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Oig Summary and Analysis of the First 17 Medical Inspections of Ca Prisons Aug 2010

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SUMMARY AND ANALYSIS OF THE
FIRST 17 MEDICAL INSPECTIONS
OF CALIFORNIA PRISONS
BUREAU OF AUDITS AND INVESTIGATIONS
OFFICE OF THE
INSPECTOR GENERAL
D AV I D R . S H A W
INSPECTOR GENERAL
S TAT E O F C A L I F O R N I A
AUGUST 2010

David R~ Shaw, Inspector General

Office ofthe Inspector General

August 26,2010

J. Clark Kelso, Receiver
California Prison Health Care Receivership Corporation
501 J Street, Suite 100
Sacramento, California 95814
Dear Mr. Kelso:
Enclosed is the Office of the Inspector General's (OIG) final report on the first 17 medical
inspections of California's 33 adult prisons. The purpose of the report is to summarize and
analyze the results of our first 17 medical inspections of adult prisons operated by the California
Department of Corrections and Rehabilitation (CDCR), denoting the halfway point of the OIG's
first cycle of prison medical inspections. The report also includes analysis of the scores in five
medical areas - medication management, access to medical providers and services, continuity of
care, primary care provider responsibilities, and nurse responsibilities.
Results suggest that the Receiver has not fully implemented a system that ensures that CDCR
medical policies and procedures are followed across the prison system. However, higher scores
in some component areas and medical categories demonstrate that system-wide improvement can
be achieved. A copy of the report can also be found 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,

David R. Shaw
Inspector General
Enclosure
cc:

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

Arnold Schwarzenegger, Governor
P.O. Box 348780, SACRAMENTO, CALIFORNIA 95834..8780 PHONE (916) 830..3600 FAX (916) 928..4684

Contents
Executive Summary ..................................................................................................................... 1
Introduction .................................................................................................................................. 4
OIG Medical Inspection Program .......................................................................................... 4
Objectives, Scope, and Methodology .................................................................................... 7
Results of the First 17 Medical Inspections ............................................................................... 10
Overall Scores and Medical Components............................................................................. 11

Chronic Care .................................................................................................................. 16
Clinical Services ............................................................................................................ 18
Health Screening ............................................................................................................ 20
Specialty Services .......................................................................................................... 22
Urgent Services .............................................................................................................. 24
Emergency Services ....................................................................................................... 26
Prenatal Care/Childbirth/Post-Delivery ......................................................................... 28
Diagnostic Services ........................................................................................................ 30
Access to Health Care Information ................................................................................ 32
Outpatient Housing Unit ................................................................................................ 34
Internal Reviews ............................................................................................................ 36
Inmate Transfers ............................................................................................................ 38
Clinic Operations ........................................................................................................... 40
Preventive Services ........................................................................................................ 42
Pharmacy Services ......................................................................................................... 44
Other Services ................................................................................................................ 46
Inmate Hunger Strikes ................................................................................................... 48
Chemical Agent Contraindications ................................................................................ 50
Staffing Levels and Training .......................................................................................... 52
Nursing Policy ............................................................................................................... 56

General Medical Categories ................................................................................................. 58
Medication Management ............................................................................................... 62
Access to Providers and Services .................................................................................. 64
Continuity of Care .......................................................................................................... 67
Primary Care Provider Responsibilities.......................................................................... 69
Nurse Responsibilities ................................................................................................... 72
State of California • August 2010

Conclusion ................................................................................................................................. 74
Appendices ................................................................................................................................. 77
A: Component Definitions ................................................................................................... 79
B: Prisons’ Scores by Component ........................................................................................ 81
C: Component Questions and Scores.................................................................................... 82
D: Category Questions and Scores..................................................................................... 120
California Prison Health Care Receivership Corporation’s Response ..................................... 142

Bureau of Audits and Investigations, Office of the Inspector General

Executive Summary
This report summarizes and analyzes the results of the Office of the Inspector General’s
(OIG) first 17 medical inspections of adult prisons operated by the California Department
of Corrections and Rehabilitation (CDCR). These first 17 medical inspections denote
the halfway point of the Office of the Inspector General’s first cycle of prison medical
inspections. Following completion of our inspection reports on all 33 prisons, we will issue a
comprehensive report that covers the results of all 33 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 institution. In September 2008 we
began our statewide inspections using teams of physicians, registered nurses, deputy inspectors
general, and analysts. The inspection program uses “yes” and “no” answers to 166 questions 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. Compliance is measured in
“yes” answers. Our inspections result in an overall weighted score for each institution.
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 17-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.

State of California • August 2010	

Page 1

Results in Brief
The results of our first 17 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 two institutions exceeded the 75 percent minimum score for moderate adherence, and
at 76 and 78 percent, those prisons barely achieved the minimum. Fifteen of the 17 prisons
performed below the minimum score for moderate adherence; the average overall weighted
score was 70 percent. Prisons’ scores ranged from 78 percent down to 62 percent.
We reviewed the 17 prisons’ performance in these five general medical categories: medication
management; access to medical providers and services; continuity of care; primary care
provider responsibilities; 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. Sixteen of the 17 institutions either failed to timely administer, provide,
or deliver medications or failed to document that they had done so. The 17 prisons’ average
score of 58 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 17 prisons was poor access to medical providers
and services. Prisons were generally ineffective at ensuring that inmates are seen or provided
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. No prisons met the 75 percent minimum score for moderate adherence on access to
providers and services, while seven prisons scored 60 percent or less. The average score, at 60
percent, was significantly less than the minimum score for moderate adherence.
The 17 prisons fared better in continuity of care and primary care provider responsibilities;
the average score was 74 percent in each of these categories, which is only one percentage
point below the minimum score for moderate adherence. Moreover, in nurse responsibilities,
Bureau of Audits and Investigations, Office of the Inspector General	

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the prisons scored 80 percent, five percentage points above the minimum score for moderate
adherence.
Other findings from our first 17 medical inspections follow.
Prisons scored particularly poorly in four component areas: preventive services, inmate
hunger strikes, access to health care information, and specialty services. The average
score for preventive services was only 37 percent, and we found alarmingly low scores
in tuberculosis treatment, which affects 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 46 percent. In providing necessary access to health care information on
inmates, prisons scored a very poor 59 percent average, and none of the prisons updated inmate
medical records by promptly filing new documents into those records. Prisons also scored
a very poor 60 percent average in specialty services; we found prisons not granting inmates
timely access and not providing prompt follow-up related to those services. Specialty services
include services such as cardiology, oncology, and neurology.
The prisons’ average score met the 75 percent minimum score for moderate adherence
in 11 of the 20 component areas. Scores in five of those 11 components were 86 percent or
higher. The 94 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 face-to-face triage techniques in a prison setting. The 91 percent average score in
chemical agent contraindications and the 90 percent average score in clinic operations are also
noteworthy. On individual questions, the prisons achieved average scores of 86 percent or
higher on 60 of the 166 questions in our medical inspection program.
However, the prisons scored consistently poorly on 42 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, 15 of the 17 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 29 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
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.

State of California • August 2010	

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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 first 17
medical inspections.
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. In addition, we agreed to inspect each state prison annually.
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.
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:
•	 CDCR’s policies and procedures
•	 relevant Court orders
Bureau of Audits and Investigations, Office of the Inspector General	

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•	 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 Prison Law
Office
Based on this research, we established an on-site inspection program that collects over 1,000
data elements from each prison using up to 166 questions that cover 20 essential components
of medical care delivery. Our inspection teams consist of physicians, registered nurses, deputy
inspectors general, and analysts. The inspection tool they
20 Components of the OIG’s
use allows for a broadly scoped and consistent method
Medical Inspections
of examining medical care at correctional institutions.
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 are
given more weight than those that pose less risk.1 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. Conversely,
we assigned proportionately fewer points to all other
components. Definitions of components are listed in
Appendix A.

(in order of importance):

Chronic Care
Clinical Services
Health Screening
Specialty Services
Urgent Services
Emergency Services
Prenatal Care/Childbirth/PostDelivery
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

The inspections identify instances of inadequate
performance and 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. 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,
1 One question (Question 18.002) in the staffing levels and training component does not factor into the overall
inspection score a prison receives.
State of California • August 2010	

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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. We
conduct a live medical emergency drill and evaluate 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
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 itemize how the prison intends to remedy conditions that
contributed to a score of 60 percent or lower on each question.

Bureau of Audits and Investigations, Office of the Inspector General	

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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.
We anticipate issuing our last report for the first cycle of 33 prison medical inspections by
October 2010. Following this first cycle we will summarize and analyze the data for all 33
inspections and issue a comprehensive report.
Objectives, Scope, and Methodology
In September 2008, we began our statewide inspections. Sixteen months later, in January 2010,
we issued our seventeenth inspection report. This report summarizes the results of those first
17 medical inspections—covering more than one-half of the state’s 33 prisons— and provides
additional analysis of the data obtained from those inspections. The report includes data from
inspections performed at 15 men’s prisons and two women’s prisons. The prisons are:
•	 California State Prison, Sacramento (SAC)
•	 California Medical Facility (CMF)
•	 Richard J. Donovan Correctional Facility (RJD)
•	 California State Prison, Centinela (CEN)
•	 Deuel Vocational Institution (DVI)
•	 Central California Women’s Facility (CCWF)
•	 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)
•	 High Desert State Prison (HDSP)
•	 San Quentin State Prison (SQ)
•	 California Conservation Center (CCC)
In analyzing and summarizing the results of our first 17 medical inspections, our objective was
State of California • August 2010	

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to provide a practical interpretation of the data and an assessment of the quality of medical
care provided to inmates.2 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 17-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 to relevant policies and procedures.3 Scores below 75 percent denote low adherence,
while those 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 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 17 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.

2 Each of the 17 inspection reports can be viewed at www.oig.ca.gov.
3 All average scores in this report are based on the arithmetic mean. We developed no median or modal averages.
Bureau of Audits and Investigations, Office of the Inspector General	

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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
Continuity of Care
Primary Care Provider Responsibilities
Nurse Responsibilities

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. Although we have reported the component-based
results of all 17 inspections, including the results of all questions, we have not previously
reported the results of this five-category analysis to the Court, the Receiver, or the Prison Law
Office.
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: A synopsis of each institution’s scores by component.
•	 Appendix C: Cites the text for each question in the 20 components and contains the 17
prisons’ scores for each question.
•	 Appendix D: Cites the text for each question in the five medical categories and contains
the 17 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 17
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
three of the 350 combined overall and component scores from our 17 medical inspections. In
all three cases, the rounding favored the prisons because the rounded score moved the prisons
from low adherence in a component to moderate adherence. In the first case, we rounded the
17 prisons’ average health screening score of 74.6 percent to 75 percent. In the second case, we
rounded CRC’s score of 74.8 percent in outpatient housing unit to 75 percent. In the third case,
we rounded SAC’s score of 74.5 percent in pharmacy services to 75 percent.

State of California • August 2010	

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Results of the First 17 Medical Inspections
Only two prisons’ overall scores exceeded the 75 percent minimum score for moderate
adherence, and at 76 and 78 percent, those prisons barely crested the minimum score for
moderate adherence. Prisons’ overall scores ranged from 78 percent down to 62 percent,
averaging 70 percent. These scores reveal that the Receiver and the prisons can improve
compliance with CDCR’s medical policies and procedures and selected medical community
standards.
While overall scores varied by only 16 percentage points, there were differences of as much as
89 percentage points in the scores among institutions on individual components. Clearly, some
prison staff understood and carried out relevant policies and procedures while others did not.
The highest average component scores were 94 percent in staffing levels and training, 91
percent in chemical agent contraindications, and 90 percent in clinic operations. The prisons
achieved high adherence on 60 of the 166 questions in our medical inspection program. The 17
prisons’ lowest average component scores were 37 percent in preventive services, 46 percent
in inmate hunger strikes, 59 percent in access to health care information, and 60 percent in
specialty services. The prisons scored 60 percent or less on 42 of the 166 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 42 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. The average score in
medication management was only 58 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 60 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 74 percent down to 45
percent. In the remaining three categories only nurse responsibilities, with an average score
of 80 percent, exceeded the 75 percent minimum score for moderate adherence. However,
continuity of care and primary care provider responsibilities were close, with average scores of
74 percent.
The following sections of this report summarize and analyze the 17 prisons’ overall scores,
their scores in each of the 20 components, and their scores in each of the five general medical
categories.

Bureau of Audits and Investigations, Office of the Inspector General	

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Chart 1: OIG First Seventeen Medical Inspection Results, in Chronological Order of Report Date.
100%
Institution
Total
ScoreScore

95%

Average Score = 70%
MinimumScore
Moderate
Adherence = 75%
Average
= 70%

85%
78%

75%

74%

72%

73%

76%

74%

72%

71%

70%

68%

65%

65%

65%

73%
70%

64%

68%

62%

55%

SAC
Nov.
2008

CMF
Jan.
2009

RJD
Feb.
2009

CEN
Feb.
2009

DVI
CCWF
Mar.
May
2009 2009

CMC SCC
May
Jun.
2009 2009

LAC
Jul.
2009

PVSP
Aug.
2009

CCI
Sep.
2009

CRC
Oct.
2009

CIW
Nov.
2009

ASP
Nov.
2009

HDSP
Dec.
2009

SQ
Dec.
2009

CCC
Jan.
2010

Overall Scores and Medical Components
Only two prisons’ overall scores met the 75 percent minimum score for moderate
adherence. As shown in Chart 1, the average score for the 17 prisons was 70 percent. The
scores varied only 16 percentage points from highest to lowest. Only two prisons (CCWF
and SCC) had scores that exceeded the 75 percent minimum score for moderate adherence
with medical policies and procedures. CCWF’s score of 78 percent was the highest, while
SCC’s score of 76 percent was a close second. The combined average score of these two
highest-scoring prisons was 77 percent. Another nine institutions 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 six prisons had scores that ranged from 68 percent to
62 percent.
Component Analysis
Individual prisons’ component scores varied widely. We have summarized all 17
institutions’ scores for each of the 20 components on one table in Appendix B.

State of California • August 2010	

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There were wide variations in some prisons’ scores, while in other cases the variations
were substantially narrower. For example:
•	 The largest variation in an individual prison’s scores was 89 percentage points. This
characteristic was shared by RJD and SAC. Each prison scored only 11 percentage
points in inmate hunger strikes and yet each received 100 percent scores in other
components.
•	 The smallest variation in scores was the 41 percentage points achieved by CRC,
which scored only 59 percent in specialty services and diagnostic services, yet
received 100 percent in two other components. CRC tied with CEN for the third
highest overall score of 74 percent.
Sixteen of the 17 prisons scored 100 percent in at least one component, with CCWF’s and
HDSP’s four 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 some 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. These
scores ranged from a high of 94 percent in staffing levels and training down to 37 percent
in preventive services, presenting a range of 57 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 94 percent in staffing
levels and training, the prisons achieved average scores of 91 percent in chemical agent
contraindications, 90 percent in clinic operations, and 86 percent in inmate transfers and
other services.
The 94 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 six components had average scores of 75 percent to 85 percent, indicating that the
prisons were performing moderately well. The six components were pharmacy services,
urgent services, emergency services, outpatient housing unit, internal reviews, and health
screening. Thus, a total of 11 of the 20 component average scores met or exceeded the 75
percent minimum score for moderate adherence.
The average scores in the following four component areas indicate low adherence to
medical policies and procedures and the need for improvement:
•	 Preventive services (37 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.

Bureau of Audits and Investigations, Office of the Inspector General	

Page 12

Chart 2: Average Score by Medical Component, Sorted by Order of Importance
Chronic Care

64%

Clinical Services

66%

Health Screening

75%

Specialty Services

60%

Urgent Services

79%

Emergency Services

77%

Prenatal Care/Childbirth/Post-delivery

61%

Diagnostic Services

69%

Access to Health Care Information

59%

Outpatient Housing Unit

77%

Internal Reviews

76%

Inmate Transfers

86%

Clinic Operations

90%

Preventive Services

37%

Pharmacy Services

85%

Other Services

86%

Inmate Hunger Strikes

46%

Chemical Agent Contraindications

91%

Staffing Levels and Training

94%

Nursing Policy

74%

25%

35%

45%

55%

65%

75%

85%

95% 100%

•	 Inmate hunger strikes (46 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.
•	 Access to health care information (59 percent). This low score shows the prisons are not
effective in filing, storing, and retrieving medical records and medical information in a
timely manner.
•	 Specialty services (60 percent). The low average score reflects poorly on the prisons’
ability to schedule and follow up on outside specialty services in a timely manner.
The variation in component scores among institutions indicates that the 17 prisons were
not consistently executing CDCR’s medical policies and procedures, or complying with
community medical standards.

State of California • August 2010	

Page 13

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

Low

Average

Variation Between
High/Low

Chronic Care

84 percent

45 percent

64 percent

39 percentage points

Clinical Services

87 percent

47 percent

66 percent

40 percentage points

Health Screening

87 percent

61 percent

75 percent

26 percentage points

Specialty Services

74 percent

43 percent

60 percent

31 percentage points

Urgent Services

89 percent

63 percent

79 percent

26 percentage points

Emergency Services

90 percent

48 percent

77 percent

42 percentage points

Prenatal Care/Childbirth/
Post-Delivery

61 percent

61 percent

61 percent

N/A

Diagnostic Services

87 percent

43 percent

69 percent

44 percentage points

Access to Health Care
Information

82 percent

20 percent

59 percent

62 percentage points

Outpatient Housing Unit

86 percent

63 percent

77 percent

23 percentage points

Internal Reviews

100 percent

60 percent

76 percent

40 percentage points

Inmate Transfers

100 percent

43 percent

86 percent

57 percentage points

Clinic Operations

100 percent

82 percent

90 percent

18 percentage points

Preventive Services

82 percent

7 percent

37 percent

75 percentage points

Pharmacy Services

100 percent

58 percent

85 percent

42 percentage points

Other Services

100 percent

55 percent

86 percent

45 percentage points

Inmate Hunger Strikes

100 percent

11 percent

46 percent

89 percentage points

Chemical Agent
Contraindications

100 percent

65 percent

91 percent

35 percentage points

Staffing Levels and
Training

100 percent

80 percent

94 percent

20 percentage points

Nursing Policy

100 percent

36 percent

74 percent

64 percentage points

Medical Component

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 understood and carried
out relevant medical policies and procedures while others did not.
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
Bureau of Audits and Investigations, Office of the Inspector General	

Page 14

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
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 • August 2010	

Page 15

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 care conditions: asthma, diabetes,
HIV (Human Immunodeficiency Virus), and hypertension.
Results in Brief: Only three prisons scored at or above the 75 percent
minimum score for moderate adherence. RJD, CCC, and HDSP
performed the worst. Documentation at most of the 17 prisons
indicated that inmates were not receiving their prescribed chronic
care medications. Further, at all prisons there was inadequate
documentation of inmates’ clinical histories.

Key Statistics

•	Component Average:...... 64%
•	Top Two Average: . ........ 83%
•	Range of Scores: . . 84%-45%
•	Variation: ....................... 39%
•	Number of Prisons with:
	 High Adherence ................. 0
	 Moderate Adherence . ........ 3
	 Low Adherence . .............. 14

Chart 3: Chronic Care Scores by Institution, Sorted Highest to Lowest Score
100%
95%

85%

75%

Institution Score
Chronic Care
Average Score = 64%
Average
= 64%
MinimumScore
Moderate
Adherence = 75%

84%
81%
75%

74%

73%
70%

70%
67%

65%

65%

63%

62%
59%

57%

57%

55%
49%
46%

45%

45%

35%

CMF CEN SCC

DVI CCWF LAC

CIW CRC

SQ

SAC CCI

ASP CMC PVSP RJD CCC HDSP

This component includes nine questions.

Bureau of Audits and Investigations, Office of the Inspector General	

Page 16

Medical Component: Chronic Care Profile
Page 2 of 2

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 31 percent. Fourteen of the 17 prisons had scores of 50 percent or less, and
CMC, PVSP, and CIW received only 4 percent.

Question
03.235

The clinical histories in inmates’ medical files were consistently inadequate. The
average score was only 56 percent. Not one of the 17 prisons had a score that met
the 75 percent minimum score for moderate adherence, and nine prisons scored 60
percent or below on this question.

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 58
percent, and seven prisons scored 52 percent or lower. SAC received only 4 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.

State of California • August 2010	

Page 17

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.
Results in Brief: Fifteen of the 17 prisons failed to ensure that inmates
received their prescribed medications in a timely manner. Thirteen
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.

Key Statistics

•	Component Average: ..... 66%
•	Top Two Average: . ........ 84%
•	Range of Scores: . .. 87%-47%
•	Variation: ........................40%
•	Number of Prisons with:
	 High Adherence ................. 1
	 Moderate Adherence . ........ 1
	 Low Adherence . .............. 15

Chart 4: Clinical Services Scores by Institution, Sorted Highest to Lowest Score
100%
95%

Institution
Score
Clinical
Services
Average Score = 66%

Average Score = 66%

87%

Minimum Moderate Adherence = 75%

85%
80%

75%

74%

74%

73%

71%

70%
67%

65%

67%

66%

66%

64%

62%
57%

55%

51%
47%

47%

45%

35%

CMF CEN CMC CCWF DVI

SCC CRC RJD SAC CCC LAC

ASP CIW

CCI HDSP PVSP SQ

This component includes 14 questions.

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. Fifteen of the 17 prisons scored 55 percent or less, and the
average score for this question was only 35 percent. PVSP received 11 percent and
CRC scored just 10 percent.

Bureau of Audits and Investigations, Office of the Inspector General	

Page 18

Medical Component: Clinical Services Profile
Page 2 of 2
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 51 percent. RJD received 13 percent.

Question
01.247

Fourteen of the 17 prisons did not conduct timely follow-up appointments with
inmates when the initial sick call visits called for them. The average score for this
question was only 53 percent. SCC received zero 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 53 percent. CRC and HDSP scored just 5 and 7 percent
respectively.
Most prisons failed to audit their clinic response bags daily or neglected to ensure
that the bags contained essential items. The average score for this question was only
59 percent. Four prisons received zero percent.

Question
15.234

Areas Achieving High Adherence with Scores of 86 Percent or More
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 94 percent.

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. Thirteen of the 17 prisons
achieved scores of 86 percent or higher on this question, and the average score was
87 percent.

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

State of California • August 2010	

Page 19

Medical Component: Health Screening Profile
Page 1 of 2
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.
Results in Brief: More than half of the prisons inspected scored below
the 75 percent minimum score for moderate adherence. Even though
prisons were regularly performing initial health screenings, we found
that they were not following up to ensure that inmates received
required medications or treatment for medical conditions identified
during those health screenings.

Key Statistics

•	Component Average:.......75%
•	Top Two Average:............86%
•	Range of Scores: . .. 87%-61%
•	Variation: ....................... 26%
•	Number of Prisons with:
	 High Adherence ................. 1
	 Moderate Adherence . ........ 7
	 Low Adherence . ................ 9

Chart 5: Health Screening Scores by Institution, Sorted Highest to Lowest Score
100%
Health
Screening
Institution
Score

95%

Average Score = 75%

Average Score = 75%

Minimum Moderate Adherence = 75%

87%
85%

84%
81%

81%
78%

78%

77%

76%
74%

75%

74%

73%

72%
70%

69%

68%

67%

65%
61%

55%

CMF CCWF ASP CCC CCI

CEN

SQ

SAC

DVI

CRC CMC HDSP CIW LAC

RJD PVSP SCC

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.

Bureau of Audits and Investigations, Office of the Inspector General	

Page 20

Medical Component: Health Screening Profile
Page 2 of 2

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 were receiving existing medication orders by the calendar day
following their arrival. The average score for this question was only 30 percent.
Sixteen of the 17 prisons had scores of 50 percent or less, and DVI, PVSP, and CIW
received zero percent.

Question
02.215

This question applies only to prisons with reception centers. Some reception centers
were not completing a portion of the History and Physical Examination form. The
average score for this question was only 45 percent. RJD and HDSP 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 47 percent. Thirteen of the 17 prisons had scores of 71 percent or less, and eight
prisons scored below 50 percent. LAC received zero percent for the question.

Areas Achieving High Adherence with Scores of 86 Percent or More
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 88 percent to 93 percent on each of these questions.

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 93
percent on this question. Seven 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 91 percent. Five prisons scored 100 percent.

Question
02.007

Within one calendar day of the inmate’s arrival, most prisons’ licensed health care
staff reviewed and signed the health care transfer information form. The average
score for this question was 90 percent. Four prisons scored 100 percent.

Question
02.015

For inmates with positive tuberculin tests, most prisons completed a review of
symptoms and the infection control nurses reviewed the results. The average score
for this question was 87 percent. Seven 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 86 percent. Nine
prisons scored 100 percent.

See Appendix C-3 for detailed information on questions and scores for this component.
State of California • August 2010	

Page 21

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.
Results in Brief: All 17 prisons performed poorly in providing inmates
timely access to specialty services and prompt follow-up related to
those services. The low scores associated with three specialty services
questions were so significant that they reduced the 17 prisons’
average score in specialty services by 19 percentage points. Without
the three questions, the 17 prisons’ average score would have been 79
percent instead of the 60 percent average score they received.

Key Statistics

•	Component Average:.......60%
•	Top Two Average:............74%
•	Range of Scores: . .. 74%-43%
•	Variation: ....................... 31%
•	Number of Prisons with:
	 High Adherence ................. 0
	 Moderate Adherence . ........ 0
	 Low Adherence . .............. 17

Chart 6: Specialty Services Scores by Institution, Sorted Highest to Lowest Score
100%
95%

Institution Score

Specialty Services

Average Score = 60%

Minimum
Moderate
Average
Score
= 60% Adherence = 75%

85%

75%

74%

73%

65%

71%

70%
63%

63%

62%

61%

60%

59%

58%

57%

55%

53%

53%

53%
47%

45%

43%

35%

ASP SCC CCC LAC CMC CIW

RJD PVSP CEN CRC

SQ

CCI

DVI HDSPCCWF SAC CMF

This component includes 9 questions.

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

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 21 percent. CIW
scored the highest with 38 percent, while CCWF and SQ scored zero percent.

Bureau of Audits and Investigations, Office of the Inspector General	

Page 22

Medical Component: Specialty Services Profile
Page 2 of 2
Question
07.261

Fifteen prisons were not scheduling high-priority (urgent) specialty services within
14 days as required. For this question, the 17 prisons had an average score of only
29 percent. Nine prisons received zero percent.

Question
07.043

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 29
percent. HDSP’s score of zero percent was the lowest.

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

Sixteen of the 17 prisons’ physical therapists properly assessed inmates, documented
their treatment plans, and documented the treatment provided. The average score for
this question was 98 percent.

Question
07.270

This question asks if the prisons’ specialty service providers provided timely
findings and recommendations, or if 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 92 percent. Fourteen of the 17 prisons scored at
least 88 percent.

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

State of California • August 2010	

Page 23

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.
Results in Brief: On average, the 17 prisons performed relatively well
in providing urgent services. Only four prisons did not meet the 75
percent minimum score for moderate adherence to policies and
procedures. However, upon inmates’ discharge from a community
hospital, few of the prisons administered or delivered all prescribed
medications to the inmates within specified time frames.

Key Statistics

•	Component Average:.......79%
•	Top Two Average:............89%
•	Range of Scores: . .. 89%-63%
•	Variation: ....................... 26%
•	Number of Prisons with:
	 High Adherence ................. 2
	 Moderate Adherence . ...... 11
	 Low Adherence . ................ 4

Chart 7: Urgent Services Scores by Institution, Sorted Highest to Lowest Score
100%
Institution Score

95%

Average Score = 79%

89%

89%

Minimum Moderate Adherence = 75%

84%

85%

84%

83%

83%

81%

81%

80%

80%

79%

78%
75%

75%

73%

72%

70%

65%

63%

55%

CCWF SCC CCC CMC CCI

SAC CRC PVSP CEN LAC CMF

DVI

CIW

RJD HDSP ASP

SQ

This component includes eight questions. Two questions were not applicable at all prisons.

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 55 percent. PVSP, ASP, and SQ scored 13
percent or lower.

Bureau of Audits and Investigations, Office of the Inspector General	

Page 24

Medical Component: Urgent Services Profile
Page 2 of 2

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. Fourteen prisons scored 100 percent.

Question
21.250

This question asks whether, 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 92 percent. Although RJD
scored only 50 percent, nine prisons scored 100 percent.

Question
21.276

This question asks whether the clinical care rendered by the attending provider
was adequate and timely while the patient was in the triage and treatment area. The
average score for this question was 87 percent, and CCWF, CMF, and SCC scored
100 percent.

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

State of California • August 2010	

Page 25

Medical Component: Emergency Services Profile
Page 1 of 2
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.
Results in Brief: Most prisons performed relatively well in providing
emergency services, with 12 exceeding the 75 percent minimum
score for moderate adherence to policies and procedures and four
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.

Key Statistics

•	Component Average:...... 77%
•	Top Two Average:........... 90%
•	Range of Scores: . .. 90%-48%
•	Variation:........................ 42%
•	Number of Prisons with:
	 High Adherence ................. 3
	 Moderate Adherence . ........ 9
	 Low Adherence . ................ 5

Chart 8: Emergency Services Scores by Institution, Sorted Highest to Lowest Score
100%
95%
90%

Institution Score

90%
86%

85%

Average Score = 77%

84%

Average Score
= 77%Adherence = 75%
Minimum
Moderate

83%
80%

80%

78%

78%

78%

75%

77%

76%
73%

72%

72%

71%

65%

55%
48%
45%

35%

RJD CCC CMC LAC PVSPCCWF CIW

SQ

ASP CCI

CEN SCC CRC CMF HDSP DVI

SAC

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 24 percent, with nine prisons
receiving zero percent.

Bureau of Audits and Investigations, Office of the Inspector General	

Page 26

Medical Component: Emergency Services Profile
Page 2 of 2
Question
15.257

This question pertains to our emergency medical response drill, which we ran at
16 prisons.4 Eight responding officers failed to properly perform cardiopulmonary
resuscitation. The average score for this question was only 47 percent.

Question
15.255

During the emergency medical response drill at eight prisons, the responding
officers failed to carry and use the proper equipment, such as a protective shield, a
micro-mask, and protective gloves. The average score for this question was only 50
percent.

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
15.285

In the emergency medical response drill, all emergency medical responders
continued basic life support activities. 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 were certified in basic life support. The average score for this
question was 94 percent.

Question
08.184

For actual medical emergencies reviewed, the medical emergency responder arrived
at the location of the medical emergency within five minutes of initial notification.
The average score for this question was 91 percent.

Question
08.185

For actual medical emergencies reviewed, the medical emergency responder used
proper equipment and provided adequate medical care within the scope of his or her
license. The average score for this question was 91 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 87 percent.

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

4 We did not complete the emergency response drill at Centinela State Prison due to special circumstances.
State of California • August 2010	

Page 27

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 was the only prison with female inmates who
met our screening criteria for this component. CIW’s score was 61
percent, which is significantly below the 75 percent minimum score
for moderate adherence to policies and procedures. The prison did not
administer timely pregnancy tests to newly arrived inmates who were
reportedly pregnant, and there were inconsistencies in reported
problems and risks when compared to prenatal tests and physical
examinations.

Key Statistics

•	Component Average:...... 61%
•	Top Two Average:........... N/A
•	Range of Scores: . .......... N/A
•	Variation: ........................ N/A
•	Number of Prisons with:
	 High Adherence ................. 0
	 Moderate Adherence . ........ 0
	 Low Adherence . ................ 1

Chart 9: Prenatal Care/Childbirth/Post Delivery Scores by Institution, Sorted Highest to Lowest Score
100%
95%
Institution Score
Minimum Moderate Adherence = 75%

85%

75%

65%

61%

55%

No Prenatal/Childbirth/Post-Delivery cases at these prisons
45%

CIW SAC CMF RJD CEN DVI CCWF CMC SCC LAC PVSP CCI CRC ASP HDSP SQ

CCC

This component includes nine questions.
Areas Requiring Significant Improvement Due to Scores of 60 Percent or Less
Question
09.066

For newly arrived inmates, CIW did not routinely administer a pregnancy test within
three business days to positively identify the inmate’s pregnancy. The prison scored
zero percent on this question.

Bureau of Audits and Investigations, Office of the Inspector General	

Page 28

Medical Component: Prenatal Care/Child Birth/Post-Delivery Profile
Page 2 of 2
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. CIW scored zero percent on this question.

Question
09.068

The prison did not always issue pregnant inmates a Form 7410 (Comprehensive
Accommodation Chrono) for a lower bunk and lower-tier housing when the inmate
was housed in a multi-tiered housing unit. The prison scored only 43 percent on this
question.

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. CIW 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 prison scored 86 percent on this question.

Question
09.071

An obstetrician generally met with pregnant inmates according to applicable time
frames. CIW scored 86 percent on this question.

Question
09.223

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

See Appendix C-7 for detailed information on questions and scores for this component.

State of California • August 2010	

Page 29

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 three 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.

Key Statistics

•	Component Average: ..... 69%
•	Top Two Average: . ........ 87%
•	Range of Scores: . .. 87%-43%
•	Variation: ....................... 44%
•	Number of Prisons with:
	 High Adherence ................. 2
	 Moderate Adherence . ........ 1
	 Low Adherence . .............. 14

Chart 10: Diagnostic Services Scores by Institution, Sorted Highest to Lowest Score
100%
95%

Institution Score

Diagnostic Services

87%
85%

Average Score = 69%

86%

Average
Score
= 69% Adherence = 75%
Minimum
Moderate

84%

74%

75%

74%

72%

71%

71%

70%

69%

65%

68%

65%

64%
60%

59%
54%

55%

45%

43%

35%

ASP SCC CCWF CEN

DVI

CMF CCC CIW CMC

SQ

SAC PVSP RJD CCI

CRC LAC HDSP

This component includes seven questions.

Areas Requiring Significant Improvement Due to Scores of 60 Percent or 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 38 percent. Eleven
of the 17 prisons had scores of 20 percent or less, and six of those 11 received zero
percent.

Bureau of Audits and Investigations, Office of the Inspector General	

Page 30

Medical Component: Diagnostic Services Profile
Page 2 of 2
Question
06.202

Sixteen of the 17 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 39 percent. Twelve of the 17 prisons had
scores of 50 percent or less. LAC, HDSP, and SQ 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 93 percent.
CEN and HDSP, with scores of 60 percent, were the only prisons not to achieve the
75 percent minimum score for moderate adherence.

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

State of California • August 2010	

Page 31

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 four prisons scored above the 75 percent
minimum score for moderate adherence to policies and procedures.
ASP’s score of 20 percent was the lowest, 19 percentage points below
any other prison. None of the prisons kept inmates’ medical records
up to date by promptly filing loose documents. Further, most of the
prisons failed to explain why certain requested medical records were
not available for our inspection.

Key Statistics

•	Component Average:...... 59%
•	Top Two Average:........... 82%
•	Range of Scores: . .. 82%-20%
•	Variation: ....................... 62%
•	Number of Prisons with:
	 High Adherence ................. 0
	 Moderate Adherence . ........ 4
	 Low Adherence . .............. 13

Chart 11: Access to Healthcare Information Scores by Institution, Sorted Highest to Lowest Score
100%
95%
85%

Institution Score
Average Score = 59%

82%

82%

Minimum Moderate Adherence = 75%

78%
75%
65%

78%
73%
63%
59%

59%

59%

59%
55%

55%

54%

54%
44%

45%

39%

39%

35%
25%

20%

15%

CEN SCC CRC CCC LAC PVSP CMF DVI

CIW HDSP CCI CCWF SQ

RJD SAC CMC ASP

This component includes 6 questions.

Bureau of Audits and Investigations, Office of the Inspector General	

Page 32

Medical Component: Access to Health Care Information Profile
Page 2 of 2

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.)
All 17 prisons failed the question and received zero percent.

Question
19.243

The 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, 11 of the 17 prisons’ medical
records staff failed to explain why files were missing. For this question, the 17
prisons had an average score of only 35 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, which scored zero percent, all prisons received 100 percent on
this question.

See Appendix C-9 for detailed information on questions and scores for this component.

State of California • August 2010	

Page 33

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:...... 77%
physician’s plan addressed the placement diagnosis.
•	Top Two Average: . ........ 85%
•	Range of Scores: . .. 86%-63%
•	Variation: ....................... 23%

Results in Brief: Only ten prisons had outpatient housing units.
Seven 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 did not make their rounds with the required frequency
when call buttons were not operational.

•	Number of Prisons with:
	 High Adherence ................. 1
	 Moderate Adherence . ........ 6
	 Low Adherence . ................ 3

Chart 12: Outpatient Housing Unit Scores by Institution, Sorted Highest to Lowest Score
100%
95%

Institution Score
Average Score = 77%

85%

Minimum Moderate Adherence = 75%

86%
83%

83%

82%
76%

75%

75%

75%

73%

65%

71%

63%

No Outpatient Housing Units
at these prisons

55%

45%

CMF

SQ

DVI

CCC SAC SCC CRC CCI

ASP CIW RJD CEN CCWF CMC LAC PVSP HDSP

This component includes ten questions.

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

Utilization management nurses 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 6 percent. Eight of the ten prisons
received zero percent.

Bureau of Audits and Investigations, Office of the Inspector General	

Page 34

Medical Component: Outpatient Housing Unit Profile
Page 2 of 2
Question
15.103

This question asks if patient call buttons were operational or if medical staff
were making their rounds every 30 minutes. The average score was only 40
percent. Six of the ten 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. Nine of the ten prisons scored 100 percent on this question.

Question
04.230

This question asks whether 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 94 percent.

Question
15.225

With the exception of CRC, all prisons’ outpatient housing units used
disinfectant daily in common patient areas. The average score was 90 percent.

Question
04.052

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

See Appendix C-10 for detailed information on questions and scores for this component.

State of California • August 2010	

Page 35

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’ medical appeals and the prison’s
use of inmate death reviews.
Results in Brief: Six prisons performed very well. However, none of
the other 11 scored 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.

Key Statistics

•	Component Average: ..... 76%
•	Top Two Average: . ........ 99%
•	Range of Scores: . 100%-60%
•	Variation: ....................... 40%
•	Number of Prisons with:
	 High Adherence ................. 6
	 Moderate Adherence . ........ 0
	 Low Adherence . .............. 11

Chart 13: Internal Reviews Scores by Institution, Sorted Highest to Lowest Score
100%

100%

98%

Institution
Score
Internal
Reviews

95%

95%

93%

Average Score = 76%

91%

Average
= 76%Adherence = 75%
MinimumScore
Moderate

86%

85%

75%

73%

71%

70%

70%

69%

69%
66%

65%

63%

61%

60%

60%

55%

RJD CCWF CIW

DVI

CRC CCC LAC PVSP CMC SAC CMF

SQ

ASP HDSP CEN SCC CCI

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 35 percent. Eleven of the 17 prisons had scores of zero percent.

Bureau of Audits and Investigations, Office of the Inspector General	

Page 36

Medical Component: Internal Reviews Profile
Page 2 of 2
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 47 percent.
Nine of the 17 prisons scored zero percent.

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

This question asks whether 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 96 percent, and 15 prisons had
scores of 100 percent.

Question
17.135

Sixteen of the 17 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 was 94 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 89 percent.

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

State of California • August 2010	

Page 37

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

Results in Brief: Most prisons performed well in transferring inmates
to other prisons. Fifteen prisons met or exceeded the 75 percent
minimum score for moderate adherence to policies and procedures.
Eleven of these 15 prisons scored above the 86 percent minimum
score for high adherence. However, CMF and CCI performed very
poorly.

•	Component Average:...... 86%
•	Top Two Average: . ...... 100%
•	Range of Scores: . 100%-43%
•	Variation: ....................... 57%
•	Number of Prisons with:
	 High Adherence ............... 11
	 Moderate Adherence . ........ 4
	 Low Adherence . ................ 2

Chart 14: Inmate Transfers Scores by Institution, Sorted Highest to Lowest Score
100%

100%

100%

100%

100%

100%

100%

100%

95%

95%

94%

93%
90%

85%
80%

79%
76%

75%

75%

65%

Institution Score

55%

Average Score = 86%
Minimum Moderate Adherence = 75%

45%

50%

43%

CEN CCWF LAC CRC ASP HDSP SQ

SCC CMC CCC RJD CIW

DVI PVSP SAC CMF CCI

This component includes five questions.

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

Bureau of Audits and Investigations, Office of the Inspector General	

Page 38

Medical Component: Inmate Transfers Profile
Page 2 of 2

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

All 17 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
05.110

Twelve 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 91 percent.

Question
05.172

Fifteen 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 and CCI failed to do so.
The average score for this question was 88 percent.

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

State of California • August 2010	

Page 39

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 health care request forms.
Results in Brief: Prisons performed very well in clinic operations. The
90 percent average score for this component is the third highest in the
20 component areas. All 17 prisons scored above the 75 percent
minimum score for moderate adherence to policies and procedures,
with 14 meeting or exceeding the 86 percent minimum score for high
adherence.

Key Statistics

•	Component Average: ..... 90%
•	Top Two Average: . ........ 99%
•	Range of Scores: . 100%-82%
•	Variation: ....................... 18%
•	Number of Prisons with:
	 High Adherence ............... 14
	 Moderate Adherence . ........ 3
	 Low Adherence . ................ 0

Chart 15: Clinic Operations Scores by Institution, Sorted Highest to Lowest Score
100%

100% 98%

97%
95%

95%

94%

93%
91%

91%

91%

90%
88%

88%
86%

86%

85%

85%
83%

82%

75%

Institution Score
Average Score = 90%
Minimum Moderate Adherence = 75%

65%

SQ

CIW CCC RJD ASP PVSP SAC HDSP CCI

LAC

DVI

SCC CRC CCWF CMC CMF CEN

This component includes ten questions.

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

Bureau of Audits and Investigations, Office of the Inspector General	

Page 40

Medical Component: Clinic Operations Profile
Page 2 of 2

Areas Achieving High Adherence with Scores of 86 Percent or More
Questions
14.032
14.033

These questions pertain to the inmate ducating (medical appointment) process.
The first question asks whether the prisons’ medical staff understood their prison’s
priority ducating process. All prisons scored 100 percent. The second question asks
whether the prisons had adequate processes to ensure that inmates moved to new
cells still received their medical ducats. The average score for this question was 97
percent.

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 were aware of those inmates
on modified programs or confined to quarters, and they 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 94 percent to 100 percent.

Question
14.023

The prisons were making the Form 7362 (Health Care Services Request Form)
available to inmates. The average score for this question was 98 percent. Fifteen
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 and CRC consistently failed to do so. The average score for
this question was 89 percent.

See Appendix C-13 for detailed information on questions and scores for this component.

State of California • August 2010	

Page 41

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.
Results in Brief: The 17 prisons had the lowest performance in this
component, with the average score only 37 percent. With the
exception of CRC, no prison scored higher than 60 percent. CCI
had a score of 7 percent. We found very low scores in tuberculosis
treatment. Tuberculosis is infectious and it jeopardizes the health of
staff members and inmates alike. Three tuberculosis-related
questions and two cancer screening questions disclosed consistently
poor performance by prisons.

Key Statistics

•	Component Average:...... 37%
•	Top Two Average:........... 71%
•	Range of Scores: . ... 82%-7%
•	Variation: ....................... 75%
•	Number of Prisons with:
	 High Adherence ................. 0
	 Moderate Adherence . ........ 1
	 Low Adherence . .............. 16

Chart 16: Preventive Services Scores by Institution, Sorted Highest to Lowest Score
100%
95%
85%

82%

75%
65%
55%

Institution Score

60%

59%

Average Score = 37%

53%

Minimum Moderate Adherence = 75%

49%
44%

45%

37%
33%

35%

32%
28%

25%

27%

24%

24%

22%

20%

19%

15%
7%
5%
0%

CRC ASP CCWF CMC

SQ

CMF CCC CIW

SAC SCC PVSP RJD HDSP DVI

LAC CEN

CCI

This component includes seven questions. However, two questions apply only to female prisons; and,
one question applies only to male prisons.

Bureau of Audits and Investigations, Office of the Inspector General	

Page 42

Medical Component: Preventive Services Profile
Page 2 of 2

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 27 percent. Four 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 9 percent, and 13 prisons
received zero percent.

Question
10.085

Most of the 15 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 31 percent. Eleven 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 39 percent. Although five prisons scored 100 percent, seven
prisons received zero percent.

Question
10.274

For females age 41 to 64, the two women’s prisons did not consistently provide Pap
smears in compliance with policy. Pap smears can detect cervical cancer. CCWF
scored 60 percent and CIW scored 50 percent, for an average score of 55 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 We did not test CCWF and CIW for compliance with this question because current CDCR policy requires the
FOBT for male inmates only.
State of California • August 2010	

Page 43

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.
Results in Brief: Fourteen of the 17 prisons scored at or above the 75
percent minimum score for moderate adherence to policies and
procedures, and ten 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 drug night lockers, and some did not maintain
required provider information.

Key Statistics

•	Component Average: ..... 85%
•	Top Two Average: . ...... 100%
•	Range of Scores: . 100%-58%
•	Variation: ....................... 42%
•	Number of Prisons with:
	 High Adherence ............... 10
	 Moderate Adherence . ........ 4
	 Low Adherence . ................ 3

Chart 17: Pharmacy Services Scores by Institution, Sorted Highest to Lowest Score
100%
95%

100%

100%

95%

93%

92%

92%

92%

91%

91%
86%

85%

79%

79%
76%

75%

75%
72%
69%

65%
58%
55%

Institution Score
Average Score = 85%
Minimum Moderate Adherence = 75%

45%

LAC HDSP CIW

RJD

DVI CCWF ASP CMC SCC

SQ

CCI

CRC CMF SAC PVSP CCC CEN

This component includes eight questions.

Bureau of Audits and Investigations, Office of the Inspector General	

Page 44

Medical Component: Pharmacy Services Profile
Page 2 of 2

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 44 percent. Eight of the 17
prisons scored zero percent.

Question
13.144

Some prisons did not maintain information to ensure that medications are prescribed
by licensed health care providers lawfully authorized to do so. The average score for
this question was only 59 percent. Seven of the 17 prisons received zero percent.

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

These are certification questions. The first question asks if the prison conspicuously
posted a valid permit in its pharmacies. The second question asks if the license of the
pharmacist in charge is current. All 17 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 17 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 had zero percent.

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

State of California • August 2010	

Page 45

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.
Results in Brief: Eleven of the 17 prisons scored well above the 75
percent minimum score for moderate adherence to policies and
procedures and another four prisons came close. Nine of the 11
exceeded the 86 percent minimum score for high adherence.
However, CIW’s and SCC’s performance was far below that of the
other prisons.

Key Statistics

•	Component Average: ..... 86%
•	Top Two Average: . ...... 100%
•	Range of Scores:... 100%-55%
•	Variation: ....................... 45%
•	Number of Prisons with:
	 High Adherence ................. 9
	 Moderate Adherence . ........ 2
	 Low Adherence . ................ 6

Chart 18: Other Services Scores by Institution, Sorted Highest to Lowest Score
100%

100%

100%

100%

100%

100%

100%

100%

95%
91%

85%

91%

85%

85%

75%

73%
70%

70%

70%

65%

57%

55%

Institution Score

55%

Average Score = 86%
Minimum Moderate Adherence = 75%

45%

CMF RJD CEN

DVI CCWF LAC CCC CMC SAC CCI

SQ HDSP PVSP CRC ASP CIW SCC

This component includes five questions.

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

Bureau of Audits and Investigations, Office of the Inspector General	

Page 46

Medical Component: Other Services Profile
Page 2 of 2

Areas Achieving High Adherence with Scores of 86 Percent or More
Question
15.059

All eight prisons that offered therapeutic diets properly provided them to inmates.
Each of the eight prisons scored 100 percent on this question.

Question
15.134

This question determines if the institutions properly responded to all active cases of
tuberculosis (TB) in the last six months. Only one case of active TB was identified in
the 17 inspections. SAC properly responded to this active TB case resulting in a 100
percent score for this question.

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 99 percent.

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

State of California • August 2010	

Page 47

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 46 percent was the
second lowest of all 20 component areas we inspected. Eleven of the
12 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, 21
percentage points lower than that of any other prison.

Key Statistics

•	Component Average: ..... 46%
•	Top Two Average: . ........ 86%
•	Range of Scores: . 100%-11%
•	Variation: ....................... 89%
•	Number of Prisons with:
	 High Adherence ................. 1
	 Moderate Adherence . ........ 0
	 Low Adherence . .............. 11

Chart 19: Inmate Hunger Strikes Scores by Institution, Sorted Highest to Lowest Score
100%
95%

100%

Institution Score

85%

Average Score = 46%
Minimum Moderate Adherence = 75%

75%

71%

68%

65%
54%

55%

46%

45%

44%

42%
37%

35%

32%

32%

25%
15%

11%

11%

5%

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

0%

CCWF CMC CCC

SQ

CCI HDSP LAC PVSP CMF CEN SAC RJD

DVI

SCC CRC CIW

ASP

This component includes three questions.

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

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 39 percent. Five prisons received zero percent.

Bureau of Audits and Investigations, Office of the Inspector General	

Page 48

Medical Component: Inmate Hunger Strikes Profile
Page 2 of 2
Question
11.100

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 44 percent. Five prisons scored zero percent.

Questions
11.097

Registered nurses did not always: conduct timely face-to-face triages; document
the inmates’ reasons for the hunger strike; and, record the inmates’ weight, vital
signs, and physical condition. The average score for this question was only 54
percent. PVSP, CCI, and CCC 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.

State of California • August 2010	

Page 49

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), commonly referred to as “pepper spray.”
For example, an adverse outcome from OC exposure might occur if the inmate has asthma.
Results in Brief: Prisons generally performed well in this component.
The 91 percent average score is the second highest achieved in the 20
component areas. Fourteen prisons not only scored above the 75
percent minimum score for moderate adherence to policies and
procedures, but they also exceeded the 86 percent minimum score for
high adherence. However, PVSP, CCI, and CCWF scored far below
the other prisons. These three prisons routinely failed to document
important procedures.

Key Statistics

•	Component Average: ..... 91%
•	Top Two Average: . ...... 100%
•	Range of Scores: . 100%-65%
•	Variation: ....................... 35%
•	Number of Prisons with:
	 High Adherence ............... 14
	 Moderate Adherence . ........ 0
	 Low Adherence . ................ 3

Chart 20: Chemical Agent Contraindication Scores by Institution, Sorted Highest to Lowest Score
100%

100%

100%

100%

100%

100%

100%

95%

100%

100%

94%
91%
89%

89%

89%
87%

85%

75%

66%

65%

66%

65%

Institution Score
Average Score = 91%
Minimum Moderate Adherence = 75%

55%

SAC CMC SCC CRC CIW

ASP HDSP CCC RJD LAC CEN

DVI

SQ

CMF PVSP CCI CCWF

This component includes two questions.

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

Bureau of Audits and Investigations, Office of the Inspector General	

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Medical Component: Chemical Agent Contraindications Profile
Page 2 of 2

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

Prisons normally recorded how they decontaminated inmates and followed
decontamination policy. The average score for this question was 94 percent.

Question
12.062

The prisons generally 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 88 percent.

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

State of California • August 2010	

Page 51

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 94 percent average score for this component was
the highest of all 20 component areas. All 17 prisons’ scores exceeded
the 75 percent minimum score for moderate adherence to policies and
procedures, and the scores of 13 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: ..... 94%
•	Top Two Average: . ...... 100%
•	Range of Scores: . 100%-80%
•	Variation: ....................... 20%
•	Number of Prisons with:
	 High Adherence ............... 13
	 Moderate Adherence . ........ 4
	 Low Adherence . ................ 0

Chart 21: Staffing Levels and Training Scores by Institution, Sorted Highest to Lowest Score
100%

100%

100%

100%

100%

100%

100%

100%

95%

95%

95%

95%

95%
90%

90%
85%

85%

85%

85%
80%

75%

65%
Institution
Score
Staffing
Levels
and Training
Average Score = 94%
Average
Score
= 94% Adherence = 75%
Minimum
Moderate

55%

RJD CEN CMC SCC ASP HDSP CCC SAC CMF DVI

SQ

LAC CCI CCWF CRC CIW PVSP

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.

Bureau of Audits and Investigations, Office of the Inspector General	

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Medical Component: Staffing Levels and Training Profile
Page 2 of 4

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 17 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 17 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 17 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 17 prisons on the following pages.

State of California • August 2010	

Page 53

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

Data Not Included in Scoring: Results of Staffing and Vacancy Rate Analysis
The 17 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 9 percent, and nine 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 licensed medical
classifications: management, primary care providers, supervisors, and rank and file nursing.
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 5 combines the data from the four medical classifications and summarizes each of the 17
prisons’ reported staffing levels and vacancy rates. Table 5 shows that the vacancy rates ranged
from a low of zero percent at SAC to a high of 29 percent at PVSP. Six prisons had vacancy
rates of 5 percent or less, and the other 11 had vacancy rates of 6 percent or more. Of this latter
group, nine had double-digit vacancy rates. (While not shown on Table 5, the average vacancy
rate of the 17 prisons was 9 percent.)
PVSP and CCI, the prisons with the two highest vacancy rates, had among the lowest overall
inspection scores, with 65 percent and 64 percent respectively. 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, with its 11 percent vacancy rate, had the second highest
overall score (76 percent) of the 17 prisons.
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 5, some prisons
relied extensively on private registries. Four prisons had 47 or more registry staff members.
PVSP, with its 29 percent vacancy rate, had the most registry staff.

Bureau of Audits and Investigations, Office of the Inspector General	

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

Institution

Total number
Total number
of filled
of vacancies:
positions:

Total number
of positions:

Vacancy
percentage:

Number of
staff hired
within last
six months:

Total number
of registry
staff:

PVSP

67.0

26.7

93.7

29%

14.0

67

CCI

87.0

17.7

104.7

17%

12.0

48

HDSP

80.3

10.7

91.0

12%

10.0

4

CEN

68.0

9.0

77.0

12%

5.0

9

CMC

183.0

23.8

206.8

12%

30.0

30

SCC

52.6

6.8

59.4

11%

1.0

18

CCC

58.8

7.5

66.3

11%

8.0

3

SQ

115.0

13.8

128.8

11%

12.0

38

CRC

68.6

8.0

76.6

10%

0

26

RJD

128.6

11.1

139.7

8%

39.0

2

ASP

109.0

7.0

116.0

6%

13.0

31

LAC

106.9

5.6

112.4

5%

12.0

20

DVI

109.5

5.0

114.5

4%

5.0

12

CIW

79.5

3.6

83.1

4%

5.5

32

CCWF

107.1

2.5

109.6

2%

9.0

47

CMF

229.0

5.0

234.0

2%

27.0

25

SAC

84.5

0

84.5

0%

11.0

49

* This table summarizes numbers previously published in the medical inspection reports for individual
institutions. 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. CCI, with a vacancy rate second only to that of PVSP, is similarly
situated. By way of contrast, SAC, with its zero percent vacancy rate, is located near a larger
urban area. CMF, with the second lowest vacancy rate, is adjacent to both the Bay Area and the
greater Sacramento area.

State of California • August 2010	

Page 55

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 review their duty statements and whether supervisors
periodically review the work of nurses to ensure they properly follow established nursing protocols.
Results in Brief: There was wide variation in the prisons’ scores, with
nine prisons exceeding the 75 percent minimum score for moderate
adherence to policies and procedures. CCWF and PVSP performed
very well. On the other hand, DVI and CMF performed the worst,
scoring only 36 percent.

Key Statistics

•	Component Average: ..... 74%
•	Top Two Average: . ...... 100%
•	Range of Scores: . 100%-36%
•	Variation: ....................... 64%
•	Number of Prisons with:
	 High Adherence ................. 6
	 Moderate Adherence . ........ 3
	 Low Adherence . ................ 8

Chart 22: Nursing Policy Scores by Institution, Sorted Highest to Lowest Score
100%

100%

100%

94%

95%

94%

Institution Score

89%

Nursing Policy

89%

Average Score = 74%
Average
Score
= 74% Adherence = 75%
Minimum
Moderate

85%
79%

79%
76%

75%

71%

70%
67%
64%

65%

57%

55%
50%

45%
36%

35%

CCWF PVSP SCC CCC RJD HDSP SAC CMC CRC CEN

SQ

ASP CIW LAC CCI

36%

CMF DVI

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 53 percent.
Five prisons scored zero percent.

Bureau of Audits and Investigations, Office of the Inspector General	

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Medical Component: Nursing Policy Profile
Page 2 of 2

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

All 17 prisons scored 100 percent on this question, which asks if the prison has
written nursing policies and procedures that adhere to CDCR’s guidelines.

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

State of California • August 2010	

Page 57

General Medical Categories
After sorting the data from 100 key questions into five general medical categories recommended
by our lead physician, we found significant problems in the categories of medication management
and access to providers and services. The average score in medication management was only 58
percent 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 CMF, with a score
of 84 percent, had a score that exceeded 69 percent. The average score for access to providers and
services was only 60 percent. 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 74 percent down to 45 percent. In the remaining three categories, only
nurse responsibilities, with an average score of 80 percent, exceeded the 75 percent minimum score
for moderate adherence to policies and procedures. However, continuity of care and primary care
provider responsibilities were close, with average scores of 74 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 166 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)
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.
Bureau of Audits and Investigations, Office of the Inspector General	

Page 58

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)

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-toface assessment of the inmate?
(Question 21.248)

Primary Care
Provider
Responsibilities

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)

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 • August 2010	

Page 59

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

Medical Component

Medication
Management

Access to
Primary Care
Continuity
Providers and
Provider
of Care
Services
Responsibilities

Chronic Care

√

√

Clinical Services

√

√

Health Screening

√

√

√

√

√

√

√

Specialty Services
Urgent Services

√

Nurse
Responsibilities

√
√
√

√

√

√

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 and Investigations, Office of the Inspector General	

√

√

Page 60

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 58 percent in medication management
to a high of 80 percent in nurse responsibilities. Our analysis clearly demonstrates that
prisons’ performances in medication management and access to providers and services merit
the Receiver’s attention, as the 17 prisons’ average scores of 58 percent and 60 percent,
respectively, are far below the 75 percent minimum score for moderate adherence to policies
and procedures. More encouragingly, in nurse responsibilities the prisons exceeded the
minimum score for moderate adherence with an average score of 80 percent, while they
were close to the minimum score for moderate adherence in the remaining two categories. In
continuity of care and primary care provider responsibilities they averaged 74 percent.
In the following sections, we provide a more in-depth analysis of the 17 prisons’ performances
in each of the five medical categories.
Chart 23: Scores by Category, Sorted Lowest to Highest Score.

Medication Management

58%

Access to Providers and Services

60%

Continuity of Care

74%

Primary Care Provider
Responsibilities

74%

Nurse Responsibilities

40%

State of California • August 2010	

80%

50%

60%

70%

80%

90%

100%

Page 61

Medical Category: Medication Management
Page 1 of 2

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 17 prisons’ average score for medication management was only 58 percent. This is
the lowest average score within any of the five general medical categories, and it clearly indicates
that medication management is weak. Only CMF, with a score of 84 percent, scored higher than
69 percent. Particularly troubling is that eight of the prisons scored 55 percent or less.
The prisons performed especially poorly in medication delivery. They had an average score
of only 34 percent. Sixteen of the 17 prisons scored 53 percent or less, and ten of them scored
from 32 percent down to 8 percent. CMF’s score of 84 percent was the only one to exceed the
75 percent minimum score for moderate adherence. The prisons’ very low scores in delivering
Chart 24: Medication Management Scores by Institution, Sorted Highest to Lowest Score
100%
95%

85%

M
edication Score
M anagement
Institution

AverageScore
Score
58%
Average
==
53%

84%

Minimum Moderate Adherence = 75%

75%
69%
65%

55%

68%

68%

67%

64%

62%

61%

60%
55%

55%

53%

45%

51%

49%
43%

42%

40%

35%

25%

CMF CCI RJD CCWF SAC DVI LAC CRC CEN SCC HDSP CCC CMC ASP PVSP CIW

Bureau of Audits and Investigations, Office of the Inspector General	

SQ

Page 62

Medical Category: Medication Management
Page 2 of 2

medications to inmates offset the 91 percent average score they achieved on the other nine, less
heavily weighted questions in medication management.
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 prisons’ administering of Isoniazid, a drug prescribed to treat
latent or active tuberculosis, we found that in 73 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 44 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 sick call medications (new orders) to inmates
•	 Providing chronic care medications and following polices when inmates refuse their
medications
•	 Delivering medications to inmates within one day of arrival at the prison
•	 Providing medications to inmates upon discharge from an outside hospital
•	 Delivering tuberculosis medications to inmates and ensuring they take them
These five areas pertain to the basic delivery of medications to inmates. As suggested by the
poor 34 percent average score achieved by the 17 prisons, medication delivery is a significant
health issue.
See Appendix D-1 for detailed information on questions and scores for this category.

State of California • August 2010	

Page 63

Medical Category: Access to Providers and Services
Page 1 of 3

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 17 prisons’ average score
for access to providers and services was only 60 percent. This is the second lowest average
score within the five general medical categories. With scores ranging from a high of 74 percent
down to 45 percent, prisons are deficient in providing inmates timely access to the primary care
providers and medical services they need. Only three prisons had scores of 70 percent or more,
but none of them exceeded the 75 percent minimum score for moderate adherence to policies
and procedures. HDSP, with a score of 45 percent, was the worst performer.
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

Chart 25: Access to Providers and Services Scores by Institution, Sorted Highest to Lowest Score.
100%
95%

Institution Score
Average Score = 60%
Minimum Moderate Adherence = 75%

85%

75%

74%

72%

70%

69%

67%

65%

66%

65%

63%

62%

61%

60%

55%

54%

52%

52%

50%
47%

45%

CCWF CMC CRC

ASP

CCC

SQ

CIW

CMF

DVI

SCC

CEN

SAC

Bureau of Audits and Investigations, Office of the Inspector General	

LAC PVSP

CCI

RJD

45%

HDSP

Page 64

Medical Category: Access to Providers and Services
Page 2 of 3

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 preventiverelated

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 57 percent. In contrast, the average
access to providers and services score for screening and preventive-related procedures was 71
percent. 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.
Chart 26: Problem-related and Screening and Preventive-related Access to Providers and Services
Scores by Institution, Sorted by Highest Problem-related Score to Lowest Problem-related Score
100%
95%
89%
87%
85%

85%

84%

81%

79%

75%
71%
68%

65%

72%

70%
67%

70%
66%
64%

64%

64%

66%

66%

65%
63%

63%
61%
57%

59%

59%

58%
55%

55%
51%

51%
48%

45%

35%

Problem-related Access to Care Score
Average Problem-related Access to Care Score = 57%
Screening and Preventive-related Access to Care Score
Average Screening and Preventive-related Access to Care Score = 71%
Minimum Moderate Adherence = 75%

CCWF CMC CCC CIW CRC ASP CMF CEN

State of California • August 2010	

DVI

48%

44%
40%
38%

SQ

SCC PVSP CCI

SAC LAC RJD HDSP

Page 65

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

With scores ranging from 71 percent down to 38 percent, all prisons failed to meet 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 significantly 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 and Investigations, Office of the Inspector General	

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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.
Most prisons must improve the continuity of care they provide inmates to achieve moderate
adherence to policies and procedures. As shown in Chart 27, the 17 prisons’ average score
for continuity of care was 74 percent. While still below the 75 percent minimum score for
moderate adherence, this score ties that of primary care provider responsibilities as the second
highest average score in the five general medical categories. The 74 percent average score
indicates that the prisons generally need to improve the continuity of their services if they are
to achieve moderate adherence with medical policies and procedures. Seven prisons exceeded
the 75 percent minimum score for moderate adherence.
Prisons failed to achieve moderate adherence in the continuity of care category partly as the
result of these problems:
•	 Failing to transmit accurate health care information on transferring inmates who need
specialty services.
Chart 27: Continuity of Care Scores by Institution, Sorted Highest to Lowest Score
100%
95%

Institution of
Score
Continuity
Care
Average Score = 74%
Average Score = 74%

Minimum Moderate Adherence = 75%

85%

84%

83%

83%

83%
80%

79%

75%

78%
74%

72%

72%

71%

70%

68%

68%

67%

67%
64%

65%

55%

CRC CCWF CEN CCC SCC ASP LAC HDSP SAC CMC PVSP RJD CIW SQ

State of California • August 2010	

CMF CCI

DVI

Page 67

Medical Category: Continuity of Care
Page 2 of 2

•	 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-3 for detailed information on questions and scores for this category.

Bureau of Audits and Investigations, Office of the Inspector General	

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Medical Category: Primary Care Provider Responsibilities
Page 1 of 3

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 28, the 17 prisons’ average score for primary care provider
Chart 28: Primary Care Provider Responsibilities Scores by Institution, Sorted Highest to Lowest Score
100%
Institution Score

95%

Average Score = 74%
Minimum Moderate Adherence = 75%

85%

85%

84%

83%

81%

80%

79%

75%

78%

77%

76%

76%

74%

72%

71%
68%

65%

66%

55%

55%

54%

45%

SCC CCWF CMF

DVI

CEN

SQ

CRC CIW LAC

CCI PVSP ASP SAC CMC CCC HDSP RJD

6 In performing our inspections, judgment questions are answered by physician inspectors. When a physician
inspector takes exception to the judgment of a primary care provider, the physician inspector consults with our
lead physician before confirming the exception.
State of California • August 2010	

Page 69

Medical Category: Primary Care Provider Responsibilities
Page 2 of 3

responsibilities was 74 percent. This score ties that of continuity of care as the second highest
average score in the five general medical categories. The 74 percent average score does not
meet the 75 percent minimum score for moderate adherence to policies and procedures.
However, ten prisons’ scores met or exceeded the 75 percent minimum score for moderate
adherence, with SCC’s 85 percent the highest score. HDSP’s score of 55 percent and RJD’s
score of 54 percent stand 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.
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 29 and analyzed the results of the judgment questions exclusively.
Judgment functioned far better than process. As shown in Chart 29, the 17 prisons’ average
score on judgment questions was 77 percent, a score that by itself meets the 75 percent
minimum score for moderate adherence. However, the prisons’ performance on the process
questions reduced the category score three percentage points to the 74 percent score achieved
Chart 29: Primary Care Provider Judgment Scores by Institution, Sorted Highest to Lowest Score
100%
95%
90%
86%

85%

88%

86%

85%

84%

84%

84%
80%

79%

79%

78%

78%

78%
76%

75%

75%

74%
72%

71%

69%

68%
66%

65%

66%

66%

64%
61%

59%

55%

57%

58%
56%

54%

45%
39%

35%

CMF CCWF SQ

CEN

DVI

SCC SAC LAC

Primary Care Provider Judgment Score
Average Primary Care Provider Judgment Score = 77%
Primary Care Provider Process Score
Average Primary Care Provider Process Score = 63%
Minimum Moderate Adherence = 75%

CCI

CRC PVSP CIW

Bureau of Audits and Investigations, Office of the Inspector General	

43%

35%

ASP CMC CCC RJD HDSP

Page 70

Medical Category: Primary Care Provider Responsibilities
Page 3 of 3

using both types of questions. The average score on the process questions was only 63 percent.
The larger number and heavier weight of the judgment questions kept the category score from
falling more than it did. On judgment questions, 12 prisons had scores that met or exceeded the
75 percent minimum score for moderate adherence.
See Appendix D-4 for detailed information on questions and scores for this category.

State of California • August 2010	

Page 71

Medical Category: Nurse Responsibilities
Page 1 of 2

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
in providing nursing care.7 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 17 prisons’ average score
for nurse responsibilities was 80 percent. This average score is the highest average score within
the five general medical categories and it is the only score to exceed the 75 percent minimum
Chart 30: Nurse Responsibilities Scores by Institution, Sorted Highest to Lowest Score
100%
95%

94%

Institution Score

91%

85%

90%

88%

Average Score = 80%

86%

85%

Minimum Moderate Adherence = 75%

84%

83%

82%

81%
78%

75%

76%

74%

72%
69%

67%

65%

66%

55%

45%

CCWF CEN

CRC CMC RJD SAC

ASP

SCC CCC LAC

DVI

CIW HDSP SQ

CMF CCI

PVSP

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

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Medical Category: Nurse Responsibilities
Page 2 of 2

score for moderate adherence. Twelve of the 17 prisons exceeded the 75 percent minimum
score for moderate adherence, with five of them achieving high adherence scores of 86 percent
or more. CCWF’s score of 94 percent was the highest.
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 negligible. The 17 prisons’ average score on the
judgment questions was 80 percent, which is the same as the average score achieved using both
types of questions. The average score for process questions was 81 percent, meaning that there
was only a one percentage point gap between the average scores for the two types of questions.
All three scores fall in the middle of the moderate adherence range. Therefore, we conclude
that the impact of the nurse judgment questions was negligible.
See Appendix D-5 for detailed information on questions and scores for this category.

State of California • August 2010	

Page 73

Conclusion
The results of our first 17 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 two of the 17 prisons’ overall weighted scores exceeded 75 percent, the Receiver’s
minimum score for moderate adherence to medical policies and procedures. At 76 and 78
percent, those scores barely achieved the minimum.
•	 In the 20 component areas of our inspection program, prisons scored particularly poorly
in preventive services. The average score was only 37 percent, and we found very low
scores in tuberculosis treatment, which affects the health of inmates and staff alike.
Further, as evidenced by the average score of 46 percent, the prisons performed quite
poorly in monitoring inmates on hunger strikes lasting longer than three days. The prisons
also scored poorly in providing access to health care information on inmates. The average
score was only 59 percent, and none of the prisons kept inmates’ medical records updated
with recently filed documents. Specialty services had an average score of only 60 percent.
Within this component, we found consistent problems with granting inmates timely
access to specialty services and in providing prompt follow-up related to those services.
•	 Notwithstanding the problems cited above, the prisons performed well in several
components. Their average scores were 86 percent or higher in five components,
indicating high adherence with medical policies and procedures. The 94 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 91 percent score in chemical agent
contraindications and the 90 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 60 questions. However, the prisons scored consistently poorly
on 42 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 medication management was only 58 percent because the prisons scored only 34
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 60 percent. In contrast, nurse responsibilities had an
average score of 80 percent, making it the only general medical category to exceed the
75 percent minimum score for moderate adherence. However, the continuity of care and
primary care provider responsibilities categories, with average scores of 74 percent came
close to the 75 percent minimum score for moderate adherence.
We find that the wide variation among component scores within prisons, and the wide variation
Bureau of Audits and Investigations, Office of the Inspector General	

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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 • August 2010	

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Bureau of Audits and Investigations, Office of the Inspector General	

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APPENDIX PREFACE
This report contains the following four appendices:
Appendix A: The definitions of the 20 components we use in our medical inspection
program.
Appendix B: A synopsis of each prison’s scores on the 20 components in our medical
inspection program.
Appendix C: The text of each question in the 20 components and the 17 prisons’ scores for
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 17-prison average
score for each question and each prison’s total score for each component.
Appendix D: The text of each question in the five medical categories and the 17 prisons’
scores for 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 17-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, seven of the 17 prisons did not have outpatient housing units.
Therefore, the ten questions in the outpatient housing unit component would not apply to
these seven 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 one of
the 17 prisons had discovered an active case of tuberculosis in the six months preceding the
inspection, only that prison 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. Further, totals may not sum due to this rounding.

State of California • August 2010	

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APPENDICES: Table of Contents

Appendix A: Component Definitions .................................................................................. 79
Appendix B: Prisons’ Scores by Component ....................................................................... 81
Appendix C: Component Questions and Scores

Appendix C-1: Chronic Care ......................................................................................... 82
Appendix C-2: Clinical Services ................................................................................... 84
Appendix C-3: Health Screening ................................................................................... 87
Appendix C-4: Specialty Services ................................................................................. 91
Appendix C-5: Urgent Services ..................................................................................... 93
Appendix C-6: Emergency Services .............................................................................. 95
Appendix C-7: Prenatal Care ......................................................................................... 98
Appendix C-8: Diagnostic Services ............................................................................. 100
Appendix C-9: Access to Health Care Information ..................................................... 102
Appendix C-10: Outpatient Housing Unit ................................................................... 104
Appendix C-11: Internal Reviews ................................................................................ 106
Appendix C-12: Inmate Transfers ................................................................................ 108
Appendix C-13: Clinic Operations .............................................................................. 109
Appendix C-14: Preventive Services ........................................................................... 111

Appendix C-15: Pharmacy Services ............................................................................ 113
Appendix C-16: Other Services ................................................................................... 115
Appendix C-17: Inmate Hunger Strikes ...................................................................... 116
Appendix C-18: Chemical Agent Contraindications ................................................... 117
Appendix C-19: Staffing Levels and Training ............................................................. 118
Appendix C-20: Nursing Policy ................................................................................... 119
Appendix D: Category Questions and Scores

Appendix D-1: Medication Management .................................................................... 120
Appendix D-2: Access to Care ..................................................................................... 123
Appendix D-3: Primary Care Provider Responsibilities .............................................. 129
Appendix D-4: Continuity of Care .............................................................................. 133
Appendix D-5: Registered Nurse Responsibilities ...................................................... 138

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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 anticoagulation therapy and the following chronic care conditions: asthma, 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/post-delivery: Focuses on the prenatal and post-delivery medical care
provided to pregnant inmates. This component is 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.1 This component also evaluates whether the placement provided the inmate with adequate care and whether the physician’s
plan addressed the placement diagnosis.
1 An outpatient housing unit (OHU) is a facility that provides outpatient health services to inmates and assists
them with the activities of daily living.
State of California • August 2010	

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APPENDIX A: Component Definitions

Internal reviews: 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’ medical appeals and the prison’s use of inmate death
reviews.
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 inmate carries for
scheduled medical appointments), and availability of health care request forms.
Preventive services: Focuses on inmate cancer screening, 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 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.
Bureau of Audits and Investigations, Office of the Inspector General	

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State of California • August 2010	

53%

89%

80%

N/A

84%

54%

N/A

98%

100%

86%

59%

92%

100%

100%

65%

85%

Specialty Services

Urgent Services

Emergency Services

Prenatal/Childbirth/
Post-delivery Care

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

78%

84%

Health Screening

Institutional Average

74%

Clinical Services

100%

73%

Chronic Care

Nursing Policy

CCWF

Medical Component

76%

94%

100%

100%

N/A

55%

91%

28%

88%

95%

60%

75%

82%

86%

N/A

76%

89%

73%

61%

71%

75%

SCC

74%

71%

100%

89%

32%

100%

58%

19%

82%

100%

61%

N/A

82%

74%

N/A

77%

80%

60%

78%

80%

81%

CEN

74%

76%

85%

100%

N/A

70%

79%

82%

86%

100%

91%

75%

78%

59%

N/A

73%

81%

59%

74%

70%

67%

CRC

73%

94%

100%

100%

68%

100%

69%

37%

97%

93%

86%

82%

78%

71%

N/A

90%

84%

71%

81%

66%

46%

CCC

73%

36%

95%

89%

N/A

100%

92%

22%

88%

79%

93%

83%

59%

74%

N/A

71%

78%

53%

74%

73%

74%

DVI

72%

36%

95%

87%

32%

100%

76%

44%

83%

50%

69%

86%

59%

72%

N/A

72%

79%

43%

87%

87%

84%

CMF

72%

57%

90%

91%

42%

100%

100%

20%

90%

100%

73%

N/A

73%

54%

N/A

84%

80%

70%

69%

66%

70%

LAC

71%

79%

100%

100%

71%

91%

91%

53%

85%

94%

70%

N/A

39%

70%

N/A

86%

84%

63%

73%

74%

57%

CMC

70%

67%

100%

100%

N/A

70%

92%

60%

94%

100%

66%

71%

20%

87%

N/A

78%

70%

74%

81%

64%

59%

ASP

70%

64%

85%

100%

N/A

57%

95%

33%

98%

80%

95%

63%

59%

71%

61%

80%

75%

63%

70%

62%

70%

CIW

68%

70%

95%

89%

54%

85%

86%

49%

100%

100%

69%

83%

54%

69%

N/A

78%

63%

58%

77%

47%

65%

SQ

Page 81

65%

79%

95%

100%

11%

91%

75%

32%

91%

75%

70%

76%

39%

68%

N/A

48%

83%

47%

76%

67%

63%

SAC

high adherence

68%

89%

100%

94%

11%

100%

93%

24%

95%

90%

100%

N/A

44%

64%

N/A

90%

73%

62%

68%

67%

49%

RJD

PRISONS’ SCORES BY COMPONENT

64%

50%

90%

66%

46%

85%

79%

7%

91%

43%

60%

73%

55%

60%

N/A

78%

83%

57%

78%

57%

62%

CCI

62%

89%

100%

100%

44%

73%

100%

24%

91%

100%

63%

N/A

59%

43%

N/A

72%

72%

53%

72%

51%

45%

HDSP

moderate adherence

65%

100%

80%

66%

37%

70%

72%

27%

93%

76%

71%

N/A

63%

65%

N/A

83%

81%

61%

67%

47%

57%

PVSP

16%

64%

20%

35%

89%

45%

42%

75%

18%

57%

40%

23%

62%

44%

N/A

42%

26%

31%

26%

40%

39%

Range

low adherence

70%

74%

94%

91%

46%

86%

85%

37%

90%

86%

76%

77%

59%

69%

61%

77%

79%

60%

75%

66%

64%

Average
Score

APPENDIX B: Prisons’ Scores by Component

Bureau of Audits and Investigations, Office of the Inspector General	
0.4
4%

Received Points

Score

10

88%

Score

Possible Points

8.8

Received Points

03.077

10

Possible Points

03.076

91%

9.1

10

87%

8.7

10

46%

4.6

10

48%

4.8

10

74%

7.4

10

95%

9.5

10

CEN

78%

7.8

10

56%

5.6

10

DVI

85%

8.5

10

90%

9

10

CCWF

52%

5.2

10

76%

7.6

10

CMC

85%

8.5

10

60%

6

10

SCC

76%

7.6

10

64%

6.4

10

LAC

24%

2.4

10

72%

7.2

10

PVSP

52%

5.2

10

68%

6.8

10

CCI

60%

6

10

96%

9.6

10

CRC

72%

7.2

10

75%

7.5

10

60%

6

10

72%

7.2

10

28%

2.8

10

44%

4.4

10

72%

7.2

10

84%

8.4

10

SQ

28%

2.8

10

56%

5.6

10

CCC

58%

98.7

170

72%

123.1

170

Average
Score

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

03.262

HDSP

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

03.238

ASP

Is the assessment adequate?

03.237

CIW

Is the focused clinical examination adequate?

03.236

RJD

Is the clinical history adequate?

03.235

CMF

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?

03.175

SAC

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

03.082

Ref
Number

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?

03.077

COMPONENT SCORES: Chronic Care

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?

03.076

COMPONENT QUESTIONS: Chronic Care

APPENDIX C-1: Component Questions and Scores - Chronic Care

Page 82

State of California • August 2010	

03.262

03.238

03.237

03.236

03.235

8
6.4
80%
133
83.4
63%

Received Points

Score

Total Possible Points

Total Received Points

Total Score

Score

Possible Points

11
58%

Received Points

Score
19

13.9
73%

Received Points

Possible Points

19

85%

Score

Possible Points

19
16.2

Possible Points

60%

Score

Received Points

18
10.8

Possible Points

46%

Score

Received Points

18
8.3

64%

Score

Possible Points

7.7

Received Points

Received Points

12

Possible Points

03.082

03.175

SAC

Ref
Number

84%

111.1

133

48%

3.8

8

95%

18.1

19

91%

17.2

19

96%

18.2

19

74%

13.3

18

77%

13.9

18

74%

8.9

12

CMF

49%

64.9

133

28%

2.2

8

50%

9.5

19

40%

7.6

19

76%

14.4

19

36%

6.5

18

50%

9

18

52%

6.2

12

RJD

81%

107.6

133

100%

8

8

90%

17

19

100%

19

19

80%

15.2

19

70%

12.6

18

55%

9.9

18

75%

9

12

CEN

74%

97.7

133

83%

6.7

8

93%

17.7

19

88%

16.6

19

72%

13.7

19

67%

12

18

65%

11.6

18

50%

6

12

DVI

73%

97.3

133

10%

0.8

8

94%

17.9

19

84%

16

19

70%

13.3

19

70%

12.6

18

40%

7.2

18

100%

12

12

CCWF

57%

76.2

133

84%

6.7

8

82%

15.6

19

72%

13.7

19

64%

12.2

19

48%

8.6

18

4%

0.8

18

48%

5.8

12

CMC

75%

99.8

133

90%

7.2

8

89%

16.9

19

84%

16

19

90%

17.1

19

65%

11.7

18

31%

5.6

18

90%

10.8

12

SCC

70%

93.2

133

32%

2.6

8

96%

18.2

19

75%

14.3

19

83%

15.8

19

64%

11.5

18

29%

5.3

18

96%

11.5

12

LAC

57%

75.7

133

96%

7.7

8

88%

16.8

19

63%

12

19

72%

13.7

19

44%

7.9

18

4%

0.8

18

60%

7.2

12

PVSP

62%

82.2

133

60%

4.8

8

71%

13.6

19

44%

8.4

19

76%

14.4

19

60%

10.8

18

48%

8.6

18

80%

9.6

12

CCI

67%

89.2

133

80%

6.4

8

85%

16.2

19

86%

16.4

19

72%

13.7

19

32%

5.8

18

20%

3.6

18

96%

11.5

12

CRC

COMPONENT SCORES: Chronic Care, continued

70%

92.6

133

80%

6.4

8

86%

16.3

19

86%

16.4

19

80%

15.2

19

68%

12.2

18

4%

0.8

18

88%

10.6

12

CIW

59%

78.8

133

100%

8

8

74%

14

19

71%

13.5

19

68%

12.9

19

48%

8.6

18

18%

3.3

18

44%

5.3

12

ASP

45%

59.8

133

64%

5.1

8

57%

10.9

19

59%

11.2

19

48%

9.1

19

32%

5.8

18

8%

1.4

18

76%

9.1

12

HDSP

65%

85.9

133

76%

6.1

8

92%

17.4

19

92%

17.4

19

76%

14.4

19

68%

12.2

18

8%

1.4

18

12%

1.4

12

SQ

46%

60.8

133

60%

4.8

8

53%

10

19

47%

9

19

60%

11.4

19

44%

7.9

18

17%

3.1

18

52%

6.2

12

CCC

64%

1456.2

2261

69%

93.7

136

80%

257.1

323

74%

238.6

323

75%

240.9

323

56%

170.8

306

31%

94.6

306

68%

138.8

204

Average
Score

APPENDIX C-1

Page 83

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

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

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

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

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

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?

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?

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

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

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

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

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

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

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

01.024

01.025

01.027

01.124

01.157

01.158

01.159

01.162

01.163

01.244

01.246

01.247

15.234

21.278

COMPONENT QUESTIONS: Clinical Services

APPENDIX C-2: Component Questions and Scores - Clinical Services

Bureau of Audits and Investigations, Office of the Inspector General	

Page 84

State of California • August 2010	
3.9
77%

Received Points

Score

Score
5

6.4
92%

Received Points

Possible Points

7

91%

Score

Possible Points

6
5.5

Possible Points

96%

Score

Received Points

6
5.7

92%

Score

Possible Points

6.4

Received Points

Received Points

7

22%

Score

Possible Points

1.3

Received Points

29%

Score
6

2.4

Received Points

Possible Points

8

76%

Score

Possible Points

continued on page 86

01.163

01.162

01.159

01.158

01.157

01.124

01.027

4.6

Received Points

Score
6

3.8
96%

Received Points

Possible Points

4

Possible Points

01.024

01.025

SAC

Ref
Number

94%

4.7

5

94%

6.6

7

77%

4.6

6

88%

5.3

6

96%

6.7

7

80%

4.8

6

82%

6.6

8

84%

5

6

96%

3.8

4

CMF

90%

4.5

5

100%

7

7

80%

4.8

6

79%

4.8

6

83%

5.8

7

55%

3.3

6

13%

1

8

80%

4.8

6

93%

3.7

4

RJD

93%

4.7

5

97%

6.8

7

90%

5.4

6

89%

5.4

6

100%

7

7

77%

4.6

6

50%

4

8

76%

4.6

6

87%

3.5

4

CEN

70%

3.5

5

96%

6.7

7

67%

4

6

91%

5.5

6

83%

5.8

7

33%

2

6

79%

6.3

8

88%

5.3

6

76%

3

4

DVI

96%

4.8

5

96%

6.7

7

88%

5.3

6

96%

5.8

6

92%

6.4

7

52%

3.1

6

56%

4.5

8

88%

5.3

6

52%

2.1

4

CCWF

85%

4.3

5

98%

6.8

7

73%

4.4

6

83%

5

6

93%

6.5

7

28%

1.7

6

75%

6

8

78%

4.7

6

90%

3.6

4

CMC

90%

4.5

5

95%

6.6

7

80%

4.8

6

95%

5.7

6

80%

5.6

7

13%

0.8

6

75%

6

8

65%

3.9

6

30%

1.2

4

SCC

86%

4.3

5

100%

7

7

55%

3.3

6

90%

5.4

6

59%

4.1

7

33%

2

6

35%

2.8

8

83%

5

6

77%

3.1

4

LAC

57%

2.8

5

63%

4.4

7

53%

3.2

6

33%

2

6

50%

3.5

7

11%

0.7

6

47%

3.8

8

33%

2

6

87%

3.5

4

PVSP

80%

4

5

92%

6.4

7

68%

4.1

6

68%

4.1

6

64%

4.5

7

41%

2.5

6

25%

2

8

60%

3.6

6

92%

3.7

4

CCI

95%

4.8

5

100%

7

7

90%

5.4

6

90%

5.4

6

45%

3.2

7

10%

0.6

6

54%

4.3

8

80%

4.8

6

45%

1.8

4

CRC

COMPONENT SCORES: Clinical Services

71%

3.5

5

96%

6.7

7

76%

4.6

6

79%

4.8

6

54%

3.8

7

28%

1.7

6

71%

5.6

8

68%

4.1

6

80%

3.2

4

CIW

82%

4.1

5

94%

6.6

7

59%

3.5

6

74%

4.4

6

65%

4.5

7

30%

1.8

6

52%

4.2

8

26%

1.5

6

89%

3.5

4

ASP

64%

3.2

5

100%

7

7

50%

3

6

61%

3.6

6

57%

4

7

44%

2.6

6

27%

2.1

8

40%

2.4

6

40%

1.6

4

HDSP

64%

3.2

5

100%

7

7

50%

3

6

27%

1.6

6

32%

2.2

7

22%

1.3

6

56%

4.4

8

34%

2.1

6

11%

0.5

4

SQ

63%

3.2

5

90%

6.3

7

79%

4.7

6

58%

3.5

6

79%

5.5

7

14%

0.9

6

46%

3.6

8

84%

5

6

80%

3.2

4

CCC

80%

68

85

94%

112

119

72%

73.6

102

76%

78

102

72%

85.5

119

35%

35.7

102

51%

69.6

136

67%

68.7

102

72%

48.8

68

Average
Score

APPENDIX C-2

Page 85

21.278

15.234

01.247

0%

Score
14.5
73%
95
63.6
67%

Received Points

Score

Total Possible Points

Total Received Points

Total Score

20

0

Possible Points

5

Possible Points

25%

Score

Received Points

7
1.8

Possible Points

92%

Score

Received Points

4.6

Received Points

92%

Score
5

2.8

Received Points

Possible Points

3

Possible Points

01.244

01.246

SAC

Ref
Number

87%

82.7

95

83%

16.7

20

100%

5

5

78%

5.4

7

92%

4.6

5

94%

2.8

3

CMF

67%

63.9

95

67%

13.3

20

50%

2.5

5

22%

1.6

7

87%

4.3

5

80%

2.4

3

RJD

80%

76.1

95

80%

16

20

0%

0

5

100%

7

7

90%

4.5

5

93%

2.8

3

CEN

73%

69.2

95

79%

15.7

20

0%

0

5

60%

4.2

7

96%

4.8

5

79%

2.4

3

DVI

74%

70.4

95

60%

12

20

50%

2.5

5

67%

4.7

7

96%

4.8

5

80%

2.4

3

CCWF

74%

70.4

95

81%

16.3

20

0%

0

5

67%

4.7

7

88%

4.4

5

80%

2.4

3

CMC

71%

67.5

95

85%

16.9

20

100%

5

5

0%

0

7

100%

5

5

50%

1.5

3

SCC

66%

62.2

95

80%

16

20

50%

2.5

5

20%

1.4

7

86%

4.3

5

35%

1

3

LAC

47%

44.4

95

33%

6.7

20

100%

5

5

36%

2.5

7

67%

3.3

5

33%

1

3

PVSP

57%

54.5

95

46%

9.1

20

50%

2.5

5

57%

4

7

64%

3.2

5

28%

0.8

3

CCI

70%

66.7

95

67%

13.3

20

100%

5

5

88%

6.1

7

95%

4.8

5

5%

0.2

3

CRC

COMPONENT SCORES: Clinical Services, continued

62%

58.6

95

36%

7.3

20

100%

5

5

56%

3.9

7

80%

4

5

12%

0.4

3

CIW

64%

61.2

95

60%

12

20

100%

5

5

63%

4.4

7

77%

3.8

5

65%

1.9

3

ASP

51%

48.5

95

41%

8.2

20

50%

2.5

5

50%

3.5

7

87%

4.3

5

7%

0.2

3

HDSP

47%

44.3

95

40%

8

20

50%

2.5

5

50%

3.5

7

91%

4.5

5

18%

0.5

3

SQ

66%

62.6

95

56%

11.1

20

100%

5

5

67%

4.7

7

90%

4.5

5

47%

1.4

3

CCC

66%

1066.8

1615

63%

213.1

340

59%

50

85

53%

63.4

119

87%

73.7

85

53%

26.9

51

Average
Score

APPENDIX C-2

Bureau of Audits and Investigations, Office of the Inspector General	

Page 86

State of California • August 2010	

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?

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

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

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?

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

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?

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?

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?

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

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?

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?

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

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

02.014

02.015

02.016

02.017

02.018

02.020

02.021

02.022

02.111

02.128

02.211

02.212

02.213

continued on page 88

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?

02.007

COMPONENT QUESTIONS: Health Screening

APPENDIX C-3: Component Questions and Scores - Health Screening

Page 87

Bureau of Audits and Investigations, Office of the Inspector General	

02.017

02.016

02.015

02.014

7

9

100%

8

Received Points

Score

8

Possible Points

100%

Received Points

Score

9

Possible Points

100%

Received Points

Score

7

Possible Points

Score

56%

4.4

8

100%

9

9

94%

7.6

8

97%

8.7

9

100%

7

7

90%

93%

7.5

8

100%

9

9

100%

7

64%

7
6.3
7

93%

7
4.5

Possible Points

100%

7
6.5

CEN

Received Points

Score

7
7

Possible Points

Received Points

02.007

RJD

100%

8

8

100%

9

9

100%

7

7

DVI

100%

8

8

100%

9

9

67%

4.7

7

CCWF

100%

8

8

100%

9

9

75%

5.3

7

0%

0

7

85%

6

7

CMC

29%

2.3

8

100%

9

9

83%

5.8

7

75%

5.3

7

SCC

46%

3.7

8

90%

8.1

9

100%

7

7

88%

6.1

7

LAC

70%

5.6

8

65%

5.9

9

95%

6.6

7

PVSP

100%

8

8

77%

6.9

9

33%

2.3

7

100%

7

7

95%

6.6

7

CCI

100%

8

8

95%

8.6

9

100%

7

7

100%

7

7

CRC

87%

6.9

8

95%

8.6

9

CIW

100%

8

8

90%

8.1

9

100%

7

7

95%

6.6

7

ASP

100%

8

8

93%

8.4

9

100%

7

7

85%

6

7

HDSP

90%

8.1

9

100%

7

7

100%

7

7

SQ

100%

8

8

85%

7.7

9

100%

7

7

100%

7

7

100%

7

7

CCC

86%

110

128

93%

142.1

153

87%

67.1

77

83%

35

42

90%

88.5

98

Average
Score

Reception center history and physical: Has required intake testing been ordered?

02.219

CMF

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?

02.218

SAC

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

02.217

Ref
Number

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?

02.216

COMPONENT SCORES: Health Screening

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

02.215

COMPONENT QUESTIONS: Health Screening, continued

APPENDIX C-3

Page 88

State of California • August 2010	
6

7

4

Score

100%

2

Received Points

88%

Score
2

1.8

Received Points

Possible Points

2

75%

Possible Points

Score

50%
1.5

88%

8

Received Points

Score

8

4.5
75%

2

2.7
33%

Received Points

6
100%

Possible Points

8

Possible Points

67%

4

Score

Received Points

6

0%

Score
6

0

Possible Points

4

Possible Points

56%

Score

Received Points

5

87%
2.8

70%

5.2

6

13%

1

8

RJD

Possible Points

90%

Score

4.2

6

100%

8

8

CMF

Received Points

6
5.4

Possible Points

Received Points

continued on page 90

02.213

02.212

02.211

02.128

02.111

02.022

02.021

02.020

2

Received Points
25%

8

Possible Points

02.018

Score

SAC

Ref
Number

50%

4

8

33%

2

6

90%

5.4

6

60%

4.8

8

CEN

100%

2

2

60%

1.2

2

92%

1.8

2

0%

0

8

55%

2.8

5

100%

6

6

50%

4

8

DVI

100%

2

2

100%

2

2

100%

2

2

43%

3.4

8

55%

2.8

5

100%

6

6

86%

6.9

8

CCWF

13%

1

8

100%

6

6

85%

5.1

6

100%

8

8

CMC

25%

2

8

95%

5.7

6

29%

2.3

8

SCC

75%

1.5

2

85%

1.7

2

40%

0.8

2

42%

3.3

8

75%

4.5

6

50%

2.5

5

100%

6

6

0%

0

8

LAC

0%

0

8

100%

6

6

85%

5.1

6

71%

5.7

8

PVSP

100%

2

2

100%

2

2

89%

1.8

2

43%

3.4

8

100%

6

6

100%

5

5

80%

4.8

6

33%

2.7

8

CCI

23%

1.8

8

75%

4.5

6

100%

6

6

11%

0.9

8

CRC

COMPONENT SCORES: Health Screening, continued

75%

1.5

2

90%

1.8

2

82%

1.6

2

0%

0

8

40%

2

5

90%

5.4

6

CIW

30%

2.4

8

100%

6

6

85%

5.1

6

55%

4.4

8

ASP

80%

1.6

2

90%

1.8

2

60%

1.2

2

35%

2.8

8

100%

6

6

100%

5

5

97%

5.8

6

17%

1.3

8

HDSP

24%

1.9

8

50%

3

6

95%

4.8

5

96%

5.8

6

61%

4.9

8

SQ

17%

1.3

8

100%

6

6

100%

6

6

40%

3.2

8

CCC

90%

12.6

14

88%

12.3

14

76%

10.7

14

30%

41

136

83%

64.5

78

0%

0

4

69%

27.7

40

91%

93

102

47%

60.1

128

Average
Score

APPENDIX C-3

Page 89

02.219

02.218

02.217

02.216

02.215

59

52

76%

Total Score

87%

45.1
68%

58.5

86

70%

Score
45.1

2.8

Received Points

Total Possible Points

4

Possible Points

100%

2

Received Points

Score

2

88%

Score

Possible Points

1.8

Received Points

75%

Score
2

1.5

Received Points

Possible Points

2

Score

Possible Points

0
0%

Received Points

RJD
2

CMF

Possible Points

SAC

Total Received Points

Ref
Number

78%

45.9

59

CEN

74%

51.3

69

50%

2

4

85%

1.7

2

95%

1.9

2

95%

1.9

2

100%

2

2

DVI

84%

56.5

67

100%

4

4

100%

2

2

90%

1.8

2

100%

2

2

CCWF

73%

48.3

66

CMC

61%

32.4

53

SCC

69%

56.4

82

95%

3.8

4

100%

2

2

100%

2

2

100%

2

2

70%

1.4

2

LAC

67%

34.9

52

PVSP

78%

69.7

89

90%

3.6

4

100%

2

2

100%

2

2

100%

2

2

80%

1.6

2

CCI

74%

43.8

59

CRC

COMPONENT SCORES: Health Screening, continued

70%

37.7

54

100%

4

4

100%

2

2

89%

1.8

2

85%

1.7

2

20%

0.4

2

CIW

81%

47.6

59

ASP

72%

59.3

82

20%

0.8

4

67%

1.3

2

56%

1.1

2

60%

1.2

2

0%

0

2

HDSP

77%

45.9

60

85%

3.4

4

SQ

81%

53.2

66

CCC

75%

831.6

1114

76%

24.4

32

93%

13

14

89%

12.4

14

88%

12.3

14

45%

5.4

12

Average
Score

APPENDIX C-3

Bureau of Audits and Investigations, Office of the Inspector General	

Page 90

State of California • August 2010	
8
0.6
8%

Received Points

Score

46%

Score

Possible Points

3.6

Received Points

continued on page 92

07.038

8

47%

Score

Possible Points

4.2

Received Points

07.037

9

Possible Points

07.035

31%

2.5

8

46%

3.6

8

35%

3.2

9

25%

2

8

100%

8

8

59%

5.3

9

15%

1.2

8

64%

5.1

8

59%

5.3

9

CEN

9%

0.7

8

55%

4.4

8

59%

5.3

9

DVI

0%

0

8

70%

5.6

8

94%

8.5

9

CCWF

23%

1.8

8

91%

7.3

8

59%

5.3

9

CMC

36%

2.9

8

64%

5.1

8

77%

6.9

9

SCC

29%

2.3

8

91%

7.3

8

65%

5.8

9

LAC

8%

0.7

8

86%

6.9

8

69%

6.2

9

PVSP

29%

2.4

8

77%

6.2

8

41%

3.7

9

CCI

7%

0.5

8

50%

4

8

29%

2.6

9

CRC

38%

3

8

79%

6.3

8

88%

7.9

9

33%

2.7

8

73%

5.8

8

77%

6.9

9

7%

0.5

8

96%

7.6

8

47%

4.2

9

0%

0

8

91%

7.3

8

65%

5.8

9

SQ

56%

4.4

8

82%

6.5

8

88%

7.9

9

CCC

21%

28.2

136

74%

100.6

136

62%

95

153

Average
Score

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?

07.270

HDSP

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

07.261

ASP

Was the institution’s denial of the PCP’s request for specialty services consistent with the “medical necessity” requirement?

07.260

CIW

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

07.259

RJD

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

07.090

CMF

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?

07.043

SAC

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?

07.038

Ref
Number

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

07.037

COMPONENT SCORES: Specialty Services

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

07.035

COMPONENT QUESTIONS: Specialty Services

APPENDIX C-4: Component Questions and Scores - Specialty Services

Page 91

07.270

07.261

07.260

07.259

07.090

2

Received Points

47%

Total Score

71

71
33.7

Total Possible Points

Total Received Points

59%

53%

Score

6

Bureau of Audits and Investigations, Office of the Inspector General	
43%

30.2

3.5

6

0%

3.2

0%

Score

0

9

Possible Points

0

60%

5.4

9

80%

4

5

67%

5.3

8

29%

2.6

9

CMF

Received Points

9

Possible Points

Received Points

100%

9

Received Points

Score

9

Possible Points

60%

3

Received Points

Score

5

Possible Points

100%

8

Received Points

Score

8

Possible Points

22%

9

Possible Points

07.043

Score

SAC

Ref
Number

62%

44.2

71

88%

5.3

6

0%

0

9

100%

9

9

100%

5

5

100%

8

8

19%

1.7

9

RJD

60%

42.3

71

100%

6

6

0%

0

9

100%

9

9

80%

4

5

100%

8

8

41%

3.7

9

CEN

53%

37.9

71

77%

4.6

6

50%

4.5

9

75%

6.8

9

60%

3

5

100%

8

8

8%

0.7

9

DVI

53%

37.4

71

100%

6

6

0%

0

9

67%

6

9

33%

1.7

5

100%

8

8

18%

1.6

9

CCWF

63%

45

71

100%

6

6

50%

4.5

9

100%

9

9

40%

2

5

100%

8

8

13%

1.1

9

CMC

73%

51.9

71

94%

5.6

6

100%

9

9

80%

7.2

9

100%

5

5

100%

8

8

25%

2.3

9

SCC

70%

49.9

71

100%

6

6

50%

4.5

9

100%

9

9

75%

3.8

5

100%

8

8

36%

3.2

9

LAC

61%

43

71

100%

6

6

0%

0

9

100%

9

9

60%

3

5

100%

8

8

36%

3.2

9

PVSP

57%

40.7

71

100%

6

6

0%

0

9

80%

7.2

9

60%

3

5

100%

8

8

47%

4.2

9

CCI

59%

42

71

100%

6

6

50%

4.5

9

100%

9

9

80%

4

5

100%

8

8

38%

3.4

9

CRC

COMPONENT SCORES: Specialty Services, continued

63%

44.8

71

100%

6

6

0%

0

9

100%

9

9

50%

2.5

5

100%

8

8

23%

2.1

9

CIW

74%

52.6

71

100%

6

6

50%

4.5

9

80%

7.2

9

100%

5

5

100%

8

8

73%

6.5

9

ASP

53%

37.8

71

94%

5.6

6

50%

4.5

9

60%

5.4

9

40%

2

5

100%

8

8

0%

0

9

HDSP

58%

41.2

71

100%

6

6

0%

0

9

100%

9

9

60%

3

5

100%

8

8

23%

2.1

9

SQ

71%

50.2

71

100%

6

6

100%

9

9

40%

3.6

9

20%

1

5

100%

8

8

42%

3.8

9

CCC

60%

724.8

1207

92%

93.8

102

29%

45

153

85%

129.8

153

65%

55

85

98%

133.3

136

29%

44.2

153

Average
Score

APPENDIX C-4

Page 92

State of California • August 2010	
7
5.1
73%

Received Points

Score

60%

Score

Possible Points

4.2

Received Points

continued on page 94

21.250

7

79%

Score

Possible Points

5.5

Received Points

21.249

7

Possible Points

21.248

80%

5.6

7

85%

6

7

90%

6.3

7

50%

3.5

7

24%

1.7

7

65%

4.6

7

RJD

100%

7

7

65%

4.6

7

75%

5.3

7

CEN

96%

6.7

7

64%

4.5

7

88%

6.2

7

DVI

100%

7

7

52%

3.6

7

92%

6.4

7

CCWF

100%

7

7

88%

6.1

7

84%

5.9

7

CMC

100%

7

7

92%

6.4

7

100%

7

7

SCC

100%

7

7

40%

2.8

7

96%

6.7

7

LAC

96%

6.7

7

58%

4.1

7

88%

6.2

7

PVSP

100%

7

7

48%

3.3

7

92%

6.4

7

CCI

96%

6.7

7

84%

5.9

7

100%

7

7

CRC

96%

6.7

7

56%

3.9

7

84%

5.9

7

100%

7

7

52%

3.6

7

92%

6.4

7

100%

7

7

48%

3.4

7

32%

2.2

7

72%

5

7

48%

3.4

7

52%

3.6

7

SQ

100%

7

7

82%

5.8

7

88%

6.2

7

CCC

92%

109

119

62%

73.3

119

82%

97.8

119

Average
Score

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?

21.281

HDSP

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

21.279

ASP

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

21.276

CIW

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

21.275

CMF

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?

21.251

SAC

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?

21.250

Ref
Number

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?

21.249

COMPONENT SCORES: Urgent Services

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?

21.248

COMPONENT QUESTIONS: Urgent Services

APPENDIX C-5: Component Questions and Scores - Urgent Services

Page 93

21.281

21.279

21.276

21.275

6
59
48.7
83%

Total Possible Points

Total Received Points

Total Score

100%

Received Points

Score

6

Possible Points

100%

8

Score

Received Points

Score
8

6.4
91%

Received Points

Possible Points

7

65%

Score

Possible Points

10
6.5

Possible Points

Received Points

100%

7
7

Possible Points

Received Points

21.251

Score

SAC

Ref
Number

79%

40.4

51

100%

6

6

100%

7

7

95%

9.5

10

0%

0

7

CMF

73%

43.2

59

58%

3.5

6

100%

8

8

95%

6.7

7

83%

8.3

10

100%

7

7

RJD

80%

41.7

52

79%

4.7

6

83%

6.7

8

91%

6.3

7

72%

7.2

10

CEN

78%

45.7

59

79%

4.7

6

100%

8

8

92%

6.4

7

92%

9.2

10

0%

0

7

DVI

89%

52.8

59

88%

5.3

6

100%

8

8

100%

7

7

84%

8.4

10

100%

7

7

CCWF

84%

36.8

44

64%

3.8

6

91%

6.4

7

76%

7.6

10

CMC

89%

46.3

52

48%

2.9

6

100%

8

8

100%

7

7

80%

8

10

SCC

80%

41.7

52

38%

2.3

6

100%

8

8

87%

6.1

7

88%

8.8

10

LAC

81%

47.5

59

13%

0.8

6

100%

8

8

96%

6.7

7

80%

8

10

100%

7

7

PVSP

83%

43

52

67%

4

6

100%

8

8

95%

6.7

7

76%

7.6

10

CCI

81%

42.2

52

47%

2.8

6

100%

8

8

83%

5.8

7

60%

6

10

CRC

COMPONENT SCORES: Urgent Services, continued

75%

39.2

52

44%

2.6

6

100%

8

8

81%

5.7

7

64%

6.4

10

CIW

70%

36.5

52

10%

0.6

6

100%

8

8

64%

4.5

7

64%

6.4

10

ASP

72%

37.4

52

47%

2.8

6

100%

8

8

63%

4.4

7

96%

9.6

10

HDSP

63%

32.7

52

7%

0.4

6

100%

8

8

79%

5.5

7

68%

6.8

10

SQ

84%

43.5

52

50%

3

6

100%

8

8

67%

4.7

7

88%

8.8

10

CCC

79%

719.3

910

55%

56.2

102

99%

118.7

120

87%

103.3

119

78%

133.1

170

67%

28

42

Average
Score

APPENDIX C-5

Bureau of Audits and Investigations, Office of the Inspector General	

Page 94

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

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

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?

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?

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

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

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

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?

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?

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

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

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

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

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

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

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

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

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? Note: We eliminated this question following
the first inspection due to the potential for inconsistent answers.

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

08.183

08.184

08.185

08.186

08.187

08.222

08.241

08.242

15.240

15.255

15.256

15.257

15.258

15.282

15.283

15.284

15.285

15.286

15.287

COMPONENT QUESTIONS: Emergency Services

APPENDIX C-6: Component Questions and Scores - Emergency Services

State of California • August 2010	

Page 95

Bureau of Audits and Investigations, Office of the Inspector General	

15.240

08.242

08.241

08.222

08.187

08.186

08.185

100%

2

Received Points

Score

2

Possible Points

50%

3

Received Points

Score

6

Score

Possible Points

0
0%

Received Points

Score
6

3.5
50%

Received Points

Possible Points

7

50%

Possible Points

Score

4
2

Possible Points

100%

Received Points

Score

4
4

Possible Points

50%

Score

Received Points

7
3.5

Possible Points

Received Points

100%

4

Received Points

Score

4

Possible Points

100%

5

Received Points

Score

5

Possible Points

08.183

08.184

SAC

Ref
Number

100%

2

2

100%

6

6

40%

2.4

6

0%

0

7

100%

4

4

100%

4

4

100%

7

7

100%

4

4

100%

5

5

CMF

100%

2

2

100%

6

6

80%

4.8

6

100%

7

7

100%

4

4

100%

4

4

100%

7

7

80%

3.2

4

100%

5

5

RJD

100%

6

6

50%

3

6

0%

0

7

100%

4

4

100%

4

4

100%

7

7

100%

4

4

100%

5

5

CEN

100%

2

2

60%

3.6

6

100%

6

6

0%

0

7

100%

4

4

100%

4

4

80%

5.6

7

100%

4

4

100%

5

5

DVI

100%

2

2

80%

4.8

6

100%

6

6

40%

2.8

7

80%

3.2

4

100%

4

4

100%

7

7

67%

2.7

4

100%

5

5

CCWF

100%

2

2

100%

6

6

100%

6

6

0%

0

7

100%

4

4

100%

4

4

80%

5.6

7

100%

4

4

100%

5

5

CMC

100%

2

2

100%

6

6

50%

3

6

0%

0

7

100%

4

4

100%

4

4

100%

7

7

100%

4

4

100%

5

5

SCC

100%

2

2

75%

4.5

6

100%

6

6

0%

0

7

100%

4

4

100%

4

4

100%

7

7

100%

4

4

100%

5

5

LAC

100%

2

2

100%

6

6

100%

6

6

0%

0

7

100%

4

4

100%

4

4

100%

7

7

75%

3

4

100%

5

5

PVSP

100%

2

2

75%

4.5

6

100%

6

6

0%

0

7

67%

2.7

4

100%

4

4

100%

7

7

50%

2

4

100%

5

5

CCI

100%

2

2

60%

3.6

6

67%

4

6

25%

1.8

7

60%

2.4

4

100%

4

4

100%

7

7

100%

4

4

80%

4

5

CRC

100%

2

2

CIW

COMPONENT SCORES: Emergency Services

100%

2

2

75%

4.5

6

100%

6

6

50%

3.5

7

0%

0

4

100%

4

4

75%

5.3

7

100%

4

4

100%

5

5

ASP

100%

2

2

100%

6

6

100%

6

6

25%

1.8

7

67%

2.7

4

100%

4

4

75%

5.3

7

100%

4

4

100%

5

5

HDSP

100%

2

2

60%

3.6

6

60%

3.6

6

0%

0

7

100%

4

4

100%

4

4

100%

7

7

80%

3.2

4

100%

5

5

SQ

100%

2

2

100%

6

6

100%

6

6

100%

7

7

100%

4

4

0%

0

4

100%

7

7

100%

4

4

100%

5

5

CCC

100%

32

32

83%

80.1

96

78%

74.8

96

24%

27.4

112

83%

53

64

94%

60

64

91%

102.3

112

91%

58.1

64

99%

79

80

Average
Score

APPENDIX C-6

Page 96

State of California • August 2010	

15.287

15.286

15.285

15.284

15.283

15.282

15.258

15.257

1

Score
0
0%
59
28
48%

Received Points

Score

Total Possible Points

Total Received Points

Total Score

2

0
0%

Received Points

Possible Points

1

Possible Points

100%

Received Points

Score

1

0%

Score

Possible Points

1
0

Possible Points

0%

Score

Received Points

1
0

0%

Score

Possible Points

0

Received Points

Received Points

2

0%

Score

Possible Points

0

Received Points

0%

Score
2

0

Received Points

Possible Points

2

0%

Score

Possible Points

0

Received Points

Score
1

0
0%

Received Points

Possible Points

1

Possible Points

15.255

15.256

SAC

Ref
Number

Page 97
72%

40.4

56

100%

1

1

0%

0

1

100%

1

1

100%

2

2

0%

0

2

100%

2

2

0%

0

1

0%

0

1

CMF

90%

52

58

0%

0

2

100%

1

1

100%

1

1

100%

1

1

100%

2

2

100%

2

2

0%

0

2

100%

1

1

100%

1

1

RJD

77%

33

43

CEN

71%

41.2

58

0%

0

2

100%

1

1

100%

1

1

0%

0

1

100%

2

2

100%

2

2

0%

0

2

100%

1

1

0%

0

1

DVI

80%

46.5

58

100%

2

2

100%

1

1

100%

1

1

100%

1

1

100%

2

2

100%

2

2

0%

0

2

0%

0

1

0%

0

1

CCWF

86%

49.6

58

100%

2

2

100%

1

1

100%

1

1

100%

1

1

100%

2

2

100%

2

2

100%

2

2

100%

1

1

100%

1

1

CMC

76%

44

58

100%

2

2

100%

1

1

100%

1

1

100%

1

1

100%

2

2

0%

0

2

100%

2

2

0%

0

1

0%

0

1

SCC

84%

44.5

53

100%

2

2

100%

2

2

100%

2

2

100%

1

1

100%

1

1

LAC

83%

48

58

0%

0

2

100%

1

1

100%

1

1

100%

1

1

100%

2

2

100%

2

2

100%

2

2

100%

1

1

100%

1

1

PVSP

78%

45.2

58

100%

2

2

100%

1

1

100%

1

1

100%

1

1

100%

2

2

100%

2

2

100%

2

2

100%

1

1

0%

0

1

CCI

73%

40.8

56

100%

2

2

100%

1

1

100%

1

1

0%

0

1

100%

2

2

0%

0

2

100%

1

1

100%

1

1

CRC

COMPONENT SCORES: Emergency Services, continued

80%

12

15

100%

2

2

100%

1

1

100%

1

1

100%

1

1

100%

2

2

100%

2

2

0%

0

2

100%

1

1

0%

0

1

CIW

78%

45.3

58

100%

2

2

100%

1

1

100%

1

1

100%

1

1

100%

2

2

100%

2

2

0%

0

2

100%

1

1

100%

1

1

ASP

72%

41.8

58

100%

2

2

100%

1

1

0%

0

1

100%

1

1

0%

0

2

0%

0

2

0%

0

2

100%

1

1

0%

0

1

HDSP

78%

45.4

58

100%

2

2

100%

1

1

100%

1

1

100%

1

1

100%

2

2

100%

2

2

100%

2

2

100%

1

1

100%

1

1

SQ

90%

52

58

100%

2

2

100%

1

1

100%

1

1

100%

1

1

100%

2

2

100%

2

2

0%

0

2

100%

1

1

100%

1

1

CCC

77%

709.7

920

73%

22

30

0%

0

1

100%

15

15

80%

12

15

80%

12

15

87%

26

30

69%

22

32

47%

14

30

75%

12

16

50%

8

16

Average
Score

APPENDIX C-6

Did the inmate receive her six-week check-up (post-delivery)?

Were the results of the inmate’s specified prenatal screening tests documented on Form 5703N?

Was the inmate’s weight and blood pressure documented at each clinic visit?

09.074

09.223

09.224

Bureau of Audits and Investigations, Office of the Inspector General	

09.068

09.067

09.066

SCC

LAC

PVSP

CCI

CRC

CIW

5
2.1
43%

Possible Points

Received Points

Score

100%

5

Score

5

Possible Points

Received Points

0%

CMC

Score

CCWF

0

DVI

Received Points

CEN

5

RJD

Possible Points

CMF

ASP

HDSP

43%

2.1

5

100%

5

5

0%

0

5

Average
Score

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

09.072

CCC

Did the inmate visit with an OB physician according to the applicable time frames?

09.071

SQ

Did medical staff promptly order extra daily nutritional supplements and food for the inmate?

09.069

SAC

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?

09.068

Ref
Number

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?

09.067

COMPONENT SCORES: Prenatal Care/Childbirth/Post-Delivery

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?

09.066

COMPONENT QUESTIONS: Prenatal Care/Childbirth/Post-Delivery

APPENDIX C-7: Component Questions and Scores - Prenatal Care

Page 98

State of California • August 2010	

09.224

09.223

09.074

09.072

09.071

09.069

CMC

SCC

LAC

PVSP

CCI

CRC

CIW

Score

4.3
71%
53
32.5
61%

Score

Total Possible Points

Total Received Points

Total Score

6

4.3
86%

Received Points

Possible Points

5

80%

Score

Possible Points

7
5.6

0%

Score

Possible Points

0

Received Points

7

Possible Points

86%

Score

Received Points

8
6.9

Possible Points

Received Points

86%

CCWF

Score

DVI

4.3

CEN

Received Points

RJD
5

CMF

Possible Points

SAC

Received Points

Ref
Number
ASP

COMPONENT SCORES: Prenatal Care/Childbirth/Post-Delivery, continued
HDSP

SQ

CCC

61%

32.5

53

71%

4.3

6

86%

4.3

5

80%

5.6

7

0%

0

7

86%

6.9

8

86%

4.3

5

Average
Score

APPENDIX C-7

Page 99

Bureau of Audits and Investigations, Office of the Inspector General	

06.202

06.200

06.191

06.188

7

0%

Score
2.1
30%

Received Points

Score

7

0

Received Points

Possible Points

7

78%

Score

Possible Points

5.4

Received Points

Score
7

5.4
90%

Received Points

Possible Points

6

Possible Points

100%

Received Points

Score

7

Possible Points

06.049

50%

3.5

7

20%

1.4

7

87%

6.1

7

90%

5.4

6

80%

5.6

7

60%

4.2

7

0%

0

7

58%

4.1

7

50%

3

6

100%

7

7

RJD

50%

3.5

7

100%

7

7

88%

6.1

7

60%

3.6

6

100%

7

7

CEN

60%

4.2

7

100%

7

7

75%

5.3

7

80%

4.8

6

20%

1.4

7

DVI

40%

2.8

7

100%

7

7

80%

5.6

7

70%

4.2

6

100%

7

7

CCWF

50%

3.5

7

20%

1.4

7

70%

4.9

7

80%

4.8

6

80%

5.6

7

CMC

70%

4.9

7

100%

7

7

56%

3.9

7

100%

6

6

100%

7

7

SCC

0%

0

7

0%

0

7

14%

1

7

90%

5.4

6

100%

7

7

LAC

10%

0.7

7

0%

0

7

73%

5.1

7

70%

4.2

6

80%

5.6

7

PVSP

10%

0.7

7

0%

0

7

67%

4.7

7

40%

2.4

6

80%

5.6

7

CCI

40%

2.8

7

20%

1.4

7

64%

4.5

7

90%

5.4

6

0%

0

7

CRC

60%

4.2

7

20%

1.4

7

69%

4.8

7

50%

3

6

100%

7

7

100%

7

7

80%

5.6

7

87%

6.1

7

70%

4.2

6

60%

4.2

7

0%

0

7

20%

1.4

7

62%

4.3

7

30%

1.8

6

60%

4.2

7

HDSP

0%

0

7

0%

0

7

89%

6.2

7

100%

6

6

100%

7

7

SQ

30%

2.1

7

60%

4.2

7

73%

5.1

7

70%

4.2

6

60%

4.2

7

CCC

39%

46.2

119

38%

44.8

119

70%

83.2

119

72%

73.8

102

78%

92.4

119

Average
Score

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

06.263

ASP

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

06.245

CIW

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?

06.202

CMF

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?

06.200

SAC

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

06.191

Ref
Number

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

06.188

COMPONENT SCORES: Diagnostic Services

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

06.049

COMPONENT QUESTIONS: Diagnostic Services

APPENDIX C-8: Component Questions and Scores - Diagnostic Services

Page 100

68%

Total Score

52

52
35.4

Total Possible Points

Total Received Points

92%

91%

Score

10

72%

37.5

9.2

10

80%

9.1

80%

Score

6.4

Possible Points

6.4

Received Points

8

CMF

Received Points

8

Possible Points

06.245

06.263

SAC

Ref
Number

64%

33.3

52

70%

7

10

100%

8

8

RJD

74%

38.7

52

67%

6.7

10

60%

4.8

8

CEN

74%

38.3

52

77%

7.7

10

100%

8

8

DVI

84%

43.6

52

90%

9

10

100%

8

8

CCWF

70%

36.4

52

82%

8.2

10

100%

8

8

CMC

86%

44.6

52

78%

7.8

10

100%

8

8

SCC

54%

28.1

52

67%

6.7

10

100%

8

8

LAC

65%

33.6

52

100%

10

10

100%

8

8

PVSP

60%

31.4

52

100%

10

10

100%

8

8

CCI

59%

30.4

52

83%

8.3

10

100%

8

8

CRC

COMPONENT SCORES: Diagnostic Services, continued

71%

36.7

52

83%

8.3

10

100%

8

8

CIW

87%

45.1

52

100%

10

10

100%

8

8

ASP

43%

22.3

52

58%

5.8

10

60%

4.8

8

HDSP

69%

36.1

52

89%

8.9

10

100%

8

8

SQ

71%

36.8

52

90%

9

10

100%

8

8

CCC

69%

608.3

884

83%

141.7

170

93%

126.4

136

Average
Score

APPENDIX C-8

State of California • August 2010	

Page 101

Bureau of Audits and Investigations, Office of the Inspector General	

19.271

19.266

19.243

15

5
0
0%

Received Points

Score

0%

Score

Possible Points

0

Received Points

Score
5

0
0%

Received Points

Possible Points

12

Possible Points

100%

Received Points

Score

15

0%

Score

Possible Points

0

19.169

9

Possible Points

Received Points

19.150

100%

5

5

100%

5

5

0%

0

12

100%

15

15

0%

0

9

CMF

0%

0

5

100%

5

5

0%

0

12

100%

15

15

0%

0

9

RJD

100%

5

5

100%

5

5

100%

12

12

100%

15

15

0%

0

9

CEN

100%

5

5

100%

5

5

0%

0

12

100%

15

15

0%

0

9

DVI

100%

5

5

100%

5

5

0%

0

12

100%

15

15

0%

0

9

CCWF

0%

0

5

100%

5

5

0%

0

12

100%

15

15

0%

0

9

CMC

100%

5

5

100%

5

5

100%

12

12

100%

15

15

0%

0

9

SCC

100%

5

5

100%

5

5

100%

12

12

100%

15

15

0%

0

9

LAC

100%

5

5

0%

0

5

100%

12

12

100%

15

15

0%

0

9

PVSP

60%

3

5

100%

5

5

0%

0

12

100%

15

15

0%

0

9

CCI

100%

5

5

100%

5

5

100%

12

12

100%

15

15

0%

0

9

CRC

100%

5

5

100%

5

5

0%

0

12

100%

15

15

0%

0

9

CIW

100%

5

5

0%

0

5

0%

0

12

0%

0

15

0%

0

9

ASP

100%

5

5

100%

5

5

0%

0

12

100%

15

15

0%

0

9

100%

5

5

100%

5

5

0%

0

12

100%

15

15

0%

0

9

100%

5

5

100%

5

5

100%

12

12

100%

15

15

0%

0

9

CCC

80%

68

85

82%

70

85

35%

72

204

94%

240

255

0%

0

153

Average
Score

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

19.272

SQ

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

19.271

HDSP

Does the institution properly file inmates’ medical information?

19.266

SAC

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

19.243

Ref
Number

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

19.169

COMPONENT SCORES: Access to Health Care Information

Is the medical records office current with its loose filing?

19.150

COMPONENT QUESTIONS: Access to Health Care Information

APPENDIX C-9: Component Questions and Scores - Access to Health Care Information

Page 102

20
39%

Total Score

59%

30

51

51

Total Possible Points

Total Received Points

5
100%

5

Received Points

5

CMF

100%

5

Possible Points

19.272

Score

SAC

Ref
Number

44%

22.5

51

50%

2.5

5

RJD

82%

42

51

100%

5

5

CEN

59%

30

51

100%

5

5

DVI

54%

27.5

51

50%

2.5

5

CCWF

39%

20

51

0%

0

5

CMC

82%

42

51

100%

5

5

SCC

73%

37

51

0%

0

5

LAC

63%

32

51

0%

0

5

PVSP

55%

28

51

100%

5

5

CCI

78%

39.5

51

50%

2.5

5

CRC

59%

30

51

100%

5

5

CIW

5

5

ASP

20%

10

51

100%

COMPONENT SCORES: Access to Health Care Information, continued

59%

30

51

100%

5

5

HDSP

54%

27.5

51

50%

2.5

5

SQ

78%

39.5

51

50%

2.5

5

CCC

59%

507.5

867

68%

57.5

85

Average
Score

APPENDIX C-9

State of California • August 2010	

Page 103

Bureau of Audits and Investigations, Office of the Inspector General	

04.054

04.053

4
0
0%

Received Points

Score

30%

Score

Possible Points

1.2

Received Points

90%

Score
4

4.5

Received Points

Possible Points

5

Score

Possible Points

4.5
90%

Received Points

04.052

5

Possible Points

04.051

Does the OHU use disinfectant daily in common patient areas?

15.225

11%

0.4

4

78%

3.1

4

100%

5

5

80%

4

5

RJD

CEN

0%

0

4

100%

4

4

80%

4

5

80%

4

5

DVI

CCWF

CMC

0%

0

4

50%

2

4

100%

5

5

100%

5

5

SCC

LAC

PVSP

50%

2

4

33%

1.3

4

60%

3

5

80%

4

5

CCI

0%

0

4

100%

4

4

100%

5

5

100%

5

5

CRC

0%

0

4

100%

4

4

90%

4.5

5

70%

3.5

5

CIW

0%

0

4

75%

3

4

80%

4

5

80%

4

5

0%

0

4

100%

4

4

100%

5

5

80%

4

5

0%

0

4

50%

2

4

90%

4.5

5

80%

4

5

6%

2.4

40

72%

28.6

40

89%

44.5

50

84%

42

50

Average
Score

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

15.103

CCC

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

04.230

SQ

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

04.208

HDSP

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

04.112

ASP

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

04.056

CMF

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

04.054

SAC

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?

04.053

Ref
Number

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

04.052

COMPONENT SCORES: Outpatient Housing Unit

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

04.051

COMPONENT QUESTIONS: Outpatient Housing Unit

APPENDIX C-10: Component Questions and Scores - Outpatient Housing Unit

Page 104

State of California • August 2010	

15.225

15.103

04.230

04.208

04.112

5

Received Points

48
36.3
76%

Total Possible Points

Total Received Points

Total Score

100%

3

Score

Received Points

Score
3

0
0%

Received Points

Possible Points

3

Possible Points

100%

5

Score

5

Possible Points

Received Points

100%

9

Score

9

Possible Points

82%

Score

Received Points

5
4.1

Possible Points

Received Points

100%

5

Possible Points

04.056

Score

SAC

Ref
Number

86%

41.1

48

100%

3

3

100%

3

3

90%

4.5

5

100%

9

9

90%

4.5

5

90%

4.5

5

CMF

RJD

CEN

83%

39.8

48

100%

3

3

100%

3

3

100%

5

5

100%

9

9

80%

4

5

75%

3.8

5

DVI

CCWF

CMC

75%

36.1

48

100%

3

3

0%

0

3

89%

4.4

5

100%

9

9

78%

3.9

5

75%

3.8

5

SCC

LAC

PVSP

73%

35.2

48

100%

3

3

0%

0

3

100%

5

5

100%

9

9

70%

3.5

5

88%

4.4

5

CCI

75%

35.9

48

0%

0

3

0%

0

3

100%

5

5

100%

9

9

70%

3.5

5

89%

4.4

5

CRC

63%

30.4

48

100%

3

3

0%

0

3

100%

5

5

78%

7

9

30%

1.5

5

38%

1.9

5

CIW

COMPONENT SCORES: Outpatient Housing Unit, continued

71%

34.2

48

100%

3

3

100%

3

3

63%

3.1

5

100%

9

9

40%

2

5

63%

3.1

5

ASP

HDSP

83%

40

48

100%

3

3

0%

0

3

100%

5

5

100%

9

9

100%

5

5

100%

5

5

SQ

82%

39.5

48

100%

3

3

100%

3

3

100%

5

5

100%

9

9

80%

4

5

100%

5

5

CCC

77%

368.5

480

90%

27

30

40%

12

30

94%

47

50

98%

88

90

72%

36

50

82%

40.9

50

Average
Score

APPENDIX C-10

Page 105

Bureau of Audits and Investigations, Office of the Inspector General	

17.135

17.132

17.119
5

100%

5

Score

Received Points

Score
5

4.2
83%

Received Points

Possible Points

5

Possible Points

100%

Received Points

Score

5

Possible Points

100%

5

Score

5

Possible Points

Received Points

17.118

5

100%

5

5

83%

4.2

5

83%

4.2

5

83%

4.2

100%

5

5

100%

5

5

100%

5

5

100%

5

5

100%

5

5

83%

4.2

5

50%

2.5

5

33%

1.7

5

CEN

100%

5

5

83%

4.2

5

100%

5

5

83%

4.2

5

DVI

100%

5

5

83%

4.2

5

100%

5

5

100%

5

5

CCWF

100%

5

5

83%

4.2

5

100%

5

5

100%

5

5

CMC

100%

5

5

50%

2.5

5

100%

5

5

33%

1.7

5

SCC

100%

5

5

83%

4.2

5

100%

5

5

100%

5

5

LAC

100%

5

5

100%

5

5

100%

5

5

100%

5

5

PVSP

100%

5

5

50%

2.5

5

100%

5

5

83%

4.2

5

CCI

100%

5

5

83%

4.2

5

100%

5

5

100%

5

5

CRC

100%

5

5

67%

3.3

5

100%

5

5

100%

5

5

100%

5

5

83%

4.2

5

100%

5

5

100%

5

5

0%

0

5

100%

5

5

100%

5

5

100%

5

5

HDSP

100%

5

5

100%

5

5

100%

5

5

100%

5

5

SQ

100%

5

5

100%

5

5

100%

5

5

100%

5

5

CCC

94%

80

85

84%

71.1

85

96%

81.7

85

89%

76

85

Average
Score

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?

17.221

ASP

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

17.174

CIW

Do the Emergency Response Review Committee (ERRC) meeting minutes document the warden’s (or his or her designee’s)
attendance?

17.138

RJD

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

17.136

CMF

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

17.135

SAC

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

17.132

Ref
Number

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

17.119

COMPONENT SCORES: Internal Reviews

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

17.118

COMPONENT QUESTIONS: Internal Reviews

APPENDIX C-11: Component Questions and Scores - Internal Reviews

Page 106

State of California • August 2010	

17.221

17.174

17.138

4

Received Points

5
0
0%
40
28.2
70%

Score

Total Possible Points

Total Received Points

Total Score

0%

Score

Possible Points

0

Received Points

5

Possible Points

Received Points

100%

5

Score

5

Possible Points

Received Points

80%

5

Possible Points

17.136

Score

SAC

Ref
Number

69%

27.5

40

0%

0

5

100%

5

5

0%

0

5

100%

5

5

CMF

100%

40

40

100%

5

5

100%

5

5

100%

5

5

100%

5

5

RJD

61%

24.3

40

100%

5

5

0%

0

5

60%

3

5

60%

3

5

CEN

93%

37.3

40

100%

5

5

100%

5

5

80%

4

5

100%

5

5

DVI

98%

39.2

40

100%

5

5

100%

5

5

100%

5

5

100%

5

5

CCWF

70%

28.2

40

0%

0

5

0%

0

5

100%

5

5

80%

4

5

CMC

60%

24.2

40

0%

0

5

100%

5

5

100%

5

5

0%

0

5

SCC

73%

29.2

40

0%

0

5

0%

0

5

100%

5

5

100%

5

5

LAC

71%

28.2

40

0%

0

5

0%

0

5

83%

4.2

5

80%

4

5

PVSP

60%

24

40

0%

0

5

0%

0

5

67%

3.3

5

80%

4

5

CCI

91%

36.2

40

100%

5

5

100%

5

5

60%

3

5

80%

4

5

CRC

COMPONENT SCORES: Internal Reviews, continued

95%

33.3

35

100%

5

5

100%

5

5

100%

5

5

CIW

66%

26.2

40

0%

0

5

0%

0

5

80%

4

5

60%

3

5

ASP

63%

25

40

0%

0

5

0%

0

5

100%

5

5

100%

5

5

HDSP

69%

27.5

40

0%

0

5

0%

0

5

50%

2.5

5

100%

5

5

SQ

86%

34.2

40

0%

0

5

100%

5

5

83%

4.2

5

100%

5

5

CCC

76%

512.7

675

35%

30

85

47%

40

85

80%

68.2

85

83%

66

80

Average
Score

APPENDIX C-11

Page 107

Bureau of Audits and Investigations, Office of the Inspector General	

05.172

05.171

05.110

05.109
8

8

0
0%
38
28.6
75%

Received Points

Score

Total Possible Points

Total Received Points

Total Score

Score
8

5.6
80%

Received Points

Possible Points

7

Possible Points

100%

Received Points

Score

8

Possible Points

100%

Received Points

Score

8

100%

Possible Points

Score

7
7

Possible Points

Received Points

05.108

50%

19

38

100%

8

8

0%

0

7

50%

4

8

0%

0

8

100%

7

7

90%

34

38

100%

8

8

100%

7

7

100%

8

8

50%

4

8

100%

7

7

RJD

100%

38

38

100%

8

8

100%

7

7

100%

8

8

100%

8

8

100%

7

7

CEN

79%

30

38

100%

8

8

100%

7

7

100%

8

8

0%

0

8

100%

7

7

DVI

100%

38

38

100%

8

8

100%

7

7

100%

8

8

100%

8

8

100%

7

7

CCWF

94%

28.3

30

100%

8

8

75%

5.3

7

100%

8

8

100%

7

7

CMC

95%

28.6

30

100%

8

8

80%

5.6

7

100%

8

8

100%

7

7

SCC

100%

30

30

100%

8

8

100%

7

7

100%

8

8

100%

7

7

LAC

76%

22.8

30

100%

8

8

20%

1.4

7

80%

6.4

8

100%

7

7

PVSP

43%

16.4

38

0%

0

8

20%

1.4

7

100%

8

8

0%

0

8

100%

7

7

CCI

100%

38

38

100%

8

8

100%

7

7

100%

8

8

100%

8

8

100%

7

7

CRC

80%

30.4

38

100%

8

8

60%

4.2

7

40%

3.2

8

100%

8

8

100%

7

7

CIW

100%

22

22

100%

8

8

100%

7

7

100%

7

7

ASP

100%

30

30

100%

8

8

100%

7

7

100%

8

8

100%

7

7

HDSP

100%

22

22

100%

8

8

100%

7

7

100%

7

7

SQ

93%

35.2

38

100%

8

8

60%

4.2

7

100%

8

8

100%

8

8

100%

7

7

CCC

86%

491.3

574

88%

120

136

76%

90.7

119

91%

109.6

120

65%

52

80

100%

119

119

Average
Score

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?

05.172

CMF

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

05.171

SAC

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

05.110

Ref
Number

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

05.109

COMPONENT SCORES: Inmate Transfers

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

05.108

COMPONENT QUESTIONS: Inmate Transfers

APPENDIX C-12: Component Questions and Scores - Inmate Transfers

Page 108

State of California • August 2010	
100%

4

Score

4

Possible Points

Received Points

100%

2

Score

2

Possible Points

Received Points

continued on page 110

14.033

14.032

Score

100%

4

4

100%

2

2

100%

4

Received Points

100%
4

100%

4

4

Possible Points

Score

4

Received Points

14.029

4

Possible Points

14.023

100%

4

4

100%

2

2

100%

4

4

100%

4

4

100%

4

4

100%

2

2

100%

4

4

100%

4

4

CEN

100%

4

4

100%

2

2

100%

4

4

100%

4

4

DVI

100%

4

4

100%

2

2

100%

4

4

100%

4

4

CCWF

100%

4

4

100%

2

2

100%

4

4

100%

4

4

CMC

100%

4

4

100%

2

2

100%

4

4

100%

4

4

SCC

100%

4

4

100%

2

2

100%

4

4

100%

4

4

LAC

100%

4

4

100%

2

2

100%

4

4

83%

3.3

4

PVSP

100%

4

4

100%

2

2

100%

4

4

89%

3.6

4

CCI

100%

4

4

100%

2

2

100%

4

4

100%

4

4

CRC

100%

4

4

100%

2

2

100%

4

4

100%

4

4

50%

2

4

100%

2

2

100%

4

4

100%

4

4

100%

4

4

100%

2

2

50%

2

4

100%

4

4

100%

4

4

100%

2

2

100%

4

4

100%

4

4

100%

4

4

100%

2

2

100%

4

4

100%

4

4

CCC

97%

66

68

100%

34

34

97%

62

64

98%

66.9

68

Average
Score

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

14.166

SQ

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

14.165

HDSP

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

14.164

ASP

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

14.160

CIW

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

14.131

RJD

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

14.106

CMF

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

14.033

SAC

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

14.032

Ref
Number

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?

14.029

COMPONENT SCORES: Clinic Operations

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

14.023

COMPONENT QUESTIONS: Clinic Operations

APPENDIX C-13: Component Questions and Scores - Clinic Operations

Page 109

14.166

14.165

14.164

14.160

14.131

2

Received Points

4

4

91%

Total Score

Bureau of Audits and Investigations, Office of the Inspector General	
83%

27.3

33

29
26.4

Total Possible Points

Total Received Points

100%

2

2

67%

1.3

2

0%

0

3

50%

2

4

100%

4

4

100%

4

4

CMF

100%

2

Received Points

Score

2

100%

Possible Points

Score

2

Received Points

80%

Score
2

2.4

Received Points

Possible Points

3

Possible Points

100%

Received Points

Score

4

Possible Points

100%

Received Points

Score

4

Possible Points

50%

4

Possible Points

14.106

Score

SAC

Ref
Number

95%

31.3

33

100%

2

2

67%

1.3

2

100%

3

3

100%

4

4

100%

4

4

75%

3

4

RJD

82%

27

33

100%

2

2

100%

2

2

100%

3

3

100%

4

4

0%

0

4

50%

2

4

CEN

88%

29

33

100%

2

2

0%

0

2

100%

3

3

50%

2

4

100%

4

4

100%

4

4

DVI

86%

28.3

33

100%

2

2

67%

1.3

2

100%

3

3

0%

0

4

100%

4

4

100%

4

4

CCWF

85%

28

33

100%

2

2

100%

2

2

100%

3

3

0%

0

4

100%

4

4

75%

3

4

CMC

88%

29

33

100%

2

2

100%

2

2

100%

3

3

0%

0

4

100%

4

4

100%

4

4

SCC

90%

29.7

33

100%

2

2

33%

0.7

2

100%

3

3

50%

2

4

100%

4

4

100%

4

4

LAC

93%

30.6

33

100%

2

2

67%

1.3

2

100%

3

3

100%

4

4

100%

4

4

75%

3

4

PVSP

91%

29.9

33

100%

2

2

0%

0

2

75%

2.3

3

100%

4

4

100%

4

4

100%

4

4

CCI

86%

28.5

33

100%

2

2

0%

0

2

50%

1.5

3

100%

4

4

100%

4

4

75%

3

4

CRC

COMPONENT SCORES: Clinic Operations, continued

98%

32.3

33

100%

2

2

67%

1.3

2

100%

3

3

100%

4

4

100%

4

4

100%

4

4

CIW

94%

31

33

100%

2

2

100%

2

2

100%

3

3

100%

4

4

100%

4

4

100%

4

4

ASP

91%

30

33

100%

2

2

100%

2

2

100%

3

3

100%

4

4

100%

4

4

75%

3

4

HDSP

100%

33

33

100%

2

2

100%

2

2

100%

3

3

100%

4

4

100%

4

4

100%

4

4

SQ

97%

32

33

100%

2

2

100%

2

2

100%

3

3

100%

4

4

100%

4

4

75%

3

4

CCC

90%

503.3

557

100%

34

34

68%

23.2

34

89%

45.2

51

74%

50

68

94%

64

68

85%

58

68

Average
Score

APPENDIX C-13

Page 110

State of California • August 2010	
5

6
2.4
40%

Possible Points

Received Points

Score

Score

80%

4.8

6
20%

1.2

6
0%

0

6
0%

0

6

100%

6

6

10%
6
86%

5.1

40%

2.4

6

60%

3

50%

3

6

30%

5
0.5

CCWF

Received Points

75%

4.5

6

30%

5
1.5

DVI

5

80%

Score

5
1.5

CEN

Possible Points

6
4.8

Possible Points

70%

3.5

Received Points

50%

Score

continued on page 112

10.228

10.087

10.086

5
2.5

Possible Points

Received Points

10.085

RJD

20%

1.2

6

100%

6

6

90%

4.5

5

CMC

0%

0

6

100%

6

6

20%

1

5

SCC

20%

1.2

6

80%

4.8

6

0%

0

5

LAC

20%

1.2

6

0%

0

6

0%

0

5

PVSP

20%

1.2

6

0%

0

6

20%

1

5

CCI

80%

4.8

6

56%

3.3

6

70%

3.5

5

CRC

6

0%

0

6

70%

3.5

5

90%

5.4

5

40%

2.4

6

100%

6

6

30%

1.5

20%

1.2

6

60%

3.6

6

20%

1

5

HDSP

20%

1.2

6

90%

5.4

6

20%

1

5

SQ

40%

2.4

6

100%

6

6

0%

0

5

CCC

27%

27.6

102

65%

6.5

10

73%

69.9

96

31%

23

75

Average
Score

Female inmates age 41 to 64: Did the inmate receive a Pap smear in compliance with policy?

10.274

ASP

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

10.232

CIW

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

10.229

CMF

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

10.228

SAC

Female inmates age 41 or older: Did the inmate receive a mammogram within the previous 24 months?

10.087

Ref
Number

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

10.086

COMPONENT SCORES: Preventive Services

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?

10.085

COMPONENT QUESTIONS: Preventive Services

APPENDIX C-14: Component Questions and Scores - Preventive Services

Page 111

10.274

10.232
0

44%

24%

19%

5.7
22%

6.5
59%

20.5

Total Score

7.2

7.7
32%

Total Received Points

13.1

35

24

30

0
0%

Total Possible Points

30

0
0%

60%
30

1.2
20%

6

100%

7

7

CCWF

Score
30

0
0%

6

0%

0

7

DVI

3

0%

6

0%

0

7

CEN

Received Points

Score

6

0%

0

7

RJD

5

0
0%

Received Points

6

0%

0

7

CMF

53%

15.9

30

0%

0

6

60%

4.2

7

CMC

28%

8.4

30

0%

0

6

20%

1.4

7

SCC

20%

6

30

0%

0

6

0%

0

7

LAC

27%

8.2

30

0%

0

6

100%

7

7

PVSP

7%

2.2

30

0%

0

6

0%

0

7

CCI

82%

24.6

30

100%

6

6

100%

7

7

CRC

COMPONENT SCORES: Preventive Services, continued

Possible Points

6

40%

Score

Possible Points

7
2.8

Possible Points

10.229

Received Points

SAC

Ref
Number

33%

11.4

35

50%

2.5

5

0%

0

6

0%

0

7

CIW

60%

18.1

30

20%

1.2

6

100%

7

7

ASP

24%

7.2

30

0%

0

6

20%

1.4

7

HDSP

49%

14.6

30

0%

0

6

100%

7

7

SQ

37%

11

30

20%

1.2

6

20%

1.4

7

CCC

37%

188.3

514

55%

5.5

10

9%

9.6

102

39%

46.2

119

Average
Score

APPENDIX C-14

Bureau of Audits and Investigations, Office of the Inspector General	

Page 112

State of California • August 2010	
6
0
0%

Possible Points

Received Points

Score

100%

5

Score

Received Points

Score
5

1.6
80%

Received Points

Possible Points

2

100%

Possible Points

continued on page 114

13.144

13.142

13.141

Score

2
2

Possible Points

Received Points

13.139

2

0%

0

6

100%

5

5

100%

2

2

100%

2

100%

6

6

100%

5

5

100%

2

2

100%

2

2

RJD

0%

0

6

100%

5

5

100%

2

2

100%

2

2

CEN

100%

6

6

100%

5

5

100%

2

2

100%

2

2

DVI

100%

6

6

100%

5

5

100%

2

2

100%

2

2

CCWF

100%

6

6

100%

5

5

100%

2

2

100%

2

2

CMC

100%

6

6

100%

5

5

100%

2

2

100%

2

2

SCC

100%

6

6

100%

5

5

100%

2

2

100%

2

2

LAC

0%

0

6

100%

5

5

100%

2

2

100%

2

2

PVSP

0%

0

6

100%

5

5

100%

2

2

100%

2

2

CCI

0%

0

6

100%

5

5

100%

2

2

100%

2

2

CRC

100%

6

6

100%

5

5

100%

2

2

100%

2

2

100%

6

6

100%

5

5

0%

0

2

100%

2

2

100%

6

6

100%

5

5

100%

2

2

100%

2

2

100%

6

6

100%

5

5

0%

0

2

100%

2

2

SQ

0%

0

6

100%

5

5

50%

1

2

100%

2

2

CCC

59%

60

102

100%

85

85

84%

28.6

34

100%

34

34

Average
Score

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

13.253

HDSP

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

13.252

ASP

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?

13.148

CIW

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

13.145

CMF

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

13.144

SAC

Is the pharmacist in charge’s license current?

13.142

Ref
Number

Does the institution properly maintain its emergency crash cart medications?

13.141

COMPONENT SCORES: Pharmacy Services

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

13.139

COMPONENT QUESTIONS: Pharmacy Services

APPENDIX C-15: Component Questions and Scores - Pharmacy Services

Page 113

13.253

13.252

13.148

7

Received Points

4

2
1
0
0%
29
21.6
75%

Possible Points

Received Points

Score

Total Possible Points

Total Received Points

Total Score

100%

Received Points

Score

2

Possible Points

100%

Received Points

Score

4

Possible Points

100%

7

Possible Points

13.145

Score

SAC

Ref
Number

76%

22

29

100%

1

1

50%

1

2

100%

4

4

100%

7

7

CMF

93%

27.1

29

40%

0.4

1

33%

0.7

2

100%

4

4

100%

7

7

RJD

58%

16.8

29

75%

0.8

1

0%

0

2

0%

0

4

100%

7

7

CEN

92%

26.7

29

67%

0.7

1

0%

0

2

100%

4

4

100%

7

7

DVI

92%

26.7

29

67%

0.7

1

0%

0

2

100%

4

4

100%

7

7

CCWF

91%

26.3

29

33%

0.3

1

0%

0

2

100%

4

4

100%

7

7

CMC

91%

26.3

29

33%

0.3

1

0%

0

2

100%

4

4

100%

7

7

SCC

100%

29

29

100%

1

1

100%

2

2

100%

4

4

100%

7

7

LAC

72%

21

29

100%

1

1

0%

0

2

100%

4

4

100%

7

7

PVSP

79%

23

29

100%

1

1

100%

2

2

100%

4

4

100%

7

7

CCI

79%

23

29

100%

1

1

100%

2

2

100%

4

4

100%

7

7

CRC

COMPONENT SCORES: Pharmacy Services, continued

95%

27.6

29

25%

0.3

1

67%

1.3

2

100%

4

4

100%

7

7

CIW

92%

26.7

29

67%

0.7

1

100%

2

2

100%

4

4

100%

7

7

ASP

100%

29

29

100%

1

1

100%

2

2

100%

4

4

100%

7

7

HDSP

86%

25

29

100%

1

1

0%

0

2

100%

4

4

100%

7

7

SQ

69%

20

29

100%

1

1

0%

0

2

100%

4

4

100%

7

7

CCC

85%

417.8

493

72%

12.2

17

44%

15

34

94%

64

68

100%

119

119

Average
Score

APPENDIX C-15

Bureau of Audits and Investigations, Office of the Inspector General	

Page 114

State of California • August 2010	

20.092

15.265

15.134

15.059

15.058

14.5
91%

Total Score

16

100%

Total Received Points

Total Possible Points

Score

4

Received Points

50%

Score
4

1.5

Received Points

Possible Points

3

Possible Points

100%

5

Received Points

Score

5

Possible Points

100%

4

Received Points

Score

4

Possible Points

100%

11

11

100%

4

4

100%

3

3

100%

4

4

100%

11

11

100%

4

4

100%

3

3

100%

4

4

3

100%

10

10

100%

4

4

100%

3

3

100%

Received Points

Score

3

CEN

Possible Points

RJD

100%

11

11

100%

4

4

100%

3

3

100%

4

4

DVI

100%

11

11

100%

4

4

100%

3

3

100%

4

4

CCWF

91%

10

11

75%

3

4

100%

3

3

100%

4

4

CMC

55%

5.5

10

100%

4

4

50%

1.5

3

0%

0

3

SCC

100%

11

11

100%

4

4

100%

3

3

100%

4

4

LAC

70%

7

10

100%

4

4

100%

3

3

0%

0

3

PVSP

85%

8.5

10

100%

4

4

50%

1.5

3

100%

3

3

CCI

70%

7

10

100%

4

4

100%

3

3

0%

0

3

CRC

57%

4

7

100%

4

4

0%

0

3

CIW

70%

7

10

100%

4

4

0%

0

3

100%

3

3

ASP

73%

8

11

100%

4

4

0%

0

3

100%

4

4

HDSP

85%

8.5

10

100%

4

4

50%

1.5

3

100%

3

3

SQ

100%

10

10

100%

4

4

100%

3

3

100%

3

3

CCC

86%

155

180

99%

67

68

71%

36

51

100%

5

5

100%

32

32

63%

15

24

Average
Score

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

20.092

CMF

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

15.265

SAC

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

15.134

Ref
Number

Did the institution properly provide therapeutic diets to inmates?

15.059

COMPONENT SCORES: Other Services

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

15.058

COMPONENT QUESTIONS: Other Services

APPENDIX C-16: Component Questions and Scores - Other Sevices

Page 115

11.100

11.099

2

0%

Score

Bureau of Audits and Investigations, Office of the Inspector General	
2

Total Possible Points

Total Received Points
11%

19

Score

Total Score

0
0%

Received Points

7

0

Possible Points

6

Possible Points

Received Points

33%

6

Possible Points

Received Points

11.097

Score

SAC

32%

6

19

0%

0

7

0%

0

6

100%

6

6

CMF

11%

2

19

0%

0

7

0%

0

6

33%

2

6

RJD

32%

6

19

0%

0

7

0%

0

6

100%

6

6

CEN

DVI

100%

19

19

100%

7

7

100%

6

6

100%

6

6

CCWF

71%

13.5

19

50%

3.5

7

67%

4

6

100%

6

6

CMC

SCC

42%

8

19

50%

3.5

7

50%

3

6

25%

1.5

6

LAC

37%

7

19

100%

7

7

0%

0

6

0%

0

6

PVSP

46%

8.7

19

67%

4.7

7

67%

4

6

0%

0

6

CCI

CRC

CIW

ASP

44%

8.4

19

0%

0

7

60%

3.6

6

80%

4.8

6

HDSP

54%

10.2

19

60%

4.2

7

20%

1.2

6

80%

4.8

6

SQ

68%

13

19

100%

7

7

100%

6

6

0%

0

6

CCC

46%

103.8

228

44%

36.9

84

39%

27.8

72

54%

39.1

72

Average
Score

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

11.100

Ref
Number

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?

11.099

COMPONENT SCORES: Inmate Hunger Strikes

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?

11.097

COMPONENT QUESTIONS: Inmate Hunger Strikes

APPENDIX C-17: Component Questions and Scores - Inmate Hunger Strikes

Page 116

12.064

State of California • August 2010	
8

17
100%

Total Received Points

Total Score

17

Total Possible Points

100%

Received Points

Score

8

Possible Points

100%

9
9

Possible Points

Received Points

12.062

Score

SAC

Ref
Number

87%

14.8

17

100%

8

8

75%

6.8

9

CMF

94%

16

17

88%

7

8

100%

9

9

RJD

89%

15.2

17

100%

8

8

80%

7.2

9

CEN

89%

15.2

17

100%

8

8

80%

7.2

9

DVI

65%

11

17

100%

8

8

33%

3

9

CCWF

100%

17

17

100%

8

8

100%

9

9

CMC

100%

17

17

100%

8

8

100%

9

9

SCC

91%

15.4

17

80%

6.4

8

100%

9

9

LAC

66%

5.3

8

67%

5.3

8

PVSP

66%

5.3

8

67%

5.3

8

CCI

100%

8

8

100%

8

8

CRC

100%

8

8

100%

8

8

CIW

100%

17

17

100%

8

8

100%

9

9

ASP

100%

17

17

100%

8

8

100%

9

9

HDSP

89%

15.2

17

100%

8

8

80%

7.2

9

SQ

100%

17

17

100%

8

8

100%

9

9

CCC

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

12.064

COMPONENT SCORES: Chemical Agent Contraindications

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

12.062

COMPONENT QUESTIONS: Chemical Agent Contraindications

91%

231.4

253

94%

128

136

88%

103.4

117

Average
Score

APPENDIX C-18: Component Questions and Scores - Chemical Agent Contraindications

Page 117

Bureau of Audits and Investigations, Office of the Inspector General	

18.006

18.005

18.004

18.002

80%

Score

4

4

16
15.2
95%

Total Possible Points

Total Received Points

Total Score

100%

4

Received Points

Score

4

Possible Points

100%

Received Points

Score

4

Possible Points

100%

Received Points

Score

4

Possible Points

Score

Received Points

Possible Points

4
3.2

Possible Points

Received Points

18.001

95%

15.2

16

100%

4

4

100%

4

4

100%

4

4

80%

3.2

4

CMF

100%

16

16

100%

4

4

100%

4

4

100%

4

4

100%

4

4

RJD

100%

16

16

100%

4

4

100%

4

4

100%

4

4

100%

4

4

CEN

95%

15.2

16

100%

4

4

100%

4

4

100%

4

4

80%

3.2

4

DVI

85%

13.6

16

100%

4

4

100%

4

4

100%

4

4

40%

1.6

4

CCWF

100%

16

16

100%

4

4

100%

4

4

100%

4

4

100%

4

4

CMC

100%

16

16

100%

4

4

100%

4

4

100%

4

4

100%

4

4

SCC

90%

14.4

16

100%

4

4

100%

4

4

100%

4

4

60%

2.4

4

LAC

80%

12.8

16

100%

4

4

100%

4

4

100%

4

4

20%

0.8

4

PVSP

90%

14.4

16

100%

4

4

100%

4

4

100%

4

4

60%

2.4

4

CCI

85%

13.6

16

100%

4

4

100%

4

4

100%

4

4

40%

1.6

4

CRC

85%

13.6

16

100%

4

4

100%

4

4

100%

4

4

40%

1.6

4

CIW

100%

16

16

100%

4

4

100%

4

4

100%

4

4

100%

4

4

100%

16

16

100%

4

4

100%

4

4

100%

4

4

100%

4

4

HDSP

95%

15.2

16

100%

4

4

100%

4

4

100%

4

4

80%

3.2

4

SQ

100%

16

16

100%

4

4

100%

4

4

100%

4

4

100%

4

4

CCC

94%

255.2

272

100%

68

68

100%

68

68

100%

68

68

75%

51.2

68

Average
Score

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?

18.006

ASP

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?

18.005

SAC

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

18.004

Ref
Number

Information purposes only: Calculate the institution’s average vacancy percentages, the number of health care staff starting
within six (6) months of the OIG visit, and the number of health care staff hired from the registry. Note: We do not factor this
question into the institution’s score for staffing levels and training.

18.002

COMPONENT SCORES: Staffing Levels and Training

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

18.001

COMPONENT QUESTIONS: Staffing Levels and Training

APPENDIX C-19: Component Questions and Scores - Staffing Levels and Training

Page 118

State of California • August 2010	

16.254

16.231

5

Received Points

2

4
14
11
79%

Total Possible Points

Total Received Points

Total Score

100%

Received Points

Score

4

Possible Points

40%

Received Points

Score

5

Possible Points

100%

5

Possible Points

16.154

Score

SAC

36%

5

14

0%

0

4

0%

0

5

100%

5

5

CMF

89%

12.4

14

60%

2.4

4

100%

5

5

100%

5

5

RJD

71%

10

14

100%

4

4

20%

1

5

100%

5

5

CEN

36%

5

14

0%

0

4

0%

0

5

100%

5

5

DVI

100%

14

14

100%

4

4

100%

5

5

100%

5

5

CCWF

79%

11

14

100%

4

4

40%

2

5

100%

5

5

CMC

94%

13.2

14

80%

3.2

4

100%

5

5

100%

5

5

SCC

57%

8

14

0%

0

4

60%

3

5

100%

5

5

LAC

100%

14

14

100%

4

4

100%

5

5

100%

5

5

PVSP

50%

7

14

0%

0

4

40%

2

5

100%

5

5

CCI

76%

10.6

14

40%

1.6

4

80%

4

5

100%

5

5

CRC

64%

9

14

0%

0

4

80%

4

5

100%

5

5

CIW

67%

9.4

14

60%

2.4

4

40%

2

5

100%

5

5

ASP

89%

12.4

14

60%

2.4

4

100%

5

5

100%

5

5

HDSP

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

16.254

Ref
Number

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

16.231

COMPONENT SCORES: Nursing Policy

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

16.154

COMPONENT QUESTIONS: Nursing Policy

70%

9.8

14

20%

0.8

4

80%

4

5

100%

5

5

SQ

94%

13.2

14

80%

3.2

4

100%

5

5

100%

5

5

CCC

74%

175

238

53%

36

68

64%

54

85

100%

85

85

Average
Score

APPENDIX C-20: Component Questions and Scores - Nursing Policy

Page 119

Bureau of Audits and Investigations, Office of the Inspector General	

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

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?

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

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

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?

13.253

14.029

14.131

14.166

21.281

6
1.3
22%

Possible Points

Received Points

Score

6
80%

4.8
55%

3.3

6

RJD

77%

4.6

6

CEN

33%

2

6

DVI

52%

3.1

6

CCWF

28%

1.7

6

CMC

13%

0.8

6

SCC

33%

2

6

LAC

11%

0.7

6

PVSP

41%

2.5

6

CCI

10%

0.6

6

CRC

28%

1.7

6

CIW

6
30%

1.8

6
44%

2.6

6
22%

1.3

6
14%

0.9

35%

35.7

Average
Score
102

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

13.252

CCC

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?

13.148

SQ

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

13.145

HDSP

Does the institution properly maintain its emergency crash cart medications?

13.141

ASP

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

10.228

CMF

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

05.110

SAC

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?

03.175

Ref
Number
01.124

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?

02.128

CATEGORY SCORES: Medication Management

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

01.124

CATEGORY QUESTIONS: Medication Management

APPENDIX D-1: Category Questions and Scores - Medication Management

Page 120

State of California • August 2010	
7

1

Score

100%

4

100%
4

Score

Possible Points

0
0%

Received Points

1

50%

1

2

100%

4

4

100%

7

7

100%

2

2

80%

4.8

6

50%

4

8

77%

13.9

18

88%

7

8

CMF

Received Points

1

Possible Points

100%

2

Score

2

Possible Points

Received Points

100%

4

Score

4

Possible Points

Received Points

100%

Received Points

Score

7

80%

Score

Possible Points

2
1.6

Score

Possible Points

2.4
40%

Received Points

Received Points

6

Possible Points

100%

8

Received Points

Score

8

46%

Score

Possible Points

18
8.3

Score

Possible Points

2.7
33%

Received Points

Received Points

8

SAC

Possible Points

continued on page 122

14.029

13.253

13.252

13.148

13.145

13.141

10.228

05.110

03.175

Ref
Number
02.128

100%

4

4

40%

0.4

1

33%

0.7

2

100%

4

4

100%

7

7

100%

2

2

20%

1.2

6

100%

8

8

50%

9

18

50%

4

8

RJD

100%

4

4

75%

0.8

1

0%

0

2

0%

0

4

100%

7

7

100%

2

2

0%

0

6

100%

8

8

55%

9.9

18

50%

4

8

CEN

100%

4

4

67%

0.7

1

0%

0

2

100%

4

4

100%

7

7

100%

2

2

0%

0

6

100%

8

8

65%

11.6

18

0%

0

8

DVI

100%

4

4

67%

0.7

1

0%

0

2

100%

4

4

100%

7

7

100%

2

2

40%

2.4

6

100%

8

8

40%

7.2

18

43%

3.4

8

CCWF

100%

4

4

33%

0.3

1

0%

0

2

100%

4

4

100%

7

7

100%

2

2

20%

1.2

6

100%

8

8

4%

0.8

18

13%

1

8

CMC

100%

4

4

33%

0.3

1

0%

0

2

100%

4

4

100%

7

7

100%

2

2

0%

0

6

100%

8

8

31%

5.6

18

25%

2

8

SCC

100%

4

4

100%

1

1

100%

2

2

100%

4

4

100%

7

7

100%

2

2

20%

1.2

6

100%

8

8

29%

5.3

18

42%

3.3

8

LAC

100%

4

4

100%

1

1

0%

0

2

100%

4

4

100%

7

7

100%

2

2

20%

1.2

6

80%

6.4

8

4%

0.8

18

0%

0

8

PVSP

100%

4

4

100%

1

1

100%

2

2

100%

4

4

100%

7

7

100%

2

2

20%

1.2

6

100%

8

8

48%

8.6

18

43%

3.4

8

CCI

100%

4

4

100%

1

1

100%

2

2

100%

4

4

100%

7

7

100%

2

2

80%

4.8

6

100%

8

8

20%

3.6

18

23%

1.8

8

CRC

2

2

0%

0

6

40%

3.2

8

4%

0.8

18

0%

0

8

CIW

100%

4

4

25%

0.3

1

67%

1.3

2

100%

4

4

100%

7

7

100%

CATEGORY SCORES: Medication Management, continued

100%

4

4

67%

0.7

1

100%

2

2

100%

4

4

100%

7

7

0%

0

2

40%

2.4

6

18%

3.3

18

30%

2.4

8

ASP

50%

2

4

100%

1

1

100%

2

2

100%

4

4

100%

7

7

100%

2

2

20%

1.2

6

100%

8

8

8%

1.4

18

35%

2.8

8

HDSP

100%

4

4

100%

1

1

0%

0

2

100%

4

4

100%

7

7

0%

0

2

20%

1.2

6

8%

1.4

18

24%

1.9

8

SQ

100%

4

4

100%

1

1

0%

0

2

100%

4

4

100%

7

7

50%

1

2

40%

2.4

6

100%

8

8

17%

3.1

18

17%

1.3

8

CCC

97%

62

64

72%

12.2

17

44%

15

34

94%

64

68

100%

119

119

84%

28.6

34

27%

27.6

102

91%

109.6

120

31%

94.6

306

30%

41

Average
Score
136

APPENDIX D-1

Page 121

21.281

14.166

Ref
Number
14.131

2

74
49.3
67%

Total Possible Points

Total Received Points

Total Score

84%

65.5

78

6
100%

6

6

100%

2

2

100%

100%

Received Points

Score

6

Possible Points

100%

Received Points

Score

2

Possible Points

100%

4

Score

4

4

Possible Points

Received Points

4

CMF

SAC

68%

53.1

78

58%

3.5

6

100%

2

2

100%

4

4

RJD

60%

47

78

79%

4.7

6

100%

2

2

0%

0

4

CEN

64%

50

78

79%

4.7

6

100%

2

2

100%

4

4

DVI

68%

53.1

78

88%

5.3

6

100%

2

2

100%

4

4

CCWF

51%

39.8

78

64%

3.8

6

100%

2

2

100%

4

4

CMC

55%

42.6

78

48%

2.9

6

100%

2

2

100%

4

4

SCC

62%

48.1

78

38%

2.3

6

100%

2

2

100%

4

4

LAC

43%

33.9

78

13%

0.8

6

100%

2

2

100%

4

4

PVSP

69%

53.7

78

67%

4

6

100%

2

2

100%

4

4

CCI

61%

47.6

78

47%

2.8

6

100%

2

2

100%

4

4

CRC
4

4

CIW

42%

32.9

78

44%

2.6

6

100%

2

2

100%

CATEGORY SCORES: Medication Management, continued

49%

34.2

70

10%

0.6

6

100%

2

2

100%

4

4

ASP

55%

42.8

78

47%

2.8

6

100%

2

2

100%

4

4

HDSP

40%

28.2

70

7%

0.4

6

100%

2

2

100%

4

4

SQ

53%

41.7

78

50%

3

6

100%

2

2

100%

4

4

CCC

58%

763.5

1306

55%

56.2

102

100%

34

34

94%

64

Average
Score
68

APPENDIX D-1

Bureau of Audits and Investigations, Office of the Inspector General	

Page 122

State of California • August 2010	

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?

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

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

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

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?

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

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?

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?

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?

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

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

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?

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

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

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

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?

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?

01.027

01.247

02.015

02.016

02.017

02.018

02.020

02.021

03.076

04.051

04.052

04.053

06.049

06.188

07.035

07.038

07.043

continued on page 124

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

01.025

CATEGORY QUESTIONS: Access to Care

APPENDIX D-2: Category Questions and Scores - Access to Care

Page 123

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

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?

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?

Did the inmate visit with an OB physician according to the applicable time frames?

Did the inmate receive her six-week check-up (post-delivery)?

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?

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

Female inmates age 41 or older: Did the inmate receive a mammogram within the previous 24 months?

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

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

Female inmates age 41 to 64: Did the inmate receive a Pap smear in compliance with policy?

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?

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?

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

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

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

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?

08.184

09.066

09.067

09.071

09.074

10.085

10.086

10.087

10.229

10.232

10.274

11.097

11.099

11.100

15.258

15.282

21.249

CATEGORY QUESTIONS: Access to Care, continued

APPENDIX D-2

Bureau of Audits and Investigations, Office of the Inspector General	

Page 124

State of California • August 2010	
9

4.2

5.2

56%

Score

87%
5

70%
2.8

Score

6

13%

1

8

94%

7.6

8

97%

8.7

9

100%

7

7

22%

1.6

7

13%

1

8

80%

Possible Points

5.4
90%

Received Points

6

100%

8

8

56%

4.4

8

100%

9

9

78%

5.4

7

82%

6.6

8

84%

4.8

6

RJD

Received Points

6

Possible Points

25%

2

Score

8

Possible Points

Received Points

100%

8

Score

8

Possible Points

Received Points

100%

Received Points

Score

9

Possible Points

100%

7

Score

7

Possible Points

Score

Received Points

1.8
25%

Received Points

29%

Score
7

2.4

Received Points

Possible Points

8

76%

Score

Possible Points

5

6

6
4.6

Possible Points

CMF

SAC

Received Points

continued on page 126

02.021

02.020

02.018

02.017

02.016

02.015

01.247

01.027

Ref
Number
01.025

90%

5.4

6

60%

4.8

8

93%

7.5

8

100%

9

9

100%

7

7

50%

4

8

76%

4.6

6

CEN

55%

2.8

5

100%

6

6

50%

4

8

100%

8

8

100%

9

9

100%

7

7

60%

4.2

7

79%

6.3

8

88%

5.3

6

DVI

55%

2.8

5

100%

6

6

86%

6.9

8

100%

8

8

100%

9

9

67%

4.7

7

67%

4.7

7

56%

4.5

8

88%

5.3

6

CCWF

85%

5.1

6

100%

8

8

100%

8

8

100%

9

9

75%

5.3

7

67%

4.7

7

75%

6

8

78%

4.7

6

CMC

95%

5.7

6

29%

2.3

8

29%

2.3

8

100%

9

9

83%

5.8

7

0%

0

7

75%

6

8

65%

3.9

6

SCC

50%

2.5

5

100%

6

6

0%

0

8

46%

3.7

8

90%

8.1

9

100%

7

7

20%

1.4

7

35%

2.8

8

83%

5

6

LAC

85%

5.1

6

71%

5.7

8

70%

5.6

8

65%

5.9

9

36%

2.5

7

47%

3.8

8

33%

2

6

PVSP

100%

5

5

80%

4.8

6

33%

2.7

8

100%

8

8

77%

6.9

9

33%

2.3

7

57%

4

7

25%

2

8

60%

3.6

6

CCI

100%

6

6

11%

0.9

8

100%

8

8

95%

8.6

9

100%

7

7

88%

6.1

7

54%

4.3

8

80%

4.8

6

CRC

CATEGORY SCORES: Access to Care

40%

2

5

90%

5.4

6

87%

6.9

8

95%

8.6

9

56%

3.9

7

71%

5.6

8

68%

4.1

6

CIW

85%

5.1

6

55%

4.4

8

100%

8

8

90%

8.1

9

63%

4.4

7

52%

4.2

8

26%

1.5

6

ASP

100%

5

5

97%

5.8

6

17%

1.3

8

100%

8

8

93%

8.4

9

50%

3.5

7

27%

2.1

8

40%

2.4

6

HDSP

95%

4.8

5

96%

5.8

6

61%

4.9

8

90%

8.1

9

100%

7

7

50%

3.5

7

56%

4.4

8

34%

2.1

6

SQ

100%

6

6

40%

3.2

8

100%

8

8

85%

7.7

9

100%

7

7

67%

4.7

7

46%

3.6

8

84%

5

6

CCC

69%

27.7

40

91%

93

102

47%

60.1

128

86%

110

128

93%

142.1

153

87%

67.1

77

53%

63.4

119

51%

69.6

136

67%

68.7

Average
Score
102

APPENDIX D-2

Page 125

Bureau of Audits and Investigations, Office of the Inspector General	

08.184

07.043

07.038

07.035

06.188

06.049

04.053

04.052

04.051

Ref
Number
03.076

4
100%

Received Points

Score

4

Possible Points

22%

2

Score

9

Possible Points

Score

Received Points

0.6
8%

Received Points

Score
8

4.2
47%

Received Points

Possible Points

9

90%

Score

Possible Points

6
5.4

Possible Points

Received Points

100%

7

Score

Received Points

30%

Score
7

1.2

Received Points

Possible Points

4

90%

Score

Possible Points

5
4.5

Score

Possible Points

4.5
90%

Received Points

Received Points

5

88%

Score

Possible Points

100%

4

4

29%

2.6

9

31%

2.5

8

35%

3.2

9

90%

5.4

6

80%

5.6

7

78%

3.1

4

100%

5

5

80%

4

5

87%

8.7

10

10
8.8

Possible Points

Received Points

CMF

SAC

80%

3.2

4

19%

1.7

9

25%

2

8

59%

5.3

9

50%

3

6

100%

7

7

48%

4.8

10

RJD

100%

4

4

41%

3.7

9

15%

1.2

8

59%

5.3

9

60%

3.6

6

100%

7

7

95%

9.5

10

CEN

100%

4

4

8%

0.7

9

9%

0.7

8

59%

5.3

9

80%

4.8

6

20%

1.4

7

100%

4

4

80%

4

5

80%

4

5

56%

5.6

10

DVI

67%

2.7

4

18%

1.6

9

0%

0

8

94%

8.5

9

70%

4.2

6

100%

7

7

90%

9

10

CCWF

100%

4

4

13%

1.1

9

23%

1.8

8

59%

5.3

9

80%

4.8

6

80%

5.6

7

76%

7.6

10

CMC

100%

4

4

25%

2.3

9

36%

2.9

8

77%

6.9

9

100%

6

6

100%

7

7

50%

2

4

100%

5

5

100%

5

5

60%

6

10

SCC

100%

4

4

36%

3.2

9

29%

2.3

8

65%

5.8

9

90%

5.4

6

100%

7

7

64%

6.4

10

LAC

75%

3

4

36%

3.2

9

8%

0.7

8

69%

6.2

9

70%

4.2

6

80%

5.6

7

72%

7.2

10

PVSP

50%

2

4

47%

4.2

9

29%

2.4

8

41%

3.7

9

40%

2.4

6

80%

5.6

7

33%

1.3

4

60%

3

5

80%

4

5

68%

6.8

10

CCI

100%

4

4

38%

3.4

9

7%

0.5

8

29%

2.6

9

90%

5.4

6

0%

0

7

100%

4

4

100%

5

5

100%

5

5

96%

9.6

10

CRC

CATEGORY SCORES: Access to Care, continued

23%

2.1

9

38%

3

8

88%

7.9

9

50%

3

6

100%

7

7

100%

4

4

90%

4.5

5

70%

3.5

5

75%

7.5

10

CIW

100%

4

4

73%

6.5

9

33%

2.7

8

77%

6.9

9

70%

4.2

6

60%

4.2

7

75%

3

4

80%

4

5

80%

4

5

72%

7.2

10

ASP

100%

4

4

0%

0

9

7%

0.5

8

47%

4.2

9

30%

1.8

6

60%

4.2

7

44%

4.4

10

HDSP

80%

3.2

4

23%

2.1

9

0%

0

8

65%

5.8

9

100%

6

6

100%

7

7

100%

4

4

100%

5

5

80%

4

5

84%

8.4

10

SQ

100%

4

4

42%

3.8

9

56%

4.4

8

88%

7.9

9

70%

4.2

6

60%

4.2

7

50%

2

4

90%

4.5

5

80%

4

5

56%

5.6

10

CCC

91%

58.1

64

29%

44.2

153

21%

28.2

136

62%

95

153

72%

73.8

102

78%

92.4

119

72%

28.6

40

89%

44.5

50

84%

42

50

72%

123.1

Average
Score
170

APPENDIX D-2

Page 126

State of California • August 2010	
6

5

5

5

5

PVSP

5

CCI

5

CRC

CIW

3.5

0%

6
20%

1.2

0

0%

0

6

0%

7

0%

0

6

100%

Score

60%

3

0%

0

6

0
0%

7

60%

Received Points

0%

Score

0

6

0
0%

7

86%

5

0

0
0%

7

100%

5.1

Possible Points

6

Score

Possible Points

2.8
40%

Received Points

Received Points

7

Score

Possible Points

7

50%

6

6

3

75%

3

6

0.5
10%

Received Points
7

6
4.5

1.5
30%

5

80%

Score

1.5
30%

Possible Points

6
4.8

70%

Possible Points

Score

Received Points

2.5
50%

Received Points

0%

0

6

60%

4.2

7

100%

6

6

90%

4.5

0%

0

6

20%

1.4

7

100%

6

6

20%

1

0%

0

6

0%

0

7

80%

4.8

6

0%

0

0%

0

6

100%

7

7

0%

0

6

0%

0

0%

0

6

0%

0

7

0%

0

6

20%

1

100%

6

6

100%

7

7

56%

3.3

6

70%

3.5

50%

2.5

5

0%

0

6

0%

0

7

70%

3.5

5

90%

5.4

6

80%
5

Score

Possible Points

7
5.6

Possible Points

86%

Score

Received Points

8
6.9

Possible Points

100%

Received Points

Score

5

5

LAC

Received Points

5

SCC

5

5

CMC

Possible Points

5

CCWF

0%

DVI

Score

CEN
5

RJD
0

CMF

Possible Points

SAC

Received Points

continued on page 128

10.274

10.232

10.229

10.087

10.086

10.085

09.074

09.071

09.067

Ref
Number
09.066

CATEGORY SCORES: Access to Care, continued

20%

1.2

6

100%

7

7

100%

6

6

30%

1.5

5

ASP

0%

0

6

20%

1.4

7

60%

3.6

6

20%

1

5

HDSP

0%

0

6

100%

7

7

90%

5.4

6

20%

1

5

SQ

20%

1.2

6

20%

1.4

7

100%

6

6

0%

0

5

CCC

55%

5.5

10

9%

9.6

102

39%

46.2

119

65%

6.5

10

73%

69.9

96

31%

23

75

80%

5.6

7

86%

6.9

8

100%

5

5

0%

0

Average
Score
5

APPENDIX D-2

Page 127

21.249

15.282

15.258

11.100

11.099

Ref
Number
11.097

2

54%

Total Score

173

174
93.9

Total Possible Points

Total Received Points

85%

60%

Score

63%

109

6

7

7
4.2

100%

Possible Points

Score

2

0%

0

2

0%

0

7

0%

0

6

100%

Received Points

0
0%

Received Points

0%

Score
2

0

Possible Points

2

Possible Points

Score

Received Points

0
0%

Received Points

Score
7

0
0%

Received Points

Possible Points

6

33%

Possible Points

Score

6

6
2

Possible Points

Received Points

6

CMF

SAC

47%

80.4

171

24%

1.7

7

100%

2

2

100%

2

2

0%

0

7

0%

0

6

33%

2

6

RJD

60%

92.9

155

65%

4.6

7

0%

0

7

0%

0

6

100%

6

6

CEN

62%

102.1

166

64%

4.5

7

100%

2

2

100%

2

2

DVI

74%

129.6

176

52%

3.6

7

100%

2

2

100%

2

2

100%

7

7

100%

6

6

100%

6

6

CCWF

72%

119.3

166

88%

6.1

7

100%

2

2

100%

2

2

50%

3.5

7

67%

4

6

100%

6

6

CMC

61%

98.9

161

92%

6.4

7

100%

2

2

0%

0

2

SCC

52%

88.2

169

40%

2.8

7

100%

2

2

50%

3.5

7

50%

3

6

25%

1.5

6

LAC

52%

82.8

159

58%

4.1

7

100%

2

2

100%

2

2

100%

7

7

0%

0

6

0%

0

6

PVSP

50%

91.7

185

48%

3.3

7

100%

2

2

100%

2

2

67%

4.7

7

67%

4

6

0%

0

6

CCI

70%

112.9

161

84%

5.9

7

100%

2

2

0%

0

2

CRC

CATEGORY SCORES: Access to Care, continued

65%

115.8

177

56%

3.9

7

100%

2

2

100%

2

2

CIW

69%

105.7

154

52%

3.6

7

100%

2

2

100%

2

2

ASP

45%

73.4

164

48%

3.4

7

0%

0

2

0%

0

2

0%

0

7

60%

3.6

6

80%

4.8

6

HDSP

66%

117.1

177

48%

3.4

7

100%

2

2

100%

2

2

60%

4.2

7

20%

1.2

6

80%

4.8

6

SQ

67%

121.2

180

82%

5.8

7

100%

2

2

100%

2

2

100%

7

7

100%

6

6

0%

0

6

CCC

60%

1734.9

2868

62%

73.3

119

87%

26

30

69%

22

32

44%

36.9

84

39%

27.8

72

54%

39.1

Average
Score
72

APPENDIX D-2

Bureau of Audits and Investigations, Office of the Inspector General	

Page 128

State of California • August 2010	

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?

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

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?

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

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

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

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

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

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

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?

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?

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?

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

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?

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?

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?

02.014

02.111

02.128

04.051

04.052

05.108

05.109

05.110

05.171

05.172

07.043

07.270

14.033

21.248

21.249

21.250

continued on page 130

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?

02.007

CATEGORY QUESTIONS: Continuity of Care

APPENDIX D-3: Category Questions and Scores - Continuity of Care

Page 129

Bureau of Audits and Investigations, Office of the Inspector General	

05.108

04.052

04.051

02.128

02.111

02.014

Ref
Number
02.007

100%

7

Received Points

Score

7

90%

Score

Possible Points

5
4.5

Score

Possible Points

4.5
90%

Received Points

Received Points

5

33%

Score

Possible Points

8
2.7

Possible Points

Received Points

67%

4

Score

6

Possible Points

Received Points

Score

100%

7

7

100%

5

5

80%

4

5

88%

7

8

100%

6

6

6

100%

7

7

50%

4

8

75%

4.5

100%

7

7

50%

4

8

33%

2

6

100%

7

90%

Received Points

64%

6.3

7

CEN

7

93%

4.5

7

RJD

Possible Points

100%

7

Score

7

7

Possible Points

Received Points

6.5

CMF

SAC

100%

7

7

80%

4

5

80%

4

5

0%

0

8

DVI

100%

7

7

43%

3.4

8

CCWF

100%

7

7

13%

1

8

100%

6

6

0%

0

7

85%

6

7

CMC

100%

7

7

100%

5

5

100%

5

5

25%

2

8

75%

5.3

7

SCC

100%

7

7

42%

3.3

8

75%

4.5

6

88%

6.1

7

LAC

100%

7

7

0%

0

8

100%

6

6

95%

6.6

7

PVSP

100%

7

7

60%

3

5

80%

4

5

43%

3.4

8

100%

6

6

100%

7

7

95%

6.6

7

CCI

100%

7

7

100%

5

5

100%

5

5

23%

1.8

8

75%

4.5

6

100%

7

7

CRC

100%

7

7

90%

4.5

5

70%

3.5

5

0%

0

8

CIW

100%

7

7

80%

4

5

80%

4

5

30%

2.4

8

100%

6

6

100%

7

7

95%

6.6

7

ASP

100%

7

7

35%

2.8

8

100%

6

6

100%

7

7

85%

6

7

HDSP

100%

7

7

100%

5

5

80%

4

5

24%

1.9

8

50%

3

6

100%

7

7

SQ

100%

7

7

90%

4.5

5

80%

4

5

17%

1.3

8

100%

6

6

100%

7

7

100%

7

7

CCC

100%

119

119

89%

44.5

50

84%

42

50

30%

41

136

83%

64.5

78

83%

35

42

90%

88.5

Average
Score
98

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?

21.281

CATEGORY SCORES: Continuity of Care

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?

21.251

CATEGORY QUESTIONS: Continuity of Care, continued

APPENDIX D-3

Page 130

State of California • August 2010	
8

7
5.1
73%

Received Points

Score

60%

Score

Possible Points

7
4.2

Score

Possible Points

5.5
79%

Received Points

Received Points

7

Possible Points

100%

4

Received Points

Score

4

53%

Score

Possible Points

6
3.2

Possible Points

Received Points

22%

2

Score

Received Points

0%

Score
9

0

Possible Points

8

Possible Points

80%

Score

Received Points

7
5.6

Possible Points

Received Points

100%

Received Points

Score

8

Possible Points

100%

8

Score

8

8

Possible Points

Received Points

80%

5.6

7

85%

6

7

90%

6.3

7

100%

4

4

59%

3.5

6

29%

2.6

9

100%

8

8

0%

0

7

50%

4

8

0%

0

CMF

SAC

continued on page 132

21.250

21.249

21.248

14.033

07.270

07.043

05.172

05.171

05.110

Ref
Number
05.109

50%

3.5

7

24%

1.7

7

65%

4.6

7

100%

4

4

88%

5.3

6

19%

1.7

9

100%

8

8

100%

7

7

100%

8

8

50%

4

8

RJD

100%

7

7

65%

4.6

7

75%

5.3

7

100%

4

4

100%

6

6

41%

3.7

9

100%

8

8

100%

7

7

100%

8

8

100%

8

8

CEN

96%

6.7

7

64%

4.5

7

88%

6.2

7

100%

4

4

77%

4.6

6

8%

0.7

9

100%

8

8

100%

7

7

100%

8

8

0%

0

8

DVI

100%

7

7

52%

3.6

7

92%

6.4

7

100%

4

4

100%

6

6

18%

1.6

9

100%

8

8

100%

7

7

100%

8

8

100%

8

8

CCWF

100%

7

7

88%

6.1

7

84%

5.9

7

100%

4

4

100%

6

6

13%

1.1

9

100%

8

8

75%

5.3

7

100%

8

8

CMC

100%

7

7

92%

6.4

7

100%

7

7

100%

4

4

94%

5.6

6

25%

2.3

9

100%

8

8

80%

5.6

7

100%

8

8

SCC

100%

7

7

40%

2.8

7

96%

6.7

7

100%

4

4

100%

6

6

36%

3.2

9

100%

8

8

100%

7

7

100%

8

8

LAC

96%

6.7

7

58%

4.1

7

88%

6.2

7

100%

4

4

100%

6

6

36%

3.2

9

100%

8

8

20%

1.4

7

80%

6.4

8

PVSP

100%

7

7

48%

3.3

7

92%

6.4

7

100%

4

4

100%

6

6

47%

4.2

9

0%

0

8

20%

1.4

7

100%

8

8

0%

0

8

CCI

96%

6.7

7

84%

5.9

7

100%

7

7

100%

4

4

100%

6

6

38%

3.4

9

100%

8

8

100%

7

7

100%

8

8

100%

8

8

CRC

CATEGORY SCORES: Continuity of Care, continued

96%

6.7

7

56%

3.9

7

84%

5.9

7

100%

4

4

100%

6

6

23%

2.1

9

100%

8

8

60%

4.2

7

40%

3.2

8

100%

8

8

CIW

100%

7

7

52%

3.6

7

92%

6.4

7

50%

2

4

100%

6

6

73%

6.5

9

100%

8

8

100%

7

7

ASP

100%

7

7

48%

3.4

7

32%

2.2

7

100%

4

4

94%

5.6

6

0%

0

9

100%

8

8

100%

7

7

100%

8

8

HDSP

72%

5

7

48%

3.4

7

52%

3.6

7

100%

4

4

100%

6

6

23%

2.1

9

100%

8

8

100%

7

7

SQ

100%

7

7

82%

5.8

7

88%

6.2

7

100%

4

4

100%

6

6

42%

3.8

9

100%

8

8

60%

4.2

7

100%

8

8

100%

8

8

CCC

92%

109

119

62%

73.3

119

82%

97.8

119

97%

66

68

92%

93.8

102

29%

44.2

153

88%

120

136

76%

90.7

119

91%

109.6

120

65%

52

Average
Score
80

APPENDIX D-3

Page 131

21.281

Ref
Number
21.251

122
88.3
72%

Total Possible Points

Total Received Points

Total Score

67%

81.5

122

6
100%

6

6

0%

100%

Received Points

Score

6

Possible Points

100%

7

Score

7

7

Possible Points

Received Points

0

CMF

SAC

70%

78.3

112

58%

3.5

6

100%

7

7

RJD

83%

92.6

112

79%

4.7

6

CEN

64%

69.4

109

79%

4.7

6

0%

0

7

DVI

83%

82.3

99

88%

5.3

6

100%

7

7

CCWF

72%

75.2

104

64%

3.8

6

CMC

80%

81.1

101

48%

2.9

6

SCC

78%

75.9

97

38%

2.3

6

LAC

71%

73.4

104

13%

0.8

6

100%

7

7

PVSP

67%

81.3

122

67%

4

6

CCI

84%

97.1

115

47%

2.8

6

CRC

CATEGORY SCORES: Continuity of Care, continued

68%

69.6

102

44%

2.6

6

CIW

79%

84.1

106

10%

0.6

6

ASP

74%

76.8

104

47%

2.8

6

HDSP

68%

67.4

99

7%

0.4

6

SQ

83%

100.8

122

50%

3

6

CCC

74%

1375.1

1852

55%

56.2

102

67%

28

Average
Score
42

APPENDIX D-3

Bureau of Audits and Investigations, Office of the Inspector General	

Page 132

State of California • August 2010	

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?

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

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

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

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?

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

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?

Reception center history and physical: Has required intake testing been ordered?

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?

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

Is the clinical history adequate?

Is the focused clinical examination adequate?

Is the assessment adequate?

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

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

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

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

02.211

02.212

02.213

02.215

02.216

02.217

02.218

02.219

03.077

03.082

03.235

03.236

03.237

03.238

03.262

04.056

04.112

continued on page 134

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?

02.022

CATEGORY QUESTIONS: Primary Care Provider Responsibilities

APPENDIX D-4: Category Questions and Scores - Primary Care Provider Responsibilities

Page 133

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

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?

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

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

11.100

21.250

21.276

21.279

Bureau of Audits and Investigations, Office of the Inspector General	

02.212

02.211

2
1.8
88%

Possible Points

Score

Score

Received Points

1.5
75%

Received Points

0%

Score
2

0

Possible Points

4

Possible Points

RJD

Received Points

CMF

CEN

60%

1.2

2

92%

1.8

2

DVI

100%

2

2

100%

2

2

CCWF

CMC

SCC

85%

1.7

2

40%

0.8

2

LAC

PVSP

100%

2

2

89%

1.8

2

CCI

CRC

90%

1.8

2

82%

1.6

2

CIW

ASP

90%

1.8

2

60%

1.2

2

88%

12.3

14

76%

10.7

14

0%

0

Average
Score
4

Were the results of the inmate’s specified prenatal screening tests documented on Form 5703N?

09.223

CCC

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

09.072

SQ

Did medical staff promptly order extra daily nutritional supplements and food for the inmate?

09.069

HDSP

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

06.263

SAC

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

06.191

Ref
Number
02.022

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

04.230

CATEGORY SCORES: Primary Care Provider Responsibilities

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

04.208

CATEGORY QUESTIONS: Primary Care Provider Responsibilities, continued

APPENDIX D-4

Page 134

State of California • August 2010	
10

2

19
16.2
85%

Received Points

Score

60%

Score

Possible Points

18
10.8

Score

Possible Points

7.7
64%

Received Points

Received Points

12

4%

Score

Possible Points

0.4

Received Points

96%

18.2

19

74%

13.3

18

74%

8.9

12

91%

9.1

76%

14.4

19

36%

6.5

18

52%

6.2

12

46%

4.6

10

70%
10

Score

Possible Points

4
2.8

Possible Points

Received Points

100%

Received Points

Score

2

88%

Score

Possible Points

2
1.8

Possible Points

75%

Score

Received Points

2
1.5

Score

Possible Points

0
0%

Received Points

Received Points

2

100%

Possible Points

Score

2

RJD
2

CMF

Possible Points

SAC

Received Points

continued on page 136

03.236

03.235

03.082

03.077

02.219

02.218

02.217

02.216

02.215

Ref
Number
02.213

80%

15.2

19

70%

12.6

18

75%

9

12

74%

7.4

10

CEN

72%

13.7

19

67%

12

18

50%

6

12

78%

7.8

10

50%

2

4

85%

1.7

2

95%

1.9

2

95%

1.9

2

100%

2

2

100%

2

2

DVI

70%

13.3

19

70%

12.6

18

100%

12

12

85%

8.5

10

100%

4

4

100%

2

2

90%

1.8

2

100%

2

2

100%

2

2

CCWF

64%

12.2

19

48%

8.6

18

48%

5.8

12

52%

5.2

10

CMC

90%

17.1

19

65%

11.7

18

90%

10.8

12

85%

8.5

10

SCC

83%

15.8

19

64%

11.5

18

96%

11.5

12

76%

7.6

10

95%

3.8

4

100%

2

2

100%

2

2

100%

2

2

70%

1.4

2

75%

1.5

2

LAC

72%

13.7

19

44%

7.9

18

60%

7.2

12

24%

2.4

10

PVSP

76%

14.4

19

60%

10.8

18

80%

9.6

12

52%

5.2

10

90%

3.6

4

100%

2

2

100%

2

2

100%

2

2

80%

1.6

2

100%

2

2

CCI

72%

13.7

19

32%

5.8

18

96%

11.5

12

60%

6

10

CRC

80%

15.2

19

68%

12.2

18

88%

10.6

12

72%

7.2

10

100%

4

4

100%

2

2

89%

1.8

2

85%

1.7

2

20%

0.4

2

75%

1.5

2

CIW

68%

12.9

19

48%

8.6

18

44%

5.3

12

60%

6

10

ASP

CATEGORY SCORES: Primary Care Provider Responsibilities, continued

48%

9.1

19

32%

5.8

18

76%

9.1

12

28%

2.8

10

20%

0.8

4

67%

1.3

2

56%

1.1

2

60%

1.2

2

0%

0

2

80%

1.6

2

HDSP

76%

14.4

19

68%

12.2

18

12%

1.4

12

72%

7.2

10

85%

3.4

4

SQ

60%

11.4

19

44%

7.9

18

52%

6.2

12

28%

2.8

10

CCC

75%

240.9

323

56%

170.8

306

68%

138.8

204

58%

98.7

170

76%

24.4

32

93%

13

14

89%

12.4

14

88%

12.3

14

45%

5.4

12

90%

12.6

Average
Score
14

APPENDIX D-4

Page 135

Bureau of Audits and Investigations, Office of the Inspector General	

09.069

06.263

06.191

04.230

04.208

04.112

04.056

03.262

03.238

Ref
Number
03.237

90%

82%

8.2

10

70%

4.9

7

84%

6.7

8

82%

15.6

19

72%

78%

7.8

10

56%

3.9

7

89%

4.4

5

100%

9

9

78%

3.9

5

75%

3.8

5

90%

7.2

8

89%

16.9

19

84%

16

19

SCC

67%

6.7

10

14%

1

7

32%

2.6

8

96%

18.2

19

75%

14.3

19

LAC

100%

10

10

73%

5.1

7

96%

7.7

8

88%

16.8

19

63%

12

19

PVSP

100%

10

10

67%

4.7

7

100%

5

5

100%

9

9

70%

3.5

5

88%

4.4

5

60%

4.8

8

71%

13.6

19

44%

8.4

19

CCI

83%

8.3

10

64%

4.5

7

100%

5

5

100%

9

9

70%

3.5

5

89%

4.4

5

80%

6.4

8

85%

16.2

19

86%

16.4

19

CRC

83%

8.3

10

69%

4.8

7

100%

5

5

78%

7

9

30%

1.5

5

38%

1.9

5

80%

6.4

8

86%

16.3

19

86%

16.4

19

CIW

86%

77%

9

10

80%

5.6

7

10%

0.8

8

94%

17.9

19

84%

13.7

19

CMC

Score

67%

7.7

10

75%

5.3

7

100%

5

5

100%

9

9

80%

4

5

75%

3.8

5

83%

6.7

8

93%

17.7

19

88%

16

19

CCWF

5

70%

6.7

10

88%

6.1

7

100%

8

8

90%

17

19

100%

16.6

19

DVI

4.3

92%

7

10

58%

4.1

7

28%

2.2

8

50%

9.5

19

40%

19

19

CEN

Possible Points

91%

Score

9.2

10

87%

6.1

7

90%

4.5

5

100%

9

9

90%

4.5

5

90%

4.5

5

48%

3.8

8

95%

18.1

19

91%

7.6

19

RJD

Received Points

10
9.1

Score

Possible Points

5.4
78%

Received Points

Received Points

7

Possible Points

100%

5

Score

5

Possible Points

Received Points

100%

9

Score

Received Points

82%

Score
9

4.1

Received Points

Possible Points

5

Possible Points

100%

5

Score

5

Possible Points

Score

Received Points

6.4
80%

Received Points

58%

Score
8

11

Possible Points

19

Possible Points

Received Points

73%

Score

17.2

19

19
13.9

Possible Points

Received Points

CMF

SAC

100%

10

10

87%

6.1

7

63%

3.1

5

100%

9

9

40%

2

5

63%

3.1

5

100%

8

8

74%

14

19

71%

13.5

19

ASP

CATEGORY SCORES: Primary Care Provider Responsibilities, continued

58%

5.8

10

62%

4.3

7

64%

5.1

8

57%

10.9

19

59%

11.2

19

HDSP

89%

8.9

10

89%

6.2

7

100%

5

5

100%

9

9

100%

5

5

100%

5

5

76%

6.1

8

92%

17.4

19

92%

17.4

19

SQ

90%

9

10

73%

5.1

7

100%

5

5

100%

9

9

80%

4

5

100%

5

5

60%

4.8

8

53%

10

19

47%

9

19

CCC

86%

4.3

5

83%

141.7

170

70%

83.2

119

94%

47

50

98%

88

90

72%

36

50

82%

40.9

50

69%

93.7

136

80%

257.1

323

74%

238.6

Average
Score
323

APPENDIX D-4

Page 136

State of California • August 2010	

21.279

21.276

21.250

11.100

09.223

Ref
Number
09.072

7

7

7

7

7

CIW

100%
175
123.5
71%

Score

Total Received Points

Total Score

8

Total Possible Points

8

Score

Possible Points

6.4
91%

Received Points

Received Points

7

73%

Score

Possible Points

7
5.1

0%

Score

Possible Points

0

Received Points

7

Possible Points

Received Points

83%

139

167

100%

7

7

80%

5.6

7

0%

0

54%

93.7

173

100%

8

8

95%

6.7

7

50%

3.5

7

0%

0

80%

121

151

83%

6.7

8

91%

6.3

7

100%

7

7

0%

0

81%

150.9

186

100%

8

8

92%

6.4

7

96%

6.7

84%

140.5

167

100%

8

8

100%

7

7

100%

7

7

100%

7

68%

97.8

143

91%

6.4

7

100%

7

7

50%

3.5

85%

143

168

100%

8

8

100%

7

7

100%

7

76%

129

169

100%

8

8

87%

6.1

7

100%

7

7

50%

3.5

74%

111.2

151

100%

8

8

96%

6.7

7

96%

6.7

7

100%

7

76%

146.8

193

100%

8

8

95%

6.7

7

100%

7

7

67%

4.7

78%

131.2

168

100%

8

8

83%

5.8

7

96%

6.7

77%

156.6

203

100%

8

8

81%

5.7

7

96%

6.7

7

4.3
7

CRC

86%
7

CCI

Score
7

PVSP

Received Points
7

LAC

5

7

SCC

Possible Points

7

CMC

0%

CCWF

Score

DVI
0

CEN
7

RJD

Possible Points

CMF

Received Points

SAC

72%

121.1

168

100%

8

8

64%

4.5

7

100%

7

7

ASP

CATEGORY SCORES: Primary Care Provider Responsibilities, continued

55%

92.5

169

100%

8

8

63%

4.4

7

100%

7

7

0%

0

7

HDSP

79%

141.3

179

100%

8

8

79%

5.5

7

72%

5

7

60%

4.2

7

SQ

66%

115.9

175

100%

8

8

67%

4.7

7

100%

7

7

100%

7

7

CCC

74%

2155

2905

99%

118.7

120

87%

103.3

119

92%

109

119

44%

36.9

84

86%

4.3

5

0%

0

Average
Score
7

APPENDIX D-4

Page 137

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

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

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?

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?

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

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

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

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

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

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?

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?

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

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

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

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?

Was the inmate’s weight and blood pressure documented at each clinic visit?

01.024

01.157

01.158

01.159

01.162

01.163

01.244

01.246

02.015

02.017

02.020

05.109

05.110

05.171

08.185

09.224

CATEGORY QUESTIONS: Nurse Responsibilities

APPENDIX D-5: Category Questions and Scores - Nurse Responsibilities

Bureau of Audits and Investigations, Office of the Inspector General	

Page 138

State of California • August 2010	
6
5.5
91%

Received Points

Score

96%

Score

Possible Points

6
5.7

Score

Possible Points

6.4
92%

Received Points

Received Points

7

96%

Score

Possible Points

continued on page 140

01.159

01.158

01.157

77%

4.6

6

88%

5.3

6

96%

6.7

7

96%

3.8

4

4
3.8

Possible Points

Received Points

80%

4.8

6

79%

4.8

6

83%

5.8

7

93%

3.7

4

RJD

90%

5.4

6

89%

5.4

6

100%

7

7

87%

3.5

4

CEN

67%

4

6

91%

5.5

6

83%

5.8

7

76%

3

4

DVI

88%

5.3

6

96%

5.8

6

92%

6.4

7

52%

2.1

4

CCWF

73%

4.4

6

83%

5

6

93%

6.5

7

90%

3.6

4

CMC

80%

4.8

6

95%

5.7

6

80%

5.6

7

30%

1.2

4

SCC

55%

3.3

6

90%

5.4

6

59%

4.1

7

77%

3.1

4

LAC

53%

3.2

6

33%

2

6

50%

3.5

7

87%

3.5

4

PVSP

68%

4.1

6

68%

4.1

6

64%

4.5

7

92%

3.7

4

CCI

90%

5.4

6

90%

5.4

6

45%

3.2

7

45%

1.8

4

CRC

4

76%

4.6

6

79%

4.8

6

54%

3.8

7

80%

3.2

4

59%

3.5

6

74%

4.4

6

65%

4.5

7

89%

3.5

50%

3

6

61%

3.6

6

57%

4

7

40%

1.6

4

HDSP

50%

3

6

27%

1.6

6

32%

2.2

7

11%

0.5

4

SQ

79%

4.7

6

58%

3.5

6

79%

5.5

7

80%

3.2

4

CCC

72%

73.6

102

76%

78

102

72%

85.5

119

72%

48.8

Average
Score
68

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?

21.251

ASP

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?

21.248

CIW

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

15.285

CMF

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

15.283

SAC

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

15.282

Ref
Number
01.024

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

14.131

CATEGORY SCORES: Nurse Responsibilities

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?

11.097

CATEGORY QUESTIONS: Nurse Responsibilities, continued

APPENDIX D-5

Page 139

Bureau of Audits and Investigations, Office of the Inspector General	

05.171

05.110

05.109

02.020

02.017

02.015

01.246

01.244

01.163

Ref
Number
01.162

8

8

7
5.6
80%

Possible Points

Received Points

Score

100%

8

Score

8

Possible Points

Received Points

100%

Received Points

Score

8

90%

Score

Possible Points

6
5.4

Possible Points

Received Points

100%

Received Points

Score

8

Possible Points

100%

7

Received Points

Score

7

92%

Score

Possible Points

5
4.6

Score

Possible Points

2.8
92%

Received Points

Received Points

3

77%

Score

Possible Points

5
3.9

Possible Points

Received Points

92%

Score

0%

0

7

50%

4

8

0%

0

8

70%

4.2

6

56%

4.4

8

92%

4.6

5

94%

2.8

3

94%

4.7

5

94%

6.6

7

7
6.4

Possible Points

Received Points

CMF

SAC

100%

7

7

100%

8

8

50%

4

8

87%

5.2

6

94%

7.6

8

100%

7

7

87%

4.3

5

80%

2.4

3

90%

4.5

5

100%

7

7

RJD

100%

7

7

100%

8

8

100%

8

8

90%

5.4

6

93%

7.5

8

90%

4.5

5

93%

2.8

3

93%

4.7

5

97%

6.8

7

CEN

100%

7

7

100%

8

8

0%

0

8

100%

6

6

100%

8

8

100%

7

7

96%

4.8

5

79%

2.4

3

70%

3.5

5

96%

6.7

7

DVI

100%

7

7

100%

8

8

100%

8

8

100%

6

6

100%

8

8

67%

4.7

7

96%

4.8

5

80%

2.4

3

96%

4.8

5

96%

6.7

7

CCWF

75%

5.3

7

100%

8

8

85%

5.1

6

100%

8

8

75%

5.3

7

88%

4.4

5

80%

2.4

3

85%

4.3

5

98%

6.8

7

CMC

80%

5.6

7

100%

8

8

95%

5.7

6

29%

2.3

8

83%

5.8

7

100%

5

5

50%

1.5

3

90%

4.5

5

95%

6.6

7

SCC

100%

7

7

100%

8

8

100%

6

6

46%

3.7

8

100%

7

7

86%

4.3

5

35%

1

3

86%

4.3

5

100%

7

7

LAC

20%

1.4

7

80%

6.4

8

85%

5.1

6

70%

5.6

8

67%

3.3

5

33%

1

3

57%

2.8

5

63%

4.4

7

PVSP

20%

1.4

7

100%

8

8

0%

0

8

80%

4.8

6

100%

8

8

33%

2.3

7

64%

3.2

5

28%

0.8

3

80%

4

5

92%

6.4

7

CCI

100%

7

7

100%

8

8

100%

8

8

100%

6

6

100%

8

8

100%

7

7

95%

4.8

5

5%

0.2

3

95%

4.8

5

100%

7

7

CRC

CATEGORY SCORES: Nurse Responsibilities, continued

60%

4.2

7

40%

3.2

8

100%

8

8

90%

5.4

6

87%

6.9

8

80%

4

5

12%

0.4

3

71%

3.5

5

96%

6.7

7

CIW

100%

7

7

85%

5.1

6

100%

8

8

77%

3.8

5

65%

1.9

3

82%

4.1

5

94%

6.6

7

ASP

100%

7

7

100%

8

8

97%

5.8

6

100%

8

8

87%

4.3

5

7%

0.2

3

64%

3.2

5

100%

7

7

HDSP

100%

7

7

96%

5.8

6

100%

7

7

91%

4.5

5

18%

0.5

3

64%

3.2

5

100%

7

7

SQ

60%

4.2

7

100%

8

8

100%

8

8

100%

6

6

100%

8

8

100%

7

7

90%

4.5

5

47%

1.4

3

63%

3.2

5

90%

6.3

7

CCC

76%

90.7

119

91%

109.6

120

65%

52

80

91%

93

102

86%

110

128

87%

67.1

77

87%

73.7

85

53%

26.9

51

80%

68

85

94%

112

Average
Score
119

APPENDIX D-5

Page 140

State of California • August 2010	

21.251

21.248

15.285

15.283

15.282

14.131

11.097

09.224

Ref
Number
08.185

100%
122
104.1
85%

Score

Total Received Points

Total Score

7

Total Possible Points

7

Score

Possible Points

5.5
79%

Received Points

Received Points

7

100%

Possible Points

Score

1

Received Points

0%

Score
1

0

Possible Points

1

Score

Possible Points

0
0%

Received Points

Received Points

2

Possible Points

100%

4

Score

4

Possible Points

Received Points

33%

2

Score

6

Possible Points

Received Points

69%

79

115

0%

0

7

90%

6.3

7

100%

1

1

100%

1

1

100%

2

2

100%

4

4

100%

6

6

86%

104.7

122

100%

7

7

65%

4.6

7

100%

1

1

100%

1

1

100%

2

2

100%

4

4

33%

2

6

91%

94.3

104

75%

5.3

7

0%

0

4

100%

6

6

78%

90.5

116

0%

0

7

88%

6.2

7

100%

1

1

0%

0

1

100%

2

2

100%

4

4

94%

114.4

122

100%

7

7

92%

6.4

7

100%

1

1

100%

1

1

100%

2

2

100%

4

4

100%

6

6

100%

88%

94.6

107

84%

5.9

7

100%

1

1

100%

1

1

100%

2

2

100%

4

4

100%

6

6

80%

83%

84.3

101

100%

7

7

100%

1

1

100%

1

1

100%

2

2

100%

4

4

100%

7

7

SCC

81%

83.4

103

96%

6.7

7

100%

4

4

25%

1.5

6

100%

7

7

LAC

66%

70.4

107

100%

7

7

88%

6.2

7

100%

1

1

100%

1

1

100%

2

2

100%

4

4

0%

0

6

100%

7

7

PVSP

67%

76.7

115

92%

6.4

7

100%

1

1

100%

1

1

100%

2

2

100%

4

4

0%

0

6

100%

7

7

CCI

90%

97.6

109

100%

7

7

100%

1

1

0%

0

1

100%

2

2

100%

4

4

100%

7

7

CRC

CIW

76%

76.9

101

84%

5.9

7

100%

1

1

100%

1

1

100%

2

2

100%

4

4

4.3

80%

5.6

7

CMC

71%

100%

7

7

CCWF

Score

100%

5.6

7

DVI

Received Points

100%

7

7

CEN

6

50%

7

7

RJD

Possible Points

Score

7

7

7
3.5

Possible Points

Received Points

CMF

SAC

CATEGORY SCORES: Nurse Responsibilities, continued

84%

72.1

86

92%

6.4

7

100%

1

1

100%

1

1

100%

2

2

100%

4

4

75%

5.3

7

ASP

74%

74

100

32%

2.2

7

100%

1

1

100%

1

1

0%

0

2

100%

4

4

80%

4.8

6

75%

5.3

7

HDSP

72%

65.7

91

52%

3.6

7

100%

1

1

100%

1

1

100%

2

2

100%

4

4

80%

4.8

6

100%

7

7

SQ

82%

94.7

115

88%

6.2

7

100%

1

1

100%

1

1

100%

2

2

100%

4

4

0%

0

6

100%

7

7

CCC

80%

1477.4

1836

67%

28

42

82%

97.8

119

100%

15

15

80%

12

15

87%

26

30

94%

64

68

54%

39.1

72

72%

4.3

6

91%

102.3

Average
Score
112

APPENDIX D-5

Page 141

California Prison Health Care
Receivership Corporation’s
Response

Bureau of Audits and Investigations, Office of the Inspector General	

Page 142

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

J. Clark Kelso, Receiver

PRISON HEALTH CARE SERVICES

August 23,2010

Mr. David R. Shaw
Inspector General
Office of Inspector General
P.O. Box 348780
Sacramento, CA 95834-8780
Re: Response to OIG - Mid-Tenn Medical Inspections Summary Report
Dear Mr. Shaw:
Thank you for the opportunity to review the above draft report from the Office of Inspector
General, and we concur with the audit findings and recommendations. While we are
committed to refonn the California prison medical health care utilizing best practices with
the most cost effective manner, tremendous efforts and ongoing improvements have been
undertaken as addressed in the Receiver's Turnaround Plan of Action Tri-Annual and
monthly reports. You can find the Tri-Annual and monthly reports on our website at
http://www.cphcs.ca. gov/receiver.aspx.
Again, we would like to thank you and your staff for the valuable review and recommendations.
Sincerely,

Receiver
cc:

Elaine Bush, Chief Deputy Receiver, CPHCS
Kathleen Webb, Director (Acting), Policy and Risk Management Services, CPHCS

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

State of California • August 2010	

Page 143

SPECIALREPORT
REPORT
SPECIAL
INMATE CELL PHONE USE ENDANGERS PRISON
SECURITY AND PUBLIC SAFETY

SUMMARY AND ANALYSIS OF THE FIRST 17 MEDICAL INSPECTIONS OF
CALIFORNIA PRISONS
OFFICE OF THE
INSPECTOR GENERAL

OFFICE OF THE INSPECTOR GENERAL
DAVID R. SHAW

INSPECTOR GENERAL

STATE OF CALIFORNIA

David R. Shaw

MAY 2009

INSPECTOR GENERAL



Jerry Twomey
CHIEF ASSISTANT INSPECTOR GENERAL

Nancy Faszer

DEPUTY INSPECTOR GENERAL, IN-CHARGE

STATE OF CALIFORNIA
AUGUST 2010
WWW.OIG.CA.GOV

 

 

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