.101, 100%). In contrast, case review found opportunities for improvement when receiving and release (R&R) nurses did not administer essential medications before a patient’s transfer and did not inform the receiving institution or pharmacy of the patient’s missing medications. Compliance testing showed patients at SCC on layover inconsistently received their medications (MIT 7.006, 75.0%). Furthermore, compliance tests found staff maintained medication continuity for only half of newly arrived patients (MIT 6.003, 50.0%). Similarly, OIG clinicians found, when patients had an existing order for a rescue inhaler, the R&R nurse did not confirm whether the patients had their inhalers on their person and did not issue the patients new inhalers. Additional information can be found in the Transfers indicator. Medication Administration Compliance testing showed nurses performed excellently in administering tuberculosis (TB) medications within required time frames (MIT 9.001, 100%). OIG clinicians did not have any 53 Patients received untimely chronic care medications in cases 8, 11, 13, and 15. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 56 case review samples with events related to TB medications. OIG clinicians found nurses performed well overall in administering prescribed medications. Clinician On-Site Inspection During the on-site inspection, OIG clinicians met with the pharmacist in charge (PIC) and discussed both specific patients and pharmacy operations, including medication distribution to the 31 fire camps throughout California. The PIC explained the SCC pharmacy along with the A yard nursing staff were responsible for camp medication distribution. The PIC indicated most of the fire camp patients’ medications were filled through CCHCS’s central fill pharmacy and delivered to the SCC pharmacy, which accepted the medications. The pharmacy staff then delivered the camp patients’ medications to the A facility nurse. This nurse made a copy of the medication administration record (MAR) to later reconcile when the patients received their medications. Once per week, an internal transportation courier obtained the medications and the corresponding MAR, and delivered them to the patients’ assigned camps. Custody staff at the fire camps issued the patients their medications and instructed the patients to sign the MAR. Custody staff was then responsible to fax the signed MAR to the A facility medication area, where the LVN could then reconcile the signed MAR and document the medication was administered on the MAR in EHRS.54 Staff later scanned the MAR into the patient’s medical record. In the event the patient was not at the fire camp and was deployed to an active fire, the medications were returned to the SCC pharmacy utilizing the transportation courier system. The PIC explained the pharmacy staff did not inform the A facility nurse of the returned medications, which the A yard nurse confirmed during interview. The LVN indicated, when they did not receive a signed MAR, the nurses continued to contact the fire camp’s custody staff by telephone until they received a signed MAR. The clinicians also learned pharmacy staff did not attempt to reissue these returned medications. Instead, actively deployed patients were required to utilize the sick call process to request a medication refill. However, when camp patients returned to the fire camp from the emergency room or urgent care and required medications urgently, SCC had a system in place allowing pharmacists located near the fire camps to fill the prescriptions. OIG clinicians also went to the C facility medication administration area, which was located in the medical clinic. The medication administration area was staffed with two LVNs during the morning shift and three LVNs during the afternoon shift. An LVN informed the clinicians how they distributed work: one LVN completed the daily diabetic line and the weekly “Ozempic” line, while the other LVN would administer and issue KOP medications. The nurse indicated pharmacy staff delivered medications two to three times each business day. The nurses prepared a KOP pick-up list, which they posted in the medication administration window, in the dining hall, and in the housing units. The LVN explained patients could pick up their KOP medication at any time during the morning and afternoon shifts. If the patients did not pick up or refused their KOP medications, the LVN would educate the patient at the window or refer the patient to the LVN care coordinator for further education. 54 EHRS is the Electronic Health Records System. The department’s electronic health record system is used for storing the patient’s medical history. The health care staff use the system to communicate. This record stays with the patient throughout the patient’s time in department’s correctional system. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 57 Medication Practices and Storage Controls The institution adequately stored and secured narcotic medications in all of eight applicable clinic and medication line locations (MIT 7.101, 100%). SCC appropriately stored and secured nonnarcotic medications in only three of eight applicable clinic and medication line locations (MIT 7.102, 37.5%). In five locations, we observed one or more of the following deficiencies: nurses did not maintain unissued medication in its original labeled packaging; the medication storage area was disorganized; the treatment cart log was missing daily security check entries; and the medication nurse did not follow the process in place to return medications with an expired pharmacy label that can be potentially restocked and reissued by the pharmacy. Staff kept medications protected from physical, chemical, and temperature contamination in six of the eight applicable clinic and medication line locations (MIT 7.103, 75.0%). In one location, staff stored medication with cleaning materials, and the medication refrigerator was unsanitary. In the other location, staff did not separate the storage of oral and topical medications. Staff successfully stored valid, unexpired medications in six of the eight applicable medication line locations (MIT 7.104, 75.0%). In two locations, we found expired medications. Nurses exercised proper hand hygiene and contamination control protocols in only two of seven applicable locations (MIT 7.105, 28.6%). In the remaining five locations, nurses neglected to wash or sanitize their hands when required, such as before applying gloves or before each subsequent re-gloving. Staff in all medication preparation and administration areas showed appropriate administrative controls and protocols when preparing medications for patients (MIT 7.106, 100%). Staff in three of seven applicable medication areas used appropriate administrative controls and protocols when distributing medications to their patients (MIT 7.107, 42.9%). In three clinics, we observed a medication nurse who did not follow the CCHCS care guide when administering Suboxone medication. In the remaining clinic, medication nurses did not reliably observe patients while they swallowed direct observation therapy medications, and we observed medication nurses who did not properly disinfect the vial’s port prior to withdrawing medication. Pharmacy Protocols SCC followed general security, organization, and cleanliness management protocols in its pharmacy (MIT 7.108, 100%). In its pharmacy, staff did not properly store nonrefrigerated medication (MIT 7.109, zero). We found the following deficiencies: unorganized medications, an inaccurately labeled medication storage bin, and bulk food stored long-term within the medication area. The institution did not properly store refrigerated or frozen medications in its pharmacy (MIT 7.110, zero). We found an unsanitary medication refrigerator. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 58 The PIC correctly accounted for narcotic medications stored in SCC’s pharmacy (MIT 7.111, 100%). We examined nine 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 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 SCC, the OIG did not find any applicable medication errors (MIT 7.998). The OIG interviewed patients in restricted housing unit to determine whether they had immediate access to their prescribed asthma rescue inhalers or nitroglycerin medications. All 10 applicable patients we interviewed indicated they had access to their rescue medications (MIT 7.999). Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 59 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 3 13 9 18.8% 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 11 14 0 44.0% 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 4 15 6 21.1% required time frames? (7.003) For patients received from a county jail: Were all medications ordered by the institution’s reception center provider administered, made available, or delivered to N/A N/A N/A N/A the patient within the required time frames? (7.004) Upon the patient’s transfer from one housing unit to another: Were medications 25 0 0 100% continued without interruption? (7.005) For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications administered or delivered 3 1 0 75.0% 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 8 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 3 5 3 37.5% 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 2 3 75.0% the assigned storage areas? (7.103) All clinical and medication line storage areas for nonnarcotic medications: Does the institution safely store nonnarcotic medications that have yet to expire in the 6 2 3 75.0% assigned storage areas? (7.104) Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols during medication preparation and 2 5 4 28.6% 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 4 100% patients? (7.106) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when administering medications 3 4 4 42.9% to patients? (7.107) Pharmacy: Does the institution employ and follow general security, organization, and 1 0 0 100% cleanliness management protocols in its main and remote pharmacies? (7.108) Pharmacy: Does the institution’s pharmacy properly store nonrefrigerated 0 1 0 0 medications? (7.109) Pharmacy: Does the institution’s pharmacy properly store refrigerated or frozen 0 1 0 0 medications? (7.110) Pharmacy: Does the institution’s pharmacy properly account for narcotic 1 0 0 100% medications? (7.111) Pharmacy: Does the institution follow key medication error reporting protocols? 9 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): 59.9% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 60 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 2 2 21 50.0% 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 7 0 3 100% required documents? (6.101) Patients prescribed TB medication: Did the institution administer the 25 0 0 100% medication to the patient as prescribed? (9.001) Patients prescribed TB medication: Did the institution monitor the patient per policy for the most recent three months he or she was on the 24 1 0 96.0% medication? (9.002) Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient N/A N/A N/A N/A within required time frames? (13.003) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 61 Recommendations • SCC leadership should develop and implement measures to ensure the fire camp patients receive all medications without delay and ensure pharmacy staff communicate with nurses when medications are returned to the institution. Leadership should implement remedial measures as appropriate. • SCC leadership should determine the challenges to providing medication continuity for patients with chronic care medications, newly ordered medications, transfer-in medications, and community hospital discharge medications. Leadership should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 62 Preventive Services In this indicator, OIG compliance inspectors tested whether the institution offered or provided cancer screenings, tuberculosis (TB) screenings, influenza vaccines, and other immunizations. If the department designated the institution as being at high risk for coccidioidomycosis (Valley Fever), we tested the institution’s performance in transferring patients out quickly. The OIG rated this indicator solely according to the compliance score. Our case review clinicians do not rate this indicator. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Adequate (84.7%) SCC performed well overall in this indicator. Staff performed excellently in administering TB medications to patients as prescribed, monitoring patients taking 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, staff needed improvement in screening patients annually for TB. In addition, they performed poorly in offering required immunizations to chronic care patients. These findings are set forth in the table on the next page. Based on the overall Preventive Services compliance score result, the OIG rated this indicator adequate. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 63 Compliance Score Results Table 15. Preventive Services Scored Answer Compliance Questions Yes No N/A Yes % Patients prescribed TB medication: Did the institution administer the 25 0 0 100% medication to the patient as prescribed? (9.001) Patients prescribed TB medication: Did the institution monitor the patient per policy for the most recent three months he or she was on the 24 1 0 96.0% medication? (9.002) Annual TB screening: Was the patient screened for TB within the last year? 17 8 0 68.0% (9.003) Were all patients offered an influenza vaccination for the most recent 25 0 0 100% influenza season? (9.004) All patients from the age of 45 through the age of 75: Was the patient 25 0 0 100% offered colorectal cancer screening? (9.005) Female patients from the age of 50 through the age of 74: Was the patient N/A N/A N/A N/A offered a mammogram in compliance with policy? (9.006) Female patients from the age of 21 through the age of 65: Was patient N/A N/A N/A N/A offered a pap smear in compliance with policy? (9.007) Are required immunizations being offered for chronic care patients? (9.008) 4 5 16 44.4% Are patients at the highest risk of coccidioidomycosis (Valley Fever) N/A N/A N/A N/A infection transferred out of the facility in a timely manner? (9.009) Overall percentage (MIT 9): 84.7% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 64 Recommendations • Health care leadership should determine the root cause(s) for challenges to timely providing immunizations to chronic care patients and should implement appropriate remedial measures. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 65 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 Inadequate Not Applicable In Cycle 7, case review found SCC’s nursing performance declined. Compared with Cycle 6, SCC nurses’ overall deficiencies and significant deficiencies both increased. OIG clinicians found medication management was a relative strength, as most nurses administered medication as prescribed. However, OIG clinicians also identified reoccurring patterns in outpatient assessments, emergency care, documentation, and care coordination. Common deficiencies included incomplete nursing assessments, delayed or absent provider consultations, and inadequate documentation of patient symptoms and clinical findings. We cited specific concerns regarding missing same-day evaluations of urgent sick call complaints, poor wound care documentation, and gaps in continuity of care when patients returned from a community hospital or emergency room, transferred into or out of SCC, or returned from an off-site specialist appointment. These findings reflect systemic challenges in clinical decision making, communication, and comprehensive documentation that may compromise patient safety and care quality. In addition, SCC’s nursing leadership did not identify opportunities for improvement and did not have sufficient mechanisms in place to monitor the quality of nurses’ clinical performances. The OIG rated the case review component of this indicator inadequate. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 66 Case Review Results We reviewed 158 nursing encounters in 38 cases. Of the nursing encounters we reviewed, 67 were in the outpatient setting, and 50 were sick call requests. We identified 90 nursing performance deficiencies, 21 of which were significant.55 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. Nurses needed improvement in their assessments, interventions, and plans of care. OIG clinicians identified 41 outpatient nursing deficiencies, eight of which were significant.56 These deficiencies occurred when nurses performed sick call triage and did not arrange a next business day appointment when the patient had symptoms. The nurses also did not arrange a same day appointment when the patient’s symptoms warranted. Additionally, nurses’ assessments were frequently incomplete, and nurses inconsistently consulted a provider when their patients condition warranted. Examples are listed in the following cases: • In cases 6, 15, 32, 35, 39, 40, and 41, nurses assessed these patients but did not obtain complete vital signs. • In case 11, the nurse reviewed a sick call complaint for chest and back pains. Considering the patient’s medical history, high risk medical status, and complaints, the nurse should have assessed the patient the same day but instead arranged an appointment for the next day. • In case 15, on a Sunday, a nurse had concerns when a heart failure patient in the housing unit had increased shortness of breath and was unable to ambulate to the medication line due to difficulty breathing. The nurse also documented concerns the patient had fluid overload.57 However, instead of promptly consulting a provider, the nurse sent a message in the EHRS to the provider and care team. Additionally, the nurse did not obtain the patient’s vital signs or listen to lung sounds and did not subjectively assess the patient’s KOP medication compliance. • In case 18, the nurse triaged the sick call request in which this patient reported diarrhea, fatigue, and vomiting blood. The nurse did not initiate a nursing appointment during the review period for these sick call complaints. We identified similar deficiencies in cases 10, 11, and 14. 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’ 55 Deficiencies occurred in cases 1-4, 6, 10-15, 17, 18, 21, 24-37, and 39-41. Significant deficiencies occurred in cases 2-4, 6, 11, 13, 15, 18, 21, 28, 35, and 37. 56 Deficiencies occurred in cases 1, 2, 6, 10-15, 18, 21, 30-37, 39, 40, and 41. Significant deficiencies occurred in cases 2, 11, 15, 18, 35, and 37. 57 Fluid overload occurs when there is excess fluid in the body, which may lead to swelling, high blood pressure, or other medical complications. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 67 conditions. Nurses sometimes documented care thoroughly; however, examples of opportunities for improvement are listed below: • In case 34, a sick call nurse assessed a patient with a back rash. The nurse did not document the rash appearance. • In case 39, the nurse assessed the patient for arm numbness, but the nurse did not document whether the numbness was in the right or left arm. Wound Care We reviewed four cases in which patients had wounds and required wound care.58 We identified opportunities for improvement in each of these cases. In all four cases, nurses did not provide thorough descriptions of the wounds. In two cases, the nurses did not consult a provider when warranted. An example of poor nursing assessment and documentation is listed below: • In case 18, an RN assessed this patient who had an abdominal incision and a gastric tube.59 The gastric tube stoma was red and had drainage. The nurse did not assess when the redness and drainage began and did not document the amount of drainage. Emergency Services We reviewed 40 urgent or emergent events, we identified 24 nursing deficiencies, six of which were significant.60 Nurses responded promptly to emergent events. We identified a pattern in which nurses did not intervene sufficiently in emergencies, which we detail further in the Emergency Services indicator. The following are examples: • In case 6, an LVN requested a TTA RN when the patient had difficulty breathing; however, the LVN did not obtain the patient’s respiratory rate, oxygen saturation level, or any other vital signs. • Also in case 6, when the TTA RN arrived, the patient’s oxygen saturation result was significantly low, breathing was irregular, and the patient had an elevated pulse. The RN initiated oxygen; however, the RN did not increase the rate of oxygen administration to maintain an adequate oxygen saturation level. Additionally, the RN did not place the patient in a position to promote oxygenation and did not sufficiently monitor the patient’s vital signs. Hospital Returns We reviewed 18 nursing events in nine cases that involved returns from off-site hospitals or emergency rooms. We identified 10 nursing deficiencies, three of which were significant.61 58 Wound care occurred in cases 14, 17, 18, and 21. 59 A gastric tube, often called a G-tube, is a soft, flexible tube inserted into the stomach, which is used deliver food, fluids, and medication to someone who cannot swallow or eat safely by mouth. 60 Nursing deficiencies occurred in cases 2-4, 6, 11-13, 15, and 17. Significant deficiencies occurred in cases 2-4, 6, 13, and 15. 61Deficiencies occurred in cases 6, 12-15, 17, and 18. Significant deficiencies occurred in cases 6, 13, and 15. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 68 Nurses performed poorly in providing thorough assessments and interventions, which we detailed further in the Transfers indicator. The following are examples: • In case 12, this patient returned to SCC after a hospital admission for rectal bleeding, anemia, and ulcerative colitis. The patient had abdominal pain; however, the nurse did not describe the patient’s abdominal appearance and did not palpate the abdomen for tenderness. • In case 13, this patient with a history of a stroke returned to SCC after a community emergency room encounter. The emergency room provider indicated the patient should have been taking a daily blood thinner; however, the patient’s order for the blood thinner had expired nine days prior. The nurse did not consult the provider to obtain an order for this essential medication. Transfers We reviewed eight cases involving transfer-in and transfer-out processes and identified seven nursing performance deficiencies, two of which were significant and are detailed further in the Transfers indicator. The following is an example: • In case 29, the patient transferred from SCC. The nurse did not communicate to the receiving facility the patient’s pending endocrinology referral. Also, on the day of transfer, the nurse did not document assessing the patient. Specialty Services We reviewed 23 events within seven cases in which patients returned after specialty procedures or consultations. We identified seven deficiencies, two of which were significant.62 OIG clinicians found opportunities for improvement when nurses either did not initiate provider follow-ups at all or did not initiate a provider follow-up within the required time frame. Please refer to the Specialty Services indicator for additional details. Medication Management OIG clinicians reviewed 112 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 on-site inspection, the OIG clinicians met with nursing staff, supervisors, and the CNE. While touring the various medical areas, we interviewed nurses and medical staff. OIG clinicians inquired about various systems in place to ensure patient care continuity. OIG clinicians attended huddles in both A/B yard and C yard medical clinics. The medical assistants (MAs) conducted the shared huddle in the A/B yard medical clinic, while an LVN care coordinator and an MA conducted the C yard medical clinic huddle. Both clinics’ presenters utilized the pre-populated standardized huddle reports and did not present patient specific information. Instead, they only reported the number of patients for each 62 Deficiencies occurred in cases 12, 13, 15, 18, and 21. Significant deficiencies occurred in cases 13 and 21. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 69 topic of the huddle. These huddles were conducted rapidly and the sections with patients warranting possible action or discussion were not addressed. The TTA nursing staff reported discussing patients returning from a routine specialty service appointment at the morning huddles to determine whether a follow-up was clinically necessary. However, the OIG clinicians observed the care teams did not discuss whether patients returning from specialty appointments needed follow-up appointments in any of the huddles. After the A/B yard medical clinic huddle, the OIG clinicians inquired about a few of the patients listed on the huddle report whose cases warranted clarity or who may have required a care team follow- up. After discussion with the care team, OIG clinicians found the care team was not knowledgeable regarding their patient population, despite reviewing the EHRS. Please refer to the Access to Care indicator for further details. OIG clinicians learned the C facility housed medium- and high-risk patients, including those requiring mental health services and those in restrictive housing units. In the A/B facility, the population consisted of patients who hoped to attend a fire camp. The clinicians interviewed a supervising registered nurse (SRN). The SRN reported conducting monthly RN sick call audits, which consisted of auditing five patients who the sick call RN had scheduled and assessed. The SRN indicated the audit was only conducted for the one primary care RN; therefore, the audit did not include all RNs performing sick calls. During OIG clinicians’ inspection, the clinicians interviewed an LVN care coordinator who had been in this position for the past two years. The LVN shared she had received no formal training for the role, relying instead on peer learning and self-initiated processes. SCC medical staff and leadership shared information about their fire camps. The clinicians learned a large percent of SCC patients resided in 31 fire camps throughout California, including incarcerated persons who were trained in firefighting skills or other needed functions at the camp, such as cooks and grounds maintenance workers. Although a majority of this population were considered “healthy,” SCC medical leadership indicated these patients could access health care and request medication refills utilizing the sick call process. OIG clinicians asked various medical staff specific details about how SCC RNs received patients’ sick call requests; however, the responses were inconsistent. Some staff indicated the camp custody staff collected the requests, which they picked up weekly and transported by vehicle to SCC. Once at the institution, these staff indicated the camp custody staff would drop off the requests to the SCC mail room or the SRN office or a medical clinic. Other staff, however, stated camp custody sometimes faxed or emailed requests to the TTA nurses or to the A yard LVNs managed medication refills. OIG clinicians also inquired whether the public health nurse (PHN) was involved in addressing ongoing public health or communicable disease concerns that occurred within the fire camps. The PHN and infection control nurse both reported they were not involved with the fire camps, other than ensuring patients’ immunizations met the fire camp. OIG clinicians also learned about SCC’s medical emergency response team (MERT). This team was led by an SRN, who ensured medical supplies and staff were always prepared to deploy. SCC’s MERT team was composed of a medical provider and nursing staff members who traveled to the staging area of wildfires to care for both incarcerated and community fire fighters. When this occurred, SCC’s medical and nursing staff who remained at the institution would cover the vacated positions. OIG clinicians met with the CNE and discussed specific patient questions as well as SCC’s missions and operations. The CNE, who had been in this role at SCC for two years, indicated SCC did not currently have a formal process to evaluate the quality of nursing care. In addition, SCC did not have a process to proactively identify areas of improvement other than Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 70 its emergency medical response (EMR) clinical review process when patients had an unscheduled transfer to a higher level of care. After researching patient-specific questions the OIG clinicians presented, the CNE acknowledged SCC nursing areas needed improvements. The CNE hoped CCHCS’s quality management team would assist SCC in developing processes to monitor and improve nursing performance. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 71 Recommendations • Nursing leadership should identify the challenges preventing SCC nurses from performing complete assessments and interventions and should implement remedial measures as appropriate. • Nursing leadership should develop and implement strategies, such as sick call audits, to ensure supervisors evaluate the nursing triage process to confirm the nurses properly assess patients’ requests and schedule patients with urgent or emergent symptoms in an appropriate time frame. Leadership should implement remedial measures as appropriate. • SCC nursing and medical leadership should develop strategies to ensure primary care huddles are thorough and comprehensive, and the care teams address all pending or unresolved items. Leadership should implement remedial measures as appropriate and educate all medical staff on proper huddle expectations. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 72 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 Inadequate Not Applicable Case review found SCC providers delivered overall poor care, declining significantly since Cycle 6. During Cycle 7, the number of provider deficiencies doubled and the number of significant deficiencies increased from two to 35. Nine of the 20 cases we reviewed were inadequate in Cycle 7 versus only two in Cycle 6. Deficiencies and errors increased as the patients were more medically complex or had unusual presentations. We found poor provider assessment, decision making, and lapses in medical chart review in multiple cases. In addition, providers periodically ordered specialty service referrals with priority time frames that were not appropriate for the patients’ medical conditions. While documentation was generally complete, we found missing progress notes for important events. Providers usually sent patient test notification letters, but the letters did not always contain all required components. On a positive note, providers usually timely endorsed diagnostic reports, off-site specialty reports, hospital reports, and laboratory reports. After careful consideration of all factors, the OIG rated this indicator inadequate. Case Review Results OIG clinicians reviewed 119 medical provider encounters and identified 111 deficiencies, 35 of which were significant.63 In addition, we examined the quality of care in 20 comprehensive case reviews. Of these 20 cases, we found 11 adequate and nine inadequate, primarily due to poor provider performance. Outpatient Assessment and Decision-Making Providers’ performance with appropriate assessments and decision making varied. OIG clinicians identified 49 outpatient provider assessment and decision-making deficiencies, 20 of which were significant.64 Poor decision making related more to the degree of patient medical complexity than to any particular provider, although some providers had more 63 Deficiencies occurred in cases 1-2, 6-23, 26, and 28. Significant deficiencies occurred in cases 2, 6, 8, 11-13, 15, 17-18, 20-21, and 23. 64 Deficiencies occurred in cases 2, 6-9, and 11-23. Significant deficiencies occurred in cases 2, 6, 8, 11-13, 15, 17, 18, 20-21, and 23. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 73 deficiencies than others. We found deficiencies with not addressing abnormal vital signs, not ordering follow-up appointments or not ordering them timely, poor physical exams, errors in diagnoses, and allowing critical medications to expire. The following are examples of significant deficiencies: • In case 2, the provider erroneously documented the patient had a history of atrial fibrillation, both in the patient’s medical record and with a recent echocardiogram.65 However, the medical record actually contained no prior objective evidence or medical history of atrial fibrillation. The echocardiogram also showed no atrial fibrillation. Based on this error, the provider ordered a cardiology specialty follow-up to determine whether the patient needed cardioversion or anticoagulation medication. Both of these carry significant medical risks. This error and inaccurate diagnosis would have not only caused the patient distress but may have subjected him to unnecessary treatments and procedures. • Also in case 2, two months later the provider evaluated the patient for hospital follow-up for chest pain, thrombolytic therapy, and cardiac catheterization.66 In this post-hospital evaluation, the provider documented not having received hospital documentation but noted the patient mentioned having 55 percent coronary blockage. Despite not having the hospital documentation, the provider added coronary artery disease (CAD) to this patient’s medical problem list without confirmation and without knowing the patient had misunderstood his hospital diagnosis. Three days later, the provider reviewed and endorsed the associated hospital reports, which clearly documented the patient did not have significant coronary artery disease by cardiac catheterization. However, the provider did not recognize the discrepancy, did not clarify the error to the patient, and did not correct the diagnosis or problem in the patient’s chart. The provider continued her misdiagnoses of atrial fibrillation and coronary artery disease in this relatively healthy patient throughout the review period. The patient paroled to the community believing he had two significant cardiac conditions that he, in fact, did not have. • In case 12, the patient underwent a colonoscopy, which confirmed a significant diagnosis of colitis and proctitis, and the specialist recommended starting the patient on important medications.67 Upon the patient’s return to SCC, the on-call provider ordered the recommended medications and provider follow-up appointment to occur in 14 days. On the appointment day, the provider did not see the patient but reviewed the colonoscopy report, documented an out-to- medical return progress note, and closed the appointment as completed despite not having seen the patient. Due to the significance of the colonoscopy findings and the importance of medication compliance, the provider should have seen the patient and should not have marked the appointment as completed when the patient was not seen. Ten days later, the patient was transferred to the hospital for rectal bleeding and severe anemia due to colitis, which may have 65 An echocardiogram is a procedure using an ultrasound to examine and image the heart. 66 Thrombolytic therapy is the use of medications to dissolve blood clots inside blood vessels to restore blood flow. Cardiac catheterization is a medical procedure used to diagnose and treat heart blood vessel blockages. 67 Colitis is irritation or swelling of the lining of the colon. Proctitis is irritation or swelling of the lining of the rectum. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 74 been prevented had the provider seen the patient and discussed the treatment plan. • Also in case 12, one month after the above hospitalization, the provider allowed this patient’s only ulcerative colitis medication to expire. The medication is used to control the inflammation, helping to reduce bleeding. This medication lapse contributed to a four-day hospitalization another month later for a significant rectal ulcerative colitis flair and severe anemia, requiring blood transfusions. The patient’s suffering and the hospitalization may have been preventable had the provider ensured the continuity of this patient’s medication. • In case 17, the provider evaluated this patient with a history of removal of a portion of the small intestines for blockage and intussusception.68 The patient’s blood pressure was critically low and oxygen saturation abnormal; however, the provider did not address either of these abnormal vital signs. Two weeks later, the patient was hospitalized in the ICU for heart failure, sepsis, and other conditions. Again, this may have been prevented had the provider taken steps to further address the abnormal vital signs at the appointment two weeks prior. Review of Records Providers frequently reviewed records appropriately; however, we found nine errors, one of which was significant.69 Most of these errors involved provider review of current treatment plans and pertinent medical histories. Inappropriate record review can lead to medical errors, as follows: • In case 11, the patient’s diabetes was not well controlled. On two separate occasions, the provider did not thoroughly review the patient’s medication administration record and, as a result, inaccurately documented the patient’s uncontrolled diabetes was due to frequent medication refusals when the patient was actually medication compliant. The provider also did not adjust an important diabetes medication that would have improved the patient’s diabetes. • In case 21, the provider evaluated the patient to follow up on a recurrent neck abscess.70 The patient had developed new lesions while taking the antibiotic, clindamycin, indicating the medication was not effective. However, the provider did not adequately review the record, so the provider was unaware the patient had completed the antibiotic course three days prior. The provider also did not acknowledge the antibiotic was not helping. As a result, the provider simply ordered the patient to complete the clindamycin course instead of starting a more effective antibiotic or culturing the draining wounds. Fourteen days later, the patient was transferred to the hospital for worsening infection, which may have been preventable. 68 Intussusception is a medical emergency in which a portion of the intestine slides over another portion, creating a telescoping effect. 69 Deficiencies occurred in cases 2, 11, 15, 18, 21, and 22. A significant deficiency occurred in case 21. 70 An abscess is a localized collection of pus, usually caused by a bacterial infection. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 75 Emergency Care Providers performed poorly in provider emergency care. OIG clinicians reviewed 40 emergency events and identified 21 deficiencies, seven of which were significant. Thirteen of the 21 deficiencies related to poor provider assessment and decision making, five of which were significant.71 In addition, providers did not always complete documentation. We discussed this further in the Emergency Services indicator. Chronic Care Providers performed sufficiently in managing stable, noncomplex patients who had typical presentations of common chronic medical conditions, such as hypertension, diabetes, and asthma. Providers needed improvement in appropriately managing patients with unusual presentations or multiple medical problems. OIG clinicians reviewed 24 provider events involving chronic care and identified 16 deficiencies, four of which were significant as follows:72 • In case 12, the patient with chronic parathyroid disorder and colitis had rectal bleeding and, eventually, inflammation and bleeding of the colon that required medication and close monitoring.73 When the patient’s blood counts dropped, indicating the patient continued to bleed, the provider did not see the patient but instead ordered a blood test to be completed in two weeks. The patient was hospitalized three days later, at which time the patient required blood transfusions. • Also in case 12, after this hospitalization, the patient submitted a sick call slip for symptoms of heavy bleeding from the rectum, and being thirsty, weak, and pale. The RN scheduled an appointment, but the patient refused. Additionally, an important medication for his colitis had expired. A few days later, the provider evaluated the patient but only addressed the patient’s POLST.74 The provider did not address the patient’s expired medication and did not address the patient’s complaints of worsening symptoms. The patient’s condition continued to worsen, and about two weeks later, the patient was hospitalized again. • In case 15, the patient suffered from congestive heart failure and his health continued to worsen. On at least two separate occasions, the providers did not perform appropriate physical examinations or widen the differential diagnosis to include other conditions that could be causing the patient’s deterioration. • In case 20, the provider started the patient on lisinopril for chronic kidney disease.75 For at least six months, the provider did not reassess the patient’s 71 Emergency related deficiencies occurred in cases 2, 11-12, 15, 17-18, 20-21 and 23. Significant deficiencies occurred in cases 2, 15, 17 and 20. 72 Deficiencies in chronic care occurred in cases 1, 2, 7-8, 11, 16, 20 and 22. Three significant deficiencies occurred in cases 8, 11 and 20. 73 Colitis is a medication condition of the intestines with inflammation, pain, and bleeding. 74 POLST, also known as Physicians Order for Life Sustaining Treatment, is a form used to specify health care treatments during a medical emergency or end-of-life care. 75 Lisinopril is a blood pressure medication. It can adversely affect the kidneys and increase potassium levels. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 76 compliance with lisinopril, assess for side effects, or document review of follow- up blood pressure readings. The most frequent chronic care diagnosis was substance use disorder in patients on medication assisted treatment (MAT). The headquarters ISUDT team often managed these cases; however, due to frequent ISUDT team delays, the SCC providers also managed MAT. Please see the Clinician On-site section below for further discussion on ISUDT and patient population details. Specialty Services OIG clinicians identified 21 provider performance deficiencies related to specialty services, eight of which were significant.76 SCC providers often referred patients for specialty consultations and endorsed specialty consultation reports timely; however, we identified 15 deficiencies involving providers ordering specialty services with priority time frames that were not appropriate for the patients’ medical conditions. In seven of these deficiencies, the specialists made recommendations, but the providers did not follow them and did not document the medical rationale for not doing so. The following are examples of significant deficiencies: • In case 11, the patient had an abnormal chest CT that showed a large anterior mediastinal mass.77 The specialist recommended a PET/CT scan to determine whether hypermetabolic activity in the mass was present, which would indicate cancer activity.78 The provider did not order this urgently needed PET/CT scan until nearly four months later and did not discuss the specialist’s recommendation with the patient until that appointment. When the provider addressed the CT results with the patient, the provider ordered the PET/CT scan as medium-priority time frame instead of high-priority, as was medically indicated. This further delayed care and increased the patient’s risk of the cancer to spread. • In case 13, the provider saw the patient for hospital return in which the patient had been diagnosed with patent foramen ovale and stroke.79 The hospital records contained discrepant and incomplete information about the duration of the specialist’s recommended blood-thinning medication (Eliquis) and the hospital records requested a neurology specialist follow-up within one month to help manage this complex patient. Instead, the SCC provider ordered a medium- priority time frame neurology referral due approximately six weeks after the patient’s hospital discharge and did not timely address the Eliquis discrepancy. • In case 20, the provider endorsed a patient’s right hand x-ray. The x-ray showed a recent bone fracture with angulation and displacement and the bone had shortened due to the fracture fragments overlapping. The next day, the provider ordered the orthopedic surgery referral as medium-priority, due within 45 days, instead of emergent or high-priority time frame, which was medically indicated. 76 Provider performance specialty services deficiencies occurred in cases 1, 11-15, 18, 20-21, 26 and 28. Eight significant deficiencies occurred in cases 11, 13, and 20-21. 77 Abnormal growths were located in the front portion of the chest, between the lungs. 78 A positron emission tomography (PET) scan is an imaging test of organs and soft tissues. 79 Patent foramen ovale is a hole in the heart muscle that allows blood to inappropriately flow from the right to left atria, which shunts some blood flow from the lungs to the rest of the body. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 77 Furthermore, medical leadership approved the referral for this inappropriate time frame. Because the orthopedic surgery consultation occurred 21 days after the injury, partial healing had occurred, and the surgeon was unable to non- surgically reduce the displaced fracture. As a result, the patient subsequently required orthopedic surgery. • In case 21, the provider ordered a neck CT scan for a patient with a neck abscess with a medium-priority time frame, with a compliance date of six weeks later. The CT scan should have been completed emergently for the infection; however, the patient did not receive the CT scan until after the patient worsened 15 days later and required hospitalization. • Further in case 21, the provider evaluated the patient with a six-month history of recurrent neck abscesses. The provider documented more new lesions and purulent drainage.80 The provider documented an infectious disease specialist consult was necessary but ordered the referral with a medium-priority time frame, to be completed in six weeks. Considering the high-risk location of the patient’s neck lesions, their frequent recurrence, and the delayed healing, the provider should have ordered the referral with high-priority or at least requested a sooner electronic specialty services consultation, pending the in- person infectious disease appointment. Documentation Quality Documentation is important because it shows the provider’s thought process during clinical decision making and allows future caregivers to understand the patient’s management and plan of care. Although providers usually documented well, OIG clinicians identified 26 documentation deficiencies. Providers sometimes did not update problem lists, and consequently, important errors in outpatient documentation occurred.81 In addition, providers did not always document clinically relevant information when contacted by nurses for emergencies or co-consultation as in the following: • In case 2, providers evaluated the patient in the TTA, but no providers documented progress notes for the significant emergency events. Patient Notification Letters Providers usually sent patient notification letters to patients; however, the letters frequently did not contain the four elements required by policy. We discuss this further in the Diagnostic Services and Health Information Management indicators. Provider Continuity Patients generally received good provider continuity. Providers were assigned to specific clinics or fire camps to ensure continuity of care. 80 Purulent drainage is a thick, opaque fluid that usually indicates an infected wound. 81 Documentation deficiencies occurred in cases 1-2, 7, 11-13, 15, 17-18, 20-21, and 23. Significant deficiencies occurred in case 2. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 78 Clinician On-Site Inspection OIG clinicians met with the medical leadership and providers to discuss patient care. SCC had a new chief executive officer (CEO), who had served at other CCHCS institutions. The chief medical executive (CME) had been in place for several years, including during the Cycle 6 inspection. A new chief physician and surgeon (CP&S) had been in place for approximatively one year and served as an SCC line physician prior to the promotion. During the review period, SCC had six providers, consisting of three physicians and three nurse practitioners (NPs). One NP was responsible for and travelled to treat off-site fire camp patients. One CCHCS headquarters telemedicine NP, the remaining on-site NP, and the physicians all supported the SCC clinics. One new physician was in the process of onboarding. All on-site providers took overnight calls and rotations in the TTA. Leadership reported after the SCC Cycle 6 inspection, California Correctional Center (CCC) closed. SCC became a hub for CCC’s 14 fire camps and all associated incarcerated persons, as well as some of CCC’s institution patients. OIG clinicians spoke to medical leadership and providers about various aspect of patient care. Medical leadership discussed the implementation and effects of the ISUDT program. We also discussed the ordering of time priority of specialty referrals. In our case reviews, we identified how the providers ordered most of the specialty services referrals as medium- priority or routine-priority, regardless of medical indication for a higher priority. However, we also found most medium-priority referrals that should have been high-priority actually resulted in specialty appointments occurring within or near a high-priority timeframe. When we inquired about this, providers stated, if they know a high-priority referral will likely not result in an appointment within the 14-day compliance timeframe, they will order the referral as medium-priority, regardless of medical need. Medical leadership stated SCC has a system to ensure medium-priority and routine-priority specialty services are ordered as quickly as possible. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 79 Recommendations • Medical leadership should identify the root cause(s) for poor provider care of medically complex patients and should implement remedial measures as appropriate. • Medical leadership should develop and implement strategies to ensure patients receive specialty services within priority time frames appropriate to their medical conditions. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 80 Specialized Medical Housing In this indicator, OIG inspectors evaluate the quality of care in the specialized medical housing units. We evaluate the performance of medical staff in assessing, monitoring, and intervening for medically complex patients requiring close medical supervision. Our inspectors also evaluate the timeliness and quality of provider and nursing intake assessments and care plans. We assess staff members’ performance in responding promptly when patients’ conditions deteriorate and look for good communication when staff consult with one another while providing continuity of care. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Not Applicable At the time of our inspection, SCC had no specialized medical housing unit. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 81 Compliance Score Results Table 16. Specialized Medical Housing Scored Answer Compliance Questions Yes No N/A Yes % For OHU, CTC, and SNF: Did the registered nurse complete an initial N/A N/A N/A N/A assessment of the patient on the day of admission? (13.001) Was a written history and physical examination completed within the N/A N/A N/A N/A required time frame? (13.002) Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient N/A N/A N/A N/A within required time frames? (13.003) For specialized health care housing (CTC, SNF, hospice, OHU): Do specialized health care housing maintain an operational call N/A N/A N/A N/A system? (13.101) For specialized health care housing (CTC, SNF, hospice, OHU): Do health care staff perform patient safety checks according to institution’s local N/A N/A N/A N/A operating procedure or within the required time frames? (13.102) Overall percentage (MIT 13): N/A Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 82 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 83 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 Adequate (80.1%) Case review found SCC generally provided satisfactory specialty services for its patients. Specialty service appointments occurred as ordered and nurses frequently assessed patients appropriately upon return from off-site medical appointments. However, we identified providers ordering specialty referrals with time frames not appropriate for the patients’ medical conditions. Staff also often retrieved specialty documents; however, some misfiling occurred. Considering all factors, the OIG rated the case review component of this indicator adequate. Compliance testing showed mixed results in this indicator. Preapproved specialty services for newly arrived patients only intermittently occurred within required time frames, while performance in retrieving specialty reports and the timeliness of provider endorsements varied. Based on the overall Specialty Services compliance score result, the OIG rated the compliance testing component of this indicator adequate. Case Review and Compliance Testing Results OIG clinicians reviewed 105 events related to specialty services; 82 were specialty consultations and procedures. We identified 31 deficiencies in this category, 10 of which were significant.82 An additional 19 deficiencies related to providers either not ordering necessary specialty services or ordering the services for inappropriate priority levels. Access to Specialty Services SCC’s performance in this area was mixed. Compliance testing showed SCC staff offered excellent access for high-priority and routine-priority specialty appointments (MIT 14.001, 93.3% and MIT 14.007, 93.3%) and very good access for medium-priority specialty appointments (MIT 14.004, 80.0 %). However, staff needed improvement in completing preapproved specialty appointments for patients transferring into SCC (MIT 14.010, 61.5%). OIG clinicians reviewed 82 specialty consultations and procedures and found most specialty appointments occurred timely. We found six deficiencies, five of which were significant.83 82 Deficiencies occurred in cases 1, 12-15, 18, and 20-22. Significant deficiencies occurred in cases 12-15 and 21. 83 Deficiencies occurred in cases 1, 12, 14, and 21. Significant deficiencies occurred in cases 12, 14, and 21. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 84 Three deficiencies involved delayed specialty service consultations, two of which were significant: • In case 14, the patient underwent a right kidney removal for renal cancer almost two months late. This increased the patient’s risk of the cancer spreading. • In case 21, the patient’s appointment with CCHCS addiction medicine central team follow-up appointment did not occur. The addiction specialist cancelled the order and deferred the appointment back to the provider due to the backlog in the addiction medicine central team appointments, delaying specialty care to this patient. The three other significant deficiencies involved SCC staff not reconciling specialty services orders upon a patient’s hospital return, delaying or omitting care to the patient. The following examples all occurred in Case 12: • The patient’s endocrinology specialty referral to manage both hyperparathyroidism and medication was cancelled due to patient’s hospital admission. SCC staff did not reconcile or reorder this referral when the patient returned to SSC after the hospitalization.84 The patient was not evaluated by endocrinology specialty for hyperparathyroidism management as needed. • Prior to the same hospital admission, the patient had an ENT specialist appointment for hyperparathyroidism surgical evaluation. The order was cancelled automatically when the patient was admitted to the hospital and SCC staff did not reconcile or reorder this missed appointment when the patient returned to SSC after the hospitalization. • Two weeks after the above hospitalization, a provider ordered the ENT specialty follow-up appointment. However, the patient was again admitted to the hospital; consequently, the ENT specialty follow-up appointment was cancelled. Again, upon the patient’s return, staff did not reconcile or order the missed ENT specialty appointment. This specialty follow-up appointment then occurred over seven weeks late, delaying specialty care for this patient. Provider Performance SCC provider performance in specialty services was mixed. Compliance testing revealed SCC needed improvement in ensuring provider follow-up appointments after specialty appointments occurred within required time frames (MIT 1.008, 69.1%). In addition to medium-priority and routine-priority specialty referrals, OIG clinicians reviewed approximately 14 high-priority specialty referrals related to follow-up provider appointments and identified four deficiencies, none of which were significant. OIG clinicians found providers often did not order specialty services for medically appropriate time frames, did not always follow the specialists’ recommendations, and did not document the medical rationale. We identified 19 such deficiencies, eight of which were significant. For high-priority specialty referrals, patients need to see their primary care provider within five days of completion of 84 Endocrinology is a medical specialty involving the evaluation and management of glandular and hormonal conditions, including diabetes mellitus and thyroid diseases. Hyperparathyroidism is a condition in which the parathyroid glands in the neck produce excess parathyroid hormone. This results in increased calcium levels in the blood, weakened bones, and the formation of kidney stones. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 85 the specialty referral appointment. However, OIG clinicians found providers scheduled medium- and routine-priority referral follow-up instead. As discussed in more detail in the Provider Performance indicator, this provider referral pattern may delay specialty care to the patient and may also affect the system’s automatic trigger to schedule the SCC provider follow-up appointment within five days. This may delay or prevent patients from receiving timely provider follow-up with specialist’s recommendations. In addition, this referral pattern may alter the required medical hold for high- priority referrals, increasing the patient’s risk of erroneous transfer to another institution, potentially in the midst of urgent medical care. Nursing Performance SCC nurses performed satisfactorily in assessing patients who returned to the facility from off-site specialty service appointments. Nursing performed 23 assessments for patients returning from specialty appointments and usually assessed patients appropriately, contacted providers as needed, and appropriately entered follow-up orders. OIG clinicians identified seven deficiencies, two of which were significant as follows:85 • In case 13, the RN assessed the patient after a high-priority specialty orthopedic appointment. The RN ordered a 14-day follow-up appointment with the primary care provider. However, the RN should have ordered a five-day follow-up following the high-priority specialty orthopedic appointment. • In case 21, the RN assessed the patient after return from a specialty consultation for recurrent neck abscesses. The RN signed the documents with the specialist’s recommendations but did not consult a provider. Instead, the RN ordered a provider follow-up appointment in 14 days, delaying implementation of specialty recommendations for the patient. Health Information Management Compliance testing revealed SCC performed satisfactorily in timely receipt and review of medium-priority specialty reports (MIT 14.005, 76.9%); however, SCC needed improvement in timely receipt and review of routine- and high-priority specialty reports specialty reports (MIT 14.008, 53.3% and MIT 14.002, 73.3%). Staff needed further improvement in timely scanning specialty documents into the patients’ medical records (MIT 4.002, 73.3%). OIG clinicians reviewed 82 specialty consultations and procedures, identifying 13 health information management deficiencies, three of which were significant. Most related to misfiled or mislabeled consultation reports or to staff not timely retrieving consultation progress notes. Notably, providers often endorsed the specialty service reports timely, once they were received. We also discuss these deficiencies in the Health Information Management indicator. Clinician On-Site Inspection We discussed the specialty services processes with SCC medical leadership, health information management (HIM) supervisors, specialty nursing, ancillary staff, and providers. HIM is responsible for collecting and scanning specialty services consultation reports as discussed in the Health Information Management indicator. 85 Deficiencies occurred in cases 12, 13, 15, 18, and 21. Significant deficiencies occurred in cases 13 and 21. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 86 SCC leadership reported a significant backlog of CCHCS headquarters Integrated Substance Use Disorder Treatment (ISUDT) follow-up appointments due to the ISUDT providers reportedly being often unable to meet compliance time frames combined with the severe backlog of the mental health licensed clinical social workers (LCSWs) who perform ISUDT screenings. On-site providers were to treat the patients for substance use disorder prior to receiving the LCSW assessment. SCC medical staff reported fire camp patients from all but the closest camps had a high rate of refusing specialty appointments. As discussed in Diagnostic Services, patients from the more distant camps refused specialty appointments that required an overnight stay at SCC due to the prevalence of violence between incarcerated residents. Medical staff attributed the high violence rate in part to SCC incarcerated being non-designated, meaning they are housed by general population and not separated by gang affiliation. Informal incarcerated gang leaders on the yards (colloquially referred to as “shot callers”) will demand “payments” from all incarcerated persons arriving at SCC, regardless of length of stay. If the new arrival does not comply, they need to fight to protect themselves and risk being harmed. To improve both safety and compliance with specialty appointments, SCC leadership is piloting a potential solution of housing distant incarcerated patients at a camp closer to SCC, allowing them to transport those campers into and out of SCC only for the day of the specialty appointment. SCC staff reported the politics of violence does not extend into the fire camps. When discussing providers’ pattern of ordering specialty referrals for medically inappropriate priority time frames, medical leadership stated SCC has systems in place to ensure medium- and routine-priority specialty services are ordered as quickly as possible, regardless of the ordered compliance date. We discuss further in the Provider Performance Indicator. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 87 Compliance Score Results Table 17. Specialty Services Scored Answer Compliance Questions Yes No N/A Yes % Did the patient receive the high-priority specialty service within 14 calendar days of the primary care provider order or the Physician Request for 14 1 0 93.3% Service? (14.001) Did the institution receive and did the primary care provider review the high-priority specialty service consultant report within the required time 11 4 0 73.3% 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? 8 1 6 88.9% (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 12 3 0 80.0% 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 10 3 2 76.9% 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? 7 0 8 100% (14.006) Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician Request for 14 1 0 93.3% Service? (14.007) Did the institution receive and did the primary care provider review the routine-priority specialty service consultant report within the required time 8 7 0 53.3% frame? (14.008) Did the patient receive the subsequent follow-up to the routine-priority specialty service appointment as ordered by the primary care provider? 9 1 5 90.0% (14.009) For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the sending 8 5 0 61.5% 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 2 0 0 100% services within required time frames? (14.011) Following the denial of a request for specialty services, was the patient 1 1 0 50.0% informed of the denial within the required time frame? (14.012) Overall percentage (MIT 14): 80.1% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 88 Table 18. Other Tests Related to Specialty Services Scored Answer Compliance Questions Yes No N/A Yes % Specialty service follow-up appointments: Did the clinician follow-up visits 29 13 3 69.1% occur within required time frames? (1.008) * Are specialty documents scanned into the patient’s electronic health record 22 8 15 73.3% within five calendar days of the encounter date? (4.002) * CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician follow-up visits following specialty services. As a result, we tested MIT 1.008 only for high-priority specialty services or when staff ordered follow-ups. The OIG continued to test the clinical appropriateness of specialty follow-ups through its case review testing. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 89 Recommendations • Health care leadership should determine the root cause(s) of untimely preapproved specialty appointments for transfer-in patients and implement appropriate remedial measures. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 90 Administrative Operations In this indicator, OIG compliance inspectors evaluated health care administrative processes. Our inspectors examined the timeliness of the medical grievance process and checked whether the institution followed reporting requirements for adverse or sentinel events and patient deaths. Inspectors checked whether the Emergency Medical Response Review Committee (EMRRC) met and reviewed incident packages. We investigated and determined whether the institution conducted required emergency response drills. Inspectors also assessed whether the Quality Management Committee (QMC) met regularly and addressed program performance adequately. In addition, our inspectors determined whether the institution provided training and job performance reviews for its employees. We checked whether staff possessed current, valid professional licenses, certifications, and credentials. The OIG rated this indicator solely based on the compliance score. Our case review clinicians do not rate this indicator. Because none of the tests in this indicator directly affected clinical patient care (it is a secondary indicator), the OIG did not consider this indicator’s rating when determining the institution’s overall quality rating. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Inadequate (67.4%) SCC’s performance was mixed in this indicator. While SCC scored well in some applicable tests, it needed improvement in several areas. The EMMRC rarely completed the required checklists or reviewed the cases within required time frames. In addition, staff conducted medical emergency response drills with incomplete documentation or without the required emergency response drill forms. Physician managers only occasionally completed annual performance appraisals in a timely manner. Lastly, the nurse educator did not ensure all newly hired nurses received the required onboarding training and only intermittently ensured nurses who administer medications timely complete their annual competency testing. These findings are set forth in the table on the next page. Based on the overall Administrative Operations compliance score result, the OIG rated this indicator inadequate. Compliance Testing Results Nonscored Results At SCC, the OIG did not have any applicable adverse sentinel events requiring root cause analysis during our inspection period (MIT 15.001). We obtained CCHCS Mortality Case Review reporting data. In our inspection, for one applicable patient, we found no evidence in the submitted documentation the preliminary mortality report had been completed. This report was overdue at the time of the OIG’s inspection (MIT 15.998). Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 91 Compliance Score Results Table 19. Administrative Operations Scored Answer Compliance Questions Yes No N/A Yes % For health care incidents requiring root cause analysis (RCA): Did the This is a nonscored test. Please refer to the institution meet RCA reporting requirements? (15.001) discussion in this indicator. Did the institution’s Quality Management Committee (QMC) meet monthly? 6 0 0 100% (15.002) For Emergency Medical Response Review Committee (EMRRC) reviewed cases: Did the EMRRC review the cases timely, and did the incident 1 2 9 33.3% packages the committee reviewed include the required documents? (15.003) For institutions with licensed care facilities: Did the Local Governing Body (LGB) or its equivalent meet quarterly and discuss local operating N/A N/A N/A N/A procedures and any applicable policies? (15.004) Did the institution conduct medical emergency response drills during each watch of the most recent quarter, and did health care and custody staff 0 3 0 0 participate in those drills? (15.101) Did the responses to medical grievances address all of the patients’ 10 0 0 100% appealed issues? (15.102) Did the medical staff review and submit initial patient death reports to the 1 0 0 100% CCHCS Mortality Case Review Unit on time? (15.103) Did nurse managers ensure the clinical competency of nurses who 5 4 1 55.6% administer medications? (15.104) Did physician managers complete provider clinical performance appraisals 1 4 0 20.0% timely? (15.105) Did the providers maintain valid state medical licenses? (15.106) 9 0 0 100% Did the staff maintain valid Cardiopulmonary Resuscitation (CPR), Basic Life Support (BLS), and Advanced Cardiac Life Support (ACLS) certifications? 2 0 1 100% (15.107) Did the nurses and the pharmacist-in-charge (PIC) maintain valid professional licenses and certifications, and did the pharmacy maintain a 6 0 1 100% valid correctional pharmacy license? (15.108) Did the pharmacy and the providers maintain valid Drug Enforcement Agency (DEA) registration certificates, and did the pharmacy maintain valid 1 0 0 100% Automated Drug Delivery System (ADDS) licenses? (15.109) Did nurse managers ensure their newly hired nurses received the required 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): 67.4% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 92 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 93 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 SCC Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 94 Case Reviews The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders, which continues in the Cycle 7 medical inspections. Below, Table A–1 provides important definitions that describe this process. Table A–1. Case Review Definitions Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 95 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. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 96 Figure A–2. Case Review Testing Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 97 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. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 98 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. Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 99 Appendix B: Case Review Data Table B–1. SCC Case Review Sample Sets Sample Set Total Death Review/Sentinel Events 1 Diabetes 3 Emergency Services – CPR 2 Emergency Services – Non-CPR 2 High Risk 4 Hospitalization 5 Intrasystem Transfers In 3 Intrasystem Transfers Out 3 RN Sick Call 12 Specialty Services 5 40 Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 100 Table B–2. SCC Case Review Chronic Care Diagnoses Sample Set Total Anemia 5 Anticoagulation 2 Arthritis/Degenerative Joint Disease 1 Asthma 4 Cancer 2 Cardiovascular Disease 1 Chronic Kidney Disease 1 Chronic Pain 8 Coccidioidomycosis (Valley Fever) 1 COPD 2 COVID-19 1 Diabetes 4 Gastroesophageal Reflux Disease (GERD) 5 Gastrointestinal Bleed 1 Hepatitis C 7 Hyperlipidemia 6 Hypertension 8 Mental Health 6 Migraine Headaches 1 Rheumatological Disease 1 Seizure Disorder 2 Sleep Apnea 1 Substance Abuse 17 87 Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 101 Table B–3. SCC Case Review Events by Program Diagnosis Total Diagnostic Services 117 Emergency Care 73 Hospitalization 34 Intrasystem Transfers In 9 Intrasystem Transfers Out 6 Outpatient Care 359 Specialty Services 126 724 Table B–4. SCC Case Review Sample Summary Sample Set Total MD Reviews Detailed 20 MD Reviews Focused 0 RN Reviews Detailed 10 RN Reviews Focused 20 Total Reviews 50 Total Unique Cases 40 Overlapping Reviews (MD & RN) 10 Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 102 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 103 Appendix C: Compliance Sampling Methodology Sierra Conservation Center 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 32 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 4 OIG on-site review • Randomly select one housing unit Health Care from each yard Services Request Forms Diagnostic Services MITs 2.001 – 003 Radiology 10 Radiology Logs • Appointment date (90 days – 9 months) • Randomize • Abnormal MITs 2.004 – 006 Laboratory 10 Quest • Appt. date (90 days – 9 months) • Order name (CBC, BMP, or CMPs only) • Randomize • Abnormal MITs 2.007 – 009 Laboratory STAT 0 Quest • Appt. date (90 days – 9 months) • Order name (CBC, BMP, or CMPs only) • Randomize • Abnormal MITs 2.010 – 012 Pathology 10 InterQual • Appt. date (90 days – 9 months) • Service (pathology related) • Randomize Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 104 Quality No. of Indicator Sample Category Samples Data Source Filters Health Information Management (Medical Records) MIT 4.001 Health Care Services 32 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 8 OIG inspector • Identify and inspect all on-site clinical MITs 5.107 – 111 on-site review areas Transfers MITs 6.001 – 003 Intrasystem Transfers 25 SOMS • Arrival date (3 – 9 months) • Arrived from (another departmental facility) • Rx count • Randomize MIT 6.101 Transfers Out 10 OIG inspector • R&R IP transfers with medication on-site review Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 105 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 4 SOMS • Date of transfer (2– 8 months) • Sending institution (another departmental facility) • Randomize • NA/DOT meds MITs 7.101 – 103 Medication Storage Varies OIG inspector • Identify and inspect clinical & med Areas by test on-site review line areas that store medications MITs 7.104 – 107 Medication Varies OIG inspector • Identify and inspect on-site clinical Preparation and by test on-site review areas that prepare and administer Administration Areas medications MITs 7.108 – 111 Pharmacy 1 OIG inspector • Identify & inspect all on-site on-site review pharmacies MIT 7.112 Medication Error 9 Medication error • All medication error reports with Reporting reports Level 4 or higher • Select total of 25 medication error reports (recent 12 months) MIT 7.999 Restricted Unit 10 On-site active • KOP rescue inhalers & nitroglycerin KOP Medications medication listing medications for IPs housed in restricted units Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 106 Quality No. of Indicator Sample Category Samples Data Source Filters Prenatal and Postpartum Care MITs 8.001 – 007 Recent Deliveries N/A at this OB Roster • Delivery date (2 – 12 months) institution • Most recent deliveries (within date range) Pregnant Arrivals N/A at this OB Roster • Arrival date (2 – 12 months) institution • Earliest arrivals (within date range) Preventive Services MITs 9.001 – 002 TB Medications 25 Maxor • Dispense date (past 9 months) • Time period on TB meds (3 months or 12 weeks) • Randomize MIT 9.003 TB Evaluation, 25 SOMS • Arrival date (at least 1 year prior to Annual Screening inspection) • Birth month • Randomize MIT 9.004 Influenza 25 SOMS • Arrival date (at least 1 year prior to Vaccinations inspection) • Randomize • Filter out IPs tested in MIT 9.008 MIT 9.005 Colorectal Cancer 25 SOMS • Arrival date (at least 1 year prior to Screening inspection) • Date of birth (45 or older) • Randomize MIT 9.006 Mammogram N/A at this SOMS • Arrival date (at least 2 yrs. prior to institution inspection) • Date of birth (age 52 – 74) • Randomize MIT 9.007 Pap Smear N/A at this SOMS • Arrival date (at least three yrs. prior to institution inspection) • Date of birth (age 24 – 53) • Randomize MIT 9.008 Chronic Care 25 OIG Q: 1.001 • Chronic care conditions (at least Vaccinations 1 condition per IP — any risk level) • Randomize • Condition must require vaccination(s) MIT 9.009 Valley Fever N/A at this Cocci transfer • Reports from past 2 – 8 months institution status report • Institution • Ineligibility date (60 days prior to inspection date) • All Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 107 Quality No. of Indicator Sample Category Samples Data Source Filters Reception Center MITs 12.001 – 007 RC N/A at this SOMS • Arrival date (2 – 8 months) institution • Arrived from (county jail, return from parole, etc.) • Randomize Specialized Medical Housing MITs 13.001 – 003 Specialized Health N/A at this CADDIS • Admit date (2 – 8 months) Care Housing Unit institution • Type of stay (no MH beds) • Length of stay (minimum of 5 days) • Rx count • Randomize MITs 13.101 – 102 Call Buttons 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: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 108 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 13 Specialty Services • Arrived from (other departmental Arrivals Arrivals institution) • Date of transfer (3 – 9 months) • Randomize MITs 14.011 – 012 Denials 2 InterQual • Review date (3 – 9 months) • Randomize N/A IUMC/MAR • Meeting date (9 months) Meeting Minutes • Denial upheld • Randomize Administrative Operations MIT 15.001 Adverse/sentinel 0 Adverse/sentinel • Adverse/Sentinel events events events report (2 – 8 months) MIT 15.002 QMC Meetings 6 Quality • Meeting minutes (12 months) Management Committee meeting minutes MIT 15.003 EMRRC 12 EMRRC meeting • Monthly meeting minutes minutes (6 months) MIT 15.004 LGB N/A at this LGB meeting • Quarterly meeting minutes institution minutes (12 months) MIT 15.101 Medical Emergency 3 On-site summary • Most recent full quarter Response Drills reports & • Each watch documentation for ER drills MIT 15.102 Institutional Level 10 On-site list of • Medical grievances closed Medical Grievances grievances/closed (6 months) grievance files Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 109 Quality No. of Indicator Sample Category Samples Data Source Filters Administrative Operations (continued) MIT 15.103 Death Reports 1 Institution-list of • Most recent 10 deaths deaths in prior Initial death reports 12 months MIT 15.104 Nursing Staff 10 On-site nursing • On duty one or more years Validations education files • Nurse administers medications • Randomize MIT 15.105 Provider Annual 5 On-site provider • All required performance evaluation Evaluation Packets evaluation files documents MIT 15.106 Provider Licenses 9 Current provider • Review all listing (at start of inspection) MIT 15.107 Medical Emergency All On-site certification • All staff Response tracking logs • Providers (ACLS) Certifications • Nursing (BLS/CPR) • Custody (CPR/BLS) MIT 15.108 Nursing Staff and All On-site tracking • All required licenses and Pharmacist in Charge system, logs, or certifications Professional Licenses employee files and Certifications MIT 15.109 Pharmacy and All On-site listing of • All DEA registrations Providers’ Drug provider DEA Enforcement Agency registration #s & (DEA) Registrations pharmacy registration document MIT 15.110 Nursing Staff New All Nursing staff • New employees (hired within last Employee training logs 12 months) Orientations MIT 15.998 CCHCS Mortality 1 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: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 110 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7, Sierra Conservation Center | 111 California Correctional Health Care Services’ Response Office of the Inspector General, State of California Inspection Period: March 2024 – August 2024 Report Issued: December 2025 Cycle 7 Medical Inspection Report for Sierra Conservation Center OFFICE of the INSPECTOR GENERAL Amarik K. Singh Inspector General Shaun Spillane Chief Deputy Inspector General STATE of CALIFORNIA December 2025 OIG