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California Office of the Inspector General Prison Medical Inspection Results 2011

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MEDICAL INSPECTION RESULTS
S UM M A RY A N D A N A LYSIS OF T HE F IRST CYCL E
O F M E D I C A L I N S P E CT IONS OF CAL IF ORNIA’S
33 AD U LT P R I S O N S

OFFICE OF THE
INSPECTOR GENERAL

S TAT E O F C A L I F O R N I A
M AY 2 0 11

Bruce A..1,[onjross, Inspector General (.4.)

Office ofthe Inspector General

May 4, 2011

J. Clark Kelso, Receiver
California Prison Health Care Receivership Corporation
50 I ] Street, Suite 100
Sacramento, California 95814
Dear Mr. Kelso:
Enclosed is the Office of the Inspector General's (OIG) final report on the first cycle of medical
inspections of the 33 adult prisons operated by the California Department of Corrections and
Rehabilitation (CDCR). The repOlt analyzes and summarizes the prisons' overall scores and their
scores in up to 20 components of prison medical care. The report also includes analysis of the
scores in five general medical categories - medication management, access to medical providers
and services, primary care provider responsibilities, continuity of care, and nurse responsibilities.
Results indicate that the Receiver has not yet implemented a system that ensures that CDCR
medical policies and procedures are followed across the prison system. However, the higher
scores by some prisons in some component areas and medical categories demonstrate that
system-wide improvement can be achieved. A copy of the report can also be fowld on our
website at www.oig.ca.gov.
Please call Nancy Faszer, Deputy Inspector General, In-Charge, at (916) 830-3600 if you have
any questions.
Sincerely,

~MONr-O-SS-Inspector

neral ( )

Enclosures (if applicable)
cc:

Kathleen Webb, Director, Policy and Risk Management Services
Matthew Cate, Secretary, California Department of Corrections and Rehabilitation

Edmund G. Brown, Jr., Governor
P.O. Box 348780, SACRAMENTO, CALIFORNIA 95834-8780 PHONE (916) 830-3600 FAX (916) 928-4684

Contents
Executive Summary .................................................................................................................... 1
Introduction ................................................................................................................................. 5
OIG Medical Inspection Program ......................................................................................... 5
Objectives, Scope, and Methodology ................................................................................... 9
Results of the First Cycle of Medical Inspections .................................................................... 12
Overall Scores and Medical Components ............................................................................ 15
Chronic Care ................................................................................................................. 20
Clinical Services ........................................................................................................... 22
Health Screening ........................................................................................................... 24
Specialty Services ......................................................................................................... 28
Urgent Services ............................................................................................................. 30
Emergency Services ...................................................................................................... 32
Prenatal Care/Childbirth/Post-Delivery ........................................................................ 36
Diagnostic Services ....................................................................................................... 38
Access to Health Care Information ............................................................................... 40
Outpatient Housing Unit ............................................................................................... 42
Internal Reviews ........................................................................................................... 44
Inmate Transfers ............................................................................................................ 46
Clinic Operations .......................................................................................................... 48
Preventive Services ....................................................................................................... 50
Pharmacy Services ........................................................................................................ 52
Other Services ............................................................................................................... 54
Inmate Hunger Strikes .................................................................................................. 56
Chemical Agent Contraindications ............................................................................... 58
Staffing Levels and Training ......................................................................................... 60
Nursing Policy .............................................................................................................. 64
General Medical Categories ...................................................................................................... 66
Medication Management .............................................................................................. 70
Access to Providers and Services ................................................................................. 74
Primary Care Provider Responsibilities ........................................................................ 78
Continuity of Care.......................................................................................................... 82
Nurse Responsibilities .................................................................................................. 84

Conclusion ................................................................................................................................ 88
Appendices ................................................................................................................................ 90
Appendix Preface ................................................................................................................ 90
Appendix Table of Contents ............................................................................................... 91
A: Component Definitions .................................................................................................. 92
B: Prisonsʼ Scores by Component ....................................................................................... 93
C: Component Questions and Scores .................................................................................. 94
D: Category Questions and Scores .................................................................................... 140
California Prison Health Care Receivership Corporationʼs Response .................................... 164

Executive Summary
This report summarizes and analyzes the results of the Office of the Inspector General’s
(OIG) medical inspections of the 33 adult prisons operated by the California Department of
Corrections and Rehabilitation (CDCR). These 33 medical inspections denote the completion
of the Office of the Inspector General’s first cycle of prison medical inspections.
Background
As the result of the federal court class action lawsuit known as Plata v. Schwarzenegger,
medical care at California’s 33 prisons is the responsibility of a federal Receiver appointed
by the United States District Court for the Northern District of California (Court). The Court
appointed the Receiver in 2006 to raise the quality of medical care in California’s prisons to
constitutional standards.
At the Court’s and the Receiver’s request, the OIG developed a comprehensive inspection
program to evaluate the quality of medical care at each prison. In September 2008, we began
our statewide inspections using teams of physicians, registered nurses, deputy inspectors
general, and analysts. For the first cycle of medical inspections, the 166-question inspection
program used “yes” and “no” answers to assess the prisons’ compliance with CDCR’s medical
policies and procedures as well as with community standards in 20 key components of prison
medical care. The questions are weighted based on their importance to the delivery of medical
care to inmates. Compliance is measured in “yes” answers. Our inspections result in weighted
component scores and an overall weighted score for each prison.
All parties to the lawsuit agreed that the OIG should primarily measure prisons’ compliance
with the aforementioned CDCR medical policies and procedures. However, the Court has yet
to define what level of compliance with those policies and procedures meets constitutional
standards. Therefore, by agreement with the Court and the Receiver, our inspections do not
conclude whether a prison has passed or failed an inspection. Instead, we report each prison’s
percentage of compliance with CDCR medical policies and procedures and, in the absence of
such policies and procedures, appropriate medical community standards.
Unlike the individual inspection reports, this 33-prison report puts the prisons’ scores into a
qualitative context. We do so by comparing the prisons’ average and individual scores to the
Receiver’s scoring criteria for three levels of adherence to policies and procedures. Thus a 75
percent score is the minimum score for moderate adherence. Scores below 75 percent denote low
adherence, while those above 85 percent reflect high adherence. In providing a qualitative context
to the percentage scores, it is not our intention to determine or imply the percentage score that
meets a constitutional standard of medical care. That determination remains with the Court.
This is our second report summarizing and analyzing the results of our prison medical
inspections. Using the Receiver’s scoring criteria, we issued a report in August 2010 at the
halfway point of the first cycle of 33 prison medical inspections. That report, which covered
the 17 prisons initially inspected, found that only two of the 17 prisons achieved overall scores
State of California • May 2011

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that exceeded the Receiver’s minimum score for moderate adherence. The 17 prisons’ average
overall score was 70 percent, and we found significant problems with how the prisons managed
inmates’ medications and how they provided inmates access to medical providers and services.
Results in Brief
The results of our first 33 medical inspections demonstrate that the Receiver and CDCR can
improve prisons’ compliance with CDCR medical policies and procedures and selected medical
community standards in a number of areas.
Only nine of the 33 prisons met or exceeded the 75 percent minimum score for moderate
adherence, and no prison achieved high adherence. Twenty-four of the 33 prisons performed
below the minimum score for moderate adherence, but 12 were close, with scores of 70 percent
to 74 percent; the average overall weighted score was 72 percent. Prisons’ scores ranged from
83 percent for Folsom State Prison down to 62 percent for High Desert State Prison. Folsom
State Prison is the only prison to achieve moderate or high adherence in the six most heavily
weighted components of the inspection program.
We also reviewed the 33 prisons’ performance in these five general medical categories:
medication management; access to medical providers and services; primary care provider
responsibilities; continuity of care; and nurse responsibilities. In doing so, we noted two
significant recurring problems. First, nearly all prisons were ineffective at ensuring that inmates
receive their medications. Thirty of the 33 prisons either failed to timely administer, provide,
or deliver medications or failed to document that they had done so. The 33 prisons’ average
score of 59 percent in medication management was significantly below the minimum score for
moderate adherence.
Numerous prisons were significantly noncompliant in the following medication management
tasks: delivering sick call medications (new orders) to inmates; providing chronic care
medications; providing medications to inmates within one day of arrival at the prison;
delivering medications to inmates upon discharge from an outside hospital; and administering
tuberculosis medications.
Since failures in compliance with medication management policies can stem from a failure to
provide medications or from a failure to document having provided medications, we do not
know the extent to which either cause contributed to prisons’ poor performance in this area.
However, our inspections found numerous instances in which the documentation suggests
that inmates did not receive their medications, including Isoniazid, a medication that controls
tuberculosis. We conclude, therefore, that the prisons are not merely failing to document that
inmates received their medications; they are also failing to provide the medications to the
inmates. Both types of failure denote noncompliance and poor performance.
The second recurring problem among the 33 prisons was poor access to medical providers
and services. Prisons were generally ineffective at ensuring that inmates are seen or provided

Bureau of Audits, Office of the Inspector General

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services for routine, urgent, and emergency medical needs according to timelines set by CDCR
policy. Effective prison medical care depends on inmates’ timely access to providers and
services. Only six prisons met the 75 percent minimum score for moderate adherence on access
to providers and services, while ten prisons scored 60 percent or less. The average score, at 66
percent, was substantially less than the minimum score for moderate adherence.
More encouragingly, the 80 percent score in nurse responsibilities and the 76 percent score
in continuity of care enabled both categories to exceed the minimum score for moderate
adherence. However, by averaging 72 percent, primary care provider responsibilities fell below
the minimum score for moderate adherence.
Other findings from our first 33 medical inspections follow.
Prisons scored particularly poorly in two component areas: preventive services and inmate
hunger strikes. The average score for preventive services was only 44 percent, and we found
alarmingly low scores in tuberculosis treatment, which can affect the health of inmates and
staff alike. Prisons also performed quite poorly in monitoring inmates on hunger strikes lasting
more than three days. Hunger strikes of this length, although few in number, require careful
monitoring, yet the prisons scored only 57 percent.
The prisons’ average score exceeded the 75 percent minimum score for moderate adherence
in 12 of the 20 component areas. However, many of those 12 components are less heavily
weighted. Health screening, urgent services, and emergency services were the only components
of the six most heavily weighted components in which the prisons’ average score exceeded 75
percent. Moreover, 28 of the 33 prisons failed to achieve moderate adherence in both chronic
care and clinical services, the two most heavily weighted components. Nevertheless, the 96
percent average score in staffing levels and training reflects positively on the prisons’ efforts
to provide around-the-clock physician and nursing services and to train nursing staff on faceto-face triage techniques in a prison setting. The 93 percent average score in chemical agent
contraindications and the 92 percent average score in clinic operations are also noteworthy.
The prisons had mixed results on individual questions. The prisons achieved average scores
of 86 percent or higher on 69 of the 165 scored questions in our medical inspection program.
However, the prisons scored consistently poorly on 36 questions, averaging 60 percent or
less, and in some cases substantially less. This 60-percent mark, the Receiver’s threshold for
developing specific corrective action plans, indicates areas of prison medical care that require
significant improvement. For example, 25 of the 33 prisons routinely failed to schedule
appointments within two weeks for inmates with urgent needs for specialty services. The
prisons’ average score on this question was 42 percent.
Conclusion
We find that the wide variation among component scores within prisons, and the wide variation
among prisons’ average component scores, suggest that the Receiver has not yet implemented

State of California • May 2011

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a system that ensures that CDCR medical policies and procedures and medical community
standards are followed across the prison system. The higher scores in some component areas
and medical categories, however, demonstrate that system-wide improvement can be achieved.

Bureau of Audits, Office of the Inspector General

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Introduction
At the request of the federal Court and the Court-appointed Receiver, and authorized by
California Penal Code section 6126, which assigns oversight of the California Department
of Corrections and Rehabilitation (CDCR) to the Office of the Inspector General (OIG), the
OIG developed a comprehensive inspection program to evaluate the delivery of medical care
at each of CDCR’s 33 adult prisons. This report summarizes and analyzes the results of the
OIG’s initial medical inspections of those 33 prisons. This is our second report summarizing
and analyzing the results of our prison medical inspections. In August 2010, we issued a report
at the halfway point of the first cycle of 33 prison medical inspections.1 That report covered the
first 17 prisons inspected.
Background
In April 2001, inmates represented by the Prison Law Office filed a federal court class action
lawsuit, now known as Plata v. Schwarzenegger. The lawsuit alleged that the state provided
inadequate medical care at California adult prisons in violation of inmates’ constitutional
rights. In June 2002, the parties entered into a Stipulation for Injunctive Relief (stipulation),
and the state agreed to implement comprehensive new medical care policies and procedures at
all prisons.
More than three years later, the United States District Court for the Northern District of
California (Court) declared in October 2005 that California’s delivery system for prison
medical care still did not meet constitutional standards. Characterizing the prison health care
system as “broken beyond repair,” the Court ordered a receivership to raise medical care to
constitutional standards. On February 14, 2006, the Court appointed a Receiver with orders to
manage the state’s delivery of medical care and to develop a sustainable system that provides
constitutionally adequate medical care to inmates. The Court will remove the Receiver and
return control to CDCR once the system is stable and provides constitutionally adequate
medical care.
OIG Medical Inspection Program
To monitor and evaluate the progress of their efforts to improve medical care delivery
to inmates, the Court and the Receiver requested that the OIG establish an objective,
clinically appropriate and metric-oriented medical inspection program. In response, the OIG
developed an inspection program to test prisons’ compliance with CDCR medical policies
and procedures and medical community standards. Our objective is to conduct consistently
applied assessments of inmate medical care at all 33 California state prisons, and to present
independent and comparable results. The inspection reports are intended to be used by the
Court, the Receiver, CDCR, and the plaintiffs to assess the medical care that inmates receive at
each state prison.

1 The 17-prison report and all inspection reports can be viewed at the Office of the Inspector Generalʼs website
at www.oig.ca.gov
State of California • May 2011

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In 2007, we developed a medical inspection program to assess the medical care provided at
California adult prisons. In devising the program, we obtained and reviewed the following:
• CDCR’s policies and procedures
• Relevant Court orders
• Guidelines developed by CDCR’s Quality Medical Assurance Team
• Guidelines and standards developed by the American Correctional Association and by the
National Commission on Correctional Health Care
• Professional literature on correctional medical care and medical community standards of
care
• Input from clinical experts, the Court, the Receiver’s office, CDCR, and the plaintiffs’
counsel (Prison Law Office)
Based on this research, we established an on-site inspection program to collect over 1,000
data elements from each prison using up to 166 questions covering 20 essential components
of medical care delivery.2 Our inspection teams consist of physicians,
20 Components of the OIG’s
registered nurses, deputy inspectors general, and analysts. The
Medical Inspections
inspection tool they use allows for a broadly scoped and consistent
(in order of importance):
method of examining medical care at correctional institutions.
Chronic Care
Clinical Services
Health Screening
Specialty Services
Urgent Services
Emergency Services
Prenatal Care/Childbirth/Post-Delivery
Diagnostic Services
Access to Health Care Information
Outpatient Housing Unit
Internal Reviews
Inmate Transfers
Clinic Operations
Preventive Services
Pharmacy Services
Other Services
Inmate Hunger Strikes
Chemical Agent Contraindications
Staffing Levels and Training
Nursing Policy

For each of the 20 components of prison health care, we created
questions with “yes” or “no” answers designed to gauge performance.
We worked with clinical experts to create a weighting system that
factors in the relative importance of each component as well as
considers the relative importance of questions within a component.
This weighting ensures that components that pose the greatest medical
risk to the inmate-patient (and are thus more important) are given
3
more weight than those that pose less risk. For example, we assigned
a high number of possible points to the chronic care component
because inadequate care of inmates with chronic conditions poses
the most significant risk of all the components. Accordingly, in
cycle one, chronic care accounts for 16 percent of the total possible
points in the medical inspection program. Clinical services, the
second most heavily weighted component, accounts for 11 percent.
In total, the six most heavily weighted components account for 56
percent of the medical inspection program. Conversely, we assigned
proportionately fewer points to components that pose less risk to the

2 For the second cycle of prison medical inspections currently underway, there are 152 questions. By prior
agreement of all parties, we evaluated the medical inspection program following completion of the first cycle of
medical inspections. As a result, we made a limited number of changes. These changes include eliminating a medical
emergency drill, adding some questions and dropping others, and changing the weighting of certain questions.
3 One question (Question 18.002) in the staffing levels and training component does not factor into the overall
inspection score a prison receives.
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inmate-patient. For example, pharmacy services accounts for only three percent and chemical
agent contraindications account for only two percent. Definitions of components are listed in
Appendix A.
The inspections identify instances of noncompliance with CDCR medical policies and
procedures, as well as medical community standards of care. However, we neither attempt
to identify the causes for noncompliance nor recommend remedies for specific instances
of inadequacy. Further, we do not review for efficiency and economy of operations. Our
inspection tool is designed to present an objective and consistent assessment of medical
care—to mirror back to the prisons the reality of their health care delivery system.
Consequently, our inspection scores should be used by the prisons, CDCR, the Receiver, the
plaintiffs’ counsel, and the Court to determine whether the constitutional level of medical
care has been achieved and to identify areas that must be improved to meet the mandated
level of care.
All parties to the lawsuit agreed that the OIG should primarily measure prisons’ compliance
with the aforementioned CDCR medical policies and procedures. However, the Court has yet
to define what level of compliance with those policies and procedures meets constitutional
standards. Therefore, by agreement with the Court and the Receiver, our inspections do not
conclude whether a prison has passed or failed an inspection. Instead, we merely report each
prison’s percentage of compliance with CDCR medical policies and procedures and, in the
absence of such policies and procedures, selected medical community standards.
In performing the inspections, we identify random samples of inmates receiving or requiring
specific medical services. We then review the medical file for each inmate in our sample
to determine if the medical care provided met established criteria. For these samples 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 program also reviews 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 meetings, the contents of
inmate transfer envelopes, and assorted manual logs or tracking worksheets related to medical
care delivery. Turning from the examination of documents to the examination of people and
their actions, we observe the day-to-day medical operations at each prison. For this first cycle of
medical inspections, we conducted a live medical emergency drill and evaluated the adequacy
of the responding staff’s actions. And finally, we interview medical and custody staff about the
delivery of medical care to inmates.
For each prison, our published inspection reports present an overall percentage score as well as
percentage scores for component areas. Although the Court has yet to determine the percentage
State of California • May 2011

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score necessary for an institution to meet the constitutional standard, the Receiver currently
applies the following scoring criteria to measure each prison’s adherence to medical policies
and procedures:
• More than 85 percent: High adherence
• 75 to 85 percent: Moderate adherence
• Less than 75 percent: Low adherence
The Receiver requires that each prison develop a corrective action plan following an inspection.
The corrective action plan must describe how the prison intends to remedy conditions that
contributed to a score of 60 percent or lower on each question.
Because the Plata litigation addresses only medical care, we do not assess the provision of
dental care or mental health services in prisons. Nor do we assess the care provided in licensed
hospitals or correctional treatment centers, which are subject to inspection and oversight by
other regulatory agencies.
Using the Receiver’s scoring criteria, we issued a report in August 2010 at the halfway point
of the first cycle of 33 prison medical inspections. That report, which covered the 17 prisons
initially inspected, found that only two of the 17 prisons achieved overall scores that exceeded
the Receiver’s minimum score for moderate adherence. The 17 prisons’ average overall score
was 70 percent, and we found significant problems with how the prisons managed inmates’
medications and how they provided inmates access to medical providers and services.

Bureau of Audits, Office of the Inspector General

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Objectives, Scope, and Methodology
In September 2008, we began the first of our statewide medical inspections, and in October
2010 we completed the report on our thirty-third prison medical inspection. The thirty-third
medical inspection denotes the end of the first cycle of our prison medical inspection program.
This report summarizes the results of that first cycle of 33 medical inspections, and it provides
additional analysis of the data obtained from those inspections. The report includes data from
inspections performed at the state’s 30 men’s prisons and three women’s prisons. The prisons
are listed below:
First 17 Medical Inspections of Cycle 1

Final 16 Medical Inspections of Cycle 1

California State Prison, Sacramento (SAC)

North Kern State Prison (NKSP)

California Medical Facility (CMF)

Folsom State Prison (FSP)

R. J. Donovan Correctional Facility (RJD)

Kern Valley State Prison (KVSP)

California State Prison, Centinela (CEN)

Valley State Prison for Women (VSPW)

Deuel Vocational Institution (DVI)

California State Prison, Solano (SOL)

Central California Women’s Facility (CCWF)

California Substance Abuse Treatment Facility
and State Prison, Corcoran (SATF)

California Men’s Colony (CMC)
Sierra Conservation Center (SCC)
California State Prison, Los Angeles County (LAC)
Pleasant Valley State Prison (PVSP)
California Correctional Institution (CCI)
California Rehabilitation Center (CRC)
California Institution for Women (CIW)
Avenal State Prison (ASP)
San Quentin State Prison (SQ)
High Desert State Prison (HDSP)
California Correctional Center (CCC)

Ironwood State Prison (ISP)
Chuckawalla Valley State Prison (CVSP)
California State Prison, Corcoran (COR)
Calipatria State Prison (CAL)
Correctional Training Facility (CTF)
Mule Creek State Prison (MCSP)
California Institution for Men (CIM)
Salinas Valley State Prison (SVSP)
Pelican Bay State Prison (PBSP)
Wasco State Prison (WSP)

In analyzing and summarizing the results of our first 33 medical inspections, our objective was
to provide a practical interpretation of the data and an assessment of the quality of medical
care provided to inmates. In doing so, we looked for significant trends and variations in data,
compliance problems common to or unique to prisons, and other data characteristics we
believed noteworthy.
Unlike the individual inspection reports, this 33-prison report puts the prisons’ scores into a
qualitative context. We do so by comparing the prisons’ average and individual scores to the
Receiver’s scoring criteria. Thus a 75 percent score is the minimum score for moderate adherence
4
to relevant policies and procedures. Scores below 75 percent denote low adherence, while those
4 All average scores in this report are based on the arithmetic mean. We developed no median or modal
averages.
State of California • May 2011

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above 85 percent reflect high adherence. As discussed below, we have rounded all percentage
scores in this report and the appendices to the nearest whole number. Therefore, when we apply
rounding to the Receiver’s scoring criteria, this report reflects adherence as follows:
• 86 percent and higher: High adherence
• 75-85 percent: Moderate adherence
• 74 percent and lower: Low adherence
In providing a qualitative context to the percentage scores, it is not our intention to determine
or imply the percentage score that meets a constitutional standard of medical care. That
determination remains with the Court.
In addition to reviewing our inspection results by prison, we analyzed our data using the
following two perspectives, and we cite the results of each perspective in separate sections of
this report.
Results by Medical Component – Our first perspective compares the weighted inspection
scores of all 33 prisons in each of the 20 component areas. This perspective provides a systemwide context, comparing health care delivery performances among prisons, and provides
information about each prison’s performance in specific component areas, noting areas in
which prisons scored particularly well or particularly poorly.
In this first perspective, we present profiles of each of the 20 components. These profiles
summarize the prisons’ individual and average scores in each component of prison health care,
including the average of the top two prisons’ scores and the variation from the highest score
to the lowest score, expressed in percentage points. In addition, we identify areas requiring
significant improvement consistent with the Receiver’s requirement for corrective action plans.
We also identify areas in which the prisons’ performances reflect high adherence to medical
policies and procedures. We define areas requiring significant improvement as any area in
which prisons earned an average score of 60 percent or less — the Receiver’s threshold for
corrective action. We define areas of high adherence as any area in which prisons earned an
average score of 86 percent or more.
Results by General Medical Category – For our second perspective, we move from examining
disparate components of prison health care to examining how these components function
together to deliver health care at California’s 33 adult prisons. Working with our lead physician,
we identified 100 questions that fit into five general categories of medical care. We sorted these
questions into the general health care categories and analyzed the results. The five general medical
categories, which offer a broader perspective on the experience of prison medical care, include:
• Medication Management
• Access to Providers and Services
• Primary Care Provider Responsibilities
• Continuity of Care
• Nurse Responsibilities
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We analyze the data by prison, as well as by category, in order to help policy makers evaluate
medical care delivery in this broader context.
Appendices – Because of the technical nature of our medical inspections and the significant
volume of information in this report, we have included the following four appendices:
• Appendix A: Contains the definitions of the components we use in our medical
inspections program.
• Appendix B: Contains a synopsis of each prison’s scores by component.
• Appendix C: Cites the text for each question in the 20 components and contains the 33
prisons’ scores for each question.
• Appendix D: Cites the text for each question in the five medical categories and contains
the 33 prisons’ scores for each question.
Rounding – Throughout this report and the appendices, we have rounded all percentage scores
to the nearest whole number. As discussed in the preface to the appendices of this report,
our rounding has resulted in scores that differ slightly from those in the inspection reports
for the 33 prisons. For example, the overall score in the inspection report for DVI is 72.6
percent; however, for this report we have rounded the score to 73 percent. The net effect of
our rounding of scores is negligible, as shown by the fact that rounding affected the qualitative
assessments of only 13 of the 654 combined overall and component scores from our 33
medical inspections. In all 13 cases, the rounding favored the prisons because in four cases the
rounded score moved the prisons from low adherence to moderate adherence, and in nine cases
the rounded score moved the prisons from moderate adherence to high adherence. In only one
case did the rounding move a prison’s overall score. In that case, we rounded MCSP’s overall
score from 74.5 percent to 75 percent, moving the qualitative score from low adherence to
moderate compliance.

State of California • May 2011

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Results of the First Cycle of Medical Inspections
Nine of the 33 prisons’ overall scores met or exceeded the 75 percent minimum score for
moderate adherence. Whereas our 17-prison summary report found that only two of the first
17 prisons exceeded the 75 percent score for moderate adherence, seven of the last 16 prisons
met or exceeded the 75 percent minimum score. Prisons’ overall scores ranged from 83 percent
for FSP down to 62 percent for HDSP. FSP is the only prison to achieve moderate or high
adherence in the six most heavily weighted components. The average score for the first 17
inspections was 70 percent and the average score for the last 16 inspections was 74 percent,
resulting in an overall average score of 72 percent for all 33 prisons. These scores reveal that
the Receiver and the prisons can improve compliance with CDCR’s medical policies and
procedures and selected medical community standards.
Nearly all of the prisons failed to achieve moderate adherence in three of the six most heavily
weighted components. For example, 28 of them failed to achieve moderate adherence in both
chronic care and clinical services, the two most heavily weighted components. While overall
scores varied by only 21 percentage points, there were differences of as much as 89 percentage
points in the scores among institutions on individual components. Clearly, some prison staff
members carried out relevant policies and procedures while others did not.
The highest average component scores were 96 percent in staffing levels and training, 93
percent in chemical agent contraindications, and 92 percent in clinic operations. The prisons
achieved high adherence on 69 of the 165 scored questions in our medical inspection program.
The 33 prisons’ lowest average component scores were 44 percent in preventive services, 57
percent in inmate hunger strikes, 62 percent in chronic care, and 64 percent in access to health
care information. The prisons scored 60 percent or less on 36 of the 165 scored questions in our
medical inspection program. The Receiver can improve the prisons’ compliance with medical
policies and procedures by continuing to focus prisons’ performance on these 36 questions.
Turning from the in-depth examination of individual health care components, we examined
how those components function together to deliver health care. We sorted the data from 100
questions into five general medical categories that were recommended by our lead physician.
From this broader perspective, we found significant problems in the categories of medication
management and access to providers and services. These are the same two categories we found
problematic in our 17-prison summary report. The average score in medication management
was only 59 percent, indicating that prisons were ineffective in getting medications to inmates
in a timely manner or were failing to document their actions as required by policy. The average
score for access to providers and services was only 66 percent. This low score indicates that
the prisons were generally ineffective in ensuring that inmates are seen or provided services
for routine, urgent, and emergency medical needs according to timelines set by CDCR policy.
Access to providers and services scores ranged from 87 percent down to 45 percent. In the
remaining three categories, nurse responsibilities and continuity of care, with scores of 80

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percent and 76 percent, respectively, exceeded the 75 percent minimum score for moderate
adherence. Further, primary care provider responsibilities was close, with an average score of
72 percent.
The following sections of this report summarize and analyze the 33 prisons’ overall scores,
their scores in each of the 20 components, and their scores in each of the five general medical
categories.

State of California • May 2011

Page 13

Chart 1: Overall Scores for Each Prison, in Chronological Order of Report Date
SAC Nov. 2008

65%

CMF Jan. 2009

72%

RJD Feb. 2009

68%

CEN Feb. 2009

74%

DVI Mar. 2009

73%

CCWF May 2009

78%

CMC May 2009

71%

SCC Jun. 2009

76%

LAC Jul. 2009

Institution Score
Average Score = 72%

72%

PVSP Aug. 2009

Minimum Moderate Adherence = 75%

65%

CCI Sep. 2009

64%

CRC Oct. 2009

74%

CIW Nov. 2009

70%

ASP Nov. 2009

70%

HDSP Dec. 2009

62%

SQ Dec. 2009

68%

CCC Jan. 2010

73%

NKSP Mar. 2010

72%

KVSP Mar. 2010

64%

FSP Mar. 2010

83%

SOL Apr. 2010

67%

SATF May 2010

68%

VSPW May 2010

80%

ISP Jun. 2010

68%

CVSP Jul. 2010

69%

COR Jul. 2010

69%

CAL Jul. 2010

77%

CTF Aug. 2010

72%

MCSP Sep. 2010

75%

SVSP Oct. 2010

74%

CIM Oct. 2010

81%

PBSP Nov. 2010

81%

WSP Nov. 2010

50%

76%

55%

60%

65%

70%

Bureau of Audits, Office of the Inspector General

75%

80%

85%

90%

95%

100%

Page 14

Overall Scores and Medical Components
Nine prisons’ overall scores met or exceeded the 75 percent minimum score for moderate
adherence. As shown in Chart 1, the average score for the 33 prisons was 72 percent; this score
is two percentage points higher than the 70 percent average score we reported in our 17-prison
summary report. The scores varied 21 percentage points from highest to lowest.
Of the nine prisons that met or exceeded the 75 percent minimum score for moderate
adherence, FSP’s score of 83 percent was the highest, while CIM and PBSP tied for secondhighest score with 81 percent. VSPW scored 80 percent. With the exception of a 57 percent
score in preventive services, FSP had no component score lower than 70 percent. Further, FSP
is the only prison to achieve moderate or high adherence in the six most heavily weighted
components.
Another 12 prisons had scores that ranged from 74 percent to 70 percent, which put them close
to the 75 percent minimum score for moderate adherence. The remaining 12 prisons had scores
that ranged from 69 percent to 62 percent.
Component Analysis
Nearly all of the prisons failed to achieve moderate adherence in three of the six most
heavily weighted components. We have summarized all 33 institutions’ scores for each of the
20 components on one table in Appendix B. As shown in Appendix B, 28 of the 33 prisons
failed to achieve moderate adherence in both chronic care and clinical services, the two
most heavily weighted components in the medical inspection program, with a combined 27
percent of the total possible points in cycle one. The average score for chronic care was only
62 percent, and the score for clinical services was only 65 percent. The average score for
specialty services, another of the six most heavily weighted components, was only 66 percent.
The average of the scores in the six most heavily weighted components was only 71 percent,
whereas the average of the scores in the remaining components was 77 percent. The six most
heavily weighted components account for 56 percent of the possible points in the medical
inspection program in cycle one.
There were wide variations in some prisons’ component scores, while in other cases the
variations were substantially narrower. For example:
• The largest variation in an individual prison’s component scores was 89 percentage points.
This characteristic was shared by RJD and SAC. Each prison scored only 11 percent in
inmate hunger strikes and yet each received 100 percent scores in other components.
• The smallest variation in component scores was the 34 percentage points achieved by
VSPW, which scored only 66 percent in clinical services, yet received 100 percent in six
other components. VSPW, which had the fourth highest overall score of 80 percent, could
have had an even higher overall score if four of its lowest scores were not in the six most
heavily weighted components.

State of California • May 2011

Page 15

Thirty-two of the 33 prisons scored 100 percent in at least one component, with CAL’s seven
100 percent scores the most by any prison. CCI, with an overall score of 64, was the only
prison not to achieve a 100 percent score in any component. However, even CCI did well in
certain components. Notably, it scored 91 percent in clinic operations.
There were wide variations in average scores by component. As a group, the prisons
performed well in several components, marginally in other components, and poorly in several
components. Chart 2 compares the average scores for medical components across all prisons.
These scores ranged from a high of 96 percent in staffing levels and training down to 44
percent in preventive services, presenting a range of 52 percentage points.
In five components, the average scores met the 86 percent minimum score for high adherence
to medical policies and procedures. In addition to the 96 percent in staffing levels and training,
the prisons achieved average scores of 93 percent in chemical agent contraindications, 92
percent in clinic operations, 88 percent in inmate transfers, and 87 percent in pharmacy
services. However, none of these components accounts for more than four percent of the total
points possible in the medical inspection program in cycle one.
The 96 percent average score in staffing levels and training reflects positively on the prisons’
effort to ensure around-the-clock physician and nursing services, and to orient and train nursing
staff on face-to-face triage techniques in a prison setting.
Another seven components had average scores of 77 percent to 84 percent. The seven
components were other services, outpatient housing unit, internal reviews, emergency services,
urgent services, health screening, and nursing policy. Thus, a total of 12 of the 20 component
average scores exceeded the 75 percent minimum score for moderate adherence. However,
many of these 12 components are less heavily weighted components in the medical inspection
program.

Bureau of Audits, Office of the Inspector General

Page 16

Chart 2: Average Score by Medical Component, Sorted by Order of Importance
62%

Chronic Care

Average
Score

65%

Clinical Services

77%

Health Screening

Minimum Moderate
Adherence = 75%

66%

Specialty Services
Urgent Services

78%

Emergency Services

78%
71%

Prenatal/Childbirth/Post-delivery

69%

Diagnostic Services
64%

Access to Health Care Information

81%

Outpatient Housing Unit
78%

Internal Reviews

88%

Inmate Transfers

92%

Clinic Operations
44%

Preventive Services

87%

Pharmacy Services
84%

Other Services
57%

Inmate Hunger Strikes

93%

Chemical Agent Contraindications

96%

Staffing Levels and Training
Nursing Policy

20%

77%

30%

40%

50%

60%

70%

80%

90%

100%

The average scores in the following two component areas indicate low adherence to medical
policies and procedures and the need for improvement:
• Preventive services (44 percent). The low average score in preventive services reflects
CDCR’s systematic failure to effectively identify and schedule inmates who need cancer
screenings and tuberculosis treatment.
• Inmate hunger strikes (57 percent). This low score shows that most of the prisons failed
to effectively carry out CDCR’s policies and procedures for dealing with inmates on
hunger strikes for more than three days.
The wide variation in component scores among institutions indicates that the 33 prisons were not
consistently executing CDCR’s medical policies and procedures, or complying with community
medical standards. This inconsistency is further illustrated by Table 1, which shows the high and
low scores that contributed to each component’s average score. Clearly, some prisons carried out
relevant medical policies and procedures while others did not.

State of California • May 2011

Page 17

Table 1: Summary of High and Low Scores by Medical Component, Sorted by Order of Importance
High
Percentage

Low
Percentage

Average
Percentage

Variation Between
High/Low Percentage
Points

Chronic Care

84

45

64

39

Clinical Services

87

47

66

40

Health Screening

87

61

75

26

Specialty Services

74

43

60

31

Urgent Services

89

63

79

26

Emergency Services

90

48

77

42

Prenatal Care/
Childbirth/Post-Delivery

61

61

61

N/A

Diagnostic Services

87

43

69

44

Access to Health Care
Information

82

20

59

62

Outpatient Housing Unit

86

63

77

23

Internal Reviews

100

60

76

40

Inmate Transfers

100

43

86

57

Clinic Operations

100

82

90

18

Preventive Services

82

7

37

75

Pharmacy Services

100

58

85

42

Other Services

100

55

86

45

Inmate Hunger Strikes

100

11

46

89

Chemical Agent
Contraindications

100

65

91

35

Staffing Levels and
Training

100

80

94

20

Nursing Policy

100

36

74

64

Medical Component

Beginning in the next section, we present profiles of each of the 20 components. In these
profiles, we summarize the prisons’ individual and average scores, including the average of the
top two prisons’ scores and the variation from the top score to the lowest score, expressed in
percentage points. The average of the top two scores is important because it shows that a higher
level of performance by other prisons is possible. We also identify areas requiring significant
improvement as well as areas with scores that indicated high adherence to medical policies and
procedures. We defined “areas requiring significant improvement” as areas of prison medical
care in which prisons scored 60 percent or less. This is the Receiver’s threshold score for
Bureau of Audits, Office of the Inspector General

Page 18

requiring formal corrective action plans. We defined “areas achieving high adherence” as areas
of prison medical care that met or exceeded the 86 percent minimum score for high adherence
to medical policies and procedures.

State of California • May 2011

Page 19

Medical Component: Chronic Care Profile
Page 1 of 2
Component Definition: The Chronic Care component examines how well the prison provided care and
medications 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
Key Statistics
care conditions: asthma, diabetes, HIV (Human Immunodeficiency
Component Average: ....... 62%
Virus), and hypertension.
Top Two Average: ............ 83%
Results in Brief: Only five prisons scored at or above the 75
percent minimum score for moderate adherence. KVSP, ISP, and
SOL performed the worst. Documentation at most of the 33 prisons
indicated that inmates were not receiving their prescribed chronic
care medications. Further, at nearly all prisons there was inadequate
documentation of inmates’ clinical histories.

Range of Scores: ..... 84%-38%
Variation: ........................ 46%
Number of Prisons with:
High Adherence ..................... 0
Moderate Adherence .............. 5
Low Adherence .................... 28

This component includes nine questions.

Areas Requiring Significant Improvement Due to Scores of 60 Percent or Less
Question
03.175

Either the inmates’ medical files did not indicate that they had received their
prescribed chronic care medications during the most recent three-month period, or
the prison did not follow department policy when the inmate refused to pick up or
show up for his or her prescribed medications. The average score for this question
was only 34 percent. Twenty-four of the 33 prisons had scores of 50 percent or less,
and seven prisons received eight percent or less.

Question
03.077

Prisons were not completing key components of two chronic care forms (Forms
7419 and 7392) that document vital signs and other important information about
the inmate’s two most recent visits. The average score for this question was only 46
percent, and 22 prisons scored 54 percent or lower. SOL received zero percent.

Question
03.235

The clinical histories in inmates’ medical files were consistently inadequate. The
average score was only 54 percent. Only three of the 33 prisons had a score that met
the 75 percent minimum score for moderate adherence, and 20 prisons scored 60
percent or below on this question.

Question
03.076

The inmates’ most recent chronic care visits were not within the time frames
required by the degree of control of the inmates’ conditions based on their prior
visits. The average score for this question was only 58 percent.

Areas Achieving High Adherence with Scores of 86 Percent or More
None.
See Appendix C-1 for detailed information on questions and scores for this component.

Bureau of Audits, Office of the Inspector General

Page 20

Medical Component: Chronic Care Profile
Page 2 of 2
Chart 3: Chronic Care Scores by Prison, Sorted Highest to Lowest Score
CMF

84%

CEN

81%

FSP

79%

CAL

75%

SCC

75%

DVI

74%

CCWF

73%

VSPW

71%

PBSP

70%

MCSP

70%

CIW

70%

LAC

70%

CRC

67%

SQ

65%

SAC

63%

CIM

62%

CCI

62%

NKSP

59%

ASP

59%

COR

58%

SATF

58%

SVSP

57%

PVSP

57%

CMC

57%

CTF

56%

WSP

52%

CVSP

52%

RJD

Institution Score
Average Score = 62%

49%

Minimum Moderate Adherence = 75%
CCC

46%

HDSP

45%

SOL
ISP
KVSP

30%

42%
39%
38%

40%

50%

State of California • May 2011

60%

70%

80%

90%

100%

Page 21

Medical Component: Clinical Services Profile
Page 1 of 2
Component Definition: The Clinical Services component evaluates the inmate’s access to primary
health care services and focuses on inmates who recently received services from any of the prison’s
facilities or administrative segregation unit clinics. This component evaluates sick call processes
(doctor or nurse line), medication management, and nursing.
Key Statistics
Results in Brief: Thirty-one of the 33 prisons failed to ensure that
inmates received their prescribed medications in a timely manner.
Twenty-seven prisons failed to meet the appointment dates set by
the triage nurse for inmates’ visits with a primary care provider. As
evidenced by their overall clinical services scores, PVSP and SQ
fared the worst in this component.
This component includes 14 questions.

Component Average: ....... 65%
Top Two Average: ............ 84%
Range of Scores: ......87%-47%
Variation: ......................... 40%
Number of Prisons with:
High Adherence ..................... 1
Moderate Adherence .............. 2
Low Adherence .................... 30

Areas Requiring Significant Improvement Due to Scores of 60 Percent or Less
Question
01.124

Most prisons were not timely in the delivery of medications prescribed from
inmates’ sick call visits. Twenty-five of the 33 prisons scored less than 50 percent,
and the average score for this question was only 36 percent. CRC received ten
percent and SATF scored just seven percent.

Question
01.244

Registered nurses’ objective notes at most prisons did not always include inmates’
allergies, weight, current medication, and medication compliance. The average score
for this question was only 47 percent. CRC and HDSP scored just five and seven
percent, respectively.

Question
01.027

Most of the prisons routinely failed to meet the appointment dates established by the
triage nurse for inmates’ visits with a primary care provider. The average score for
this question was only 52 percent. RJD received 13 percent.

Areas Achieving High Adherence with Scores of 86 Percent or More
Question
01.246

At most of the prisons, the registered nurses did well in reviewing all of the inmate’s
complaints on the Health Care Services Request Form. Twenty-six of the 33 prisons
achieved scores of 86 percent or higher on this question, and the average score was
89 percent.

Question
01.162

Nearly all of the prisons did well in developing strategies to address the problems
identified in the registered nurse’s face-to-face triage. The average score for this
question was 88 percent.

See Appendix C-2 for detailed information on questions and scores for this component.

Bureau of Audits, Office of the Inspector General

Page 22

Medical Component: Clinical Services Profile
Page 2 of 2
Chart 4: Clinical Services Scores by Prison, Sorted Highest to Lowest Score
CMF

87%

CEN

80%

FSP

76%

WSP

74%

CIM

74%

CMC

74%

CCWF

74%

DVI

73%

SCC

71%

CRC

70%

PBSP

69%

MCSP

69%

COR

68%

RJD

67%

SAC

67%

VSPW

66%

CCC

66%

LAC

66%

ASP

64%

NKSP

64%

CIW

62%

SVSP

61%

CVSP

61%

ISP

61%

CAL

60%

SOL

60%

CTF

59%

KVSP

58%

CCI

57%

SATF
HDSP

Minimum Moderate Adherence = 75%
Average Score = 65%

51%

SQ

47%

PVSP

47%

30%

Institution Score

56%

40%

State of California • May 2011

50%

60%

70%

80%

90%

100%

Page 23

Medical Component: Health Screening Profile
Page 1 of 3
Component Definition: The Health Screening component focuses on the prison’s process for
screening new inmates upon arrival to the prison for health care conditions that require treatment and
monitoring, as well as ensuring inmates’ continuity of care.
Key Statistics
Component
Average:......... 77%
Results in Brief: Twenty of the prisons inspected scored at or above
Top
Two
Average:
.............. 88%
the 75 percent minimum score for moderate adherence. Even though
Range of Scores: ......89%-61%
prisons were regularly performing initial health screenings, we found
Variation: ........................ 28%
that they were not following up to ensure that inmates received
required medications or treatment for medical conditions identified
Number of Prisons with:
during those health screenings.
High Adherence ..................... 5
This component includes 19 questions. Some of these questions
apply only to prisons with a reception center; other questions apply to
prisons with general population inmates; still others apply to both.

Moderate Adherence ............ 15
Low Adherence .................... 13

Areas Requiring Significant Improvement Due to Scores of 60 Percent or Less
Question
02.128

The medical files contained no indication that the inmates who transferred from
other prisons or jails were receiving existing medication orders by the calendar day
following their arrival. The average score for this question was only 33 percent.
Twenty-eight of the 33 prisons had scores of 50 percent or less, and six prisons
received zero percent.

Question
02.018

If, during an assessment, a registered nurse referred the inmate to a clinician, the
inmate was not seen within the specified time frame. The average score for this
question was only 53 percent. Twenty-three of the 32 prisons to which this question
applied had scores of 74 percent or less, and 14 prisons scored below 50 percent.
LAC and CTF received zero percent for the question.

Question
02.215

This question applies only to prisons with reception centers. Half of the reception
centers were not completing a portion of the History and Physical Examination form.
The average score for this question was only 54 percent. VSPW scored only five
percent, and RJD and HDSP received zero percent.

Bureau of Audits, Office of the Inspector General

Page 24

Medical Component: Health Screening Profile
Page 2 of 3
Chart 5: Health Screening Scores by Prison, Sorted Highest to Lowest Score
FSP

89%

CMF

87%

WSP

86%

CIM

86%

VSPW

86%

PBSP

85%

SVSP

84%

CCWF

84%

ISP

82%

MCSP

81%

CCC

81%

ASP

81%

CAL

80%

CCI

78%

CEN

78%

SOL

77%

SQ

77%

CVSP

76%

SAC

76%

KVSP

75%

CRC

74%

DVI

74%

COR

73%

SATF

73%

CMC

73%

NKSP

72%

HDSP

72%

CIW

70%

LAC

Institution Score
Average Score = 77%

69%

Minimum Moderate Adherence = 75%
RJD

68%

PVSP

67%
64%

CTF
SCC

50%

61%

55%

60%

State of California • May 2011

65%

70%

75%

80%

85%

90%

95%

100%

Page 25

Medical Component: Health Screening Profile
Page 3 of 3

Areas Achieving High Adherence with Scores of 86 Percent or More
Question
02.016

Nearly all of the prisons were completing the initial health screening on the same
day the inmate arrived at the prison. The prisons achieved an average score of 96
percent on this question. Twenty prisons scored 100 percent.

Question
02.020

Nursing staff adequately documented either the tuberculin test or a review of signs
and symptoms for inmates with a previous positive tuberculin test. The average score
for this question was 93 percent. Fourteen prisons scored 100 percent.

Question
02.017

If “yes” was answered to any of the questions on the initial health screening forms,
most prisons’ registered nurses performed an assessment and disposition on the date
of the inmate’s arrival. The average score for this question was 92 percent. Twentythree prisons scored 100 percent.

Question
02.007

Within one calendar day of the inmate’s arrival, nearly all of the prisons’ licensed
health care staff reviewed and signed the health care transfer information form. The
average score for this question was 91 percent. Eight prisons scored 100 percent.

Questions
02.212
02.213
02.216
02.217
02.218

These questions apply only to the prisons with reception centers. These prisons did
well in completing many sections of the History and Physical Examination Form
(Form 7206) upon the inmate’s arrival. These prisons received average scores
ranging from 87 percent to 90 percent on each of these questions.

Question
02.111

Inmates needing medical accommodations received them upon arrival. The average
score for this question was 86 percent. Sixteen prisons scored 100 percent.

See Appendix C-3 for detailed information on questions and scores for this component.

Bureau of Audits, Office of the Inspector General

Page 26

State of California • May 2011

Page 27

Medical Component: Specialty Services Profile
Page 1 of 2
Component Definition: The Specialty Services component 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 cardiology services, physical therapy, oncology
services, podiatry consultations, and neurology services.
Key Statistics
Results in Brief: Most prisons performed poorly in providing inmates Component Average:......... 66%
timely access to specialty services and prompt follow-up related to
Top Two Average: .............. 91%
those services. The low scores associated with three specialty services Range of Scores: ......96%-43%
Variation: ........................ 53%
questions were so significant that they reduced the 33 prisons’
average score in specialty services by 16 percentage points. Without
Number of Prisons with:
the three questions, the 33 prisons’ average score would have been 82
High Adherence ..................... 2
percent instead of the 66 percent average score they received.
Moderate Adherence ...............5
This component includes nine questions.

Low Adherence .................... 26

Areas Requiring Significant Improvement Due to Scores of 60 Percent or Less
Question
07.038

Question
07.043

Question
07.261

Primary care providers were not seeing inmates between the date the physician
ordered the specialty service and the date the inmate received it, in accordance with
specified time frames. The average score for this question was only 32 percent. While
CAL and PBSP scored 100 percent, two prisons scored zero percent.
Primary care providers were not reviewing the consultant’s report and seeing the
inmate for a follow-up appointment within specified time frames following the
specialty services consultation. The average score for this question was only 39
percent. HDSP’s score of zero percent was the lowest.
Twenty-five prisons were not scheduling high-priority (urgent) specialty services
within 14 days as required. For this question, the 33 prisons had an average score of
only 42 percent. Thirteen prisons received zero percent.

Areas Achieving High Adherence with Scores of 86 Percent or More
Question
07.090

Thirty-two of the 33 prisons’ physical therapists properly assessed inmates,
documented their treatment plans, and documented the treatment provided. The
average score for this question was 99 percent.

Question
07.270

Either the prisons’ specialty service providers provided timely findings and
recommendations, or the prison’s registered nurse conducted timely follow-up with
the provider to ascertain the findings and recommendations. The average score for this
question was 95 percent. Thirty of the 33 prisons scored at least 88 percent.

See Appendix C-4 for detailed information on questions and scores for this component.

Bureau of Audits, Office of the Inspector General

Page 28

Medical Component: Specialty Services Profile
Page 2 of 2
Chart 6: Specialty Services Scores by Prison, Sorted Highest to Lowest Score
PBSP

96%

CVSP

86%

CIM

83%

ISP

82%

FSP

80%

MCSP

76%

CAL

75%

ASP

74%

SCC

73%

VSPW

72%

WSP

71%

SVSP

71%

CCC

71%

LAC

70%

CTF

69%

SOL

66%

CIW

63%

CMC

63%

SATF

62%

KVSP

62%

RJD

62%

NKSP

61%

PVSP

61%

CEN

60%

CRC

59%

SQ
CCI

Average Score = 66%

57%

COR

Minimum Moderate Adherence

55%

HDSP

53%

CCWF

53%

DVI

53%

SAC

47%

CMF

30%

Institution Score

58%

43%

40%

State of California • May 2011

50%

60%

70%

80%

90%

100%

Page 29

Medical Component: Urgent Services Profile
Page 1 of 2
Component Definition: The Urgent Services component addresses the care provided by the prison to
inmates before and after they were sent to a community hospital.
Key Statistics
Results in Brief: On average, the 33 prisons performed relatively well Component Average:......... 78%
Top Two Average: .............. 91%
in providing urgent services. Only eight prisons did not meet the 75
Range of Scores: ......92%-61%
percent minimum score for moderate adherence to policies and
Variation: ........................ 31%
procedures. However, upon inmates’ discharge from a community
hospital, few of the prisons administered or delivered all prescribed
Number of Prisons with:
medications to the inmates within specified time frames.
High Adherence ..................... 5
Moderate Adherence ............ 20
Low Adherence ...................... 8

This component includes eight questions.

Areas Requiring Significant Improvement Due to Scores of 60 Percent or Less
Question
21.281

Most prisons failed to administer or deliver all prescribed medications to inmates in an
appropriate time frame upon their discharge from a community hospital. The average
score for this question was only 48 percent. Six prisons scored 13 percent or lower.

Areas Achieving High Adherence with Scores of 86 Percent or More
Question
21.279

For patients sent to the triage and treatment area, if the primary care provider managed
the patient by telephone consultation alone, the provider’s decision not to come to the
triage and treatment area was appropriate. The average score for this question was 99
percent. Twenty-eight prisons scored 100 percent.

Question
21.250

Upon the inmate’s discharge from the community hospital, the inmate’s primary care
provider gave orders for appropriate housing for the inmate. The average score for
this question was 93 percent. Although RJD scored only 50 percent, fourteen prisons
scored 100 percent.

Question
21.248

Upon the inmate’s discharge from the community hospital, the treatment and triage
area (TTA) registered nurse documented that he or she reviewed the inmate’s
discharge plan and completed a face-to-face assessment of the inmate. The average
score for this question was 87 percent, and five prisons scored 100 percent.

See Appendix C-5 for detailed information on questions and scores for this component.

Bureau of Audits, Office of the Inspector General

Page 30

Medical Component: Urgent Services Profile
Page 2 of 2
Chart 7: Urgent Services Scores by Prison, Sorted Highest to Lowest Score
92%

PBSP
SCC

89%

CCWF

89%

CAL

88%

FSP

88%

WSP

85%

SVSP

84%

CCC

84%

CMC

84%

CCI

83%

SAC

83%

CRC

81%

PVSP

81%

CIM

80%

NKSP

80%

LAC

80%

CEN

80%

CMF

79%

CVSP

78%

DVI

78%

COR

76%

MCSP

75%

CTF

75%

SATF

75%

CIW

75%

RJD

73%
72%

HDSP
ISP

70%

SOL

70%

ASP

70%

VSPW

Average Score = 78%
Minimum Moderate Adherence = 75%

67%
63%

SQ
KVSP

50%

Institution Score

61%

55%

60%

State of California • May 2011

65%

70%

75%

80%

85%

90%

95%

100%

Page 31

Medical Component: Emergency Services Profile
Page 1 of 3
Component Definition: The Emergency Services component 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.
Key Statistics
Results in Brief: Most prisons performed relatively well in providing
emergency services, with 22 exceeding the 75 percent minimum
score for moderate adherence to policies and procedures and nine
coming close. However, SAC performed very poorly with a score
of 48 percent. Further, half of the first responders in our emergency
response drill failed to carry and use proper equipment and to
properly perform cardiopulmonary resuscitation. In addition, most
prisons’ Emergency Medical Response Review Committees were
slow in performing their duties.

Component Average:........ 78%
Top Two Average: ............. 90%
Range of Scores: ......90%-48%
Variation: ......................... 42%
Number of Prisons with:
High Adherence ..................... 6
Moderate Adherence ............ 16
Low Adherence .................... 11

This component includes 19 total questions, eight of which focus on actual “man down” or “woman
down” occurrences and 11 of which focus on an emergency response drill.

Areas Requiring Significant Improvement Due to Scores of 60 Percent or Less
Question
08.222

The findings of the prisons’ Emergency Medical Response Review Committee were
not always adequately documented and completed within 30 days of the emergency
situation. The average score for this question was only 21 percent, with 16 prisons
receiving zero percent.

Question
15.257

This question pertains to our emergency medical response drill. Thirteen responding
officers failed to properly perform cardiopulmonary resuscitation. The average score
for this question was only 52 percent.

Question
15.255

During the emergency medical response drill at 14 prisons, the responding officers
failed to carry and use the proper equipment, such as a protective shield, a micromask, and protective gloves. The average score for this question was only 56 percent.

Bureau of Audits, Office of the Inspector General

Page 32

Medical Component: Emergency Services Profile
Page 2 of 3
Chart 8: Emergency Services Scores by Prison, Sorted Highest to Lowest Score
CIM

90%

CCC

90%

RJD

90%

COR

88%

VSPW

88%

CMC
CAL

Institution Score

86%

Average Score = 78%

85%

Minimum Moderate Adherence = 75%

FSP

84%

LAC

84%

SVSP

83%

PVSP

83%

SOL

82%

PBSP

81%

CTF

81%

NKSP

81%

CIW

80%

CCWF

80%

SQ

78%

ASP

78%

CCI

78%

CEN

77%

SCC

76%

WSP

73%

CVSP

73%

ISP

73%

CRC

73%

KVSP

72%

HDSP

72%

CMF

72%

DVI

71%

SATF

70%

MCSP

64%

SAC

30%

48%

40%

50%

State of California • May 2011

60%

70%

80%

90%

100%

Page 33

Medical Component: Emergency Services Profile
Page 3 of 3

Areas Achieving High Adherence with Scores of 86 Percent or More
Question
15.240

In the emergency medical response drill, all responding officers activated the
emergency response system. Every participating prison scored 100 percent on this
question.

Question
08.183

For actual medical emergencies reviewed, the medical emergency responder was notified
without delay at each prison. The average score for this question was 99 percent.

Question
08.186

For actual medical emergencies reviewed, the first responder and the medical
emergency responder at nearly all prisons were certified in basic life support. The
average score for this question was 95 percent.

Question
15.282

In the emergency medical response drill, most prisons’ medical staff arrived on the
scene in five minutes or less. The average score for this question was 94 percent.

Question
08.184

For actual medical emergencies reviewed, the medical emergency responder at nearly
all prisons arrived at the location of the medical emergency within five minutes of
initial notification. The average score for this question was 92 percent.

Question
15.284

In the emergency medical response drill, the responding officer at nearly all prisons
provided accurate information to responding medical staff. The average score for this
question was 90 percent.

Question
15.283

In the emergency medical response drill, the emergency medical responders at nearly
all prisons arrived with the proper equipment. The average score for this question was
87 percent.

Question
15.285

In the emergency medical response drill, emergency medical responders at nearly all
prisons continued basic life support activities. The average score for this question was
87 percent.

Question
8.187

For actual medical emergencies reviewed, nearly all prisons provided adequate
preparation for the ambulance’s arrival, access to the inmate, and departure. The
average score for this question was 87 percent.

Question
8.185

For actual medical emergencies reviewed, the medical emergency responder at nearly
all prisons used proper equipment and provided adequate medical care within the
scope of his or her license. The average score for this question was 86 percent.

See Appendix C-6 for detailed information on questions and scores for this component.

Bureau of Audits, Office of the Inspector General

Page 34

State of California • May 2011

Page 35

Medical Component: Prenatal Care/Child Birth/Post-Delivery Profile
Page 1 of 2
Component Definition: The Prenatal Care/Childbirth/Post-Delivery component focuses on the prenatal
and post-delivery medical care provided to pregnant inmates. This component is not applicable at men’s
prisons.
Results in Brief: CIW and VSPW were the only prisons with female
inmates who met our screening criteria for this component. CIW’s
score of 61 percent was far below that of VSPW, which scored 81
percent and exceeded the 75 percent minimum score for moderate
adherence to policies and procedures. However, at both prisons there
were inconsistencies in reported problems and risks when compared
to prenatal tests and physical examinations, and neither prison
administered timely pregnancy tests to newly arrived inmates.

Key Statistics
Component Average:........ 71%
Top Two Average: ............. 71%
Range of Scores: ..... 81%-61%
Variation: ......................... 20%
Number of Prisons with:
High Adherence ..................... 0
Moderate Adherence .............. 1
Low Adherence ...................... 1

This component includes nine questions.

Areas Requiring Significant Improvement Due to Scores of 60 Percent or Less
Question
09.072

The “Problems/Risks Identified” section of the Briggs Form 5703N (Prenatal Flow
Record) did not corroborate the “Prenatal Screens” and the “Maternal Physical”
examination sections of the form. Both prisons scored zero percent on this question.

Question
09.066

For newly arrived inmates, neither prison routinely administered a pregnancy test
within three business days to positively identify the inmate’s pregnancy. The average
score for this question was 25 percent, and CIW scored zero percent.

Areas Achieving High Adherence with Scores of 86 Percent or More
Question
09.067

An obstetrician or an obstetric nurse practitioner examined newly arrived inmates within
seven business days of their arrival. Both prisons scored 100 percent on this question.

Question
09.069

In nearly all cases, medical staff promptly ordered extra daily nutritional supplements
and food for pregnant inmates. The prisons averaged 93 percent on this question.

Question
09.071

An obstetrician generally met with pregnant inmates according to applicable time
frames. The prisons averaged 93 percent on this question.

Question
09.074

In nearly all cases, inmates received their six-week, post-delivery check-up on time.
The prisons averaged 90 percent on this question.

Question
09.223

Medical staff documented on Form 5703N the results of the inmate’s specified
prenatal screening tests. The prisons averaged 86 percent on this question.

Question
09.224

In most cases, the inmate’s weight and blood pressure were documented at each clinic
visit. The prisons averaged 86 percent on this question.

See Appendix C-7 for detailed information on questions and scores for this component.
Bureau of Audits, Office of the Inspector General

Page 36

Medical Component: Prenatal Care/Child Birth/Post-Delivery Profile
Page 2 of 2
Chart 9: Prenatal Care/Childbirth/Post Delivery Scores by Prison, Sorted Highest to Lowest Score
VSPW

81%

CIW

61%

PBSP
SVSP
SCC
CEN
CIM
CTF
FSP
CCC
CRC
WSP
MCSP
COR
KVSP
NKSP
LAC

No Prenatal/Childbirth/Post-Delivery cases at these
institutions

PVSP
HDSP
DVI
CMF
SOL
SATF
CCI

Institution Score

SQ

Minimum Moderate Adherence = 75%
Average Score = 71%

CCWF
CVSP
ISP
RJD
CMC
SAC
CAL
ASP

40%

50%

State of California • May 2011

60%

70%

80%

90%

100%

Page 37

Medical Component: Diagnostic Services Profile
Page 1 of 2
Component Definition:The Diagnostic Services component addresses the timeliness of radiology
(x-ray) and laboratory services and whether the prison followed up on clinically significant results.
Results in Brief: Only eight prisons scored above the 75
percent minimum score for moderate adherence to policies and
procedures. HDSP performed the worst with a score of 43 percent.
Of particular concern is that the primary care providers at most
prisons failed to give inmates timely notice of radiological results.
Further, nearly all prisons’ primary care providers failed to give
inmates timely notice of laboratory results.
This component includes seven questions.

Key Statistics
Component Average: ....... 69%
Top Two Average: ............ 88%
Range of Scores: ......89%-43%
Variation: ........................ 46%
Number of Prisons with:
High Adherence ..................... 4
Moderate Adherence .............. 4
Low Adherence .................... 25

Areas Requiring Significant Improvement Due to Scores of 60 P
Percent or L
Less
Question
06.200

Most prisons scored poorly on this question, which asks if the primary care provider
reviewed the inmate’s diagnostic report for radiological services and completed
the inmate notification form within two business days of the prison’s receiving the
diagnostic report. The average score for this question was only 39 percent. Twenty
of the 33 prisons had scores of 20 percent or less, and ten of those 20 received zero
percent.

Question
06.202

Thirty of the 33 prisons scored poorly on primary care providers reviewing the
inmate’s diagnostic report for laboratory services and completing the inmate
notification form within two business days of the prison’s receiving the report. The
average score for this question was only 42 percent. Twenty-one of the 33 prisons had
scores of 50 percent or less. Four prisons received zero percent.

Areas Achieving High Adherence with Scores of 86 Percent or More
Question
06.245

For radiology orders, most prisons received the diagnostic report within 14 days of
the radiological service provided. The average score for this question was 89 percent.
However, five prisons, with scores ranging from 20 percent to 60 percent, did not
achieve the 75 percent minimum score for moderate adherence.

See Appendix C-8 for detailed information on questions and scores for this component.

Bureau of Audits, Office of the Inspector General

Page 38

Medical Component: Diagnostic Services Profile
Page 2 of 2
Chart 10: Diagnostic Services Scores by Prison, Sorted Highest to Lowest Score
WSP

89%

ASP

87%

KVSP

86%

SCC

86%

CCWF

84%

VSPW

81%

FSP

80%

SVSP

77%

DVI

74%

CEN

74%

CTF

72%

CMF

72%

CCC

71%

CIW

71%

CMC

70%

SQ

69%

CIM

68%

MCSP

68%

COR

68%

NKSP

68%

SAC

68%

PVSP

65%

RJD

64%

SOL

60%

CCI

60%

CRC

59%

CAL

58%

ISP

58%

PBSP
CVSP

56%

SATF

56%

LAC

Average Score = 69%
Minimum Moderate Adherence = 75%

54%

HDSP

30%

Institution Score

57%

43%

40%

50%

State of California • May 2011

60%

70%

80%

90%

100%

Page 39

Medical Component: Access to Health Care Information Profile
Page 1 of 2
Component Definition: The Access to Health Care Information component addresses the prison’s
effectiveness in filing, storing, and retrieving medical records and medical-related information.
Results in Brief: Only eleven prisons scored above the 75 percent
minimum score for moderate adherence to policies and procedures.
ASP’s score of 20 percent was the lowest, 17 percentage points
below any other prison. Only two prisons kept inmates’ medical
records up to date by promptly filing loose documents, and most did
not promptly file blood pressure logs in inmates’ unit health records.
Further, many prisons failed to explain why certain requested medical
records were not available for our inspection.

Key Statistics
Component Average:........ 64%
Top Two Average: ............. 94%
Range of Scores: ....100%-20%
Variation: ........................ 80%
Number of Prisons with:
High Adherence ..................... 2
Moderate Adherence .............. 9
Low Adherence .................... 22

This component includes six questions.

Areas Requiring Significant Improvement Due to Scores of 60 Percent or Less
Question
19.150

Prisons’ medical records offices routinely failed to file all loose documents into inmates’
unit health records within the specified time frame following medical services to the
inmate. (CDCR policy requires the filing of all loose documents no later than the close of
business each day. However, given the difficulty of complying with this requirement, we
used a four-day criterion for this question.) Thirty-one of the 33 prisons failed the question
and received zero percent. The average score for this question was only six percent.

Question
19.272

Twenty-two of the 33 prisons did not promptly file blood pressure logs in inmates’
unit health records. The average score for this question was only 48 percent.

Question
19.243

Many prisons were unable to account for all requested medical files. In requesting
such files, we stress to medical records personnel that if they cannot provide a
requested file, they must explain why. However, 15 of the 33 prisons’ medical records
staff failed to explain why files were missing. For this question, the 33 prisons had an
average score of only 55 percent.

Areas Achieving High Adherence with Scores of 86 Percent or More
Question
19.169

Medical records staff performed very well in making unit health records available
to clinic staff for inmates ducated for medical appointments the next day. With the
exception of ASP and SOL, all prisons received 100 percent on this question. The
average score was 95 percent.

Question
19.266

Notwithstanding the slowness with which they did so, nearly all prisons properly filed
inmates’ medical information. The average score for this question was 88 percent.

Question
19.271

At all but four prisons, the OIG’s registered nurse and physician inspectors were
able to locate all relevant documentation of health care provided to inmates. The
average score for this question was 87 percent.

See Appendix C-9 for detailed information on questions and scores for this component.
Bureau of Audits, Office of the Inspector General

Page 40

Medical Component: Access to Health Care Information Profile
Page 2 of 2
Chart 11: Access to Healthcare Information Scores by Prison, Sorted Highest to Lowest Score
100%

PBSP
SVSP

88%

SCC

82%

CEN

82%

CIM

78%

CTF

78%

FSP

78%

CCC

78%

CRC

78%

WSP

76%

VSPW

76%

MCSP

73%

COR

73%

KVSP

73%

NKSP

73%

LAC

73%
63%

PVSP
HDSP

59%

CIW

59%

DVI

59%

CMF

59%

SOL

58%

SATF

57%
55%

CCI
SQ

54%

CCWF

54%

CVSP

49%

ISP

49%

RJD

44%

CMC

39%

SAC

39%

Institution Score
Average Score = 64%
Minimum Moderate Adherence = 75%

CAL

37%

ASP

0%

20%

10%

20%

State of California • May 2011

30%

40%

50%

60%

70%

80%

90%

100%

Page 41

Medical Component: Outpatient Housing Unit Profile
Page 1 of 2
Component Definition: The Outpatient Housing Unit component determines whether the prison followed
CDCR policies and procedures when placing inmates in the outpatient housing unit, a facility that
provides outpatient health services to inmates and assists them with the activities of daily living. This
component also evaluates whether the outpatient housing unit
Key Statistics
placement provided the inmate with adequate care and whether the
Component
Average:........ 81%
physician’s plan addressed the placement diagnosis.
Results in Brief: Only 17 prisons had outpatient housing units.
Thirteen of them scored at or above the 75 percent minimum score for
moderate adherence to policies and procedures. However, timeliness
of services was frequently a problem. For example, utilization
management nurses did not assess inmates in a timely manner, and
medical staff members did not make their rounds with the required
frequency when call buttons were not operational.

Top Two Average: ............ 96%
Range of Scores: ......99%-62%
Variation: ........................ 37%

Number of Prisons with:
High Adherence ..................... 7
Moderate Adherence .............. 6
Low Adherence ...................... 4

This component includes ten questions.

Areas Requiring Significant Improvement Due to Scores of 60 Percent or Less
Question
04.054

Utilization management nurses at nearly all of the 17 prisons did not assess inmates
within one week of the inmate’s placement in the outpatient housing unit and every 30
days thereafter. The average score for this question was only 21 percent. Ten of the 17
prisons received zero percent.

Question
15.103

In the absence of operational call buttons for inmate-patients, medical staff members at
many prisons were not making their rounds every 30 minutes. The average score was only
59 percent. Seven of the 17 prisons had scores of zero percent.

Areas Achieving High Adherence with Scores of 86 Percent or More
Question
04.208

The level of care available in the outpatient housing unit was appropriate to the patient’s
clinical presentation. The average score for this question was 98 percent. Fifteen of the 17
prisons scored 100 percent on this question.

Question
04.230

The primary care provider’s initial assessment (or diagnosis) was appropriate for the
findings in the initial evaluation. The average score for this question was 96 percent.

Question
04.052

The registered nurse completed an initial assessment of the inmate on the day of
placement. The average score for this question was 94 percent.

Question
15.225

With the exception of CRC and COR, all prisons’ outpatient housing units used
disinfectant daily in common patient areas. The average score was 88 percent.

Question
04.051

At all prisons but CIW, the primary care provider evaluated the inmate within one
calendar day of placement. The average score for this question was 88 percent.

Question
04.056

At each prison, the primary care provider’s treatment plan adequately addressed the initial
assessment. The average score for this question was 87 percent.

See Appendix C-10 for detailed information on questions and scores for this component.
Bureau of Audits, Office of the Inspector General

Page 42

Medical Component: Outpatient Housing Unit Profile
Page 2 of 2
Chart 12: Outpatient Housing Unit Scores by Prison, Sorted Highest to Lowest Score
CVSP

99%

CIM

93%

CAL

93%

ISP

90%

VSPW

89%

CTF

87%

CMF

86%

SQ

83%

DVI

83%

CCC

82%

SAC

76%

CRC

75%

SCC

75%

CCI

73%

ASP

71%

CIW

63%

COR

62%

WSP
PBSP
SVSP
MCSP
SATF
SOL
FSP
KVSP
NKSP

No Outpatient Housing Units at
these institutions

HDSP
PVSP
LAC

Institution Score
Average Score = 81%

CMC

Minimum Moderate Adherence = 75%

CCWF
CEN
RJD

40%

50%

State of California • May 2011

60%

70%

80%

90%

100

Page 43

Medical Component: Internal Reviews Profile
Page 1 of 2
Component Definition: The Internal Reviews component focuses on the activities of the prison’s
Quality Management Committee (QMC) and its Emergency Medical Response Review Committee
(EMRRC). The component also evaluates the timeliness of inmates’
Key Statistics
medical appeals and the prison’s use of inmate death reviews.
Results in Brief: Twelve prisons performed very well. However,
17 failed to score at or above the 75 percent minimum score for
moderate adherence to policies and procedures. We found that
most prisons were not conducting timely medical emergency
response drills as required and that most prisons were not promptly
processing inmates’ medical appeals.

Component Average: ....... 78%
Top Two Average: ............ 99%
Range of Scores: ... 100%-60%
Variation: ........................ 40%
Number of Prisons with:
High Adherence ................... 12
Moderate Adherence .............. 4
Low Adherence .................... 17

This component includes eight questions.

Areas Requiring Significant Improvement Due to Scores of 60 Percent or Less
Question
17.221

Most prisons’ medical facilities did not complete a medical emergency response drill
for each watch during the most recent quarter. The average score for this question was
only 27 percent. Twenty-four of the 33 prisons had scores of zero percent.

Question
17.174

Most of the prisons did not promptly process inmates’ medical appeals during the
most recent 12 months. The average score for this question was only 48 percent.
Seventeen of the 33 prisons scored zero percent.

Areas Achieving High Adherence with Scores of 86 Percent or More
Question
17.119

The Quality Management Committee reported its findings to the health care manager
or to the chief medical officer following each of the last six meetings. The average
score for this question was 98 percent, and 31 prisons had scores of 100 percent.

Question
17.135

Thirty-two of the 33 prisons received 100 percent on this question, which asks whether
the last three Quality Management Committee meeting minutes reflect findings and
strategies for improvement. The average score for this question was 97 percent.
However, HDSP received zero percent.

Question
17.118

Most prisons’ Quality Management Committee meeting minutes documented monthly
meetings for the last six months. The average score was 94 percent.

Question
17.132

Most prisons’ Emergency Medical Response Review Committee meeting minutes
documented monthly meetings for the last six months. The average score for this
question was 89 percent.

See Appendix C-11 for detailed information on questions and scores for this component.

Bureau of Audits, Office of the Inspector General

Page 44

Medical Component: Internal Reviews Profile
Page 2 of 2
Chart 13: Internal Reviews Scores by Prison, Sorted Highest to Lowest Score
100%

RJD
FSP

98%

CCWF

98%
96%

CIM

95%

CIW
CTF

93%

DVI

93%
91%

CRC
WSP

88%

ISP

88%

VSPW

86%

CCC

86%
85%

NKSP

83%

MCSP
CAL

75%

SOL

75%

SVSP

73%

SATF

73%

LAC

73%
71%

PVSP
CMC

70%

SAC

70%

PBSP

69%

KVSP

69%

SQ

69%

CMF

69%

Institution Score

COR

66%

ASP

66%

Average Score = 78%

63%

HDSP

61%

CEN
CCI

60%

SCC

60%

50%

Minimum Moderate Adherence = 75%

68%

CVSP

55%

60%

State of California • May 2011

65%

70%

75%

80%

85%

90%

95%

100%

Page 45

Medical Component: Inmate Transfers Profile
Page 1 of 2
Component Definition: The Inmate Transfers component focuses on inmates pending transfer to
determine whether the sending prison documented medication and medical conditions to assist the
receiving prison in providing continuity of care.
Key Statistics
Component
Average: ....... 88%
Results in Brief: Most prisons performed well in transferring
Top
Two
Average:
.......... 100%
inmates to other prisons. Twenty-eight prisons met or exceeded the
Range
of
Scores:
...
100%-43%
75 percent minimum score for moderate adherence to policies and
Variation: ........................ 57%
procedures. Twenty-two of these 28 prisons scored above the 86
percent minimum score for high adherence. However, CMF and CCI
Number of Prisons with:
performed very poorly.
High Adherence ................... 22
This component includes five questions.

Moderate Adherence .............. 6
Low Adherence ...................... 5

Areas Requiring Significant Improvement Due to Scores of 60 Percent or Less
None.

Areas Achieving High Adherence with Scores of 86 Percent or More
Question
05.108

All 33 prisons received 100 percent on this question, which asks whether the
Receiving and Release office had the inmate’s unit health record and transfer envelope.

Question
05.172

Thirty prisons’ Health Records Departments maintained a copy of the inmate’s Form
7371 (Health Care Transfer Information) and Form 7231A (Outpatient Medication
Administration Record) when the inmate transferred. SAC, CCI, and CVSP failed to
do so. The average score for this question was 91 percent.

Question
05.110

Twenty-three prisons received 100 percent on this question, which asks whether the
inmate’s transfer envelope included all appropriate forms, identified all medications
ordered by the physician, and contained the medications. The average score for this
question was 90 percent.

See Appendix C-12 for detailed information on questions and scores for this component

Bureau of Audits, Office of the Inspector General

Page 46

Medical Component: Inmate Transfers Profile
Page 2 of 2
Chart 14: Inmate Transfers Scores by Prison, Sorted Highest to Lowest Score
CAL

100%

VSPW

100%

SATF

100%

Institution Score

KVSP

100%

Minimum Moderate Adherence = 75%

SQ

100%

Average Score = 88%

HDSP

100%

ASP

100%

CRC

100%

LAC

100%

CCWF

100%

CEN

100%

NKSP

96%

ISP

95%

FSP

95%

SCC

95%

CMC

94%

PBSP

93%

CIM

93%

CCC

93%

RJD

90%

WSP

89%
87%

COR
SVSP

85%

CIW

80%

SOL

79%

DVI

79%

PVSP

76%

SAC

75%

CVSP

73%

MCSP

68%

CTF

68%

CMF
CCI

40%

50%
43%

50%

State of California • May 2011

60%

70%

80%

90%

100%

Page 47

Medical Component: Clinic Operations Profile
Page 1 of 2
Component Definition: The Clinic Operations component addresses the general operational aspects
of the prison’s clinics. Generally, the questions in this component relate to the cleanliness of the clinics,
privacy afforded to inmates during non-emergency visits, use of priority ducats (slip of paper the inmate
carries for scheduled medical appointments), and availability of
Key Statistics
health care request forms.
Results in Brief: Prisons performed very well in clinic operations. The
92 percent average score for this component is the third highest in the
20 component areas. All 33 prisons scored above the 75 percent minimum score for moderate adherence to policies and procedures, with 29
meeting or exceeding the 86 percent minimum score for high adherence.
This component includes ten questions.

Component Average: ....... 92%
Top Two Average: .......... 100%
Range of Scores: ... 100%-82%
Variation: ........................ 18%

Number of Prisons with:
High Adherence ................... 29
Moderate Adherence .............. 4
Low Adherence ...................... 0

Areas Requiring Significant Improvement Due to Scores of 60 Percent or Less
None.

Areas Achieving High Adherence with Scores of 86 Percent or More
Questions
14.029
14.131
14.166

These questions pertain to medication distribution policy and administration, and to
medication storage. Medical staff in the prisons’ clinics was aware of those inmates on
modified programs or confined to quarters and had an adequate process for ensuring that
those inmates received their medications. Medication nurses understood that medications
were to be administered by the same licensed staff member who prepared it and on the
same day. Medications stored in the clinic refrigerator were stored in a sealed container if
food was present in the refrigerator. The average scores for these three questions ranged
from 95 percent to 100 percent.

Questions These questions pertain to the inmate ducating (medical appointment) process. Most
14.032
prisons’ medical personnel understood their prison’s priority ducating process, and they
14.033
scored an average of 97 percent on the question (Question 14.032). Further, the prisons had
adequate processes to ensure that inmates moved to new cells still received their medical
ducats; the average score for this question (Question 14.033) was 98 percent.
Question
14.023

The prisons were generally making the Form 7362 (Health Care Services Request Form)
available to inmates. The average score for this question was 94 percent. Twenty-seven
prisons scored 100 percent on this question.

Question
14.164

The prisons generally made areas available to ensure inmates’ privacy during the
registered nurses’ face-to-face assessments and doctors’ examinations for nonemergencies. Only CMF, CRC, and SOL consistently failed to do so. The average score
for this question was 91 percent.

Question
14.160

The prisons generally had processes to identify, review, and address urgent appointments if a
doctor’s line was canceled. The average score for this question was 86 percent.

See Appendix C-13 for detailed information on questions and scores for this component.
Bureau of Audits, Office of the Inspector General

Page 48

Medical Component: Clinic Operations Profile
Page 2 of 2
Chart 15: Clinic Operations Scores by Prison, Sorted Highest to Lowest Score
MCSP

100%

CAL

100%

VSPW

100%

SQ

100%

SATF

99%

CIW

98%

ISP
KVSP
CCC
SVSP

97%

Institution Score

97%

Minimum Moderate Adherence = 75%

97%

Average Score = 92%

96%

CIM

95%

RJD

95%

FSP

94%

ASP

94%

PBSP

93%

PVSP

93%

CTF

91%

CVSP

91%

HDSP

91%

CCI

91%

SAC

91%

WSP

90%

COR

90%

NKSP

90%

LAC

90%

SCC

88%

DVI

88%

CRC

86%

CCWF

86%

CMC

85%

SOL

84%

CMF

83%

CEN

60%

82%

65%

70%

State of California • May 2011

75%

80%

85%

90%

95%

100%

Page 49

Medical Component: Preventive Services Profile
Page 1 of 2
Component Definition: The Preventive Services component focuses on inmate cancer screening,
tuberculosis evaluation, and influenza immunizations.
Key Statistics
Component
Average:........ 44%
Results in Brief: The 33 prisons had the lowest performance in this
Top
Two
Average:
............. 82%
component, with the average score only 44 percent. Only three
Range of Scores: ....... 82%-7%
prisons scored above the 75 percent benchmark for moderate adherVariation: ........................ 75%
ence to policies and procedures. CCI had a score of seven percent.
We found very low scores in tuberculosis treatment. Tuberculosis is
Number of Prisons with:
infectious and it jeopardizes the health of staff members and inmates
High Adherence ..................... 0
Moderate Adherence .............. 3
alike. Three tuberculosis-related questions and one cancer screening
Low Adherence .................... 30
question disclosed consistently poor performance by prisons.
l only
l to ffemale
l prisons,
i
d
This component includes seven questions. However, two questions apply
and
one question applies only to male prisons.

Areas Requiring Significant Improvement Due to Scores of 60 Percent or Less
Questions
10.228
10.232

Nearly all prisons failed to properly administer the Isoniazid (INH) medication
prescribed to inmates. Inmates prescribed INH are being treated for active or latent
tuberculosis infection. The average score for this question (Question 10.228) was
only 29 percent. Eight prisons scored zero percent. The second question (Question
10.232) asks whether the prison monitored inmates monthly while they were on the
medication. For this question, the average score was only 19 percent, and 20 prisons
received zero percent.

Question
10.085

Most of the 30 adult male prisons failed to administer a fecal occult blood test (FOBT)
to their inmates aged 51 or older within the past 12 months. This is an uncomplicated
test that can be the first indicator of cancer. However, the prisons’ average score was
only 41 percent. Fifteen of the prisons had scores of 30 percent or less. LAC, CCC,
and PVSP scored zero percent.5

Question
10.229

Most prisons did not evaluate inmates with latent tuberculosis infection for signs and
symptoms of tuberculosis within the previous 12 months. The average score for this
question was only 50 percent. Although eleven prisons scored 100 percent, ten prisons
received zero percent.

Areas Achieving High Adherence with Scores of 86 Percent or More
None.
See Appendix C-14 for detailed information on questions and scores for this component.5

5 We did not test CCWF, CIW, or VSPW because CDCR policy at the time required the FOBT for male inmates
only.
Bureau of Audits, Office of the Inspector General

Page 50

Medical Component: Preventive Services Profile
Page 2 of 2
Chart 16: Preventive Services Scores by Prison, Sorted Highest to Lowest Score
82%

CRC
PBSP

81%

VSPW

81%

CIM

71%

WSP

70%
60%

ASP
CCWF

59%

SOL

58%

FSP

57%

NKSP

55%
53%

CMC
CTF

51%

SQ

49%

CAL

48%

CVSP

48%

CMF

44%

SVSP

42%

MCSP

40%
37%

CCC
SATF

36%
34%

ISP
CIW

33%

SAC

32%

Institution Score
Average Score = 44%

30%

COR

Minimum Moderate Adherence = 75%
SCC

28%

KVSP

27%

PVSP

27%

HDSP

24%

RJD

24%

DVI

22%
20%

LAC
CEN

19%

CCI

7%
0%

10%

20%

State of California • May 2011

30%

40%

50%

60%

70%

80%

90%

100%

Page 51

Medical Component: Pharmacy Services Profile
Page 1 of 2
Component Definition: The Pharmacy Services component 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. This component also addresses whether the pharmacy has an effective process for screening
medication orders for potential adverse reactions/interactions.
Key Statistics
Results in Brief: Thirty of the 33 prisons scored at or above the
75 percent minimum score for moderate adherence to policies and
procedures, and 23 of those prisons scored at or exceeded the 86
percent minimum score for high adherence. CEN, however, lagged
far behind the other prisons. Despite some good overall scores
in pharmacy services, most prisons failed to properly maintain
medications in their after-hours medication supplies.

Component Average: ....... 87%
Top Two Average: .......... 100%
Range of Scores: ... 100%-58%
Variation: ........................ 42%
Number of Prisons with:
High Adherence ................... 23
Moderate Adherence .............. 7
Low Adherence ...................... 3

This component includes eight questions.

Areas Requiring Significant Improvement Due to Scores of 60 Percent or Less
Question
13.252

Most prisons did not properly maintain medications in their after-hours medication
supplies. The average score for this question was only 39 percent. Seventeen of the 33
prisons scored zero percent.

Areas Achieving High Adherence with Scores of 86 Percent or More
Questions
13.139
13.142

These are certification questions. All prisons conspicuously posted a valid permit
in their pharmacies, and the license of the pharmacist in charge was current. All 33
prisons scored 100 percent on each of these questions.

Question
13.145

The prisons’ pharmacists in charge had an effective process for screening new
medication orders for potential adverse reactions. All 33 prisons had scores of 100
percent on this question.

Question
13.148

Nearly all of the pharmacists in charge monitored the quantity of medications on
hand, and their pharmacies conducted an annual inventory. The average score for this
question was 94 percent. However, CEN and WSP had zero percent.

See Appendix C-15 for detailed information on questions and scores for this component.

Bureau of Audits, Office of the Inspector General

Page 52

Medical Component: Pharmacy Services Profile
Page 2 of 2
Chart 17: Pharmacy Services Scores by Prison, Sorted Highest to Lowest Score
SVSP

100%

FSP

100%

HDSP

100%

LAC

100%

CAL

97%

CIM
CIW

Institution Score

96%

Average Score = 87%

95%

Minimum Moderate Adherence = 75%

PBSP

93%

MCSP

93%

NKSP

93%

RJD

93%

ASP

92%

CCWF

92%

DVI

92%

SCC

91%

CMC

91%

SATF

90%

CTF

89%

SOL

89%

WSP

86%

COR

86%

VSPW

86%

SQ

86%

CVSP

83%

ISP

83%

KVSP

83%

CRC

79%

CCI

79%

CMF

76%

SAC

75%

PVSP

72%

CCC

69%

CEN

40%

58%

50%

State of California • May 2011

60%

70%

80%

90%

100%

Page 53

Medical Component: Other Services Profile
Page 1 of 2
Component Definition: The Other Services component 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 CDCR’s Inmate Medical Services Policies and Procedures.
Key Statistics
Component
Average: ....... 84%
Results in Brief: Twenty-two of the 33 prisons scored at or above
Top
Two
Average:
.......... 100%
the 75 percent minimum score for moderate adherence to policies
Range of Scores: .....100%-50%
and procedures and another five prisons came close. Seventeen of
Variation: ........................ 50%
the 22 exceeded the 86 percent minimum score for high adherence.
However, the performance of four prisons was far below that of the
Number of Prisons with:
others.
High Adherence ................... 17
This component includes five questions.

Moderate Adherence .............. 5
Low Adherence .................... 11

Areas Requiring Significant Improvement Due to Scores of 60 Percent or Less
Question
15.134

Two of the three prisons that had active cases of tuberculosis (TB) in the last six
months failed to follow all required procedures for responding upon discovering
the case. CTF and WSP received zero percent, while SAC scored 100 percent. The
average score for this question was only 33 percent.

Areas Achieving High Adherence with Scores of 86 Percent or More
Question
20.092

Custody staff understood CDCR’s policies and procedures for identifying and
evaluating inmates displaying inappropriate hygiene management. The average score
for this question was 98 percent.

Question
15.059

Fourteen of the 16 prisons that offered therapeutic diets properly provided them to
inmates. Thirteen of the 14 prisons scored 100 percent on this question.

See Appendix C-16 for detailed information on questions and scores for this component.

Bureau of Audits, Office of the Inspector General

Page 54

Medical Component: Other Services Profile
Page 2 of 2
Chart 18: Other Services Scores by Prison, Sorted Highest to Lowest Score
PBSP

100%

CIM

100%

CAL

100%

CVSP

100%

VSPW

100%

SATF

100%

CCC

100%

LAC

100%

CCWF

100%

DVI

100%

CEN

100%

RJD

100%

CMF

100%
93%

COR
CMC

91%

SAC

91%
89%

SVSP
MCSP

85%

ISP

85%

SQ

85%

CCI

85%
75%

SOL
73%

HDSP
FSP

70%

ASP

70%

CRC

70%

PVSP

70%
69%

WSP
67%

CTF

Institution Score
Minimum Moderate Adherence = 75%

57%

CIW

Average Score = 84%
SCC

55%

KVSP

50%

NKSP

50%

40%

50%

State of California • May 2011

60%

70%

80%

90%

100%

Page 55

Medical Component: Inmate Hunger Strikes Profile
Page 1 of 2
Component Definition: The Inmate Hunger Strikes component examines medical staff members’
monitoring of inmates participating in hunger strikes lasting more than three days.
Results in Brief: The prisons performed especially poorly in
monitoring inmates on hunger strikes lasting more than three days.
Hunger strikes of this length, although few in number, require careful
monitoring, yet the prisons’ average score of 57 percent was the
second lowest of all 20 component areas we inspected. Fourteen
of the 21 prisons that met our inspection criteria failed to score at
or above the 75 percent minimum score for moderate adherence to
policies and procedures. SAC’s and RJD’s scores of 11 percent were
the worst, 15 percentage points lower than that of any other prison.

Key Statistics
Component Average: ....... 57%
Top Two Average: .......... 100%
Range of Scores: ... 100%-11%
Variation: ........................ 89%
Number of Prisons with:
High Adherence ..................... 5
Moderate Adherence .............. 2
Low Adherence .................... 14

This component includes three questions.

Areas Requiring Significant Improvement Due to Scores of 60 Percent or Less
Question
11.100
Question
11.099

After the first 72 hours, physicians did not always perform a physical examination
and order a metabolic panel and a urinalysis of the inmate. The average score for this
question was only 48 percent. Six prisons scored zero percent.
After the first 48 hours, the nurses or the primary care providers did not always
complete daily assessments documenting the inmates’ weight, physical condition,
emotional condition, vital signs and hydration status. The average score for this
question was only 50 percent. Six prisons received zero percent.

Areas Achieving High Adherence with Scores of 86 Percent or More
None.
See Appendix C-17 for detailed information on questions and scores for this component.

Bureau of Audits, Office of the Inspector General

Page 56

Medical Component: Inmate Hunger Strikes Profile
Page 2 of 2
Chart 19: Inmate Hunger Strikes Scores by Prison, Sorted Highest to Lowest Score
PBSP

100%

CIM

100%

CAL

100%

CCWF

100%
88%

SOL
82%

MCSP
SATF

79%

CMC

71%
68%

CCC
54%

SQ
KVSP

46%

CCI

46%
44%

HDSP

42%

LAC
PVSP

37%

CEN

32%

CMF

32%
30%

COR
SVSP

Institution Score

26%

RJD

11%

SAC

11%

Average Score = 57%
Minimum Moderate Adherence = 75%

WSP
CTF
CVSP
ISP
VSPW
FSP

No inmate hunger strikes lasting longer than
three days occurred at these institutions

NKSP
ASP
CIW
CRC
SCC
DVI

0%

10%

20%

State of California • May 2011

30%

40%

50%

60%

70%

80%

90%

100%

Page 57

Medical Component: Chemical Agent Contraindications Profile
Page 1 of 2
Component Definition: The Chemical Agent Contraindications component addresses the prison’s
process for handling inmates who may be predisposed to an adverse outcome from calculated uses
of force (cell extractions) involving Oleoresin Capsicum (OC),
Key Statistics
commonly referred to as “pepper spray.” For example, an adverse
Component
Average: ....... 93%
outcome from OC exposure might occur if the inmate has asthma.
Results in Brief: Prisons generally performed well in this component.
The 93 percent average score is the second highest achieved in the
20 component areas. Twenty-seven prisons exceeded the 86 percent
minimum score for high adherence. However, four prisons scored
far below the other prisons, largely because they routinely failed to
document important procedures.

Top Two Average: .......... 100%
Range of Scores: ... 100%-60%
Variation: ........................ 40%
Number of Prisons with:
High Adherence ................... 27
Moderate Adherence .............. 1
Low Adherence ...................... 4

This component includes two questions.

Areas Requiring Significant Improvement Due to Scores of 60 Percent or Less
None.

Areas Achieving High Adherence with Scores of 86 Percent or More
Question
12.064

Prisons nearly always recorded how they decontaminated inmates and followed
decontamination policy. The average score for this question was 96 percent.

Question
12.062

The prisons routinely consulted with a registered nurse or a primary care provider
before a calculated, non-emergency use of OC spray. The average score for this
question was 91 percent.

See Appendix C-18 for detailed information on questions and scores for this component.

Bureau of Audits, Office of the Inspector General

Page 58

Medical Component: Chemical Agent Contraindications Profile
Page 2 of 2
Chart 20: Chemical Agent Contraindication Scores by Prison, Sorted Highest to Lowest Score
CIM

100%

SVSP

100%

Institution Score
MCSP
CTF

Average Score = 93%

100%

Minimum Moderate Adherence = 75%

100%

CAL

100%

COR

100%

ISP

100%

VSPW

100%

SATF

100%

SOL

100%

FSP

100%

NKSP

100%

CCC

100%

HDSP

100%

ASP

100%

CIW

100%

CRC

100%

SCC

100%

CMC

100%

SAC

100%

WSP

94%

RJD

94%
91%

LAC
SQ

89%

DVI

89%

CEN

89%

CMF

87%

PBSP

79%

CCI

66%

PVSP

66%

CCWF

65%

KVSP

60%

No Chemical Agent Contraindication information available at this institution

CVSP

50%

55%

60%

State of California • May 2011

65%

70%

75%

80%

85%

90%

95%

100%

Page 59

Medical Component: Staffing Levels and Training Profile
Page 1 of 4
Component Definition: The Staffing Levels and Training component
examines the prison’s medical staffing levels and training provided.
Results in Brief: The 96 percent average score for this component
was the highest of all 20 component areas. All 33 prisons’ scores
exceeded the 75 percent minimum score for moderate adherence to
policies and procedures, and the scores of 28 prisons exceeded the
86 percent minimum score for high adherence. Registered nurses and
physicians were either on-site or available 24 hours per day, seven
days a week.

Key Statistics
Component Average: ....... 96%
Top Two Average: .......... 100%
Range of Scores: ... 100%-80%
Variation: ........................ 20%
Number of Prisons with:
High Adherence ................... 28
Moderate Adherence .............. 5
Low Adherence ...................... 0

This component includes five questions. However, one is for information only and is not scored.

Areas Requiring Significant Improvement Due to Scores of 60 Percent or Less
None.

Areas Achieving High Adherence with Scores of 86 Percent or More
Question
18.004

All prisons had a registered nurse available on site 24 hours per day, seven days a
week, for emergency care. All 33 prisons scored 100 percent on this question.

Question
18.005

Every prison had a physician on site, a physician on call, or a medical officer of the
day available 24 hours a day, seven days a week, for the last 30 days. All 33 prisons
received 100 percent for this question.

Question
18.006

Each prison’s orientation program for all newly hired nursing staff included a module
for sick call protocols that require face-to-face triage. All 33 prisons scored 100
percent on this question.

See Appendix C-19 for detailed information on questions and scores for this component.

Note: In evaluating staffing levels and training, we collect information on staffing levels and
vacancy rates at each prison. We collect this data for informational purposes only. We have
summarized this information for all 33 prisons on the following pages.

Bureau of Audits, Office of the Inspector General

Page 60

Medical Component: Staffing Levels and Training Profile
Page 2 of 4
Chart 21: Staffing Levels and Training Scores by Prison, Sorted Highest to Lowest Score
PBSP

100%

CIM

100%

SVSP

100%

MCSP

100%

CTF

100%

Institution Score

CAL

Average Score = 96%

100%

COR

Minimum Moderate Adherence = 75%

100%

CVSP

100%

ISP

100%

VSPW

100%

SATF

100%

SOL

100%

FSP

100%

CCC

100%

HDSP

100%

ASP

100%

SCC

100%

CMC

100%

CEN

100%

RJD

100%

KVSP

95%

NKSP

95%

SQ

95%

DVI

95%

CMF

95%

SAC

95%

CCI

90%

LAC

90%

CIW

85%

CRC

85%

CCWF

85%

WSP

80%

PVSP

80%

50%

60%

State of California • May 2011

70%

80%

90%

100%

Page 61

Medical Component: Staffing Levels and Training Profile
Page 3 of 4

Data Not Included in Scoring: Results of Staffing and Vacancy Rate Analysis
The 33 prisons’ vacancy rates for authorized positions ranged from a low of zero percent at
SAC to a high of 29 percent at PVSP. The average vacancy rate was eight percent, and 16
prisons had double-digit vacancy rates. We could not directly correlate vacancy rates with
medical inspection scores. Some prisons relied extensively on private registries to address
their vacancy problems. PVSP, with its 29 percent vacancy rate, had the most registry staff
members: 67. Vacancies may partially be the result of prison location. Prison medical staff
members frequently commented on the difficulty of filling vacancies in rural, isolated prisons.
Background
During our prison medical inspections, the prisons provide us with data regarding their staffing
levels and authorized position vacancy rates in the following four medical classifications:
management, primary care providers, nursing supervisors, and nursing staff. We gather this
information for the benefit of all interested parties; we do not, however, score prisons on their
staffing levels and vacancy rates because we do not have objective criteria by which to evaluate
compliance.
Table 2 combines the data from the four medical classifications and summarizes each of the
33 prisons’ reported staffing levels and vacancy rates. The table shows that the vacancy rates
ranged from a low of zero percent at SAC to a high of 29 percent at PVSP. Twelve prisons
had vacancy rates of five percent or less, and the other 21 had vacancy rates of six percent or
more. Of this latter group, 16 had double-digit vacancy rates. (While not shown on Table 2, the
average vacancy rate for authorized positions at the 33 prisons was eight percent.)
PVSP and CVSP, the prisons with the two highest vacancy rates, had overall inspection scores
of 65 percent and 69 percent respectively, placing them in the bottom third of all prisons. While
these facts imply a correlation between vacancy rates and inspection scores, we cannot make
such a correlation. This is because SAC had a zero percent vacancy rate, but its inspection
score of 65 percent tied that of PVSP. On the other hand, SCC and WSP, with their 11 percent
vacancy rates, were among only nine prisons to achieve overall scores that met the 75 percent
benchmark for moderate adherence to medical policies and procedures.
When staff vacancies occur, prisons may have to pay overtime, work salaried staff members for
longer hours, or hire temporary staff from private registries. As shown in Table 2, some prisons
relied extensively on private registries. Six prisons had 47 or more registry staff members.
PVSP, with its 29 percent vacancy rate, had the most registry staff.

Bureau of Audits, Office of the Inspector General

Page 62

Medical Component: Staffing Levels and Training Profile
Page 4 of 4
Table 2: Staffing Levels and Vacancy Rates*
Institution

Total number of
filled positions:

Total number of
vacancies:

Total number of
positions:

Vacancy
percentage:

Number of staff
hired within last
six months:

Total number of
registry staff:
67.0

PVSP

67.0

26.7

93.7

29%

14.0

CVSP

54.0

12.5

66.5

19%

10.0

9.0

CCI

87.0

17.7

104.7

17%

12.0

48.0

NKSP

93.0

15.5

108.5

14%

6.0

0.0

CTF

96.0

14.8

110.8

13%

19.0

50.0

HDSP

80.3

10.7

91.0

12%

10.0

4.0

CEN

68.0

9.0

77.0

12%

5.0

9.0
30.0

CMC

183.0

23.8

206.8

12%

30.0

VSPW

83.0

10.8

93.8

12%

5.0

0.0

WSP

101.5

13.1

114.6

11%

18.0

45.0

SCC

52.6

6.8

59.4

11%

1.0

18.0

CCC

58.8

7.5

66.3

11%

8.0

3.0

SQ

115.0

13.8

128.8

11%

12.0

38.0

KVSP

77.0

8.7

85.7

10%

4.0

27.0

CRC

68.6

8.0

76.6

10%

0.0

26.0

SATF

101.8

10.8

112.6

10%

10.0

3.0

ISP

69.0

7.2

76.2

9%

12.0

16.0

COR

182.4

17.7

200.2

9%

17.0

51.0

RJD

128.6

11.1

139.7

8%

39.0

2.0

SOL

83.8

6.1

89.9

7%

9.0

14.0

ASP

109.0

7.0

116.0

6%

13.0

31.0

SVSP

88.4

5.0

93.3

5%

9.0

37.0

LAC

106.9

5.6

112.4

5%

12.0

20.0

CAL

72.9

3.5

76.4

5%

10.2

10.0

MCSP

82.0

3.6

85.6

4%

4.0

4.0

PBSP

93.6

4.0

97.6

4%

4.0

1.4

DVI

109.5

5.0

114.5

4%

5.0

12.0

CIW

79.5

3.6

83.1

4%

5.5

32.0

CIM

208.9

6.0

214.9

3%

24.0

44.0

CCWF

107.1

2.5

109.6

2%

9.0

47.0

CMF

229.0

5.0

234.0

2%

27.0

25.0

FSP

59.8

1.0

60.8

2%

5.0

0.6

SAC

84.5

0.0

84.5

0%

11.0

49.0

* This table summarizes numbers previously published in the medical inspection reports for individual prisons. The
numbers have been rounded and may differ slightly from prior reported numbers. Further, totals and percentages may
not calculate due to rounding. The data previously published in the inspection reports were provided by the prisons
and have not been audited.

Vacancies may be partially the result of prison location. PVSP, for example, is located in a rural,
remote setting. CVSP and CCI, with vacancy rates that were second and third highest behind
PVSP, are similarly situated. By way of contrast, SAC, with its zero percent vacancy rate, is
located near a larger urban area. FSP, which tied CMF for the second lowest vacancy rate, is next
door to SAC. CMF is adjacent to both the Bay Area and the Sacramento urban area.
State of California • May 2011

Page 63

Medical Component: Nursing Policy Profile
Page 1 of 2
Component Definition: The Nursing Policy component 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 members review their duty statements
and whether supervisors periodically review the work of nurses to
Key Statistics
ensure they properly follow established nursing protocols.
Component Average: ....... 77%
Results in Brief: There was wide variation in the prisons’ scores,
with 14 prisons exceeding the 85 percent minimum score for high
adherence to policies and procedures. Seven prisons scored 100
percent. On the other hand, 16 prisons failed to meet the 75 percent
minimum score for moderate adherence. DVI and CMF performed
the worst, scoring only 36 percent.

Top Two Average: .......... 100%
Range of Scores: ... 100%-36%
Variation: ........................ 64%
Number of Prisons with:
High Adherence ................... 14
Moderate Adherence .............. 3
Low Adherence .................... 16

This component includes three questions.

Areas Requiring Significant Improvement Due to Scores of 60 Percent or Less
Question
16.254

Many of the prisons’ supervising registered nurses did not conduct periodic reviews
of nursing staff performance. The average score for this question was only 58 percent.
Ten prisons scored zero percent.

Areas Achieving High Adherence with Scores of 86 Percent or More
Question
16.154

With the exception of certain ISP policies and procedures, all prisons had written
nursing policies and procedures that adhere to CDCR’s guidelines. The average score
for this question was 99 percent.

See Appendix C-20 for detailed information on questions and scores for this component.

Bureau of Audits, Office of the Inspector General

Page 64

Medical Component: Nursing Policy Profile
Page 2 of 2
Chart 22: Nursing Policy Scores by Prison, Sorted Highest to Lowest Score
WSP

100%

SVSP

100%

CTF

100%

CAL

100%

VSPW

100%

PVSP

100%

CCWF

100%

CCC

94%

SCC

94%

CIM

93%

MCSP

89%

HDSP

89%

RJD

89%

COR

86%

CMC

79%

SAC

79%
76%

CRC
FSP

74%

CVSP

71%

SATF

71%

SOL

71%

NKSP

71%

CEN

71%

SQ

70%

ASP

67%

CIW

64%

KVSP

57%

LAC

57%

PBSP

50%

ISP

50%

CCI

50%

DVI

36%

CMF

36%

30%

40%

50%

State of California • May 2011

Institution Score
Minimum Moderate Adherence = 75%
Average Score = 77%

60%

70%

80%

90%

100%

Page 65

General Medical Categories
As we did in our 17-prison summary report, we sorted the data from 100 key questions into
five general medical categories recommended by our lead physician. In this 33-prison summary
report, we found the same significant problems in the categories of medication management
and access to providers and services. The average score in medication management was only
59 percent, an increase of one percentage point over the 17-prison score. The medication
management score was low because prisons were ineffective in delivering medications to
inmates in a timely manner or were failing to document inmates’ receipt of medications as
required by policy. This problem occurred in the distribution or administration of medications
to newly arrived inmates, to inmates returning from outside hospitalization, to resident
inmates requiring routine care, and to resident inmates in need of chronic care medications and
tuberculosis medications. Only three prisons had scores that exceeded the 75 percent minimum
score for moderate adherence to medical policies and procedures. The average score for access
to providers and services was only 66 percent, an increase of six percentage points over the
17-prison score. This low score indicates that the prisons were generally ineffective in ensuring
that inmates are seen by primary care providers or provided services for routine, urgent, and
emergency medical needs according to timelines set by CDCR policy. Access to providers and
services scores ranged from 87 percent down to 45 percent. In the remaining three categories,
nurse responsibilities and continuity of care exceeded the 75 percent minimum score for
moderate adherence to policies and procedures. Nurse responsibilities had the same 80 percent
score achieved in the 17-prison summary report. Continuity of care’s score of 76 percent was
two percentage points higher than the score from the 17-prison review. However, in primary
care provider responsibilities the score fell from 74 percent to 72 percent.
Background
While our inspections and their resultant reports show prisons’ scores in 20 components of
medical care delivery, the inspection instrument’s questions can be sorted and viewed from
various perspectives. One perspective recommended by our lead physician was to sort our inspection questions into the following five general categories of medical care: medication management, access to providers and services, continuity of care, primary care provider responsibilities, and nurse responsibilities. Of the inspection instrument’s 165 questions, we identified
100 that fit into the five categories.
Table 3 describes each category, discloses the number of questions in that category, and provides an example question from the category. The five categories include 100 questions. In
identifying the questions for the five categories, we determined that some questions were appropriate to more than one category. Therefore, we included such questions in all of the categories to which they applied. An example is the following question:
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?(Question 02.128)

Bureau of Audits, Office of the Inspector General

Page 66

The above question applies to the medication management category because it involves the
prisons’ delivery of medication to inmates. However, the question also applies to the continuity
of care category since it determines whether inmates continued to receive their medications at
their new prisons. Accordingly, while each of the five categories has a specific set of questions,
individual questions like the one above sometimes appear in multiple categories. See Appendix
D for the questions we assigned to each category.
Table 3: Description of Five General Medical Categories
Medical Category

Description

Example Question

Medication
Management

Consists of 14 questions that determine if
medications were properly administered and
delivered to inmates as required by CDCR’s
policies.

Sick Call medication: Did the
institution administer or deliver
prescription medications (new orders)
to the inmate within specified time
frames? (Question 01.124)

Access to
Providers and
Services

Consists of 35 questions that evaluate whether inmates were seen or provided services for routine,
urgent, and emergency medical needs within the
time frames specified by CDCR’s policies.

RN FTF Documentation: Did the RN
complete the face-to-face triage within
one business day after the Form 7362
(Health Care Services Request Form)
was reviewed? (Question 01.025)

Primary Care
Provider
Responsibilities
and Processes

Consists of 29 questions that determine whether
primary care providers (physicians, nurse practitioners, and physician assistants) properly provided
care to inmates and whether processes related to
providing clinical care are consistent with policy.

All Diagnostic Services: Did the
PCP adequately manage clinically
significant test results? (Question
06.263)

Continuity of Care

Consists of 19 questions that determine whether
inmates received care when moved within a prison
or from one prison to another, or were received
from an outside care provider after specialty
services or hospitalization.

Upon the inmate’s discharge from
the community hospital, did the triage
and treatment area registered nurse
document that he or she reviewed
the inmate’s discharge plan and
completed a face-to-face assessment
of the inmate? (Question 21.248)

Nurse
Responsibilities

Consists of 23 questions that evaluate whether
nurses properly provided care to inmates and
whether processes related to providing nursing
care are consistent with policy.

Did documentation indicate that
the RN reviewed all of the inmate’s
complaints listed on Form 7362
(Health Care Services Request
Form)? (Question 01.246)

We excluded other questions from categories because we determined that including them could
inappropriately impact scores. For example, Question 14.106 asks:
“Does clinical staff wash their hands (either with soap or hand sanitizer) or change
gloves between patients?”
This question pertains to the hygienic practices of all staff and does not differentiate primary
care providers from nurses. Therefore, we cannot fairly score primary care providers’
State of California • May 2011

Page 67

performance on this question when the hygienic practices of nurses cannot be separated, and
vice versa. Accordingly, we excluded this question and others with similar predicaments from
categories for which the questions skew the categories’ scores.
As shown by the checked boxes in Table 4 below, we extract questions from 14 of the
20 component areas to allow the reader to evaluate performance from this additional
perspective. Access to health care information, internal reviews, other services, chemical agent
contraindications, staffing levels and training, and nursing policy are the only components
without at least one question that fits into the five general categories.
Table 4: Distribution of Medical Component Questions within the Medical Categories
Medication
Management

Access to
Providers
and Services

Primary Care
Provider
Responsibilities

Chronic Care

√

√

√

Clinical Services

√

√

Health Screening

√

√

Medical Component

Urgent Services

√

√

Nurse
Responsibilities

√
√

√

Specialty Services

Continuity
of Care

√

√

√
√

Emergency Services

√

Prenatal Care/
Childbirth/Post-delivery

√

√

Diagnostic Services

√

√

Outpatient Housing Unit

√

√

√

√
√
√

√

Inmate Transfers

√

√

√

Clinic Operations

√

√

√

Preventive Services

√

Pharmacy Services

√

Inmate Hunger Strikes

√
√

Bureau of Audits, Office of the Inspector General

√

√

Page 68

Category Analysis
There is low adherence to policies and procedures in the medication management and
access to providers and services categories. Chart 23 summarizes the results of our sorting the
questions from the 20 component areas into the five general medical categories. The average
scores for these categories range from a low of 59 percent in medication management to a
high of 80 percent in nurse responsibilities. This range of scores is consistent with the range of
scores from the 17-prison summary report. In that report, medication management also scored
lowest at 58 percent, while nurse responsibilities were highest with the same 80 percent score.
Our analysis clearly demonstrates that prisons’ performances in medication management and
access to providers and services merit the Receiver’s continuing attention, as the 33 prisons’
average scores of 59 percent and 66 percent, respectively, are far below the 75 percent
minimum score for moderate adherence to policies and procedures. More encouragingly,
in addition to nurse responsibilities’ 80 percent score, continuity of care’s 76 percent score
enabled both categories to exceed the minimum score for moderate adherence. However, by
averaging 72 percent, primary care provider responsibilities fell below the minimum score for
moderate adherence.
In the following sections, we provide a more in-depth analysis of the 33 prisons’ performances
in each of the five medical categories.
Chart 23: Scores by Category, Sorted Lowest to Highest Score

59%

Medication Management

Access to Providers and
Services

66%

Primary Care Provider
Responsibilities

72%

Continuity of Care

76%

80%

Nurse Responsibilities

40%

50%

60%

70%

80%

90%

100%

Average Score
Minimum Moderate Adherence = 75%

State of California • May 2011

Page 69

Medical Category: Medication Management
Page 1 of 3

The medication management category evaluates the timely delivery of medications to inmates
and certain elements of medication administration. These elements include the availability of
medications, maintenance of medications, and the screening of new medications for potential
adverse reactions. To develop our analysis, we used 14 questions from the following medical
care components: chronic care, clinical services, health screening, urgent services, inmate
transfers, clinic operations, preventive services, and pharmacy services. Of the 14 questions,
five pertain to medication delivery and nine pertain to medication administration. However, the
medication delivery questions are more important, and therefore they are more heavily weighted.
Prisons are ineffective at ensuring that inmates receive their medications. As shown in Charts
23 and 24, the 33 prisons’ average score for medication management was only 59 percent, one
percentage point higher than that reported in our 17-prison summary report. This is the lowest
average score within any of the five general medical categories, and it clearly indicates that
medication management is weak. Only three prisons had scores that exceeded the 75 percent
score for moderate adherence to medical policies and procedures. Particularly troubling is that 18
of the prisons scored 57 percent or less.
The prisons performed especially poorly in medication delivery. They had an average score of
only 35 percent, which is one percentage point higher than the score reported for medication
delivery in our 17-prison summary report. Thirty of the 33 prisons scored 53 percent or less,
and 17 of them scored from 32 percent down to eight percent. CMF and PBSP, with scores
of 83 percent, were the only prisons to exceed the 75 percent minimum score for moderate
adherence. The prisons’ very low scores in delivering medications to inmates offset the 90
percent average score they achieved on the other nine, less heavily weighted questions in
medication management.

Bureau of Audits, Office of the Inspector General

Page 70

Medical Category: Medication Management
Page 2 of 3
Chart 24: Medication Management Scores by Prison, Sorted Highest to Lowest
PBSP

84%

CMF

84%

SVSP

77%

FSP

71%

CCI

69%

CCWF

68%

RJD

68%

SAC

67%

CAL

66%

MCSP

64%

DVI

64%

CTF

62%

LAC

62%

CRC

61%

CEN

60%

VSPW

57%

WSP

56%

CVSP

56%

NKSP

56%

CIM

55%

SOL

55%

HDSP

55%

SCC

55%

COR

54%

CCC

53%

CMC

51%

ASP

49%

ISP
SATF

Minimum Moderate Adherence = 75%

44%

PVSP

Average Score = 59%

43%

CIW

42%

KVSP

41%

SQ

20%

Institution Score

47%

40%

30%

40%

State of California • May 2011

50%

60%

70%

80%

90%

100%

Page 71

Medical Category: Medication Management
Page 3 of 3

Compliance problems with medication delivery stem from one of two causes. The first is
failure to administer, provide, or deliver medications in a timely manner. The second is the
medical staff’s failure to document their actions after they provided or delivered medications.
We do not know the extent to which either cause contributed to the low score in medication
delivery. However, records we inspected indicate that this noncompliance is not simply a
documentation problem, but rather a problem of inmates not receiving their medications. For
example, in reviewing the 33 prisons’ administering of Isoniazid, a drug prescribed to treat
latent or active tuberculosis, we found that in 71 percent of the cases, the institutions did not
properly administer the medication. We reviewed the underlying documentation to determine
if this was a documentation problem or if the inmates in fact did not receive the Isoniazid.
We found that in many cases, the medication administration record was either completely
missing from the file or completely blank, leaving the possibility that this was a documentation
problem. However, for at least 51 percent of the cases, we found medication administration
forms in the medical file that indicated some medications had been given to the inmate, but
sections of the same forms were blank where ordered doses of Isoniazid should have been
recorded as administered. This documentation suggests that the missing dose was not given
to the inmate. We conclude, therefore, that the prisons are not merely failing to document that
inmates received their medications; they are also failing to get the medications to the inmates.
Regardless, both types of failure denote noncompliance and poor performance.
Numerous prisons performed inadequately in the following areas:
• Delivering tuberculosis medications to inmates and ensuring they take them
• Delivering medications to inmates within one day of arrival at the prison
• Providing chronic care medications and following policies when inmates refuse their
medications
• Delivering sick call medications (new orders) to inmates
• Providing medications to inmates upon discharge from an outside hospital
These five areas pertain to the basic delivery of medications to inmates. As suggested by the
poor 35 percent average score achieved by the 33 prisons, medication delivery is a significant
health issue.
See Appendix D-1 for detailed information on questions and scores for this category.

Bureau of Audits, Office of the Inspector General

Page 72

State of California • May 2011

Page 73

Medical Category: Access to Providers and Services
Page 1 of 4

The access to providers and services category assesses the prisons’ effectiveness in ensuring
that inmates are seen by primary care providers or provided services for routine, urgent, and
emergency medical needs according to timelines set by CDCR policy. Effective prison medical
care depends on inmates’ access to providers and services; a key indicator of access is timeliness.
To develop our analysis, we used 35 access to providers and services-related questions from the
following medical care components: chronic care, clinical services, health screening, specialty
services, urgent services, emergency services, prenatal care/childbirth/post-delivery, diagnostic
services, outpatient housing unit, preventive services, and inmate hunger strikes.
Access to providers and services is poor. As shown in Chart 25, the 33 prisons’ average score
for access to providers and services was only 66 percent. While this score is six percentage
points higher than the access to providers and services score reported in our 17-prison
summary report, it is still the second lowest average score within the five general medical
categories. With scores ranging from a high of 87 percent down to 45 percent, prisons are
generally deficient in providing inmates timely access to the primary care providers and
medical services they need. Only six prisons met or exceeded the 75 percent minimum score
for moderate adherence to medical policies and procedures. HDSP, with a score of 45 percent,
was the worst performer.

Bureau of Audits, Office of the Inspector General

Page 74

Medical Category: Access to Providers and Services
Page 2 of 4
Chart 25: Access to Providers and Services Scores by Prison, Sorted Highest to Lowest
CIM

87%

FSP

86%

VSPW

85%

PBSP

80%

CAL

79%

WSP

75%

CCWF

74%

CVSP

73%

CMC

72%

CRC

70%

NKSP

69%

ASP

69%

MCSP

67%

CCC

67%

CTF

66%

ISP

66%

SOL

66%

SQ

66%

CIW

65%

CMF

63%

DVI

62%

SVSP

61%

SCC

61%

COR

60%

CEN

60%

KVSP

58%

SATF

56%

SAC

54%

PVSP

52%

LAC

52%

Institution Score
Average Score = 65%

CCI
47%

RJD
HDSP

40%

Minimum Moderate Adherence = 75%

50%

45%

45%

50%

55%

State of California • May 2011

60%

65%

70%

75%

80%

85%

90%

Page 75

Medical Category: Access to Providers and Services
Page 3 of 4

Given the low scores shown in Chart 25, we further sorted and analyzed the access to providers
and services data. Specifically, we categorized the questions into two types: those that related
or applied to a specific medical problem identified for an inmate, and those that related or
applied to various screening and preventive health processes.
The following are examples of each type of question:
Medical problem-related

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?
(Question 03.076)

Screening and preventive-related

Did the prison complete the initial health screening on the same day the inmate
arrived at the prison? (Question 02.016)

The results of this analysis identified a significant weakness in the prisons’ administration
of correctional health care. The average access to providers and services score for questions
related to inmates with specific medical problems was only 62 percent. In contrast, the average
access to providers and services score for screening and preventive-related procedures was 75
percent. (We noted a similar gap in the scores for the first 17 prisons we inspected: 57 percent
for questions related to inmates with specific medical problems, and 71 percent for questions
related to screening and preventive-related procedures.) In short, inmates with identified health
problems had greater difficulty gaining access to the providers and services for which they had
a demonstrable need. Chart 26 shows each prison’s comparative scores for the two types of
access to providers and services.
With scores ranging from 87 percent down to 38 percent, only four prisons exceeded the 75
percent minimum score for moderate adherence in providing timely access to providers and
services when inmates had identified medical problems. These identified medical problems
included chronic diseases as well as other conditions that require specialty care or medical
treatment at outside hospitals. Moreover, inmates often did not have timely access to a physician
or a specialist for the health care management or follow-up required by CDCR policy.
The lowest-scoring prisons in problem-related access to providers and services had particular
difficulty in getting inmates with medical issues seen by a primary care provider in an
appropriate time frame for both interim and follow-up appointments for specialty services.
Overall, the prisons are relatively proficient at processing inmates for routine screening and
preventive-related appointments, but they are less proficient in getting inmates who have
identified medical problems seen by appropriate medical care providers. The failure to provide
timely access to care for inmates with identified medical problems clearly increases risks to the
inmates’ health.
See Appendix D-2 for detailed information on questions and scores for this category.
Bureau of Audits, Office of the Inspector General

Page 76

Medical Category: Access to Providers and Services
Page 4 of 4
Chart 26: Access to Providers and Services Scores by Prison, Sorted Highest to Lowest
87%
87%

CIM
FSP
VSPW
CAL
PBSP
CVSP
CCWF

Screening and Preventive-related
Access to Care Score

80%
79%

Problem-related Access to Care
Score

73%

Minimum Moderate Adherence =
75%

75%
81%

71%

91%

69%
85%

68%

CCC

67%
64%

CIW
NKSP

70%

66%
76%

66%

MCSP

65%

ASP

64%

ISP

64%

CRC

64%

SOL

64%

CMF

63%
57%

CEN
CTF

78%
84%
71%
89%
71%

65%

61%
84%

60%

SVSP

59%

SQ

59%

COR

59%

DVI

59%

SCC

66%
87%
65%
70%
72%

58%

KVSP

73%

53%

PVSP

51%
44%

CCI

55%

51%

SATF

78%

50%

LAC

48%

SAC

48%

30%

94%

75%

Average Problem Related Score =
62%

CMC

HDSP

96%

81%

Average Screening Score = 75%

WSP

RJD

98%

82%

63%
79%
66%

40%

66%

38%

40%

50%

State of California • May 2011

60%

70%

80%

90%

100%

Page 77

Medical Category: Primary Care Provider Responsibilities
Page 1 of 4

The primary care provider responsibilities category assesses how well the prisons’ physicians,
nurse practitioners, and physician assistants perform their duties and whether processes related
to providing clinical care are consistent with policy. To develop our analysis, we used 29
questions from the following medical care components: chronic care, health screening, urgent
services, prenatal care/childbirth/post-delivery, diagnostic services, outpatient housing unit, and
inmate hunger strikes.
The 29 questions are of two types: judgment questions and process questions. Judgment
questions evaluate how well the primary care provider applied his or her medical knowledge,
skills, and abilities in providing medical care.6 Process questions assess the primary care
provider’s compliance with established protocols for providing services and maintaining
records. Of the 29 questions, 21 are judgment questions, and eight are process questions.
Some prisons’ primary care providers must improve their performance to achieve moderate
adherence. As shown in Chart 27, the 33 prisons’ average score for primary care provider
responsibilities was 72 percent, which is two percentage points lower than the 74 percent score
we reported in our 17-prison summary report . The 72 percent score is the third lowest average
score in the five general medical categories, and it does not meet the 75 percent minimum score
for moderate adherence to policies and procedures. Only 15 prisons’ scores met or exceeded
the 75 percent minimum score for moderate adherence, with SCC and CAL tying for the
highest score at 85 percent. KVSP’s score of 51 percent stands out as exceptionally low.
The lower-performing prisons’ scores are driven largely by poor performance in response to
questions in the chronic care component, which represents 61 percent of the total point value
for primary care provider responsibilities.

6 In performing our inspections, judgement questions are answered by physician inspectors. When a physician
inspector takes exception to the judgement of a primary care provider, the physician inspector consults with our
lead physician before confirming the exception.
Bureau of Audits, Office of the Inspector General

Page 78

Medical Category: Primary Care Provider Responsibilities
Page 2 of 4
Chart 27: Primary Care Provider Responsibilities Scores by Prison, Sorted Highest to Lowest
CAL

85%

SCC

85%

FSP

84%

CCWF

84%
83%

CMF
VSPW

81%

DVI

81%
80%

CEN
SQ

79%

CIM

78%

CRC

78%

CIW

77%

CCI

76%

LAC

76%
75%

PBSP

74%

PVSP
MCSP

73%

SATF

72%

NKSP

72%

ASP

72%

SAC

71%
70%

WSP

69%

CVSP
CTF

68%

CMC

68%

CCC

66%

SVSP

65%

COR

Institution Score
Average Score = 72%

63%

Minimum Moderate Adherence = 75%
61%

ISP
56%

SOL

55%

HDSP

54%

RJD
KVSP

40%

51%

50%

State of California • May 2011

60%

70%

80%

90%

100%

Page 79

Medical Category: Primary Care Provider Responsibilities
Page 3 of 4
Chart 28: Primary Care Provider Responsibilities Scores by Prison, Sorted Highest to Lowest
59%

CMF

90%

54%

SQ

86%
79%

CCWF

86%
81%

CAL
CEN

66%

DVI

66%

85%
84%

SCC

84%

FSP

83%

VSPW

80%
39%

SAC

88%

84%

79%
68%

CCI

78%
75%

CIM
71%

LAC

78%
78%
80%
78%

CRC
66%

PVSP

76%

CIW

84%

75%
57%

WSP

74%
64%

ASP

74%

PBSP

74%

MCSP

74%
73%
66%

NKSP

72%

54%

CVSP

72%

51%

CTF

71%
56%

CCC

69%

54%

SVSP

69%

49%

COR

80%

73%

57%

CMC

66%
61%
62%

ISP
35%

RJD

Judgment Scores by Institution
60%

43%

HDSP

Average Judgment Score = 75%
Minimum Moderate Adherence = 75%

58%

29%

30%

Process Scores by Institution

61%
43%

SOL

20%

88%

79%
50%

SATF

KVSP

86%

Average Process Score = 63%

58%

40%

50%

60%

Bureau of Audits, Office of the Inspector General

70%

80%

90%

100%

Page 80

Medical Category: Primary Care Provider Responsibilities
Page 4 of 4

Impact of Primary Care Provider Judgment
To determine if the primary care provider judgment questions were more problematic for the
prisons than the process questions, we eliminated the process questions for the data sort shown
in Chart 28 and analyzed the results of the judgment questions exclusively.
Judgment functioned far better than process. As shown in Chart 28, the 33 prisons’ average
score on judgment questions was 75 percent, a score that by itself meets the minimum score
for moderate adherence. However, the prisons’ performance on the process questions reduced
the category score three percentage points to the 72 percent score achieved using both types of
questions. The average score on the process questions was only 63 percent, or 12 percentage
points less. (These scores are consistent with the trend we first noted in our 17-prison summary
report. In that report, the average score on judgment questions was 77 percent, and the average
score on the process questions was 63 percent, or 14 percentage points less.) The larger number
and heavier weight of the judgment questions kept the category score from falling more than
it did. On judgment questions, 17 prisons had scores that met or exceeded the 75 percent
minimum score for moderate adherence.
See Appendix D-3 for detailed information on questions and scores for this category.

State of California • May 2011

Page 81

Medical Category: Continuity of Care
Page 1 of 2

The continuity of care category evaluates whether or not inmates continue to receive prescribed
medical care when they move within a prison, move between prisons, or return to prison from
receiving specialty services or from being hospitalized. To develop our analysis, we used 19
questions from the following medical care components: health screening, specialty services,
urgent services, outpatient housing unit, inmate transfers, and clinic operations.
Some prisons must improve the continuity of care they provide inmates to achieve moderate
adherence to policies and procedures. As shown in Chart 29, the 33 prisons’ average score for
continuity of care was 76 percent. This score exceeds the 75 percent minimum score for moderate
adherence, and it is the second highest average score in the five general medical categories. The
76 percent average score indicates that the prisons generally provided continuity of medical
services to the inmate-patients in their care. However, while 20 prisons met or exceeded the 75
percent minimum score for moderate adherence, the remaining 13 did not.
Those prisons that failed to achieve moderate adherence in the continuity of care category did
so partly as the result of these problems:
• Failing to transmit accurate health care information on transferring inmates who need
specialty services.
• Failing to document the delivery of medications to arriving inmates or document within
one calendar day the reasons that arriving inmates’ medications were discontinued.
• Failing to meet specified time frames for following up on specialty service consultations.
See Appendix D-4 for detailed information on questions and scores for this category.

Bureau of Audits, Office of the Inspector General

Page 82

Medical Category: Continuity of Care
Page 2 of 2
Chart 29: Continuity of Care Scores by Prison, Sorted Lowest to Highest
PBSP

91%

FSP

87%

CIM
SVSP

Institution Score

85%

Average Acore = 76%

85%

Minimum Moderate Adherence = 75%
CRC

84%

CAL

83%

CCC

83%

CCWF

83%

CEN

83%

SCC

80%

SATF

79%

ASP

79%

WSP

78%

ISP

78%

LAC

78%

CVSP

76%

SOL

76%

KVSP

76%

VSPW

75%

NKSP

75%

COR

74%

HDSP

74%

MCSP

72%

CMC

72%

SAC

72%

PVSP

71%

RJD

70%

SQ

68%

CIW

68%

CCI

67%

CMF

67%

CTF

64%

DVI

64%

50%

55%

60%

State of California • May 2011

65%

70%

75%

80%

85%

90%

95%

100%

Page 83

Medical Category: Nurse Responsibilities
Page 1 of 4

The nurse responsibilities category evaluates how well the prisons’ registered nurses and licensed
vocational nurses perform their duties and whether processes related to providing nursing care
are consistent with policy. To develop our analysis, we used 23 questions from the following
medical care components: clinical services, health screening, urgent services, emergency
services, prenatal care/childbirth/post-delivery, inmate transfers, clinic operations, and inmate
hunger strikes.
The 23 questions are of two types: judgment questions and process questions. Judgment
questions evaluate how well the nurse applied his or her medical knowledge, skills, and abilities
7
in providing nursing care. Process questions assess the nurse’s compliance with established
guidelines for providing services and maintaining records. Seven of the 23 questions are
judgment questions, and 16 are process questions.
Prisons’ nurses performed relatively well. As shown in Chart 30, the 33 prisons’ average
score for nurse responsibilities was 80 percent. This is the same score the nurse responsibilities
category earned in our 17-prison summary report. The 80 percent average score is the highest
average score within the five general medical categories, and it exceeds the 75 percent
minimum score for moderate adherence. Twenty-three of the 33 prisons exceeded the 75
percent minimum score for moderate adherence, with seven of them achieving high adherence
scores of 86 percent or more. CCWF’s score of 94 percent was the highest.

7 In performing our inspections, judgement questions are answered by registered nurse inspectors. When a
registered nurse inspector takes exception to the judgement of a prisonʼs registered nurse, the nurse inspector
consults with another registered nurse inspector or a physician inspector before confirming the exception.
Bureau of Audits, Office of the Inspector General

Page 84

Medical Category: Nurse Responsibilities
Page 2 of 4
Chart 30: Nurse Responsibilities Scores by Prison, Sorted Highest to Lowest
CCWF

94%

CEN

91%

CRC

90%

PBSP

89%

FSP

89%

CMC
RJD
WSP

88%

Institution Score
Minimum Moderate Adherence = 75%

86%

Average Score = 80%

85%

CIM

85%

SAC

85%

KVSP

84%

ASP

84%

COR

83%

SCC

83%

ISP

82%

CCC

82%

CAL

81%

SATF

81%

LAC

81%

NKSP

80%

DVI

78%

VSPW

77%

CIW

76%

SOL

74%

HDSP

74%

SVSP

73%

CTF

73%

CVSP

73%

SQ

72%

MCSP

71%

CMF

69%
67%

CCI
PVSP

40%

66%

50%

State of California • May 2011

60%

70%

80%

90%

100%

Page 85

Medical Category: Nurse Responsibilities
Page 3 of 4

Impact of Nurse Judgment
To determine if the nurse judgment questions were more problematic for the prisons than the
process questions, we analyzed the results of the judgment questions exclusively.
The impact of judgment questions was substantial. As shown in Chart 31, the 33 prisons’
average score on the judgment questions was 75 percent, which is five percentage points lower
than the average score achieved using both types of questions. The average score for process
questions was 83 percent, meaning that there was an eight percentage point gap between
the average scores for the two types of questions. While all three scores fall in the moderate
adherence range, it is apparent that the 33 prisons’ nurses performed better on process
questions than on judgment questions. This observation contrasts with the one we made in
our 17-prison summary report. In that report, we concluded that one type of question had no
more impact than the other. Our conclusion was based on the fact that for the first 17 prisons
inspected, the nurse judgment average score of 80 percent was the same as the overall nurse
responsibilities score, and that the process question average score of 81 percent was nearly the
same. However, for the last 16 prisons inspected there was a significant drop in the scores on
judgment questions and an increase in the scores on process questions. The average judgment
score for the last 16 prisons was 70 percent, far below the 86 percent the same prisons achieved
on the process questions. Therefore, for all 33 prisons we conclude that the impact of the nurse
judgment questions was substantial.
See Appendix D-5 for detailed information on questions and scores for this category.

Bureau of Audits, Office of the Inspector General

Page 86

Medical Category: Nurse Responsibilities
Page 4 of 4
Chart 31: Impact of Nurse Judgement Scores by Prison, Sorted Highest to Lowest
93%

CCWF
CEN
RJD

88%
83%

Average Judgment Score = 75%
SCC
PBSP

91%

80%

Minimum Moderate Adherence = 75%

90%

Average Process Score = 83%

89%
87%

FSP

86%

CRC

86%

CMC

86%

91%
91%
90%

85%
85%

SAC
LAC

80%
82%

COR

80%

WSP

79%

CCC

79%
61%

CCI

85%
89%
84%

79%

63%

CMF

78%

CIM

90%

76%

91%

ASP

75%

CIW

76%
75%

NKSP

83%

74%
74%
74%

SOL
KVSP

91%

72%

CTF

69%

DVI

69%

HDSP

69%

SVSP

67%

CAL

67%

75%
84%
77%
76%
90%

65%
66%

PVSP
ISP

92%

65%

SQ

79%

63%

SATF

93%

62%

MCSP

76%

61%

VSPW

91%

55%

CVSP

20%

96%

Process Scores by Institution
Judgment Scores by Institution

96%

92%

46%

30%

40%

State of California • May 2011

50%

60%

70%

80%

90%

100%

Page 87

Conclusion
The results of our first 33 medical inspections demonstrate that the Receiver and CDCR
can improve prisons’ compliance with CDCR medical policies and procedures and medical
community standards in a number of areas. In particular, we note the following results:
• Only nine of the 33 prisons’ overall weighted scores met or exceeded 75 percent, the
Receiver’s minimum score for moderate adherence to medical policies and procedures. The
highest score was FSP’s 83 percent, and FSP is the only prison to achieve moderate or high
adherence in all six of the most heavily weighted components of the medical inspection
program.
• Nearly all of the prisons failed to achieve moderate adherence in three of the six most
heavily weighted components. The average score for chronic care, the most heavily
weighted component, was only 62 percent. Failure to ensure inmates received their
chronic care medications and inadequate documentation of inmates’ clinical histories
were recurring problems. Clinical services, the second most heavily weighted component,
had an average score of only 65 percent. Within this component, we found consistent
problems with getting inmates their prescribed medications and in primary care
providers’ seeing inmates by the appointment dates set by triage nurses. The average
score for specialty services, another heavily weighted component, was only 66 percent.
We found poor performance in providing inmates timely access to specialty services and
prompt follow-up related to those services.
• In other component areas of our inspection program, prisons scored particularly poorly
in preventive services. The average score was only 44 percent, and we found very low
scores in tuberculosis treatment, which can affect the health of inmates and staff alike.
Further, as evidenced by the average score of 57 percent, the prisons performed quite
poorly in monitoring inmates on hunger strikes lasting longer than three days. In access to
health care information the average score was only 64 percent, and only two of the prisons
kept inmates’ medical records updated with recently filed documents.
• Notwithstanding the problems cited above, the prisons performed well in several
components. Their average scores were more than 86 percent in five components,
indicating high adherence with medical policies and procedures. The 96 percent score
in staffing levels and training reflects positively on the prisons’ efforts to provide
around-the-clock physician and nursing services, and to orient and train nurses on faceto-face triage techniques in a prison setting. The 93 percent score in chemical agent
contraindications and the 92 percent score in clinic operations are also noteworthy.
• In the 20 components of health care that we examined, prisons achieved an average score
of 86 percent or higher on 69 of the 165 scored questions. However, the prisons scored
consistently poorly on 36 questions, averaging 60 percent or less, and in some cases
substantially less. This 60 percent mark, the Receiver’s threshold for a formal corrective
action plan, indicates areas of prison medical care that require significant improvement.
• When sorting 100 of the questions into five general medical categories, we found
recurring problems in how the prisons managed inmates’ medication. The average score in
Bureau of Audits, Office of the Inspector General

Page 88

medication management was only 59 percent because the prisons scored only 35 percent on
questions related to medication delivery. Inmates’ access to providers and services was also
of concern, with timeliness of access the main problem. The average score for this category
was only 66 percent. In contrast, nurse responsibilities had an average score of 80 percent
and continuity of care had an average score of 76 percent, making them the only general
medical categories to exceed the 75 percent minimum score for moderate adherence.
Primary care provider responsibilities, with an average score of 72 percent, came close to
the 75 percent minimum score for moderate adherence. However, the 63 percent score on
process questions offset the 75 percent score on judgement questions, which by itself met
the Receiver’s minimum score for moderate adherence.
We find that the wide variation among component scores within prisons, and the wide variation
among prisons’ average component scores, suggest that the Receiver has not yet implemented
a system that ensures that CDCR policies and procedures and selected medical community
standards are consistently followed throughout the prison system. The higher scores in some
component areas and medical categories, however, demonstrate that system-wide improvement
can be achieved.

State of California • May 2011

Page 89

Appendix Preface
This report contains the following four appendices:
APPENDIX A: This appendix contains the definitions of the 20 components we use in our
medical inspection program.
APPENDIX B: This appendix is a synopsis of each prison’s scores on the 20 components in
our medical inspection program.
APPENDIX C: This appendix contains the 33 prisons’ scores for each question in the 20
components and cites the text of each question. In addition, for each question the appendix
discloses the possible points for the question and the points received for the question. It also
shows the 33-prison average score for each question and each prison’s total score for each
component.
APPENDIX D: This appendix contains the 33 prisons’ scores for each question in the
five medical categories and cites the text of each question. In addition, for each question
the appendix discloses the possible points for the question and the points received for the
question. It also shows the 33-prison average score for each question and each prison’s total
score for each medical category.
Blank scores in Appendices C and D:
The reader may occasionally encounter blank spaces in Appendix C and Appendix D. The
spaces are blank for two possible reasons. The first reason is that the question does not apply
to the institution. For example, 16 of the 33 prisons did not have outpatient housing units.
Therefore, the ten questions in the outpatient housing unit component would not apply to these
16 prisons. The second reason is that the question does not apply to any sample items selected
for inspection. For example, Question 15.134 asks, “Did the institution properly respond to all
active cases of TB discovered in the last six months?” Because only three of the 33 prisons had
discovered an active case of tuberculosis in the six months preceding the inspection, only those
prisons received a score for Question 15.134. When questions do not apply to a prison, we
exclude them from our scoring calculations.
Rounding in Appendices B, C, and D:
We have rounded the percentage scores in Appendices B, C, and D to the nearest whole
number. In Appendices C and D, the points received for each question are displayed to the
nearest tenth of a point. However, our computer-based scoring system carries the points
received calculation to multiple decimal points before calculating the percentage score.
Accordingly, we have included the percentage score each prison earned on each of the
applicable questions from its inspection report. As a result, the reader may notice slightly
different percentage scores among prisons for questions with the same possible points and the
same points received. In addition, totals may not sum due to this rounding.

Bureau of Audits, Office of the Inspector General

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Appendices: Table of Contents
Appendix A: Component Definitions ........................................................................................ 92
Appendix B: Prisonsʼ Scores by Component ............................................................................ 93
Appendix C: Component Questions and Scores
Appendix C-1: Chronic Care .............................................................................................. 94
Appendix C-2: Clinical Services ........................................................................................ 96
Appendix C-3: Health Screening ...................................................................................... 100
Appendix C-4: Specialty Services .................................................................................... 104
Appendix C-5: Urgent Services ........................................................................................ 106
Appendix C-6: Emergency Services ................................................................................. 108
Appendix C-7: Prenatal Care ............................................................................................ 112
Appendix C-8: Diagnostic Services .................................................................................. 114
Appendix C-9: Access to Health Care Information ......................................................... 116
Appendix C-10: Outpatient Housing Unit ........................................................................ 118
Appendix C-11: Internal Reviews ..................................................................................... 120
Appendix C-12: Inmate Transfers ..................................................................................... 122
Appendix C-13: Clinic Operations ................................................................................... 124
Appendix C-14: Preventive Services ................................................................................ 126
Appendix C-15: Pharmacy Services ................................................................................. 128
Appendix C-16: Other Services ........................................................................................ 130
Appendix C-17: Inmate Hunger Strikes ........................................................................... 132
Appendix C-18: Chemical Agent Contraindications ........................................................ 134
Appendix C-19: Staffing Levels and Training .................................................................. 136
Appendix C-20: Nursing Policy ........................................................................................ 138
Appendix D: Category Questions and Scores
Appendix D-1: Medication Management ......................................................................... 140
Appendix D-2: Access to Providers and Services ............................................................. 144
Appendix D-3: Primary Care Provider Responsibilities ................................................... 150
Appendix D-4: Continuity of Care ................................................................................... 156
Appendix D-5: Nurse Responsibilities ............................................................................. 160

State of California • May 2011

Page 91

Appendix A: Component Definitions
Chronic Care: Examines how well the
prison provided care and medication to
inmates with specific chronic care conditions, which are those that affect (or
have the potential to affect) an inmate’s
functioning and long-term prognosis for
more than six months. Our inspection
tests the following chronic care conditions: asthma, anti-coagulation therapy,
diabetes, HIV (Human Immunodeficiency Virus), and hypertension.
Clinical Services: Evaluates the inmate’s access to primary health care
services and focuses on inmates who
recently received services from any of
the prison’s facilities or administrative
segregation unit clinics. This component evaluates sick call processes
(doctor or nurse line), medication
management, and nursing.
Health Screening: 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: 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
cardiology services, physical
therapy, oncology services, podiatry
consultations, and neurology services.
Urgent Services: Addresses the care
provided by the institution to inmates
before and after they were sent to a
community hospital.
Emergency Services: Examines
how well the prison responded to
medical emergencies. Specifically, we
focused on “man down” or “woman
down” situations. Further, questions
determine the adequacy of medical
and staff response to a “man down” or
“woman down” emergency drill.
Prenatal Care/Childbirth/Postdelivery: Focuses on the prenatal and
post-delivery medical care provided
to pregnant inmates. Not applicable at
men’s institutions.

Diagnostic Services: 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:
Addresses the prison’s effectiveness
in filing, storing, and retrieving
medical records and medical-related
information.
Outpatient Housing Unit: Determines
whether the prison followed
department policies and procedures
when placing inmates in the outpatient
housing unit.8 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: Focuses on the
frequency of meetings held by
the prison’s Quality Management
Committee and Emergency Medical
Response Review Committee and
whether key staff attended the meetings.
This component also evaluates the
timeliness of the prison’s responses to
inmates’ medical appeals filed, and the
prison’s death review process.
Inmate Transfers: 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: Addresses the general operational aspects of the prison’s
facility clinics. Generally, the questions
in this component relate to the cleanliness of the clinics, privacy afforded to
inmates during non-emergency visits,
use of priority ducats (slips of paper
the inmates carries for scheduled medical appointments), and availability of
health care request forms.
Preventive Services: Focuses
on inmate cancer screening,
8 An outpatient housing unit (OHU)
is a facility that provides outpatient
health services to inmates and assists
them with the activities of daily living.

Bureau of Audits, Office of the Inspector General

tuberculosis evaluation, and influenza
immunizations.
Pharmacy Services: 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: 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: Examines
medical staff’s monitoring of inmates
participating in hunger strikes lasting
more than three days.
Chemical Agent Contraindications:
Addresses the prison’s process
for 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:
Examines the prison’s medical staffing
levels and training provided.
Nursing Policy: 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.

Page 92

79% 62% 70% 71% 73% 75% 75% 52% 70% 81% 67% 57% 46% 74% 84% 59% 56% 70% 57% 59% 70% 52% 58% 39% 65% 58% 49% 42% 63% 57% 62% 38% 45% 62% 46%

Chronic Care

State of California • May 2011

84% 90% 81% 88% 80% 85% 76% 73% 64% 77% 73% 83% 90% 71% 72% 81% 81%
84%

86% 78% 80% 73% 88% 73% 78% 70% 90% 82% 48% 83% 78% 72% 72% 78% 42%

57% 71% 81% 81% 59% 48% 28% 70% 40% 19% 82% 42% 37% 22% 44% 55% 51% 20% 53% 60% 33% 48% 30% 34% 49% 36% 24% 58% 32% 27% 7% 27% 24% 44% 75%

N/A 100% 100% N/A 100% 100% N/A N/A 82% 32% N/A 26% 68% N/A 32% N/A N/A 42% 71% N/A N/A N/A 30% N/A 54% 79% 11% 88% 11% 37% 46% 46% 44% 57% 89%

Inmate Hunger
Strikes

Page 93

83% 81% 81% 80% 78% 77% 76% 76% 75% 74% 74% 74% 73% 73% 72% 72% 72% 72% 71% 70% 70% 69% 69% 68% 68% 68% 68% 67% 65% 65% 64% 64% 62% 72% 21%

Overall Score

Low Adherence

Moderate Adherence

High Adherence

Institutional Range 43% 38% 50% 34% 47% 63% 72% 48% 60% 81% 41% 74% 63% 78% 68% 50% 49% 80% 61% 80% 67% 52% 70% 66% 53% 64% 89% 58% 89% 73% 84% 73% 76% 52%

74% 93% 50% 100% 100% 100% 94% 100% 89% 71% 76% 100% 94% 36% 36% 71% 100% 57% 79% 67% 64% 71% 86% 50% 70% 71% 89% 71% 79% 100% 50% 57% 89% 77% 64%

Nursing Policy

Staffing Levels and 100% 100% 100% 100% 85% 100% 100% 80% 100% 100% 85% 100% 100% 95% 95% 95% 100% 90% 100% 100% 85% 100% 100% 100% 95% 100% 100% 100% 95% 80% 90% 95% 100% 96% 20%
Training

Chemical Agent
100% 91% 100% 100% 100% N/A 100% 100% 89% 100% 94% 100% 100% 66% 66% 60% 100% 93% 40%
Contraindications 100% 100% 79% 100% 65% 100% 100% 94% 100% 89% 100% 100% 100% 89% 87% 100%

70% 100% 100% 100% 100% 100% 55% 69% 85% 100% 70% 89% 100% 100% 100% 50% 67% 100% 91% 70% 57% 100% 93% 85% 85% 100% 100% 75% 91% 70% 85% 50% 73% 84% 50%

Other Services

Pharmacy Services 100% 9 6% 93% 86% 92% 97% 91% 86% 93% 58% 79% 100% 69% 92% 76% 93% 89% 100% 91% 92% 95% 83% 86% 83% 86% 90% 93% 89% 75% 72% 79% 83% 100% 87% 42%

Preventive
Services

Clinic Operations 94% 95% 93% 100% 86% 100% 88% 90% 100% 82% 86% 96% 97% 88% 83% 90% 91% 90% 85% 94% 98% 91% 90% 97% 100% 99% 95% 84% 91% 93% 91% 97% 91% 92% 18%

Inmate Transfers 95% 93% 93% 100% 100% 100% 95% 89% 68% 100% 100% 85% 93% 79% 50% 96% 68% 100% 94% 100% 80% 73% 87% 95% 100% 100% 90% 79% 75% 76% 43% 100% 100% 88% 57%

Internal Reviews 98% 96% 69% 86% 98% 75% 60% 88% 83% 61% 91% 73% 86% 93% 69% 85% 93% 73% 70% 66% 95% 68% 66% 88% 69% 73% 100% 75% 70% 71% 60% 69% 63% 78% 40%

Outpatient Housing N/A 93% N/A 89% N/A 93% 75% N/A N/A N/A 75% N/A 82% 83% 86% N/A
87% N/A N/A 71% 63% 99% 62% 90% 83% N/A N/A N/A 76% N/A 73% N/A N/A 81% 37%
Unit

Access to Health 78% 78% 100% 76% 54% 37% 82% 76% 73% 82% 78% 88% 78% 59% 59% 73% 78% 73% 39% 20% 59% 49% 73% 49% 54% 57% 44% 58% 39% 63% 55% 73% 59% 64% 80%
Care Information

Diagnostic Services 80% 68% 57% 81% 84% 58% 86% 89% 68% 74% 59% 77% 71% 74% 72% 68% 72% 54% 70% 87% 71% 56% 68% 58% 69% 56% 64% 60% 68% 65% 60% 86% 43% 69% 46%

Prenatal/Childbirth/ N/A N/A N/A 81% N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 61% N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 71% 20%
Post-delivery Care

Emergency
Services

Urgent Services 88% 80% 92% 67% 89% 88% 89% 85% 75% 80% 81% 84% 84% 78% 79% 80% 75% 80% 84% 70% 75% 78% 76% 70% 63% 75% 73% 70% 83% 81% 83% 61% 72% 78% 31%

Specialty Services 80% 83% 96% 72% 53% 75% 73% 71% 76% 60% 59% 71% 71% 53% 43% 61% 69% 70% 63% 74% 63% 86% 55% 82% 58% 62% 62% 66% 47% 61% 57% 62% 53% 66% 53%

Health Screening 89% 86% 85% 86% 84% 80% 61% 86% 81% 78% 74% 84% 81% 74% 87% 72% 64% 69% 73% 81% 70% 76% 73% 82% 77% 73% 68% 77% 76% 67% 78% 75% 72% 77% 28%

Clinical Services 76% 74% 69% 66% 74% 60% 71% 74% 69% 80% 70% 61% 66% 73% 87% 64% 59% 66% 74% 64% 62% 61% 68% 61% 47% 56% 67% 60% 67% 47% 57% 58% 51% 65% 40%

FSP CIM PBSP VSPW CCWF CAL SCC WSP MCSP CEN CRC SVSP CCC DVI CMF NKSP CTF LAC CMC ASP CIW CVSP COR ISP SQ SATF RJD SOL SAC PVSP CCI KVSP HDSP Average
Score Range

Reporting
Component

APPENDIX B: Prisons’ Scores By Component

APPENDIX
C-1:Chronic Care
______________________________________________________________________________________________________________________
Page 1 of 2
Component Definition: 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.
Ref
Number
03.076

03.077

03.082

03.175

03.235

03.236

03.237

03.238

SAC

RJD

CEN

DVI

CCWF CMC

SCC

LAC

PVSP

CCI

CRC

CIW

ASP

HDSP

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? (10 points possible)
Score

88%

87%

48%

95%

56%

90%

76%

60%

64%

72%

68%

96%

75%

72%

44%

Points Received

8.8

8.7

4.8

9.5

5.6

9

7.6

6

6.4

7.2

6.8

9.6

7.5

7.2

4.4

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? (10 points possible)
Score

4%

91%

46%

74%

78%

85%

52%

85%

76%

24%

52%

60%

72%

60%

28%

Points Received

0.4

9.1

4.6

7.4

7.8

8.5

5.2

8.5

7.6

2.4

5.2

6

7.2

6

2.8

Did the institution document that it provided the inmate with health care education? (12 points possible)
Score

64%

74%

52%

75%

50%

100%

48%

90%

96%

60%

80%

96%

88%

44%

76%

Points Received

7.7

8.9

6.2

9

6

12

5.8

10.8

11.5

7.2

9.6

11.5

10.6

5.3

9.1

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? (18 points possible)
Score

46%

77%

50%

55%

65%

40%

4%

31%

29%

4%

48%

20%

4%

18%

8%

Points Received

8.3

13.9

9

9.9

11.6

7.2

0.8

5.6

5.3

0.8

8.6

3.6

0.8

3.3

1.4

Is the clinical history adequate? (18 points possible)
Score

60%

74%

36%

70%

67%

70%

48%

65%

64%

44%

60%

32%

68%

48%

32%

Points Received

10.8

13.3

6.5

12.6

12

12.6

8.6

11.7

11.5

7.9

10.8

5.8

12.2

8.6

5.8

Is the focused clinical examination adequate? (19 points possible)
Score

85%

96%

76%

80%

72%

70%

64%

90%

83%

72%

76%

72%

80%

68%

48%

Points Received

16.2

18.2

14.4

15.2

13.7

13.3

12.2

17.1

15.8

13.7

14.4

13.7

15.2

12.9

9.1

Is the assessment adequate? (19 points possible)
Score

73%

91%

40%

100%

88%

84%

72%

84%

75%

63%

44%

86%

86%

71%

59%

Points Received

13.9

17.2

7.6

19

16.6

16

13.7

16

14.3

12

8.4

16.4

16.4

13.5

11.2

Is the plan adequate and consistent with the degree of control based on the chronic care program intervention and follow up requirements?
(19 points possible)
Score
Points Received

03.262

CMF

58%

95%

50%

90%

93%

94%

82%

89%

96%

88%

71%

85%

86%

74%

57%

11

18.1

9.5

17

17.7

17.9

15.6

16.9

18.2

16.8

13.6

16.2

16.3

14

10.9

Is the inmate’s Problem List complete and filed accurately in the inmate’s unit health record (UHR)? (8 points possible)
Score

80%

48%

28%

100%

83%

10%

84%

90%

32%

96%

60%

80%

80%

100%

64%

Points Received

6.4

3.8

2.2

8

6.7

0.8

6.7

7.2

2.6

7.7

4.8

6.4

6.4

8

5.1

Total Points Received

83.4

111.1

64.9

107.6

97.7

97.3

76.2

99.8

93.2

75.7

82.2

89.2

92.6

78.8

59.8

Total Points Possible

133

133

133

133

133

133

133

133

133

133

133

133

133

133

133

Total Score

63%

84%

49%

81%

74%

73%

57%

75%

70%

57%

62%

67%

70%

59%

45%

Bureau of Audits, Office of the Inspector General

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APPENDIX
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Page 2 of 2

SQ

CCC NKSP KVSP

FSP

SOL

SATF VSPW

ISP

CVSP COR

CAL

CTF

84%

56%

60%

52%

76%

24%

24%

72%

15%

48%

42%

46%

32%

28%

8.4

5.6

6

5.2

7.6

2.4

2.4

7.2

1.5

4.8

4.2

4.6

3.2

2.8

72%

28%

32%

8%

84%

0%

40%

52%

10%

40%

24%

54%

16%

7.2

2.8

3.2

0.8

8.4

0

4

5.2

1

4

2.4

5.4

1.6

12%

52%

68%

28%

88%

28%

68%

88%

86%

84%

68%

83%

1.4

6.2

8.2

3.4

10.6

3.4

8.2

10.6

10.3

10.1

8.2

10

8%

17%

24%

16%

57%

21%

5%

32%

0%

20%

52%

1.4

3.1

4.3

2.9

10.2

3.8

0.8

5.8

0

3.6

9.4

68%

44%

58%

13%

80%

32%

72%

84%

29%

39%

12.2

7.9

10.5

2.3

14.4

5.8

13

15.1

5.1

7

76%

60%

68%

71%

92%

64%

76%

80%

62%

14.4

11.4

13

13.5

17.5

12.2

14.4

15.2

92%

47%

68%

42%

84%

55%

96%

17.4

9

13

8

16

10.5

18.2

92%

53%

65%

53%

67%

55%

17.4

10

12.4

10.1

12.7

10.4

76%

60%

96%

48%

92%

6.1

4.8

7.7

3.8

7.4

85.9

60.8

78.3

50

133

133

133

133

65%

46%

59%

38%

Average
Score

CIM

PBSP WSP

48%

70%

13%

35%

58%

4.8

7

1.3

3.5

191.6

52%

28%

25%

50%

16%

46%

5.2

2.8

2.5

5

1.6

151.8

48%

88%

72%

88%

92%

68%

70%

5.8

10.6

8.6

10.5

11

8.2

276.5

63%

72%

72%

42%

25%

75%

22%

34%

11.3

13

13

7.5

4.5

13.5

3.9

202.1

48%

71%

48%

52%

32%

58%

83%

36%

54%

8.6

12.8

8.6

9.4

5.8

10.5

15

6.5

321.2

80%

60%

78%

56%

84%

64%

64%

88%

62%

73%

11.8

15.2

11.4

14.9

10.6

16

12.1

12.1

16.6

11.8

459.2

78%

21%

57%

58%

80%

48%

76%

74%

74%

71%

77%

70%

14.9

4

10.9

11.1

15.2

9

14.4

14

14

13.5

14.5

439.8

72%

64%

57%

57%

71%

94%

79%

71%

70%

68%

50%

67%

73%

13.7

12.1

10.9

10.7

13.5

17.9

15

13.5

13.3

13

9.5

12.7

458.5

96%

28%

96%

86%

28%

96%

96%

100% 100%

88%

96%

100%

76%

76%

7.7

2.2

7.7

6.9

2.2

7.7

7.7

8

8

7

7.7

8

6.1

199.5

104.8

56.2

76.9

93.8

51.5

68.5

76.5

99.8

74.8

92.9

75.9

81.8

93.4

68.8

2700.1

133

133

133

133

133

133

133

133

133

133

133

133

133

133

4389

79%

42%

58%

71%

39%

52%

58%

75%

56%

70%

57%

62%

70%

52%

62%

State of California • May 2011

MCSP SVSP

Page 95

APPENDIX
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Page 1 of 4
Component Definition: Evaluates the inmate’s access to primary health care services and focuses on inmates who recently received services from
any of the prison’s facilities or administrative segregation unit clinics. This component evaluates sick call processes (doctor or nurse line), medication
management, and nursing.
Ref
Number
01.024

01.025

01.027

01.124

01.157

01.158

01.159

01.162

01.163

01.244

01.246

SAC

CMF

RJD

CEN

DVI

CCWF CMC

SCC

LAC

PVSP

CCI

CRC

CIW

ASP

HDSP

RN FTF Documentation: Did the inmate’s request for health care get reviewed the same day it was received? (4 points possible)
Score

96%

96%

93%

87%

76%

52%

90%

30%

77%

87%

92%

45%

80%

89%

40%

Points Received

3.8

3.8

3.7

3.5

3

2.1

3.6

1.2

3.1

3.5

3.7

1.8

3.2

3.5

1.6

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

76%

84%

80%

76%

88%

88%

78%

65%

83%

33%

60%

80%

68%

26%

40%

Points Received

4.6

5

4.8

4.6

5.3

5.3

4.7

3.9

5

2

3.6

4.8

4.1

1.5

2.4

If the RN determined a referral to a primary care provider (PCP) was necessary, was the inmate seen within the timelines specified by the
RN during the FTF triage? (8 points possible)
Score

29%

82%

13%

50%

79%

56%

75%

75%

35%

47%

25%

54%

71%

52%

27%

Points Received

2.4

6.6

1

4

6.3

4.5

6

6

2.8

3.8

2

4.3

5.6

4.2

2.1

Sick Call Medication: Did the institution administer or deliver prescription medications (new orders) to the inmate within specified time
frames? (6 points possible)
Score

22%

80%

55%

77%

33%

52%

28%

13%

33%

11%

41%

10%

28%

30%

44%

Points Received

1.3

4.8

3.3

4.6

2

3.1

1.7

0.8

2

0.7

2.5

0.6

1.7

1.8

2.6

RN FTF Documentation: Did the RN’s subjective note address the nature and history of the inmate’s primary complaint? (7 points possible)
Score

92%

96%

83%

100%

83%

92%

93%

80%

59%

50%

64%

45%

54%

65%

57%

Points Received

6.4

6.7

5.8

7

5.8

6.4

6.5

5.6

4.1

3.5

4.5

3.2

3.8

4.5

4

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? (6 points possible)
Score

96%

88%

79%

89%

91%

96%

83%

95%

90%

33%

68%

90%

79%

74%

61%

Points Received

5.7

5.3

4.8

5.4

5.5

5.8

5

5.7

5.4

2

4.1

5.4

4.8

4.4

3.6

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? (6 points possible)
Score

91%

77%

80%

90%

67%

88%

73%

80%

55%

53%

68%

90%

76%

59%

50%

Points Received

5.5

4.6

4.8

5.4

4

5.3

4.4

4.8

3.3

3.2

4.1

5.4

4.6

3.5

3

RN FTF Documentation: Did the RN’s plan include an adequate strategy to address the problems identified during the FTF triage?
(7 points possible)
Score

92%

94%

100%

97%

96%

96%

98%

95%

100%

63%

92%

100%

96%

94%

100%

Points Received

6.4

6.6

7

6.8

6.7

6.7

6.8

6.6

7

4.4

6.4

7

6.7

6.6

7

RN FTF Documentation: Did the RN’s education/instruction adequately address the problems identified during the FTF triage?
(5 points possible)
Score

77%

94%

90%

93%

70%

96%

85%

90%

86%

57%

80%

95%

71%

82%

64%

Points Received

3.9

4.7

4.5

4.7

3.5

4.8

4.3

4.5

4.3

2.8

4

4.8

3.5

4.1

3.2

RN FTF Documentation: Did the RN’s objective note include allergies, weight, current medication, and where appropriate, medication
compliance? (3 points possible)
Score

92%

94%

80%

93%

79%

80%

80%

50%

35%

33%

28%

5%

12%

65%

7%

Points Received

2.8

2.8

2.4

2.8

2.4

2.4

2.4

1.5

1

1

0.8

0.2

0.4

1.9

0.2

Did documentation indicate that the RN reviewed all of the inmate’s complaints listed on Form 7362 (Health Care Services Request Form)?
(5 points possible)
Score

92%

92%

87%

90%

96%

96%

88%

100%

86%

67%

64%

95%

80%

77%

93%

Points Received

4.6

4.6

4.3

4.5

4.8

4.8

4.4

5

4.3

3.3

3.2

4.8

4

3.8

4.6

Bureau of Audits, Office of the Inspector General

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APPENDIX
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Page 2 of 4

SQ

CCC NKSP KVSP

FSP

SOL

SATF VSPW

ISP

CVSP COR

CAL

CTF

11%

80%

48%

29%

63%

60%

56%

44%

97%

93%

46%

53%

71%

82%

0.5

3.2

1.9

1.1

2.5

2.4

2.2

1.8

3.9

3.7

1.8

2.1

2.9

3.3

34%

84%

44%

57%

80%

64%

40%

60%

70%

97%

71%

70%

71%

2.1

5

2.6

3.4

4.8

3.8

2.4

3.6

4.2

5.8

4.3

4.2

4.3

56%

46%

40%

25%

61%

48%

46%

77%

64%

57%

52%

53%

4.4

3.6

3.2

2

4.9

3.8

3.7

6.2

5.1

4.6

4.2

4.2

22%

14%

65%

18%

57%

48%

7%

48%

17%

27%

27%

1.3

0.9

3.9

1.1

3.4

2.9

0.4

2.9

1

1.6

32%

79%

40%

46%

57%

54%

55%

40%

37%

2.2

5.5

2.8

3.2

4

3.8

3.9

2.8

2.6

27%

58%

72%

80%

93%

75%

58%

58%

1.6

3.5

4.3

4.8

5.6

4.5

3.5

3.5

50%

79%

84%

63%

53%

63%

53%

3

4.7

5

3.8

3.2

3.8

100%

90%

92%

97%

100%

7

6.3

6.4

6.8

7

64%

63%

96%

89%

3.2

3.2

4.8

4.4

18%

47%

80%

0.5

1.4

2.4

91%

90%

4.5

4.5

Average
Score

CIM

PBSP WSP

50%

83%

58%

80%

68%

2

3.3

2.3

3.2

89.2

68%

70%

79%

98%

71%

68%

4.1

4.2

4.8

5.9

4.3

135.4

63%

55%

46%

57%

75%

38%

52%

5.1

4.4

3.7

4.6

6

3

138.3

46%

20%

30%

73%

12%

68%

37%

36%

1.6

2.8

1.2

1.8

4.4

0.7

4.1

2.2

71.7

50%

60%

46%

56%

39%

44%

62%

76%

68%

62%

3.5

4.2

3.2

3.9

2.7

3.1

4.3

5.3

4.7

143.5

73%

62%

80%

76%

56%

78%

52%

76%

64%

97%

74%

4.4

3.7

4.8

4.6

3.4

4.7

3.1

4.6

3.9

5.8

147.2

56%

44%

47%

71%

35%

68%

39%

56%

62%

87%

65%

66%

3.2

3.4

2.7

2.8

4.2

2.1

4.1

2.3

3.3

3.7

5.2

3.9

130.3

87%

73%

77%

60%

77%

80%

77%

68%

96%

71%

73%

96%

81%

88%

6.1

5.1

5.4

4.2

5.4

5.6

5.4

4.7

6.7

5

5.1

6.7

5.6

203.2

97%

57%

69%

83%

76%

43%

91%

60%

64%

83%

78%

81%

98%

90%

79%

4.8

2.8

3.5

4.1

3.8

2.2

4.6

3

3.2

4.1

3.9

4

4.9

4.5

130.6

23%

40%

33%

43%

24%

56%

27%

44%

12%

44%

30%

48%

29%

53%

71%

47%

0.7

1.2

1

1.3

0.7

1.7

0.8

1.3

0.3

1.3

0.9

1.4

0.9

1.6

2.1

46.5

80%

100%

97%

88%

90%

88%

86%

80%

91%

89%

85%

100%

87%

91%

98%

94%

89%

4

5

4.8

4.4

4.5

4.4

4.3

4

4.6

4.4

4.3

5

4.3

4.5

4.9

4.7

146.1

State of California • May 2011

MCSP SVSP

Page 97

APPENDIX
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______________________________________________________________________________________________________________________
Page 3 of 4
Ref
Number
01.247

15.234

SAC

RJD

CEN

DVI

CCWF CMC

SCC

LAC

PVSP

CCI

CRC

CIW

ASP

HDSP

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

25%

78%

22%

100%

60%

67%

67%

0%

20%

36%

57%

88%

56%

63%

50%

Points Received

1.8

5.4

1.6

7

4.2

4.7

4.7

0

1.4

2.5

4

6.1

3.9

4.4

3.5

Are clinic response bags audited daily and do they contain essential items? (5 points possible)
Score
Points Received

21.278

CMF

0%

100%

50%

0%

0%

50%

0%

100%

50%

100%

50%

0

5

2.5

0

0

2.5

0

5

2.5

5

2.5

100% 100% 100%
5

5

50%

5

2.5

For inmates seen in the TTA, was there adequate prior management of pre-existing medical conditions related to the reason for the TTA
visit? (20 points possible)
Score

73%

83%

67%

80%

79%

60%

81%

85%

80%

33%

46%

67%

36%

60%

Points Received

14.5

16.7

13.3

16

15.7

12

16.3

16.9

16

6.7

9.1

13.3

7.3

12

8.2

Total Points Received

63.6

82.7

63.9

76.1

69.2

70.4

70.4

67.5

62.2

44.4

54.5

66.7

58.6

61.2

48.5

Total Points Possible
Total Score

41%

95

95

95

95

95

95

95

95

95

95

95

95

95

95

95

67%

87%

67%

80%

73%

74%

74%

71%

66%

47%

57%

70%

62%

64%

51%

Bureau of Audits, Office of the Inspector General

Page 98

APPENDIX
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_____________________________________________________________________________________________________________________
Page 4 of 4
Average
Score

SQ

CCC NKSP KVSP

FSP

SOL

SATF VSPW

ISP

CVSP COR

CAL

CTF

MCSP SVSP

CIM

PBSP WSP

50%

67%

100%

50%

100%

38%

55%

75%

83%

100%

67%

100%

40%

100%

50%

100%

60%

63%

3.5

4.7

7

3.5

7

2.6

3.8

5.3

5.8

7

4.7

7

2.8

7

3.5

7

4.2

141.6

50%

100%

50%

33%

50%

100%

0%

0%

100%

68%

2.5

5

2.5

1.7

5

5

5

5

5

2.5

5

0

5

5

5

5

0

5

111.7

40%

56%

50%

67%

69%

50%

54%

67%

46%

50%

68%

69%

50%

67%

56%

89%

50%

86%

62%

8

11.1

10

13.3

13.8

10

10.8

13.3

9.1

10

13.7

13.8

10

13.3

11.1

17.8

10

17.1

410.2

44.3

62.6

60.8

54.8

72

56.9

53.3

62.4

57.8

57.6

64.6

57.1

56.2

65.3

58

70.3

60.8

70.3

2045

100% 100% 100% 100% 100%

100% 100% 100% 100%

95

95

95

95

95

95

95

95

95

95

95

95

95

95

95

95

88

95

3128

47%

66%

64%

58%

76%

60%

56%

66%

61%

61%

68%

60%

59%

69%

61%

74%

69%

74%

65%

State of California • May 2011

Page 99

APPENDIX
C-3: Health Screening
______________________________________________________________________________________________________________________
Page 1 of 4
Component Definition: 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.
Ref
Number
02.007

SAC

RJD

Points Received

HDSP

75%

88%

95%

95%

100%

95%

85%

7

6.5

4.5

6.3

6

5.3

6.1

6.6

6.6

7

6.6

6

100%

0%

100%

7

0

7

100% 100%
7

7

7

100%

100%

67%

75%

83%

100%

33%

100%

7

7

4.7

5.3

5.8

7

2.3

7

9

9

97%
8.7

100% 100% 100% 100% 100%
9

9

9

9

9

90%

65%

77%

95%

95%

90%

93%

8.1

5.9

6.9

8.6

8.6

8.1

8.4

8

56%

94%

93%

4.4

7.6

7.5

100% 100% 100%
8

8

8

29%

46%

70%

2.3

3.7

5.6

100% 100%
8

8

87%
6.9

100% 100%
8

8

If, during the assessment, the RN referred the inmate to a clinician, was the inmate seen within the time frame? (8 points possible)
Points Received

25%

100%

13%

60%

50%

86%

100%

29%

0%

71%

33%

11%

55%

17%

2

8

1

4.8

4

6.9

8

2.3

0

5.7

2.7

0.9

4.4

1.3

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? (6 points possible)
Score

90%

70%

87%

90%

Points Received

5.4

4.2

5.2

5.4

100% 100%
6

6

85%

95%

100%

85%

80%

100%

90%

85%

97%

5.1

5.7

6

5.1

4.8

6

5.4

5.1

5.8

Reception center: Did the inmate receive a complete history and physical by a Nurse Practitioner, Physician Assistant, or a Physician and
Surgeon within 14 calendar days of arrival? (5 points possible)
Score

56%

55%

55%

50%

100%

40%

100%

Points Received

2.8

2.8

2.8

2.5

5

2

5

Reception center: If the primary care provider (PCP) indicated the inmate required a special diet, did the PCP refer the inmate to a registered
dietician? (4 points possible)
Score

0%

Points Received

0

Non-reception center: Did the inmate receive medical accommodations upon arrival, if applicable? (6 points possible)
Score
Points Received

02.211

ASP

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? (8 points possible)

Score

02.128

CIW

85%

Score 100%

02.111

CRC

Did the institution complete the initial health screening on the same day the inmate arrived at the institution? (9 points possible)

Points Received

02.022

CCI

Was a review of symptoms completed if the inmate’s tuberculin test was positive, and were the results reviewed by the infection control
nurse? (7 points possible)

Points Received

02.021

PVSP

90%

Score 100% 100%

02.020

LAC

64%

Score 100%

02.018

SCC

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? (7 points possible)

Points Received

02.017

CCWF CMC

93%

Score

02.016

DVI

100%

Points Received
02.015

CEN

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? (7 points possible)
Score

02.014

CMF

67%

100%

75%

33%

100%

75%

4

6

4.5

2

6

4.5

100% 100%
6

6

75%

100% 100%

4.5

6

6

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? (8 points possible)
Score

33%

88%

50%

50%

0%

43%

13%

25%

42%

0%

43%

23%

0%

30%

35%

Points Received

2.7

7

4

4

0

3.4

1

2

3.3

0

3.4

1.8

0

2.4

2.8

Reception center history and physical: Is the “History of Present Illness” section of Form 7206 (History and Physical Examination) complete
and appropriate to the chief complaint(s), if any? (2 points possible)
Score

75%

92%

100%

40%

89%

82%

60%

Points Received

1.5

1.8

2

0.8

1.8

1.6

1.2

Bureau of Audits, Office of the Inspector General

Page 100

APPENDIX
C-3: Health Screening
_____________________________________________________________________________________________________________________
Page 2 of 4

SQ

CCC NKSP KVSP

FSP

SOL

SATF VSPW

ISP

100%

100%

100%

94%

100%

95%

100%

95%

7

7

7

6.6

7

6.7

7

6.7

100%

50%

7

3.5

100% 100%
7

7

90%

85%

8.1

7.7

0%
0

100% 100%
7

7

0%

7

9

9

9

CTF

90%

100%

75%

84%

95%

90%

85%

91%

6.3

7

5.3

5.9

6.6

6.3

6

172.9

0%

0%

100%

100%

68%

0

0

7

7

52.5

7

9

9

9

95%
8.6

100%

100%

7

7

100% 100% 100%
9

9

9

MCSP SVSP

CIM

PBSP WSP

Average
Score

CAL

100% 100%

0

100% 100% 100% 100% 100% 100% 100%
9

CVSP COR

100% 100%
7
95%
8.6

100% 100%
9

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

84%

7

123.1

95%

100%

96%

9

8.6

9

284.9

96%

75%

100%

92%

8

8

8

8

8

8

8

8

8

8

8

8

8

8

7.6

6

8

235.6

61%

40%

100%

18%

100%

85%

6%

100%

57%

55%

38%

78%

0%

40%

36%

74%

60%

100%

53%

4.9

3.2

8

1.5

8

6.8

0.5

8

4.6

4.4

3

6.2

0

3.2

2.9

5.9

4.8

8

135.9

85%

95%

90%

100%

85%

85%

90%

5.1

5.7

5.4

6

5.1

5.1

5.4

96%
5.8

100% 100% 100% 100%
6

6

6

6

95%
5.7

100% 100% 100%
6

6

6

100% 100%
6

93%

6

184.5

95%

100%

65%

75%

90%

74%

4.8

5

3.3

3.8

4.5

44.3

0%
0
50%

100%

100%

50%

3

6

6

3

100% 100%
6

6

24%

17%

0%

0%

60%

36%

20%

1.9

1.3

0

0

4.8

2.9

1.6

100% 100%

50%

100% 100% 100%

100%

86%

6

124.5

6

6

3

6

6

6

33%

40%

75%

11%

0%

14%

50%

86%

46%

83%

25%

33%

2.7

3.2

6

0.9

0

1.1

4

6.9

3.6

6.7

2

87.4

43%

85%

60%

86%

74%

0.9

1.7

1.2

1.7

16.2

State of California • May 2011

Page 101

APPENDIX
C-3: Health Screening
______________________________________________________________________________________________________________________
Page 3 of 4
Ref
Number
02.212

02.213

SAC

CMF

LAC

PVSP

CCI

CRC

CIW

ASP

HDSP

60%

100%

85%

100%

90%

90%

1.8

1.2

2

1.7

2

1.8

1.8

Reception center history and physical: Is the “Family and Social History” section of Form 7206 (History and Physical Examination)
complete? (2 points possible)
100%

100% 100%

2

2

2

75%

100%

75%

80%

1.5

2

1.5

1.6

Reception center history and physical: Is the “Review Systems” section of Form 7206 (History and Physical Examination) complete?
(2 points possible)
0%

100%

70%

80%

20%

0%

0

2

1.4

1.6

0.4

0

Reception center history and physical: Is the “Physical Examination” section of Form 7206 (History and Physical Examination) complete and
appropriate to the history and review of systems? (2 points possible)
Score

75%

95%

100%

100%

100%

85%

60%

Points Received

1.5

1.9

2

2

2

1.7

1.2

Reception center history and physical: Is the “Diagnosis/Impression” section of Form 7206 (History and Physical Examination) appropriate
to the history and physical examination? (2 points possible)
Score

88%

95%

90%

100%

100%

89%

56%

Points Received

1.8

1.9

1.8

2

2

1.8

1.1

Reception center history and physical: Is the “Plan of Action” section of Form 7206 (History and Physical Examination) appropriate to the
“Diagnosis/Impression” section of the form? (2 points possible)
Score
Points Received

02.219

SCC

88%

Score

02.218

CCWF CMC

Score

Points Received

02.217

DVI

Points Received

Score

02.216

CEN

Reception center history and physical: Are the “Past History” and “Past Medical History” sections of Form 7206 (History and Physical
Examination) complete? (2 points possible)

Points Received
02.215

RJD

100%

85%

100%

100%

100%

100%

67%

2

1.7

2

2

2

2

1.3

Reception center history and physical: Has required intake testing been ordered? (4 points possible)
Score

70%

50%

100%

95%

90%

100%

20%

Points Received

2.8

2

4

3.8

3.6

4

0.8

Total Points Received

45.1

45.1

58.5

45.9

51.3

56.5

48.3

32.4

56.4

34.9

69.7

43.8

37.7

47.6

Total Points Possible

59

52

86

59

69

67

66

53

82

52

89

59

54

59

82

76%

87%

68%

78%

74%

84%

73%

61%

69%

67%

78%

74%

70%

81%

72%

Total Score

Bureau of Audits, Office of the Inspector General

59.3

Page 102

APPENDIX
C-3: Health Screening
_____________________________________________________________________________________________________________________
Page 4 of 4
SQ

CCC NKSP KVSP

FSP

SOL

SATF VSPW

ISP

CVSP COR

CAL

CTF

MCSP SVSP

CIM

PBSP WSP

Average
Score

80%

90%

100%

95%

89%

1.6

1.8

2

1.9

19.6

65%

90%

75%

100%

87%

1.3

1.8

1.5

2

19.2

80%

5%

90%

95%

54%

1.6

0.1

1.8

1.9

10.8

90%

95%

95%

80%

89%

1.8

1.9

1.9

1.6

19.5

68%

100%

94%

95%

89%

1.4

2

1.9

1.9

19.6

78%

95%

85%

80%

90%

1.6

1.9

1.7

1.6

19.8

85%

85%

100%

75%

84%

80%

3.4

3.4

4

3

3.4

38.2

45.9

53.2

49.6

44.5

52.4

45.4

37.8

59.2

54.3

44.8

42.9

41.6

42.4

47.8

38.5

76.6

45.1

53.5

1608

60

66

69

59

59

59

52

69

66

59

59

52

66

59

46

89

53

62

2092

77%

81%

72%

75%

89%

77%

73%

86%

82%

76%

73%

80%

64%

81%

84%

86%

85%

86%

77%

State of California • May 2011

Page 103

APPENDIX
C-4: Specialty Services
______________________________________________________________________________________________________________________
Page 1 of 2
Component Definition: 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 cardiology services, physical therapy, oncology services, podiatry consultations, and neurology services.
Ref
Number
07.035

07.037

07.038

07.043

SAC

SCC

LAC

PVSP

CCI

CRC

CIW

ASP

HDSP

59%

59%

59%

94%

59%

77%

65%

69%

41%

29%

88%

77%

47%

Points Received

4.2

3.2

5.3

5.3

5.3

8.5

5.3

6.9

5.8

6.2

3.7

2.6

7.9

6.9

4.2

Did the institution approve or deny the PCP’s request for specialty services within the specified time frames? (8 points possible)
Score

46%

46%

100%

64%

55%

70%

91%

64%

91%

86%

77%

50%

79%

73%

96%

Points Received

3.6

3.6

8

5.1

4.4

5.6

7.3

5.1

7.3

6.9

6.2

4

6.3

5.8

7.6

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? (8 points possible)
Score

8%

31%

25%

15%

9%

0%

23%

36%

29%

8%

29%

7%

38%

33%

7%

Points Received

0.6

2.5

2

1.2

0.7

0

1.8

2.9

2.3

0.7

2.4

0.5

3

2.7

0.5

Did the PCP review the consultant’s report and see the inmate for a follow-up appointment after the specialty services consultation within
specified time frames? (9 points possible)
22%

29%

19%

41%

8%

18%

13%

25%

36%

36%

47%

38%

23%

73%

0%

2

2.6

1.7

3.7

0.7

1.6

1.1

2.3

3.2

3.2

4.2

3.4

2.1

6.5

0

Physical therapy services: Did the physical therapist assess the inmate and document the treatment plan and treatment provided to the
inmate? (8 points possible)
8

67%
5.3

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
8

8

8

8

8

8

8

8

8

8

8

8

8

Was there adequate documentation of the reason for the denial of specialty services? (5 points possible)
Score
Points Received

60%

80%

100%

80%

60%

33%

40%

100%

75%

60%

60%

80%

50%

100%

40%

3

4

5

4

3

1.7

2

5

3.8

3

3

4

2.5

5

2

Was the institution’s denial of the PCP’s request for specialty services consistent with the “medical necessity” requirement?
(9 points possible)
Score 100%
Points Received

9

60%
5.4

100% 100%
9

9

75%

67%

100%

80%

6.8

6

9

7.2

100% 100%
9

80%

9

80%

60%

7.2

100% 100%
9

9

7.2

5.4

Is the institution scheduling high-priority (urgent) specialty services within 14 days? (9 points possible)
Score
Points Received

07.270

CCWF CMC

35%

Score 100%

07.261

DVI

47%

Points Received

07.260

CEN

Score

Points Received

07.259

RJD

Did the inmate receive the specialty service within specified time frames? (9 points possible)

Score

07.090

CMF

0%

0%

0%

0%

50%

0%

50%

100%

50%

0%

0%

50%

0%

50%

50%

0

0

0

0

4.5

0

4.5

9

4.5

0

0

4.5

0

4.5

4.5

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? (6 points possible)
Score

53%

59%

88%

100%

77%

100% 100%

94%

100% 100% 100% 100% 100% 100%

94%

Points Received

3.2

3.5

5.3

6

4.6

6

6

5.6

6

6

6

6

6

6

5.6

Total Points Received

33.7

30.2

44.2

42.3

37.9

37.4

45

51.9

49.9

43

40.7

42

44.8

52.6

37.8

Total Points Possible
Total Score

71

71

71

71

71

71

71

71

71

71

71

71

71

71

71

47%

43%

62%

60%

53%

53%

63%

73%

70%

61%

57%

59%

63%

74%

53%

Bureau of Audits, Office of the Inspector General

Page 104

APPENDIX
C-4: Specialty Services
_____________________________________________________________________________________________________________________
Page 2 of 2

SQ

CCC NKSP KVSP

FSP

SOL

SATF VSPW

ISP

CVSP COR

CAL

CTF

MCSP SVSP

65%

88%

65%

82%

100%

41%

56%

100%

94%

88%

71%

88%

59%

93%

5.8

7.9

5.8

7.4

9

3.7

5.1

9

8.5

7.9

6.4

7.9

5.3

91%

82%

77%

82%

96%

86%

95%

59%

73%

77%

41%

43%

7.3

6.5

6.2

6.5

7.6

6.9

7.6

4.7

5.8

6.2

3.3

3.4

0%

56%

17%

20%

67%

22%

17%

25%

33%

75%

25%

0

4.4

1.3

1.6

5.3

1.8

1.3

2

2.7

6

2

23%

42%

31%

25%

73%

80%

60%

25%

62%

64%

2.1

3.8

2.8

2.3

6.6

7.2

5.4

2.3

5.5

5.8

PBSP WSP

77%

94%

94%

77%

71%

8.4

6.9

8.5

8.5

6.9

210.2

46%

68%

65%

96%

96%

68%

73%

3.6

5.5

5.2

7.6

7.6

5.5

193.8

100%

50%

67%

100%

32%

8

4

5.3

8

77.5

27%

43%

14%

27%

54%

64%

80%

50%

39%

2.5

3.9

1.3

2.5

4.8

5.7

7.2

4.5

114.5

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
8

8

8

8

8

8

8

8

8

8

8

8

60%

20%

80%

60%

0%

80%

33%

60%

80%

100%

20%

80%

3

1

4

3

0

4

1.7

3

4

5

1

4

5

5

3.3

5

100%

40%

75%

100%

80%

60%

80%

80%

100%

67%

9

3.6

9

9

5.4

9

9

6.8

9

7.2

5.4

7.2

7.2

9

6

0%

100%

0%

0%

100%

0%

0%

50%

50%

100%

50%

0

9

0

0

9

0

0

4.5

4.5

9

4.5

93%

94%

100% 100%

60%

100% 100%

100% 100% 100% 100% 100% 100%

94%

100% 100% 100%
9

9

9

Average
Score

CIM

100% 100% 100% 100% 100%

8

8

100% 100%

8

8

99%

8

261.3

60%

67%

5

3

111

80%

100%

67%

85%

7.2

9

6

251.2

50%

50%

100%

50%

42%

4.5

4.5

9

4.5

126

67%

8

100% 100%

100% 100% 100% 100%

95%

6

6

6

6

6

6

5.6

6

6

6

6

6

5.6

5.6

6

6

6

6

188.6

41.2

50.2

43.1

43.8

56.9

46.6

43.7

50.8

58.5

61.1

39.1

52.9

49

53.8

44.7

52.5

68.3

44.4

1534

71

71

71

71

71

71

71

71

71

71

71

71

71

71

63

63

71

63

2319

58%

71%

61%

62%

80%

66%

62%

72%

82%

86%

55%

75%

69%

76%

71%

83%

96%

71%

66%

State of California • May 2011

Page 105

APPENDIX
C-5: Urgent Services
______________________________________________________________________________________________________________________
Page 1 of 2
Component Definition: Addresses the care provided by the institution to inmates before and after they were sent to a community hospital.
Ref
Number
21.248

21.249

21.250

21.251

SAC

21.279

DVI

CCWF CMC

SCC

LAC

PVSP

CCI

CRC

CIW

ASP

HDSP

Score

79%

90%

65%

75%

88%

92%

84%

100%

96%

88%

92%

100%

84%

92%

32%

5.5

6.3

4.6

5.3

6.2

6.4

5.9

7

6.7

6.2

6.4

7

5.9

6.4

2.2

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? (7 points possible)
Score

60%

85%

24%

65%

64%

52%

88%

92%

40%

58%

48%

84%

56%

52%

48%

Points Received

4.2

6

1.7

4.6

4.5

3.6

6.1

6.4

2.8

4.1

3.3

5.9

3.9

3.6

3.4

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? (7 points possible)
Score

73%

80%

50%

100%

96%

Points Received

5.1

5.6

3.5

7

6.7

100% 100% 100% 100%
7

7

7

7

96%

100%

96%

96%

6.7

7

6.7

6.7

100% 100%
7

7

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? (7 points possible)
7

0%

100%

0%

100%

100%

0

7

0

7

7

Was the documentation of the clinical care provided in the TTA adequate? (10 points possible)
Score

65%

95%

83%

72%

92%

84%

76%

80%

88%

80%

76%

60%

64%

64%

96%

Points Received

6.5

9.5

8.3

7.2

9.2

8.4

7.6

8

8.8

8

7.6

6

6.4

6.4

9.6

While the patient was in the TTA, was the clinical care rendered by the attending provider adequate and timely? (7 points possible)
Score

91%

100%

95%

91%

92%

100%

91%

100%

87%

96%

95%

83%

81%

64%

63%

Points Received

6.4

7

6.7

6.3

6.4

7

6.4

7

6.1

6.7

6.7

5.8

5.7

4.5

4.4

For patients managed by telephone consultation alone, was the provider’s decision not to come to the TTA appropriate? (8 points possible)
Score 100%
Points Received

21.281

CEN

Points Received

Score 100%

21.276

RJD

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? (7 points possible)

Points Received
21.275

CMF

8

100%

83%

8

6.7

100% 100%
8

100% 100% 100% 100% 100% 100% 100%

8

8

8

8

8

8

8

8

100%
8

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? (6 points possible)
Score 100% 100%

58%

79%

79%

88%

64%

48%

38%

13%

67%

47%

44%

10%

47%

6

6

3.5

4.7

4.7

5.3

3.8

2.9

2.3

0.8

4

2.8

2.6

0.6

2.8

Total Points Received

48.7

40.4

43.2

41.7

45.7

52.8

36.8

46.3

41.7

47.5

43

42.2

39.2

36.5

37.4

Total Points Possible

59

51

59

52

59

59

44

52

52

59

52

52

52

52

52

83%

79%

73%

80%

78%

89%

84%

89%

80%

81%

83%

81%

75%

70%

72%

Points Received

Total Score

Bureau of Audits, Office of the Inspector General

Page 106

APPENDIX
C-5: Urgent Services
_____________________________________________________________________________________________________________________
Page 2 of 2

SQ

CCC NKSP KVSP

FSP

SOL

SATF VSPW

ISP

CVSP COR

CAL

CTF

52%

88%

100%

72%

92%

88%

92%

100%

92%

96%

96%

96%

88%

96%

3.6

6.2

7

5

6.4

6.2

6.4

7

6.4

6.7

6.7

6.7

6.2

6.7

48%

82%

63%

57%

100%

40%

56%

68%

24%

72%

72%

80%

71%

3.4

5.8

4.4

4

7

2.8

3.9

4.8

1.7

5

5

5.6

72%

100%

88%

92%

91%

92%

92%

92%

5

7

6.1

6.4

6.4

6.4

6.4

6.4

100% 100%
7

7

100% 100%
7

7

MCSP SVSP

Average
Score

CIM

PBSP WSP

100%

96%

96%

88%

87%

7

6.7

6.7

6.2

201.8

42%

80%

76%

84%

78%

64%

5

2.9

5.6

5.3

5.9

5.5

147.7

92%

96%

100%

96%

96%

96%

93%

6.4

6.7

7

6.7

6.7

6.7

215.3

100%

0%

63%

7

0

35

68%

88%

76%

40%

80%

75%

79%

60%

80%

64%

68%

88%

68%

68%

68%

75%

92%

80%

76%

6.8

8.8

7.6

4

8

7.5

7.9

6

8

6.4

6.8

8.8

6.8

6.8

6.8

7.5

9.2

8

249.2

79%

67%

87%

62%

76%

67%

82%

62%

75%

86%

68%

92%

77%

67%

77%

74%

79%

92%

82%

5.5

4.7

6.1

4.3

5.3

4.7

5.7

4.3

5.3

6

4.8

6.4

5.4

4.7

5.4

5.2

5.5

6.4

188.8

100% 100% 100%

92%

100% 100% 100% 100% 100% 100%

8

8

8

7.4

8

8

8

8

8

8

100% 100% 100% 100% 100% 100%

100%

99%

8

8

8

8

8

8

8

238.1

7%

50%

39%

0%

50%

17%

13%

50%

11%

33%

50%

57%

18%

50%

64%

33%

100%

59%

48%

0.4

3

2.3

0

3

1

0.8

3

0.7

2

3

3.4

1.1

3

3.8

2

6

3.5

94.8

32.7

43.5

41.5

31.7

51.7

36.6

39.1

39.5

36.5

40.5

33.3

45.9

38.9

38.8

43.6

41.4

48

44.3

1370.6

52

52

52

52

59

52

52

59

52

52

44

52

52

52

52

52

52

52

1748

63%

84%

80%

61%

88%

70%

75%

67%

70%

78%

76%

88%

75%

75%

84%

80%

92%

85%

78%

State of California • May 2011

Page 107

APPENDIX
C-6: Emergency Services
______________________________________________________________________________________________________________________
Page 1 of 4
Component Definition: 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.
Ref
Number
08.183

SAC

CMF

RJD

CEN

DVI

CCWF CMC

SCC

LAC

PVSP

CCI

Score 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
5

5

Score 100% 100%

08.186

5

5

5

5

5

5

5

5

5

80%

100% 100%

4

5

4

4

80%
3.2

100% 100%
4

4

67%
2.7

100% 100% 100%
4

4

4

75%

50%

100%

3

2

4

Score

50%

4

Points Received

3.5

100% 100% 100%
7

7

7

80%

100%

80%

5.6

7

5.6

100% 100% 100% 100% 100%
7

7

7

7

7

4

4

4

4

4

4

4

4

4

4

4

100% 100%

4

4

4

50%
2

100% 100% 100% 100%
4

4

4

4

80%
3.2

100% 100% 100% 100%
4

4

4

4

67%

60%

0%

67%

2.7

2.4

0

2.7

0%

100%

0%

0%

40%

0%

0%

0%

0%

0%

25%

50%

25%

Points Received

3.5

0

7

0

0

2.8

0

0

0

0

0

1.8

3.5

1.8

Did the first responder provide adequate basic life support (BLS) prior to medical staff arriving? (6 points possible)
0%

40%

80%

50%

0

2.4

4.8

3

100% 100% 100%
6

6

6

50%
3

100% 100% 100%
6

6

6

67%

100% 100%

4

6

6

Did licensed health care staff call 911 without unnecessary delay after a life-threatening condition was identified by a licensed health care
provider or peace officer? (6 points possible)
Points Received

50%
3

100% 100% 100%
6

6

6

60%

80%

3.6

4.8

100% 100%
6

6

75%

100%

75%

60%

75%

100%

4.5

6

4.5

3.6

4.5

6

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? (2 points possible)
Score 100% 100% 100%
Points Received

2

2

2

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
2

2

2

2

2

2

2

2

2

2

2

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 point possible)
Score
Points Received

0%

0%

100%

0%

0%

100%

0%

0

0

1

0

0

1

0

100% 100%
1

1

0%

100%

0%

100%

0%

0

1

0

1

0

Emergency Medical Response Drill: Did the responding officer properly perform an assessment on the patient for responsiveness?
(1 point possible)
Score
Points Received

15.257

5.3

50%

Score

15.256

5.3

Score

Score

15.255

75%

Were the findings of the institution’s Emergency Medical Response Review Committee (EMRRC) supported by the documentation and
completed within 30 days? (7 points possible)

Points Received

15.240

75%

Did the institution provide adequate preparation for the ambulance’s arrival, access to the inmate, and departure? (4 points possible)
Points Received

08.242

4

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 points possible)

Score

08.241

5

100% 100%

Score 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

08.222

HDSP

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? (7 points possible)

Points Received
08.187

ASP

Did the medical emergency responder arrive at the location of the medical emergency within five (5) minutes of initial notification?
(4 points possible)
Points Received

08.185

CIW

Was the medical emergency responder notified of the medical emergency without delay? (5 points possible)
Points Received

08.184

CRC

0%

0%

100%

100%

0%

100%

0%

0

0

1

1

0

1

0

100% 100% 100% 100% 100% 100% 100%
1

1

1

1

1

1

1

0%

0%

0%

0

0

0

Emergency Medical Response Drill: Did the responding officer properly perform CPR? (2 points possible)
Score
Points Received

0%

100%

0%

0%

0%

0

2

0

0

0

Bureau of Audits, Office of the Inspector General

100% 100% 100% 100% 100%
2

2

2

2

2

Page 108

APPENDIX
C-6: Emergency Services
_____________________________________________________________________________________________________________________
Page 2 of 4

SQ

CCC NKSP KVSP

100% 100% 100%
5

80%
3.2

5

5

100% 100%
4

100% 100%
7

7

100%

0%

4

0

100% 100%

80%
4

80%

4

3.2

67%

60%

4.7

4.2

FSP

SOL

SATF VSPW

ISP

CVSP COR

CAL

CTF

MCSP SVSP

CIM

PBSP WSP

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
5

5

5

5

100% 100% 100% 100%
4

4

100% 100%
7

7

100% 100% 100% 100%
4

4

4

50%

100%

50%

4

5

75%

5

100% 100%

4

4

3

4

60%

80%

100%

0%

4.2

5.6

7

0

80%
3.2

100% 100% 100%
4

4

5

4

4

5

5

5

75%

100%

67%

3

4

2.7

100% 100% 100%
7

75%
3

7

7

40%
2.8

5

5

5

100% 100% 100%
4

4

4

100% 100% 100%
7

7

7

5

4

4

100% 100% 100% 100% 100% 100% 100% 100% 100%

4
75%

4

4

100% 100%

99%
158

80%

92%

3.2

117.2

80%

86%

5.6

192.4

100% 100% 100% 100% 100% 100% 100%
4

Average
Score

95%

4

122.2

80%

87%

4

4

2

4

2

4

4

4

4

4

4

4

4

4

3

4

4

3.2

111.2

0%

100%

33%

0%

50%

40%

20%

40%

0%

0%

20%

25%

0%

0%

0%

25%

0%

20%

21%

0

7

2.3

0

3.5

2.8

1.4

2.8

0

0

1.4

1.8

0

0

0

1.8

0

1.4

46.6

100%

80%

6

4.8

60%

80%

50%

100%

50%

3.6

100% 100%
6

6

4.8

3

6

3

6

6

60%

100%

67%

80%

80%

100%

0%

100%

75%

100%

60%

3.6

6

4

4.8

4.8

6

0

6

4.5

6

3.6

100% 100%
6

6

100% 100% 100% 100%
6

6

100% 100% 100% 100%
6

6

100% 100%
6

6

6

156.4

67%

80%

82%

4

4.8

152.6

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
2

2

2

2

100% 100% 100% 100%
1

1

1

1

2

2

2

0%

0%

0%

0

0

0

100% 100% 100% 100% 100%

0%

1

1

1

1

1

0

100%

0%

100%

0%

100%

0%

2

0

2

0

2

0

State of California • May 2011

2

2

2

2

2

100% 100% 100% 100% 100%
1

1

1

1

1

2

2

2

0%

100%

0%

0

1

0

100% 100% 100% 100% 100% 100% 100%
1

1

1

1

1

1

100% 100% 100% 100%
2

2

2

2

2

2

100% 100%
1

84%

6

1

100% 100% 100%

100%

2

64

0%

56%

0

18

0%

81%

1

0

25

100%

0%

0%

52%

2

0

0

28

1

1

0%
0

1

Page 109

APPENDIX
C-6: Emergency Services
______________________________________________________________________________________________________________________
Page 3 of 4
Ref
Number
15.258

SAC
Score

Score

Score

Score

0%

0%

100%

0

0

2

100% 100% 100%
2

0%
0

100% 100%
2

LAC

2

2

0%
0

PVSP

CCI

100% 100% 100%
2

100% 100% 100% 100%

2

2

0%
0

100% 100%
1

0%

1

0

0%

0%

100%

0

0

1

2

2

CRC

CIW

ASP

2

0%

2

0

100% 100%
2

2

100% 100% 100% 100% 100%

2

2

100% 100% 100%
1

1

2

100% 100%

1

1

100% 100% 100% 100%
1

Score 100% 100% 100%

HDSP
0%
0

2

2

2

0%
0

1

0%
0

100% 100% 100%
1

1

1

1

1

100% 100% 100% 100% 100%

1

1

1

1

1

1

0%
0

1

1

100% 100% 100% 100%

1

1

1

1

100% 100% 100% 100% 100% 100%

1

1

1

1

1

1

1

Emergency Medical Response Drill: Did medical staff continue with CPR without transporting the patient until the arrival of ambulance
personnel? If the patient was transported, was this decision justified? (1 point possible)
Score
Points Received

15.287

SCC

Emergency Medical Response Drill: Did emergency medical responders continue basic life support? (1 point possible)
Points Received

15.286

CCWF CMC

Emergency Medical Response Drill: Did the responding officer provide accurate information to responding medical staff? (1 point possible)
Points Received

15.285

DVI

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

15.284

CEN

Emergency Medical Response Drill: Did medical staff arrive on scene in five minutes or less? (2 points possible)
Points Received

15.283

RJD

Emergency Medical Response Drill: Did the responding officer begin CPR without unnecessary delay? (2 points possible)
Points Received

15.282

CMF

0%
0

Emergency Medical Response Drill: Was 911 called without unnecessary delay? (2 points possible)
0%

0%

0%

Points Received

Score

0

0

0

2

2

2

2

0

2

2

2

2

2

Total Points Received

28

40.4

52

33

41.2

46.5

49.6

44

44.5

48

45.2

40.8

12

45.3

41.8

Total Points Possible

59

56

58

43

58

58

58

58

53

58

58

56

15

58

58

48%

72%

90%

77%

71%

80%

86%

76%

84%

83%

78%

73%

80%

78%

72%

Total Score

Bureau of Audits, Office of the Inspector General

100% 100% 100% 100%

0%

100% 100% 100% 100% 100%

Page 110

APPENDIX
C-6: Emergency Services
_____________________________________________________________________________________________________________________
Page 4 of 4
SQ

FSP

SOL

100% 100% 100% 100% 100%

0%

2

CCC NKSP KVSP

2

2

2

2

SATF VSPW

0

MCSP SVSP

100% 100% 100% 100% 100% 100%

100%

100%

0%

76%

2

2

0

44

2

CVSP COR

2

2

CAL

2

2

CIM

PBSP WSP

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
2

2

2

2

2

2

2

2

2

2

2

2

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
1

1

1

1

1

1

1

1

1

1

1

1

2

0%
0

2

2

2

2

2

100% 100% 100% 100% 100%
1

1

1

1

1

1

1

100% 100% 100%
1

1

1

1

1

100% 100% 100%

1

1

1

1

1

1

0%

0%

0

0

1

1

1

1

100% 100% 100% 100%
1

1

1

1

1

1

0%

0%

0

0

1

1

1

1

87%
27

1

90%
28

100% 100% 100%
1

94%
58

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
1

Average
Score

CTF

2

ISP

1

87%
26

0%
0
100% 100% 100% 100% 100% 100%

0%

100%

100%

2

2

2

2

2

2

0

2

2

45.4

52

47

41

48.5

47.8

37.6

49.4

41

38

58

58

58

57

58

58

54

56

56

78%

90%

81%

72%

84%

82%

70%

88%

73%

State of California • May 2011

100% 100%

0%

100% 100% 100% 100%

79%

2

2

0

2

2

2

2

46

49.4

44.3

47

33.9

48

48.8

47

42.2

1420.6

52

56

52

58

53

58

54

58

58

1816

73%

88%

85%

81%

64%

83%

90%

81%

73%

78%

Page 111

APPENDIX
C-7: Prenatal Care/Childbirth/Post-Delivery
______________________________________________________________________________________________________________________
Page 1 of 2
Component Definition: Focuses on the prenatal and post-delivery medical care provided to pregnant inmates. This component is not applicable at men’s
institutions.
Ref
Number
09.066

SAC

CMF

RJD

CEN

DVI

CCWF CMC

SCC

LAC

PVSP

CCI

CRC

Points Received

Score

09.069

09.071

09.072

09.224

0

100%
5

Score

43%

Points Received

2.1

Did medical staff promptly order extra daily nutritional supplements and food for the inmate? (5 points possible)
Score

86%

Points Received

4.3

Did the inmate visit with an OB physician according to the applicable time frames? (8 points possible)
Score

86%

Points Received

6.9

Did the “Problems/Risks Identified” section of the Briggs Form 5703N (Prenatal Flow Record) corroborate the “Prenatal Screens” and the
“Maternal Physical” examination sections? (7 points possible)
Points Received

09.223

0%

Was the pregnant inmate issued a Form 7410 (Comprehensive Accommodation Chrono) for a lower bunk and lower-tier housing if housed
in a multi-tiered housing unit? (5 points possible)

Score
09.074

HDSP

New arrival only: Was the inmate seen by an OB physician or OB nurse practitioner within seven (7) business days of her arrival at the
institution? (5 points possible)
Points Received

09.068

ASP

New arrival only: Did the inmate receive a pregnancy test within three (3) business days of arrival at the institution to positively identify her
pregnancy? (5 points possible)
Score

09.067

CIW

0%
0

Did the inmate receive her six-week check-up (post-delivery)? (7 points possible)
Score

80%

Points Received

5.6

Were the results of the inmate’s specified prenatal screening tests documented on Form 5703N? (5 points possible)
Score

86%

Points Received

4.3

Was the inmate’s weight and blood pressure documented at each clinic visit? (6 points possible)
Score

71%

Points Received

4.3

Total Points Received

32.5

Total Points Possible
Total Score

Bureau of Audits, Office of the Inspector General

53
61%

Page 112

APPENDIX
C-7: Prenatal Care/Childbirth/Post-Delivery
_____________________________________________________________________________________________________________________
Page 2 of 2

SQ

CCC NKSP KVSP

FSP

SOL

State of California • May 2011

SATF VSPW

ISP

CVSP COR

CAL

CTF

MCSP SVSP

CIM

PBSP WSP

Average
Score

50%

25%

2.5

2.5

100%

100%

5

10

100%

71%

5

7.1

100%

93%

5

9.3

100%

93%

8

14.9

0%

0%

0

0

100%

90%

7

12.6

86%

86%

4.3

8.6

100%

86%

6

10.3

42.8

75.3

53

106

81%

71%

Page 113

APPENDIX
C-8: Diagnostic Services
______________________________________________________________________________________________________________________
Page 1 of 2
Component Definition: Addresses the timeliness of radiology (x-ray) and laboratory services and whether the prison followed up on clinically significant results.
Ref
Number
06.049

SAC
Score 100%

06.191

06.200

06.263

DVI

CCWF CMC

SCC

LAC

PVSP

CCI

CRC

CIW

ASP

HDSP

7

80%
5.6

100% 100%
7

7

20%

100%

80%

1.4

7

5.6

100% 100%
7

7

80%

80%

0%

100%

60%

60%

5.6

5.6

0

7

4.2

4.2

Score

90%

90%

50%

60%

80%

70%

80%

100%

90%

70%

40%

90%

50%

70%

30%

Points Received

5.4

5.4

3

3.6

4.8

4.2

4.8

6

5.4

4.2

2.4

5.4

3

4.2

1.8

All diagnostic services: Did the PCP document the clinically significant diagnostic test results on Form 7230 (Interdisciplinary Progress
Notes)? (7 points possible)
Score

78%

87%

58%

88%

75%

80%

70%

56%

14%

73%

67%

64%

69%

87%

62%

Points Received

5.4

6.1

4.1

6.1

5.3

5.6

4.9

3.9

1

5.1

4.7

4.5

4.8

6.1

4.3

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? (7 points possible)
Score

06.245

CEN

All laboratory orders: Was the specimen collected within the applicable time frames of the physician’s order? (6 points possible)

Points Received
06.202

RJD

Radiology order: Was the radiology service provided within the time frame specified in the physician’s order? (7 points possible)
Points Received

06.188

CMF

0%

20%

0%

0

1.4

0

100% 100% 100%
7

7

7

20%

100%

0%

0%

0%

20%

20%

80%

20%

1.4

7

0

0

0

1.4

1.4

5.6

1.4

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? (7 points possible)
Score

30%

50%

60%

50%

60%

40%

50%

70%

0%

10%

10%

40%

60%

100%

0%

Points Received

2.1

3.5

4.2

3.5

4.2

2.8

3.5

4.9

0

0.7

0.7

2.8

4.2

7

0

Radiology order: Was the diagnostic report received by the institution within 14 days? (8 points possible)
Score

80%

80%

100%

60%

Points Received

6.4

6.4

8

4.8

100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
8

8

8

8

8

8

8

60%

8

8

8

4.8
58%

All diagnostic services: Did the PCP adequately manage clinically significant test results? (10 points possible)
Score

91%

92%

70%

67%

77%

90%

82%

78%

67%

83%

83%

100%

Points Received

9.1

9.2

7

6.7

7.7

9

8.2

7.8

6.7

10

10

8.3

8.3

10

5.8

Total Points Received

35.4

37.5

33.3

38.7

38.3

43.6

36.4

44.6

28.1

33.6

31.4

30.4

36.7

45.1

22.3

Total Points Possible

52

52

52

52

52

52

52

52

52

52

52

52

52

52

52

68%

72%

64%

74%

74%

84%

70%

86%

54%

65%

60%

59%

71%

87%

43%

Total Score

Bureau of Audits, Office of the Inspector General

100% 100%

Page 114

APPENDIX
C-8: Diagnostic Services
_____________________________________________________________________________________________________________________
Page 2 of 2

SQ

CCC

NKSP KVSP

100%

60%

100% 100% 100% 100%

7

4.2

7

7

7

7

100%

70%

100%

90%

70%

6

4.2

6

5.4

4.2

89%

73%

73%

90%

6.2

5.1

5.1

6.3

0%

60%

0%

0

4.2

0

0%

30%

0

2.1

100% 100%

FSP

SOL

ISP

CVSP COR

CAL

CTF

40%

80%

60%

40%

100%

80%

100% 100% 100% 100%

60%

100%

81%

2.8

5.6

4.2

2.8

7

5.6

7

7

7

7

4.2

7

187.6

90%

20%

90%

60%

70%

80%

70%

83%

70%

70%

70%

80%

80%

73%

5.4

1.2

5.4

3.6

4.2

4.8

4.2

5

4.2

4.2

4.2

4.8

4.8

145.4

92%

64%

43%

100%

39%

64%

42%

71%

23%

46%

60%

67%

60%

78%

67%

6.5

4.5

3

7

2.7

4.5

2.9

5

1.6

3.2

4.2

4.7

4.2

5.4

154

100%

20%

0%

100%

60%

0%

0%

20%

20%

60%

100%

60%

20%

20%

80%

39%

7

1.4

0

7

4.2

0

0

1.4

1.4

4.2

7

4.2

1.4

1.4

5.6

91

60%

70%

100%

10%

0%

30%

40%

70%

30%

30%

20%

70%

60%

10%

30%

80%

42%

4.2

4.9

7

0.7

0

2.1

2.8

4.9

2.1

2.1

1.4

4.9

4.2

0.7

2.1

5.6

95.9

100% 100% 100% 100% 100%

MCSP SVSP

CIM

PBSP WSP

Average
Score

SATF VSPW

50%

80%

80%

100%

20%

100%

20%

8

8

4

6.4

8

8

8

8

8

6.4

8

1.6

8

1.6

8

8

8

8

89%

90%

90%

75%

77%

55%

71%

100%

86%

64%

90%

75%

83%

92%

50%

100%

83%

8.9

9

9

7.5

7.7

5.5

7.1

10

8.6

6.4

9

10

10

7.5

8.3

9.2

5

10

272.5

36.1

36.8

35.3

44.5

41.8

31.1

29.1

42.3

29.9

29.2

35.2

29.9

37.2

35.4

40.1

35.2

29.7

46.4

1180.6

52

52

52

52

52

52

52

52

52

52

52

52

52

52

52

52

52

52

1716

69%

71%

68%

86%

80%

60%

56%

81%

58%

56%

68%

58%

72%

68%

77%

68%

57%

89%

69%

State of California • May 2011

100% 100%

100% 100% 100% 100%

89%
234.4

Page 115

APPENDIX
C-9: Access to Health Care Information
______________________________________________________________________________________________________________________
Page 1 of 2
Component Definition: Addresses the prison’s effectiveness in filing, storing, and retreiving medical records and medical-related information.
Ref
Number
19.150

SAC

RJD

CEN

DVI

CCWF CMC

SCC

LAC

PVSP

CCI

CRC

CIW

ASP

HDSP

Is the medical records office current with its loose filing? (9 points possible)
Score
Points Received

19.169

CMF

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

Did medical records staff make unit health records (UHR) available to clinic staff for the inmates ducated for medical appointments the next
day? (15 points possible)
Score 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Points Received

19.243

Score

Points Received

15

15

15

15

15

15

15

0%

100%

15

15

15

0

15

0%

0%

0%

100%

0%

0%

0%

0

0

0

12

0

0

0

100% 100% 100%
12

12

12

0%

100%

0%

0%

0%

0

12

0

0

0

0%
0

100% 100% 100% 100% 100% 100% 100% 100%
5

5

5

5

5

5

5

5

0%

0%

100%

0

0

5

100% 100% 100%
5

5

5

While reviewing unit health records (UHR) as part of the OIG’s inspection, were the OIGs RN and MD inspectors able to locate all relevant
documentation of health care provided to inmates? (5 points possible)
Score
Points Received

19.272

15

Does the institution properly file inmates’ medical information? (5 points possible)
Score

19.271

15

Was the institution able to account for the OIG’s requested UHR files? (12 points possible)
Points Received

19.266

15

0%

100%

0%

0

5

0

100% 100% 100%
5

5

5

0%
0

100% 100% 100%
5

5

5

60%

100% 100% 100% 100%

3

5

100%

50%

5

5

5

Does the institution promptly file blood pressure logs in unit health records (UHR)? (5 points possible)
Score 100% 100%

50%

100% 100%

50%

0%

100%

0%

0%

100% 100% 100%

Points Received

5

5

2.5

5

5

2.5

0

5

0

0

5

2.5

5

5

5

Total Points Received

20

30

22.5

42

30

27.5

20

42

37

32

28

39.5

30

10

30

Total Points Possible
Total Score

51

51

51

51

51

51

51

51

51

51

51

51

51

51

51

39%

59%

44%

82%

59%

54%

39%

82%

73%

63%

55%

78%

59%

20%

59%

Bureau of Audits, Office of the Inspector General

Page 116

APPENDIX
C-9: Access to Health Care Information
_____________________________________________________________________________________________________________________
Page 2 of 2

SQ

CCC NKSP KVSP

FSP

SOL

0%

0%

0%

0%

0%

0%

0%

0%

0%

0%

0

0

0

0

0

0

0

0

0

0

100% 100% 100% 100% 100%
15
0%
0

15

15

15

15

50%
7.5

100% 100% 100% 100% 100%
12

12

12

12

12

SATF VSPW

ISP

CVSP COR

CAL

CTF

0%

0%

0%

0%

0

0

0

0

15

15

15

15

15

15

0%

100%

0%

0%

100%

0%

0

12

0

0

12

0

5

5

5

5

5

100% 100% 100% 100% 100% 100%

5

5

5

5

5

100% 100% 100%

0%
0

80%

15

15

PBSP WSP

100%

0%

100%

0%

6%

9

0

9

0

18

15

15

15

15

100% 100% 100% 100% 100% 100%
12

12

12

12

12

12

100% 100% 100% 100% 100% 100%
5

5

100% 100%

Average
Score

CIM

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
5

MCSP SVSP

5

80%

5

5

100% 100%

95%
472.5
55%
216
88%

5

145

80%

80%

80%

87%

5

5

5

5

5

5

4

4

5

5

5

4

5

5

4

5

5

4

143

50%

50%

0%

0%

50%

0%

100%

50%

0%

0%

0%

0%

50%

0%

0%

50%

100%

50%

48%

2.5

2.5

0

0

2.5

0

5

2.5

0

0

0

0

2.5

0

0

2.5

5

2.5

80

27.5

39.5

37

37

39.5

29.5

29

38.5

25

25

37

19

39.5

37

45

39.5

51

38.5

1074.5

51

51

51

51

51

51

51

51

51

51

51

51

51

51

51

51

51

51

1683

54%

78%

73%

73%

78%

58%

57%

76%

49%

49%

73%

37%

78%

73%

88%

78%

100%

76%

64%

State of California • May 2011

Page 117

APPENDIX
C-10: Outpatient Housing Unit
______________________________________________________________________________________________________________________
Page 1 of 2
Component Definition: 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.
Ref
Number
04.051

04.052

04.053

04.054

SAC

LAC

PVSP

CCI

CRC

CIW

ASP

100%

80%

100%

70%

80%

HDSP

Points Received

4.5

4

4

5

4

5

3.5

4

Did the RN complete an initial assessment of the inmate on the day of placement? (5 points possible)
Score

90%

100%

80%

100%

60%

100%

90%

80%

Points Received

4.5

5

4

5

3

5

4.5

4

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? (4 points possible)
Score

30%

78%

100%

50%

33%

Points Received

1.2

3.1

4

2

1.3

100% 100%
4

75%

4

3

Did the utilization management (UM) nurse assess the inmate within one week of the inmate’s placement and every 30 days thereafter?
(4 points possible)
0%

11%

0%

0%

50%

0%

0%

0%

0

0.4

0

0

2

0

0

0

Did the PCP’s plan adequately address the initial assessment? (5 points possible)
5

90%

75%

75%

88%

89%

38%

63%

4.5

3.8

3.8

4.4

4.4

1.9

3.1

Was the PCP’s initial evaluation adequate for the problem(s) requiring OHU placement? (5 points possible)
Score

82%

90%

80%

78%

70%

70%

30%

40%

Points Received

4.1

4.5

4

3.9

3.5

3.5

1.5

2

78%

100%

7

9

Was the level of care available in the OHU appropriate to the patient’s clinical presentation? (9 points possible)
Score 100% 100%
9

9

100%

100%

9

9

100% 100%
9

9

Was the PCP’s initial assessment (or diagnoses) appropriate for the findings in the initial evaluation? (5 points possible)
Score 100%
Points Received

5

90%

100%

89%

4.5

5

4.4

100% 100% 100%
5

5

63%

5

3.1

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

15.225

SCC

80%

Points Received

15.103

CCWF CMC

80%

Score 100%

04.230

DVI

90%

Points Received

04.208

CEN

Score

Points Received

04.112

RJD

Did the primary care provider (PCP) evaluate the inmate within one calendar day after placement? (5 points possible)

Score
04.056

CMF

0%

100%

100%

0%

0%

0%

0%

100%

0

3

3

0

0

0

0

3

100%

0%

Does the OHU use disinfectant daily in common patient areas? (3 points possible)
Score 100% 100%
Points Received
Total Points Received
Total Points Possible
Total Score

100%

100%

100% 100%

3

3

3

3

3

0

3

3

36.3

41.1

39.8

36.1

35.2

35.9

30.4

34.2

48

48

48

48

48

48

48

48

76%

86%

83%

75%

73%

75%

63%

71%

Bureau of Audits, Office of the Inspector General

Page 118

APPENDIX
C-10: Outpatient Housing Unit
_____________________________________________________________________________________________________________________
Page 2 of 2

SQ

CCC NKSP KVSP

FSP

SOL

80%

80%

4

4

100%

90%

5

4.5

100%

50%

4

2

4

4

4

0

4

4

0%

0%

0%

25%

100%

0%

100%

0

0

0

1

4

0

100% 100%

SATF VSPW

ISP

100% 100%
5

5

CAL

CTF

90%

75%

90%

100%

100%

88%

4.5

3.8

4.5

5

5

74.8

100%

94%

5

79.5

100%

77%

4

52.6

33%

33%

21%

4

1.3

1.3

14

100% 100% 100% 100% 100% 100%
5

5

5

100% 100% 100%

0%

5

5

100% 100%

CIM

PBSP WSP

75%

89%

90%

100%

87%

5

5

5

5

5

3.8

4.4

4.5

5

73.6

100%

80%

70%

63%

100%

0%

80%

100%

89%

72%

5

4

3.5

3.1

5

0

4

5

4.4

61

90%

100%

100%

98%

8.1

9

9

150.1

89%

100%

100%

96%

4.4

5

5

81.4

0%

100%

59%

0

3

30

100%

88%

100% 100%
9

9

100% 100%
5

5

0%

100%

0

3

100% 100%

100% 100% 100%

5

MCSP SVSP

Average
Score

CVSP COR

100% 100% 100% 100%
9

9

9

9

100% 100% 100% 100%
5

5

5

5

100% 100% 100% 100% 100%
3

3

3

100% 100% 100%

3
0%

3

100% 100%

3

3

3

3

3

0

3

3

3

45

40

39.5

42.5

43.1

47.5

29.6

44.4

41.8

44.7

662.1

48

48

48

48

48

48

48

48

48

816

83%

82%

89%

90%

99%

62%

93%

87%

93%

81%

State of California • May 2011

Page 119

APPENDIX
C-11: Internal Reviews
______________________________________________________________________________________________________________________
Page 1 of 2
Component Definition: Focuses on the activities of the prison’s Quality Management Committee (QMC) and its Emergency Medical Response Review
Committee (EMRRC). The component also evaluates the timelines of inmates’ medical appeals and the prison’s use of inmate death reviews.
Ref
Number
17.118

SAC
Score 100%
5

Score 100%

17.135

CEN

DVI

CCWF CMC

SCC

LAC

PVSP

CCI

CRC

CIW

ASP

83%

100%

33%

83%

4.2

5

1.7

4.2

100% 100%
5

5

33%
1.7

100% 100%
5

5

83%
4.2

100% 100% 100% 100%
5

5

5

5

83%

100%

50%

4.2

5

2.5

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
5

5

5

5

5

5

5

5

5

5

5

Score

83%

83%

100%

83%

83%

83%

83%

50%

83%

100%

50%

83%

67%

83%

100%

Points Received

4.2

4.2

5

4.2

4.2

4.2

4.2

2.5

4.2

5

2.5

4.2

3.3

4.2

5

Did the last three Quality Management Committee (QMC) meeting minutes reflect findings and strategies for improvement?
(5 points possible)
Score 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
5

Score

80%
4

Score 100%

5

5

5

5

5

5

5

5

5

5

0%

5

0

100% 100%
5

5

60%
3

100% 100%
5

5

80%

0%

100%

80%

80%

80%

60%

100%

4

0

5

4

4

4

3

5

5

0%

100%

60%

80%

0

5

3

4

100% 100% 100% 100%
5

5

5

5

83%

67%

60%

100%

80%

100%

4.2

3.3

3

5

4

5

0%

0%

0

0

Did the institution promptly process inmate medical appeals during the most recent 12 months? (5 points possible)
Score
Points Received

17.221

5

Do the Emergency Medical Response Review Committee (EMRRC) meeting minutes document the warden’s (or his or her designee’s)
attendance? (5 points possible)
Points Received

17.174

5

For each death sampled, did the institution complete the death review process? (5 points possible)
Points Received

17.138

5

Do the Emergency Medical Response Review Committee (EMRRC) meeting minutes document monthly meetings for the last
six (6) months? (5 points possible)

Points Received
17.136

HDSP

Did the Quality Management Committee (QMC) report its findings to the HCM/CMO each of the last six (6) meetings? (5 points possible)
Points Received

17.132

RJD

Do the Quality Management Committee (QMC) meeting minutes document monthly meetings for the last six (6) months? (5 points possible)
Points Received

17.119

CMF

0%
0

100% 100%
5

5

0%
0

100% 100%
5

5

0%

100%

0%

0%

0%

0

5

0

0

0

100% 100%
5

5

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? (5 points possible)
Score
Points Received
Total Points Received
Total Points Possible
Total Score

0%

0%

0%

0%

0%

0%

0%

0

0

100% 100% 100% 100%
5

5

5

5

0

0

0

0

0

100% 100%
5

5

0%
0

0%
0

28.2

27.5

40

24.3

37.3

39.2

28.2

24.2

29.2

28.2

24

36.2

33.3

26.2

25

40

40

40

40

40

40

40

40

40

40

40

40

35

40

40

70%

69%

100%

61%

93%

98%

70%

60%

73%

71%

60%

91%

95%

66%

63%

Bureau of Audits, Office of the Inspector General

Page 120

APPENDIX
C-11: Internal Reviews
_____________________________________________________________________________________________________________________
Page 2 of 2

SQ

CCC NKSP KVSP

100% 100% 100%
5

5

5

83%
4.2

FSP

SOL

SATF VSPW

ISP

CVSP COR

CAL

CTF

MCSP SVSP

CIM

PBSP WSP

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
5

5

5

5

5

5

5

5

5

5

5

5

5

5

5

5

100% 100% 100%
5

5

5

5

67%
3.3

5

5

5

5

5

100% 100% 100% 100% 100%
5

5

5

5

5

5

5

83%

67%

4.2

3.3

5

5

5

5

5

5

5

5

5

5

5

5

5

5

100% 100%
5

5

50%

83%

2.5

4.2

0%

5
80%
4

5

100% 100%

5

100% 100% 100%
5

100% 100%
5

5

5

83%

5

5
80%
4

100% 100%

5

4.2

5

5

5

5

100% 100%

5

5

5

5

5

5

75%

60%

100%

60%

60%

80%

5

5

3.8

3

5

3

3

4

83%

100%

80%

4.2

5

4

5

5

100% 100%

100% 100%

83%
4.2

100% 100%
5

100% 100%

5

5

5

5

5

97%
160

100% 100% 100%
5

89%
146.9

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
5

98%
161.7

100% 100% 100% 100% 100% 100% 100%
5

94%
155.2

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
5

Average
Score

85%
135.8

67%

50%

100%

85%

5

3.3

2.5

5

140.6

0%

100%

0%

0%

0%

0%

0%

0%

100%

0%

100%

48%

0

5

5

0

5

0

0

5

5

0

0

0

5

5

0

5

0

5

80

0%

0%

0%

0%

100%

0%

0%

0%

0%

0%

0%

0%

100%

0%

0%

100%

0%

0%

27%

0

0

0

0

5

0

0

0

0

0

0

0

5

0

0

5

0

0

45

27.5

34.2

34

27.5

39.2

30

29

34.2

35

27

26.3

30

37.2

33

29

38.3

27.5

35

1024.9

40

40

40

40

40

40

40

40

40

40

40

40

40

40

40

40

40

40

1315

69%

86%

85%

69%

98%

75%

73%

86%

88%

68%

66%

75%

93%

83%

73%

96%

69%

88%

78%

State of California • May 2011

Page 121

APPENDIX
C-12: Inmate Transfers
______________________________________________________________________________________________________________________
Page 1 of 2
Component Definition: 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.
Ref
Number
05.108

SAC

CMF

RJD

CEN

DVI

CCWF CMC

SCC

LAC

PVSP

CCI

CRC

CIW

ASP

HDSP

Did Receiving and Release have the inmate’s UHR and transfer envelope? (7 points possible)
Score 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Points Received

05.109

7

Score 100%
8

Points Received

05.172

7

7

7

7

7

7

7

7

7

7

7

7

0%

50%

100%

0%

100%

0%

0

4

8

0

8

0

100% 100%
8

8

Do all appropriate forms in the transfer envelope identify all medications ordered by the physician, and are the medications in the transfer
envelope? (8 points possible)
Score 100%

05.171

7

If the inmate was scheduled for any upcoming specialty services, were the services noted on Form 7371 (Health Care Transfer
Information)? (8 points possible)
Points Received

05.110

7

8

50%
4

100% 100% 100% 100% 100% 100% 100%
8

8

8

8

8

8

8

80%
6.4

100% 100%
8

8

40%

100%

3.2

8

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

80%

0%

Points Received

5.6

0

100% 100% 100% 100%
7

7

7

7

75%

80%

100%

20%

20%

100%

60%

5.3

5.6

7

1.4

1.4

7

4.2

100% 100%
7

7

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? (8 points possible)
Score
Points Received

0%

100% 100% 100% 100% 100% 100% 100% 100% 100%

0%

100% 100% 100% 100%

0

8

8

8

8

8

8

8

8

8

0

8

8

8

8

Total Points Received

28.6

19

34

38

30

38

28.3

28.6

30

22.8

16.4

38

30.4

22

30

Total Points Possible

38

38

38

38

38

38

30

30

30

30

38

38

38

22

30

75%

50%

90%

100%

79%

100%

94%

95%

100%

76%

43%

100%

80%

Total Score

Bureau of Audits, Office of the Inspector General

100% 100%

Page 122

APPENDIX
C-12: Inmate Transfers
_____________________________________________________________________________________________________________________
Page 2 of 2

SQ

CCC NKSP KVSP

FSP

SOL

SATF VSPW

ISP

CVSP COR

CAL

CTF

MCSP SVSP

CIM

PBSP WSP

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
7

7

7

7

7

100% 100% 100%
8

8

100%

80%

8

6.4

100%

60%

7

4.2

8

7

7

7

7

7

7

7

0%

0%

0%

100%

0

0

0

8

50%

100%

8

4

8

40%

100%

20%

2.8

7

1.4

100% 100% 100% 100% 100% 100% 100%
8

100% 100%
7

7

7

8

80%
5.6

8

8

8

100% 100% 100%
7

7

7

8

80%
5.6

100% 100% 100% 100% 100% 100% 100% 100% 100%

8

7

50%
4

7

100% 100%
8

100% 100% 100%
7

0%

7

7

7

7

7

Average
Score
100%
231

100% 100%

64%

8

8

92

75%

67%

100%

90%

6

5.3

8

223.3

100% 100%
7

7

40%

80%

2.8

185.9

100% 100% 100% 100% 100% 100% 100% 100%

91%

8

8

8

8

8

8

8

8

8

0

8

8

8

8

8

8

8

8

240

22

35.2

36.4

38

28.6

30

30

30

28.6

22

26

30

25.8

26

32.4

28

35.3

33.8

972.2

22

38

38

38

30

38

30

30

30

30

30

30

38

38

38

30

38

38

1118

100%

93%

96%

100%

95%

79%

95%

73%

87%

100%

68%

68%

85%

93%

93%

89%

88%

State of California • May 2011

100% 100%

Page 123

APPENDIX
C-13: Clinic Operations
______________________________________________________________________________________________________________________
Page 1 of 2
Component Definition: Addresses the general operational aspects of the prison’s facility clinics. Generally, the questions in this component relate to the
cleanliness of the clinics, privacy afforded to inmates during non-emergency visits, use of priority ducats (slips of paper the inmate carries for scheduled
medical appointments), and availability of health care request forms.
Ref
Number
14.023

SAC

CMF

RJD

CEN

DVI

CCWF CMC

SCC

LAC

Points Received

CRC

CIW

ASP

HDSP

4

4

4

4

4

4

4

4

4

83%

89%

3.3

3.6

100% 100% 100% 100%
4

4

4

4

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? (4 points possible)
Score

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Points Received
14.032

CCI

Does the institution make the Form 7362 (Health Care Services Request Form) available to inmates? (4 points possible)
Score 100% 100% 100% 100% 100% 100% 100% 100% 100%

14.029

PVSP

4

4

4

4

4

4

4

4

4

4

4

4

50%

4

2

Does medical staff understand the institution’s priority ducat process? (2 points possible)
Score 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Points Received

14.033

2

2

2

2

2

2

2

2

2

2

2

2

2

Points Received
Score

4

4

4

100%

75%

50%

2

4

3

2

Points Received

4

4

4

4

4

4

4

4

4

2

4

100% 100%
4

4

75%
3

100% 100%
4

4

75%

100%

75%

3

4

3

100% 100%
4

4

75%
3

4

4

0%
0

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
4

4

4

4

4

4

4

4

4

4

4

4

50%
2

100% 100%
4

4

50%

0%

0%

0%

50%

2

0

0

0

2

100% 100% 100% 100% 100% 100%
4

4

4

4

4

4

Are areas available to ensure privacy during RN face-to-face assessments and doctors’ examinations for non-emergencies?
(3 points possible)
Score

80%

0%

Points Received

2.4

0

100% 100% 100% 100% 100% 100% 100% 100%
3

3

3

3

3

3

3

3

75%

50%

2.3

1.5

100% 100% 100%
3

3

3

Are the clinic floors, waiting room chairs, and equipment cleaned with a disinfectant daily? (2 points possible)
Score 100%
Points Received

14.166

4

Does the institution have a process to identify, review, and address urgent appointments if a doctor’s line is canceled?
(4 points possible)
Score 100%

14.165

100%

Do medication nurses understand that medication is to be administered by the same licensed staff member who prepares it and on the
same day? (4 points possible)
Points Received

14.164

4

50%

Score 100% 100% 100%

14.160

50%

Does clinical staff wash their hands (either with soap or hand sanitizer) or change gloves between patients? (4 points possible)
Points Received

14.131

2

Does the institution have an adequate process to ensure inmates who are moved to a new cell still receive their medical ducats?
(4 points possible)
Score 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

14.106

2

2

67%

67%

100%

0%

67%

1.3

1.3

2

0

1.3

100% 100%
2

2

33%

67%

0%

0%

67%

0.7

1.3

0

0

1.3

100% 100%
2

2

Was the medication stored in a sealed container if food was present in the clinic refrigerator? (2 points possible)
Score 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Points Received

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

Total Points Received

26.4

27.3

31.3

27

29

28.3

28

29

29.7

30.6

29.9

28.5

32.3

31

30

Total Points Possible

29

33

33

33

33

33

33

33

33

33

33

33

33

33

33

91%

83%

95%

82%

88%

86%

85%

88%

90%

93%

91%

86%

98%

94%

91%

Total Score

Bureau of Audits, Office of the Inspector General

Page 124

APPENDIX
C-13: Clinic Operations
_____________________________________________________________________________________________________________________
Page 2 of 2

SQ

FSP

SOL

SATF VSPW

100% 100% 100% 100% 100%

67%

100% 100% 100% 100%

4

CCC NKSP KVSP

4

4

4

100% 100% 100%
4

4

4

2.7

4

4

ISP

4

100% 100% 100% 100% 100%

4

4

4

4

4

4

100% 100% 100% 100% 100% 100% 100% 100% 100%
2

2

2

2

2

2

2

2

2

CVSP COR

4

50%
2

67%
2.7

CAL

50%

MCSP SVSP

100% 100% 100%
4

100% 100%
4

CTF

4

4

50%
2

4

63%
2.5

2

2

PBSP WSP

100% 100%
4

4

4

4

2

2

4

4

94%

1.6

124.4

4

4

4

4

4

100%

75%

75%

100%

50%

50%

4

3

3

4

2

2

4

4

100% 100%
4

4

4

4

4

4

4

75%

100%

75%

100%

75%

3

4

3

4

3

4

4

118

50%

100%

97%

1

2

60

4

100% 100% 100%
4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

130

75%

75%

85%

3

3

112

4

4

4

100% 100%
3

3

100% 100%
2

2

4

67%

4

4

100% 100%

2

3

33%

50%

0.7

1

3

4

33%
1

100% 100%
2

2

4

4

4

4

4

4

4

4

4

4

4

4

75%
1.5

3

3

3

100% 100% 100%
2

2

2

3
67%
1.3

3

3

3

3

100% 100% 100% 100%
2

2

2

2

86%
114

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
3

97%
128

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
4

98%

4

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
4

95%

4

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
4

Average
Score

40%

100% 100% 100% 100% 100%

100% 100% 100% 100%

1

CIM

91%

3

3

3

90.2

67%

33%

100%

75%

1.3

0.7

2

49.7

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

100%

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

66

33

32

29.7

28

31

27.7

32.5

33

32

30

28

33

30

33

31.5

31.3

28.7

29.6

992.3

33

33

33

29

33

33

33

33

33

33

31

33

33

33

33

33

31

33

1077

100%

97%

90%

97%

94%

84%

99%

100%

97%

91%

90%

100%

91%

100%

96%

95%

93%

90%

92%

State of California • May 2011

Page 125

APPENDIX
C-14: Preventive Services
______________________________________________________________________________________________________________________
Page 1 of 2
Component Definition: Focuses on inmate cancer screening, tuberculosis evaluation, and influenza immunizations.
Ref
Number
10.085

10.086

10.087

SAC

CMF

RJD

CEN

DVI

CCWF CMC

10.232

CCI

CRC

CIW

ASP

HDSP

Score

50%

70%

30%

30%

10%

90%

20%

0%

0%

20%

70%

30%

20%

2.5

3.5

1.5

1.5

0.5

4.5

1

0

0

1

3.5

1.5

1

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? (6 points possible)
Score

80%

75%

50%

100%

86%

Points Received

4.8

4.5

3

6

5.1

100% 100%
6

6

80%

0%

0%

56%

90%

100%

60%

4.8

0

0

3.3

5.4

6

3.6

Female inmates age 41 or older: Did the inmate receive a mammogram within the previous 24 months? (5 points possible)
60%

70%

3

3.5

Inmates prescribed INH: Did the institution properly administer the medication to the inmate? (6 points possible)
Score

40%

80%

20%

0%

0%

40%

20%

0%

20%

20%

20%

80%

0%

40%

20%

Points Received

2.4

4.8

1.2

0

0

2.4

1.2

0

1.2

1.2

1.2

4.8

0

2.4

1.2

Inmates with TB code 34: Was the inmate evaluated for signs and symptoms of TB within the previous 12 months? (7 points possible)
Score

40%

0%

0%

0%

0%

100%

60%

20%

0%

100%

0%

100%

0%

100%

20%

Points Received

2.8

0

0

0

0

7

4.2

1.4

0

7

0

7

0

7

1.4

Inmates prescribed INH: Did the institution monitor the inmate monthly for the most recent three months he or she was on the medication?
(6 points possible)
Score
Points Received

10.274

PVSP

Points Received

Score

10.229

LAC

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? (5 points possible)

Points Received
10.228

SCC

0%

0%

0%

20%

0%

0%

0%

0%

0%

0%

0%

100%

0%

20%

0%

0

0

0

1.2

0

0

0

0

0

0

0

6

0

1.2

0

Female inmates age 41 to 64: Did the inmate receive a Pap smear in compliance with policy? (5 points possible)
Score

60%

Points Received

50%

3

2.5

Total Points Received

7.7

13.1

7.2

5.7

6.5

20.5

15.9

8.4

6

8.2

2.2

24.6

11.4

18.1

7.2

Total Points Possible

24

30

30

30

30

35

30

30

30

30

30

30

35

30

30

32%

44%

24%

19%

22%

59%

53%

28%

20%

27%

7%

82%

33%

60%

24%

Total Score

Bureau of Audits, Office of the Inspector General

Page 126

APPENDIX
C-14: Preventive Services
_____________________________________________________________________________________________________________________
Page 2 of 2

CIM

PBSP WSP

Average
Score

60%

20%

100% 100%

41%

3

1

5

5

61

50%

80%

100%

90%

50%

77%

3

4.8

6

5.4

3

147.9

SQ

CCC NKSP KVSP

FSP

SOL

SATF VSPW

ISP

CVSP COR

CAL

CTF

20%

0%

50%

60%

80%

40%

40%

10%

70%

50%

10%

30%

40%

1

0

2.5

3

4

2

2

0.5

3.5

2.5

0.5

1.5

2

20%

100%

80%

1.2

6

4.8

90%
5.4

100% 100%
6

6

100% 100% 100% 100%
6

6

6

6

30%
1.8

100% 100%
6

6

MCSP SVSP

90%

73%

4.5

11

20%

40%

40%

20%

0%

20%

0%

0%

40%

60%

20%

20%

60%

0%

60%

20%

100%

40%

29%

1.2

2.4

2.4

1.2

0

1.2

0

0

2.4

3.6

1.2

1.2

3.6

0

3.6

1.2

6

2.4

57.6

100%

20%

80%

40%

40%

100%

0%

20%

0%

80%

60%

100%

0%

100%

80%

100%

50%

7

1.4

5.6

2.8

7

7

2.8

7

0

1.4

0

5.6

4.2

7

0

7

5.6

7

116.2

0%

20%

0%

0%

0%

40%

0%

100%

20%

0%

60%

20%

0%

0%

20%

100%

40%

60%

19%

0

1.2

0

0

0

2.4

0

6

1.2

0

3.6

1.2

0

0

1.2

6

2.4

3.6

37.2

100% 100%

100%

70%

5

10.5

14.6

11

16.5

8.2

17

17.4

10.8

28.5

10.1

14.5

9.1

14.5

15.3

12

12.6

21.2

24.4

21

441.4

30

30

30

30

30

30

30

35

30

30

30

30

30

30

30

30

30

30

999

49%

37%

55%

27%

57%

58%

36%

81%

34%

48%

30%

48%

51%

40%

42%

71%

81%

70%

44%

State of California • May 2011

Page 127

APPENDIX
C-15: Pharmacy Services
______________________________________________________________________________________________________________________
Page 1 of 2
Component Definition: 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
addresses whether the pharmacy has an effective process for screening medication orders for potential adverse reactions/interactions.
Ref
Number
13.139

SAC

CMF

RJD

CEN

DVI

CCWF CMC

SCC

LAC

PVSP

CCI

CRC

CIW

ASP

HDSP

Does the institution conspicuously post a valid permit in its pharmacies? (2 points possible)
Score 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Points Received

13.141

13.142

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

0%

100%

0

2

Does the institution properly maintain its emergency crash cart medications? (2 points possible)
Score

80%

Points Received

1.6

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
2

2

2

2

2

2

2

2

2

2

2

2

Is the Pharmacist in Charge’s license current? (5 points possible)
Score 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Points Received

13.144

Score
Points Received
13.145

5

5

5

5

5

5

5

5

5

5

5

5

5

5

5

Does the institution have information to ensure that medications are prescribed by licensed health-care providers lawfully authorized to do
so? (6 points possible)
0%

0%

100%

0%

0

0

6

0

100% 100% 100% 100% 100%
6

6

6

6

6

0%

0%

0%

0

0

0

100% 100% 100%
6

6

6

Does the pharmacist in charge have an effective process for screening new medication orders for potential adverse reactions?
(7 points possible)
Score 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Points Received

13.148

7

7

7

Points Received

7

7

7

7

7

7

7

7

7

7

4

4

4

0%
0

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
4

4

4

4

4

4

4

4

4

4

4

Does the institution properly maintain medications in its after-hours medication supply(ies)? (2 points possible)
Score 100%
Points Received

13.253

7

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? (4 points possible)
Score 100% 100% 100%

13.252

7

2

50%

33%

0%

0%

0%

0%

0%

100%

0%

1

0.7

0

0

0

0

0

2

0

100% 100%
2

2

67%

100% 100%

1.3

2

2
100%

Does the institution conduct monthly inspections of its emergency cart and after-hours medication supply(ies)? (1 point possible)
Score
Points Received
Total Points Received
Total Points Possible
Total Score

0%

100%

40%

75%

67%

67%

33%

33%

25%

67%

0

1

0.4

0.8

0.7

0.7

0.3

0.3

100% 100% 100% 100%
1

1

1

1

0.3

0.7

1

21.6

22

27.1

16.8

26.7

26.7

26.3

26.3

29

21

23

23

27.6

26.7

29

29

29

29

29

29

29

29

29

29

29

29

29

29

29

29

75%

76%

93%

58%

92%

92%

91%

91%

100%

72%

79%

79%

95%

92%

100%

Bureau of Audits, Office of the Inspector General

Page 128

APPENDIX
C-15: Pharmacy Services
_____________________________________________________________________________________________________________________
Page 2 of 2

SQ

CCC NKSP KVSP

FSP

SOL

SATF VSPW

ISP

CVSP COR

CAL

CTF

MCSP SVSP

CIM

PBSP WSP

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
2

2

2

2

2

2

2

2

2

2

2

2

2

2

0%

50%

100%

0%

100%

38%

67%

0%

0%

0%

0%

100%

33%

0%

0

1

2

0

2

0.8

1.3

0

0

0

0

2

0.7

0

2

2

100% 100%
2

2

5

100%

0%

6

0

5

5

5

5

5

5

5

5

5

5

5

5

5

5

2

66

54%

100%

67%

1.1

2

44.5

5

5

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

7

7

7

7

7

7

7

7

7

7

7

7

7

7

7

7

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
4

4

4

4

4

4

4

4

4

4

4

4

4

0%

0%

0%

0%

100%

0%

0%

0%

0%

0%

0%

50%

0%

0

0

0

0

2

0

0

0

0

0

0

1

0

100% 100% 100%

0%

100% 100%

4

4

100% 100%
2

2

79%
156

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
7

100%
165

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
6

100%

2

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
5

Average
Score

100%

7

231

0%

94%

4

4

0

124

40%

50%

100%

39%

0.8

1

2

25.8

75%

100%

0%

0%

1

1

1

0

1

1

0.8

1

0

0

100% 100% 100% 100% 100% 100% 100% 100%
1

1

1

1

1

1

1

1

76%
25

25

20

27

24

29

25.8

26.1

25

24

24

25

28

25.7

27

29

27.8

27.1

25

837.3

29

29

29

29

29

29

29

29

29

29

29

29

29

29

29

29

29

29

957

86%

69%

93%

83%

100%

89%

90%

86%

83%

83%

86%

97%

89%

93%

100%

96%

93%

86%

87%

State of California • May 2011

Page 129

APPENDIX
C-16: Other Services
______________________________________________________________________________________________________________________
Page 1 of 2
Component Definition: 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.
Ref
Number
15.058

SAC

CMF

RJD

Score

CCWF CMC

SCC

LAC

PVSP

CCI

CRC

CIW

ASP

100%

0%

0%

100%

0%

100%

3

0

0

3

0

HDSP

3

Did the institution properly provide therapeutic diets to inmates? (4 points possible)
Score 100% 100% 100%
Points Received

15.134

DVI

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? (3 points possible)
Points Received

15.059

CEN

4

4

100% 100% 100%

4

4

4

4

100%

100%

4

4

Did the institution properly respond to all active cases of TB discovered in the last six months? (5 points possible)
Score 100%
Points Received

15.265

20.092

5

Is the most current version of the CDCR Health Services Policies and Procedures available in the institution’s law library?
(3 points possible)
Score

50%

Points Received

1.5

100% 100% 100% 100% 100% 100%
3

3

3

3

3

3

50%
1.5

100% 100%
3

3

50%

100%

0%

0%

0%

1.5

3

0

0

0

Hygiene Intervention: Did custody staff understand the department’s policies and procedures for identifying and evaluating inmates
displaying inappropriate hygiene management? (4 points possible)
Score 100% 100% 100% 100% 100% 100%
Points Received

75%

100% 100% 100% 100% 100% 100% 100% 100%

4

4

4

4

4

4

3

4

4

4

4

4

4

4

4

Total Points Received

14.5

11

11

10

11

11

10

5.5

11

7

8.5

7

4

7

8

Total Points Possible

16

11

11

10

11

11

11

10

11

10

10

10

7

10

11

91%

55%

100%

70%

85%

70%

57%

70%

73%

Total Score

91%

100% 100% 100% 100% 100%

Bureau of Audits, Office of the Inspector General

Page 130

APPENDIX
C-16: Other Services
_____________________________________________________________________________________________________________________
Page 2 of 2

SQ

CCC NKSP KVSP

100% 100%
3

FSP

SOL

SATF VSPW

100% 100%

3

3

ISP

CVSP COR

100% 100% 100%

3

3

3

3

0%

100%

80%

0

0

4

3.2

100%

50%

50%

0%

50%

1.5

3

1.5

1.5

0

1.5

100% 100% 100% 100% 100%

75%

100% 100%
3

3

50%
1.5

CTF

3

CIM

PBSP WSP

3

3

4

3

Average
Score

82%

3

42

100% 100% 100% 100%

55.2

0%

0%

33%

0

0

5

3

50%

50%

1.5

1.5

4

4

86%

4

100% 100% 100% 100%
3

MCSP SVSP

100% 100% 100% 100%

3

0%

50%

CAL

100% 100% 100%
3

3

3

73%
72

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

98%

4

4

4

4

4

3

4

4

4

4

4

4

4

4

4

4

4

4

130

8.5

10

5.5

5.5

7

7.5

11

10

8.5

10

10.2

10

10

8.5

12.5

11

11

11

304.2

10

10

11

11

10

10

11

10

10

10

11

10

15

10

14

11

11

16

361

85%

100%

50%

50%

70%

75%

85%

100%

93%

100%

67%

85%

89%

69%

84%

State of California • May 2011

100% 100%

100% 100%

Page 131

APPENDIX
C-17: Inmate Hunger Strikes
______________________________________________________________________________________________________________________
Page 1 of 2
Component Definition: Examines medical staff’s monitoring of inmates participating in hunger strikes lasting more than three days.
Ref
Number
11.097

SAC

Score

CEN

DVI

CCWF CMC

SCC

LAC

PVSP

CCI

CRC

CIW

ASP

HDSP

33%

100%

33%

100%

2

6

2

6

100% 100%
6

6

25%

0%

0%

80%

1.5

0

0

4.8

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? (6 points possible)
Score
Points Received

11.100

RJD

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? (6 points possible)
Points Received

11.099

CMF

0%

0%

0%

0%

100%

67%

50%

0%

67%

60%

0

0

0

0

6

4

3

0

4

3.6

After the first 72 hours, did a physician perform a physical examination and order a metabolic panel and a urinalysis of the inmate?
(7 points possible)
Score

0%

0%

0%

0%

100%

50%

50%

100%

67%

0%

Points Received

0

0

0

0

7

3.5

3.5

7

4.7

0

Total Points Received

2

6

2

6

19

13.5

8

7

8.7

8.4

Total Points Possible

19

19

19

19

19

19

19

19

19

19

11%

32%

11%

32%

100%

71%

42%

37%

46%

44%

Total Score

Bureau of Audits, Office of the Inspector General

Page 132

APPENDIX
C-17: Inmate Hunger Strikes
_____________________________________________________________________________________________________________________
Page 2 of 2

SQ

CCC NKSP KVSP

FSP

SOL

SATF VSPW

80%

0%

100%

4.8

0

6

CVSP COR

CAL

6

6

75%
4.5

20%

100%

0%

100%

80%

1.2

6

0

6

60%

100%

40%

CTF

PBSP WSP

Average
Score

MCSP SVSP

CIM

100%

100%

20%

100% 100%

6

6

1.2

6

20%

100%

100%

40%

100%

50%

4.8

1.2

6

6

2.4

6

60.2

67%

60%

0%

100%

50%

20%

100%

48%

100% 100%

ISP

6

69%
86.8

4.2

7

2.8

4.7

4.2

0

7

3.5

1.4

7

10.2

13

8.8

16.7

15

5.7

19

15.5

5

19

6

214.5

19

19

19

19

19

19

19

19

19

19

6

386

54%

68%

46%

88%

79%

30%

100%

82%

26%

State of California • May 2011

67.5

100% 100%

57%

Page 133

APPENDIX
C-18: Chemical Agent Contraindications
______________________________________________________________________________________________________________________
Page 1 of 2
Component Definition: Addresses the prison’s process for 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
Ref
Number
12.062

SAC

RJD

CEN

DVI

CCWF CMC

SCC

LAC

PVSP

CCI

CRC

CIW

ASP

HDSP

Did the institution document that it consulted with an RN or primary care provider (PCP) before a calculated use of OC?
(9 points possible)
Score 100%
Points Received

12.064

CMF

9

75%

100%

80%

80%

33%

6.8

9

7.2

7.2

3

100% 100% 100%
9

9

100% 100%

9

9

9

Did the institution record how it decontaminated the inmate and did it follow the decontamination policy? (8 points possible)
Score 100% 100%
Points Received

8

8

Total Points Received

17

Total Points Possible

17

Total Score 100%

88%

100% 100% 100% 100% 100%

80%

67%

67%

8

8

8

6.4

5.3

5.3

8

8

8

8

15.2

11

17

17

15.4

5.3

5.3

8

8

17

17

17

17

17

17

17

8

8

8

8

17

17

89%

65%

91%

66%

66%

7

8

8

14.8

16

15.2

17

17

17

87%

94%

89%

Bureau of Audits, Office of the Inspector General

100% 100%

100% 100% 100% 100%

100% 100% 100% 100%

Page 134

APPENDIX
C-18: Chemical Agent Contraindications
_____________________________________________________________________________________________________________________
Page 2 of 2

SQ

CCC

80%

100% 100%

7.2

9

NKSP KVSP

9

100% 100% 100%

50%
4.5

SOL

SATF VSPW

ISP

100% 100% 100% 100% 100%
9

9

9

9

9

CAL

CTF

MCSP SVSP

CIM

100% 100% 100% 100% 100% 100%
9

9

9

9

9

9

PBSP WSP

Average
Score

60%

100%

91%

5.4

9

230.3

88%

96%

8

8

5.7

8

8

8

8

8

8

8

8

8

8

8

8

7

244.7

15.2

17

17

10.2

17

17

17

17

17

17

17

17

17

17

17

13.4

16

475

17

17

17

17

17

17

17

17

17

17

17

17

17

17

17

17

17

508

79%

94%

93%

100% 100%

60%

100% 100% 100% 100% 100%

CVSP COR

8

89%

71%

FSP

100% 100% 100% 100% 100%

State of California • May 2011

100% 100% 100% 100% 100% 100% 100%

100% 100% 100% 100% 100% 100%

Page 135

APPENDIX
C-19: Staffing Levels and Training
______________________________________________________________________________________________________________________
Page 1 of 2
Component Definition: Examines the prison’s medical staffing levels and training provided.
Ref
Number
18.001

18.004

SAC

CMF

RJD

CEN

DVI

CCWF CMC

SCC

LAC

PVSP

CCI

CRC

CIW

ASP

HDSP

100% 100%

Are licensed health care staff current with their certifications and did they attend required training? (4 points possible)
Score

80%

80%

Points Received

3.2

3.2

100% 100%
4

4

80%

40%

3.2

1.6

100% 100%
4

4

60%

20%

60%

40%

40%

2.4

0.8

2.4

1.6

1.6

4

4

Did the institution have a registered nurse (RN) available on site 24 hours a day, seven days a week, for emergency care?
(4 points possible)
Score 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Points Received

18.005

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

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? (4 points possible)
Score 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Points Received

18.006

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

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? (4 points possible)
Score 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Points Received
Total Points Received
Total Points Possible
Total Score

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

15.2

15.2

16

16

15.2

13.6

16

16

14.4

12.8

14.4

13.6

13.6

16

16

16

16

16

16

16

16

16

16

95%

95%

100% 100%

16

16

95%

85%

Bureau of Audits, Office of the Inspector General

100% 100%

16

16

16

16

16

90%

80%

90%

85%

85%

100% 100%

Page 136

APPENDIX
C-19: Staffing Levels and Training
_____________________________________________________________________________________________________________________
Page 2 of 2

SQ

CCC NKSP KVSP

FSP

80%

100%

80%

80%

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

3.2

4

3.2

3.2

4

SOL

4

SATF VSPW

4

4

ISP

4

CVSP COR

4

4

CAL

4

CTF

4

MCSP SVSP

4

4

CIM

4

PBSP WSP

4

20%

84%

0.8

110.4

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

100%
132

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
4

Average
Score

4

100%
132

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

100%

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

132

15.2

16

15.2

15.2

16

16

16

16

16

16

16

16

16

16

16

16

16

12.8

506.4

16

16

16

16

16

16

16

16

16

16

16

16

16

16

16

16

16

95%

100%

95%

95%

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

State of California • May 2011

16

528

80%

96%

Page 137

APPENDIX
C-20: Nursing Policy
______________________________________________________________________________________________________________________
Page 1 of 2
Component Definition: 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.
Ref
Number
16.154

SAC

CMF

RJD

CEN

DVI

CCWF CMC

SCC

LAC

PVSP

CCI

CRC

CIW

ASP

HDSP

Does the institution have written nursing policies and procedures that adhere to the department’s guidelines? (5 points possible)
Score 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Points Received

16.231

Score
Points Received
16.254

5

5

5

5

5

5

5

5

5

5

5

5

5

5

5

Does the institution ensure that nursing staff review their duty statements? (5 points possible)
40%

0%

100%

20%

0%

100%

40%

100%

60%

100%

40%

80%

80%

40%

100%

2

0

5

1

0

5

2

5

3

5

2

4

4

2

5
60%

Does the institution’s supervising registered nurse (SRN) conduct periodic reviews of nursing staff? (4 points possible)
0%

60%

100%

0%

80%

0%

100%

0%

40%

0%

60%

Points Received

Score 100%
4

0

2.4

4

0

4

4

3.2

0

4

0

1.6

0

2.4

2.4

Total Points Received

11

5

12.4

10

5

14

11

13.2

8

14

7

10.6

9

9.4

12.4

Total Points Possible
Total Score

100% 100%

14

14

14

14

14

14

14

14

14

14

14

14

14

14

14

79%

36%

89%

71%

36%

100%

79%

94%

57%

100%

50%

76%

64%

67%

89%

Bureau of Audits, Office of the Inspector General

Page 138

APPENDIX
C-20: Nursing Policy
_____________________________________________________________________________________________________________________
Page 2 of 2

SQ

SATF VSPW

ISP

CVSP COR

100% 100% 100% 100% 100% 100% 100% 100%

60%

100% 100% 100% 100% 100% 100% 100% 100% 100%

5

CCC NKSP KVSP

5

5

SOL

5

5

5

5

5

3

5

5

CAL

5

CTF

5

MCSP SVSP

5

5

PBSP WSP

Average
Score
99%

5

5

5

163

80%

40%

100%

70%

4

2

5

115
58%

60%

60%

100%

20%

100%

0%

100%

60%

5

5

3

3

5

1

5

0

5

3

20%

80%

0%

0%

60%

0%

0%

100%

0.8

3.2

0

0

2.4

0

4

4

4

0

4

4

4

2.4

4

4

0

4

76.8

9.8

13.2

10

8

10.4

10

10

14

7

10

12

14

14

12.4

14

13

7

14

354.8

14

14

100% 100% 100%

0%

5

5

100% 100% 100%

14

14

14

14

14

14

14

14

14

14

14

70%

94%

71%

57%

74%

71%

71%

100%

50%

71%

86%

State of California • May 2011

100% 100% 100% 100%

CIM

4

80%

100% 100%

FSP

100% 100%

5
60%

5

100% 100%

14

14

14

14

14

462

89%

100%

93%

50%

100%

77%

Page 139

APPENDIX
D-1: Medication Management
______________________________________________________________________________________________________________________
Page 1 of 4
Category Definition: Evaluates the timely delivery of medications to inmates and certain elements of medication administration.
Ref
Number
01.124

02.128

03.175

05.110

SAC

13.145

CEN

DVI

CCWF CMC

SCC

LAC

PVSP

CCI

CRC

CIW

ASP

HDSP

Score

22%

80%

55%

77%

33%

52%

28%

13%

33%

11%

41%

10%

28%

30%

44%

Points Received

1.3

4.8

3.3

4.6

2

3.1

1.7

0.8

2

0.7

2.5

0.6

1.7

1.8

2.6

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? (8 points possible)
Score

33%

88%

50%

50%

0%

43%

13%

25%

42%

0%

43%

23%

0%

30%

35%

Points Received

2.7

7

4

4

0

3.4

1

2

3.3

0

3.4

1.8

0

2.4

2.8

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? (18 points possible)
Score

46%

77%

50%

55%

65%

40%

4%

31%

29%

4%

48%

20%

4%

18%

8%

Points Received

8.3

13.9

9

9.9

11.6

7.2

0.8

5.6

5.3

0.8

8.6

3.6

0.8

3.3

1.4

Do all appropriate forms in the transfer envelope identify all medications ordered by the physician, and are the medications in the transfer
envelope? (9 points possible)
Score 100%

13.141

RJD

Sick Call Medication: Did the institution administer or deliver prescription medications (new orders) to the inmate within specified time
frames? (6 points possible)

Points Received
10.228

CMF

8

50%
4

100% 100% 100% 100% 100% 100% 100%
8

8

8

8

8

8

8

80%
6.4

100% 100%
8

40%

100%

8

3.2

8

Inmates prescribed INH: Did the institution properly administer the medication to the inmate? (8 points possible)
Score

40%

80%

20%

0%

0%

40%

20%

0%

20%

20%

20%

80%

0%

40%

20%

Points Received

2.4

4.8

1.2

0

0

2.4

1.2

0

1.2

1.2

1.2

4.8

0

2.4

1.2

0%

100%

0

2

Does the institution properly maintain its emergency crash cart medications? (2 points possible)
Score

80%

Points Received

1.6

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
2

2

2

2

2

2

2

2

2

2

2

2

Does the pharmacist in charge have an effective process for screening new medication orders for potential adverse reactions?
(7 points possible)
Score 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Points Received

13.148

7

7

7

Score 100% 100% 100%
Points Received
13.252

4

Points Received
Score

2

7

7

4

4

0%
0

7

7

7

7

7

7

7

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
4

4

4

4

4

4

50%

33%

0%

0%

0%

0%

0%

100%

0%

1

0.7

0

0

0

0

0

2

0

0%

100%

40%

75%

67%

67%

33%

33%

0

1

0.4

0.8

0.7

0.7

0.3

0.3

4

4

4

4

4

100% 100%
2

2

67%
1.3

100% 100%
2

2

100% 100% 100% 100%
1

1

1

1

25%

67%

100%

0.3

0.7

1

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? (4 points possible)
Score

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Points Received
14.131

7

Does the institution conduct monthly inspections of its emergency cart and after-hours medication supply(ies)? (9 points possible)
Points Received

14.029

7

Does the institution properly maintain medications in its after-hours medication supply(ies)? (2 points possible)
Score 100%

13.253

7

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? (4 points possible)

4

4

4

4

4

4

4

4

4

4

4

4

4

50%
2

Do medication nurses understand that medication is to be administered by the same licensed staff member who prepares it and on the
same day? (4 points possible)
Score 100% 100% 100%
Points Received

4

4

4

0%
0

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
4

Bureau of Audits, Office of the Inspector General

4

4

4

4

4

4

4

4

4

4

Page 140

APPENDIX
D-1: Medication Management
_____________________________________________________________________________________________________________________
Page 2 of 4

SQ

CCC NKSP KVSP

FSP

SOL

SATF VSPW

ISP

CVSP COR

CAL

CTF

22%

14%

65%

18%

57%

48%

7%

1.3

0.9

3.9

1.1

3.4

2.9

0.4

24%

17%

0%

0%

60%

36%

1.9

1.3

0

0

4.8

8%

17%

24%

16%

1.4

3.1

4.3

2.9

100%

80%

8

6.4

48%

17%

27%

27%

46%

20%

30%

2.9

1

1.6

1.6

2.8

1.2

1.8

20%

33%

40%

75%

11%

0%

14%

2.9

1.6

2.7

3.2

6

0.9

0

57%

21%

5%

32%

0%

20%

52%

10.2

3.8

0.8

5.8

0

3.6

8

8

8

8

8

8

8

4

8

8

20%

40%

40%

20%

0%

20%

0%

0%

40%

60%

20%

20%

1.2

2.4

2.4

1.2

0

1.2

0

0

2.4

3.6

1.2

0%

50%

100%

0%

100%

38%

67%

0%

0%

0%

0

1

2

0

2

0.8

1.3

0

0

0

100% 100% 100% 100% 100% 100% 100%

MCSP SVSP

PBSP WSP

73%

12%

68%

37%

36%

4.4

0.7

4.1

2.2

71.7

50%

86%

46%

83%

25%

33%

1.1

4

6.9

3.6

6.7

2

87.4

63%

72%

72%

42%

25%

75%

22%

34%

9.4

11.3

13

13

7.5

4.5

13.5

3.9

202.1

50%

100% 100%

50%

100%

75%

67%

100%

90%

4

8

6

5.3

8

223.3

60%

0%

60%

20%

100%

40%

29%

1.2

3.6

0

3.6

1.2

6

2.4

57.6

0%

100%

33%

0%

54%

100%

67%

0

2

0.7

0

1.1

2

44.5

100% 100%
2

2

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
7

7

7

7

7

7

7

7

7

7

7

7

7

7

7

7

7

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
4

4

4

4

4

4

4

4

4

4

4

4

4

0%

0%

0%

0%

100%

0%

0%

0%

0%

0%

0%

50%

0%

0

0

0

0

2

0

0

0

0

0

0

1

0

75%

100%

0%

0%

0.8

1

0

0

100% 100% 100%
1

1

1

0%
0

100% 100% 100%
4

4

100% 100%
1

1

100% 100% 100% 100% 100%

4

4

4

4

4

4

50%
2

4

4

100% 100%
2

2

231

0%

94%

4

4

0

124

40%

50%

100%

39%

0.8

1

2

25.8

100% 100% 100% 100% 100% 100% 100% 100%
1

1

100% 100%
4

4

1

50%
2

1

1

1

1

1

4

4

4

4

4

4

4

4

State of California • May 2011

4

4

4

4

4

4

4

4

4

4

4

4

4

76%
25

100% 100% 100% 100% 100%
4

100%

7

95%
118

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
4

Average
Score

CIM

97%
128

Page 141

APPENDIX
D-1: Medication Management
______________________________________________________________________________________________________________________
Page 3 of 4
Ref
Number
14.166

SAC

CMF

RJD

CEN

DVI

CCWF CMC

SCC

LAC

PVSP

CCI

CRC

CIW

ASP

HDSP

Was the medication stored in a sealed container if food was present in the clinic refrigerator? (2 points possible)
Score 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Points Received

21.281

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

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? (6 points possible)
Score 100% 100%
Points Received
Total Points Received
Total Points Possible
Total Score

58%

79%

79%

88%

64%

48%

38%

13%

67%

47%

44%

10%

47%

6

6

3.5

4.7

4.7

5.3

3.8

2.9

2.3

0.8

4

2.8

2.6

0.6

2.8

49.3

65.5

53.1

47

50

53.1

39.8

42.6

48.1

33.9

53.7

47.6

32.9

34.2

42.8

74

78

78

78

78

78

78

78

78

78

78

78

78

70

78

67%

84%

68%

60%

64%

68%

51%

55%

62%

43%

69%

61%

42%

49%

55%

Bureau of Audits, Office of the Inspector General

Page 142

APPENDIX
D-1: Medication Management
_____________________________________________________________________________________________________________________
Page 4 of 4
SQ

CCC NKSP KVSP

FSP

SOL

SATF VSPW

ISP

CVSP COR

CAL

CTF

MCSP SVSP

CIM

PBSP WSP

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Average
Score
100%

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

66

7%

50%

39%

0%

50%

17%

13%

50%

11%

33%

50%

57%

18%

50%

64%

33%

100%

59%

48%

0.4

3

2.3

0

3

1

0.8

3

0.7

2

3

3.4

1.1

3

3.8

2

6

3.5

94.8

28.2

41.7

43.3

30.2

55.4

42.6

34.7

44.4

36.3

43.8

42.1

51.7

48.7

49.8

60.2

42.8

65.7

44

1499.2

70

78

78

74

78

78

78

78

78

78

78

78

78

78

78

78

78

78

2550

40%

53%

56%

41%

71%

55%

44%

57%

47%

56%

54%

66%

62%

64%

77%

55%

84%

56%

59%

State of California • May 2011

Page 143

APPENDIX
D-2: Access to Providers and Services
______________________________________________________________________________________________________________________
Page 1 of 6
Category Definition: Assesses the prisons’ effectiveness in ensuring that inmates are seen by primary care providers or provided services for routine,
urgent, and emergency medical needs according to timelines set by CDCR policy.
Ref
Number
01.025

01.027

01.247

02.015

SAC

CMF

CRC

CIW

ASP

HDSP

88%

78%

65%

83%

33%

60%

80%

68%

26%

40%

Points Received

4.6

5

4.8

4.6

5.3

5.3

4.7

3.9

5

2

3.6

4.8

4.1

1.5

2.4

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? (8 points possible)
Score

29%

82%

13%

50%

79%

56%

75%

75%

35%

47%

25%

54%

71%

52%

27%

Points Received

2.4

6.6

1

4

6.3

4.5

6

6

2.8

3.8

2

4.3

5.6

4.2

2.1

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

25%

78%

22%

100%

60%

67%

67%

0%

20%

36%

57%

88%

56%

63%

50%

Points Received

1.8

5.4

1.6

7

4.2

4.7

4.7

0

1.4

2.5

4

6.1

3.9

4.4

3.5

Was a review of symptoms completed if the inmate’s tuberculin test was positive, and were the results reviewed by the infection control
nurse? (7 points possible)
7

100%

100%

67%

75%

83%

100%

33%

100%

7

7

4.7

5.3

5.8

7

2.3

7

Did the institution complete the initial health screening on the same day the inmate arrived at the institution? (9 points possible)
9

9

97%
8.7

100% 100% 100%
9

9

9

100% 100%
9

9

90%

65%

77%

95%

95%

90%

93%

8.1

5.9

6.9

8.6

8.6

8.1

8.4

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? (8 points possible)
8

56%

94%

93%

4.4

7.6

7.5

100% 100%
8

8

100%

29%

46%

70%

100%

100%

87%

8

2.3

3.7

5.6

8

8

6.9

100% 100%
8

8

If, during the assessment, the RN referred the inmate to a clinician, was the inmate seen within the time frame? (8 points possible)
Score

04.052

CCI

88%

Points Received

04.051

PVSP

76%

Score 100%

03.076

LAC

80%

Points Received

02.021

SCC

84%

Score 100% 100%

02.020

CCWF CMC

76%

Points Received

02.018

DVI

Score

Score 100%

02.017

CEN

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

Points Received
02.016

RJD

25%

100%

13%

60%

50%

86%

100%

29%

0%

71%

33%

11%

55%

17%

2

8

1

4.8

4

6.9

8

2.3

0

5.7

2.7

0.9

4.4

1.3

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? (6 points possible)
Score

90%

70%

87%

90%

Points Received

5.4

4.2

5.2

5.4

100% 100%
6

6

85%

95%

100%

85%

80%

100%

90%

85%

97%

5.1

5.7

6

5.1

4.8

6

5.4

5.1

5.8

Reception center: Did the inmate receive a complete history and physical by a Nurse Practitioner, Physician Assistant, or a Physician and
Surgeon within 14 calendar days of arrival? (5 points possible)
Score

56%

55%

55%

50%

100%

40%

100%

Points Received

2.8

2.8

2.8

2.5

5

2

5

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? (10 points possible)
Score

88%

87%

48%

95%

56%

90%

76%

60%

64%

72%

68%

96%

75%

72%

44%

Points Received

8.8

8.7

4.8

9.5

5.6

9

7.6

6

6.4

7.2

6.8

9.6

7.5

7.2

4.4

Did the primary care provider (PCP) evaluate the inmate within one calendar day after placement? (5 points possible)
Score

90%

80%

80%

100%

80%

100%

70%

80%

Points Received

4.5

4

4

5

4

5

3.5

4

Did the RN complete an initial assessment of the inmate on the day of placement? (5 points possible)
Score

90%

100%

80%

100%

60%

100%

90%

80%

Points Received

4.5

5

4

5

3

5

4.5

4

Bureau of Audits, Office of the Inspector General

Page 144

APPENDIX
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Page 2 of 6

SQ

CCC NKSP KVSP

FSP

SOL

SATF VSPW

ISP

CVSP COR

CAL

CTF

34%

84%

44%

57%

80%

64%

40%

60%

70%

97%

71%

70%

71%

68%

2.1

5

2.6

3.4

4.8

3.8

2.4

3.6

4.2

5.8

4.3

4.2

4.3

56%

46%

40%

25%

61%

48%

46%

77%

64%

57%

52%

53%

4.4

3.6

3.2

2

4.9

3.8

3.7

6.2

5.1

4.6

4.2

4.2

50%

67%

100%

50%

100%

38%

55%

75%

83%

100%

67%

3.5

4.7

7

3.5

7

2.6

3.8

5.3

5.8

7

4.7

100% 100%
7

7

90%

85%

8.1

7.7

0%
0

100% 100%
7

7

0%

100% 100%

0

7

7

100% 100% 100% 100% 100% 100% 100%
9

9

9

9

9

9

9

95%
8.6

PBSP WSP

70%

79%

98%

71%

68%

4.1

4.2

4.8

5.9

4.3

135.4

63%

55%

46%

57%

75%

38%

52%

5.1

4.4

3.7

4.6

6

3

138.3

100%

40%

100%

50%

100%

60%

63%

7

2.8

7

3.5

7

4.2

141.6

100%

7

7

100% 100% 100%
9

Average
Score

CIM

100%

9

9

MCSP SVSP

100% 100%
7
95%
8.6

100% 100%
9

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

84%

7

123.1

95%

100%

96%

9

8.6

9

284.9

96%

75%

100%

92%

8

8

8

8

8

8

8

8

8

8

8

8

8

8

7.6

6

8

235.6

61%

40%

100%

18%

100%

85%

6%

100%

57%

55%

38%

78%

0%

40%

36%

74%

60%

100%

53%

4.9

3.2

8

1.5

8

6.8

0.5

8

4.6

4.4

3

6.2

0

3.2

2.9

5.9

4.8

8

135.9

85%

95%

90%

100%

85%

85%

90%

5.1

5.7

5.4

6

5.1

5.1

5.4

96%
5.8

100% 100% 100% 100%
6

6

6

6

95%
5.7

100% 100% 100%
6

6

6

100% 100%
6

93%

6

184.5

95%

100%

65%

75%

90%

74%

4.8

5

3.3

3.8

4.5

44.3

84%

56%

60%

52%

76%

24%

24%

72%

15%

48%

42%

46%

32%

28%

48%

70%

13%

35%

58%

8.4

5.6

6

5.2

7.6

2.4

2.4

7.2

1.5

4.8

4.2

4.6

3.2

2.8

4.8

7

1.3

3.5

191.6

80%

80%

90%

75%

90%

100%

100%

88%

4

4

4.5

3.8

4.5

5

5

74.8

100%

90%

100%

94%

5

4.5

5

79.5

State of California • May 2011

100% 100%
5

5

100% 100% 100% 100% 100% 100%
5

5

5

5

5

5

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APPENDIX
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______________________________________________________________________________________________________________________
Page 3 of 6
Ref
Number
04.053

06.049

SAC

07.038

07.043

CCWF CMC

SCC

LAC

PVSP

CCI

30%

78%

100%

50%

33%

1.2

3.1

4

2

1.3

CRC

7

80%

100% 100%
4

5.6

100% 100%
7

7

20%

100%

80%

1.4

7

5.6

100% 100%
7

7

0%

100%

60%

60%

5.6

5.6

0

7

4.2

4.2

Score

90%

90%

50%

60%

80%

70%

80%

100%

90%

70%

40%

90%

50%

70%

30%

5.4

5.4

3

3.6

4.8

4.2

4.8

6

5.4

4.2

2.4

5.4

3

4.2

1.8

Did the inmate receive the specialty service within specified time frames? (9 points possible)
Score

47%

35%

59%

59%

59%

94%

59%

77%

65%

69%

41%

29%

88%

77%

47%

Points Received

4.2

3.2

5.3

5.3

5.3

8.5

5.3

6.9

5.8

6.2

3.7

2.6

7.9

6.9

4.2

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? (8 points possible)
Score

8%

31%

25%

15%

9%

0%

23%

36%

29%

8%

29%

7%

38%

33%

7%

Points Received

0.6

2.5

2

1.2

0.7

0

1.8

2.9

2.3

0.7

2.4

0.5

3

2.7

0.5

Did the PCP review the consultant’s report and see the inmate for a follow-up appointment after the specialty services consultation within
specified time frames? (9 points possible)
22%

29%

19%

41%

8%

18%

13%

25%

36%

36%

47%

38%

23%

73%

0%

2

2.6

1.7

3.7

0.7

1.6

1.1

2.3

3.2

3.2

4.2

3.4

2.1

6.5

0

Did the medical emergency responder arrive at the location of the medical emergency within five (5) minutes of initial notification?
(4 points possible)
4

4

80%
3.2

100% 100%
4

4

67%
2.7

100% 100% 100%
4

4

4

75%

50%

100%

3

2

4

100% 100%
4

4

New arrival only: Did the inmate receive a pregnancy test within three (3) business days of arrival at the institution to positively identify her
pregnancy? (5 points possible)
0%
0

New arrival only: Was the inmate seen by an OB physician or OB nurse practitioner within seven (7) business days of her arrival at the
institution? (5 points possible)
Score

100%

Points Received

10.086

3

80%

Score

10.085

75%

4

80%

Points Received

09.074

HDSP

Points Received

Points Received

09.071

ASP

All laboratory orders: Was the specimen collected within the applicable time frames of the physician’s order? (6 points possible)

Score 100% 100%

09.067

CIW

Radiology order: Was the radiology service provided within the time frame specified in the physician’s order? (7 points possible)

Score

09.066

DVI

Score

Points Received
08.184

CEN

Points Received

Points Received

07.035

RJD

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? (4 points possible)

Score 100%
06.188

CMF

5

Did the inmate visit with an OB physician according to the applicable time frames? (8 points possible)
Score

86%

Points Received

6.9

Did the inmate receive her six-week check-up (post-delivery)? (7 points possible)
Score

80%

Points Received

5.6

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? (5 points possible)
Score

50%

70%

30%

30%

10%

90%

20%

0%

0%

20%

70%

30%

20%

Points Received

2.5

3.5

1.5

1.5

0.5

4.5

1

0

0

1

3.5

1.5

1

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? (6 points possible)
Score

80%

75%

50%

100%

86%

Points Received

4.8

4.5

3

6

5.1

Bureau of Audits, Office of the Inspector General

100% 100%
6

6

80%

0%

0%

56%

90%

100%

60%

4.8

0

0

3.3

5.4

6

3.6

Page 146

APPENDIX
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_____________________________________________________________________________________________________________________
Page 4 of 6
SQ

CCC NKSP KVSP

FSP

100%

50%

4

2

100%

60%

7

4.2

7

7

7

100%

70%

100%

90%

6

4.2

6

5.4

65%

88%

65%

5.8

7.9

5.8

0%

56%

0

4.4

23%
2.1

80%
3.2

SOL

SATF VSPW

ISP

CVSP COR

100% 100% 100%

0%

CAL

CTF

MCSP SVSP

100% 100%

PBSP WSP

Average
Score

100%

77%

4

52.6

4

4

4

0

4

40%

80%

60%

40%

100%

80%

7

2.8

5.6

4.2

2.8

7

5.6

7

7

7

70%

90%

20%

90%

60%

70%

80%

70%

83%

70%

4.2

5.4

1.2

5.4

3.6

4.2

4.8

4.2

5

4.2

82%

100%

41%

56%

100%

94%

88%

71%

88%

59%

7.4

9

3.7

5.1

9

8.5

7.9

6.4

7.9

5.3

17%

20%

67%

22%

17%

25%

33%

75%

25%

100%

50%

67%

100%

32%

1.3

1.6

5.3

1.8

1.3

2

2.7

6

2

8

4

5.3

8

77.5

42%

31%

25%

73%

80%

60%

25%

62%

64%

27%

43%

14%

27%

54%

64%

80%

50%

39%

3.8

2.8

2.3

6.6

7.2

5.4

2.3

5.5

5.8

2.5

3.9

1.3

2.5

4.8

5.7

7.2

4.5

114.5

75%

100%

67%

80%

92%

3

4

2.7

3.2

117.2

100% 100% 100% 100%

100% 100%
4

4

80%
3.2

100% 100% 100% 100%
4

4

4

4

75%
3

100% 100%
4

4

4

CIM

100% 100% 100% 100%

60%

100%

81%

7

4.2

7

187.6

70%

70%

80%

80%

73%

4.2

4.2

4.8

4.8

145.4

93%

77%

94%

94%

77%

71%

8.4

6.9

8.5

8.5

6.9

210.2

100% 100% 100%
4

4

4

50%

25%

2.5

2.5

100%

100%

5

10

100%

93%

8

14.9

100%

90%

7

12.6

20%

0%

50%

60%

80%

40%

40%

10%

70%

50%

10%

30%

40%

60%

20%

1

0

2.5

3

4

2

2

0.5

3.5

2.5

0.5

1.5

2

3

1

5

5

20%

100%

80%

50%

80%

100%

90%

50%

77%

1.2

6

4.8

3

4.8

6

5.4

3

147.9

90%
5.4

100% 100%
6

6

State of California • May 2011

100% 100% 100% 100%
6

6

6

6

30%
1.8

100% 100%
6

6

100% 100%

41%
61

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Page 5 of 6
Ref
Number
10.087

SAC

CMF

RJD

CEN

DVI

CCWF CMC

Score

10.232

60%

70%

3

3.5

0%

100%

60%

20%

0%

100%

0%

100%

0%

100%

20%

Points Received

2.8

0

0

0

0

7

4.2

1.4

0

7

0

7

0

7

1.4

Inmates prescribed INH: Did the institution monitor the inmate montley for the most recent three months he or she was on the medication?
(6 points possible)
0%

0%

0%

20%

0%

0%

0%

0%

0%

0%

0%

100%

0%

20%

0%

0

0

0

1.2

0

0

0

0

0

0

0

6

0

1.2

0

Female inmates age 41 to 64: Did the inmate receive a Pap smear in compliance with policy? (5 points possible)
60%

50%

3

2.5

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? (6 points possible)
33%

100%

33%

100%

2

6

2

6

100% 100%
6

6

25%

0%

0%

80%

1.5

0

0

4.8

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? (6 points possible)
Score
Points Received

0%

0%

0%

0%

100%

67%

50%

0%

67%

60%

0

0

0

0

6

4

3

0

4

3.6

After the first 72 hours, did a physician perform a physical examination and order a metabolic panel and a urinalysis of the inmate?
(7 points possible)
Score
Points Received

0%

0%

0%

0%

100%

50%

50%

100%

67%

0%

0

0

0

0

7

3.5

3.5

7

4.7

0

Emergency Medical Response Drill: Did the responding officer begin CPR without unnecessary delay? (2 points possible)
Score
Points Received

0%

0%

100%

0

0

2

100% 100%
2

2

100%

0%

2

0

100% 100% 100%
2

2

2

0%
0

100% 100%
2

2

0%
0

Emergency Medical Response Drill: Did the medical staff arrive on scene in five minutes or less? (2 points possible)
Score
Points Received

21.249

HDSP

0%

Points Received

15.282

ASP

0%

Score

15.258

CIW

0%

Score

11.100

CRC

40%

Points Received

11.099

CCI

Score

Points Received

11.097

PVSP

Inmates with TB code 34: Was the inmate evaluated for signs and symptoms of TB within the previous 12 months? (7 points possible)

Score
10.274

LAC

Female inmates age 41 or older: Did the inmate receive a mammogram within the previous 24 months? (5 points possible)
Points Received

10.229

SCC

0%
0

100% 100%
2

100% 100% 100% 100%

2

2

2

2

100% 100% 100% 100% 100%

2

2

2

2

2

2

0%
0

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? (7 points possible)
Score

60%

85%

24%

65%

Points Received

4.2

6

1.7

4.6

Total Points Received

93.9

109

80.4

92.9

64%

52%

4.5

3.6

102.1 129.6

88%

92%

40%

58%

48%

84%

56%

52%

48%

6.1

6.4

2.8

4.1

3.3

5.9

3.9

3.6

3.4

119.3

98.9

88.2

82.8

91.7

112.9

115.8

105.7

73.4

Total Points Possible

174

173

171

155

166

176

166

161

169

159

185

161

177

154

164

Total Score

54%

63%

47%

60%

62%

74%

72%

61%

52%

52%

50%

70%

65%

69%

45%

Bureau of Audits, Office of the Inspector General

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Page 6 of 6
SQ

CCC NKSP KVSP

FSP

100%

20%

80%

40%

7

1.4

5.6

2.8

7

0%

20%

0%

0%

0

1.2

0

0

SOL

100% 100%

CAL

CTF

MCSP SVSP

CIM

PBSP WSP

Average
Score

90%

73%

4.5

11
0%

20%

0%

80%

60%

100%

0%

100%

80%

100%

50%

7

2.8

7

0

1.4

0

5.6

4.2

7

0

7

5.6

7

116.2

0%

40%

0%

100%

20%

0%

60%

20%

0%

0%

20%

100%

40%

60%

19%

0

2.4

0

6

1.2

0

3.6

1.2

0

0

1.2

6

2.4

3.6

37.2

100%

4.8

0

6

6

20%

100%

0%

1.2

6

0

60%

100%

4.2

7

100%

70%

5

10.5

100% 100%

75%

100%

100%

20%

6

4.5

6

6

1.2

6

100%

80%

20%

100%

100%

40%

100%

50%

6

4.8

1.2

6

6

2.4

6

60.2

40%

67%

60%

0%

100%

50%

20%

100%

48%

2.8

4.7

4.2

0

7

3.5

1.4

7

67.5

100% 100% 100% 100% 100%
2

CVSP COR

100%

0%

2

ISP

40%

80%

2

SATF VSPW

2

2

0%

100% 100% 100% 100% 100% 100%

0

2

2

2

2

2

2

100% 100%

69%

6

86.8

100%

100%

0%

76%

2

2

0

44

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

94%

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

2

58

48%

82%

63%

57%

100%

40%

56%

68%

24%

72%

72%

80%

71%

42%

80%

76%

84%

78%

64%

5.8

4.4

7

2.8

4.8

1.7

5

5

5.6

5

2.9

3.4
117.1

121.2 104.2

4
96.3

126.4 108.9

3.9
87.3

165.7 106.1

112.4 108.2 136.6 106.7 105.7

5.6

5.3

5.9

5.5

147.7

91.7

151.8

116.6

103

3562.5

177

180

152

166

147

166

157

196

161

154

180

173

161

157

151

175

146

137

5447

66%

67%

69%

58%

86%

66%

56%

85%

66%

73%

60%

79%

66%

67%

61%

87%

80%

75%

66%

State of California • May 2011

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Page 1 of 6
Category Definition: Assesses how well the prisons’ physicians, nurse practitioners, and physician assistants perform their duties and whether processes
related to providing clinical care are consistent with policy.
Ref
Number
02.022

SAC

CMF

02.213

03.082

03.235

CRC

CIW

ASP

HDSP

92%

100%

40%

89%

82%

60%

1.5

1.8

2

0.8

1.8

1.6

1.2

Reception center history and physical: Are the “Past History” and “Past Medical History” sections of Form 7206 (History and Physical
Examination) complete? (2 points possible)
Score

88%

60%

100%

85%

100%

90%

90%

Points Received

1.8

1.2

2

1.7

2

1.8

1.8

Reception center history and physical: Is the “Family and Social History” section of Form 7206 (History and Physical Examination)
complete? (2 points possible)
100%

100% 100%

2

2

2

75%

100%

75%

80%

1.5

2

1.5

1.6

Reception center history and physical: Is the “Review Systems” section of Form 7206 (History and Physical Examination) complete?
(2 points possible)
0%

100%

70%

80%

20%

0%

0

2

1.4

1.6

0.4

0

Reception center history and physical: Is the “Physical Examination” section of Form 7206 (History and Physical Examination) complete
and appropriate to the history and review of systems? (2 points possible)
Score

75%

95%

100%

100%

100%

85%

60%

Points Received

1.5

1.9

2

2

2

1.7

1.2

Reception center history and physical: Is the “Diagnosis/Impression” section of Form 7206 (History and Physical Examination) appropriate
to the history and physical examination? (2 points possible)
Score

88%

95%

90%

100%

100%

89%

56%

Points Received

1.8

1.9

1.8

2

2

1.8

1.1

Reception center history and physical: Is the “Plan of Action” section of Form 7206 (History and Physical Examination) appropriate to the
“Diagnosis/Impression” section of the form? (2 points possible)
Score

03.077

CCI

75%

Points Received
02.219

PVSP

Score

Score

02.218

LAC

Points Received

Points Received

02.217

SCC

0

Score

02.216

CCWF CMC

Reception center history and physical: Is the “History of Present Illness” section of Form 7206 (History and Physical Examination) complete
and appropriate to the chief complaint(s), if any? (2 points possible)

Points Received
02.215

DVI

0%

Points Received

02.212

CEN

Reception center: If the primary care provider (PCP) indicated the inmate required a special diet, did the PCP refer the inmate to a registered
dietician? (4 points possible)
Score

02.211

RJD

100%

85%

100%

100%

100%

100%

67%

2

1.7

2

2

2

2

1.3

Reception center history and physical: Has required intake testing been ordered? (4 points possible)
Score

70%

50%

100%

95%

90%

100%

20%

Points Received

2.8

2

4

3.8

3.6

4

0.8

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? (10 points possible)
Score

4%

91%

46%

74%

78%

85%

52%

85%

76%

24%

52%

60%

72%

60%

28%

Points Received

0.4

9.1

4.6

7.4

7.8

8.5

5.2

8.5

7.6

2.4

5.2

6

7.2

6

2.8

Did the institution document that it provided the inmate with health care education? (12 points possible)
Score

64%

74%

52%

75%

50%

100%

48%

90%

96%

60%

80%

96%

88%

44%

76%

Points Received

7.7

8.9

6.2

9

6

12

5.8

10.8

11.5

7.2

9.6

11.5

10.6

5.3

9.1

Is the clinical history adequate? (18 points possible)
Score

60%

74%

36%

70%

67%

70%

48%

65%

64%

44%

60%

32%

68%

48%

32%

Points Received

10.8

13.3

6.5

12.6

12

12.6

8.6

11.7

11.5

7.9

10.8

5.8

12.2

8.6

5.8

Bureau of Audits, Office of the Inspector General

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Page 2 of 6

SQ

CCC NKSP KVSP

FSP

SOL

SATF VSPW

ISP

CVSP COR

CAL

CTF

MCSP SVSP

CIM

PBSP WSP

Average
Score

0%
0

43%

85%

60%

86%

74%

0.9

1.7

1.2

1.7

16.2

80%

90%

100%

95%

89%

1.6

1.8

2

1.9

19.6

65%

90%

75%

100%

87%

1.3

1.8

1.5

2

19.2

80%

5%

90%

95%

54%

1.6

0.1

1.8

1.9

10.8

90%

95%

95%

80%

89%

1.8

1.9

1.9

1.6

19.5

68%

100%

94%

95%

89%

1.4

2

1.9

1.9

19.6

78%

95%

85%

80%

90%

1.6

1.9

1.7

1.6

19.8

85%

85%

100%

75%

84%

80%

3.4

3.4

4

3

3.4

38.2

72%

28%

32%

8%

84%

0%

40%

52%

10%

40%

24%

54%

16%

52%

28%

25%

50%

16%

46%

7.2

2.8

3.2

0.8

8.4

0

4

5.2

1

4

2.4

5.4

1.6

5.2

2.8

2.5

5

1.6

151.8

12%

52%

68%

28%

88%

28%

68%

88%

86%

84%

68%

83%

48%

88%

72%

88%

92%

68%

70%

1.4

6.2

8.2

3.4

10.6

3.4

8.2

10.6

10.3

10.1

8.2

10

5.8

10.6

8.6

10.5

11

8.2

276.5

68%

44%

58%

13%

80%

32%

72%

84%

29%

39%

48%

71%

48%

52%

32%

58%

83%

36%

54%

12.2

7.9

10.5

2.3

14.4

5.8

13

15.1

5.1

7

8.6

12.8

8.6

9.4

5.8

10.5

15

6.5

321.2

State of California • May 2011

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______________________________________________________________________________________________________________________
Page 3 of 6
Ref
Number
03.236

03.237

03.238

SAC

09.072

CCI

CRC

CIW

ASP

HDSP

76%

80%

72%

70%

64%

90%

83%

72%

76%

72%

80%

68%

48%

14.4

15.2

13.7

13.3

12.2

17.1

15.8

13.7

14.4

13.7

15.2

12.9

9.1

Is the assessment adequate? (19 points possible)
Score

73%

91%

40%

100%

88%

84%

72%

84%

75%

63%

44%

86%

86%

71%

59%

Points Received

13.9

17.2

7.6

19

16.6

16

13.7

16

14.3

12

8.4

16.4

16.4

13.5

11.2

Is the plan adequate and consistent with the degree of control based on the chronic care program intervention and follow up requirements?
(19 points possible)
58%

95%

50%

90%

93%

94%

82%

89%

96%

88%

71%

85%

86%

74%

57%

11

18.1

9.5

17

17.7

17.9

15.6

16.9

18.2

16.8

13.6

16.2

16.3

14

10.9

Is the inmate’s Problem List complete and filed accurately in the inmate’s unit health record (UHR)? (8 points possible)
Score

80%

48%

28%

100%

83%

10%

84%

90%

32%

96%

60%

80%

80%

100%

64%

Points Received

6.4

3.8

2.2

8

6.7

0.8

6.7

7.2

2.6

7.7

4.8

6.4

6.4

8

5.1

Did the PCP’s plan adequately address the initial assessment? (5 points possible)
5

90%

75%

75%

88%

89%

38%

63%

4.5

3.8

3.8

4.4

4.4

1.9

3.1

Was the PCP’s initial evaluation adequate for the problem(s) requiring OHU placement? (5 points possible)
Score

82%

90%

80%

78%

70%

70%

30%

40%

Points Received

4.1

4.5

4

3.9

3.5

3.5

1.5

2

78%

100%

7

9

Was the level of care available in the OHU appropriate to the patient’s clinical presentation? (9 points possible)
9

9

100%

100%

9

9

100% 100%
9

9

Was the PCP’s initial assessment (or diagnoses) appropriate for the findings in the initial evaluation? (5 points possible)
Score 100%

09.069

PVSP

18.2

Points Received

06.263

LAC

96%

Score 100% 100%

06.191

SCC

16.2

Points Received
04.230

CCWF CMC

85%

Score 100%

04.208

DVI

Score

Points Received
04.112

CEN

Points Received

Score

04.056

RJD

Is the focused clinical examination adequate? (19 points possible)

Points Received
03.262

CMF

5

90%

100%

89%

4.5

5

4.4

100% 100% 100%
5

5

3.1

Score

78%

87%

58%

88%

75%

80%

70%

56%

14%

73%

67%

64%

69%

87%

62%

Points Received

5.4

6.1

4.1

6.1

5.3

5.6

4.9

3.9

1

5.1

4.7

4.5

4.8

6.1

4.3

83%

83%

100%

58%

8.3

8.3

10

5.8

All diagnostic services: Did the PCP adequately manage clinically significant test results? (10 points possible)
Score

91%

92%

70%

67%

77%

90%

82%

78%

67%

Points Received

9.1

9.2

7

6.7

7.7

9

8.2

7.8

6.7

100% 100%
10

10

Did medical staff promptly order extra daily nutritional supplements and food for the inmate? (5 points possible)
Score

86%

Points Received

4.3

Did the “Problems/Risks Identified” section of the Briggs Form 5703N (Prenatal Flow Record) corroborate the “Prenatal Screens” and the
“Maternal Physical” examination sections? (7 points possible)
Score

11.100

63%

All diagnostic services: Did the PCP document the clinically significant diagnostic test results on Form 7230 (Interdisciplinary Progress
Notes)? (7 points possible)

0%

Points Received
09.223

5

0

Were the results of the inmate’s specified prenatal screening tests documented on Form 5703N? (5 points possible)
Score

86%

Points Received

4.3

After the first 72 hours, did a physician perform a physical examination and order a metabolic panel and a urinalysis of the inmate?
(7 points possible)
Score
Points Received

0%

0%

0%

0%

100%

50%

50%

100%

67%

0%

0

0

0

0

7

3.5

3.5

7

4.7

0

Bureau of Audits, Office of the Inspector General

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Page 4 of 6
SQ

CCC NKSP KVSP

FSP

SOL

SATF VSPW

ISP

CVSP COR

CAL

CTF

76%

60%

68%

71%

92%

64%

76%

80%

62%

80%

60%

78%

56%

84%

14.4

11.4

13

13.5

17.5

12.2

14.4

15.2

11.8

15.2

11.4

14.9

10.6

16

92%

47%

68%

42%

84%

55%

96%

78%

21%

57%

58%

80%

48%

17.4

9

13

8

16

10.5

18.2

14.9

4

10.9

11.1

15.2

9

92%

53%

65%

53%

67%

55%

72%

64%

57%

57%

71%

94%

17.4

10

12.4

10.1

12.7

10.4

13.7

12.1

10.9

10.7

13.5

17.9

76%

60%

96%

48%

92%

96%

28%

96%

86%

28%

96%

96%

6.1

4.8

7.7

3.8

7.4

7.7

2.2

7.7

6.9

2.2

7.7

7.7

8

100% 100%

100% 100% 100%

MCSP SVSP

Average
Score

CIM

PBSP WSP

64%

64%

88%

62%

73%

12.1

12.1

16.6

11.8

459.2

76%

74%

74%

71%

77%

70%

14.4

14

14

13.5

14.5

439.8

79%

71%

70%

68%

50%

67%

73%

15

13.5

13.3

13

9.5

12.7

458.5

100% 100%

88%

96%

100%

76%

76%

7

7.7

8

6.1

199.5

8

75%

89%

90%

100%

87%

5

5

5

5

5

3.8

4.4

4.5

5

73.6

100%

80%

70%

63%

100%

0%

80%

100%

89%

72%

5

4

3.5

3.1

5

0

4

5

4.4

61

90%

100%

100%

98%

8.1

9

9

150.1

100% 100%
9

100% 100% 100% 100%

9

9

100% 100%

9

9

9

100% 100% 100% 100%

89%

100%

100%

96%

5

5

5

5

4.4

5

5

81.4

43%

100%

39%

64%

42%

71%

23%

46%

60%

67%

60%

78%

67%

3

7

2.7

4.5

2.9

5

1.6

3.2

4.2

4.7

4.2

5.4

154

55%

71%

100%

86%

64%

90%

75%

83%

92%

50%

100%

83%

5.5

7.1

10

8.6

6.4

9

7.5

8.3

9.2

5

10

272.5

5

5

89%

73%

73%

90%

92%

64%

6.2

5.1

5.1

6.3

6.5

4.5

89%

90%

90%

75%

77%

8.9

9

9

7.5

7.7

100% 100%
10

10

100%

93%

5

9.3

0%

0%

0

0

86%

86%

4.3

8.6

60%

100%

40%

67%

60%

0%

100%

50%

20%

100%

48%

4.2

7

2.8

4.7

4.2

0

7

3.5

1.4

7

67.5

State of California • May 2011

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Page 5 of 6
Ref
Number
21.250

21.276

21.279

SAC

CMF

RJD

CEN

DVI

CCWF CMC

SCC

LAC

PVSP

CCI

CRC

CIW

ASP

HDSP

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? (7 points possible)
Score

73%

80%

50%

100%

96%

Points Received

5.1

5.6

3.5

7

6.7

100% 100% 100% 100%
7

7

7

7

96%

100%

96%

96%

6.7

7

6.7

6.7

100% 100%
7

7

While the patient was in the TTA, was the clinical care rendered by the attending provider adequate and timely? (7 points possible)
Score

91%

100%

95%

91%

92%

100%

91%

100%

87%

96%

95%

83%

81%

64%

63%

Points Received

6.4

7

6.7

6.3

6.4

7

6.4

7

6.1

6.7

6.7

5.8

5.7

4.5

4.4

For patients managed by telephone consultation alone, was the provider’s decision not to come to the TTA appropriate? (8 points possible)
Score 100%
Points Received

8

Total Points Received 123.4 138.9

100%

83%

8

6.7

100% 100%
8

100% 100% 100% 100% 100% 100% 100% 100%

8

150.9 140.5

8

8

8

8

8

8

8

93.6

121

97.8

142.9

129

111.2

Total Points Possible

175

167

173

151

186

167

143

168

169

151

193

168

203

168

169

Total Score

71%

83%

54%

80%

81%

84%

68%

85%

76%

74%

76%

78%

77%

72%

55%

Bureau of Audits, Office of the Inspector General

146.8 131.2 156.6 121.1

8
92.5

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SQ

CCC NKSP KVSP

72%

100%

88%

5

7

6.1

7

7

79%

67%

87%

62%

5.5

4.7

6.1

4.3

100% 100% 100%

FSP

SOL

SATF VSPW

ISP

CVSP COR

100% 100%

92%

91%

92%

92%

92%

6.4

6.4

6.4

6.4

6.4

7

7

76%

67%

82%

62%

75%

86%

68%

5.3

4.7

5.7

4.3

5.3

6

4.8

92%

CAL

CTF

100% 100%

92%

96%

6.4

6.7

92%

77%

6.4

5.4

100% 100% 100% 100% 100% 100%

8

8

7.4

8

8

8

8

141.3

115.9

115.9

77.2

121.5

83.8

179

175

162

151

144

151

151

203

168

168

167

175

79%

66%

72%

51%

84%

56%

72%

81%

61%

69%

63%

85%

108.1 163.5 103.1

8
115.4

8
104.4 148.2

Average
Score

CIM

PBSP WSP

100%

96%

96%

96%

93%

7

6.7

6.7

6.7

215.3

67%

77%

74%

79%

92%

82%

4.7

5.4

5.2

5.5

6.4

188.8

100% 100% 100% 100% 100% 100% 100%

8

State of California • May 2011

8

MCSP SVSP

99%

8

8

8

8

8

8

238.1

113.5

110.7

97.9

149.5

108

113.9

3989.2

168

151

151

193

144

162

5514

68%

73%

65%

78%

75%

70%

72%

Page 155

APPENDIX
D-4: Continuity of Care
______________________________________________________________________________________________________________________
Page 1 of 4
Category Definition: Evaluates whether or not inmates continue to receive prescribed medical care when they move within a prison, move between
prisons, or return to prison from receiving specialty services or from being hospitalized.
Ref
Number
02.007

SAC

RJD

Score 100%
7

05.108

LAC

PVSP

CCI

CRC

CIW

ASP

HDSP

64%

90%

85%

75%

88%

95%

95%

100%

95%

85%

4.5

6.3

6

5.3

6.1

6.6

6.6

7

6.6

6

100%

0%

100%

7

0

7

100% 100%
7

7

Non-reception center: Did the inmate receive medical accommodations upon arrival, if applicable? (6 points possible)
Score

04.052

SCC

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? (7 points possible)

Points Received

04.051

CCWF CMC

6.5

Points Received

02.128

DVI

93%

Score
02.111

CEN

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? (7 points possible)
Points Received

02.014

CMF

67%

100%

75%

33%

100%

75%

4

6

4.5

2

6

4.5

100% 100%
6

6

75%

100% 100%

4.5

6

6

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? (8 points possible)
Score

33%

88%

50%

50%

0%

43%

13%

25%

42%

0%

43%

23%

0%

30%

35%

Points Received

2.7

7

4

4

0

3.4

1

2

3.3

0

3.4

1.8

0

2.4

2.8

Did the primary care provider (PCP) evaluate the inmate within one calendar day after placement? (5 points possible)
Score

90%

80%

80%

100%

80%

100%

70%

80%

Points Received

4.5

4

4

5

4

5

3.5

4

Did the RN complete an initial assessment of the inmate on the day of placement? (5 points possible)
Score

90%

100%

80%

100%

60%

100%

90%

80%

Points Received

4.5

5

4

5

3

5

4.5

4

Did Receiving and Release have the inmate’s UHR and transfer envelope? (7 points possible)
Score 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
Points Received

05.109

7

Score 100%
Points Received
05.110

8

Score 100%

05.172

7

7

7

7

7

7

7

7

7

7

7

7

0%

50%

100%

0%

100%

0%

0

4

8

0

8

0

100% 100%
8

8

8

50%
4

100% 100% 100% 100% 100% 100% 100%
8

8

8

8

8

8

8

80%
6.4

100% 100%
8

8

40%

100%

3.2

8

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

80%

0%

Points Received

5.6

0

100% 100% 100% 100%
7

7

7

7

75%

80%

100%

20%

20%

100%

60%

5.3

5.6

7

1.4

1.4

7

4.2

100% 100%
7

7

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? (8 points possible)
Score
Points Received

07.043

7

Do all appropriate forms in the transfer envelope identify all medications ordered by the physician, and are the medications in the transfer
envelope? (8 points possible)
Points Received

05.171

7

If the inmate was scheduled for any upcoming specialty services, were the services noted on Form 7371 (Health Care Transfer
Information)? (8 points possible)

0%
0

100% 100% 100% 100% 100% 100% 100% 100% 100%
8

8

8

8

8

8

8

8

8

0%
0

100% 100% 100% 100%
8

8

8

8

Did the PCP review the consultant’s report and see the inmate for a follow-up appointment after the specialty services consultation within
specified time frames? (9 points possible)
Score
Points Received

22%

29%

19%

41%

8%

18%

13%

25%

36%

36%

47%

38%

23%

73%

0%

2

2.6

1.7

3.7

0.7

1.6

1.1

2.3

3.2

3.2

4.2

3.4

2.1

6.5

0

Bureau of Audits, Office of the Inspector General

Page 156

APPENDIX
D-4: Continuity of Care
_____________________________________________________________________________________________________________________
Page 2 of 4

SQ

CCC NKSP KVSP

7

CAL

CTF

100%

95%

90%

100%

75%

84%

7

6.7

6.3

7

5.3

5.9

100%

50%

0%

0%

100%

100%

68%

7

3.5

0

0

7

7

52.5

7

SOL

SATF VSPW

100%

94%

100%

95%

7

6.6

7

6.7

50%

100%

100%

50%

3

6

6

3

100% 100%
6

6

24%

17%

0%

0%

60%

36%

20%

1.9

1.3

0

0

4.8

2.9

1.6

80%

80%

4

4

100%

90%

5

4.5

ISP

100% 100%

50%

MCSP SVSP

CIM

PBSP WSP

95%

90%

85%

91%

6.6

6.3

6

172.9

100% 100% 100%

100%

86%

6

124.5

6

6

3

6

6

6

33%

40%

75%

11%

0%

14%

50%

86%

46%

83%

25%

33%

2.7

3.2

6

0.9

0

1.1

4

6.9

3.6

6.7

2

87.4

90%

75%

90%

100%

100%

88%

4.5

3.8

4.5

5

5

74.8

100%

94%

5

79.5

100% 100%
5

5

100% 100% 100% 100% 100% 100%
5

5

5

5

5

5

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
7

Average
Score

CVSP COR

100% 100%

FSP

7

7

7

7

100% 100% 100%
8

8

100%

80%

8

6.4

100%

60%

7

4.2

8

7

7

7

7

7

7

7

0%

0%

0%

100%

0

0

0

8

100% 100% 100% 100% 100% 100% 100%
8

100% 100%
7

7

7

8

80%
5.6

8

8

8

100% 100% 100%
7

7

7

8

80%
5.6

100% 100% 100% 100% 100% 100% 100% 100% 100%

8

7

50%
4

7

100% 100%
8

100% 100% 100%
7

0%

7

7

7

7

7

231

100% 100%
8

8

100%

64%
92

50%

100%

75%

67%

100%

90%

8

4

8

6

5.3

8

223.3

40%

100%

20%

2.8

7

1.4

100% 100%
7

7

40%

80%

2.8

185.9

100% 100% 100% 100% 100% 100% 100% 100%

91%

8

8

8

8

8

8

8

8

8

0

8

8

8

8

8

8

8

8

240

23%

42%

31%

25%

73%

80%

60%

25%

62%

64%

27%

43%

14%

27%

54%

64%

80%

50%

39%

2.1

3.8

2.8

2.3

6.6

7.2

5.4

2.3

5.5

5.8

2.5

3.9

1.3

2.5

4.8

5.7

7.2

4.5

114.5

State of California • May 2011

Page 157

APPENDIX
D-4: Continuity of Care
______________________________________________________________________________________________________________________
Page 3 of 4
Ref
Number
07.270

14.033

SAC

CMF

RJD

CEN

DVI

CCWF CMC

SCC

LAC

PVSP

CCI

CRC

CIW

Score

53%

59%

88%

100%

77%

Points Received

3.2

3.5

5.3

6

4.6

100% 100%
6

6

94%
5.6

100% 100% 100% 100% 100% 100%
6

6

6

6

6

21.250

21.251

4

5.6

4

4

4

4

4

4

4

4

4

4

4

4

50%

100%

2

4

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? (7 points possible)
Score

79%

90%

65%

75%

88%

92%

84%

100%

96%

88%

92%

100%

84%

92%

32%

Points Received

5.5

6.3

4.6

5.3

6.2

6.4

5.9

7

6.7

6.2

6.4

7

5.9

6.4

2.2

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? (7 points possible)
Score

60%

85%

24%

65%

64%

52%

88%

92%

40%

58%

48%

84%

56%

52%

48%

Points Received

4.2

6

1.7

4.6

4.5

3.6

6.1

6.4

2.8

4.1

3.3

5.9

3.9

3.6

3.4

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? (7 points possible)
Score

73%

80%

50%

100%

96%

Points Received

5.1

5.6

3.5

7

6.7

100% 100% 100% 100%
7

7

7

7

96%

100%

96%

96%

6.7

7

6.7

6.7

100% 100%
7

7

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? (7 points possible)
Score 100%
Points Received

21.281

94%

6

Does the institution have an adequate process to ensure inmates who are moved to a new cell still receive their medical ducats?
(4 points possible)
Score 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

21.249

HDSP

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? (6 points possible)

Points Received
21.248

ASP

7

0%

100%

0%

100%

100%

0

7

0

7

7

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? (6 points possible)
Score 100% 100%

58%

79%

79%

88%

64%

48%

38%

13%

67%

47%

44%

10%

6

6

3.5

4.7

4.7

5.3

3.8

2.9

2.3

0.8

4

2.8

2.6

0.6

2.8

Total Points Received

88.3

81.5

78.3

92.6

69.4

82.3

75.2

81.1

75.9

73.4

81.3

97.1

69.6

84.1

76.8

Total Points Possible

122

122

112

112

109

99

104

101

97

104

122

115

102

106

104

Total Score

72%

67%

70%

83%

64%

83%

72%

80%

78%

71%

67%

84%

68%

79%

74%

Points Received

Bureau of Audits, Office of the Inspector General

47%

Page 158

APPENDIX
D-4: Continuity of Care
_____________________________________________________________________________________________________________________
Page 4 of 4
SQ

CCC NKSP KVSP

FSP

SOL

100% 100% 100% 100% 100% 100%
6

6

6

6

6

6

SATF VSPW

94%
5.6

CAL

CTF

100% 100% 100% 100% 100%

93%

94%

5.6

5.6

6

ISP

6

CVSP COR

6

6

6

MCSP SVSP

CIM

PBSP WSP

100% 100% 100% 100%
6

6

6

6

Average
Score

95%
188.6

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

98%

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

52%

88%

100%

72%

92%

88%

92%

100%

92%

96%

96%

96%

88%

96%

100%

96%

96%

88%

87%

3.6

6.2

7

5

6.4

6.2

6.4

7

6.4

6.7

6.7

6.7

6.2

6.7

7

6.7

6.7

6.2

201.8

48%

82%

63%

57%

100%

40%

56%

68%

24%

72%

72%

80%

71%

42%

80%

76%

84%

78%

64%

3.4

5.8

4.4

4

7

2.8

3.9

4.8

1.7

5

5

5.6

5

2.9

5.6

5.3

5.9

5.5

147.7

72%

100%

88%

92%

91%

92%

92%

92%

92%

96%

100%

96%

96%

96%

93%

5

7

6.1

6.4

6.4

6.4

6.4

6.4

6.4

6.7

7

6.7

6.7

6.7

215.3

100% 100%
7

7

100% 100%
7

7

130

100%

0%

63%

7

0

35

7%

50%

39%

0%

50%

17%

13%

50%

11%

33%

50%

57%

18%

50%

64%

33%

100%

59%

0.4

3

2.3

0

3

1

0.8

3

0.7

2

3

3.4

1.1

3

3.8

2

6

3.5

94.8

67.4

100.8

69

79.3

90

79.5

76.8

76.2

89

86.1

79.2

89.1

77.8

80.3

84.1

97.3

90.5

72.2

2691.5

99

122

92

105

104

105

97

101

114

114

107

107

122

112

99

114

99

92

3536

68%

83%

75%

76%

87%

76%

79%

75%

78%

76%

74%

83%

64%

72%

85%

85%

91%

78%

76%

State of California • May 2011

48%

Page 159

APPENDIX
D-5: Nurse Responsibilities
______________________________________________________________________________________________________________________
Page 1 of 4
Category Definition: Evaluates how well the prisons’ registered nurses and licensed vocational nurses perform their duties and whether processes related
to providing nursing care are consistent with policy.
Ref
Number
01.024

01.157

01.158

01.159

01.162

01.163

01.244

01.246

02.015

SAC

CMF

CCWF CMC

SCC

LAC

PVSP

CCI

CRC

CIW

ASP

HDSP

Score

96%

96%

93%

87%

76%

52%

90%

30%

77%

87%

92%

45%

80%

89%

40%

3.8

3.8

3.7

3.5

3

2.1

3.6

1.2

3.1

3.5

3.7

1.8

3.2

3.5

1.6

RN FTF Documentation: Did the RN’s subjective note address the nature and history of the inmates primary complaint? (7 points possible)
Score

92%

96%

83%

100%

83%

92%

93%

80%

59%

50%

64%

45%

54%

65%

57%

Points Received

6.4

6.7

5.8

7

5.8

6.4

6.5

5.6

4.1

3.5

4.5

3.2

3.8

4.5

4

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? (6 points possible)
Score

96%

88%

79%

89%

91%

96%

83%

95%

90%

33%

68%

90%

79%

74%

61%

Points Received

5.7

5.3

4.8

5.4

5.5

5.8

5

5.7

5.4

2

4.1

5.4

4.8

4.4

3.6

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? (6 points possible)
Score

91%

77%

80%

90%

67%

88%

73%

80%

55%

53%

68%

90%

76%

59%

50%

Points Received

5.5

4.6

4.8

5.4

4

5.3

4.4

4.8

3.3

3.2

4.1

5.4

4.6

3.5

3

RN FTF Documentation: Did the RN’s plan include an adequate strategy to address the problems identified during the FTF triage?
(7 points possible)
Score

92%

94%

100%

97%

96%

96%

98%

95%

100%

63%

92%

100%

96%

94%

100%

Points Received

6.4

6.6

7

6.8

6.7

6.7

6.8

6.6

7

4.4

6.4

7

6.7

6.6

7

RN FTF Documentation: Did the RN’s education/instruction adequately address the problems identified during the FTF triage?
(5 points possible)
Score

77%

94%

90%

93%

70%

96%

85%

90%

86%

57%

80%

95%

71%

82%

64%

Points Received

3.9

4.7

4.5

4.7

3.5

4.8

4.3

4.5

4.3

2.8

4

4.8

3.5

4.1

3.2

RN FTF Documentation: Did the RN’s objective note include allergies, weight, current medication, and where appropriate, medication
compliance? (3 points possible)
Score

92%

94%

80%

93%

79%

80%

80%

50%

35%

33%

28%

5%

12%

65%

7%

Points Received

2.8

2.8

2.4

2.8

2.4

2.4

2.4

1.5

1

1

0.8

0.2

0.4

1.9

0.2

Did documentation indicate that the RN reviewed all of the inmate’s complaints listed on Form 7362 (Health Care Services Request Form)?
(5 points possible)
Score

92%

92%

87%

90%

96%

96%

88%

100%

86%

67%

64%

95%

80%

77%

93%

Points Received

4.6

4.6

4.3

4.5

4.8

4.8

4.4

5

4.3

3.3

3.2

4.8

4

3.8

4.6

Was a review of symptoms completed if the inmate’s tuberculin test was positive, and were the results reviewed by the infection control
nurse? (7 points possible)
7

100%

100%

67%

75%

83%

100%

33%

100%

7

7

4.7

5.3

5.8

7

2.3

7

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? (8 points possible)
Score 100%
Points Received

05.109

DVI

Points Received

Score 100%

02.020

CEN

RN FTF Documentation: Did the inmate’s request for health care get reviewed the same day it was received? (4 points possible)

Points Received
02.017

RJD

8

56%

94%

93%

4.4

7.6

7.5

100% 100% 100%
8

8

8

29%

46%

70%

2.3

3.7

5.6

100% 100%
8

8

87%

100% 100%

6.9

8

8

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? (6 points possible)
Score

90%

70%

87%

90%

Points Received

5.4

4.2

5.2

5.4

100% 100%
6

6

85%

95%

100%

85%

80%

100%

90%

85%

97%

5.1

5.7

6

5.1

4.8

6

5.4

5.1

5.8

If the inmate was scheduled for any upcoming specialty services, were the services noted on Form 7371 (Health Care Transfer
Information)? (8 points possible)
Score 100%
Points Received

8

0%

50%

100%

0%

100%

0%

0

4

8

0

8

0

Bureau of Audits, Office of the Inspector General

100% 100%
8

8

Page 160

APPENDIX
D-5: Nurse Responsibilities
_____________________________________________________________________________________________________________________
Page 2 of 4

SQ

CCC NKSP KVSP

FSP

SOL

SATF VSPW

ISP

CVSP COR

CAL

CTF

11%

80%

48%

29%

63%

60%

56%

44%

97%

93%

46%

53%

71%

82%

0.5

3.2

1.9

1.1

2.5

2.4

2.2

1.8

3.9

3.7

1.8

2.1

2.9

3.3

32%

79%

40%

46%

57%

54%

55%

40%

37%

50%

60%

46%

56%

2.2

5.5

2.8

3.2

4

3.8

3.9

2.8

2.6

3.5

4.2

3.2

3.9

27%

58%

72%

80%

93%

75%

58%

58%

73%

62%

80%

76%

1.6

3.5

4.3

4.8

5.6

4.5

3.5

3.5

4.4

3.7

4.8

4.6

50%

79%

84%

63%

53%

63%

53%

56%

44%

47%

71%

3

4.7

5

3.8

3.2

3.8

3.2

3.4

2.7

2.8

4.2

100%

90%

92%

97%

100%

87%

73%

77%

60%

77%

7

6.3

6.4

6.8

7

6.1

5.1

5.4

4.2

5.4

64%

63%

96%

89%

97%

57%

69%

83%

76%

3.2

3.2

4.8

4.4

4.8

2.8

3.5

4.1

3.8

18%

47%

80%

23%

40%

33%

43%

24%

0.5

1.4

2.4

0.7

1.2

1

1.3

91%

90%

80%

100%

97%

88%

4.5

4.5

4

5

4.8

4.4

100% 100%
7

7

0%
0

100% 100%
7

7

PBSP WSP

50%

83%

58%

80%

68%

2

3.3

2.3

3.2

89.2

39%

44%

62%

76%

68%

62%

2.7

3.1

4.3

5.3

4.7

143.5

56%

78%

52%

76%

64%

97%

74%

3.4

4.7

3.1

4.6

3.9

5.8

147.2

35%

68%

39%

56%

62%

87%

65%

66%

2.1

4.1

2.3

3.3

3.7

5.2

3.9

130.3

80%

77%

68%

96%

71%

73%

96%

81%

88%

5.6

5.4

4.7

6.7

5

5.1

6.7

5.6

203.2

43%

91%

60%

64%

83%

78%

81%

98%

90%

79%

2.2

4.6

3

3.2

4.1

3.9

4

4.9

4.5

130.6

56%

27%

44%

12%

44%

30%

48%

29%

53%

71%

47%

0.7

1.7

0.8

1.3

0.3

1.3

0.9

1.4

0.9

1.6

2.1

46.5

90%

88%

86%

80%

91%

89%

85%

100%

87%

91%

98%

94%

89%

4.5

4.4

4.3

4

4.6

4.4

4.3

5

4.3

4.5

4.9

4.7

146.1

100% 100%

0

7

7

100%

100%

7

7

100% 100%

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
8

96%
5.8

8

8

8

100% 100% 100% 100%
6

6

6

100% 100% 100%
8

8

8

6

Average
Score

CIM

0%

MCSP SVSP

7

7

84%
123.1

96%

75%

100%

92%

8

8

8

8

8

8

7.6

6

8

235.6

85%

95%

90%

100%

85%

85%

90%

5.1

5.7

5.4

6

5.1

5.1

5.4

0%

0%

0%

100%

0

0

0

8

8

95%
5.7

State of California • May 2011

8

8

8

100% 100% 100%
6

6

6

100% 100%
6

6

100% 100%
8

8

93%
184.5

64%
92

Page 161

APPENDIX
D-5: Nurse Responsibilities
______________________________________________________________________________________________________________________
Page 3 of 4
Ref
Number
05.110

SAC

Score 100%

08.185

09.224

11.097

8

50%
4

Score

80%

0%

Points Received

5.6

0

Score

50%

Points Received

3.5

PVSP

CCI

CRC

CIW

8

8

8

8

8

8

8

80%
6.4

100% 100%
8

8

ASP

HDSP

40%

100%

3.2

8

100% 100% 100% 100%
7

7

7

7

75%

80%

100%

20%

20%

100%

60%

5.3

5.6

7

1.4

1.4

7

4.2

100% 100% 100%
7

7

7

80%

100%

80%

5.6

7

5.6

100% 100% 100% 100% 100%
7

7

7

7

7
71%

100% 100%
7

7

75%

75%

5.3

5.3

Points Received

4.3

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? (6 points possible)
33%

100%

33%

100%

2

6

2

6

100% 100%
6

6

25%

0%

0%

80%

1.5

0

0

4.8

Do medication nurses understand that medication is to be administered by the same licensed staff member who prepares it and on the
same day? (4 points possible)
4

4

4

0%
0

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
4

4

4

4

4

4

4

4

4

4

4

Emergency Medical Response Drill: Did medical staff arrive on scene in five mintues or less? (2 points possible)
Points Received

0%
0

100% 100%
2

100% 100% 100% 100%

2

2

2

2

100% 100% 100% 100% 100%

2

2

2

2

2

0%

2

0

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

0%
0

100% 100%
1

0%

1

0

100% 100% 100%
1

1

100% 100%

1

1

1

0%
0

100% 100% 100%
1

1

1

Emergency Medical Response Drill: Did emergency medical responders continue basic life support? (1 point possible)
Score 100% 100% 100%
Points Received

21.251

LAC

Score

Score

21.248

SCC

100% 100% 100% 100% 100% 100% 100%

Score 100% 100% 100%

15.285

CCWF CMC

Was the inmate’s weight and blood pressure documented at each clinic visit? (6 points possible)

Points Received

15.283

DVI

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? (7 points possible)

Points Received

15.282

CEN

Did an RN complete all applicable sections of Form 7371 (Health Care Transfer Information) based on the inmate’s UHR? (7 points possible)

Score

14.131

RJD

Do all appropriate forms in the transfer envelope identify all medications ordered by the physician, and are the medications in the transfer
envelope? (8 points possible)
Points Received

05.171

CMF

1

1

100% 100% 100% 100%

1

1

1

1

100% 100% 100% 100% 100% 100%

1

1

1

1

1

1

1

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? (7 points possible)
Score

79%

90%

65%

75%

88%

92%

84%

100%

96%

88%

92%

100%

84%

92%

32%

Points Received

5.5

6.3

4.6

5.3

6.2

6.4

5.9

7

6.7

6.2

6.4

7

5.9

6.4

2.2

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? (7 points possible)
Score 100%
Points Received

7

Total Points Received 104.1

0%

100%

0%

100%

0

7

0

7

100%

79

104.7

94.3

90.5

114.4

94.6

84.3

83.4

70.4

7
76.7

97.6

76.9

72.1

74.3

Total Points Possible

122

115

122

104

116

122

107

101

103

107

115

109

101

86

100

Total Score

85%

69%

86%

91%

78%

94%

88%

83%

81%

66%

67%

90%

76%

84%

74%

Bureau of Audits, Office of the Inspector General

Page 162

APPENDIX
D-5: Nurse Responsibilities
_____________________________________________________________________________________________________________________
Page 4 of 4
SQ

CCC NKSP KVSP

100%

80%

8

6.4

100%

60%

7

4.2

100% 100%
7

7

FSP

SOL

SATF VSPW

ISP

CVSP COR

100% 100% 100% 100% 100% 100% 100%
8

100% 100%
7

7

67%

60%

4.7

4.2

80%

0%

100%

4.8

0

6

8
80%
5.6

8

8

100% 100% 100%
7

100% 100%
7

8

7

8
80%

8

4

7

7

5.6

7

60%

80%

100%

0%

4.2

5.6

7

0

7

CTF

100% 100%
8

100% 100% 100%
7

7

CIM

PBSP WSP

50%

100%

75%

67%

100%

90%

4

8

6

5.3

8

223.3

40%

100%

20%

40%

80%

2.8

7

1.4

2.8

185.9

80%

86%

5.6

192.4

7

40%
2.8

100% 100%
7

7

100% 100% 100%
7

7

7

86%

6

10.3

6

75%

100%

100%

20%

4.5

6

6

1.2

100% 100%
6

69%

6

86.8

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

4

2

2

2

2

2

2

2

2

2

2

2

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
1

1

1

1

100% 100% 100%
1

1

1

52%

88%

100%

3.6

6.2

7

1

1

1

100% 100% 100%

1

1

0%

0%

1

1

1

2

0%
0

100% 100% 100% 100%

2

2

2

2

2

1

0%

0%

1

1

94%
58

100% 100% 100% 100% 100%
1

97%
128

100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
2

Average
Score

8

100% 100% 100%
7

MCSP SVSP

100%

100% 100%
6

50%

CAL

1

87%
27

100% 100% 100%

87%

1

1

1

0

0

1

1

1

1

0

0

1

1

1

26

72%

92%

88%

92%

100%

92%

96%

96%

96%

88%

96%

100%

96%

96%

88%

87%

5

6.4

6.2

6.4

7

6.4

6.7

6.7

6.7

6.2

6.7

7

6.7

6.7

6.2

201.8

100%

0%

7

0

63%
35

65.7

94.7

86.7

96

96.1

84.7

80.8

87.7

82.6

68.9

89

81.2

79.8

76.3

78.8

91.1

101.8

87.1

2846.3

91

115

109

114

108

115

100

114

101

94

107

100

109

108

108

107

115

102

3547

72%

82%

80%

84%

89%

74%

81%

77%

82%

73%

83%

81%

73%

71%

73%

85%

89%

85%

80%

State of California • May 2011

Page 163

California Prison Health Care
Receivership Corporation’s
Response

Bureau of Audits, Office of the Inspector General

Page 164

California Prison Health Care Receivership
Corporation’s Response (page 1 of 1)

State of California • May 2011

Page 165

MEDICAL INSPECTION RESULTS
SUMMARY AND ANALYSIS OF THE FIRST CYCLE OF MEDICAL INSPECTIONS
OF CALIFORNIA’S 33 ADULT PRISONS
OFFICE OF THE INSPECTOR GENERAL
Bruce Monfross

INSPECTOR GENERAL (A)

Nancy Faszer

DEPUTY INSPECTOR GENERAL, IN-CHARGE

STATE OF CALIFORNIA
MAY 2011
WWW.OIG.CA.GOV

 

 

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