CALIPATRIA STATE PRISON
MEDICAL INSPECTION RESULTS
BUREAU OF AUDITS AND INVESTIGATIONS

OFFICE OF THE
INSPECTOR GENERAL

DAVID R. SHAW
INSPECTOR GENERAL

STATE OF CALIFORNIA
July 2010

David R. Shaw, Inspector General

. Office ofthe Inspector General

July 22,2010

J. Clark Kelso, Receiver
California Prison Health Care Receivership Corporation
501 J Street, Suite 100
Sacramento, California 95814
Dear Mr. Kelso:
Enclosed is the Office of the Inspector General's final report on its inspection of medical care
delivery at Calipatria State Prison. The purpose of our inspection was to evaluate and monitor
the progress of medical care delivery to inmates at the institution.
The report finds that based on our weighted scoring system encompassing 19 components,
Calipatria State Prison received 76.6 percent of the total weighted points possible. The report
contains a detailed breakdown of the institution's score in each ofthe 19 relevant components,.
including the results of all 143 questions. A copy of the report can also be found on our website
at www.oig.ca.gov.
Thank you for the courtesy and cooperation extended to my staff during the inspection. Please
call Nancy Faszer, Deputy Inspector General, In-Charge, at (916) 830-3600 if you have any
. questions.
Sincerely,

David R. Shaw
Inspector General
Enclosure
cc:

Kathleen Webb, Director, Policy and Risk Management Services
California Prison Health Care Services
K. Ball, D.O., Health Care Manager & Chief Medical Officer,
Calipatria State Prison
Scott McEwen, Warden (A), Calipatria State Prison
Matthew Cate, Secretary, California Department of Corrections and Rehabilitation

P.O.

Box 348780,

Arnold Schwarzenegger, Governor
95834-8780 PHONE (916) 830-3600 FAX (916) 928-4684

SACRAMENTO, CALIFORNIA

Contents
Executive Summary ......................................................................................… 1
Introduction …................................................................................................… 3
Background …....................................................................................… 3
About the Institution …......................................................................… 4
Objectives, Scope, and Methodology ….............................................. 4
Medical Inspection Results ….......................................................................… 7
California Prison Health Care Receivership
Corporation's Response …............................................................................. 29

Executive Summary
An April 2001 class action lawsuit filed by inmates represented by the Prison Law Office alleged that
the state provided constitutionally inadequate medical care at California state prisons in violation of
inmates’ constitutional rights. And, in October 2005, the U.S. Northern District Court of California
declared that California’s delivery system for prison medical care was “broken beyond repair” and still
not meeting constitutional standards. As a result, the federal court imposed a receivership to raise the
delivery of medical care to constitutional standards. To evaluate and monitor the progress of medical
care delivery to inmates, the receiver requested, and the Office of the Inspector General (OIG) agreed,
to establish an objective, clinically appropriate, and metric-oriented medical program to annually
inspect the delivery of medical care at each state prison.
Overall
Score

76.6%

In April 2010, we inspected Calipatria State Prison (CAL). Our medical
inspection encompassed 19 components of medical delivery and comprised 143
questions. The questions are weighted based on their importance to the delivery
of medical care to inmates. CAL received 76.6 percent of the total weighted
points possible.

The following summary table lists the components we inspected in order of importance (highest to
lowest), with the institution’s score and the definitions of each inspection component. The detailed
medical inspection results, with the questions for each component, begin on page 7 of this report.
While we are committed to helping each institution achieve a higher level of medical care, it is not our
intent to determine the percentage score needed by an institution to meet constitutional standards—that
is a legal matter for the federal court to determine.

Executive Summary Table
Component

Weighted Score Definition

Chronic Care

75.0%

Examines how well the prison provided care and medication to inmates with specific
chronic care conditions, which are those that affect (or have the potential to affect) an
inmate's functioning and long-term prognosis for more than six months. Our inspection tests
anticoagulation therapy and the following chronic care conditions: asthma, diabetes, HIV
(Human Immunodeficiency Virus), and hypertension.

Clinical Services

60.1%

Evaluates the inmate's access to primary health care services and focuses on inmates who
recently received services from any of the prison's facility or administrative segregation unit
clinics. This component evaluates sick call processes (doctor or nurse line), medication
management, and nursing.

Health Screening

80.0%

Focuses on the prison's process for screening new inmates upon arrival to the institution for
health care conditions that require treatment and monitoring, as well as ensuring inmates'
continuity of care.

Specialty Services

74.5%

Focuses on the prison's process for approving, denying, and scheduling services that are
outside the specialties of the prison's medical staff. Common examples of these services
include physical therapy, oncology services, podiatry consultations, and neurology services.

Urgent Services

88.3%

Addresses the care provided by the institution to inmates before and after they were sent to a
community hospital.

Emergency Services

85.2%

Examines how well the prison responded to medical emergencies. Specifically, we focused
on "man down" or "woman down" situations. Further, questions determine the adequacy of
medical and staff response to a "man down" or "woman down" emergency drill.

Bureau of Audits and Investigations
Office of the Inspector General

Page 1
State of California

Component

Weighted Score Definition

Prenatal Care/Childbirth/
Post-delivery

N/A

Focuses on the prenatal and post-delivery medical care provided to pregnant inmates. Not
applicable at men's institutions.

Diagnostic Services

57.5%

Addresses the timeliness of radiology (x-ray) and laboratory services and whether the prison
followed up on clinically significant results.

Access to Health Care
Information

37.3%

Addresses the prison's effectiveness in filing, storing, and retrieving medical records and
medical-related information.

Outpatient Housing Unit

92.5%

Determines whether the prison followed department policies and procedures when placing
inmates in the outpatient housing unit. This component also evaluates whether the
placement provided the inmate with adequate care and whether the physician's plan
addressed the placement diagnosis.

Internal Reviews

75.0%

Focuses on the frequency of meetings held by the prison's Quality Management Committee
(QMC) and Emergency Medical Response Review Committee (EMRRC) and whether key
staff attended the meetings, the number of medical appeals filed, and the prison's death
review process.

Inmate Transfers

100.0%

Focuses on inmates pending transfer to determine whether the sending institution
documented medication and medical conditions to assist the receiving institution in
providing continuity of care.

Clinic Operations

100.0%

Addresses the general operational aspects of the prison's facility clinics. Generally, the
questions in this component relate to the overall cleanliness of the clinics, privacy afforded
to inmates during nonemergency visits, use of priority ducats (slip of paper the inmate
carries for scheduled medical appointments), and availability of health care request forms.

Preventive Services

48.3%

Focuses on inmate cancer screening, tuberculosis evaluation, and influenza immunizations.

Pharmacy Services

96.6%

Addresses whether the prison's pharmacy complies with various operational policies, such
as conducting periodic inventory counts, maintaining the currency of medications in its
crash carts and after-hours medication supplies, and having valid permits. In addition, this
component also addresses whether the pharmacy has an effective process for screening
medication orders for potential adverse reactions/interactions.

Other Services

100.0%

Examines additional areas that are not captured in the other components. The areas
evaluated in this component include the prison's provision of therapeutic diets, its handling
of inmates who display poor hygiene, and the availability of the current version of the
department's Inmate Medical Services Policies and Procedures.

Inmate Hunger Strikes

100.0%

Examines medical staff's monitoring of inmates participating in hunger strikes lasting longer
than three days.

Chemical Agent
Contraindications

100.0%

Addresses the prison's process of handling inmates who may be predisposed to an adverse
outcome from calculated uses of force (cell extractions) involving Oleoresin Capsicum
(OC), which is commonly referred to as "pepper spray." For example, this might occur if the
inmate has asthma.

Staffing Levels and
Training

100.0%

Examines the prison's medical staffing levels and training provided.

Nursing Policy

100.0%

Determines whether the prison maintains written policies and procedures for the safe and
effective provision of quality nursing care. The questions in this component also determine
whether nursing staff review their duty statements and whether supervisors periodically
review the work of nurses to ensure they properly follow established nursing protocols.

Overall Score

76.6%

Bureau of Audits and Investigations
Office of the Inspector General

Page 2
State of California

Introduction
Under the authority of California Penal Code section 6126, which assigns the Office of the Inspector
General (OIG) responsibility for oversight of the California Department of Corrections and
Rehabilitation, and at the request of the federal receiver, the OIG developed a comprehensive
inspection program to evaluate the delivery of medical care at each of the California Department of
Corrections and Rehabilitation’s 33 adult prisons.
In April 2010, we inspected Calipatria State Prison (CAL). Our medical inspection encompassed 19
components of medical delivery and comprised 143 questions. To help readers understand the medical
risk associated with certain components of medical delivery—which pose a greater risk to an inmatepatient—we developed a weighting system and assigned points to each question. Consequently, we
assigned more total points to more critical components, such as chronic care, clinical services, and
health screening. We assigned fewer total points to less critical components, such as inmate hunger
strikes, staffing levels and training, and chemical agent contraindications. (For a detailed description of
the weighting system, see Objectives, Scope, and Methodology on the next page.)

Background
In April 2001, inmates represented by the Prison Law Office filed a class action lawsuit, known as
Plata v. Schwarzenegger. The lawsuit alleged that the state provided constitutionally inadequate
medical care at California state prisons in violation of inmates’ constitutional rights. In June 2002, the
parties entered into a Stipulation for Injunctive Relief, and the state agreed to implement over several
years comprehensive new medical care policies and procedures at all institutions.
Nevertheless, the U.S. Northern District Court of California declared in October 2005 that California’s
delivery system for prison medical care was “broken beyond repair” and still not meeting constitutional
standards. Thus, the federal court imposed a receivership to raise the delivery of medical care to
constitutional standards. In essence, the court ordered the receiver to manage the state’s delivery of
medical care and restructure day-to-day operations to develop and sustain a system that provides
constitutionally adequate medical care to inmates. The court stated that it would remove the receiver
and return control to the state once the system is stable and provides for constitutionally adequate
medical care.
To evaluate and monitor the progress of medical care delivery to inmates, the receiver requested that
the OIG establish an objective, clinically appropriate, and metric-oriented medical inspection program.
Toward that end, the Inspector General agreed to inspect each state prison annually. We are committed
to helping each institution achieve a higher level of medical care, but it is up to the federal court to
determine the percentage score necessary for an institution to meet constitutional standards.

Bureau of Audits and Investigations
Office of the Inspector General

Page 3
State of California

About the Institution
The primary mission of Calipatria State Prison (CAL) is to provide for the confinement of general
population minimum custody (Level I) and maximum custody (Level IV) inmates who are willing to
participate in vocational and/or academic programs, prison industries or support services. Additionally,
a portion of the prison is designated for the US Immigration and Naturalization Services to house those
inmates with active holds that are within 30-45 days of their scheduled release dates. As of
June 23, 2010, the California Department of Corrections and Rehabilitation reported that CAL had
custody over 4,073 male inmates, of which 3,794 are Level IV inmates. CAL operates six medical
clinics where staff handle non-urgent requests for medical services. CAL also treats inmates needing
urgent or emergency care in its triage and treatment area (TTA). According to information provided by
the institution, CAL's vacancy rate among licensed medical managers, primary care providers,
supervisors, and rank and file nurses is 4.6 percent.
K. Ball, D.O., serves as the prison's health care manager and chief medical officer.

Objectives, Scope, and Methodology
In designing the medical inspection program, we reviewed the California Department of Corrections
and Rehabilitation’s policies and procedures, relevant court orders, guidelines developed by the
department’s Quality Medical Assurance Team, and guidance developed by the American Correctional
Association. We also reviewed professional literature on correctional medical care, consulted with
clinical experts, and met with stakeholders from the court, the receiver’s office, the department, and the
Prison Law Office to discuss the nature and scope of the inspection program. Based on input from these
stakeholders, we developed a medical inspection program that evaluates medical care delivery. Within
each of 20 components, we created “yes” or “no” questions designed to gauge performance.
To make the inspection results meaningful to both a medical expert and a lay reader, we worked with
clinical experts to create a weighting system that factors the relative importance of each component
compared to other components. Further, the program considers the relative importance of each question
within a component to the other questions in that component. This weighting ensures that more critical
components—such as those that pose the greatest medical risk to the inmate-patient—are given more
weight compared to those considered less serious. For example, we assign a high number of possible
points to the chronic care component because we consider this the most serious of all the components.
We assign proportionately fewer points to all other components.
Each inspection question is weighted and scored. The score is derived from the percentage of “yes”
answers for each question from all items sampled. We then multiply the percentage of “yes” answers
within a given question by the question’s weight to arrive at a score. The following example shows how
this scoring system works.
Example Question: Institution X
Answers

Is the clinical history adequate?

Weighting Points

Yes

No

Yes + No

Yes %

Possible

40

10

50

80%

20

Bureau of Audits and Investigations
Office of the Inspector General

Received
16

Score %
80.0%

N/A

Unk

0

0

Page 4
State of California

If the institution receives 40 “yes” answers and 10 “no” answers, the percentage of “yes” answers to
this question equals 80 percent. We calculate the number of points the institution would receive by
multiplying the “yes” percent of 80 by the number of possible points for this question, which is 20, to
arrive at 16 points.
To arrive at the total score, we add the points received for each question and then for each program
component. Finally, we calculate the institution’s overall score by dividing the sum of the points
received by the sum of the points possible. We do not include in the institution’s overall score the
weight for questions that are not applicable or, in some cases, where a lack of documentation would
result in numerous “no” answers for one deviation from policy (unknown). For instance, an institution
may not be able to provide documentation that its Emergency Medical Response Review Committee
met for a particular month. Therefore, when we evaluate whether meeting minutes document monthly
meetings for a particular month, the institution would receive a “no” answer for that question.
However, when we evaluate whether the meeting minutes document the warden’s attendance at the
meeting, the answer would be “unknown” so that the institution’s score is not penalized twice for the
same reason, not documenting the meeting.
To evaluate the institution’s delivery of medical care, we obtained various electronic data files
maintained by the institution for inmate medical scheduling and tracking, pharmacy, and census data.
We used these electronic data files only to identify random samples of inmates receiving or requiring
specific medical services. We then reviewed the medical file for each inmate in our sample. We did not
rely on the medical care information contained in these electronic data files.
Our inspection program assumes that if a prison's medical staff does not document an event in an
inmate's unit health record, the event in question did not happen. If an inmate's record does not show
that the inmate received his medications on a specified date, for example, we assume that the inmate
did not receive the medications. While it is possible that the inmate received his medications and the
staff neglected to document the event, our program cannot assume that appropriate care was provided.
Our medical inspection at CAL encompassed 19 of the 20 components of medical delivery. One of the
components was not applicable during the period inspected. In total, we reviewed 182 inmate medical
files, which are referred to as unit health records. In addition, we reviewed staffing level reports,
medical appeals summaries, nursing policies and procedures, summaries of medical drills and
emergencies, minutes from Quality Management Committee and Emergency Medical Response
Review Committee hearings, contents of inmate transfer envelopes, and assorted manual logs or
tracking worksheets related to medical care delivery. We also conducted a live medical emergency drill
and evaluated the adequacy of the responding staff’s actions. Finally, we interviewed medical and
custody staff members about the delivery of medical care to inmates, and we observed day-to-day
medical delivery at the institution.
We do not test the care provided in the licensed hospitals or correctional treatment centers because they
are subject to inspections and oversight by other regulatory agencies.

Bureau of Audits and Investigations
Office of the Inspector General

Page 5
State of California

Consistent with our agreement with the receiver, our report only addresses the conditions found related
to the medical care criteria. We do not discuss the causes of noncompliance, nor do we make specific
recommendations in this report. However, if we learn of an inmate-patient who needs immediate care,
we notify the health care manager and request a status report. Moreover, if we learn of significant
departures from community standards, we may report such departures to the institution’s health care
manager or the receiver’s office. Because these matters involve confidential medical information
protected by state and federal privacy laws, specific details related to these cases are not included in our
report.
For ease of reference, following is a table of abbreviations used in the remainder of this report.
Abbreviations used in this report
AED
BLS
CMO
CTC
CTQ
EMRRC
FTF
GACH
HCM
INH
LVN
MOD
OB
OC
OHU
OIG
PCP
QMC
RN
SOAPE
SRN
TB
TTA
UHR
UM

Automatic External Defibrillator
Basic Life Support
Chief Medical Officer
Correctional Treatment Center
Confined to Quarters
Emergency Medical Response Review Committee
Face-to-Face
General Acute Care Hospital
Health Care Manager
Isoniazid (antituberculous medication)
Licensed Vocational Nurse
Medical Officer of the Day
Obstetrician
Oleoresin Capsicum (pepper spray)
Outpatient Housing Unit
Office of the Inspector General
Primary Care Provider
Quality Management Committee
Registered Nurse
Subjective, Objective, Assessment, Plan, Education
Supervising Registered Nurse
Tuberculosis
Triage and Treatment Area
Unit Health Record
Utilization Management

Bureau of Audits and Investigations
Office of the Inspector General

Page 6
State of California

CALIPATRIA STATE PRISON

OFFICE OF THE INSPECTOR GENERAL

Overall Score:

MEDICAL INSPECTION RESULTS

76.6%

04/05/2010 – 04/08/2010

Page

Component

Yes

Answers
No Yes + No

Weighting Points
Yes % Points Possible Points Received Score %

Questions Not Answered
Not Applicable
Unknown

Chronic Care

8

149

55

204

73.0%

133

99.8

75.0%

2

10

Clinical Services

9

171

131

302

56.6%

95

57.1

60.1%

73

12

Health Screening

11

80

7

87

92.0%

52

41.6

80.0%

91

2

Specialty Services

12

61

25

86

70.9%

71

52.9

74.5%

52

0

Urgent Services

13

137

17

154

89.0%

52

45.9

88.3%

44

2

Emergency Services

14

33

5

38

86.8%

52

44.3

85.2%

4

0

Diagnostic Services

16

35

23

58

60.3%

52

29.9

57.5%

7

0

Access to Health Care Information

17

6

6

12

50.0%

51

19.0

37.3%

0

0

Outpatient Housing Unit

18

59

6

65

90.8%

48

44.4

92.5%

15

2

Internal Reviews

19

30

2

32

93.8%

40

30.0

75.0%

0

0

Inmate Transfers

20

12

0

12

100.0%

30

30.0

100.0%

3

0

Clinic Operations

21

27

0

27

100.0%

33

33.0

100.0%

0

0

Preventive Services

22

17

18

35

48.6%

30

14.5

48.3%

0

0

Pharmacy Services

23

10

1

11

90.9%

29

28.0

96.6%

0

0

Other Services

24

7

0

7

100.0%

10

10.0

100.0%

2

0

Inmate Hunger Strikes

25

9

0

9

100.0%

19

19.0

100.0%

0

0

Chemical Agent Contraindications

26

10

0

10

100.0%

17

17.0

100.0%

0

0

Staffing Levels and Training

27

8

0

8

100.0%

16

16.0

100.0%

1

0

Nursing Policy

28

15

0

15

100.0%

14

14.0

100.0%

0

0

74.7%

844

Totals

Bureau of Audits and Investigations
Office of the Inspector General

876

296

1172

646.4

76.6%

294

28

Page 7
State of California

Answers
Reference
Number

Chronic Care

Yes

No

Yes + No

Weighting Points
Yes %

Possible Received Score %

N/A

Unk

03.076

Was the inmate's most recent chronic care visit within the time frame
required by the degree of control of the inmate's condition based on his or
her prior visit?

11

13

24

45.8%

10

4.6

45.8%

0

0

03.077

Were key elements on Forms 7419 (Chronic Care Follow-Up Visit) and
7392 (Primary Care Flow Sheet) filled out completely for the inmate's two
most recent visits?

13

11

24

54.2%

10

5.4

54.2%

0

0

03.082

Did the institution document that it provided the inmate with health care
education?

20

4

24

83.3%

12

10.0

83.3%

0

0

03.175

Did the inmate receive his or her prescribed chronic care medications during
the most recent three-month period or did the institution follow
departmental policy if the inmate refused to pick up or show up for his or
her medications?

15

9

24

62.5%

18

11.3

62.5%

0

0

03.235

Is the clinical history adequate?

17

7

24

70.8%

18

12.8

70.8%

0

0

03.236

Is the focused clinical examination adequate?

18

5

23

78.3%

19

14.9

78.3%

1

0

03.237

Is the assessment adequate?

16

4

20

80.0%

19

15.2

80.0%

0

4

03.238

Is the plan adequate and consistent with the degree of control based on the
chronic care program intervention and follow up requirements?

16

1

17

94.1%

19

17.9

94.1%

1

6

03.262

Is the inmate's Problem List complete and filed accurately in the inmate's
unit health record (UHR)?

23

1

24

95.8%

8

7.7

95.8%

0

0

149

55

204

133

99.8

Components Subtotals:

Bureau of Audits and Investigations
Office of the Inspector General

73.0%

75.0%

2

10

Page 8
State of California

Answers
Reference
Number

Clinical Services

Yes

No

Yes + No

Weighting Points
Yes %

Possible Received Score %

N/A

Unk

01.024

RN FTF Documentation: Did the inmate's request for health care get
reviewed the same day it was received?

16

14

30

53.3%

4

2.1

53.3%

0

0

01.025

RN FTF Documentation: Did the RN complete the face-to-face (FTF) triage
within one (1) business day after the Form 7362 was reviewed?

21

9

30

70.0%

6

4.2

70.0%

0

0

01.246

Did documentation indicate that the RN reviewed all of the inmate's
complaints listed on Form 7362 (Health Care Services Request Form)?

24

3

27

88.9%

5

4.4

88.9%

2

1

01.157

RN FTF Documentation: Did the RN's subjective note address the nature
and history of the inmates primary complaint?

12

14

26

46.2%

7

3.2

46.2%

3

1

01.159

RN FTF Documentation: Did the RN's objective note include vital signs and
a focused physical examination, and did it adequately address the problems
noted in the subjective note?

9

17

26

34.6%

6

2.1

34.6%

3

1

01.244

RN FTF Documentation: Did the RN's objective note include allergies,
weight, current medication, and where appropriate, medication compliance?

3

23

26

11.5%

3

0.3

11.5%

3

1

01.158

RN FTF Documentation: Did the RN's assessment provide conclusions
based on subjective and objective data, were the conclusions formulated as
patient problems, and did it contain applicable nursing diagnoses?

19

6

25

76.0%

6

4.6

76.0%

3

2

01.162

RN FTF Documentation: Did the RN's plan include an adequate strategy to
address the problems identified during the FTF triage?

20

6

26

76.9%

7

5.4

76.9%

2

2

01.163

RN FTF Documentation: Did the RN's education/instruction adequately
address the problems identified during the FTF triage?

15

10

25

60.0%

5

3.0

60.0%

3

2

01.027

If the RN determined a referral to a primary care physician (PCP) was
necessary, was the inmate seen within the timelines specified by the RN
during the FTF triage?

9

8

17

52.9%

8

4.2

52.9%

13

0

01.247

Sick Call Follow-up: If the provider ordered a follow-up sick call
appointment, did it take place within the time frame specified?

1

0

1

100.0%

7

7.0

100.0%

29

0

Bureau of Audits and Investigations
Office of the Inspector General

Page 9
State of California

Answers
Reference
Number

Clinical Services

Yes

No

Yes + No

Weighting Points
Yes %

Possible Received Score %

N/A

Unk

01.124

Sick Call Medication: Did the institution administer or deliver prescription
medications (new orders) to the inmate within specified time frames?

13

15

28

46.4%

6

2.8

46.4%

2

0

15.234

Are clinic response bags audited daily and do they contain essential items?

0

2

2

0.0%

5

0.0

0.0%

0

0

21.278

For inmates seen in the TTA, was there adequate prior management of preexisting medical conditions related to the reason for the TTA visit?

9

4

13

69.2%

20

13.8

69.2%

10

2

95

57.1

60.1%

73

Components Subtotals:

Bureau of Audits and Investigations
Office of the Inspector General

171 131

302

56.6%

12

Page 10
State of California

Answers
Reference
Number

Health Screening

Yes

No

Weighting Points

Yes + No

Yes %

Possible Received Score %

N/A

Unk

02.016

Did the institution complete the initial health screening on the same day the
inmate arrived at the institution?

20

0

20

100.0%

9

9.0

100.0%

0

0

02.017

If yes was answered to any of the questions on the initial health screening
form(s), did the RN provide an assessment and disposition on the date of
arrival?

12

0

12

100.0%

8

8.0

100.0%

8

0

02.018

If, during the assessment, the RN referred the inmate to a clinician, was the
inmate seen within the time frame?

7

2

9

77.8%

8

6.2

77.8%

11

0

02.020

Did the LVN/RN adequately document the tuberculin test or a review of
signs and symptoms if the inmate had a previous positive tuberculin test?

18

2

20

90.0%

6

5.4

90.0%

0

0

02.015

Was a review of symptoms completed if the inmate's tuberculin test was
positive, and were the results reviewed by the infection control nurse?

0

0

0

0.0%

0

0.0

0.0%

20

0

02.128

If the inmate had an existing medication order upon arrival at the institution,
did the inmate receive the medications by the next calendar day, or did a
physician explain why the medications were not to be continued?

0

3

3

0.0%

8

0.0

0.0%

17

0

02.007

Non-reception center: Does the health care transfer information form
indicate that it was reviewed and signed by licensed health care staff within
one calendar day of the inmate's arrival at the institution?

19

0

19

100.0%

7

7.0

100.0%

0

1

02.014

Non-reception center: If the inmate was scheduled for a specialty
appointment at the sending institution, did the receiving institution schedule
the appointment within 30 days of the original appointment date?

0

0

0

0.0%

0

0.0

0.0%

19

1

02.111

Non-reception center: Did the inmate receive medical accommodations
upon arrival, if applicable?

4

0

4

100.0%

6

6.0

100.0%

16

0

80

7

87

52

41.6

91

2

Components Subtotals:

Bureau of Audits and Investigations
Office of the Inspector General

92.0%

80.0%

Page 11
State of California

Answers
Reference
Number

Specialty Services

Yes

No

Yes + No

Weighting Points
Yes %

Possible Received Score %

N/A

Unk

07.037

Did the institution approve or deny the PCP's request for specialty services
within the specified time frames?

9

12

21

42.9%

8

3.4

42.9%

0

0

07.038

Did the PCP see the inmate between the date the PCP ordered the service
and the date the inmate received it, in accordance with specified time
frames?

3

0

3

100.0%

8

8.0

100.0%

18

0

07.035

Did the inmate receive the specialty service within specified time frames?

15

2

17

88.2%

9

7.9

88.2%

4

0

07.090

Physical therapy services: Did the physical therapist assess the inmate and
document the treatment plan and treatment provided to the inmate?

2

0

2

100.0%

8

8.0

100.0%

19

0

07.043

Did the PCP review the consultant's report and see the inmate for a followup appointment after the specialty services consultation within specified
time frames?

6

8

14

42.9%

9

3.9

42.9%

7

0

07.260

Was the institution's denial of the PCP's request for specialty services
consistent with the "medical necessity" requirement?

4

1

5

80.0%

9

7.2

80.0%

0

0

07.259

Was there adequate documentation of the reason for the denial of specialty
services?

4

1

5

80.0%

5

4.0

80.0%

0

0

07.270

Did the specialty provider provide timely findings and recommendations or
did an RN document that he or she called the specialty provider to ascertain
the findings and recommendations?

17

0

17

100.0%

6

6.0

100.0%

4

0

07.261

Is the institution scheduling high-priority (urgent) specialty services within
14 days?

1

1

2

50.0%

9

4.5

50.0%

0

0

61

25

86

71

52.9

74.5%

52

0

Components Subtotals:

Bureau of Audits and Investigations
Office of the Inspector General

70.9%

Page 12
State of California

Answers
Reference
Number

Urgent Services

Yes

No

Yes + No

Weighting Points
Yes %

Possible Received Score %

N/A

Unk

21.248

Upon the inmate's discharge from the community hospital, did the triage
and treatment area (TTA) registered nurse document that he or she reviewed
the inmate's discharge plan and completed a face-to-face assessment of the
inmate?

24

1

25

96.0%

7

6.7

96.0%

0

0

21.250

Upon the inmate's discharge from the community hospital, did the inmate's
Primary Care Provider (PCP) provide orders for appropriate housing for the
inmate?

25

0

25

100.0%

7

7.0

100.0%

0

0

21.251

Upon the inmate's discharge from the community hospital, did the
Registered Nurse intervene if the inmate was housed in an area that was
inappropriate for nursing care based on the primary care provider's (PCP)
housing orders?

0

0

0

0.0%

0

0.0

0.0%

25

0

21.249

Upon the inmate's discharge from the community hospital, did the inmate
receive a follow-up appointment with his or her primary care provider
(PCP) within five calendar days of discharge?

20

5

25

80.0%

7

5.6

80.0%

0

0

21.281

Upon the inmate's discharge from a community hospital, did the institution
administer or deliver all prescribed medications to the inmate within
specified time frames?

8

6

14

57.1%

6

3.4

57.1%

11

0

21.275

Was the documentation of the clinical care provided in the TTA adequate?

22

3

25

88.0%

10

8.8

88.0%

0

0

21.276

While the patient was in the TTA, was the clinical care rendered by the
attending provider adequate and timely?

22

2

24

91.7%

7

6.4

91.7%

0

1

21.279

For patients managed by telephone consultation alone, was the provider's
decision not to come to the TTA appropriate?

16

0

16

100.0%

8

8.0

100.0%

8

1

137

17

154

52

45.9

44

2

Components Subtotals:

Bureau of Audits and Investigations
Office of the Inspector General

89.0%

88.3%

Page 13
State of California

Answers
Reference
Number

Emergency Services

Yes

No

Weighting Points

Yes + No

Yes %

Possible Received Score %

N/A

Unk

08.183

Was the medical emergency responder notified of the medical emergency
without delay?

4

0

4

100.0%

5

5.0

100.0%

0

0

08.241

Did the first responder provide adequate basic life support (BLS) prior to
medical staff arriving?

0

0

0

0.0%

0

0.0

0.0%

4

0

08.184

Did the medical emergency responder arrive at the location of the medical
emergency within five (5) minutes of initial notification?

3

1

4

75.0%

4

3.0

75.0%

0

0

08.185

Did the medical emergency responder use proper equipment to address the
emergency and was adequate medical care provided within the scope of his
or her license?

4

0

4

100.0%

7

7.0

100.0%

0

0

08.242

Did licensed health care staff call 911 without unnecessary delay after a lifethreatening condition was identified by a licensed health care provider or
peace officer?

3

1

4

75.0%

6

4.5

75.0%

0

0

08.187

Did the institution provide adequate preparation for the ambulance's arrival,
access to the inmate, and departure?

4

0

4

100.0%

4

4.0

100.0%

0

0

08.186

Were both the first responder (if peace officer or licensed health care staff)
and the medical emergency responder basic life support (BLS) certified at
the time of the incident?

4

0

4

100.0%

4

4.0

100.0%

0

0

08.222

Were the findings of the institution's Emergency Medical Response Review
Committee (EMRRC) supported by the documentation and completed
within 30 days?

1

3

4

25.0%

7

1.8

25.0%

0

0

15.240

Emergency Medical Response Drill: Did the responding officer activate the
emergency response system by providing the pertinent information to the
relevant parties, immediately and without delay?

1

0

1

100.0%

2

2.0

100.0%

0

0

15.255

Emergency Medical Response Drill: Did the responding officer carry and
use the proper equipment (protective shield or micro-mask, gloves) required
by the department?

1

0

1

100.0%

1

1.0

100.0%

0

0

Bureau of Audits and Investigations
Office of the Inspector General

Page 14
State of California

Answers
Reference
Number

Emergency Services

Yes

No

Weighting Points

Yes + No

Yes %

Possible Received Score %

N/A

Unk

15.256

Emergency Medical Response Drill: Did the responding officer properly
perform an assessment on the patient for responsiveness?

1

0

1

100.0%

1

1.0

100.0%

0

0

15.257

Emergency Medical Response Drill: Did the responding officer properly
perform CPR?

1

0

1

100.0%

2

2.0

100.0%

0

0

15.258

Emergency Medical Response Drill: Did the responding officer begin CPR
without unnecessary delay?

1

0

1

100.0%

2

2.0

100.0%

0

0

15.282

Emergency Medical Response Drill: Did medical staff arrive on scene in
five minutes or less?

1

0

1

100.0%

2

2.0

100.0%

0

0

15.283

Emergency Medical Response Drill: Did the emergency medical responders
arrive with proper equipment (ER bag, bag-valve-mask, AED)?

1

0

1

100.0%

1

1.0

100.0%

0

0

15.284

Emergency Medical Response Drill: Did the responding officer provide
accurate information to responding medical staff?

1

0

1

100.0%

1

1.0

100.0%

0

0

15.285

Emergency Medical Response Drill: Did emergency medical responders
continue basic life support?

1

0

1

100.0%

1

1.0

100.0%

0

0

15.287

Emergency Medical Response Drill: Was 911 called without unnecessary
delay?

1

0

1

100.0%

2

2.0

100.0%

0

0

33

5

38

52

44.3

Components Subtotals:

Bureau of Audits and Investigations
Office of the Inspector General

86.8%

85.2%

4

0

Page 15
State of California

Answers
Reference
Number

Diagnostic Services

Yes

No

Yes + No

Weighting Points
Yes %

Possible Received Score %

N/A

Unk

06.049

Radiology order: Was the radiology service provided within the time frame
specified in the physician's order?

4

1

5

80.0%

7

5.6

80.0%

0

0

06.245

Radiology order: Was the diagnostic report received by the institution
within 14 days?

1

4

5

20.0%

8

1.6

20.0%

0

0

06.200

Radiology order: Did the primary care provider (PCP) review the diagnostic
report and initiate written notice to the inmate within two (2) business days
of the date the institution received the diagnostic reports?

1

4

5

20.0%

7

1.4

20.0%

0

0

06.188

All laboratory orders: Was the specimen collected within the applicable time
frames of the physician's order?

7

3

10

70.0%

6

4.2

70.0%

0

0

06.191

All diagnostic services: Did the PCP document the clinically significant
diagnostic test results on Form 7230 (Interdisciplinary Progress Notes)?

10

4

14

71.4%

7

5.0

71.4%

1

0

06.263

All diagnostic services: Did the PCP adequately manage clinically
significant test results?

9

0

9

100.0%

10

10.0

100.0%

6

0

06.202

All laboratory orders: Did the PCP review the diagnostic reports and initiate
written notice to the inmate within two (2) business days of the date the
institution received the diagnostic reports?

3

7

10

30.0%

7

2.1

30.0%

0

0

35

23

58

52

29.9

Components Subtotals:

Bureau of Audits and Investigations
Office of the Inspector General

60.3%

57.5%

7

0

Page 16
State of California

Answers
Reference
Number

Access to Health Care Information

Yes

No

Yes + No

Weighting Points
Yes %

Possible Received Score %

N/A

Unk

19.150

Is the medical records office current with its loose filing?

0

1

1

0.0%

9

0.0

0.0%

0

0

19.169

Did medical records staff make unit health records (UHR) available to clinic
staff for the inmates ducated for medical appointments the next day?

2

0

2

100.0%

15

15.0

100.0%

0

0

19.243

Was the institution able to account for the OIG's requested UHR files?

0

1

1

0.0%

12

0.0

0.0%

0

0

19.266

Does the institution properly file inmates' medical information?

0

1

1

0.0%

5

0.0

0.0%

0

0

19.271

While reviewing unit health records (UHR) as part of the OIG's inspection,
were the OIG's RN and MD inspectors able to locate all relevant
documentation of health care provided to inmates?

4

1

5

80.0%

5

4.0

80.0%

0

0

19.272

Does the institution promptly file blood pressure logs in unit health records
(UHR)?

0

2

2

0.0%

5

0.0

0.0%

0

0

6

6

12

50.0%

51

19.0

Components Subtotals:

Bureau of Audits and Investigations
Office of the Inspector General

37.3%

0

0

Page 17
State of California

Answers
Reference
Number

Outpatient Housing Unit

Yes

No

10

Weighting Points

Yes + No

Yes %

Possible Received Score %

0

10

100.0%

5

5.0

N/A

Unk

100.0%

0

0

04.052

Did the RN complete an initial assessment of the inmate on the day of
placement?

04.051

Did the primary care provider (PCP) evaluate the inmate within one
calendar day after placement?

9

1

10

90.0%

5

4.5

90.0%

0

0

04.053

While the inmate was placed in the OHU, did the PCP complete the
Subjective, Objective, Assessment, Plan and Education (SOAPE) at a
minimum of every 14 days?

2

0

2

100.0%

4

4.0

100.0%

8

0

04.054

Did the utilization management (UM) nurse assess the inmate within one
week of the inmate's placement and every 30 days thereafter?

3

0

3

100.0%

4

4.0

100.0%

7

0

04.112

Was the PCP's initial evaluation adequate for the problem(s) requiring OHU
placement?

8

2

10

80.0%

5

4.0

80.0%

0

0

04.230

Was the PCP's initial assessment (or diagnoses) appropriate for the findings
in the initial evaluation?

8

1

9

88.9%

5

4.4

88.9%

0

1

04.056

Did the PCP's plan adequately address the initial assessment?

8

1

9

88.9%

5

4.4

88.9%

0

1

04.208

Was the level of care available in the OHU appropriate to the patient's
clinical presentation?

9

1

10

90.0%

9

8.1

90.0%

0

0

15.103

In the outpatient housing unit (OHU), are patient call buttons operational or
does medical staff make rounds every 30 minutes?

1

0

1

100.0%

3

3.0

100.0%

0

0

15.225

Does the OHU use disinfectant daily in common patient areas?

1

0

1

100.0%

3

3.0

100.0%

0

0

59

6

65

48

44.4

15

2

Components Subtotals:

Bureau of Audits and Investigations
Office of the Inspector General

90.8%

92.5%

Page 18
State of California

Answers
Reference
Number

Internal Reviews

Yes

No

Yes + No

Weighting Points
Yes %

Possible Received Score %

N/A

Unk

17.221

Did the institution complete a medical emergency response drill for each
watch and include participation from each medical facility during the most
recent full quarter?

0

1

1

0.0%

5

0.0

0.0%

0

0

17.174

Did the institution promptly process inmate medical appeals during the most
recent 12 months?

0

1

1

0.0%

5

0.0

0.0%

0

0

17.136

For each death sampled, did the institution complete the death review
process?

3

0

3

100.0%

5

5.0

100.0%

0

0

17.132

Do the Emergency Medical Response Review Committee (EMRRC)
meeting minutes document monthly meetings for the last six (6) months?

6

0

6

100.0%

5

5.0

100.0%

0

0

17.138

Do the Emergency Medical Response Review Committee (EMRRC)
meeting minutes document the warden's (or his or her designee's)
attendance?

6

0

6

100.0%

5

5.0

100.0%

0

0

17.118

Do the Quality Management Committee (QMC) meeting minutes document
monthly meetings for the last six (6) months?

6

0

6

100.0%

5

5.0

100.0%

0

0

17.119

Did the Quality Management Committee (QMC) report its findings to the
HCM/CMO each of the last six (6) meetings?

6

0

6

100.0%

5

5.0

100.0%

0

0

17.135

Did the last three Quality Management Committee (QMC) meeting minutes
reflect findings and strategies for improvement?

3

0

3

100.0%

5

5.0

100.0%

0

0

30

2

32

40

30.0

Components Subtotals:

Bureau of Audits and Investigations
Office of the Inspector General

93.8%

75.0%

0

0

Page 19
State of California

Answers
Reference
Number

Inmate Transfers

Yes

No

Weighting Points

Yes + No

Yes %

Possible Received Score %

N/A

Unk

05.108

Did Receiving and Release have the inmate's UHR and transfer envelope?

3

0

3

100.0%

7

7.0

100.0%

0

0

05.109

If the inmate was scheduled for any upcoming specialty services, were the
services noted on Form 7371 (Health Care Transfer Information)?

0

0

0

0.0%

0

0.0

0.0%

3

0

05.110

Do all appropriate forms in the transfer envelope identify all medications
ordered by the physician, and are the medications in the transfer envelope?

3

0

3

100.0%

8

8.0

100.0%

0

0

05.171

Did an RN accurately complete all applicable sections of Form 7371
(Health Care Transfer Information) based on the inmate's UHR?

3

0

3

100.0%

7

7.0

100.0%

0

0

05.172

Did the Health Records Department maintain a copy of the inmate's Form
7371 (Health Care Transfer Information) and Form 7231A (Outpatient
Medication Administration Record) when the inmate transferred?

3

0

3

100.0%

8

8.0

100.0%

0

0

12

0

12

100.0%

30

30.0

Components Subtotals:

Bureau of Audits and Investigations
Office of the Inspector General

100.0%

3

0

Page 20
State of California

Answers
Reference
Number

Clinic Operations

Yes

No

Weighting Points

Yes + No

Yes %

Possible Received Score %

N/A

Unk

14.023

Does the institution make the Form 7362 (Health Care Services Request
Form) available to inmates?

5

0

5

100.0%

4

4.0

100.0%

0

0

14.164

Are areas available to ensure privacy during RN face-to-face assessments
and doctors' examinations for non-emergencies?

3

0

3

100.0%

3

3.0

100.0%

0

0

14.166

Was the medication stored in a sealed container if food was present in the
clinic refrigerator?

2

0

2

100.0%

2

2.0

100.0%

0

0

14.131

Do medication nurses understand that medication is to be administered by
the same licensed staff member who prepares it and on the same day?

2

0

2

100.0%

4

4.0

100.0%

0

0

14.106

Does clinical staff wash their hands (either with soap or hand sanitizer) or
change gloves between patients?

4

0

4

100.0%

4

4.0

100.0%

0

0

14.033

Does the institution have an adequate process to ensure inmates who are
moved to a new cell still receive their medical ducats?

2

0

2

100.0%

4

4.0

100.0%

0

0

14.032

Does medical staff understand the institution's priority ducat process?

2

0

2

100.0%

2

2.0

100.0%

0

0

14.160

Does the institution have a process to identify, review, and address urgent
appointments if a doctor's line is canceled?

2

0

2

100.0%

4

4.0

100.0%

0

0

14.029

Does medical staff in the facility clinic know which inmates are on modified
program or confined to quarters (CTQ) and does staff have an adequate
process to ensure those inmates receive their medication?

2

0

2

100.0%

4

4.0

100.0%

0

0

14.165

Are the clinic floors, waiting room chairs, and equipment cleaned with a
disinfectant daily?

3

0

3

100.0%

2

2.0

100.0%

0

0

27

0

27

100.0%

33

33.0

Components Subtotals:

Bureau of Audits and Investigations
Office of the Inspector General

100.0%

0

0

Page 21
State of California

Answers
Reference
Number

Preventive Services

Yes

No

Yes + No

Weighting Points
Yes %

Possible Received Score %

N/A

Unk

10.228

Inmates prescribed INH: Did the institution properly administer the
medication to the inmate?

1

4

5

20.0%

6

1.2

20.0%

0

0

10.232

Inmates prescribed INH: Did the institution monitor the inmate monthly for
the most recent three months he or she was on the medication?

1

4

5

20.0%

6

1.2

20.0%

0

0

10.229

Inmates with TB code 34: Was the inmate evaluated for signs and symptoms
of TB within the previous 12 months?

4

1

5

80.0%

7

5.6

80.0%

0

0

10.086

All inmates age 66 or older: Did the inmate receive an influenza vaccination
within the previous 12 months or was the inmate's refusal documented?

10

0

10

100.0%

6

6.0

100.0%

0

0

10.085

Male inmates age 51 or older: Did the inmate receive a fecal occult blood
test (FOBT) within the previous 12 months or was the inmate's refusal
documented?

1

9

10

10.0%

5

0.5

10.0%

0

0

17

18

35

30

14.5

Components Subtotals:

Bureau of Audits and Investigations
Office of the Inspector General

48.6%

48.3%

0

0

Page 22
State of California

Answers
Reference
Number

Pharmacy Services

Yes

No

Weighting Points

Yes + No

Yes %

Possible Received Score %

N/A

Unk

13.139

Does the institution conspicuously post a valid permit in its pharmacies?

1

0

1

100.0%

2

2.0

100.0%

0

0

13.141

Does the institution properly maintain its emergency crash cart
medications?

1

0

1

100.0%

2

2.0

100.0%

0

0

13.252

Does the institution properly maintain medications in its after-hours
medication supply(ies)?

1

1

2

50.0%

2

1.0

50.0%

0

0

13.253

Does the institution conduct monthly inspections of its emergency cart and
after-hours medication supply(ies)?

3

0

3

100.0%

1

1.0

100.0%

0

0

13.142

Is the Pharmacist in Charge's license current?

1

0

1

100.0%

5

5.0

100.0%

0

0

13.144

Does the institution have information to ensure that medications are
prescribed by licensed health-care providers lawfully authorized to do so?

1

0

1

100.0%

6

6.0

100.0%

0

0

13.145

Does the pharmacist in charge have an effective process for screening new
medication orders for potential adverse reactions?

1

0

1

100.0%

7

7.0

100.0%

0

0

13.148

Does the pharmacist in charge monitor the quantity of medications on hand,
and does the pharmacy conduct an annual inventory to ensure that the
quantity of medications in the system matches the quantity of medications
on hand?

1

0

1

100.0%

4

4.0

100.0%

0

0

10

1

11

29

28.0

Components Subtotals:

Bureau of Audits and Investigations
Office of the Inspector General

90.9%

96.6%

0

0

Page 23
State of California

Answers
Reference
Number

Other Services

Yes

No

Yes + No

Weighting Points
Yes %

Possible Received Score %

N/A

Unk

15.059

Did the institution properly provide therapeutic diets to inmates?

0

0

0

0.0%

0

0.0

0.0%

1

0

15.058

If the institution does not offer therapeutic diets, does staff know the
department's procedures for transferring inmates who are determined to
require a therapeutic diet?

1

0

1

100.0%

3

3.0

100.0%

0

0

15.134

Did the institution properly respond to all active cases of TB discovered in
the last six months?

0

0

0

0.0%

0

0.0

0.0%

1

0

15.265

Is the most current version of the CDCR Health Services Policies and
Procedures available in the institution's law library?

2

0

2

100.0%

3

3.0

100.0%

0

0

20.092

Hygiene Intervention: Did custody staff understand the department's
policies and procedures for identifying and evaluating inmates displaying
inappropriate hygiene management?

4

0

4

100.0%

4

4.0

100.0%

0

0

7

0

7

100.0%

10

10.0

Components Subtotals:

Bureau of Audits and Investigations
Office of the Inspector General

100.0%

2

0

Page 24
State of California

Answers
Reference
Number

Inmate Hunger Strikes

Yes

No

Weighting Points

Yes + No

Yes %

Possible Received Score %

N/A

Unk

11.097

Did the RN conduct a face-to-face triage of the inmate within two (2)
business days of receipt of the Form 128-B and document the inmate's
reasons for the hunger strike, most recent recorded weight, current weight,
vital signs, and physical condition?

3

0

3

100.0%

6

6.0

100.0%

0

0

11.099

After the first 48 hours, did an RN or PCP complete daily assessments
documenting the inmate's weight, physical condition, emotional condition,
vital signs, and hydration status?

3

0

3

100.0%

6

6.0

100.0%

0

0

11.100

After the first 72 hours, did a physician perform a physical examination and
order a metabolic panel and a urinalysis of the inmate?

3

0

3

100.0%

7

7.0

100.0%

0

0

9

0

9

100.0%

19

19.0

Components Subtotals:

Bureau of Audits and Investigations
Office of the Inspector General

100.0%

0

0

Page 25
State of California

Answers
Reference
Number

Chemical Agent Contraindications

Yes

No

Weighting Points

Yes + No

Yes %

Possible Received Score %

N/A

Unk

12.062

Did the institution document that it consulted with an RN or primary care
provider (PCP) before a calculated use of OC?

5

0

5

100.0%

9

9.0

100.0%

0

0

12.064

Did the institution record how it decontaminated the inmate and did it
follow the decontamination policy?

5

0

5

100.0%

8

8.0

100.0%

0

0

10

0

10

100.0%

17

17.0

Components Subtotals:

Bureau of Audits and Investigations
Office of the Inspector General

100.0%

0

0

Page 26
State of California

Answers
Reference
Number

18.002

Staffing Levels and Training
Information purposes only: Calculate the institution's average vacancy
percentages, the number of health care staff starting within six (6) months of
the OIG visit, and the number of health care staff hired from the registry.

Yes + No

Weighting Points

Yes

No

Yes %

Possible Received Score %

0

0

0

0.0%

0

0.0

N/A

Unk

0.0%

1

0

The institution provided vacancy statistics within four licensed medical
staffing groups: (1) management; (2) primary care providers; (3)
supervision; and (4) rank and file nursing.
Total number of filled positions: 72.9
Total number of vacancies: 3.5
Total number of positions: 76.4
Vacancy percentage: 4.58%
Number of staff hired within last six months: 10.2
Total number of registry staff: 10
18.004

Did the institution have a registered nurse (RN) available on site 24 hours a
day, seven days a week, for emergency care?

1

0

1

100.0%

4

4.0

100.0%

0

0

18.005

Did the institution have a physician on site, a physician on call, or an MOD
available 24 hours a day, seven days a week, for the last 30 days?

1

0

1

100.0%

4

4.0

100.0%

0

0

18.006

Does the institution's orientation program for all newly hired nursing staff
include a module for sick call protocols that require face-to-face triage?

1

0

1

100.0%

4

4.0

100.0%

0

0

18.001

Are licensed health care staff current with their certifications and did they
attend required training?

5

0

5

100.0%

4

4.0

100.0%

0

0

8

0

8

100.0%

16

16.0

Components Subtotals:

Bureau of Audits and Investigations
Office of the Inspector General

100.0%

1

0

Page 27
State of California

Answers
Reference
Number

Nursing Policy

Yes

No

Weighting Points

Yes + No

Yes %

Possible Received Score %

N/A

Unk

16.231

Does the institution ensure that nursing staff review their duty statements?

5

0

5

100.0%

5

5.0

100.0%

0

0

16.154

Does the institution have written nursing policies and procedures that
adhere to the department's guidelines?

5

0

5

100.0%

5

5.0

100.0%

0

0

16.254

Does the institution's supervising registered nurse (SRN) conduct periodic
reviews of nursing staff?

5

0

5

100.0%

4

4.0

100.0%

0

0

15

0

15

100.0%

14

14.0

Components Subtotals:

Bureau of Audits and Investigations
Office of the Inspector General

100.0%

0

0

Page 28
State of California

California Prison Health Care
Receivership Corporation's
Response

Bureau of Audits and Investigations
Office of the Inspector General

Page 29
State of California

STATE OF CALIFORNIA

J. Clark Kelso, Receiver

PRISON HEALTH CARE SERVICES

July 1,2010

David R. Shaw, Inspector General
Office ofthe Inspector General
P.O. Box 348780
Sacramento, CA 95834-8780
Dear Mr. Shaw,
The purpose of this letter is to inform you that the Office of the Receiver has reviewed the draft
report of the Office ofthe Inspector General's (OIG) Medical Inspection Results (MIR) for the
April 2010 inspection of Calipatria State Prison (CAL). At this time, we would like to
acknowledge that CAL accepts all OIG findings and will formulate corrective action plans for
each of the deficiencies noted that were rated 60% or less.
Thank you for preparing the report. Your efforts have advanced our mutual objective of
ensuring transparency and accountability in the California Prison Health Care Services
operations. Should you have any questions or concerns, please contact Olga Durette, Health
Program Manager II, Program Compliance Section at (916) 322-7669.
Sincerely,

KATHLEEN WEBB, Director
Policy and Risk Management Services
California Prison Health Care Services
cc:

1. Clark Kelso, Receiver
Elaine Bush, ChiefDeputy, Office of the Receiver
Dwight W. Winslow, M.D., Chief Physician Executive, Medical Services
Karen Rea, Statewide ChiefNurse Executive
Brenda Epperly-Ellis, Director, Allied Health Services
Starr Babcock, Special Assistagt to the Court
Mary Jo Bruns, Southern Regional Administrator
Steve Ritter, Southern Regional Medical Executive
Susan Scott, Southern Regional ChiefNurse Executive
K. Ball, Health Care Manager, CAL
Steve Fama, Attorney, Prison Law Office
Nancy Faszer, Deputy Inspector General In-Charge
Bernie Fernandez, Deputy Inspector General Senior
Rob Hughes, Deputy Inspector General
Sueann Gawel, Deputy Inspector General

P.O. Box 4038 • Sacramento, CA 95812-4038

David R. Shaw, Inspector General
July 1,2010
Page 2
Matthew Espenshade, Deputy Inspector General
Johnny Hui, Chief ofIntemal Audit, CPHCS
Olga Durette, Health Program Manager II, Program Compliance Section