OIG
Summary and Trend Analysis of the OIG’s Seventh Cycle of Medical Inspections
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Cycle 7 Analysis and Trends | i
Contents
Illustrations ii
Introduction 1
Methodology 2
Summary and Analysis of Cross-Cycle Trends and Cycle 7 Cross-
Institution Trends 3
Cross-Cycle Summary and Trends 3
Cycle 7 Cross-Institution Summary and Trends 5
Correlations Discovered between Compliance and Case
Review Inspection Findings in Cycle 7 8
Top Cycle 7 Recommendations Across Institutions 12
Hand Hygiene in Health Care Settings 12
Patient Medications 13
Diagnostic Test Result Patient Notification Letters 14
Medical Supplies 15
Patient Care Access in Less Common Circumstances 16
Patient Nursing Assessments and Documentation 17
Conclusion 19
Office of the Inspector General, State of California
Cycle 7 Analysis and Trends | ii
Illustrations
Figures
1. Percentage of Institutions with Passing Case Review Scores by
Indicator, Cycles 4 through 7 3
2. Percentage of Institutions with Passing Compliance Scores by
Indicator, Cycles 4 through 7 4
3. Top 10 Compliance Test Scores, Cycle 7 5
4. Bottom 10 Compliance Test Scores, Cycle 7 6
5. Compliance Tests on Patient Access to Care 8
6. Compliance Tests on Emergency Preparation and
Response Review 9
7. Compliance Tests on Nursing-Related Requirements 10
Office of the Inspector General, State of California
Cycle 7 Analysis and Trends | 1
Introduction
California Penal Code section 6126 assigns the Office of the Inspector General (OIG)
responsibility for oversight of the California Department of Corrections and
Rehabilitation (CDCR or the department). Under subdivision (f), the OIG conducts an
objective medical inspection program, which consists of periodically reviewing and
reporting on the delivery of the medical care provided to incarcerated people in each of
the department’s adult prisons.
This report examines and analyzes trends across all California prison institutions
through OIG’s seventh cycle of medical inspections. The Cycle 7 medical inspection
process for these 31 institutions began in November 2022 and concluded in August
2025, and we published the report for the final institution of this cycle in April 2026.
This report also compares the inspection results of these same institutions across
Cycles 4, 5, 6, and 7, as the inspection processes were similar for these four cycles.
However, due to minor differences in these processes, the cross-cycle comparisons are
not exact.
Two indicators, Prenatal & Postpartum Care and Reception Centers, applied to only
two and three institutions, respectively. For this reason, the OIG generally omitted the
results in those two indicators when discussing department-level recommendations,
and their compliance scores have not been included in department averages for this
report.
Readers desiring a more detailed review of any specific institution should refer to the
individually published Cycle 7 medical inspection reports on the OIG’s website,
www.oig.ca.gov.
Office of the Inspector General, State of California
Cycle 7 Analysis and Trends | 2
Methodology
In Cycle 7, the OIG applied similar assessment methodologies used in Cycles 4, 5, and
6, including clinical case review and compliance testing. Specifically, our case review
clinicians, composed of a team of physicians and nurse consultants — program review
(NCPRs), examined whether providers and nurses used sound medical judgment during
the course of patients’ treatments, then qualitatively rated the medical care across
multiple health care indicators.1 Our compliance registered nurse (RN) inspectors
collected data to quantitatively assess compliance- and performance-related measures
as established in the OIG’s Policy Compliance Medical Inspection Tool (MIT).2 We
developed our testing requirements directly from the department’s Health Care
Department Operations Manual (HCDOM),3 which contains the department’s own
predetermined policies to provide sustainable, acceptable care. Taken together, these
methods provide a comprehensive overview of how an institution’s health care system
functions.
While we continued in Cycle 7 to review institutional health care using the
methodologies over the same 15 indicators, the OIG altered the manner in which we
reported our medical inspection findings. Specifically, beginning in Cycle 7, instead of
providing a single overall rating for an institution, the OIG began providing two
separate ratings: one rating from case review and one from compliance testing. Neither
the methodologies nor the factors for consideration changed. However, we determined
separating the ratings from each component more clearly communicates the OIG’s
findings, and the separate ratings better facilitate comparable analyses across
institutions.
In addition, during Cycle 7, we developed a new tracking system that allowed us to
better track and analyze performance trends both across the past four cycles as well as
within this single cycle. In this report, we present both our cross-cycle and Cycle 7
cross-institution analyses.
1. We evaluate the quality of healthcare across 15 indicators. Each indicator represents a set of unique
components that are necessary for a successful correctional healthcare system. The 15 indicators of
healthcare are: Access to Care, Diagnostic Services, Emergency Services, Health Information Management,
Health Care Environment, Transfers, Medication Management, Prenatal & Postpartum Care, Preventive
Services, Nursing Performance, Provider Performance, Reception Centers, Specialized Medical Housing,
Specialty Services, and Administrative Operations.
2. Our medical inspection tool (MIT) is publicly available for review at: www.oig.ca.gov/dataExplorer/MIU
Compliance Tool
3. The OIG’s medical inspection oversight is unique in that we tailor our compliance testing to mirror this
correctional health care organization’s own established rules and requirements. When the department
updates its policies and its requirements in the HCDOM, the OIG similarly updates our policy-compliance
testing to reflect the department’s changes. If a necessary health system compliance standard or timeline is
not defined in the HCDOM, our compliance methodology applies OIG standards and timeframes that we
based on currently accepted community and correctional health care statutes, regulations, and guidelines.
Office of the Inspector General, State of California
Cycle 7 Analysis and Trends | 3
Summary and Analysis of Cross-Cycle Trends
and Cycle 7 Cross-Institution Trends
Cross-Cycle Summary and Trends
The OIG commends the department for the institutions’ progress in employing good
clinical judgment and decision-making, as evaluated by our case review physicians and
NCPRs. Figure 1 below compares the percent of institutions that passed the case
review component of each indicator over the past four cycles.
As reflected in Figure 1 above, average performance across most indicators reveals
sustained improvement in the percent of institutions passing the case review
component of each indicator over the past four inspection cycles. The department
should be recognized for the substantial progress achieved over successive inspection
cycles in improving the clinical quality of patient care.
In contrast to the gains observed in the case review indicators, the compliance
indicators reflected mixed performance across the inspection cycles. Performance
Office of the Inspector General, State of California
%38
%47
%58
%17
%68
%47 %47
%08
%17
%15
%08
%19
%08
%06
%17 %47
%36 %26
%08 %08
%17 %77
%36
%47 %57 %47
%97
%47 %77
%58
Figure 1. Percentage of Institutions with Passing Case Review Scores by Indicator,
Cycles 4 through 7
Figure 1. Perce9n4ta%ge of Institutions with Passing Case Review Scores by Indicator,
90%
100%
84% 84%
81% 81%
77%
71%
58%
ACCESS TO DIAGNOSTIC EMERGENCY HEALTH TRANSFERS MEDICATION NURSING PROVIDER SPECIALIZED SPECIALTY
CARE SERVICES SERVICES INFORMATION MANAGEMENTPERFORMANCE PERFORMANCE MEDICAL SERVICES
MANAGEMENT HOUSING
Cycle 4 Cycle 5 Cycle 6 Cycle 7
Source: OIG Medical Inspection results, www.oig.ca.gov.
Cycle 7 Analysis and Trends | 4
trends through the compliance indicators were less consistent overall in the percent of
institutions passing the compliance testing components, with several indicators
demonstrating stagnation at a low passing percent or decline in the passing percent.
Figure 2 below compares the percent of institutions that passed the compliance
component of each indicator over the past four cycles.
As indicated in Figure 2, two indicators maintained strong cross-institution
performance over at least the past three cycles: Access to Care and Health Information
Management. Three indicators showed modest improvements since Cycle 6 in the
percent of institutions passing: Diagnostic Services, Transfers, and Preventive Services;
however, the passing percent remained low in Diagnostic Services. The remaining five
indicators all experienced decreases in the percent of passing compliance scores over at
least the past three cycles: Medication Management, Specialized Medical Housing,
Specialty Services, Health Care Environment, and Administrative Operations. Two of
those indicators, Medication Management and Health Care Environment, both fell to
low cross-institution passing levels in Cycle 7. The inconsistent performance in the
compliance component across institutions and across the past four cycles highlights
ongoing challenges in sustaining and standardizing systemic compliance with
departmental expectations.
Office of the Inspector General, State of California
%38 %08 %18
%06
%17
%95
%32
%77 %48 %08
%47
%86
%94
%86
%06 %75
%18
%17
%19
%68
%77
%66
%87
%37
%15
%86
%95
%92
%97
%47
Figure 2: Percentage of Institutions with Passing Compliance Scores by Indicator,
Cycles 4 through 7
84%
80%
79%
72% 72% 73%
67%
63%
59%
53%
ACCESS TO DIAGNOSTIC HEALTH TRANSFERS MEDICATION PREVENTATIVE SPECIALIZED SPECIALTY HEALTH CARE ADMINISTRATIVE
CARE SERVICES INFORMATION MANAGEMENT SERVICES MEDICAL SERVICES ENVIRONMENT OPERATIONS
MANAGEMENT HOUSING
Cycle 4 Cycle 5 Cycle 6 Cycle 7
Source: OIG Medical Inspection results, www.oig.ca.gov.
Cycle 7 Analysis and Trends | 5
Cycle 7 Cross-Institution Summary and Trends
Next, we studied department-wide performance trends across the institutions in Cycle
7, comparing those indicators in which institutions generally all demonstrated strong
performance as well as those indicators in which institutions uniformly struggled.
First, by bifurcating the ratings between the case review and compliance components
of our inspections, we found 74.2 percent (nearly three quarters) of institutions
achieved overall adequate ratings in the case review component, indicating generally
strong cross-institution performance in clinical judgment and decision-making in this
most recent cycle. In contrast, only 25.8 percent (just over one quarter) of the
institutions achieved overall adequate ratings in the compliance component. In further
analyzing cross-institution performance in the compliance tests in each indicator, we
further identified interesting common factors correlating with the areas of cross-
institutional proficiency and inadequacy.
Specifically, the highest-performing compliance measures reflected strong institutional
performance in regulatory, administrative, and documentation-based requirements, as
demonstrated in Figure 3.
Figure 3. Top 10 Compliance Test Scores, Cycle 7
Nurses & PIC maintained valid professional licences,
100%
and the pharmacy maintained valid correctional license
Providers maintained valid state medical licenses 100%
Medical Grievance Responses addressed
100%
all patients' appealed issues
All female patients aged 50–74 were offered mammograms 100%
Health care service request forms were timely
99.5%
scanned into the electronic health record
Staff maintained valid CPR, BLS, and ACLS certifications 98.4%
The institution’s Quality Management Committee met monthly 98.4%
All patients were offered an influenza vaccination
98.2%
for the most recent influenza season
Clinical health care areas controlled exposure to
97.0%
bloodborne pathogens and contaminated waste
Pharmacy and providers maintained valid DEA registration
96.8%
certificates, and the pharmacy maintained valid licenses
Tests involving professional licensure, certification maintenance, grievance response
procedures, electronic health record documentation, and preventive care consistently
Office of the Inspector General, State of California
801.51601.51201.51
600.9
100.4
701.51200.51
400.9
501.5
901.51
Source: OIG Medical Inspection results, www.oig.ca.gov.
Cycle 7 Analysis and Trends | 6
achieved perfect to near-perfect scores in every institution. The cross-institution
proficiency in these tests suggests the department has successfully implemented cross-
institution processes to meet these highly standardized, policy-driven expectations. For
example, all institutions scored perfectly in maintaining necessary pharmacy and
clinical licenses as well as properly responding to patient medical grievances. In
addition, the following preventive health measures scored very well:
• 100% – Mammogram compliance for eligible women aged 50–74
• 98.18% – Influenza vaccination offered during flu season
• 96.95% – Clinical areas controlled exposure to blood-borne pathogens
However, this pattern contrasts with lower-performing clinical process implementation
measures observed in other compliance tests. This contradiction indicates stronger
cross-institution performance in administrative compliance than in operational
delivery of care. Specifically, the lowest-performing compliance tests primarily involved
operational aspects of health care delivery requiring real-time clinical execution,
interdisciplinary coordination, and sustained workflow reliability. Deficiencies were
particularly pronounced in diagnostic follow-up, emergency preparedness, medication
continuity, infection control practices, and supply management, as demonstrated in
Figure 4.
Providers generated complete and timely
7.8%
pathology patient notification letters
The institution conducted timely medical emergency
10.8%
response drills, and appropriate staff participated therein
Clinical health care staff adhered to
24.1%
universal hand hygiene precautions
Providers timely ordered medications upon
25.2%
patients' discharge from community hospitals
Each clinic followed adequate protocols for
25.7%
managing and storing bulk medical supplies
EMRBs were inspected and inventoried
27.6%
timely and contained essential items
Patients received chronic care medications timely, or the
28.4%
institution followed policy for refusals or no-shows
The EMRRC reviewed cases timely, and incident
28.6%
packages reviewed included required documents
Medical supply management in non-clinical areas adequately
29.0%
supported the needs of the medical health care program
Providers generated timely and complete
29.4%
laboratory patient notification letters
Office of the Inspector General, State of California
210.2101.51401.5
300.7
701.5
111.5
100.7300.51601.5
600.2
Figure 4. Bottom 10 Compliance Test Scores, Cycle 7
Source: OIG Medical Inspection results, www.oig.ca.gov.
Cycle 7 Analysis and Trends | 7
In contrast to the near-perfect performance observed in administrative and
documentation-based requirements, these findings suggest institutions experienced
greater difficulty consistently implementing complex care delivery processes in
practice.
The gap between the highest and lowest cross-institution average percentage scores in
the compliance tests was dramatic:
• Highest average compliance test score across all institutions: 100%
• Lowest average compliance test score across all institutions: 7.82%
This 92-point spread suggests a system in which compliance is not uniformly weak but
rather highly polarized; some processes strictly adhered to the HCDOM while other
processes consistently revealed noncompliance across institutions. These cross-
institution struggles in the lowest performing compliance tests suggest compliance
failures with these policy requirements are not isolated facility problems, but rather
systemic operational weaknesses concentrated in specific domains of care delivery.
Office of the Inspector General, State of California
Cycle 7 Analysis and Trends | 8
Correlations Discovered between Compliance and Case
Review Inspection Findings in Cycle 7
In studying the department-wide trends in Cycle 7, we further discovered several areas
in which compliance testing results paralleled case review findings. These correlations
provide greater insight and clarity into cross-institution strengths and weaknesses.
Some of these correlations between compliance testing and case review findings
revealed areas of excellence across the 31 institutions. For example, the Access to Care
indicator, which both compliance inspectors and case review clinicians evaluate, was
consistently high scoring in both components. All 31 institutions passed the case
review component of this indicator, with 19 institutions achieving an adequate rating,
and 12 achieving a proficient rating. Similarly, the average compliance score in this
indicator among the 31 institutions was 80.7 percent, near the top of the adequate
range, with seven institutions achieving proficient scores.
Interestingly, we found the extraordinarily strong performance in five of the
compliance tests involving some key measures of good patient care access was echoed
in the clinical quality of the patient Access to Care case review component. Figure 5
illustrates the department’s high cross-institution average performance in five key
compliance tests in the Access to Care indicator.
Figure 5. Compliance Tests on Patient Access to Care
MIT 1.003 Timely Nursing Triage of Patient Requests
MIT 1.004 Timely Face-to-Face Nurse Assessments
MIT 1.005 Timely Primary Care Physician Appointment
MIT 1.006 Timely Primary Care Physician Follow-Ups
MIT 1.007 Timely Follow-Up After Hospital Discharge
0% 20% 40% 60% 80% 100%
Source: OIG Medical Inspection results, www.oig.ca.gov.
Specifically, tests regarding the timeliness of nurses triaging patient care requests (MIT
1.003, average score 96.05 percent), subsequent face-to-face nurse assessments (MIT
1.004, average score 89.44 percent), subsequent primary care physician (PCP)
appointments (MIT 1.005, average score 80.93 percent), PCP follow-up appointments
Office of the Inspector General, State of California
Cycle 7 Analysis and Trends | 9
(MIT 1.006, average score 87.18 percent), and follow-ups after hospital discharge (MIT
1.007, average score 88.01 percent) were five of the consistently highest scoring tests,
with institutions averaging within the proficient or high adequate scoring ranges. This
correlation indicates the strong adherence to policy requirements positively affected
the clinical quality of decision-making in this indicator.
In contrast, the poorest performing case review indicator was Emergency Services.
None of the 31 institutions (zero percent) achieved a proficient rating, only 18 achieved
adequate ratings, and 13 institutions ultimately received inadequate ratings for their
clinical performance in the case review component of this indicator. Here again, we
saw the clinical performance struggles in this indicator echoed in the related
compliance tests. Figure 6 illustrates the low cross-institution average performance in
three compliance tests relating to emergency preparedness and post-response review.
Figure 6. Compliance Tests on Emergency Preparation and Response Review
MIT 15.101 Quarterly Medical Emergency
Response Drills
MIT 5.111 Emergency Medical Response Bags &
Treatment Carts
MIT 15.003 Emergency Medical Response
Review Committees
0% 20% 40% 60% 80% 100%
Source: OIG Medical Inspection results, www.oig.ca.gov.
Specifically, in Figure 6, above, tests regarding the adequacy of the institutions’
quarterly emergency response drills (MIT 15.101, average score 10.75 percent), the
readiness of emergency medical response bags (EMRBs) and treatment carts (MIT
5.111, average score 27.57 percent), and the adequacy of post-response emergency
medical response review committee (EMRRC) incident packages (MIT 15.003, average
score 28.62 percent) were three of the consistently lowest scoring tests. These
emergency measures are vital to ensuring an institution’s readiness to respond properly
to emergency situations. This correlation suggests the weak adherence to these policy
requirements negatively affected the clinical quality of decision-making in this
indicator.
The poor scores across all institutions in these tests indicate these struggles are not
institution specific but rather require a systemic solution. The department should
undertake a department-level approach to identify the root causes of the persistently
Office of the Inspector General, State of California
Cycle 7 Analysis and Trends | 10
low performance across institutions in these areas. The department should update
policies as needed and should develop, implement, and monitor strategies to ensure all
EMRBs, treatment carts, and disaster carts remain properly stocked and monitored;
health care and custody staff regularly drill on emergency responses to habitualize
proper emergency protocols; and EMRRCs conduct timely and meaningful analyses of
emergency responses in which they identify and correct areas needing improvement.
To aid the department in this endeavor, beginning in Cycle 8, the OIG relocated these
three, and one other, compliance tests relating to emergency preparation and review,
which previously existed in Indicator 5. Health Care Environment and Indicator 15.
Administrative Operations, into a new compliance component for Indicator 3.
Emergency Services. This will allow the OIG to better evaluate and highlight the
correlation between these emergency-related compliance tests and the case review
findings regarding the overall clinical quality of the institution’s provision of
emergency services through the next cycle.
After Emergency Services, the Nursing Performance indicator was the second poorest
scoring indicator across all 31 institutions. Again, none of the institutions (zero
percent) achieved a proficient rating, 22 achieved adequate ratings, and nine received
inadequate ratings.
Similar to Emergency Services, we saw these nursing performance struggles mirrored
in compliance tests relating to proper nurse training and attention to nursing
requirement details. Figure 7 illustrates the low cross-institution average performance
in six nursing-related compliance tests.
Figure 7. Compliance Tests on Nursing-Related Requirements
MIT 15.110 All Newly Hired Nurses Received Required
Onboarding Training
MIT 6.001 Registered Nurses timely complete the
initial health care screening for incoming patients
MIT 5.104 Clinic Staff, including Nurses, Adhere to
Universal Hand Hygeine
MIT 5.108 Clinic Areas Contain Essential Core Medical
Equipment and Supplies
MIT 7.105 Nurses Administering Medications Adhere
to Universal Hand Hygiene
MIT 7.107 Nurses Administering Medications Employ
Proper Administrative Controls
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%100%
Source: OIG Medical Inspection results, www.oig.ca.gov.
Office of the Inspector General, State of California
Cycle 7 Analysis and Trends | 11
Specifically, only 11 of 31 institutions passed our test regarding whether nurse
managers ensured their newly hired nurses received the required onboarding and
clinical competency training (MIT 15.110, average score 35.48 percent). Interestingly,
we also found persistently low scores in tests requiring nurses to demonstrate strong
attention to detail in HCDOM nursing requirements, such as tests relating to:
(1) whether, for patients received from another CDCR institution, nursing staff
completed the initial health screening and answered all screening questions within the
required time frame (MIT 6.001, average score 38.4 percent), (2) proper sanitation and
infection control (MITs 5.101–5.104, average score among four tests 55.0 percent), and
(3) using proper administrative protocols in handling and administering patient
medications (MITs 7.105 and 7.107, average score among two tests 37.8 percent).
These findings suggest a link between the lack of appropriate training leading to poor
compliance with nursing requirements and the case review findings regarding lapses in
clinical nursing judgment, decision-making, and attention to detail. The department
should undertake a department-level approach to identify the root causes of
persistently low performance across the institutions in ensuring proper onboarding and
clinical competency training that will promote staff attention to detail and habitual
adherence to these nursing HCDOM requirements. The department should implement
necessary corrective measures, including updating policies as indicated. The
department should further study the effects of the corrective measures implemented on
the cross institution compliance with lower scoring nursing compliance test measures
and amend their corrective processes as indicated.
These correlations between the persistent policy noncompliance and the lower clinical
performance ratings in both the Emergency Services and Nursing Performance
indicators also underscore the importance of both the case review and compliance
testing components to the overall assessment of health care quality. Specifically, they
provide greater insight into the potential causes for the cross-institution struggles to
achieve adequate scores in the case review component in these indicators. Using
Emergency Services as an example, compliance testing alone would have revealed the
institutions did not comply with emergency preparation and review policies, but would
not necessarily demonstrate how this non-compliance affected the clinical quality of
the emergency response care. In contrast, conducting case review alone would have
identified clinical judgment lapses during emergency services, but would not
necessarily have identified the potential cause as lack of proper training, emergency
preparedness, and post-response reviews. Both components are necessary to
understand the impact of compliance lapses and identify specific areas for
improvement that could positively impact the clinical quality of emergency responses.
Office of the Inspector General, State of California
Cycle 7 Analysis and Trends | 12
Top Cycle 7 Recommendations Across
Institutions
In addition to the cross-institution performance trends, we also studied the prevalence
of their related recommendations across this cycle. This study allowed us to more
clearly segregate those health care deficiencies in Cycle 7 that may be more localized to
individual institutions versus those that may indicate more widespread areas of
systemic proficiency or needing systemic improvements. The OIG used this analysis to
enhance our inspection process for Cycle 8. We present below the six most commonly
issued recommendations in Cycle 7, along with our analysis of the prevalence of each
recommendation.
Hand Hygiene in Health
CDC Guidance for Hand Hygiene in
Care Settings
Health Care settings:
The Guideline for Hand Hygiene in Health-Care
The OIG issued recommendations
Settings provides health-care workers (HCWs) with a
regarding hand hygiene to 30 of 31 review of data regarding handwashing and hand
institutions during Cycle 7 medical antisepsis in health-care settings. In addition, it
provides specific recommendations to promote
inspections, indicating failure to
improved hand-hygiene practices and reduce
adhere to hand-hygiene policies was transmission of pathogenic microorganisms to
patients and personnel in health-care settings.
systemic rather than institution
specific. Gloving Policies Section: hands should be
decontaminated or washed after removing gloves.
Under the Center for Disease Reference Part II. Recommendations 1. contains
Control (CDC) guidelines, to which indications for handwashing and hand antisepsis –
Part C, Part F, Part I, & Part J.
HCDOM policy requires adherence,
gloves are intended as an addition
to, not a substitute for, hand
hygiene.4 Hands must be sanitized both before and after glove use.
Staff across institutions consistently omitted sanitization before donning gloves and
immediately after removing them. Additionally, lapses often occurred during the
movement between tasks and patient zones. The OIG found staff frequently failed to
sanitize when entering or leaving a patient’s immediate environment. Further, we
found staff often sanitized after contact with the patient or their equipment had already
begun, rather than prior to donning gloves at the beginning of the appointment. Cross-
contamination potential existed when staff shifted between different patients, or
4. Guideline for Hand Hygiene in Health-Care Settings:
https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm
Office of the Inspector General, State of California
Cycle 7 Analysis and Trends | 13
distinct tasks on the same patient, without remembering to deglove, sanitize hands,
and don new sterile gloves.
Notably, in the few institutions in which individual staff members passed the tests
associated with hand hygiene, our inspectors could readily observe the strict adherence
to all hygiene protocols was habitual and automatic for those staff members, rather
than actions requiring conscious policy adherence. This observation suggests a
department-wide strategy to habitualize strict adherence to these hygiene
requirements, such as through repetitive drills, may improve staff compliance in this
area.
Patient Medications
Medication Continuity
• Correctional Settings (CCR Title 15 § 3999.315):
The OIG issued Patients arriving from non-CDCR institutions must be seen
by a provider or have medications ordered within 8 hours.
recommendations regarding
Prescribers must renew orders specifically to “facilitate
medications at 30 of 31 medication continuity”.
institutions during Cycle 7
Discharge & Transfer Delays
medical inspections.5 These • Discharge Procedures (CCR Title 22 § 97520.11):
Written procedures must ensure medical records are
included recommendations to
checked, discharge instructions are complete, and patients
improve medication
are advised on the proper use and storage of prescribed
continuity, particularly during drugs.
• Providing Medications (CCR Title 22 § 73369 & §
hospital discharge or transfer
785.28): Drugs may be sent with a patient upon discharge
to or from another institution, if ordered by the physician, and this must be recorded in
and medication the health record.
documentation. Documentation Failures
• Nursing Requirements (CCR Title 22 § 73313): The
person who administers the drug must properly record the
Medication Continuity: The
time and dose in the patient's medication record.
OIG provided multiple • General Administration (CCR Title 22 § 79215): As
recommendations to improve evidence of administration, health records must contain
the drug name, dosage, time, and the name or initial of the
significant delays or
person who gave it.
interruptions in staff • Documentation Standards (CCR Title 22 § 81075 & §
87919): Records for centrally stored medications must
providing medications for
include the resident’s name, physician, drug name,
chronic conditions, newly strength, quantity, date filled, and prescription number.
5. HCDOM References: Medication Availability: Ch. 3. Article 5 3.5.8.(e)(14)(B).1-2:
https://www.cdcr.ca.gov/hcdom/dom/chapter-3-health-care-operations/article-5-pharmacy/3-5-8-prescription-
order-requirements-and-medication-availability/
Medication Administration Lines – General Population: Ch.3 Article 5 3.5.29.(c)(3)(E)1-3:
https://www.cdcr.ca.gov/hcdom/dom/chapter-3-health-care-operations/article-5-pharmacy/3-5-29-medication-
administration/
Medication No-Shows for Medication Lines (Medication Administration): Ch. 3 Article 5 3.5.30.(c)(4)(B)1-3:
https://www.cdcr.ca.gov/hcdom/dom/chapter-3-health-care-operations/article-5-pharmacy/3-5-30-medication-
adherence/
Office of the Inspector General, State of California
Cycle 7 Analysis and Trends | 14
ordered medications, and medications for patients returning from hospitals or off-site
specialty appointments.
Discharge and Transfer Delays:
Several medication continuity recommendations focused specifically on improvements
for staff providing medications timely for patients who discharged from a higher level
of care or who transferred to or from another institution.
Documentation Failures: The OIG also provided multiple recommendations to
improve staff accuracy when recording medication administration in the electronic
health records system (EHRS) and the medication administration record (MAR).
The prevalence of errors relating to patient medication processes again indicates the
struggles with strict policy adherence in this area is systemic, rather than institution
specific. This suggests the department should undertake analysis at the department
level to determine the root causes for medication distribution noncompliance; should
update their policies as needed; and should develop, implement, and monitor strategies
to habitualize strict policy adherence in staff across all institutions.
Diagnostic Test
September 2025 CCHCS HC DOM Ch. 3 Article 1
Result Patient
3.1.13.c.6.A.1;
Provider Review of Imaging Studies Results and Patient
Notification Letters
Notification and Follow-up
A. Following the finalization of all imaging studies as described
The OIG issued in Sections (c)(3) through (5) above, the health care provider
shall:
recommendations regarding
1. Review and endorse the report within five calendar days of
untimely or incomplete patient receiving an examination report notification into the Electronic
Health Records System (EHRS).
letters at 30 of 31 institutions
2. Create a patient notification letter in the EHRS at the time of
during Cycle 7 medical the provider’s review of the examination results. The patient
inspections. notification letters shall include the following:
a. Date of the examination results.
b. Name of the health care provider who reviewed and
Policy requires providers to
endorsed the medical imaging result.
create and issue letters c. The clinical significance or meaning of the medical
imaging results such as, but not limited to, whether the
educating patients about the
results are unchanged, or within normal limits, or as
results of their diagnostic tests expected, or whether additional testing is required.
at the same time the provider d. Whether a follow-up appointment with the provider is
required and that it will be scheduled.
endorses (meaning approves or
B. Patient notification letters shall be printed for collection by the
signs off for) those diagnostic designated staff member to be distributed to the patients.
test results.6
6. California Code of Regulations, Title 22, Division 5, Chapter 9, Article 4, Section 77139, Health Record
Service; Section 77141, Health Record Content; and Section 77143, Health Record Availability; Patient Health
Care Inquiry Response (15 CCR § 3999.218); Scheduling and Access to Care (15 CCR § 3999.303); Health Care
Grievance Process (15 CCR § 3999.227): https://www.dir.ca.gov/dlse/ccr.htm
Office of the Inspector General, State of California
Cycle 7 Analysis and Trends | 15
The OIG frequently offered recommendations to correct significant delays between the
time a provider endorsed a diagnostic test result and the time the provider issued the
test result notification letter to the patient. The OIG also issued multiple
recommendations to correct erroneously omitted patient notification letters as well as
to ensure these patient letters contained all required elements mandated by policy (see
policy, above).7
During Cycle 7, the creation and issuance of these letters were manual, meaning these
letters did not automatically generate upon provider endorsement and populate
accurately, instead requiring providers to consciously remember to create the letter and
manually include the four required elements to meet result notification requirements.
However, the frequency of these recommendations indicates this lack of automation
increased the risk of error. We understand the department has begun developing and
implementing a systemic strategy to automate this process, which we anticipate will
significantly increase cross-institution compliance in this area.
Medical Supplies
CCR Title 22 § 78439(a): Mandates that equipment and
supplies must be maintained in adequate quality and
The OIG issued recommendations
quantity for patient care.
regarding medical supply
CCR Title 22 § 79835: Storage and Organization
management and control at 28 of
Standards require that clean and soiled materials are kept
31 institutions during Cycle 7 in separate to prevent contamination.
response to finding that staff did
CCR Title 22 § 79835(b), (e), (f): Requires dedicated,
not consistently follow protocols equipped, and staffed areas for storing sterile materials,
for managing medical equipment along with proper separation from contaminated items
and an orderly, rotated storage.
and supplies.
January 2024 CCHCS HCDOM Ch. 3 Article 7 3.7.1-1.
d:
The OIG offered multiple
(14) Required equipment and supplies are always
recommendations to correct clinic readily accessible in the institution to health care staff in
examination rooms missing the TTA, clinical areas, EMRVs, and other areas as
deemed appropriate by the CEO and the Warden.
essential core equipment and
(15) A process is in place to document that required
inadequately stocked storage inventories and maintenance have been performed.
Procedures shall ensure that the required
areas. The OIG further offered
documentation is retained for one year, audited
frequent recommendations to
monthly, and reviewed as part of the institution’s EMRS
correct improper storage of quality improvement process system.
medical supplies both inside and
7. HCDOM References: Radiology: Ch. 3 Article 1. 3.1.13.c.6.A.2:
https://www.cdcr.ca.gov/hcdom/dom/chapter-3-health-care-operations/article-1-complete-care-model/3-1-13-
medical-imaging-services/; Laboratory: Ch.3 Article 1 3.1.14.c.4.E:
https://www.cdcr.ca.gov/hcdom/dom/chapter-3-health-care-operations/article-1-complete-care-model/3-1-14-
laboratory-services/; Pathology: Ch. 3 Article 1 3.1.14 Appendix 3:
https://www.cdcr.ca.gov/hcdom/dom/chapter-3-health-care-operations/article-1-complete-care-model/
Office of the Inspector General, State of California
Cycle 7 Analysis and Trends | 16
outside of clinic areas, indicating staff systemically failed to conduct equipment checks
and inventory supplies.8
The OIG’s repeated recommendations about proper medical supply control and storage
suggests the department should conduct a department-wide analysis to identify
whether the root causes of these breakdowns across all institutions are due to a lack of
training, poor storage layouts, unclear protocols, or other causes. Department
leadership should update policies as needed and develop, implement, and monitor
department-wide strategies to address and correct the identified causes.9
Patient Care Access
in Less Common California Code of Regulations (CCR)
Scheduling and Access to Care: CCR Title 15, § 3999.303,
Circumstances mandates an efficient scheduling system for timely access.
• Routine Primary Care Physician (PCP) Referrals:
Must be seen within 14 calendar days.
While, as previously noted,
• Urgent Referrals: Must be seen within 24 hours.
access to common patient Specialty Services: The Prison Health Care Provider Network
care was generally proficient Operations Manual oversees the process for specialty medical
services, including cardiology, surgery, and procedures like
across all institutions in
colonoscopies.
Cycle 7, the OIG issued
HCDOM References:
recommendations regarding
For general access to care
the inadequate scheduling of Ch 3, Article 1, section 3.1.5.c.2.B contains the relevant
requirements for scheduling and access to care, including timing
less common patient
of encounters after requests for services and determination of
appointments at 28 of 31 urgency of requests.
institutions during Cycle 7
For patient follow-up appointments
medical inspections. Ch 3, Article 1, section 3.1.9(c)(3)(F)(10) requires that patients
discharged to an outpatient setting from a community hospital,
emergency department, or any non-mental health CDCR health
The OIG offered frequent
care bed shall be seen by their PCP within five calendar days of
recommendations to correct discharge.
delays in timely providing Ch. 3, Article 1, 3.1.11.(c)(7)(B) & (C) requires the PCP to see
the patient within 5 calendar days of a high priority specialty
specialty appointments,
appointment.
particularly for high-priority
referrals, chronic care, and
prenatal/obstetric services.
OIG recommendations also frequently focused on failures to ensure follow-up
appointments occur after specialty encounters, emergency room encounters, or
hospital discharges within required timeframes. We further offered multiple
8. California Code of Regulations (CCR): https://www.dir.ca.gov/dlse/ccr.htm
9. HCDOM Reference: https://www.cdcr.ca.gov/hcdom/dom/chapter-3-health-care-operations/article-6-
durable-medical-equipment-supplies-and-accommodations/3-6-1-durable-medical-equipment-and-medical-
supply/
Office of the Inspector General, State of California
Cycle 7 Analysis and Trends | 17
recommendations to improve incomplete patient screenings and documentation of
pending specialty care for patients transferring between institutions.10
The prevalence of these recommendations again indicates these struggles are not
institution specific but rather require a systemic solution. The department should
undertake a department-level analysis to identify the root causes of the consistent
noncompliance in these less common areas of patient access to care.11 For example, the
department may wish to investigate the workflow and communication logistics to
identify the disconnects that result in chronic or follow-up appointment scheduling
delays; failure to communicate specialty results to primary care teams; and failure to
ensure care continuity during transfers, specialty returns, and hospital discharge
returns. The department should update policies as needed and should develop,
implement, and monitor strategies to address and correct these issues.
Patient Nursing
HCDOM Reference:
Assessments and
Patient Care/Coordination
Ch. 3. Article 1 3.1.11(c)(7)(E)
Documentation
(E) At the follow-up appointment, the PCP or dentist shall
discuss the specialty provider’s findings and
The OIG issued recommendations recommendations with the patient, as clinically
appropriate, and document the discussion in the health
regarding insufficient or untimely
record.
patient assessments in 27 of 31 1. Ongoing treatments such as dialysis, chemotherapy,
radiation therapy, pacemaker interrogations, and
institutions during Cycle 7
related follow-ups require only an initial approval to
medical inspections. initiate the series of treatments and consultations.
2. If the specialty provider recommends a new
procedure, surgery, or specialist consultation, and
The OIG offered multiple
the PCP or dentist agrees with the specialty
recommendations to improve
provider’s recommendations, a new RFS shall be
nursing performance in submitted.
3. Follow-up with the specialty provider after a
conducting thorough patient
procedure or surgery does not require another RFS
assessments across various order if completed within the global surgery
settings (emergencies, specialized schedule time frames.
4. All other specialty follow-up services occurring 12
housing, and clinics). Many of
months after the date of the original RFS order
these recommendations focused require a new RFS order.
on ensuring nurses timely and
10. California Code of Regulations (CCR): https://www.dir.ca.gov/dlse/ccr.htm
11. HCDOM Reference: https://www.cdcr.ca.gov/hcdom/dom/chapter-3-health-care-operations/article-1-
complete-care-model/3-1-5-scheduling-and-access-to-care-3-2-2/;
https://www.cdcr.ca.gov/hcdom/dom/chapter-3-health-care-operations/article-1-complete-care-model/3-1-5-
scheduling-and-access-to-care-3-2-2/;
https://www.cdcr.ca.gov/hcdom/dom/chapter-3-health-care-operations/article-1-complete-care-model/3-1-9-
health-care-transfer/;
https://www.cdcr.ca.gov/hcdom/dom/chapter-3-health-care-operations/article-1-complete-care-model/3-1-11-
outpatient-specialty-services/. See also California Code of Regulations (CCR) – 22 CCR 80069, 22 CCR 70211,
22 CCR 70701.
Office of the Inspector General, State of California
Cycle 7 Analysis and Trends | 18
accurately recorded critical patient information, including vitals and follow-up care
plans. Other recommendations focused on ensuring timely notification to providers
regarding abnormal findings and correcting failures to properly document specialty
appointment results.
Interestingly, the deficiencies for insufficient nursing assessments spanned a wide
variety of causes.12 Assessment deficiencies included skills that require significant
clinical competency, such as complex wound care or PICC line maintenance;
interventions that require maintaining presence of mind in high stress situations, such
as in urgent and emergency circumstances; and tasks requiring significant attention to
detail, such as completing all aspects of a full head-to-toe assessment and thoroughly
documenting each finding. As noted above in the section on Cycle 7 case review and
compliance correlations, many of these nursing deficiencies may relate to the
consistent cross-institution struggle to ensure new nurses receive required onboarding
and competency training. In emergency responses, some of these deficiencies may also
relate to the lack of proper equipment from improperly stocked EMRBs and treatment
carts as well as insufficient hands-on training drills involving both custody and health
care staff.
The frequency and variance of these assessment errors across so many institutions
indicate the department should undertake department-level analysis to identify the root
causes for each variation of these deficiencies.13 The department should update policies
as needed to clarify expectations and processes, and department leadership should
develop, implement, and monitor strategies across all institutions to ensure health care
staff, particularly nurses, receive all necessary skill trainings; engage in high-stress
circumstance response drills; properly stock all medical supplies, particularly for
emergency responses; and habitualize attention to detail.
12. California Code of Regulations (CCR): https://www.dir.ca.gov/dlse/ccr.htm
13. Outpatient Specialty Services: https://www.cdcr.ca.gov/hcdom/dom/chapter-3-health-care-
operations/article-1-complete-care-model/3-1-11-outpatient-specialty-services/
Office of the Inspector General, State of California
Cycle 7 Analysis and Trends | 19
Conclusion
Overall, the analysis of the cross-institution performance trends we identified during
our seventh cycle of medical inspections indicates strong policy adherence in
administrative health care requirements, but a need for systemic improvement in staff
compliance with operational implementation of daily patient care. However, our
analysis also highlighted the consistently passing performance in the case review
component across most institutions and the cross-cycle trends displaying consistent
and sustained systemic improvement in the quality of clinical care over the past three
cycles. The strong case review scores indicate these areas of systemic noncompliance
are generally not negatively impacting the quality of clinical judgment and decision-
making patients receive in these institutions, except as noted in the Emergency
Services and Nursing Performance indicators.
The OIG used this analysis in part to enhance our inspection process for Cycle 8.
Specifically, as noted above, our new testing methodologies provide greater focus on
emergency response testing, and we further amended our inspection processes to
promote greater inspection accuracy, as agreed by our stakeholders during meetings we
held prior to initiating Cycle 8.
We appreciate the opportunity to evaluate institution performance through our Cycle 7
inspection process, allowing us to assess the institution’s medical care on both
individual and system levels. We hope this report will provide a meaningful analysis of
how the department can continue in its efforts to continually improve health care for
California’s incarcerated patient population. We look forward to continuing our work
in partnership with our stakeholders to ensure the ongoing health care provided meets
or exceeds both general correctional and community health care standards as well as
the specific health regulations and policies governing the department, codified in
Titles 15 and 22 of the California Code of Regulations and the department’s HCDOM.
Office of the Inspector General, State of California
Cycle 7 Analysis and Trends | 20
Summary and Trend Analysis
of the OIG’s Seventh Cycle
of Medical Inspections
November 2022 – April 2026
OFFICE of the INSPECTOR GENERAL
Amarik K. Singh
Inspector General
Shaun Spillane
Chief Deputy Inspector General
STATE of CALIFORNIA
June 2026
OIG
Office of the Inspector General, State of California