SUMMARY AND ANALYSIS OF THE FIRST 17 MEDICAL INSPECTIONS OF CALIFORNIA PRISONS BUREAU OF AUDITS AND INVESTIGATIONS OFFICE OF THE INSPECTOR GENERAL DAVID R. SHAW INSPECTOR GENERAL STATE OF CALIFORNIA AUGUST 2010
Mar 17, 2016
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 WI N S P E C T O R G E N E R A L
S TAT E O F C A L I F O R N I AA U G U S T 2 0 1 0
State of California • August 2010
Contents
Executive Summary .................................................................................................................... 1
Introduction ................................................................................................................................. 4 OIG Medical Inspection Program ......................................................................................... 4 Objectives, Scope, and Methodology ................................................................................... 7
Results of the First 17 Medical Inspections .............................................................................. 10Overall Scores and Medical Components ............................................................................ 11
Chronic Care ................................................................................................................. 16Clinical Services ........................................................................................................... 18Health Screening ........................................................................................................... 20Specialty Services ......................................................................................................... 22Urgent Services ............................................................................................................. 24Emergency Services ...................................................................................................... 26Prenatal Care/Childbirth/Post-Delivery ........................................................................ 28Diagnostic Services ....................................................................................................... 30Access to Health Care Information ............................................................................... 32Outpatient Housing Unit ............................................................................................... 34Internal Reviews ........................................................................................................... 36Inmate Transfers ............................................................................................................ 38Clinic Operations .......................................................................................................... 40Preventive Services ....................................................................................................... 42Pharmacy Services ........................................................................................................ 44Other Services ............................................................................................................... 46Inmate Hunger Strikes .................................................................................................. 48Chemical Agent Contraindications ............................................................................... 50Staffing Levels and Training ......................................................................................... 52Nursing Policy .............................................................................................................. 56
General Medical Categories ................................................................................................ 58Medication Management .............................................................................................. 62Access to Providers and Services ................................................................................. 64Continuity of Care ......................................................................................................... 67Primary Care Provider Responsibilities ......................................................................... 69Nurse Responsibilities .................................................................................................. 72
Bureau of Audits and Investigations, Office of the Inspector General
Conclusion ................................................................................................................................ 74
Appendices ................................................................................................................................ 77A: Component Definitions .................................................................................................. 79B: Prisons’ Scores by Component ....................................................................................... 81C: Component Questions and Scores ................................................................................... 82D: Category Questions and Scores .................................................................................... 120
California Prison Health Care Receivership Corporation’s Response .................................... 142
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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.
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Results in BriefThe 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,
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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.
ConclusionWe 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.
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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.
BackgroundIn 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 ProgramTo 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
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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 use allows for a broadly scoped and consistent method 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.
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.
20 Components of the OIG’s Medical Inspections (in order of importance):
Chronic CareClinical ServicesHealth ScreeningSpecialty ServicesUrgent ServicesEmergency ServicesPrenatal Care/Childbirth/Post-
DeliveryDiagnostic ServicesAccess to Health Care InformationOutpatient Housing UnitInternal ReviewsInmate TransfersClinic OperationsPreventive ServicesPharmacy ServicesOther ServicesInmate Hunger StrikesChemical Agent ContraindicationsStaffing Levels and TrainingNursing Policy
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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.
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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 MethodologyIn 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
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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 system-wide 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.
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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.
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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.
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Overall Scores and Medical ComponentsOnly 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 AnalysisIndividual prisons’ component scores varied widely. We have summarized all 17 institutions’ scores for each of the 20 components on one table in Appendix B.
65% 65%64%
62%
71% 72%
76%
72%
68%
73% 73%
68%70%70%
78%
55%
65%
75%
85%
95%
100%
SAC Nov.2008
CMFJan.2009
RJD Feb.2009
CEN Feb.2009
DVI Mar.2009
CCWF May2009
CMCMay2009
SCC Jun.2009
LAC Jul.2009
PVSP Aug.2009
CCI Sep.2009
CRC Oct.2009
CIW Nov.2009
ASP Nov.2009
HDSPDec.2009
SQ Dec.2009
CCC Jan.2010
Total Score
Average Score = 70%
Institution Score
Average Score = 70%
Minimum Moderate Adherence = 75%
74%74%
Chart 1: OIG First Seventeen Medical Inspection Results, in Chronological Order of Report Date.
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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.
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• 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.
Chart 2: Average Score by Medical Component, Sorted by Order of Importance
94%
91%
46%
86%
85%
37%
90%
86%
76%
77%
59%
69%
61%
77%
79%
60%
66%
64%
25% 35% 45% 55% 65% 75% 85% 95% 100%
Nursing PolicyStaffing Levels and Training
Chemical Agent ContraindicationsInmate Hunger Strikes
Other ServicesPharmacy Services
Preventive ServicesClinic OperationsInmate TransfersInternal Reviews
Outpatient Housing UnitAccess to Health Care Information
Diagnostic ServicesPrenatal Care/Childbirth/Post-delivery
Emergency ServicesUrgent Services
Specialty ServicesHealth ScreeningClinical Services
Chronic Care
74%
75%
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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
Table 1: Summary of High and Low Scores by Medical Component, Sorted by Order of Importance
Medical Component High Low Average Variation BetweenHigh/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
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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.
Bureau of Audits and Investigations, Office of the Inspector General Page 16
Medical Component: Chronic Care ProfilePage 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.
Chart 3: Chronic Care Scores by Institution, Sorted Highest to Lowest Score
84%81%
70%
65%
46% 45%
49%
57%57%59%
62%63%
67%70%
35%
45%
55%
65%
75%
85%
95%
100%
CMF CEN SCC DVI CCWF LAC CIW CRC SQ SAC CCI ASP CMC PVSP RJD CCC HDSP
Chronic Care
Average Score = 64%
Institution Score
Average Score = 64%
Minimum Moderate Adherence = 75%
75%73%74%
This component includes nine questions.
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
State of California • August 2010 Page 17
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.
Question03.077
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.
Medical Component: Chronic Care ProfilePage 2 of 2
Bureau of Audits and Investigations, Office of the Inspector General Page 18
Medical Component: Clinical Services ProfilePage 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.
Chart 4: Clinical Services Scores by Institution, Sorted Highest to Lowest Score
80%
66%
51%
70%
47%47%
57%
62%64%
66%67%67%
71%
87%
35%
45%
55%
65%
75%
85%
95%
100%
CMF CEN CMC CCWF DVI SCC CRC RJD SAC CCC LAC ASP CIW CCI HDSP PVSP SQ
Clinical Services
Average Score = 66%
Institution Score
Average Score = 66%
Minimum Moderate Adherence = 75%
73%74%74%
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.
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
State of California • August 2010 Page 19
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.
Question01.247
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.
Question01.244
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.
Question15.234
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.
Areas Achieving High Adherence with Scores of 86 Percent or More
Question01.162
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.
Question01.246
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.
Medical Component: Clinical Services ProfilePage 2 of 2
Bureau of Audits and Investigations, Office of the Inspector General Page 20
Medical Component: Health Screening ProfilePage 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.
Chart 5: Health Screening Scores by Institution, Sorted Highest to Lowest Score
77% 76%
67%
61%
70%68%69%
72%
78%78%
81%81%
84%87%
55%
65%
75%
85%
95%
100%
CMF CCWF ASP CCC CCI CEN SQ SAC DVI CRC CMC HDSP CIW LAC RJD PVSP SCC
Health Screening
Average Score = 75%
Institution Score
Average Score = 75%
Minimum Moderate Adherence = 75%
73%74%74%
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.
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
State of California • August 2010 Page 21
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.
Question02.018
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 02.21202.21302.21602.21702.218
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.
Question02.020
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.
Question02.007
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.
Question02.015
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.
Question02.017
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.
Medical Component: Health Screening ProfilePage 2 of 2
Bureau of Audits and Investigations, Office of the Inspector General Page 22
Medical Component: Specialty Services ProfilePage 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.
Chart 6: Specialty Services Scores by Institution, Sorted Highest to Lowest Score
43%
53%53%53%
61%62%63%63%
47%
57%58%59%60%
70%71%73%74%
35%
45%
55%
65%
75%
85%
95%
100%
ASP SCC CCC LAC CMC CIW RJD PVSP CEN CRC SQ CCI DVI HDSPCCWF SAC CMF
Specialty Services
Average Score = 60%
Institution Score
Average Score = 60%
Minimum Moderate Adherence = 75%
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.
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
State of California • August 2010 Page 23
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
Question07.090
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.
Question07.270
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.
Medical Component: Specialty Services ProfilePage 2 of 2
Bureau of Audits and Investigations, Office of the Inspector General Page 24
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.
Chart 7: Urgent Services Scores by Institution, Sorted Highest to Lowest Score
81% 81% 80% 80%
70%
79%
75%
72%
63%
73%
78%
83%83%84%84%
89%89%
55%
65%
75%
85%
95%
100%
CCWF SCC CCC CMC CCI SAC CRC PVSP CEN LAC CMF DVI CIW RJD HDSP ASP SQ
Institution Score
Average Score = 79%
Minimum Moderate Adherence = 75%
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.
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
State of California • August 2010 Page 25
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.
Question21.276
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.
Medical Component: Urgent Services ProfilePage 2 of 2
Bureau of Audits and Investigations, Office of the Inspector General Page 26
Medical Component: Emergency Services ProfilePage 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.
Chart 8: Emergency Services Scores by Institution, Sorted Highest to Lowest Score
86%84% 83%
80% 80%
90%90%
78% 78% 78% 77% 76%
72% 72% 71%
48%
35%
45%
55%
65%
75%
85%
95%
100%
RJD CCC CMC LAC PVSPCCWF CIW SQ ASP CCI CEN SCC CRC CMF HDSP DVI SAC
Average Score = 77%
Institution Score
Average Score = 77%
Minimum Moderate Adherence = 75%
73%
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.
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
State of California • August 2010 Page 27
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.
Question15.255
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
Question15.240
In the emergency medical response drill, all responding officers activated the emergency response system. Every participating prison scored 100 percent on this question.
Question15.285
In the emergency medical response drill, all emergency medical responders continued basic life support activities. Every participating prison scored 100 percent on this question.
Question08.183
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.
Question08.186
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.
Question08.184
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.
Question08.185
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.
Question15.282
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.
Medical Component: Emergency Services ProfilePage 2 of 2
4 We did not complete the emergency response drill at Centinela State Prison due to special circumstances.
Bureau of Audits and Investigations, Office of the Inspector General Page 28
Medical Component: Prenatal Care/Child Birth/Post-Delivery ProfilePage 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.
Chart 9: Prenatal Care/Childbirth/Post Delivery Scores by Institution, Sorted Highest to Lowest Score
45%
55%
65%
75%
85%
95%
100%
CIW SAC CMF RJD CEN DVI CCWF CMC SCC LAC PVSP CCI CRC ASP HDSP SQ CCC
No Prenatal/Childbirth/Post-Delivery cases at these prisons
Institution Score
Minimum Moderate Adherence = 75%
61%
This component includes nine questions.
Areas Requiring Significant Improvement Due to Scores of 60 Percent or Less
Question09.066
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.
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
State of California • August 2010 Page 29
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.
Question09.068
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 MoreQuestion 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.
Question09.069
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.
Question09.071
An obstetrician generally met with pregnant inmates according to applicable time frames. CIW scored 86 percent on this question.
Question09.223
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.
Medical Component: Prenatal Care/Child Birth/Post-Delivery ProfilePage 2 of 2
Bureau of Audits and Investigations, Office of the Inspector General Page 30
Medical Component: Diagnostic Services ProfilePage 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.
Chart 10: Diagnostic Services Scores by Institution, Sorted Highest to Lowest Score
43%
54%
59%60%
64%65%68%69%70%71%71%72%
84%86%87%
35%
45%
55%
65%
75%
85%
95%
100%
ASP SCC CCWF CEN DVI CMF CCC CIW CMC SQ SAC PVSP RJD CCI CRC LAC HDSP
Diagnostic Services
Average Score = 69%
Institution Score
Average Score = 69%
Minimum Moderate Adherence = 75%
74%74%
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.
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
State of California • August 2010 Page 31
Question06.202
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 MoreQuestion06.245
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.
Medical Component: Diagnostic Services ProfilePage 2 of 2
Bureau of Audits and Investigations, Office of the Inspector General Page 32
Medical Component: Access to Health Care Information ProfilePage 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.
Chart 11: Access to Healthcare Information Scores by Institution, Sorted Highest to Lowest Score
82%
39%
82%
59%
78%
44%
54%
78%
59%59%
39%
55%59%
63%
20%
54%
15%
25%
35%
45%
55%
65%
75%
85%
95%
100%
CEN SCC CRC CCC LAC PVSP CMF DVI CIW HDSP CCI CCWF SQ RJD SAC CMC ASP
Institution Score
Average Score = 59%
Minimum Moderate Adherence = 75%
73%
This component includes 6 questions.
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
State of California • August 2010 Page 33
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
Question19.169
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.
Medical Component: Access to Health Care Information ProfilePage 2 of 2
Bureau of Audits and Investigations, Office of the Inspector General Page 34
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 placement provided the inmate with adequate care and whether the physician’s plan addressed the placement diagnosis.
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.
Chart 12: Outpatient Housing Unit Scores by Institution, Sorted Highest to Lowest Score
86%
83% 83% 82%
63%
71%73%
45%
55%
65%
75%
85%
95%
100%
CMF SQ DVI CCC SAC SCC CRC CCI ASP CIW RJD CEN CCWF CMC LAC PVSP HDSP
No Outpatient Housing Units at these prisons
76%
Institution Score
Average Score = 77%
Minimum Moderate Adherence = 75%
75%75%
This component includes ten questions.
Areas Requiring Significant Improvement Due to Scores of 60 Percent or LessQuestion 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.
Key Statistics• Component Average: ..... 77%• Top Two Average: ......... 85%• Range of Scores: ...86%-63%• Variation: ...................... 23%
• Number of Prisons with: High Adherence ................ 1 Moderate Adherence ......... 6 Low Adherence ................. 3
State of California • August 2010 Page 35
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
Question04.208
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.
Question04.230
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.
Question15.225
With the exception of CRC, all prisons’ outpatient housing units used disinfectant daily in common patient areas. The average score was 90 percent.
Question04.052
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.
Medical Component: Outpatient Housing Unit ProfilePage 2 of 2
Bureau of Audits and Investigations, Office of the Inspector General Page 36
Medical Component: Internal Reviews ProfilePage 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.
Chart 13: Internal Reviews Scores by Institution, Sorted Highest to Lowest Score
60%60%61%
63%
66%
70%70%71%
86%
91%93%
95%
69%69%
73%
98%
55%
65%
75%
85%
95%
100%
RJD CCWF CIW DVI CRC CCC LAC PVSP CMC SAC CMF SQ ASP HDSP CEN SCC CCI
Internal Reviews
Average Score = 76%
Institution Score
Average Score = 76%
Minimum Moderate Adherence = 75%
100%
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.
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
State of California • August 2010 Page 37
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
Question17.119
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.
Question17.135
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.
Question17.118
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.
Medical Component: Internal Reviews ProfilePage 2 of 2
Bureau of Audits and Investigations, Office of the Inspector General Page 38
Medical Component: Inmate Transfers ProfilePage 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.
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.
Chart 14: Inmate Transfers Scores by Institution, Sorted Highest to Lowest Score
43%
50%
76%
93%94%95%
90%
79%80%
45%
55%
65%
75%
85%
95%
100%
CEN CCWF LAC CRC ASP HDSP SQ SCC CMC CCC RJD CIW DVI PVSP SAC CMF CCI
Institution Score
Average Score = 86%
Minimum Moderate Adherence = 75%
100%100%100%100%100%100%100%
75%
This component includes five questions.
Areas Requiring Significant Improvement Due to Scores of 60 Percent or Less
None.
Key Statistics• 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
State of California • August 2010 Page 39
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.
Question05.110
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.
Question05.172
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.
Medical Component: Inmate Transfers ProfilePage 2 of 2
Bureau of Audits and Investigations, Office of the Inspector General Page 40
Medical Component: Clinic Operations ProfilePage 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.
Chart 15: Clinic Operations Scores by Institution, Sorted Highest to Lowest Score
82%83%
85%86%86%
88%88%
90%91%91%91%
93%94%
95%97%
98%
65%
75%
85%
95%
100%
SQ CIW CCC RJD ASP PVSP SAC HDSP CCI LAC DVI SCC CRC CCWF CMC CMF CEN
Institution Score
Average Score = 90%
Minimum Moderate Adherence = 75%
100%
This component includes ten questions.
Areas Requiring Significant Improvement Due to Scores of 60 Percent or Less
None.
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
State of California • August 2010 Page 41
Areas Achieving High Adherence with Scores of 86 Percent or More
Questions14.03214.033
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.
Questions14.02914.13114.166
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.
Question14.023
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.
Question14.164
The prisons generally made areas available to ensure inmates’ privacy during the registered nurses’ face-to-face assessments and doctors’ examinations for non-emergencies. 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.
Medical Component: Clinic Operations ProfilePage 2 of 2
Bureau of Audits and Investigations, Office of the Inspector General Page 42
Medical Component: Preventive Services ProfilePage 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.
Chart 16: Preventive Services Scores by Institution, Sorted Highest to Lowest Score
82%
60% 59%
53%
28%
22%20% 19%
7%
24%24%
37%
27%
32%33%
44%
49%
0%
15%
5%
25%
35%
45%
55%
65%
75%
85%
95%
100%
CRC ASP CCWF CMC SQ CMF CCC CIW SAC SCC PVSP RJD HDSP DVI LAC CEN CCI
Institution Score
Average Score = 37%
Minimum Moderate Adherence = 75%
This component includes seven questions. However, two questions apply only to female prisons; and, one question applies only to male 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
State of California • August 2010 Page 43
Areas Requiring Significant Improvement Due to Scores of 60 Percent or Less
Questions 10.22810.232
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.
Question10.274
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.
Medical Component: Preventive Services ProfilePage 2 of 2
5 We did not test CCWF and CIW for compliance with this question because current CDCR policy requires the FOBT for male inmates only.
Bureau of Audits and Investigations, Office of the Inspector General Page 44
Medical Component: Pharmacy Services ProfilePage 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.
Chart 17: Pharmacy Services Scores by Institution, Sorted Highest to Lowest Score
76%
58%
69%
72%
75%
79%79%
86%
91%91%92%92%92%93%95%
100% 100%
45%
55%
65%
75%
85%
95%
100%
LAC HDSP CIW RJD DVI CCWF ASP CMC SCC SQ CCI CRC CMF SAC PVSP CCC CEN
Institution Score
Average Score = 85%
Minimum Moderate Adherence = 75%
This component includes eight questions.
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
State of California • August 2010 Page 45
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.
Question13.144
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
Questions13.13913.142
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.
Question13.145
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.
Question13.148
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.
Medical Component: Pharmacy Services ProfilePage 2 of 2
Bureau of Audits and Investigations, Office of the Inspector General Page 46
Medical Component: Other Services ProfilePage 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.
Chart 18: Other Services Scores by Institution, Sorted Highest to Lowest Score
100%
55%57%
70%70%70%
73%
85%85%
91%91%
100%100%100%100%100%100%
45%
55%
65%
75%
85%
95%
100%
CMF RJD CEN DVI CCWF LAC CCC CMC SAC CCI SQ HDSP PVSP CRC ASP CIW SCC
Institution Score
Average Score = 86%
Minimum Moderate Adherence = 75%
This component includes five questions.
Areas Requiring Significant Improvement Due to Scores of 60 Percent or Less
None.
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
State of California • August 2010 Page 47
Areas Achieving High Adherence with Scores of 86 Percent or More
Question15.059
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.
Question20.092
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.
Medical Component: Other Services ProfilePage 2 of 2
Bureau of Audits and Investigations, Office of the Inspector General Page 48
Medical Component: Inmate Hunger Strikes ProfilePage 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.
Chart 19: Inmate Hunger Strikes Scores by Institution, Sorted Highest to Lowest Score
11%11%
32%32%
37%
42%44%
46%
54%
68%71%
100%
0%
5%
15%
25%
35%
45%
55%
65%
75%
85%
95%
100%
CCWF CMC CCC SQ CCI HDSP LAC PVSP CMF CEN SAC RJD DVI SCC CRC CIW ASP
No inmate hunger strikes lasting longer than three days occurred at these prisons.
Institution Score
Average Score = 46%
Minimum Moderate Adherence = 75%
This component includes three questions.
Areas Requiring Significant Improvement Due to Scores of 60 Percent or LessQuestion11.099
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.
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
State of California • August 2010 Page 49
Question11.100
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.
Medical Component: Inmate Hunger Strikes ProfilePage 2 of 2
Bureau of Audits and Investigations, Office of the Inspector General Page 50
Medical Component: Chemical Agent Contraindications ProfilePage 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.
Chart 20: Chemical Agent Contraindication Scores by Institution, Sorted Highest to Lowest Score
94%
66% 66%65%
87%89%89%89%
91%
100%100%100%100%100%100%100%100%
55%
65%
75%
85%
95%
100%
SAC CMC SCC CRC CIW ASP HDSP CCC RJD LAC CEN DVI SQ CMF PVSP CCI CCWF
Institution Score
Average Score = 91%
Minimum Moderate Adherence = 75%
This component includes two questions.
Areas Requiring Significant Improvement Due to Scores of 60 Percent or Less
None.
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
State of California • August 2010 Page 51
Areas Achieving High Adherence with Scores of 86 Percent or More
Question12.064
Prisons normally recorded how they decontaminated inmates and followed decontamination policy. The average score for this question was 94 percent.
Question12.062
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.
Medical Component: Chemical Agent Contraindications ProfilePage 2 of 2
Bureau of Audits and Investigations, Office of the Inspector General Page 52
Medical Component: Staffing Levels and Training ProfilePage 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.
Chart 21: Staffing Levels and Training Scores by Institution, Sorted Highest to Lowest Score
95% 95% 95% 95%
90% 90%
85% 85% 85%
80%
100% 100% 100% 100% 100% 100% 100%
55%
65%
75%
85%
95%
100%
RJD CEN CMC SCC ASP HDSP CCC SAC CMF DVI SQ LAC CCI CCWF CRC CIW PVSP
Staffing Levels and Training
Average Score = 94%
Institution Score
Average Score = 94%
Minimum Moderate Adherence = 75%
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.
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
State of California • August 2010 Page 53
Areas Achieving High Adherence with Scores of 86 Percent or More
Question18.004
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.
Question18.005
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.
Question18.006
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.
Medical Component: Staffing Levels and Training ProfilePage 2 of 4
Bureau of Audits and Investigations, Office of the Inspector General Page 54
Data Not Included in Scoring: Results of Staffing and Vacancy Rate AnalysisThe 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.
BackgroundDuring 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.
Medical Component: Staffing Levels and Training ProfilePage 3 of 4
State of California • August 2010 Page 55
Table 2: Staffing Levels and Vacancy Rates*
InstitutionTotal number
of filled positions:
Total number of vacancies:
Total number of positions:
Vacancy percentage:
Number of staff hired within last
six months:
Total number of registry
staff:
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
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.
* 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.
Medical Component: Staffing Levels and Training ProfilePage 4 of 4
Bureau of Audits and Investigations, Office of the Inspector General Page 56
Medical Component: Nursing Policy ProfilePage 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.
Chart 22: Nursing Policy Scores by Institution, Sorted Highest to Lowest Score
94%
76%
64%
50%
36% 36%
94%
70%71%
89% 89%
79% 79%
67%
57%
100% 100%
35%
45%
55%
65%
75%
85%
95%
100%
CCWF PVSP SCC CCC RJD HDSP SAC CMC CRC CEN SQ ASP CIW LAC CCI CMF DVI
Nursing Policy
Average Score = 74%
Institution Score
Average Score = 74%
Minimum Moderate Adherence = 75%
This component includes three questions.
Areas Requiring Significant Improvement Due to Scores of 60 Percent or LessQuestion16.254
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.
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
State of California • August 2010 Page 57
Medical Component: Nursing Policy ProfilePage 2 of 2
Areas Achieving High Adherence with Scores of 86 Percent or More Question16.154
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.
Bureau of Audits and Investigations, Office of the Inspector General Page 58
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.
BackgroundWhile 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.
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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-to-face 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’
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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 Providers and
Services
Continuity of Care
Primary Care Provider
Responsibilities
Nurse Responsibilities
Chronic Care √ √ √
Clinical Services √ √ √
Health Screening √ √ √ √ √
Specialty Services √ √
Urgent Services √ √ √ √ √
Emergency Services √ √
Prenatal Care/Childbirth/Post-delivery √ √ √
Diagnostic Services √ √
Outpatient Housing Unit √ √ √
Inmate Transfers √ √ √
Clinic Operations √ √ √
Preventive Services √ √
Pharmacy Services √
Inmate Hunger Strikes √ √ √
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Category AnalysisThere 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.
80%
60%
58%
40% 50% 60% 70% 80% 90% 100%
Nurse Responsibilities
Primary Care Provider Responsibilities
Continuity of Care
Access to Providers and Services
Medication Management
74%
74%
Chart 23: Scores by Category, Sorted Lowest to Highest Score.
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Medical Category: Medication ManagementPage 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
69% 68% 68% 67%64%
62%60%
40%
49%51%
55% 55%53%
42%43%
61%
84%
25%
35%
45%
55%
65%
75%
85%
95%
100%
CMF CCI RJD CCWF SAC DVI LAC CRC CEN SCC HDSP CCC CMC ASP PVSP CIW SQ
Medication Management
Average Score = 53%
Institution Score
Average Score = 58%
Minimum Moderate Adherence = 75%
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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.
Medical Category: Medication ManagementPage 2 of 2
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63%62%
54%
47%45%
52%50%
52%
61% 60%
67%65%
66%
69%70%72%
45%
55%
65%
75%
85%
95%
100%
PVSPCCCCCWF CMC CRC ASP SQ CIW CMF DVI CENSCC SAC LAC CCI RJD HDSP
Institution Score
Average Score = 60%
Minimum Moderate Adherence = 75%
74%
Chart 25: Access to Providers and Services Scores by Institution, Sorted Highest to Lowest Score.
Medical Category: Access to Providers and ServicesPage 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
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or applied to a specific medical problem identified for an inmate, and those that related or applied to various screening and preventive health processes.
The following are examples of each type of question:
Medical problem-related
Was the inmate’s most recent chronic care visit within the time frame required by the degree of control of the inmate’s condition based on his or her prior visit? (Question 03.076)
Screening and preventive-related
Did the prison complete the initial health screening on the same day the inmate arrived at the prison? (Question 02.016)
The results of this analysis identified a significant weakness in the prisons’ administration of correctional health care. The average access to providers and services score for questions related to inmates with specific medical problems was only 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
81%
85%
70%
64%
57%
70%
87%
72%
44%
79%
66%
40%38%
68%67%
66%64% 64%
63%61%
59%
51%
48%
59%58%
48%
51%
63%65%
55%
66%
89%
84%
35%
45%
55%
65%
75%
85%
95%
100%
CCWF CMC CCC CIW CRC ASP CMF CEN DVI SQ SCC PVSP CCI SAC LAC RJD HDSP
Minimum Moderate Adherence = 75%
71%
Problem-related Access to Care Score
Screening and Preventive-related Access to Care ScoreAverage Problem-related Access to Care Score = 57%
Average Screening and Preventive-related Access to Care Score = 71%
Medical Category: Access to Providers and ServicesPage 2 of 3
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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.
Medical Category: Access to Providers and ServicesPage 3 of 3
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Medical Category: Continuity of CarePage 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
83% 83% 83%
64%
67%68% 67%68%70%71%72%72%74%
78%79%80%
84%
55%
65%
75%
85%
95%
100%
CRC CCWF CEN CCC SCC ASP LAC HDSP SAC CMC PVSP RJD CIW SQ CMF CCI DVI
Continuity of Care
Average Score = 74%
Institution Score
Average Score = 74%
Minimum Moderate Adherence = 75%
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• 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.
Medical Category: Continuity of CarePage 2 of 2
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Medical Category: Primary Care Provider ResponsibilitiesPage 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
85% 84% 83%
54%
81% 80%
55%
66%68%
71%72%
76%76%77%
45%
55%
65%
75%
85%
95%
100%
SCC CCWF CMF DVI CEN SQ CRC CIW LAC CCI PVSP ASP SAC CMC CCC HDSP RJD
Institution Score
Average Score = 74%
Minimum Moderate Adherence = 75%
78%79%
74%
Chart 28: Primary Care Provider Responsibilities Scores by Institution, Sorted Highest to Lowest Score
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.
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Chart 29: Primary Care Provider Judgment Scores by Institution, Sorted Highest to Lowest Score
59%
79%
54%
66%
71%
68%
80%
66%64%
57%
43%
61%
58%
86% 86%85%
84% 84%
79%78% 78%
75%
72%
78%76%
69%
56%
39%
84%
35%
66%
88%
35%
45%
55%
65%
75%
85%
95%
100%
CMF CCWF SQ CEN DVI SCC SAC LAC CCI CRC PVSP CIW ASP CMC CCC RJD HDSP
Minimum Moderate Adherence = 75%
90%
Primary Care Provider Judgment Score
Primary Care Provider Process ScoreAverage Primary Care Provider Judgment Score = 77%
Average Primary Care Provider Process Score = 63%
74%
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 JudgmentTo 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
Medical Category: Primary Care Provider ResponsibilitiesPage 2 of 3
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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.
Medical Category: Primary Care Provider ResponsibilitiesPage 3 of 3
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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
91% 90%88%
86% 85%
67% 66%
69%
72%
76%78%
81%82%83%84%
94%
45%
55%
65%
75%
85%
95%
100%
CCWF CEN CRC CMC RJD SAC ASP SCC CCC LAC DVI CIW HDSP SQ CMF CCI PVSP
Institution Score
Average Score = 80%
Minimum Moderate Adherence = 75%
74%
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.
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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 JudgmentTo 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.
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ConclusionThe 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 face-to-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
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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.
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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.
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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 ScoresAppendix C-1: Chronic Care ........................................................................................ 82Appendix C-2: Clinical Services .................................................................................. 84Appendix C-3: Health Screening .................................................................................. 87Appendix C-4: Specialty Services ................................................................................ 91Appendix C-5: Urgent Services .................................................................................... 93Appendix C-6: Emergency Services ............................................................................. 95Appendix C-7: Prenatal Care ........................................................................................ 98Appendix C-8: Diagnostic Services ............................................................................ 100Appendix C-9: Access to Health Care Information .................................................... 102Appendix C-10: Outpatient Housing Unit .................................................................. 104Appendix C-11: Internal Reviews ............................................................................... 106Appendix C-12: Inmate Transfers ............................................................................... 108Appendix C-13: Clinic Operations ............................................................................. 109Appendix C-14: Preventive Services .......................................................................... 111Appendix C-15: Pharmacy Services ........................................................................... 113Appendix C-16: Other Services .................................................................................. 115Appendix C-17: Inmate Hunger Strikes ..................................................................... 116Appendix C-18: Chemical Agent Contraindications .................................................. 117Appendix C-19: Staffing Levels and Training ............................................................ 118Appendix C-20: Nursing Policy .................................................................................. 119
Appendix D: Category Questions and ScoresAppendix D-1: Medication Management ................................................................... 120Appendix D-2: Access to Care .................................................................................... 123Appendix D-3: Primary Care Provider Responsibilities ............................................. 129Appendix D-4: Continuity of Care ............................................................................. 133Appendix 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. Spe-cifically, we focused on “man down” or “woman down” situations. Further, questions deter-mine the adequacy of medical and staff response to a “man down” or “woman down” emer-gency 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 evalu-ates 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.
Bureau of Audits and Investigations, Office of the Inspector General Page 80
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. Gen-erally, 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 influ-enza immunizations.
Pharmacy services: Addresses whether the prison’s pharmacy complies with various op-erational 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 screen-ing 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 han-dling 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 hun-ger 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 periodi-cally review the work of nurses to ensure they properly follow established nursing protocols.
APPENDIX A: Component Definitions
State of California • August 2010 Page 81
APPENDIX B: Prisons’ Scores by Component
PR
ISO
NS
’ SC
OR
ES
BY
CO
MP
ON
EN
TMe
dical
Comp
onen
tCC
WFSC
CCE
NCR
CCC
CDV
ICM
FLA
CCM
CAS
PCIW
SQRJ
DSA
CPV
SPCC
IHD
SPAv
erage
Sc
oreRa
nge
Chro
nic C
are
73%
75%
81%
67%
46%
74%
84%
70%
57%
59%
70%
65%
49%
63%
57%
62%
45%
64%
39%
Clini
cal S
ervic
es74
%71
%80
%70
%66
%73
%87
%66
%74
%64
%62
%47
%67
%67
%47
%57
%51
%66
%40
%
Healt
h Scre
ening
84%
61%
78%
74%
81%
74%
87%
69%
73%
81%
70%
77%
68%
76%
67%
78%
72%
75%
26%
Spec
ialty
Servi
ces
53%
73%
60%
59%
71%
53%
43%
70%
63%
74%
63%
58%
62%
47%
61%
57%
53%
60%
31%
Urge
nt Se
rvice
s89
%89
%80
%81
%84
%78
%79
%80
%84
%70
%75
%63
%73
%83
%81
%83
%72
%79
%26
%
Emer
genc
y Ser
vices
80%
76%
77%
73%
90%
71%
72%
84%
86%
78%
80%
78%
90%
48%
83%
78%
72%
77%
42%
Pren
atal/C
hildb
irth/
Post-
deliv
ery C
are
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
61%
N/A
N/A
N/A
N/A
N/A
N/A
61%
N/A
Diag
nosti
c Ser
vices
84%
86%
74%
59%
71%
74%
72%
54%
70%
87%
71%
69%
64%
68%
65%
60%
43%
69%
44%
Acce
ss to
Hea
lth
Care
Infor
matio
n54
%82
%82
%78
%78
%59
%59
%73
%39
%20
%59
%54
%44
%39
%63
%55
%59
%59
%62
%
Outpa
tient
Hous
ing
Unit
N/A
75%
N/A
75%
82%
83%
86%
N/A
N/A
71%
63%
83%
N/A
76%
N/A
73%
N/A
77%
23%
Inter
nal R
eview
s98
%60
%61
%91
%86
%93
%69
%73
%70
%66
%95
%69
%10
0%70
%71
%60
%63
%76
%40
%
Inmate
Tran
sfers
100%
95%
100%
100%
93%
79%
50%
100%
94%
100%
80%
100%
90%
75%
76%
43%
100%
86%
57%
Clini
c Ope
ratio
ns86
%88
%82
%86
%97
%88
%83
%90
%85
%94
%98
%10
0%95
%91
%93
%91
%91
%90
%18
%
Prev
entiv
e Ser
vices
59%
28%
19%
82%
37%
22%
44%
20%
53%
60%
33%
49%
24%
32%
27%
7%24
%37
%75
%
Phar
macy
Ser
vices
92%
91%
58%
79%
69%
92%
76%
100%
91%
92%
95%
86%
93%
75%
72%
79%
100%
85%
42%
Othe
r Ser
vices
100%
55%
100%
70%
100%
100%
100%
100%
91%
70%
57%
85%
100%
91%
70%
85%
73%
86%
45%
Inmate
Hun
ger
Strik
es10
0%N/
A32
%N/
A68
%N/
A32
%42
%71
%N/
AN/
A54
%11
%11
%37
%46
%44
%46
%89
%
Chem
ical A
gent
Contr
aindic
ation
s65
%10
0%89
%10
0%10
0%89
%87
%91
%10
0%10
0%10
0%89
%94
%10
0%66
%66
%10
0%91
%35
%
Staffi
ng Le
vels
and
Train
ing85
%10
0%10
0%85
%10
0%95
%95
%90
%10
0%10
0%85
%95
%10
0%95
%80
%90
%10
0%94
%20
%
Nursi
ng P
olicy
100%
94%
71%
76%
94%
36%
36%
57%
79%
67%
64%
70%
89%
79%
100%
50%
89%
74%
64%
Institu
tiona
l Ave
rage
78%
76%
74%
74%
73%
73%
72%
72%
71%
70%
70%
68%
68%
65%
65%
64%
62%
70%
16%
high a
dher
ence
mode
rate
adhe
renc
elow
adhe
renc
e
Bureau of Audits and Investigations, Office of the Inspector General Page 82
CO
MP
ON
EN
T Q
UE
STI
ON
S: C
hron
ic C
are
03.0
76W
as th
e in
mat
e’s
mos
t rec
ent c
hron
ic c
are
visi
t with
in th
e tim
e fra
me
requ
ired
by th
e de
gree
of c
ontro
l of t
he in
mat
e’s
cond
ition
ba
sed
on h
is o
r her
prio
r vis
it?
03.0
77W
ere
key
elem
ents
on
Form
s 74
19 (C
hron
ic C
are
Follo
w-U
p Vi
sit)
and
7392
(Prim
ary
Car
e Fl
ow S
heet
) fille
d ou
t com
plet
ely
for
the
inm
ate’
s tw
o m
ost r
ecen
t vis
its?
03.0
82D
id th
e in
stitu
tion
docu
men
t tha
t it p
rovi
ded
the
inm
ate
with
hea
lth c
are
educ
atio
n?
03.1
75D
id th
e in
mat
e re
ceiv
e hi
s or
her
pre
scrib
ed c
hron
ic c
are
med
icat
ions
dur
ing
the
mos
t rec
ent t
hree
-mon
th p
erio
d or
did
the
inst
itutio
n fo
llow
dep
artm
enta
l pol
icy
if th
e in
mat
e re
fuse
d to
pic
k up
or s
how
up
for h
is o
r her
med
icat
ions
?
03.2
35Is
the
clin
ical
his
tory
ade
quat
e?
03.2
36Is
the
focu
sed
clin
ical
exa
min
atio
n ad
equa
te?
03.2
37Is
the
asse
ssm
ent a
dequ
ate?
03.2
38Is
the
plan
ade
quat
e an
d co
nsis
tent
with
the
degr
ee o
f con
trol b
ased
on
the
chro
nic
care
pro
gram
inte
rven
tion
and
follo
w u
p re
quire
men
ts?
03.2
62Is
the
inm
ate’
s P
robl
em L
ist c
ompl
ete
and
filed
acc
urat
ely
in th
e in
mat
e’s
unit
heal
th re
cord
(UH
R)?
APPENDIX C-1: Component Questions and Scores - Chronic Care
CO
MP
ON
EN
T S
CO
RE
S: C
hron
ic C
are
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
03.07
6Po
ssibl
e Poin
ts10
1010
1010
1010
1010
1010
1010
1010
1010
170
Rece
ived P
oints
8.88.7
4.89.5
5.69
7.66
6.47.2
6.89.6
7.57.2
4.48.4
5.612
3.1
Scor
e88
%87
%48
%95
%56
%90
%76
%60
%64
%72
%68
%96
%75
%72
%44
%84
%56
%72
%
03.07
7Po
ssibl
e Poin
ts10
1010
1010
1010
1010
1010
1010
1010
1010
170
Rece
ived P
oints
0.49.1
4.67.4
7.88.5
5.28.5
7.62.4
5.26
7.26
2.87.2
2.898
.7
Scor
e4%
91%
46%
74%
78%
85%
52%
85%
76%
24%
52%
60%
72%
60%
28%
72%
28%
58%
State of California • August 2010 Page 83
APPENDIX C-1
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
03.08
2Po
ssibl
e Poin
ts12
1212
1212
1212
1212
1212
1212
1212
1212
204
Rece
ived P
oints
7.78.9
6.29
612
5.810
.811
.57.2
9.611
.510
.65.3
9.11.4
6.213
8.8
Scor
e64
%74
%52
%75
%50
%10
0%48
%90
%96
%60
%80
%96
%88
%44
%76
%12
%52
%68
%
03.17
5Po
ssibl
e Poin
ts18
1818
1818
1818
1818
1818
1818
1818
1818
306
Rece
ived P
oints
8.313
.99
9.911
.67.2
0.85.6
5.30.8
8.63.6
0.83.3
1.41.4
3.194
.6
Scor
e46
%77
%50
%55
%65
%40
%4%
31%
29%
4%48
%20
%4%
18%
8%8%
17%
31%
03.23
5Po
ssibl
e Poin
ts18
1818
1818
1818
1818
1818
1818
1818
1818
306
Rece
ived P
oints
10.8
13.3
6.512
.612
12.6
8.611
.711
.57.9
10.8
5.812
.28.6
5.812
.27.9
170.8
Scor
e60
%74
%36
%70
%67
%70
%48
%65
%64
%44
%60
%32
%68
%48
%32
%68
%44
%56
%
03.23
6Po
ssibl
e Poin
ts19
1919
1919
1919
1919
1919
1919
1919
1919
323
Rece
ived P
oints
16.2
18.2
14.4
15.2
13.7
13.3
12.2
17.1
15.8
13.7
14.4
13.7
15.2
12.9
9.114
.411
.424
0.9
Scor
e85
%96
%76
%80
%72
%70
%64
%90
%83
%72
%76
%72
%80
%68
%48
%76
%60
%75
%
03.23
7Po
ssibl
e Poin
ts19
1919
1919
1919
1919
1919
1919
1919
1919
323
Rece
ived P
oints
13.9
17.2
7.619
16.6
1613
.716
14.3
128.4
16.4
16.4
13.5
11.2
17.4
923
8.6
Scor
e73
%91
%40
%10
0%88
%84
%72
%84
%75
%63
%44
%86
%86
%71
%59
%92
%47
%74
%
03.23
8Po
ssibl
e Poin
ts19
1919
1919
1919
1919
1919
1919
1919
1919
323
Rece
ived P
oints
1118
.19.5
1717
.717
.915
.616
.918
.216
.813
.616
.216
.314
10.9
17.4
1025
7.1
Scor
e58
%95
%50
%90
%93
%94
%82
%89
%96
%88
%71
%85
%86
%74
%57
%92
%53
%80
%
03.26
2Po
ssibl
e Poin
ts8
88
88
88
88
88
88
88
88
136
Rece
ived P
oints
6.43.8
2.28
6.70.8
6.77.2
2.67.7
4.86.4
6.48
5.16.1
4.893
.7
Scor
e80
%48
%28
%10
0%83
%10
%84
%90
%32
%96
%60
%80
%80
%10
0%64
%76
%60
%69
%
Total
Pos
sible
Point
s13
313
313
313
313
313
313
313
313
313
313
313
313
313
313
313
313
322
61
Total
Rec
eived
Poin
ts83
.411
1.164
.910
7.697
.797
.376
.299
.893
.275
.782
.289
.292
.678
.859
.885
.960
.814
56.2
Tota
l Sco
re63
%84
%49
%81
%74
%73
%57
%75
%70
%57
%62
%67
%70
%59
%45
%65
%46
%64
%
CO
MP
ON
EN
T S
CO
RE
S: C
hron
ic C
are,
con
tinue
d
Bureau of Audits and Investigations, Office of the Inspector General Page 84
01
.024
RN
FTF
Doc
umen
tatio
n: D
id th
e in
mat
e’s
requ
est f
or h
ealth
car
e ge
t rev
iew
ed th
e sa
me
day
it w
as re
ceiv
ed?
01.0
25R
N F
TF D
ocum
enta
tion:
Did
the
RN
com
plet
e th
e fa
ce-to
-face
(FTF
) tria
ge w
ithin
one
(1) b
usin
ess
day
afte
r the
For
m 7
362
was
re
view
ed?
01.0
27If
the
RN
det
erm
ined
a re
ferr
al to
a p
rimar
y ca
re p
rovi
der (
PC
P) w
as n
eces
sary
, was
the
inm
ate
seen
with
in th
e tim
elin
es
spec
ified
by
the
RN
dur
ing
the
FTF
triag
e
01.1
24S
ick
Cal
l Med
icat
ion:
Did
the
inst
itutio
n ad
min
iste
r or d
eliv
er p
resc
riptio
n m
edic
atio
ns (n
ew o
rder
s) to
the
inm
ate
with
in s
peci
fied
time
fram
es?
01.1
57R
N F
TF D
ocum
enta
tion:
Did
the
RN
’s s
ubje
ctiv
e no
te a
ddre
ss th
e na
ture
and
his
tory
of t
he in
mat
e’s
prim
ary
com
plai
nt?
01.1
58R
N F
TF D
ocum
enta
tion:
Did
the
RN
’s a
sses
smen
t pro
vide
con
clus
ions
bas
ed o
n su
bjec
tive
and
obje
ctiv
e da
ta, w
ere
the
conc
lusi
ons
form
ulat
ed a
s pa
tient
pro
blem
s, a
nd d
id it
con
tain
app
licab
le n
ursi
ng d
iagn
oses
?
01.1
59R
N F
TF D
ocum
enta
tion:
Did
the
RN
’s o
bjec
tive
note
incl
ude
vita
l sig
ns a
nd a
focu
sed
phys
ical
exa
min
atio
n, a
nd d
id it
ad
equa
tely
add
ress
the
prob
lem
s no
ted
in th
e su
bjec
tive
note
?
01.1
62R
N F
TF D
ocum
enta
tion:
Did
the
RN
’s p
lan
incl
ude
an a
dequ
ate
stra
tegy
to a
ddre
ss th
e pr
oble
ms
iden
tified
dur
ing
the
FTF
triag
e?01
.163
RN
FTF
Doc
umen
tatio
n: D
id th
e R
N’s
edu
catio
n/in
stru
ctio
n ad
equa
tely
add
ress
the
prob
lem
s id
entifi
ed d
urin
g th
e FT
F tri
age?
01.2
44R
N F
TF D
ocum
enta
tion:
Did
the
RN
’s o
bjec
tive
note
incl
ude
alle
rgie
s, w
eigh
t, cu
rren
t med
icat
ion,
and
whe
re a
ppro
pria
te,
med
icat
ion
com
plia
nce?
01.2
46D
id d
ocum
enta
tion
indi
cate
that
the
RN
revi
ewed
all
of th
e in
mat
e’s
com
plai
nts
liste
d on
For
m 7
362
(Hea
lth C
are
Ser
vice
s R
eque
st F
orm
)?01
.247
Sic
k C
all F
ollo
w-u
p: If
the
prov
ider
ord
ered
a fo
llow
-up
sick
cal
l app
oint
men
t, di
d it
take
pla
ce w
ithin
the
time
fram
e sp
ecifi
ed?
15.2
34A
re c
linic
resp
onse
bag
s au
dite
d da
ily a
nd d
o th
ey c
onta
in e
ssen
tial i
tem
s?
21.2
78Fo
r inm
ates
see
n in
the
TTA
, was
ther
e ad
equa
te p
rior m
anag
emen
t of p
re-e
xist
ing
med
ical
con
ditio
ns re
late
d to
the
reas
on fo
r th
e TT
A vi
sit?
APPENDIX C-2: Component Questions and Scores - Clinical ServicesC
OM
PO
NE
NT
QU
ES
TIO
NS
: Clin
ical
Ser
vice
s
State of California • August 2010 Page 85
APPENDIX C-2
CO
MP
ON
EN
T S
CO
RE
S: C
linic
al S
ervi
ces
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
01.02
4Po
ssibl
e Poin
ts4
44
44
44
44
44
44
44
44
68
Rece
ived P
oints
3.83.8
3.73.5
32.1
3.61.2
3.13.5
3.71.8
3.23.5
1.60.5
3.248
.8
Scor
e96
%96
%93
%87
%76
%52
%90
%30
%77
%87
%92
%45
%80
%89
%40
%11
%80
%72
%
01.02
5Po
ssibl
e Poin
ts6
66
66
66
66
66
66
66
66
102
Rece
ived P
oints
4.65
4.84.6
5.35.3
4.73.9
52
3.64.8
4.11.5
2.42.1
568
.7
Scor
e76
%84
%80
%76
%88
%88
%78
%65
%83
%33
%60
%80
%68
%26
%40
%34
%84
%67
%
01.02
7Po
ssibl
e Poin
ts8
88
88
88
88
88
88
88
88
136
Rece
ived P
oints
2.46.6
14
6.34.5
66
2.83.8
24.3
5.64.2
2.14.4
3.669
.6
Scor
e29
%82
%13
%50
%79
%56
%75
%75
%35
%47
%25
%54
%71
%52
%27
%56
%46
%51
%
01.12
4Po
ssibl
e Poin
ts6
66
66
66
66
66
66
66
66
102
Rece
ived P
oints
1.34.8
3.34.6
23.1
1.70.8
20.7
2.50.6
1.71.8
2.61.3
0.935
.7
Scor
e22
%80
%55
%77
%33
%52
%28
%13
%33
%11
%41
%10
%28
%30
%44
%22
%14
%35
%
01.15
7Po
ssibl
e Poin
ts7
77
77
77
77
77
77
77
77
119
Rece
ived P
oints
6.46.7
5.87
5.86.4
6.55.6
4.13.5
4.53.2
3.84.5
42.2
5.585
.5
Scor
e92
%96
%83
%10
0%83
%92
%93
%80
%59
%50
%64
%45
%54
%65
%57
%32
%79
%72
%
01.15
8Po
ssibl
e Poin
ts6
66
66
66
66
66
66
66
66
102
Rece
ived P
oints
5.75.3
4.85.4
5.55.8
55.7
5.42
4.15.4
4.84.4
3.61.6
3.578
Scor
e96
%88
%79
%89
%91
%96
%83
%95
%90
%33
%68
%90
%79
%74
%61
%27
%58
%76
%
01.15
9Po
ssibl
e Poin
ts6
66
66
66
66
66
66
66
66
102
Rece
ived P
oints
5.54.6
4.85.4
45.3
4.44.8
3.33.2
4.15.4
4.63.5
33
4.773
.6
Scor
e91
%77
%80
%90
%67
%88
%73
%80
%55
%53
%68
%90
%76
%59
%50
%50
%79
%72
%
01.16
2Po
ssibl
e Poin
ts7
77
77
77
77
77
77
77
77
119
Rece
ived P
oints
6.46.6
76.8
6.76.7
6.86.6
74.4
6.47
6.76.6
77
6.311
2
Scor
e92
%94
%10
0%97
%96
%96
%98
%95
%10
0%63
%92
%10
0%96
%94
%10
0%10
0%90
%94
%
01.16
3Po
ssibl
e Poin
ts5
55
55
55
55
55
55
55
55
85
Rece
ived P
oints
3.94.7
4.54.7
3.54.8
4.34.5
4.32.8
44.8
3.54.1
3.23.2
3.268
Scor
e77
%94
%90
%93
%70
%96
%85
%90
%86
%57
%80
%95
%71
%82
%64
%64
%63
%80
%
cont
inue
d on
pag
e 86
Bureau of Audits and Investigations, Office of the Inspector General Page 86
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
01.24
4Po
ssibl
e Poin
ts3
33
33
33
33
33
33
33
33
51
Rece
ived P
oints
2.82.8
2.42.8
2.42.4
2.41.5
11
0.80.2
0.41.9
0.20.5
1.426
.9
Scor
e92
%94
%80
%93
%79
%80
%80
%50
%35
%33
%28
%5%
12%
65%
7%18
%47
%53
%
01.24
6Po
ssibl
e Poin
ts5
55
55
55
55
55
55
55
55
85
Rece
ived P
oints
4.64.6
4.34.5
4.84.8
4.45
4.33.3
3.24.8
43.8
4.34.5
4.573
.7
Scor
e92
%92
%87
%90
%96
%96
%88
%10
0%86
%67
%64
%95
%80
%77
%87
%91
%90
%87
%
01.24
7Po
ssibl
e Poin
ts7
77
77
77
77
77
77
77
77
119
Rece
ived P
oints
1.85.4
1.67
4.24.7
4.70
1.42.5
46.1
3.94.4
3.53.5
4.763
.4
Scor
e25
%78
%22
%10
0%60
%67
%67
%0%
20%
36%
57%
88%
56%
63%
50%
50%
67%
53%
15.23
4Po
ssibl
e Poin
ts5
55
55
55
55
55
55
55
55
85
Rece
ived P
oints
05
2.50
02.5
05
2.55
2.55
55
2.52.5
550
Scor
e0%
100%
50%
0%0%
50%
0%10
0%50
%10
0%50
%10
0%10
0%10
0%50
%50
%10
0%59
%
21.27
8Po
ssibl
e Poin
ts20
2020
2020
2020
2020
2020
2020
2020
2020
340
Rece
ived P
oints
14.5
16.7
13.3
1615
.712
16.3
16.9
166.7
9.113
.37.3
128.2
811
.121
3.1
Scor
e73
%83
%67
%80
%79
%60
%81
%85
%80
%33
%46
%67
%36
%60
%41
%40
%56
%63
%
Total
Pos
sible
Point
s95
9595
9595
9595
9595
9595
9595
9595
9595
1615
Total
Rec
eived
Poin
ts63
.682
.763
.976
.169
.270
.470
.467
.562
.244
.454
.566
.758
.661
.248
.544
.362
.610
66.8
Tota
l Sco
re67
%87
%67
%80
%73
%74
%74
%71
%66
%47
%57
%70
%62
%64
%51
%47
%66
%66
%
APPENDIX C-2C
OM
PO
NE
NT
SC
OR
ES
: Clin
ical
Ser
vice
s, c
ontin
ued
State of California • August 2010 Page 87
APPENDIX C-3: Component Questions and Scores - Health Screening
CO
MP
ON
EN
T Q
UE
STI
ON
S: H
ealth
Scr
eeni
ng
02.0
07N
on-r
ecep
tion
cent
er: D
oes
the
heal
th c
are
trans
fer i
nfor
mat
ion
form
indi
cate
that
it w
as re
view
ed a
nd s
igne
d by
lice
nsed
he
alth
car
e st
aff w
ithin
one
cal
enda
r day
of t
he in
mat
e’s
arriv
al a
t the
inst
itutio
n?
02.0
14N
on-r
ecep
tion
cent
er: I
f the
inm
ate
was
sch
edul
ed fo
r a s
peci
alty
app
oint
men
t at t
he s
endi
ng in
stitu
tion,
did
the
rece
ivin
g in
stitu
tion
sche
dule
the
appo
intm
ent w
ithin
30
days
of t
he o
rigin
al a
ppoi
ntm
ent d
ate?
02.0
15W
as a
revi
ew o
f sym
ptom
s co
mpl
eted
if th
e in
mat
e’s
tube
rcul
in te
st w
as p
ositi
ve, a
nd w
ere
the
resu
lts re
view
ed b
y th
e in
fect
ion
cont
rol n
urse
?
02.0
16D
id th
e in
stitu
tion
com
plet
e th
e in
itial
hea
lth s
cree
ning
on
the
sam
e da
y th
e in
mat
e ar
rived
at t
he in
stitu
tion?
02.0
17If
yes
was
ans
wer
ed to
any
of t
he q
uest
ions
on
the
initi
al h
ealth
scr
eeni
ng fo
rm(s
), di
d th
e R
N p
rovi
de a
n as
sess
men
t and
di
spos
ition
on
the
date
of a
rriv
al?
02.0
18If,
dur
ing
the
asse
ssm
ent,
the
RN
refe
rred
the
inm
ate
to a
clin
icia
n, w
as th
e in
mat
e se
en w
ithin
the
time
fram
e?
02.0
20D
id th
e LV
N/R
N a
dequ
atel
y do
cum
ent t
he tu
berc
ulin
test
or a
revi
ew o
f sig
ns a
nd s
ympt
oms
if th
e in
mat
e ha
d a
prev
ious
po
sitiv
e tu
berc
ulin
test
?
02.0
21R
ecep
tion
cent
er: D
id th
e in
mat
e re
ceiv
e a
com
plet
e hi
stor
y an
d ph
ysic
al b
y a
Nur
se P
ract
ition
er, P
hysi
cian
Ass
ista
nt, o
r a
Phy
sici
an a
nd S
urge
on w
ithin
14
cale
ndar
day
s of
arr
ival
?
02.0
22R
ecep
tion
cent
er: I
f the
prim
ary
care
pro
vide
r (P
CP
) ind
icat
ed th
e in
mat
e re
quire
d a
spec
ial d
iet,
did
the
PC
P re
fer t
he in
mat
e to
a re
gist
ered
die
ticia
n?
02.1
11N
on-r
ecep
tion
cent
er: D
id th
e in
mat
e re
ceiv
e m
edic
al a
ccom
mod
atio
ns u
pon
arriv
al, i
f app
licab
le?
02.1
28If
the
inm
ate
had
an e
xist
ing
med
icat
ion
orde
r upo
n ar
rival
at t
he in
stitu
tion,
did
the
inm
ate
rece
ive
the
med
icat
ions
by
the
next
ca
lend
ar d
ay, o
r did
a p
hysi
cian
exp
lain
why
the
med
icat
ions
wer
e no
t to
be c
ontin
ued?
02.2
11R
ecep
tion
cent
er h
isto
ry a
nd p
hysi
cal:
Is th
e “H
isto
ry o
f Pre
sent
Illn
ess”
sec
tion
of F
orm
720
6 (H
isto
ry a
nd P
hysi
cal
Exa
min
atio
n) c
ompl
ete
and
appr
opria
te to
the
chie
f com
plai
nt(s
), if
any?
02.2
12R
ecep
tion
cent
er h
isto
ry a
nd p
hysi
cal:
Are
the
“Pas
t His
tory
” and
“Pas
t Med
ical
His
tory
” sec
tions
of F
orm
720
6 (H
isto
ry a
nd
Phy
sica
l Exa
min
atio
n) c
ompl
ete?
02.2
13R
ecep
tion
cent
er h
isto
ry a
nd p
hysi
cal:
Is th
e “F
amily
and
Soc
ial H
isto
ry” s
ectio
n of
For
m 7
206
(His
tory
and
Phy
sica
l E
xam
inat
ion)
com
plet
e?
cont
inue
d on
pag
e 88
Bureau of Audits and Investigations, Office of the Inspector General Page 88
APPENDIX C-3
02.2
15R
ecep
tion
cent
er h
isto
ry a
nd p
hysi
cal:
Is th
e “R
evie
w S
yste
ms”
sec
tion
of F
orm
720
6 (H
isto
ry a
nd P
hysi
cal E
xam
inat
ion)
co
mpl
ete?
02.2
16R
ecep
tion
cent
er h
isto
ry a
nd p
hysi
cal:
Is th
e “P
hysi
cal E
xam
inat
ion”
sec
tion
of F
orm
720
6 (H
isto
ry a
nd P
hysi
cal E
xam
inat
ion)
co
mpl
ete
and
appr
opria
te to
the
hist
ory
and
revi
ew o
f sys
tem
s?
02.2
17R
ecep
tion
cent
er h
isto
ry a
nd p
hysi
cal:
Is th
e “D
iagn
osis
/Impr
essi
on” s
ectio
n of
For
m 7
206
(His
tory
and
Phy
sica
l Exa
min
atio
n)
appr
opria
te to
the
hist
ory
and
phys
ical
exa
min
atio
n?
02.2
18R
ecep
tion
cent
er h
isto
ry a
nd p
hysi
cal:
Is th
e “P
lan
of A
ctio
n” s
ectio
n of
For
m 7
206
(His
tory
and
Phy
sica
l Exa
min
atio
n)
appr
opria
te to
the
“Dia
gnos
is/Im
pres
sion
” sec
tion
of th
e fo
rm?
02.2
19R
ecep
tion
cent
er h
isto
ry a
nd p
hysi
cal:
Has
requ
ired
inta
ke te
stin
g be
en o
rder
ed?
CO
MP
ON
EN
T S
CO
RE
S: H
ealth
Scr
eeni
ngRe
f Nu
mber
SAC
CMF
RJD
CEN
DVI
CCW
FCM
CSC
CLA
CPV
SPCC
ICR
CCI
WAS
PHD
SPSQ
CCC
Aver
age
Scor
e02
.007
Poss
ible P
oints
77
77
77
77
77
77
77
98
Rece
ived P
oints
76.5
4.56.3
65.3
6.16.6
6.67
6.66
77
88.5
Scor
e10
0%93
%64
%90
%85
%75
%88
%95
%95
%10
0%95
%85
%10
0%10
0%90
%
02.01
4Po
ssibl
e Poin
ts7
77
77
742
Rece
ived P
oints
70
77
77
35
Scor
e10
0%0%
100%
100%
100%
100%
83%
02.01
5Po
ssibl
e Poin
ts7
77
77
77
77
77
77
Rece
ived P
oints
77
74.7
5.35.8
72.3
77
767
.1
Scor
e10
0%10
0%10
0%67
%75
%83
%10
0%33
%10
0%10
0%10
0%87
%
02.01
6Po
ssibl
e Poin
ts9
99
99
99
99
99
99
99
99
153
Rece
ived P
oints
99
8.79
99
99
8.15.9
6.98.6
8.68.1
8.48.1
7.714
2.1
Scor
e10
0%10
0%97
%10
0%10
0%10
0%10
0%10
0%90
%65
%77
%95
%95
%90
%93
%90
%85
%93
%
02.01
7Po
ssibl
e Poin
ts8
88
88
88
88
88
88
88
812
8
Rece
ived P
oints
84.4
7.67.5
88
82.3
3.75.6
88
6.98
88
110
Scor
e10
0%56
%94
%93
%10
0%10
0%10
0%29
%46
%70
%10
0%10
0%87
%10
0%10
0%10
0%86
%
CO
MP
ON
EN
T Q
UE
STI
ON
S: H
ealth
Scr
eeni
ng, c
ontin
ued
State of California • August 2010 Page 89
cont
inue
d on
pag
e 90
APPENDIX C-3
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
02.01
8Po
ssibl
e Poin
ts8
88
88
88
88
88
88
88
812
8
Rece
ived P
oints
28
14.8
46.9
82.3
05.7
2.70.9
4.41.3
4.93.2
60.1
Scor
e25
%10
0%13
%60
%50
%86
%10
0%29
%0%
71%
33%
11%
55%
17%
61%
40%
47%
02.02
0Po
ssibl
e Poin
ts6
66
66
66
66
66
66
66
66
102
Rece
ived P
oints
5.44.2
5.25.4
66
5.15.7
65.1
4.86
5.45.1
5.85.8
693
Scor
e90
%70
%87
%90
%10
0%10
0%85
%95
%10
0%85
%80
%10
0%90
%85
%97
%96
%10
0%91
%
02.02
1Po
ssibl
e Poin
ts5
55
55
55
540
Rece
ived P
oints
2.82.8
2.82.5
52
54.8
27.7
Scor
e56
%55
%55
%50
%10
0%40
%10
0%95
%69
%
02.02
2Po
ssibl
e Poin
ts4
4
Rece
ived P
oints
00
Scor
e0%
0%
02.11
1Po
ssibl
e Poin
ts6
66
66
66
66
66
66
78
Rece
ived P
oints
46
4.52
64.5
66
4.56
63
664
.5
Scor
e67
%10
0%75
%33
%10
0%75
%10
0%10
0%75
%10
0%10
0%50
%10
0%83
%
02.12
8Po
ssibl
e Poin
ts8
88
88
88
88
88
88
88
88
136
Rece
ived P
oints
2.77
44
03.4
12
3.30
3.41.8
02.4
2.81.9
1.341
Scor
e33
%88
%50
%50
%0%
43%
13%
25%
42%
0%43
%23
%0%
30%
35%
24%
17%
30%
02.21
1Po
ssibl
e Poin
ts2
22
22
22
14
Rece
ived P
oints
1.51.8
20.8
1.81.6
1.210
.7
Scor
e75
%92
%10
0%40
%89
%82
%60
%76
%
02.21
2Po
ssibl
e Poin
ts2
22
22
22
14
Rece
ived P
oints
1.81.2
21.7
21.8
1.812
.3
Scor
e88
%60
%10
0%85
%10
0%90
%90
%88
%
02.21
3Po
ssibl
e Poin
ts2
22
22
22
14
Rece
ived P
oints
22
21.5
21.5
1.612
.6
Scor
e10
0%10
0%10
0%75
%10
0%75
%80
%90
%
CO
MP
ON
EN
T S
CO
RE
S: H
ealth
Scr
eeni
ng, c
ontin
ued
Bureau of Audits and Investigations, Office of the Inspector General Page 90
APPENDIX C-3C
OM
PO
NE
NT
SC
OR
ES
: Hea
lth S
cree
ning
, con
tinue
dRe
f Nu
mber
SAC
CMF
RJD
CEN
DVI
CCW
FCM
CSC
CLA
CPV
SPCC
ICR
CCI
WAS
PHD
SPSQ
CCC
Aver
age
Scor
e02
.215
Poss
ible P
oints
22
22
22
12
Rece
ived P
oints
02
1.41.6
0.40
5.4
Scor
e0%
100%
70%
80%
20%
0%45
%
02.21
6Po
ssibl
e Poin
ts2
22
22
22
14
Rece
ived P
oints
1.51.9
22
21.7
1.212
.3
Scor
e75
%95
%10
0%10
0%10
0%85
%60
%88
%
02.21
7Po
ssibl
e Poin
ts2
22
22
22
14
Rece
ived P
oints
1.81.9
1.82
21.8
1.112
.4
Scor
e88
%95
%90
%10
0%10
0%89
%56
%89
%
02.21
8Po
ssibl
e Poin
ts2
22
22
22
14
Rece
ived P
oints
21.7
22
22
1.313
Scor
e10
0%85
%10
0%10
0%10
0%10
0%67
%93
%
02.21
9Po
ssibl
e Poin
ts4
44
44
44
432
Rece
ived P
oints
2.82
43.8
3.64
0.83.4
24.4
Scor
e70
%50
%10
0%95
%90
%10
0%20
%85
%76
%
Total
Pos
sible
Point
s59
5286
5969
6766
5382
5289
5954
5982
6066
1114
Total
Rec
eived
Poin
ts45
.145
.158
.545
.951
.356
.548
.332
.456
.434
.969
.743
.837
.747
.659
.345
.953
.283
1.6
Tota
l Sco
re76
%87
%68
%78
%74
%84
%73
%61
%69
%67
%78
%74
%70
%81
%72
%77
%81
%75
%
State of California • August 2010 Page 91
CO
MP
ON
EN
T Q
UE
STI
ON
S: S
peci
alty
Ser
vice
s
07.0
35D
id th
e in
mat
e re
ceiv
e th
e sp
ecia
lty s
ervi
ce w
ithin
spe
cifie
d tim
e fra
mes
?07
.037
Did
the
inst
itutio
n ap
prov
e or
den
y th
e P
CP
’s re
ques
t for
spe
cial
ty s
ervi
ces
with
in th
e sp
ecifi
ed ti
me
fram
es?
07.0
38D
id th
e P
CP
see
the
inm
ate
betw
een
the
date
the
PC
P or
dere
d th
e se
rvic
e an
d th
e da
te th
e in
mat
e re
ceiv
ed it
, in
acco
rdan
ce
with
spe
cifie
d tim
e fra
mes
?
07.0
43D
id th
e P
CP
revi
ew th
e co
nsul
tant
’s re
port
and
see
the
inm
ate
for a
follo
w-u
p ap
poin
tmen
t afte
r the
spe
cial
ty s
ervi
ces
cons
ulta
tion
with
in s
peci
fied
time
fram
es?
07.0
90P
hysi
cal t
hera
py s
ervi
ces:
Did
the
phys
ical
ther
apis
t ass
ess
the
inm
ate
and
docu
men
t the
trea
tmen
t pla
n an
d tre
atm
ent
prov
ided
to th
e in
mat
e?07
.259
Was
ther
e ad
equa
te d
ocum
enta
tion
of th
e re
ason
for t
he d
enia
l of s
peci
alty
ser
vice
s?07
.260
Was
the
inst
itutio
n’s
deni
al o
f the
PC
P’s
requ
est f
or s
peci
alty
ser
vice
s co
nsis
tent
with
the
“med
ical
nec
essi
ty” r
equi
rem
ent?
07.2
61Is
the
inst
itutio
n sc
hedu
ling
high
-prio
rity
(urg
ent)
spec
ialty
ser
vice
s w
ithin
14
days
?
07.2
70D
id th
e sp
ecia
lty p
rovi
der p
rovi
de ti
mel
y fin
ding
s an
d re
com
men
datio
ns o
r did
an
RN
doc
umen
t tha
t he
or s
he c
alle
d th
e sp
ecia
lty p
rovi
der t
o as
certa
in th
e fin
ding
s an
d re
com
men
datio
ns?
CO
MP
ON
EN
T S
CO
RE
S: S
peci
alty
Ser
vice
sRe
f Nu
mber
SAC
CMF
RJD
CEN
DVI
CCW
FCM
CSC
CLA
CPV
SPCC
ICR
CCI
WAS
PHD
SPSQ
CCC
Aver
age
Scor
e07
.035
Poss
ible P
oints
99
99
99
99
99
99
99
99
915
3
Rece
ived P
oints
4.23.2
5.35.3
5.38.5
5.36.9
5.86.2
3.72.6
7.96.9
4.25.8
7.995
Scor
e47
%35
%59
%59
%59
%94
%59
%77
%65
%69
%41
%29
%88
%77
%47
%65
%88
%62
%
07.03
7Po
ssibl
e Poin
ts8
88
88
88
88
88
88
88
88
136
Rece
ived P
oints
3.63.6
85.1
4.45.6
7.35.1
7.36.9
6.24
6.35.8
7.67.3
6.510
0.6
Scor
e46
%46
%10
0%64
%55
%70
%91
%64
%91
%86
%77
%50
%79
%73
%96
%91
%82
%74
%
07.03
8Po
ssibl
e Poin
ts8
88
88
88
88
88
88
88
88
136
Rece
ived P
oints
0.62.5
21.2
0.70
1.82.9
2.30.7
2.40.5
32.7
0.50
4.428
.2
Scor
e8%
31%
25%
15%
9%0%
23%
36%
29%
8%29
%7%
38%
33%
7%0%
56%
21%
APPENDIX C-4: Component Questions and Scores - Specialty Services
cont
inue
d on
pag
e 92
Bureau of Audits and Investigations, Office of the Inspector General Page 92
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
07.04
3Po
ssibl
e Poin
ts9
99
99
99
99
99
99
99
99
153
Rece
ived P
oints
22.6
1.73.7
0.71.6
1.12.3
3.23.2
4.23.4
2.16.5
02.1
3.844
.2
Scor
e22
%29
%19
%41
%8%
18%
13%
25%
36%
36%
47%
38%
23%
73%
0%23
%42
%29
%
07.09
0Po
ssibl
e Poin
ts8
88
88
88
88
88
88
88
88
136
Rece
ived P
oints
85.3
88
88
88
88
88
88
88
813
3.3
Scor
e10
0%67
%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%98
%
07.25
9Po
ssibl
e Poin
ts5
55
55
55
55
55
55
55
55
85
Rece
ived P
oints
34
54
31.7
25
3.83
34
2.55
23
155
Scor
e60
%80
%10
0%80
%60
%33
%40
%10
0%75
%60
%60
%80
%50
%10
0%40
%60
%20
%65
%
07.26
0Po
ssibl
e Poin
ts9
99
99
99
99
99
99
99
99
153
Rece
ived P
oints
95.4
99
6.86
97.2
99
7.29
97.2
5.49
3.612
9.8
Scor
e10
0%60
%10
0%10
0%75
%67
%10
0%80
%10
0%10
0%80
%10
0%10
0%80
%60
%10
0%40
%85
%
07.26
1Po
ssibl
e Poin
ts9
99
99
99
99
99
99
99
99
153
Rece
ived P
oints
00
00
4.50
4.59
4.50
04.5
04.5
4.50
945
Scor
e0%
0%0%
0%50
%0%
50%
100%
50%
0%0%
50%
0%50
%50
%0%
100%
29%
07.27
0Po
ssibl
e Poin
ts6
66
66
66
66
66
66
66
66
102
Rece
ived P
oints
3.23.5
5.36
4.66
65.6
66
66
66
5.66
693
.8
Scor
e53
%59
%88
%10
0%77
%10
0%10
0%94
%10
0%10
0%10
0%10
0%10
0%10
0%94
%10
0%10
0%92
%
Total
Pos
sible
Point
s71
7171
7171
7171
7171
7171
7171
7171
7171
1207
Total
Rec
eived
Poin
ts33
.730
.244
.242
.337
.937
.445
51.9
49.9
4340
.742
44.8
52.6
37.8
41.2
50.2
724.8
Tota
l Sco
re47
%43
%62
%60
%53
%53
%63
%73
%70
%61
%57
%59
%63
%74
%53
%58
%71
%60
%
APPENDIX C-4C
OM
PO
NE
NT
SC
OR
ES
: Spe
cial
ty S
ervi
ces,
con
tinue
d
State of California • August 2010 Page 93
CO
MP
ON
EN
T Q
UE
STI
ON
S: U
rgen
t Ser
vice
s
21.2
48U
pon
the
inm
ate’
s di
scha
rge
from
the
com
mun
ity h
ospi
tal,
did
the
triag
e an
d tre
atm
ent a
rea
(TTA
) reg
iste
red
nurs
e do
cum
ent
that
he
or s
he re
view
ed th
e in
mat
e’s
disc
harg
e pl
an a
nd c
ompl
eted
a fa
ce-to
-face
ass
essm
ent o
f the
inm
ate?
21.2
49U
pon
the
inm
ate’
s di
scha
rge
from
the
com
mun
ity h
ospi
tal,
did
the
inm
ate
rece
ive
a fo
llow
-up
appo
intm
ent w
ith h
is o
r her
pr
imar
y ca
re p
rovi
der (
PC
P) w
ithin
five
cal
enda
r day
s of
dis
char
ge?
21.2
50U
pon
the
inm
ate’
s di
scha
rge
from
the
com
mun
ity h
ospi
tal,
did
the
inm
ate’
s P
rimar
y C
are
Pro
vide
r (P
CP
) pro
vide
ord
ers
for
appr
opria
te h
ousi
ng fo
r the
inm
ate?
21.2
51U
pon
the
inm
ate’
s di
scha
rge
from
the
com
mun
ity h
ospi
tal,
did
the
Reg
iste
red
Nur
se in
terv
ene
if th
e in
mat
e w
as h
ouse
d in
an
area
that
was
inap
prop
riate
for n
ursi
ng c
are
base
d on
the
prim
ary
care
pro
vide
r’s (P
CP
) hou
sing
ord
ers?
21.2
75W
as th
e do
cum
enta
tion
of th
e cl
inic
al c
are
prov
ided
in th
e TT
A ad
equa
te?
21.2
76W
hile
the
patie
nt w
as in
the
TTA
, was
the
clin
ical
car
e re
nder
ed b
y th
e at
tend
ing
prov
ider
ade
quat
e an
d tim
ely?
21.2
79Fo
r pat
ient
s m
anag
ed b
y te
leph
one
cons
ulta
tion
alon
e, w
as th
e pr
ovid
er’s
dec
isio
n no
t to
com
e to
the
TTA
appr
opria
te?
21.2
81U
pon
the
inm
ate’
s di
scha
rge
from
a c
omm
unity
hos
pita
l, di
d th
e in
stitu
tion
adm
inis
ter o
r del
iver
all
pres
crib
ed m
edic
atio
ns to
th
e in
mat
e w
ithin
spe
cifie
d tim
e fra
mes
?
CO
MP
ON
EN
T S
CO
RE
S: U
rgen
t Ser
vice
sRe
f Nu
mber
SAC
CMF
RJD
CEN
DVI
CCW
FCM
CSC
CLA
CPV
SPCC
ICR
CCI
WAS
PHD
SPSQ
CCC
Aver
age
Scor
e21
.248
Poss
ible P
oints
77
77
77
77
77
77
77
77
711
9
Rece
ived P
oints
5.56.3
4.65.3
6.26.4
5.97
6.76.2
6.47
5.96.4
2.23.6
6.297
.8
Scor
e79
%90
%65
%75
%88
%92
%84
%10
0%96
%88
%92
%10
0%84
%92
%32
%52
%88
%82
%
21.24
9Po
ssibl
e Poin
ts7
77
77
77
77
77
77
77
77
119
Rece
ived P
oints
4.26
1.74.6
4.53.6
6.16.4
2.84.1
3.35.9
3.93.6
3.43.4
5.873
.3
Scor
e60
%85
%24
%65
%64
%52
%88
%92
%40
%58
%48
%84
%56
%52
%48
%48
%82
%62
%
21.25
0Po
ssibl
e Poin
ts7
77
77
77
77
77
77
77
77
119
Rece
ived P
oints
5.15.6
3.57
6.77
77
76.7
76.7
6.77
75
710
9
Scor
e73
%80
%50
%10
0%96
%10
0%10
0%10
0%10
0%96
%10
0%96
%96
%10
0%10
0%72
%10
0%92
%
APPENDIX C-5: Component Questions and Scores - Urgent Services
cont
inue
d on
pag
e 94
Bureau of Audits and Investigations, Office of the Inspector General Page 94
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
21.25
1Po
ssibl
e Poin
ts7
77
77
742
Rece
ived P
oints
70
70
77
28
Scor
e10
0%0%
100%
0%10
0%10
0%67
%
21.27
5Po
ssibl
e Poin
ts10
1010
1010
1010
1010
1010
1010
1010
1010
170
Rece
ived P
oints
6.59.5
8.37.2
9.28.4
7.68
8.88
7.66
6.46.4
9.66.8
8.813
3.1
Scor
e65
%95
%83
%72
%92
%84
%76
%80
%88
%80
%76
%60
%64
%64
%96
%68
%88
%78
%
21.27
6Po
ssibl
e Poin
ts7
77
77
77
77
77
77
77
77
119
Rece
ived P
oints
6.47
6.76.3
6.47
6.47
6.16.7
6.75.8
5.74.5
4.45.5
4.710
3.3
Scor
e91
%10
0%95
%91
%92
%10
0%91
%10
0%87
%96
%95
%83
%81
%64
%63
%79
%67
%87
%
21.27
9Po
ssibl
e Poin
ts8
88
88
88
88
88
88
88
120
Rece
ived P
oints
88
6.78
88
88
88
88
88
811
8.7
Scor
e10
0%10
0%83
%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%99
%
21.28
1Po
ssibl
e Poin
ts6
66
66
66
66
66
66
66
66
102
Rece
ived P
oints
66
3.54.7
4.75.3
3.82.9
2.30.8
42.8
2.60.6
2.80.4
356
.2
Scor
e10
0%10
0%58
%79
%79
%88
%64
%48
%38
%13
%67
%47
%44
%10
%47
%7%
50%
55%
Total
Pos
sible
Point
s59
5159
5259
5944
5252
5952
5252
5252
5252
910
Total
Rec
eived
Poin
ts48
.740
.443
.241
.745
.752
.836
.846
.341
.747
.543
42.2
39.2
36.5
37.4
32.7
43.5
719.3
Tota
l Sco
re83
%79
%73
%80
%78
%89
%84
%89
%80
%81
%83
%81
%75
%70
%72
%63
%84
%79
%
APPENDIX C-5C
OM
PO
NE
NT
SC
OR
ES
: Urg
ent S
ervi
ces,
con
tinue
d
State of California • August 2010 Page 95
CO
MP
ON
EN
T Q
UE
STI
ON
S: E
mer
genc
y S
ervi
ces
08.1
83W
as th
e m
edic
al e
mer
genc
y re
spon
der n
otifi
ed o
f the
med
ical
em
erge
ncy
with
out d
elay
?
08.1
84D
id th
e m
edic
al e
mer
genc
y re
spon
der a
rriv
e at
the
loca
tion
of th
e m
edic
al e
mer
genc
y w
ithin
five
(5) m
inut
es o
f ini
tial
notifi
catio
n?
08.1
85D
id th
e m
edic
al e
mer
genc
y re
spon
der u
se p
rope
r equ
ipm
ent t
o ad
dres
s th
e em
erge
ncy
and
was
ade
quat
e m
edic
al c
are
prov
ided
with
in th
e sc
ope
of h
is o
r her
lice
nse?
08.1
86W
ere
both
the
first
resp
onde
r (if
peac
e of
ficer
or l
icen
sed
heal
th c
are
staf
f) an
d th
e m
edic
al e
mer
genc
y re
spon
der b
asic
life
su
ppor
t (B
LS) c
ertifi
ed a
t the
tim
e of
the
inci
dent
?08
.187
Did
the
inst
itutio
n pr
ovid
e ad
equa
te p
repa
ratio
n fo
r the
am
bula
nce’
s ar
rival
, acc
ess
to th
e in
mat
e, a
nd d
epar
ture
?
08.2
22W
ere
the
findi
ngs
of th
e in
stitu
tion’
s E
mer
genc
y R
espo
nse
Rev
iew
Com
mitt
ee (E
RR
C) s
uppo
rted
by th
e do
cum
enta
tion
and
com
plet
ed w
ithin
30
days
?08
.241
Did
the
first
resp
onde
r pro
vide
ade
quat
e ba
sic
life
supp
ort (
BLS
) prio
r to
med
ical
sta
ff ar
rivin
g?
08.2
42D
id li
cens
ed h
ealth
car
e st
aff c
all 9
11 w
ithou
t unn
eces
sary
del
ay a
fter a
life
-thre
aten
ing
cond
ition
was
iden
tified
by
a lic
ense
d he
alth
car
e pr
ovid
er o
r pea
ce o
ffice
r?
15.2
40E
mer
genc
y M
edic
al R
espo
nse
Dril
l: D
id th
e re
spon
ding
offi
cer a
ctiv
ate
the
emer
genc
y re
spon
se s
yste
m b
y pr
ovid
ing
the
perti
nent
info
rmat
ion
to th
e re
leva
nt p
artie
s, im
med
iate
ly a
nd w
ithou
t del
ay?
15.2
55E
mer
genc
y M
edic
al R
espo
nse
Dril
l: D
id th
e re
spon
ding
offi
cer c
arry
and
use
the
prop
er e
quip
men
t (pr
otec
tive
shie
ld o
r mic
ro-
mas
k, g
love
s) re
quire
d by
the
depa
rtmen
t?
15.2
56E
mer
genc
y M
edic
al R
espo
nse
Dril
l: D
id th
e re
spon
ding
offi
cer p
rope
rly p
erfo
rm a
n as
sess
men
t on
the
patie
nt fo
r re
spon
sive
ness
?15
.257
Em
erge
ncy
Med
ical
Res
pons
e D
rill:
Did
the
resp
ondi
ng o
ffice
r pro
perly
per
form
CP
R?
15.2
58E
mer
genc
y M
edic
al R
espo
nse
Dril
l: D
id th
e re
spon
ding
offi
cer b
egin
CP
R w
ithou
t unn
eces
sary
del
ay?
15.2
82E
mer
genc
y M
edic
al R
espo
nse
Dril
l: D
id m
edic
al s
taff
arriv
e on
sce
ne in
five
min
utes
or l
ess?
15.2
83E
mer
genc
y M
edic
al R
espo
nse
Dril
l: D
id th
e em
erge
ncy
med
ical
resp
onde
rs a
rriv
e w
ith p
rope
r equ
ipm
ent (
ER
bag
, bag
-val
ve-
mas
k, A
ED
)?15
.284
Em
erge
ncy
Med
ical
Res
pons
e D
rill:
Did
the
resp
ondi
ng o
ffice
r pro
vide
acc
urat
e in
form
atio
n to
resp
ondi
ng m
edic
al s
taff?
15.2
85E
mer
genc
y M
edic
al R
espo
nse
Dril
l: D
id e
mer
genc
y m
edic
al re
spon
ders
con
tinue
bas
ic li
fe s
uppo
rt?
15.2
86E
mer
genc
y M
edic
al R
espo
nse
Dril
l: D
id m
edic
al s
taff
cont
inue
with
CP
R w
ithou
t tra
nspo
rting
the
patie
nt u
ntil
the
arriv
al o
f am
bula
nce
pers
onne
l? If
the
patie
nt w
as tr
ansp
orte
d, w
as th
is d
ecis
ion
just
ified
? N
ote:
We
elim
inat
ed th
is q
uest
ion
follo
win
g th
e fir
st in
spec
tion
due
to th
e po
tent
ial f
or in
cons
iste
nt a
nsw
ers.
15.2
87E
mer
genc
y M
edic
al R
espo
nse
Dril
l: W
as 9
11 c
alle
d w
ithou
t unn
eces
sary
del
ay?
APPENDIX C-6: Component Questions and Scores - Emergency Services
Bureau of Audits and Investigations, Office of the Inspector General Page 96
CO
MP
ON
EN
T S
CO
RE
S: E
mer
genc
y S
ervi
ces
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
08.18
3Po
ssibl
e Poin
ts5
55
55
55
55
55
55
55
580
Rece
ived P
oints
55
55
55
55
55
54
55
55
79
Scor
e10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%80
%10
0%10
0%10
0%10
0%99
%
08.18
4Po
ssibl
e Poin
ts4
44
44
44
44
44
44
44
464
Rece
ived P
oints
44
3.24
42.7
44
43
24
44
3.24
58.1
Scor
e10
0%10
0%80
%10
0%10
0%67
%10
0%10
0%10
0%75
%50
%10
0%10
0%10
0%80
%10
0%91
%
08.18
5Po
ssibl
e Poin
ts7
77
77
77
77
77
77
77
711
2
Rece
ived P
oints
3.57
77
5.67
5.67
77
77
5.35.3
77
102.3
Scor
e50
%10
0%10
0%10
0%80
%10
0%80
%10
0%10
0%10
0%10
0%10
0%75
%75
%10
0%10
0%91
%
08.18
6Po
ssibl
e Poin
ts4
44
44
44
44
44
44
44
464
Rece
ived P
oints
44
44
44
44
44
44
44
40
60
Scor
e10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%0%
94%
08.18
7Po
ssibl
e Poin
ts4
44
44
44
44
44
44
44
464
Rece
ived P
oints
24
44
43.2
44
44
2.72.4
02.7
44
53
Scor
e50
%10
0%10
0%10
0%10
0%80
%10
0%10
0%10
0%10
0%67
%60
%0%
67%
100%
100%
83%
08.22
2Po
ssibl
e Poin
ts7
77
77
77
77
77
77
77
711
2
Rece
ived P
oints
3.50
70
02.8
00
00
01.8
3.51.8
07
27.4
Scor
e50
%0%
100%
0%0%
40%
0%0%
0%0%
0%25
%50
%25
%0%
100%
24%
08.24
1Po
ssibl
e Poin
ts6
66
66
66
66
66
66
66
696
Rece
ived P
oints
02.4
4.83
66
63
66
64
66
3.66
74.8
Scor
e0%
40%
80%
50%
100%
100%
100%
50%
100%
100%
100%
67%
100%
100%
60%
100%
78%
08.24
2Po
ssibl
e Poin
ts6
66
66
66
66
66
66
66
696
Rece
ived P
oints
36
66
3.64.8
66
4.56
4.53.6
4.56
3.66
80.1
Scor
e50
%10
0%10
0%10
0%60
%80
%10
0%10
0%75
%10
0%75
%60
%75
%10
0%60
%10
0%83
%
15.24
0Po
ssibl
e Poin
ts2
22
22
22
22
22
22
22
232
Rece
ived P
oints
22
22
22
22
22
22
22
22
32
Scor
e10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%
APPENDIX C-6
State of California • August 2010 Page 97
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
15.25
5Po
ssibl
e Poin
ts1
11
11
11
11
11
11
11
116
Rece
ived P
oints
00
10
01
01
10
10
10
11
8
Scor
e0%
0%10
0%0%
0%10
0%0%
100%
100%
0%10
0%0%
100%
0%10
0%10
0%50
%
15.25
6Po
ssibl
e Poin
ts1
11
11
11
11
11
11
11
116
Rece
ived P
oints
00
11
01
01
11
11
11
11
12
Scor
e0%
0%10
0%10
0%0%
100%
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%75
%
15.25
7Po
ssibl
e Poin
ts2
22
22
22
22
22
22
22
30
Rece
ived P
oints
02
00
02
22
22
00
02
014
Scor
e0%
100%
0%0%
0%10
0%10
0%10
0%10
0%10
0%0%
0%0%
100%
0%47
%
15.25
8Po
ssibl
e Poin
ts2
22
22
22
22
22
22
22
232
Rece
ived P
oints
00
22
22
02
22
02
20
22
22
Scor
e0%
0%10
0%10
0%10
0%10
0%0%
100%
100%
100%
0%10
0%10
0%0%
100%
100%
69%
15.28
2Po
ssibl
e Poin
ts2
22
22
22
22
22
22
22
30
Rece
ived P
oints
02
22
22
22
22
22
02
226
Scor
e0%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
0%10
0%10
0%87
%
15.28
3Po
ssibl
e Poin
ts1
11
11
11
11
11
11
11
15
Rece
ived P
oints
01
10
11
11
10
11
11
112
Scor
e0%
100%
100%
0%10
0%10
0%10
0%10
0%10
0%0%
100%
100%
100%
100%
100%
80%
15.28
4Po
ssibl
e Poin
ts1
11
11
11
11
11
11
11
15
Rece
ived P
oints
00
11
11
11
11
11
01
112
Scor
e0%
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%0%
100%
100%
80%
15.28
5Po
ssibl
e Poin
ts1
11
11
11
11
11
11
11
15
Rece
ived P
oints
11
11
11
11
11
11
11
115
Scor
e10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%
15.28
6Po
ssibl
e Poin
ts1
1
Rece
ived P
oints
00
Scor
e0%
0%
15.28
7Po
ssibl
e Poin
ts2
22
22
22
22
22
22
22
30
Rece
ived P
oints
00
02
22
20
22
22
22
222
Scor
e0%
0%0%
100%
100%
100%
100%
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%73
%
Total
Pos
sible
Point
s59
5658
4358
5858
5853
5858
5615
5858
5858
920
Total
Rec
eived
Poin
ts28
40.4
5233
41.2
46.5
49.6
4444
.548
45.2
40.8
1245
.341
.845
.452
709.7
Tota
l Sco
re48
%72
%90
%77
%71
%80
%86
%76
%84
%83
%78
%73
%80
%78
%72
%78
%90
%77
%
APPENDIX C-6C
OM
PO
NE
NT
SC
OR
ES
: Em
erge
ncy
Ser
vice
s, c
ontin
ued
Bureau of Audits and Investigations, Office of the Inspector General Page 98
CO
MP
ON
EN
T Q
UE
STI
ON
S: P
rena
tal C
are/
Chi
ldbi
rth/P
ost-D
eliv
ery
09.0
66N
ew a
rriv
al o
nly:
Did
the
inm
ate
rece
ive
a pr
egna
ncy
test
with
in th
ree
(3) b
usin
ess
days
of a
rriv
al a
t the
inst
itutio
n to
pos
itive
ly
iden
tify
her p
regn
ancy
?
09.0
67N
ew a
rriv
al o
nly:
Was
the
inm
ate
seen
by
an O
B p
hysi
cian
or O
B n
urse
pra
ctiti
oner
with
in s
even
(7) b
usin
ess
days
of h
er a
rriv
al
at th
e in
stitu
tion?
09.0
68W
as th
e pr
egna
nt in
mat
e is
sued
a F
orm
741
0 (C
ompr
ehen
sive
Acc
omm
odat
ion
Chr
ono)
for a
low
er b
unk
and
low
er-ti
er h
ousi
ng
if ho
used
in a
mul
ti-tie
red
hous
ing
unit?
09.0
69D
id m
edic
al s
taff
prom
ptly
ord
er e
xtra
dai
ly n
utrit
iona
l sup
plem
ents
and
food
for t
he in
mat
e?09
.071
Did
the
inm
ate
visi
t with
an
OB
phy
sici
an a
ccor
ding
to th
e ap
plic
able
tim
e fra
mes
?
09.0
72D
id th
e “P
robl
ems/
Ris
ks Id
entifi
ed” s
ectio
n of
the
Brig
gs F
orm
570
3N (P
rena
tal F
low
Rec
ord)
cor
robo
rate
the
“Pre
nata
l Scr
eens
” an
d th
e “M
ater
nal P
hysi
cal”
exam
inat
ion
sect
ions
?09
.074
Did
the
inm
ate
rece
ive
her s
ix-w
eek
chec
k-up
(pos
t-del
iver
y)?
09.2
23W
ere
the
resu
lts o
f the
inm
ate’
s sp
ecifi
ed p
rena
tal s
cree
ning
test
s do
cum
ente
d on
For
m 5
703N
?09
.224
Was
the
inm
ate’
s w
eigh
t and
blo
od p
ress
ure
docu
men
ted
at e
ach
clin
ic v
isit?
CO
MP
ON
EN
T S
CO
RE
S: P
rena
tal C
are/
Chi
ldbi
rth/P
ost-D
eliv
ery
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
09.06
6Po
ssibl
e Poin
ts5
5
Rece
ived P
oints
00
Scor
e0%
0%
09.06
7Po
ssibl
e Poin
ts5
5
Rece
ived P
oints
55
Scor
e10
0%10
0%
09.06
8Po
ssibl
e Poin
ts5
5
Rece
ived P
oints
2.12.1
Scor
e43
%43
%
APPENDIX C-7: Component Questions and Scores - Prenatal Care
State of California • August 2010 Page 99
APPENDIX C-7
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
09.06
9Po
ssibl
e Poin
ts5
5
Rece
ived P
oints
4.34.3
Scor
e86
%86
%
09.07
1Po
ssibl
e Poin
ts8
8
Rece
ived P
oints
6.96.9
Scor
e86
%86
%
09.07
2Po
ssibl
e Poin
ts7
7
Rece
ived P
oints
00
Scor
e0%
0%
09.07
4Po
ssibl
e Poin
ts7
7
Rece
ived P
oints
5.65.6
Scor
e80
%80
%
09.22
3Po
ssibl
e Poin
ts5
5
Rece
ived P
oints
4.34.3
Scor
e86
%86
%
09.22
4Po
ssibl
e Poin
ts6
6
Rece
ived P
oints
4.34.3
Scor
e71
%71
%
Total
Pos
sible
Point
s53
53
Total
Rec
eived
Poin
ts32
.532
.5
Tota
l Sco
re61
%61
%
CO
MP
ON
EN
T S
CO
RE
S: P
rena
tal C
are/
Chi
ldbi
rth/P
ost-D
eliv
ery,
con
tinue
d
Bureau of Audits and Investigations, Office of the Inspector General Page 100
CO
MP
ON
EN
T Q
UE
STI
ON
S: D
iagn
ostic
Ser
vice
s06
.049
Rad
iolo
gy o
rder
: Was
the
radi
olog
y se
rvic
e pr
ovid
ed w
ithin
the
time
fram
e sp
ecifi
ed in
the
phys
icia
n’s
orde
r?06
.188
All
labo
rato
ry o
rder
s: W
as th
e sp
ecim
en c
olle
cted
with
in th
e ap
plic
able
tim
e fra
mes
of t
he p
hysi
cian
’s o
rder
?
06.1
91A
ll di
agno
stic
ser
vice
s: D
id th
e P
CP
docu
men
t the
clin
ical
ly s
igni
fican
t dia
gnos
tic te
st re
sults
on
Form
723
0 (In
terd
isci
plin
ary
Pro
gres
s N
otes
)?
06.2
00R
adio
logy
ord
er: D
id th
e pr
imar
y ca
re p
rovi
der (
PC
P) r
evie
w th
e di
agno
stic
repo
rt an
d in
itiat
e w
ritte
n no
tice
to th
e in
mat
e w
ithin
tw
o (2
) bus
ines
s da
ys o
f the
dat
e th
e in
stitu
tion
rece
ived
the
diag
nost
ic re
ports
?
06.2
02A
ll la
bora
tory
ord
ers:
Did
the
PC
P re
view
the
diag
nost
ic re
ports
and
initi
ate
writ
ten
notic
e to
the
inm
ate
with
in tw
o (2
) bus
ines
s da
ys o
f the
dat
e th
e in
stitu
tion
rece
ived
the
diag
nost
ic re
ports
?06
.245
Rad
iolo
gy o
rder
: Was
the
diag
nost
ic re
port
rece
ived
by
the
inst
itutio
n w
ithin
14
days
?06
.263
All
diag
nost
ic s
ervi
ces:
Did
the
PC
P ad
equa
tely
man
age
clin
ical
ly s
igni
fican
t tes
t res
ults
?
CO
MP
ON
EN
T S
CO
RE
S: D
iagn
ostic
Ser
vice
sRe
f Nu
mber
SAC
CMF
RJD
CEN
DVI
CCW
FCM
CSC
CLA
CPV
SPCC
ICR
CCI
WAS
PHD
SPSQ
CCC
Aver
age
Scor
e06
.049
Poss
ible P
oints
77
77
77
77
77
77
77
77
711
9
Rece
ived P
oints
75.6
77
1.47
5.67
75.6
5.60
74.2
4.27
4.292
.4
Scor
e10
0%80
%10
0%10
0%20
%10
0%80
%10
0%10
0%80
%80
%0%
100%
60%
60%
100%
60%
78%
06.18
8Po
ssibl
e Poin
ts6
66
66
66
66
66
66
66
66
102
Rece
ived P
oints
5.45.4
33.6
4.84.2
4.86
5.44.2
2.45.4
34.2
1.86
4.273
.8
Scor
e90
%90
%50
%60
%80
%70
%80
%10
0%90
%70
%40
%90
%50
%70
%30
%10
0%70
%72
%
06.19
1Po
ssibl
e Poin
ts7
77
77
77
77
77
77
77
77
119
Rece
ived P
oints
5.46.1
4.16.1
5.35.6
4.93.9
15.1
4.74.5
4.86.1
4.36.2
5.183
.2
Scor
e78
%87
%58
%88
%75
%80
%70
%56
%14
%73
%67
%64
%69
%87
%62
%89
%73
%70
%
06.20
0Po
ssibl
e Poin
ts7
77
77
77
77
77
77
77
77
119
Rece
ived P
oints
01.4
07
77
1.47
00
01.4
1.45.6
1.40
4.244
.8
Scor
e0%
20%
0%10
0%10
0%10
0%20
%10
0%0%
0%0%
20%
20%
80%
20%
0%60
%38
%
06.20
2Po
ssibl
e Poin
ts7
77
77
77
77
77
77
77
77
119
Rece
ived P
oints
2.13.5
4.23.5
4.22.8
3.54.9
00.7
0.72.8
4.27
00
2.146
.2
Scor
e30
%50
%60
%50
%60
%40
%50
%70
%0%
10%
10%
40%
60%
100%
0%0%
30%
39%
APPENDIX C-8: Component Questions and Scores - Diagnostic Services
State of California • August 2010 Page 101
APPENDIX C-8
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
06.24
5Po
ssibl
e Poin
ts8
88
88
88
88
88
88
88
88
136
Rece
ived P
oints
6.46.4
84.8
88
88
88
88
88
4.88
812
6.4
Scor
e80
%80
%10
0%60
%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%60
%10
0%10
0%93
%
06.26
3Po
ssibl
e Poin
ts10
1010
1010
1010
1010
1010
1010
1010
1010
170
Rece
ived P
oints
9.19.2
76.7
7.79
8.27.8
6.710
108.3
8.310
5.88.9
914
1.7
Scor
e91
%92
%70
%67
%77
%90
%82
%78
%67
%10
0%10
0%83
%83
%10
0%58
%89
%90
%83
%
Total
Pos
sible
Point
s52
5252
5252
5252
5252
5252
5252
5252
5252
884
Total
Rec
eived
Poin
ts35
.437
.533
.338
.738
.343
.636
.444
.628
.133
.631
.430
.436
.745
.122
.336
.136
.860
8.3
Tota
l Sco
re68
%72
%64
%74
%74
%84
%70
%86
%54
%65
%60
%59
%71
%87
%43
%69
%71
%69
%
CO
MP
ON
EN
T S
CO
RE
S: D
iagn
ostic
Ser
vice
s, c
ontin
ued
Bureau of Audits and Investigations, Office of the Inspector General Page 102
CO
MP
ON
EN
T Q
UE
STI
ON
S: A
cces
s to
Hea
lth C
are
Info
rmat
ion
19.1
50Is
the
med
ical
reco
rds
offic
e cu
rren
t with
its
loos
e fil
ing?
19.1
69D
id m
edic
al re
cord
s st
aff m
ake
unit
heal
th re
cord
s (U
HR
) ava
ilabl
e to
clin
ic s
taff
for t
he in
mat
es d
ucat
ed fo
r med
ical
ap
poin
tmen
ts th
e ne
xt d
ay?
19.2
43W
as th
e in
stitu
tion
able
to a
ccou
nt fo
r the
OIG
’s re
ques
ted
UH
R fi
les?
19.2
66D
oes
the
inst
itutio
n pr
oper
ly fi
le in
mat
es’ m
edic
al in
form
atio
n?
19.2
71W
hile
revi
ewin
g un
it he
alth
reco
rds
(UH
R) a
s pa
rt of
the
OIG
’s in
spec
tion,
wer
e th
e O
IG’s
RN
and
MD
insp
ecto
rs a
ble
to lo
cate
al
l rel
evan
t doc
umen
tatio
n of
hea
lth c
are
prov
ided
to in
mat
es?
19.2
72D
oes
the
inst
itutio
n pr
ompt
ly fi
le b
lood
pre
ssur
e lo
gs in
uni
t hea
lth re
cord
s (U
HR
)?
CO
MP
ON
EN
T S
CO
RE
S: A
cces
s to
Hea
lth C
are
Info
rmat
ion
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
19.15
0Po
ssibl
e Poin
ts9
99
99
99
99
99
99
99
99
153
Rece
ived P
oints
00
00
00
00
00
00
00
00
00
Scor
e0%
0%0%
0%0%
0%0%
0%0%
0%0%
0%0%
0%0%
0%0%
0%
19.16
9Po
ssibl
e Poin
ts15
1515
1515
1515
1515
1515
1515
1515
1515
255
Rece
ived P
oints
1515
1515
1515
1515
1515
1515
150
1515
1524
0
Scor
e10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%0%
100%
100%
100%
94%
19.24
3Po
ssibl
e Poin
ts12
1212
1212
1212
1212
1212
1212
1212
1212
204
Rece
ived P
oints
00
012
00
012
1212
012
00
00
1272
Scor
e0%
0%0%
100%
0%0%
0%10
0%10
0%10
0%0%
100%
0%0%
0%0%
100%
35%
19.26
6Po
ssibl
e Poin
ts5
55
55
55
55
55
55
55
55
85
Rece
ived P
oints
05
55
55
55
50
55
50
55
570
Scor
e0%
100%
100%
100%
100%
100%
100%
100%
100%
0%10
0%10
0%10
0%0%
100%
100%
100%
82%
19.27
1Po
ssibl
e Poin
ts5
55
55
55
55
55
55
55
55
85
Rece
ived P
oints
05
05
55
05
55
35
55
55
568
Scor
e0%
100%
0%10
0%10
0%10
0%0%
100%
100%
100%
60%
100%
100%
100%
100%
100%
100%
80%
APPENDIX C-9: Component Questions and Scores - Access to Health Care Information
State of California • August 2010 Page 103
APPENDIX C-9
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
19.27
2Po
ssibl
e Poin
ts5
55
55
55
55
55
55
55
55
85
Rece
ived P
oints
55
2.55
52.5
05
00
52.5
55
52.5
2.557
.5
Scor
e10
0%10
0%50
%10
0%10
0%50
%0%
100%
0%0%
100%
50%
100%
100%
100%
50%
50%
68%
Total
Pos
sible
Point
s51
5151
5151
5151
5151
5151
5151
5151
5151
867
Total
Rec
eived
Poin
ts20
3022
.542
3027
.520
4237
3228
39.5
3010
3027
.539
.550
7.5
Tota
l Sco
re39
%59
%44
%82
%59
%54
%39
%82
%73
%63
%55
%78
%59
%20
%59
%54
%78
%59
%
CO
MP
ON
EN
T S
CO
RE
S: A
cces
s to
Hea
lth C
are
Info
rmat
ion,
con
tinue
d
Bureau of Audits and Investigations, Office of the Inspector General Page 104
CO
MP
ON
EN
T Q
UE
STI
ON
S: O
utpa
tient
Hou
sing
Uni
t04
.051
Did
the
prim
ary
care
pro
vide
r (P
CP
) eva
luat
e th
e in
mat
e w
ithin
one
cal
enda
r day
afte
r pla
cem
ent?
04.0
52D
id th
e R
N c
ompl
ete
an in
itial
ass
essm
ent o
f the
inm
ate
on th
e da
y of
pla
cem
ent?
04.0
53W
hile
the
inm
ate
was
pla
ced
in th
e O
HU
, did
the
PC
P co
mpl
ete
the
Sub
ject
ive,
Obj
ectiv
e, A
sses
smen
t, P
lan
and
Edu
catio
n (S
OA
PE
) at a
min
imum
of e
very
14
days
?
04.0
54D
id th
e ut
iliza
tion
man
agem
ent (
UM
) nur
se a
sses
s th
e in
mat
e w
ithin
one
wee
k of
the
inm
ate’
s pl
acem
ent a
nd e
very
30
days
th
erea
fter?
04.0
56D
id th
e P
CP
’s p
lan
adeq
uate
ly a
ddre
ss th
e in
itial
ass
essm
ent?
04.1
12W
as th
e P
CP
’s in
itial
eva
luat
ion
adeq
uate
for t
he p
robl
em(s
) req
uirin
g O
HU
pla
cem
ent?
04.2
08W
as th
e le
vel o
f car
e av
aila
ble
in th
e O
HU
app
ropr
iate
to th
e pa
tient
’s c
linic
al p
rese
ntat
ion?
04.2
30W
as th
e P
CP
’s in
itial
ass
essm
ent (
or d
iagn
oses
) app
ropr
iate
for t
he fi
ndin
gs in
the
initi
al e
valu
atio
n?15
.103
In th
e ou
tpat
ient
hou
sing
uni
t (O
HU
), ar
e pa
tient
cal
l but
tons
ope
ratio
nal o
r doe
s m
edic
al s
taff
mak
e ro
unds
eve
ry 3
0 m
inut
es?
15.2
25D
oes
the
OH
U u
se d
isin
fect
ant d
aily
in c
omm
on p
atie
nt a
reas
?
CO
MP
ON
EN
T S
CO
RE
S: O
utpa
tient
Hou
sing
Uni
tRe
f Nu
mber
SAC
CMF
RJD
CEN
DVI
CCW
FCM
CSC
CLA
CPV
SPCC
ICR
CCI
WAS
PHD
SPSQ
CCC
Aver
age
Scor
e04
.051
Poss
ible P
oints
55
55
55
55
55
50
Rece
ived P
oints
4.54
45
45
3.54
44
42
Scor
e90
%80
%80
%10
0%80
%10
0%70
%80
%80
%80
%84
%
04.05
2Po
ssibl
e Poin
ts5
55
55
55
55
550
Rece
ived P
oints
4.55
45
35
4.54
54.5
44.5
Scor
e90
%10
0%80
%10
0%60
%10
0%90
%80
%10
0%90
%89
%
04.05
3Po
ssibl
e Poin
ts4
44
44
44
44
440
Rece
ived P
oints
1.23.1
42
1.34
43
42
28.6
Scor
e30
%78
%10
0%50
%33
%10
0%10
0%75
%10
0%50
%72
%
04.05
4Po
ssibl
e Poin
ts4
44
44
44
44
440
Rece
ived P
oints
00.4
00
20
00
00
2.4
Scor
e0%
11%
0%0%
50%
0%0%
0%0%
0%6%
APPENDIX C-10: Component Questions and Scores - Outpatient Housing Unit
State of California • August 2010 Page 105
APPENDIX C-10
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
04.05
6Po
ssibl
e Poin
ts5
55
55
55
55
550
Rece
ived P
oints
54.5
3.83.8
4.44.4
1.93.1
55
40.9
Scor
e10
0%90
%75
%75
%88
%89
%38
%63
%10
0%10
0%82
%
04.11
2Po
ssibl
e Poin
ts5
55
55
55
55
550
Rece
ived P
oints
4.14.5
43.9
3.53.5
1.52
54
36
Scor
e82
%90
%80
%78
%70
%70
%30
%40
%10
0%80
%72
%
04.20
8Po
ssibl
e Poin
ts9
99
99
99
99
990
Rece
ived P
oints
99
99
99
79
99
88
Scor
e10
0%10
0%10
0%10
0%10
0%10
0%78
%10
0%10
0%10
0%98
%
04.23
0Po
ssibl
e Poin
ts5
55
55
55
55
550
Rece
ived P
oints
54.5
54.4
55
53.1
55
47
Scor
e10
0%90
%10
0%89
%10
0%10
0%10
0%63
%10
0%10
0%94
%
15.10
3Po
ssibl
e Poin
ts3
33
33
33
33
330
Rece
ived P
oints
03
30
00
03
03
12
Scor
e0%
100%
100%
0%0%
0%0%
100%
0%10
0%40
%
15.22
5Po
ssibl
e Poin
ts3
33
33
33
33
330
Rece
ived P
oints
33
33
30
33
33
27
Scor
e10
0%10
0%10
0%10
0%10
0%0%
100%
100%
100%
100%
90%
Total
Pos
sible
Point
s48
4848
4848
4848
4848
4848
0
Total
Rec
eived
Poin
ts36
.341
.139
.836
.135
.235
.930
.434
.240
39.5
368.5
Tota
l Sco
re76
%86
%83
%75
%73
%75
%63
%71
%83
%82
%77
%
CO
MP
ON
EN
T S
CO
RE
S: O
utpa
tient
Hou
sing
Uni
t, co
ntin
ued
Bureau of Audits and Investigations, Office of the Inspector General Page 106
CO
MP
ON
EN
T Q
UE
STI
ON
S: I
nter
nal R
evie
ws
17.1
18D
o th
e Q
ualit
y M
anag
emen
t Com
mitt
ee (Q
MC
) mee
ting
min
utes
doc
umen
t mon
thly
mee
tings
for t
he la
st s
ix (6
) mon
ths?
17.1
19D
id th
e Q
ualit
y M
anag
emen
t Com
mitt
ee (Q
MC
) rep
ort i
ts fi
ndin
gs to
the
HC
M/C
MO
eac
h of
the
last
six
(6) m
eetin
gs?
17.1
32D
o th
e E
mer
genc
y R
espo
nse
Rev
iew
Com
mitt
ee (E
RR
C) m
eetin
g m
inut
es d
ocum
ent m
onth
ly m
eetin
gs fo
r the
last
six
(6)
mon
ths?
17.1
35D
id th
e la
st th
ree
Qua
lity
Man
agem
ent C
omm
ittee
(QM
C) m
eetin
g m
inut
es re
flect
find
ings
and
stra
tegi
es fo
r im
prov
emen
t?17
.136
For e
ach
deat
h sa
mpl
ed, d
id th
e in
stitu
tion
com
plet
e th
e de
ath
revi
ew p
roce
ss?
17.1
38D
o th
e E
mer
genc
y R
espo
nse
Rev
iew
Com
mitt
ee (E
RR
C) m
eetin
g m
inut
es d
ocum
ent t
he w
arde
n’s
(or h
is o
r her
des
igne
e’s)
at
tend
ance
?17
.174
Did
the
inst
itutio
n pr
ompt
ly p
roce
ss in
mat
e m
edic
al a
ppea
ls d
urin
g th
e m
ost r
ecen
t 12
mon
ths?
17.2
21D
id th
e in
stitu
tion
com
plet
e a
med
ical
em
erge
ncy
resp
onse
dril
l for
eac
h w
atch
and
incl
ude
parti
cipa
tion
from
eac
h m
edic
al
faci
lity
durin
g th
e m
ost r
ecen
t ful
l qua
rter?
CO
MP
ON
EN
T S
CO
RE
S: I
nter
nal R
evie
ws
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
17.11
8Po
ssibl
e Poin
ts5
55
55
55
55
55
55
55
55
85
Rece
ived P
oints
54.2
51.7
4.25
51.7
55
4.25
55
55
576
Scor
e10
0%83
%10
0%33
%83
%10
0%10
0%33
%10
0%10
0%83
%10
0%10
0%10
0%10
0%10
0%10
0%89
%
17.11
9Po
ssibl
e Poin
ts5
55
55
55
55
55
55
55
55
85
Rece
ived P
oints
54.2
52.5
55
55
55
55
55
55
581
.7
Scor
e10
0%83
%10
0%50
%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%96
%
17.13
2Po
ssibl
e Poin
ts5
55
55
55
55
55
55
55
55
85
Rece
ived P
oints
4.24.2
54.2
4.24.2
4.22.5
4.25
2.54.2
3.34.2
55
571
.1
Scor
e83
%83
%10
0%83
%83
%83
%83
%50
%83
%10
0%50
%83
%67
%83
%10
0%10
0%10
0%84
%
17.13
5Po
ssibl
e Poin
ts5
55
55
55
55
55
55
55
55
85
Rece
ived P
oints
55
55
55
55
55
55
55
05
580
Scor
e10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%0%
100%
100%
94%
APPENDIX C-11: Component Questions and Scores - Internal Reviews
State of California • August 2010 Page 107
APPENDIX C-11
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
17.13
6Po
ssibl
e Poin
ts5
55
55
55
55
55
55
55
580
Rece
ived P
oints
45
53
55
40
54
44
35
55
66
Scor
e80
%10
0%10
0%60
%10
0%10
0%80
%0%
100%
80%
80%
80%
60%
100%
100%
100%
83%
17.13
8Po
ssibl
e Poin
ts5
55
55
55
55
55
55
55
55
85
Rece
ived P
oints
50
53
45
55
54.2
3.33
54
52.5
4.268
.2
Scor
e10
0%0%
100%
60%
80%
100%
100%
100%
100%
83%
67%
60%
100%
80%
100%
50%
83%
80%
17.17
4Po
ssibl
e Poin
ts5
55
55
55
55
55
55
55
55
85
Rece
ived P
oints
05
50
55
05
00
05
50
00
540
Scor
e0%
100%
100%
0%10
0%10
0%0%
100%
0%0%
0%10
0%10
0%0%
0%0%
100%
47%
17.22
1Po
ssibl
e Poin
ts5
55
55
55
55
55
55
55
55
85
Rece
ived P
oints
00
55
55
00
00
05
50
00
030
Scor
e0%
0%10
0%10
0%10
0%10
0%0%
0%0%
0%0%
100%
100%
0%0%
0%0%
35%
Total
Pos
sible
Point
s40
4040
4040
4040
4040
4040
4035
4040
4040
675
Total
Rec
eived
Poin
ts28
.227
.540
24.3
37.3
39.2
28.2
24.2
29.2
28.2
2436
.233
.326
.225
27.5
34.2
512.7
Tota
l Sco
re70
%69
%10
0%61
%93
%98
%70
%60
%73
%71
%60
%91
%95
%66
%63
%69
%86
%76
%
CO
MP
ON
EN
T S
CO
RE
S: I
nter
nal R
evie
ws,
con
tinue
d
Bureau of Audits and Investigations, Office of the Inspector General Page 108
CO
MP
ON
EN
T Q
UE
STI
ON
S: I
nmat
e Tr
ansf
ers
05.1
08D
id R
ecei
ving
and
Rel
ease
hav
e th
e in
mat
e’s
UH
R a
nd tr
ansf
er e
nvel
ope?
05.1
09If
the
inm
ate
was
sch
edul
ed fo
r any
upc
omin
g sp
ecia
lty s
ervi
ces,
wer
e th
e se
rvic
es n
oted
on
Form
737
1 (H
ealth
Car
e Tr
ansf
er
Info
rmat
ion)
?
05.1
10D
o al
l app
ropr
iate
form
s in
the
trans
fer e
nvel
ope
iden
tify
all m
edic
atio
ns o
rder
ed b
y th
e ph
ysic
ian,
and
are
the
med
icat
ions
in th
e tra
nsfe
r env
elop
e?
05.1
71D
id a
n R
N a
ccur
atel
y co
mpl
ete
all a
pplic
able
sec
tions
of F
orm
737
1 (H
ealth
Car
e Tr
ansf
er In
form
atio
n) b
ased
on
the
inm
ate’
s U
HR
?
05.1
72D
id th
e H
ealth
Rec
ords
Dep
artm
ent m
aint
ain
a co
py o
f the
inm
ate’
s Fo
rm 7
371
(Hea
lth C
are
Tran
sfer
Info
rmat
ion)
and
For
m
7231
A (O
utpa
tient
Med
icat
ion
Adm
inis
tratio
n R
ecor
d) w
hen
the
inm
ate
trans
ferr
ed?
CO
MP
ON
EN
T S
CO
RE
S: I
nmat
e Tr
ansf
ers
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
05.10
8Po
ssibl
e Poin
ts7
77
77
77
77
77
77
77
77
119
Rece
ived P
oints
77
77
77
77
77
77
77
77
711
9
Scor
e10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%
05.10
9Po
ssibl
e Poin
ts8
88
88
88
88
880
Rece
ived P
oints
80
48
08
08
88
52
Scor
e10
0%0%
50%
100%
0%10
0%0%
100%
100%
100%
65%
05.11
0Po
ssibl
e Poin
ts8
88
88
88
88
88
88
88
120
Rece
ived P
oints
84
88
88
88
86.4
88
3.28
810
9.6
Scor
e10
0%50
%10
0%10
0%10
0%10
0%10
0%10
0%10
0%80
%10
0%10
0%40
%10
0%10
0%91
%
05.17
1Po
ssibl
e Poin
ts7
77
77
77
77
77
77
77
77
119
Rece
ived P
oints
5.60
77
77
5.35.6
71.4
1.47
4.27
77
4.290
.7
Scor
e80
%0%
100%
100%
100%
100%
75%
80%
100%
20%
20%
100%
60%
100%
100%
100%
60%
76%
05.17
2Po
ssibl
e Poin
ts8
88
88
88
88
88
88
88
88
136
Rece
ived P
oints
08
88
88
88
88
08
88
88
812
0
Scor
e0%
100%
100%
100%
100%
100%
100%
100%
100%
100%
0%10
0%10
0%10
0%10
0%10
0%10
0%88
%
Total
Pos
sible
Point
s38
3838
3838
3830
3030
3038
3838
2230
2238
574
Total
Rec
eived
Poin
ts28
.619
3438
3038
28.3
28.6
3022
.816
.438
30.4
2230
2235
.249
1.3
Tota
l Sco
re75
%50
%90
%10
0%79
%10
0%94
%95
%10
0%76
%43
%10
0%80
%10
0%10
0%10
0%93
%86
%
APPENDIX C-12: Component Questions and Scores - Inmate Transfers
State of California • August 2010 Page 109
CO
MP
ON
EN
T Q
UE
STI
ON
S: C
linic
Ope
ratio
ns14
.023
Doe
s th
e in
stitu
tion
mak
e th
e Fo
rm 7
362
(Hea
lth C
are
Ser
vice
s R
eque
st F
orm
) ava
ilabl
e to
inm
ates
?
14.0
29D
oes
med
ical
sta
ff in
the
faci
lity
clin
ic k
now
whi
ch in
mat
es a
re o
n m
odifi
ed p
rogr
am o
r con
fined
to q
uarte
rs (C
TQ) a
nd d
oes
staf
f ha
ve a
n ad
equa
te p
roce
ss to
ens
ure
thos
e in
mat
es re
ceiv
e th
eir m
edic
atio
n?14
.032
Doe
s m
edic
al s
taff
unde
rsta
nd th
e in
stitu
tion’
s pr
iorit
y du
cat p
roce
ss?
14.0
33D
oes
the
inst
itutio
n ha
ve a
n ad
equa
te p
roce
ss to
ens
ure
inm
ates
who
are
mov
ed to
a n
ew c
ell s
till r
ecei
ve th
eir m
edic
al d
ucat
s?14
.106
Doe
s cl
inic
al s
taff
was
h th
eir h
ands
(eith
er w
ith s
oap
or h
and
sani
tizer
) or c
hang
e gl
oves
bet
wee
n pa
tient
s?
14.1
31D
o m
edic
atio
n nu
rses
und
erst
and
that
med
icat
ion
is to
be
adm
inis
tere
d by
the
sam
e lic
ense
d st
aff m
embe
r who
pre
pare
s it
and
on th
e sa
me
day?
14.1
60D
oes
the
inst
itutio
n ha
ve a
pro
cess
to id
entif
y, re
view
, and
add
ress
urg
ent a
ppoi
ntm
ents
if a
doc
tor’s
line
is c
ance
led?
14.1
64A
re a
reas
ava
ilabl
e to
ens
ure
priv
acy
durin
g R
N fa
ce-to
-face
ass
essm
ents
and
doc
tors
’ exa
min
atio
ns fo
r non
-em
erge
ncie
s?14
.165
Are
the
clin
ic fl
oors
, wai
ting
room
cha
irs, a
nd e
quip
men
t cle
aned
with
a d
isin
fect
ant d
aily
?14
.166
Was
the
med
icat
ion
stor
ed in
a s
eale
d co
ntai
ner i
f foo
d w
as p
rese
nt in
the
clin
ic re
frige
rato
r?
CO
MP
ON
EN
T S
CO
RE
S: C
linic
Ope
ratio
nsRe
f Nu
mber
SAC
CMF
RJD
CEN
DVI
CCW
FCM
CSC
CLA
CPV
SPCC
ICR
CCI
WAS
PHD
SPSQ
CCC
Aver
age
Scor
e14
.023
Poss
ible P
oints
44
44
44
44
44
44
44
44
468
Rece
ived P
oints
44
44
44
44
43.3
3.64
44
44
466
.9
Scor
e10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%83
%89
%10
0%10
0%10
0%10
0%10
0%10
0%98
%
14.02
9Po
ssibl
e Poin
ts4
44
44
44
44
44
44
44
464
Rece
ived P
oints
44
44
44
44
44
44
42
44
62
Scor
e10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%50
%10
0%10
0%97
%
14.03
2Po
ssibl
e Poin
ts2
22
22
22
22
22
22
22
22
34
Rece
ived P
oints
22
22
22
22
22
22
22
22
234
Scor
e10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%
14.03
3Po
ssibl
e Poin
ts4
44
44
44
44
44
44
44
44
68
Rece
ived P
oints
44
44
44
44
44
44
42
44
466
Scor
e10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%50
%10
0%10
0%10
0%97
%
APPENDIX C-13: Component Questions and Scores - Clinic Operations
cont
inue
d on
pag
e 11
0
Bureau of Audits and Investigations, Office of the Inspector General Page 110
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
14.10
6Po
ssibl
e Poin
ts4
44
44
44
44
44
44
44
44
68
Rece
ived P
oints
24
32
44
34
43
43
44
34
358
Scor
e50
%10
0%75
%50
%10
0%10
0%75
%10
0%10
0%75
%10
0%75
%10
0%10
0%75
%10
0%75
%85
%
14.13
1Po
ssibl
e Poin
ts4
44
44
44
44
44
44
44
44
68
Rece
ived P
oints
44
40
44
44
44
44
44
44
464
Scor
e10
0%10
0%10
0%0%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
94%
14.16
0Po
ssibl
e Poin
ts4
44
44
44
44
44
44
44
44
68
Rece
ived P
oints
42
44
20
00
24
44
44
44
450
Scor
e10
0%50
%10
0%10
0%50
%0%
0%0%
50%
100%
100%
100%
100%
100%
100%
100%
100%
74%
14.16
4Po
ssibl
e Poin
ts3
33
33
33
33
33
33
33
33
51
Rece
ived P
oints
2.40
33
33
33
33
2.31.5
33
33
345
.2
Scor
e80
%0%
100%
100%
100%
100%
100%
100%
100%
100%
75%
50%
100%
100%
100%
100%
100%
89%
14.16
5Po
ssibl
e Poin
ts2
22
22
22
22
22
22
22
22
34
Rece
ived P
oints
21.3
1.32
01.3
22
0.71.3
00
1.32
22
223
.2
Scor
e10
0%67
%67
%10
0%0%
67%
100%
100%
33%
67%
0%0%
67%
100%
100%
100%
100%
68%
14.16
6Po
ssibl
e Poin
ts2
22
22
22
22
22
22
22
22
34
Rece
ived P
oints
22
22
22
22
22
22
22
22
234
Scor
e10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%
Total
Pos
sible
Point
s29
3333
3333
3333
3333
3333
3333
3333
3333
557
Total
Rec
eived
Poin
ts26
.427
.331
.327
2928
.328
2929
.730
.629
.928
.532
.331
3033
3250
3.3
Tota
l Sco
re91
%83
%95
%82
%88
%86
%85
%88
%90
%93
%91
%86
%98
%94
%91
%10
0%97
%90
%
APPENDIX C-13C
OM
PO
NE
NT
SC
OR
ES
: Clin
ic O
pera
tions
, con
tinue
d
State of California • August 2010 Page 111
CO
MP
ON
EN
T Q
UE
STI
ON
S: P
reve
ntiv
e S
ervi
ces
10.0
85M
ale
inm
ates
age
51
or o
lder
: Did
the
inm
ate
rece
ive
a fe
cal o
ccul
t blo
od te
st (F
OB
T) w
ithin
the
prev
ious
12
mon
ths
or w
as th
e in
mat
e’s
refu
sal d
ocum
ente
d?
10.0
86A
ll in
mat
es a
ge 6
6 or
old
er: D
id th
e in
mat
e re
ceiv
e an
influ
enza
vac
cina
tion
with
in th
e pr
evio
us 1
2 m
onth
s or
was
the
inm
ate’
s re
fusa
l doc
umen
ted?
10.0
87Fe
mal
e in
mat
es a
ge 4
1 or
old
er: D
id th
e in
mat
e re
ceiv
e a
mam
mog
ram
with
in th
e pr
evio
us 2
4 m
onth
s?10
.228
Inm
ates
pre
scrib
ed IN
H: D
id th
e in
stitu
tion
prop
erly
adm
inis
ter t
he m
edic
atio
n to
the
inm
ate?
10.2
29In
mat
es w
ith T
B c
ode
34: W
as th
e in
mat
e ev
alua
ted
for s
igns
and
sym
ptom
s of
TB
with
in th
e pr
evio
us 1
2 m
onth
s?
10.2
32In
mat
es p
resc
ribed
INH
: Did
the
inst
itutio
n m
onito
r the
inm
ate
mon
thly
for t
he m
ost r
ecen
t thr
ee m
onth
s he
or s
he w
as o
n th
e m
edic
atio
n?10
.274
Fem
ale
inm
ates
age
41
to 6
4: D
id th
e in
mat
e re
ceiv
e a
Pap
sm
ear i
n co
mpl
ianc
e w
ith p
olic
y?
CO
MP
ON
EN
T S
CO
RE
S: P
reve
ntiv
e S
ervi
ces
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
10.08
5Po
ssibl
e Poin
ts5
55
55
55
55
55
55
55
75
Rece
ived P
oints
2.53.5
1.51.5
0.54.5
10
01
3.51.5
11
023
Scor
e50
%70
%30
%30
%10
%90
%20
%0%
0%20
%70
%30
%20
%20
%0%
31%
10.08
6Po
ssibl
e Poin
ts6
66
66
66
66
66
66
66
696
Rece
ived P
oints
4.84.5
36
5.16
64.8
00
3.35.4
63.6
5.46
69.9
Scor
e80
%75
%50
%10
0%86
%10
0%10
0%80
%0%
0%56
%90
%10
0%60
%90
%10
0%73
%
10.08
7Po
ssibl
e Poin
ts5
510
Rece
ived P
oints
33.5
6.5
Scor
e60
%70
%65
%
10.22
8Po
ssibl
e Poin
ts6
66
66
66
66
66
66
66
66
102
Rece
ived P
oints
2.44.8
1.20
02.4
1.20
1.21.2
1.24.8
02.4
1.21.2
2.427
.6
Scor
e40
%80
%20
%0%
0%40
%20
%0%
20%
20%
20%
80%
0%40
%20
%20
%40
%27
%
APPENDIX C-14: Component Questions and Scores - Preventive Services
cont
inue
d on
pag
e 11
2
Bureau of Audits and Investigations, Office of the Inspector General Page 112
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
10.22
9Po
ssibl
e Poin
ts7
77
77
77
77
77
77
77
77
119
Rece
ived P
oints
2.80
00
07
4.21.4
07
07
07
1.47
1.446
.2
Scor
e40
%0%
0%0%
0%10
0%60
%20
%0%
100%
0%10
0%0%
100%
20%
100%
20%
39%
10.23
2Po
ssibl
e Poin
ts6
66
66
66
66
66
66
66
66
102
Rece
ived P
oints
00
01.2
00
00
00
06
01.2
00
1.29.6
Scor
e0%
0%0%
20%
0%0%
0%0%
0%0%
0%10
0%0%
20%
0%0%
20%
9%
10.27
4Po
ssibl
e Poin
ts5
510
Rece
ived P
oints
32.5
5.5
Scor
e60
%50
%55
%
Total
Pos
sible
Point
s24
3030
3030
3530
3030
3030
3035
3030
3030
514
Total
Rec
eived
Poin
ts7.7
13.1
7.25.7
6.520
.515
.98.4
68.2
2.224
.611
.418
.17.2
14.6
1118
8.3
Tota
l Sco
re32
%44
%24
%19
%22
%59
%53
%28
%20
%27
%7%
82%
33%
60%
24%
49%
37%
37%
APPENDIX C-14C
OM
PO
NE
NT
SC
OR
ES
: Pre
vent
ive
Ser
vice
s, c
ontin
ued
State of California • August 2010 Page 113
CO
MP
ON
EN
T Q
UE
STI
ON
S: P
harm
acy
Ser
vice
s13
.139
Doe
s th
e in
stitu
tion
cons
picu
ousl
y po
st a
val
id p
erm
it in
its
phar
mac
ies?
13.1
41D
oes
the
inst
itutio
n pr
oper
ly m
aint
ain
its e
mer
genc
y cr
ash
cart
med
icat
ions
?13
.142
Is th
e ph
arm
acis
t in
char
ge’s
lice
nse
curr
ent?
13.1
44D
oes
the
inst
itutio
n ha
ve in
form
atio
n to
ens
ure
that
med
icat
ions
are
pre
scrib
ed b
y lic
ense
d he
alth
-car
e pr
ovid
ers
law
fully
au
thor
ized
to d
o so
?13
.145
Doe
s th
e ph
arm
acis
t in
char
ge h
ave
an e
ffect
ive
proc
ess
for s
cree
ning
new
med
icat
ion
orde
rs fo
r pot
entia
l adv
erse
reac
tions
?
13.1
48D
oes
the
phar
mac
ist i
n ch
arge
mon
itor t
he q
uant
ity o
f med
icat
ions
on
hand
, and
doe
s th
e ph
arm
acy
cond
uct a
n an
nual
inve
ntor
y to
ens
ure
that
the
quan
tity
of m
edic
atio
ns in
the
syst
em m
atch
es th
e qu
antit
y of
med
icat
ions
on
hand
?13
.252
Doe
s th
e in
stitu
tion
prop
erly
mai
ntai
n m
edic
atio
ns in
its
afte
r-ho
urs
med
icat
ion
supp
ly(ie
s)?
13.2
53D
oes
the
inst
itutio
n co
nduc
t mon
thly
insp
ectio
ns o
f its
em
erge
ncy
cart
and
afte
r-ho
urs
med
icat
ion
supp
ly(ie
s)?
CO
MP
ON
EN
T S
CO
RE
S: P
harm
acy
Ser
vice
sRe
f Nu
mber
SAC
CMF
RJD
CEN
DVI
CCW
FCM
CSC
CLA
CPV
SPCC
ICR
CCI
WAS
PHD
SPSQ
CCC
Aver
age
Scor
e13
.139
Poss
ible P
oints
22
22
22
22
22
22
22
22
234
Rece
ived P
oints
22
22
22
22
22
22
22
22
234
Scor
e10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%
13.14
1Po
ssibl
e Poin
ts2
22
22
22
22
22
22
22
22
34
Rece
ived P
oints
1.62
22
22
22
22
22
20
20
128
.6
Scor
e80
%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%0%
100%
0%50
%84
%
13.14
2Po
ssibl
e Poin
ts5
55
55
55
55
55
55
55
55
85
Rece
ived P
oints
55
55
55
55
55
55
55
55
585
Scor
e10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%
13.14
4Po
ssibl
e Poin
ts6
66
66
66
66
66
66
66
66
102
Rece
ived P
oints
00
60
66
66
60
00
66
66
060
Scor
e0%
0%10
0%0%
100%
100%
100%
100%
100%
0%0%
0%10
0%10
0%10
0%10
0%0%
59%
APPENDIX C-15: Component Questions and Scores - Pharmacy Services
cont
inue
d on
pag
e 11
4
Bureau of Audits and Investigations, Office of the Inspector General Page 114
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
13.14
5Po
ssibl
e Poin
ts7
77
77
77
77
77
77
77
77
119
Rece
ived P
oints
77
77
77
77
77
77
77
77
711
9
Scor
e10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%
13.14
8Po
ssibl
e Poin
ts4
44
44
44
44
44
44
44
44
68
Rece
ived P
oints
44
40
44
44
44
44
44
44
464
Scor
e10
0%10
0%10
0%0%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
94%
13.25
2Po
ssibl
e Poin
ts2
22
22
22
22
22
22
22
22
34
Rece
ived P
oints
21
0.70
00
00
20
22
1.32
20
015
Scor
e10
0%50
%33
%0%
0%0%
0%0%
100%
0%10
0%10
0%67
%10
0%10
0%0%
0%44
%
13.25
3Po
ssibl
e Poin
ts1
11
11
11
11
11
11
11
11
17
Rece
ived P
oints
01
0.40.8
0.70.7
0.30.3
11
11
0.30.7
11
112
.2
Scor
e0%
100%
40%
75%
67%
67%
33%
33%
100%
100%
100%
100%
25%
67%
100%
100%
100%
72%
Total
Pos
sible
Point
s29
2929
2929
2929
2929
2929
2929
2929
2929
493
Total
Rec
eived
Poin
ts21
.622
27.1
16.8
26.7
26.7
26.3
26.3
2921
2323
27.6
26.7
2925
2041
7.8
Tota
l Sco
re75
%76
%93
%58
%92
%92
%91
%91
%10
0%72
%79
%79
%95
%92
%10
0%86
%69
%85
%
APPENDIX C-15C
OM
PO
NE
NT
SC
OR
ES
: Pha
rmac
y S
ervi
ces,
con
tinue
d
State of California • August 2010 Page 115
CO
MP
ON
EN
T Q
UE
STI
ON
S: O
ther
Ser
vice
s
15.0
58If
the
inst
itutio
n do
es n
ot o
ffer t
hera
peut
ic d
iets
, doe
s st
aff f
ollo
w th
e de
partm
ent’s
pro
cedu
res
for t
rans
ferr
ing
inm
ates
who
are
de
term
ined
to re
quire
a th
erap
eutic
die
t?15
.059
Did
the
inst
itutio
n pr
oper
ly p
rovi
de th
erap
eutic
die
ts to
inm
ates
?15
.134
Did
the
inst
itutio
n pr
oper
ly re
spon
d to
all
activ
e ca
ses
of T
B d
isco
vere
d in
the
last
six
mon
ths?
15.2
65Is
the
mos
t cur
rent
ver
sion
of t
he C
DC
R H
ealth
Ser
vice
s P
olic
ies
and
Pro
cedu
res
avai
labl
e in
the
inst
itutio
n’s
law
libr
ary?
20.0
92H
ygie
ne In
terv
entio
n: D
id c
usto
dy s
taff
unde
rsta
nd th
e de
partm
ent’s
pol
icie
s an
d pr
oced
ures
for i
dent
ifyin
g an
d ev
alua
ting
inm
ates
dis
play
ing
inap
prop
riate
hyg
iene
man
agem
ent?
CO
MP
ON
EN
T S
CO
RE
S: O
ther
Ser
vice
sRe
f Nu
mber
SAC
CMF
RJD
CEN
DVI
CCW
FCM
CSC
CLA
CPV
SPCC
ICR
CCI
WAS
PHD
SPSQ
CCC
Aver
age
Scor
e15
.058
Poss
ible P
oints
33
33
33
33
24
Rece
ived P
oints
30
03
03
33
15
Scor
e10
0%0%
0%10
0%0%
100%
100%
100%
63%
15.05
9Po
ssibl
e Poin
ts4
44
44
44
432
Rece
ived P
oints
44
44
44
44
32
Scor
e10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%
15.13
4Po
ssibl
e Poin
ts5
5
Rece
ived P
oints
55
Scor
e10
0%10
0%
15.26
5Po
ssibl
e Poin
ts3
33
33
33
33
33
33
33
33
51
Rece
ived P
oints
1.53
33
33
31.5
33
1.53
00
01.5
336
Scor
e50
%10
0%10
0%10
0%10
0%10
0%10
0%50
%10
0%10
0%50
%10
0%0%
0%0%
50%
100%
71%
20.09
2Po
ssibl
e Poin
ts4
44
44
44
44
44
44
44
44
68
Rece
ived P
oints
44
44
44
34
44
44
44
44
467
Scor
e10
0%10
0%10
0%10
0%10
0%10
0%75
%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%99
%
Total
Pos
sible
Point
s16
1111
1011
1111
1011
1010
107
1011
1010
180
Total
Rec
eived
Poin
ts14
.511
1110
1111
105.5
117
8.57
47
88.5
1015
5
Tota
l Sco
re91
%10
0%10
0%10
0%10
0%10
0%91
%55
%10
0%70
%85
%70
%57
%70
%73
%85
%10
0%86
%
APPENDIX C-16: Component Questions and Scores - Other Sevices
Bureau of Audits and Investigations, Office of the Inspector General Page 116
CO
MP
ON
EN
T Q
UE
STI
ON
S: I
nmat
e H
unge
r Stri
kes
11.0
97D
id th
e R
N c
ondu
ct a
face
-to-fa
ce tr
iage
of t
he in
mat
e w
ithin
two
(2) b
usin
ess
days
of r
ecei
pt o
f the
For
m 1
28-B
and
doc
umen
t th
e in
mat
e’s
reas
ons
for t
he h
unge
r stri
ke, m
ost r
ecen
t rec
orde
d w
eigh
t, cu
rren
t wei
ght,
vita
l sig
ns, a
nd p
hysi
cal c
ondi
tion?
11.0
99A
fter t
he fi
rst 4
8 ho
urs,
did
an
RN
or P
CP
com
plet
e da
ily a
sses
smen
ts d
ocum
entin
g th
e in
mat
e’s
wei
ght,
phys
ical
con
ditio
n,
emot
iona
l con
ditio
n, v
ital s
igns
, and
hyd
ratio
n st
atus
?
11.1
00A
fter t
he fi
rst 7
2 ho
urs,
did
a p
hysi
cian
per
form
a p
hysi
cal e
xam
inat
ion
and
orde
r a m
etab
olic
pan
el a
nd a
urin
alys
is o
f the
in
mat
e?
CO
MP
ON
EN
T S
CO
RE
S: I
nmat
e H
unge
r Stri
kes
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
11.09
7Po
ssibl
e Poin
ts6
66
66
66
66
66
672
Rece
ived P
oints
26
26
66
1.50
04.8
4.80
39.1
Scor
e33
%10
0%33
%10
0%10
0%10
0%25
%0%
0%80
%80
%0%
54%
11.09
9Po
ssibl
e Poin
ts6
66
66
66
66
66
672
Rece
ived P
oints
00
00
64
30
43.6
1.26
27.8
Scor
e0%
0%0%
0%10
0%67
%50
%0%
67%
60%
20%
100%
39%
11.10
0Po
ssibl
e Poin
ts7
77
77
77
77
77
784
Rece
ived P
oints
00
00
73.5
3.57
4.70
4.27
36.9
Scor
e0%
0%0%
0%10
0%50
%50
%10
0%67
%0%
60%
100%
44%
Total
Pos
sible
Point
s19
1919
1919
1919
1919
1919
1922
8
Total
Rec
eived
Poin
ts2
62
619
13.5
87
8.78.4
10.2
1310
3.8
Tota
l Sco
re11
%32
%11
%32
%10
0%71
%42
%37
%46
%44
%54
%68
%46
%
APPENDIX C-17: Component Questions and Scores - Inmate Hunger Strikes
State of California • August 2010 Page 117
CO
MP
ON
EN
T Q
UE
STI
ON
S: C
hem
ical
Age
nt C
ontra
indi
catio
ns12
.062
Did
the
inst
itutio
n do
cum
ent t
hat i
t con
sulte
d w
ith a
n R
N o
r prim
ary
care
pro
vide
r (P
CP
) bef
ore
a ca
lcul
ated
use
of O
C?
12.0
64D
id th
e in
stitu
tion
reco
rd h
ow it
dec
onta
min
ated
the
inm
ate
and
did
it fo
llow
the
deco
ntam
inat
ion
polic
y?
CO
MP
ON
EN
T S
CO
RE
S: C
hem
ical
Age
nt C
ontra
indi
catio
nsRe
f Nu
mber
SAC
CMF
RJD
CEN
DVI
CCW
FCM
CSC
CLA
CPV
SPCC
ICR
CCI
WAS
PHD
SPSQ
CCC
Aver
age
Scor
e12
.062
Poss
ible P
oints
99
99
99
99
99
99
911
7
Rece
ived P
oints
96.8
97.2
7.23
99
99
97.2
910
3.4
Scor
e10
0%75
%10
0%80
%80
%33
%10
0%10
0%10
0%10
0%10
0%80
%10
0%88
%
12.06
4Po
ssibl
e Poin
ts8
88
88
88
88
88
88
88
88
136
Rece
ived P
oints
88
78
88
88
6.45.3
5.38
88
88
812
8
Scor
e10
0%10
0%88
%10
0%10
0%10
0%10
0%10
0%80
%67
%67
%10
0%10
0%10
0%10
0%10
0%10
0%94
%
Total
Pos
sible
Point
s17
1717
1717
1717
1717
88
88
1717
1717
253
Total
Rec
eived
Poin
ts17
14.8
1615
.215
.211
1717
15.4
5.35.3
88
1717
15.2
1723
1.4
Tota
l Sco
re10
0%87
%94
%89
%89
%65
%10
0%10
0%91
%66
%66
%10
0%10
0%10
0%10
0%89
%10
0%91
%
APPENDIX C-18: Component Questions and Scores - Chemical Agent Contraindications
Bureau of Audits and Investigations, Office of the Inspector General Page 118
CO
MP
ON
EN
T Q
UE
STI
ON
S: S
taffi
ng L
evel
s an
d Tr
aini
ng18
.001
Are
lice
nsed
hea
lth c
are
staf
f cur
rent
with
thei
r cer
tifica
tions
and
did
they
atte
nd re
quire
d tra
inin
g?
18.0
02In
form
atio
n pu
rpos
es o
nly:
Cal
cula
te th
e in
stitu
tion’
s av
erag
e va
canc
y pe
rcen
tage
s, th
e nu
mbe
r of h
ealth
car
e st
aff s
tarti
ng
with
in s
ix (6
) mon
ths
of th
e O
IG v
isit,
and
the
num
ber o
f hea
lth c
are
staf
f hire
d fro
m th
e re
gist
ry.
Not
e: W
e do
not
fact
or th
is
ques
tion
into
the
inst
itutio
n’s
scor
e fo
r sta
ffing
leve
ls a
nd tr
aini
ng.
18.0
04D
id th
e in
stitu
tion
have
a re
gist
ered
nur
se (R
N) a
vaila
ble
on s
ite 2
4 ho
urs
a da
y, s
even
day
s a
wee
k, fo
r em
erge
ncy
care
?
18.0
05D
id th
e in
stitu
tion
have
a p
hysi
cian
on
site
, a p
hysi
cian
on
call,
or a
n M
OD
ava
ilabl
e 24
hou
rs a
day
, sev
en d
ays
a w
eek,
for t
he
last
30
days
?
18.0
06D
oes
the
inst
itutio
n’s
orie
ntat
ion
prog
ram
for a
ll ne
wly
hire
d nu
rsin
g st
aff i
nclu
de a
mod
ule
for s
ick
call
prot
ocol
s th
at re
quire
fa
ce-to
-face
tria
ge?
CO
MP
ON
EN
T S
CO
RE
S: S
taffi
ng L
evel
s an
d Tr
aini
ngRe
f Nu
mber
SAC
CMF
RJD
CEN
DVI
CCW
FCM
CSC
CLA
CPV
SPCC
ICR
CCI
WAS
PHD
SPSQ
CCC
Aver
age
Scor
e18
.001
Poss
ible P
oints
44
44
44
44
44
44
44
44
468
Rece
ived P
oints
3.23.2
44
3.21.6
44
2.40.8
2.41.6
1.64
43.2
451
.2
Scor
e80
%80
%10
0%10
0%80
%40
%10
0%10
0%60
%20
%60
%40
%40
%10
0%10
0%80
%10
0%75
%
18.00
2Po
ssibl
e Poin
ts
Rece
ived P
oints
Scor
e
18.00
4Po
ssibl
e Poin
ts4
44
44
44
44
44
44
44
44
68
Rece
ived P
oints
44
44
44
44
44
44
44
44
468
Scor
e10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%
18.00
5Po
ssibl
e Poin
ts4
44
44
44
44
44
44
44
44
68
Rece
ived P
oints
44
44
44
44
44
44
44
44
468
Scor
e10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%
18.00
6Po
ssibl
e Poin
ts4
44
44
44
44
44
44
44
44
68
Rece
ived P
oints
44
44
44
44
44
44
44
44
468
Scor
e10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%
Total
Pos
sible
Point
s16
1616
1616
1616
1616
1616
1616
1616
1616
272
Total
Rec
eived
Poin
ts15
.215
.216
1615
.213
.616
1614
.412
.814
.413
.613
.616
1615
.216
255.2
Tota
l Sco
re95
%95
%10
0%10
0%95
%85
%10
0%10
0%90
%80
%90
%85
%85
%10
0%10
0%95
%10
0%94
%
APPENDIX C-19: Component Questions and Scores - Staffing Levels and Training
State of California • August 2010 Page 119
CO
MP
ON
EN
T Q
UE
STI
ON
S: N
ursi
ng P
olic
y16
.154
D
oes
the
inst
itutio
n ha
ve w
ritte
n nu
rsin
g po
licie
s an
d pr
oced
ures
that
adh
ere
to th
e de
partm
ent’s
gui
delin
es?
16.2
31D
oes
the
inst
itutio
n en
sure
that
nur
sing
sta
ff re
view
thei
r dut
y st
atem
ents
?16
.254
Doe
s th
e in
stitu
tion’
s su
perv
isin
g re
gist
ered
nur
se (S
RN
) con
duct
per
iodi
c re
view
s of
nur
sing
sta
ff?
CO
MP
ON
EN
T S
CO
RE
S: N
ursi
ng P
olic
yRe
f Nu
mber
SAC
CMF
RJD
CEN
DVI
CCW
FCM
CSC
CLA
CPV
SPCC
ICR
CCI
WAS
PHD
SPSQ
CCC
Aver
age
Scor
e16
.154
Poss
ible P
oints
55
55
55
55
55
55
55
55
585
Rece
ived P
oints
55
55
55
55
55
55
55
55
585
Scor
e10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%
16.23
1Po
ssibl
e Poin
ts5
55
55
55
55
55
55
55
55
85
Rece
ived P
oints
20
51
05
25
35
24
42
54
554
Scor
e40
%0%
100%
20%
0%10
0%40
%10
0%60
%10
0%40
%80
%80
%40
%10
0%80
%10
0%64
%
16.25
4Po
ssibl
e Poin
ts4
44
44
44
44
44
44
44
44
68
Rece
ived P
oints
40
2.44
04
43.2
04
01.6
02.4
2.40.8
3.236
Scor
e10
0%0%
60%
100%
0%10
0%10
0%80
%0%
100%
0%40
%0%
60%
60%
20%
80%
53%
Total
Pos
sible
Point
s14
1414
1414
1414
1414
1414
1414
1414
1414
238
Total
Rec
eived
Poin
ts11
512
.410
514
1113
.28
147
10.6
99.4
12.4
9.813
.217
5
Tota
l Sco
re79
%36
%89
%71
%36
%10
0%79
%94
%57
%10
0%50
%76
%64
%67
%89
%70
%94
%74
%
APPENDIX C-20: Component Questions and Scores - Nursing Policy
Bureau of Audits and Investigations, Office of the Inspector General Page 120
CAT
EG
OR
Y Q
UE
STI
ON
S: M
edic
atio
n M
anag
emen
t
01.1
24S
ick
Cal
l Med
icat
ion:
Did
the
inst
itutio
n ad
min
iste
r or d
eliv
er p
resc
riptio
n m
edic
atio
ns (n
ew o
rder
s) to
the
inm
ate
with
in s
peci
fied
time
fram
es?
02.1
28If
the
inm
ate
had
an e
xist
ing
med
icat
ion
orde
r upo
n ar
rival
at t
he in
stitu
tion,
did
the
inm
ate
rece
ive
the
med
icat
ions
by
the
next
ca
lend
ar d
ay, o
r did
a p
hysi
cian
exp
lain
why
the
med
icat
ions
wer
e no
t to
be c
ontin
ued?
03.1
75D
id th
e in
mat
e re
ceiv
e hi
s or
her
pre
scrib
ed c
hron
ic c
are
med
icat
ions
dur
ing
the
mos
t rec
ent t
hree
-mon
th p
erio
d or
did
the
inst
itutio
n fo
llow
dep
artm
enta
l pol
icy
if th
e in
mat
e re
fuse
d to
pic
k up
or s
how
up
for h
is o
r her
med
icat
ions
?
05.1
10D
o al
l app
ropr
iate
form
s in
the
trans
fer e
nvel
ope
iden
tify
all m
edic
atio
ns o
rder
ed b
y th
e ph
ysic
ian,
and
are
the
med
icat
ions
in
the
trans
fer e
nvel
ope?
10.2
28In
mat
es p
resc
ribed
INH
: Did
the
inst
itutio
n pr
oper
ly a
dmin
iste
r the
med
icat
ion
to th
e in
mat
e?13
.141
Doe
s th
e in
stitu
tion
prop
erly
mai
ntai
n its
em
erge
ncy
cras
h ca
rt m
edic
atio
ns?
13.1
45D
oes
the
phar
mac
ist i
n ch
arge
hav
e an
effe
ctiv
e pr
oces
s fo
r scr
eeni
ng n
ew m
edic
atio
n or
ders
for p
oten
tial a
dver
se re
actio
ns?
13.1
48D
oes
the
phar
mac
ist i
n ch
arge
mon
itor t
he q
uant
ity o
f med
icat
ions
on
hand
, and
doe
s th
e ph
arm
acy
cond
uct a
n an
nual
in
vent
ory
to e
nsur
e th
at th
e qu
antit
y of
med
icat
ions
in th
e sy
stem
mat
ches
the
quan
tity
of m
edic
atio
ns o
n ha
nd?
13.2
52D
oes
the
inst
itutio
n pr
oper
ly m
aint
ain
med
icat
ions
in it
s af
ter-
hour
s m
edic
atio
n su
pply
(ies)
?13
.253
Doe
s th
e in
stitu
tion
cond
uct m
onth
ly in
spec
tions
of i
ts e
mer
genc
y ca
rt an
d af
ter-
hour
s m
edic
atio
n su
pply
(ies)
?
14.0
29D
oes
med
ical
sta
ff in
the
faci
lity
clin
ic k
now
whi
ch in
mat
es a
re o
n m
odifi
ed p
rogr
am o
r con
fined
to q
uarte
rs (C
TQ) a
nd d
oes
staf
f hav
e an
ade
quat
e pr
oces
s to
ens
ure
thos
e in
mat
es re
ceiv
e th
eir m
edic
atio
n?
14.1
31D
o m
edic
atio
n nu
rses
und
erst
and
that
med
icat
ion
is to
be
adm
inis
tere
d by
the
sam
e lic
ense
d st
aff m
embe
r who
pre
pare
s it
and
on th
e sa
me
day?
14.1
66W
as th
e m
edic
atio
n st
ored
in a
sea
led
cont
aine
r if f
ood
was
pre
sent
in th
e cl
inic
refri
gera
tor?
21.2
81U
pon
the
inm
ate’
s di
scha
rge
from
a c
omm
unity
hos
pita
l, di
d th
e in
stitu
tion
adm
inis
ter o
r del
iver
all
pres
crib
ed m
edic
atio
ns to
the
inm
ate
with
in s
peci
fied
time
fram
es?
CAT
EG
OR
Y S
CO
RE
S: M
edic
atio
n M
anag
emen
t Re
f Nu
mber
SAC
CMF
RJD
CEN
DVI
CCW
FCM
CSC
CLA
CPV
SPCC
ICR
CCI
WAS
PHD
SPSQ
CCC
Aver
age
Scor
e01
.124
Poss
ible P
oints
66
66
66
66
66
66
66
66
610
2Re
ceive
d Poin
ts1.3
4.83.3
4.62
3.11.7
0.82
0.72.5
0.61.7
1.82.6
1.30.9
35.7
Scor
e22
%80
%55
%77
%33
%52
%28
%13
%33
%11
%41
%10
%28
%30
%44
%22
%14
%35
%
APPENDIX D-1: Category Questions and Scores - Medication Management
State of California • August 2010 Page 121
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
02.12
8Po
ssibl
e Poin
ts8
88
88
88
88
88
88
88
88
136
Rece
ived P
oints
2.77
44
03.4
12
3.30
3.41.8
02.4
2.81.9
1.341
Scor
e33
%88
%50
%50
%0%
43%
13%
25%
42%
0%43
%23
%0%
30%
35%
24%
17%
30%
03.17
5Po
ssibl
e Poin
ts18
1818
1818
1818
1818
1818
1818
1818
1818
306
Rece
ived P
oints
8.313
.99
9.911
.67.2
0.85.6
5.30.8
8.63.6
0.83.3
1.41.4
3.194
.6Sc
ore
46%
77%
50%
55%
65%
40%
4%31
%29
%4%
48%
20%
4%18
%8%
8%17
%31
%05
.110
Poss
ible P
oints
88
88
88
88
88
88
88
812
0Re
ceive
d Poin
ts8
48
88
88
88
6.48
83.2
88
109.6
Scor
e10
0%50
%10
0%10
0%10
0%10
0%10
0%10
0%10
0%80
%10
0%10
0%40
%10
0%10
0%91
%10
.228
Poss
ible P
oints
66
66
66
66
66
66
66
66
610
2Re
ceive
d Poin
ts2.4
4.81.2
00
2.41.2
01.2
1.21.2
4.80
2.41.2
1.22.4
27.6
Scor
e40
%80
%20
%0%
0%40
%20
%0%
20%
20%
20%
80%
0%40
%20
%20
%40
%27
%13
.141
Poss
ible P
oints
22
22
22
22
22
22
22
22
234
Rece
ived P
oints
1.62
22
22
22
22
22
20
20
128
.6Sc
ore
80%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
0%10
0%0%
50%
84%
13.14
5Po
ssibl
e Poin
ts7
77
77
77
77
77
77
77
77
119
Rece
ived P
oints
77
77
77
77
77
77
77
77
711
9Sc
ore
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
13.14
8Po
ssibl
e Poin
ts4
44
44
44
44
44
44
44
44
68Re
ceive
d Poin
ts4
44
04
44
44
44
44
44
44
64Sc
ore
100%
100%
100%
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%94
%13
.252
Poss
ible P
oints
22
22
22
22
22
22
22
22
234
Rece
ived P
oints
21
0.70
00
00
20
22
1.32
20
015
Scor
e10
0%50
%33
%0%
0%0%
0%0%
100%
0%10
0%10
0%67
%10
0%10
0%0%
0%44
%13
.253
Poss
ible P
oints
11
11
11
11
11
11
11
11
117
Rece
ived P
oints
01
0.40.8
0.70.7
0.30.3
11
11
0.30.7
11
112
.2Sc
ore
0%10
0%40
%75
%67
%67
%33
%33
%10
0%10
0%10
0%10
0%25
%67
%10
0%10
0%10
0%72
%14
.029
Poss
ible P
oints
44
44
44
44
44
44
44
44
64Re
ceive
d Poin
ts4
44
44
44
44
44
44
24
462
Scor
e10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%50
%10
0%10
0%97
%
APPENDIX D-1
cont
inue
d on
pag
e 12
2
CAT
EG
OR
Y S
CO
RE
S: M
edic
atio
n M
anag
emen
t, co
ntin
ued
Bureau of Audits and Investigations, Office of the Inspector General Page 122
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
14.13
1Po
ssibl
e Poin
ts4
44
44
44
44
44
44
44
44
68Re
ceive
d Poin
ts4
44
04
44
44
44
44
44
44
64Sc
ore
100%
100%
100%
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%94
%14
.166
Poss
ible P
oints
22
22
22
22
22
22
22
22
234
Rece
ived P
oints
22
22
22
22
22
22
22
22
234
Scor
e10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%21
.281
Poss
ible P
oints
66
66
66
66
66
66
66
66
610
2Re
ceive
d Poin
ts6
63.5
4.74.7
5.33.8
2.92.3
0.84
2.82.6
0.62.8
0.43
56.2
Scor
e10
0%10
0%58
%79
%79
%88
%64
%48
%38
%13
%67
%47
%44
%10
%47
%7%
50%
55%
Total
Pos
sible
Point
s74
7878
7878
7878
7878
7878
7878
7078
7078
1306
Total
Rec
eived
Poin
ts49
.365
.553
.147
5053
.139
.842
.648
.133
.953
.747
.632
.934
.242
.828
.241
.776
3.5To
tal S
core
67%
84%
68%
60%
64%
68%
51%
55%
62%
43%
69%
61%
42%
49%
55%
40%
53%
58%
APPENDIX D-1C
ATE
GO
RY
SC
OR
ES
: Med
icat
ion
Man
agem
ent,
cont
inue
d
State of California • August 2010 Page 123
CAT
EG
OR
Y Q
UE
STI
ON
S: A
cces
s to
Car
e
01.0
25R
N F
TF D
ocum
enta
tion:
Did
the
RN
com
plet
e th
e fa
ce-to
-face
(FTF
) tria
ge w
ithin
one
(1) b
usin
ess
day
afte
r the
For
m 7
362
was
revi
ewed
?
01.0
27If
the
RN
det
erm
ined
a re
ferr
al to
a p
rimar
y ca
re p
rovi
der (
PC
P) w
as n
eces
sary
, was
the
inm
ate
seen
with
in th
e tim
elin
es
spec
ified
by
the
RN
dur
ing
the
FTF
triag
e?01
.247
Sic
k C
all F
ollo
w-u
p: If
the
prov
ider
ord
ered
a fo
llow
-up
sick
cal
l app
oint
men
t, di
d it
take
pla
ce w
ithin
the
time
fram
e sp
ecifi
ed?
02.0
15W
as a
revi
ew o
f sym
ptom
s co
mpl
eted
if th
e in
mat
e’s
tube
rcul
in te
st w
as p
ositi
ve, a
nd w
ere
the
resu
lts re
view
ed b
y th
e in
fect
ion
cont
rol n
urse
?02
.016
Did
the
inst
itutio
n co
mpl
ete
the
initi
al h
ealth
scr
eeni
ng o
n th
e sa
me
day
the
inm
ate
arriv
ed a
t the
inst
itutio
n?
02.0
17If
yes
was
ans
wer
ed to
any
of t
he q
uest
ions
on
the
initi
al h
ealth
scr
eeni
ng fo
rm(s
), di
d th
e R
N p
rovi
de a
n as
sess
men
t and
di
spos
ition
on
the
date
of a
rriv
al?
02.0
18If,
dur
ing
the
asse
ssm
ent,
the
RN
refe
rred
the
inm
ate
to a
clin
icia
n, w
as th
e in
mat
e se
en w
ithin
the
time
fram
e?
02.0
20D
id th
e LV
N/R
N a
dequ
atel
y do
cum
ent t
he tu
berc
ulin
test
or a
revi
ew o
f sig
ns a
nd s
ympt
oms
if th
e in
mat
e ha
d a
prev
ious
po
sitiv
e tu
berc
ulin
test
?
02.0
21R
ecep
tion
cent
er: D
id th
e in
mat
e re
ceiv
e a
com
plet
e hi
stor
y an
d ph
ysic
al b
y a
Nur
se P
ract
ition
er, P
hysi
cian
Ass
ista
nt, o
r a
Phy
sici
an a
nd S
urge
on w
ithin
14
cale
ndar
day
s of
arr
ival
?
03.0
76W
as th
e in
mat
e’s
mos
t rec
ent c
hron
ic c
are
visi
t with
in th
e tim
e fra
me
requ
ired
by th
e de
gree
of c
ontro
l of t
he in
mat
e’s
cond
ition
ba
sed
on h
is o
r her
prio
r vis
it?04
.051
Did
the
prim
ary
care
pro
vide
r (P
CP
) eva
luat
e th
e in
mat
e w
ithin
one
cal
enda
r day
afte
r pla
cem
ent?
04.0
52D
id th
e R
N c
ompl
ete
an in
itial
ass
essm
ent o
f the
inm
ate
on th
e da
y of
pla
cem
ent?
04.0
53W
hile
the
inm
ate
was
pla
ced
in th
e O
HU
, did
the
PC
P co
mpl
ete
the
Sub
ject
ive,
Obj
ectiv
e, A
sses
smen
t, P
lan
and
Edu
catio
n (S
OA
PE
) at a
min
imum
of e
very
14
days
?06
.049
Rad
iolo
gy o
rder
: Was
the
radi
olog
y se
rvic
e pr
ovid
ed w
ithin
the
time
fram
e sp
ecifi
ed in
the
phys
icia
n’s
orde
r?06
.188
All
labo
rato
ry o
rder
s: W
as th
e sp
ecim
en c
olle
cted
with
in th
e ap
plic
able
tim
e fra
mes
of t
he p
hysi
cian
’s o
rder
?07
.035
Did
the
inm
ate
rece
ive
the
spec
ialty
ser
vice
with
in s
peci
fied
time
fram
es?
07.0
38D
id th
e P
CP
see
the
inm
ate
betw
een
the
date
the
PC
P or
dere
d th
e se
rvic
e an
d th
e da
te th
e in
mat
e re
ceiv
ed it
, in
acco
rdan
ce
with
spe
cifie
d tim
e fra
mes
?
07.0
43D
id th
e P
CP
revi
ew th
e co
nsul
tant
’s re
port
and
see
the
inm
ate
for a
follo
w-u
p ap
poin
tmen
t afte
r the
spe
cial
ty s
ervi
ces
cons
ulta
tion
with
in s
peci
fied
time
fram
es?
APPENDIX D-2: Category Questions and Scores - Access to Care
cont
inue
d on
pag
e 12
4
Bureau of Audits and Investigations, Office of the Inspector General Page 124
08.1
84D
id th
e m
edic
al e
mer
genc
y re
spon
der a
rriv
e at
the
loca
tion
of th
e m
edic
al e
mer
genc
y w
ithin
five
(5) m
inut
es o
f ini
tial
notifi
catio
n?
09.0
66N
ew a
rriv
al o
nly:
Did
the
inm
ate
rece
ive
a pr
egna
ncy
test
with
in th
ree
(3) b
usin
ess
days
of a
rriv
al a
t the
inst
itutio
n to
pos
itive
ly
iden
tify
her p
regn
ancy
?
09.0
67N
ew a
rriv
al o
nly:
Was
the
inm
ate
seen
by
an O
B p
hysi
cian
or O
B n
urse
pra
ctiti
oner
with
in s
even
(7) b
usin
ess
days
of h
er a
rriv
al
at th
e in
stitu
tion?
09.0
71D
id th
e in
mat
e vi
sit w
ith a
n O
B p
hysi
cian
acc
ordi
ng to
the
appl
icab
le ti
me
fram
es?
09.0
74D
id th
e in
mat
e re
ceiv
e he
r six
-wee
k ch
eck-
up (p
ost-d
eliv
ery)
?
10.0
85M
ale
inm
ates
age
51
or o
lder
: Did
the
inm
ate
rece
ive
a fe
cal o
ccul
t blo
od te
st (F
OB
T) w
ithin
the
prev
ious
12
mon
ths
or w
as th
e in
mat
e’s
refu
sal d
ocum
ente
d?
10.0
86 i
nmat
es a
ge 6
6 or
old
er: D
id th
e in
mat
e re
ceiv
e an
influ
enza
vac
cina
tion
with
in th
e pr
evio
us 1
2 m
onth
s or
was
the
inm
ate’
s re
fusa
l doc
umen
ted?
10.0
87Fe
mal
e in
mat
es a
ge 4
1 or
old
er: D
id th
e in
mat
e re
ceiv
e a
mam
mog
ram
with
in th
e pr
evio
us 2
4 m
onth
s?10
.229
Inm
ates
with
TB
cod
e 34
: Was
the
inm
ate
eval
uate
d fo
r sig
ns a
nd s
ympt
oms
of T
B w
ithin
the
prev
ious
12
mon
ths?
10.2
32In
mat
es p
resc
ribed
INH
: Did
the
inst
itutio
n m
onito
r the
inm
ate
mon
thly
for t
he m
ost r
ecen
t thr
ee m
onth
s he
or s
he w
as o
n th
e m
edic
atio
n?10
.274
Fem
ale
inm
ates
age
41
to 6
4: D
id th
e in
mat
e re
ceiv
e a
Pap
sm
ear i
n co
mpl
ianc
e w
ith p
olic
y?
11.0
97D
id th
e R
N c
ondu
ct a
face
-to-fa
ce tr
iage
of t
he in
mat
e w
ithin
two
(2) b
usin
ess
days
of r
ecei
pt o
f the
For
m 1
28-B
and
doc
umen
t th
e in
mat
e’s
reas
ons
for t
he h
unge
r stri
ke, m
ost r
ecen
t rec
orde
d w
eigh
t, cu
rren
t wei
ght,
vita
l sig
ns, a
nd p
hysi
cal c
ondi
tion?
11.0
99A
fter t
he fi
rst 4
8 ho
urs,
did
an
RN
or P
CP
com
plet
e da
ily a
sses
smen
ts d
ocum
entin
g th
e in
mat
e’s
wei
ght,
phys
ical
con
ditio
n,
emot
iona
l con
ditio
n, v
ital s
igns
, and
hyd
ratio
n st
atus
?
11.1
00A
fter t
he fi
rst 7
2 ho
urs,
did
a p
hysi
cian
per
form
a p
hysi
cal e
xam
inat
ion
and
orde
r a m
etab
olic
pan
el a
nd a
urin
alys
is o
f the
in
mat
e?15
.258
Em
erge
ncy
Med
ical
Res
pons
e D
rill:
Did
the
resp
ondi
ng o
ffice
r beg
in C
PR
with
out u
nnec
essa
ry d
elay
?15
.282
Em
erge
ncy
Med
ical
Res
pons
e D
rill:
Did
med
ical
sta
ff ar
rive
on s
cene
in fi
ve m
inut
es o
r les
s?
21.2
49U
pon
the
inm
ate’
s di
scha
rge
from
the
com
mun
ity h
ospi
tal,
did
the
inm
ate
rece
ive
a fo
llow
-up
appo
intm
ent w
ith h
is o
r her
pr
imar
y ca
re p
rovi
der (
PC
P) w
ithin
five
cal
enda
r day
s of
dis
char
ge?
APPENDIX D-2C
ATE
GO
RY
QU
ES
TIO
NS
: Acc
ess
to C
are,
con
tinue
d
State of California • August 2010 Page 125
CAT
EG
OR
Y S
CO
RE
S: A
cces
s to
Car
eRe
f Nu
mber
SAC
CMF
RJD
CEN
DVI
CCW
FCM
CSC
CLA
CPV
SPCC
ICR
CCI
WAS
PHD
SPSQ
CCC
Aver
age
Scor
e01
.025
Poss
ible P
oints
66
66
66
66
66
66
66
66
610
2Re
ceive
d Poin
ts4.6
54.8
4.65.3
5.34.7
3.95
23.6
4.84.1
1.52.4
2.15
68.7
Scor
e76
%84
%80
%76
%88
%88
%78
%65
%83
%33
%60
%80
%68
%26
%40
%34
%84
%67
%01
.027
Poss
ible P
oints
88
88
88
88
88
88
88
88
813
6Re
ceive
d Poin
ts2.4
6.61
46.3
4.56
62.8
3.82
4.35.6
4.22.1
4.43.6
69.6
Scor
e29
%82
%13
%50
%79
%56
%75
%75
%35
%47
%25
%54
%71
%52
%27
%56
%46
%51
%01
.247
Poss
ible P
oints
77
77
77
77
77
77
77
77
711
9Re
ceive
d Poin
ts1.8
5.41.6
74.2
4.74.7
01.4
2.54
6.13.9
4.43.5
3.54.7
63.4
Scor
e25
%78
%22
%10
0%60
%67
%67
%0%
20%
36%
57%
88%
56%
63%
50%
50%
67%
53%
02.01
5Po
ssibl
e Poin
ts7
77
77
77
77
77
77Re
ceive
d Poin
ts7
77
4.75.3
5.87
2.37
77
67.1
Scor
e10
0%10
0%10
0%67
%75
%83
%10
0%33
%10
0%10
0%10
0%87
%02
.016
Poss
ible P
oints
99
99
99
99
99
99
99
99
915
3Re
ceive
d Poin
ts9
98.7
99
99
98.1
5.96.9
8.68.6
8.18.4
8.17.7
142.1
Scor
e10
0%10
0%97
%10
0%10
0%10
0%10
0%10
0%90
%65
%77
%95
%95
%90
%93
%90
%85
%93
%02
.017
Poss
ible P
oints
88
88
88
88
88
88
88
88
128
Rece
ived P
oints
84.4
7.67.5
88
82.3
3.75.6
88
6.98
88
110
Scor
e10
0%56
%94
%93
%10
0%10
0%10
0%29
%46
%70
%10
0%10
0%87
%10
0%10
0%10
0%86
%02
.018
Poss
ible P
oints
88
88
88
88
88
88
88
88
128
Rece
ived P
oints
28
14.8
46.9
82.3
05.7
2.70.9
4.41.3
4.93.2
60.1
Scor
e25
%10
0%13
%60
%50
%86
%10
0%29
%0%
71%
33%
11%
55%
17%
61%
40%
47%
02.02
0Po
ssibl
e Poin
ts6
66
66
66
66
66
66
66
66
102
Rece
ived P
oints
5.44.2
5.25.4
66
5.15.7
65.1
4.86
5.45.1
5.85.8
693
Scor
e90
%70
%87
%90
%10
0%10
0%85
%95
%10
0%85
%80
%10
0%90
%85
%97
%96
%10
0%91
%02
.021
Poss
ible P
oints
55
55
55
55
40Re
ceive
d Poin
ts2.8
2.82.8
2.55
25
4.827
.7Sc
ore
56%
55%
55%
50%
100%
40%
100%
95%
69%
APPENDIX D-2
cont
inue
d on
pag
e 12
6
Bureau of Audits and Investigations, Office of the Inspector General Page 126
APPENDIX D-2
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
03.07
6Po
ssibl
e Poin
ts10
1010
1010
1010
1010
1010
1010
1010
1010
170
Rece
ived P
oints
8.88.7
4.89.5
5.69
7.66
6.47.2
6.89.6
7.57.2
4.48.4
5.612
3.1Sc
ore
88%
87%
48%
95%
56%
90%
76%
60%
64%
72%
68%
96%
75%
72%
44%
84%
56%
72%
04.05
1Po
ssibl
e Poin
ts5
55
55
55
55
550
Rece
ived P
oints
4.54
45
45
3.54
44
42Sc
ore
90%
80%
80%
100%
80%
100%
70%
80%
80%
80%
84%
04.05
2Po
ssibl
e Poin
ts5
55
55
55
55
550
Rece
ived P
oints
4.55
45
35
4.54
54.5
44.5
Scor
e90
%10
0%80
%10
0%60
%10
0%90
%80
%10
0%90
%89
%04
.053
Poss
ible P
oints
44
44
44
44
44
40Re
ceive
d Poin
ts1.2
3.14
21.3
44
34
228
.6Sc
ore
30%
78%
100%
50%
33%
100%
100%
75%
100%
50%
72%
06.04
9Po
ssibl
e Poin
ts7
77
77
77
77
77
77
77
77
119
Rece
ived P
oints
75.6
77
1.47
5.67
75.6
5.60
74.2
4.27
4.292
.4Sc
ore
100%
80%
100%
100%
20%
100%
80%
100%
100%
80%
80%
0%10
0%60
%60
%10
0%60
%78
%06
.188
Poss
ible P
oints
66
66
66
66
66
66
66
66
610
2Re
ceive
d Poin
ts5.4
5.43
3.64.8
4.24.8
65.4
4.22.4
5.43
4.21.8
64.2
73.8
Scor
e90
%90
%50
%60
%80
%70
%80
%10
0%90
%70
%40
%90
%50
%70
%30
%10
0%70
%72
%07
.035
Poss
ible P
oints
99
99
99
99
99
99
99
99
915
3Re
ceive
d Poin
ts4.2
3.25.3
5.35.3
8.55.3
6.95.8
6.23.7
2.67.9
6.94.2
5.87.9
95Sc
ore
47%
35%
59%
59%
59%
94%
59%
77%
65%
69%
41%
29%
88%
77%
47%
65%
88%
62%
07.03
8Po
ssibl
e Poin
ts8
88
88
88
88
88
88
88
88
136
Rece
ived P
oints
0.62.5
21.2
0.70
1.82.9
2.30.7
2.40.5
32.7
0.50
4.428
.2Sc
ore
8%31
%25
%15
%9%
0%23
%36
%29
%8%
29%
7%38
%33
%7%
0%56
%21
%07
.043
Poss
ible P
oints
99
99
99
99
99
99
99
99
915
3Re
ceive
d Poin
ts2
2.61.7
3.70.7
1.61.1
2.33.2
3.24.2
3.42.1
6.50
2.13.8
44.2
Scor
e22
%29
%19
%41
%8%
18%
13%
25%
36%
36%
47%
38%
23%
73%
0%23
%42
%29
%08
.184
Poss
ible P
oints
44
44
44
44
44
44
44
44
64Re
ceive
d Poin
ts4
43.2
44
2.74
44
32
44
43.2
458
.1Sc
ore
100%
100%
80%
100%
100%
67%
100%
100%
100%
75%
50%
100%
100%
100%
80%
100%
91%
CAT
EG
OR
Y S
CO
RE
S: A
cces
s to
Car
e, c
ontin
ued
State of California • August 2010 Page 127
APPENDIX D-2
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
09.06
6Po
ssibl
e Poin
ts5
5Re
ceive
d Poin
ts0
0Sc
ore
0%0%
09.06
7Po
ssibl
e Poin
ts5
5Re
ceive
d Poin
ts5
5Sc
ore
100%
100%
09.07
1Po
ssibl
e Poin
ts8
8Re
ceive
d Poin
ts6.9
6.9Sc
ore
86%
86%
09.07
4Po
ssibl
e Poin
ts7
7Re
ceive
d Poin
ts5.6
5.6Sc
ore
80%
80%
10.08
5Po
ssibl
e Poin
ts5
55
55
55
55
55
55
55
75Re
ceive
d Poin
ts2.5
3.51.5
1.50.5
4.51
00
13.5
1.51
10
23Sc
ore
50%
70%
30%
30%
10%
90%
20%
0%0%
20%
70%
30%
20%
20%
0%31
%10
.086
Poss
ible P
oints
66
66
66
66
66
66
66
66
96Re
ceive
d Poin
ts4.8
4.53
65.1
66
4.80
03.3
5.46
3.65.4
669
.9Sc
ore
80%
75%
50%
100%
86%
100%
100%
80%
0%0%
56%
90%
100%
60%
90%
100%
73%
10.08
7Po
ssibl
e Poin
ts5
510
Rece
ived P
oints
33.5
6.5Sc
ore
60%
70%
65%
10.22
9Po
ssibl
e Poin
ts7
77
77
77
77
77
77
77
77
119
Rece
ived P
oints
2.80
00
07
4.21.4
07
07
07
1.47
1.446
.2Sc
ore
40%
0%0%
0%0%
100%
60%
20%
0%10
0%0%
100%
0%10
0%20
%10
0%20
%39
%10
.232
Poss
ible P
oints
66
66
66
66
66
66
66
66
610
2Re
ceive
d Poin
ts0
00
1.20
00
00
00
60
1.20
01.2
9.6Sc
ore
0%0%
0%20
%0%
0%0%
0%0%
0%0%
100%
0%20
%0%
0%20
%9%
10.27
4Po
ssibl
e Poin
ts5
510
Rece
ived P
oints
32.5
5.5Sc
ore
60%
50%
55%
CAT
EG
OR
Y S
CO
RE
S: A
cces
s to
Car
e, c
ontin
ued
cont
inue
d on
pag
e 12
8
Bureau of Audits and Investigations, Office of the Inspector General Page 128
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
11.09
7Po
ssibl
e Poin
ts6
66
66
66
66
66
672
Rece
ived P
oints
26
26
66
1.50
04.8
4.80
39.1
Scor
e33
%10
0%33
%10
0%10
0%10
0%25
%0%
0%80
%80
%0%
54%
11.09
9Po
ssibl
e Poin
ts6
66
66
66
66
66
672
Rece
ived P
oints
00
00
64
30
43.6
1.26
27.8
Scor
e0%
0%0%
0%10
0%67
%50
%0%
67%
60%
20%
100%
39%
11.10
0Po
ssibl
e Poin
ts7
77
77
77
77
77
784
Rece
ived P
oints
00
00
73.5
3.57
4.70
4.27
36.9
Scor
e0%
0%0%
0%10
0%50
%50
%10
0%67
%0%
60%
100%
44%
15.25
8Po
ssibl
e Poin
ts2
22
22
22
22
22
22
22
232
Rece
ived P
oints
00
22
22
02
22
02
20
22
22Sc
ore
0%0%
100%
100%
100%
100%
0%10
0%10
0%10
0%0%
100%
100%
0%10
0%10
0%69
%15
.282
Poss
ible P
oints
22
22
22
22
22
22
22
230
Rece
ived P
oints
02
22
22
22
22
22
02
226
Scor
e0%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
0%10
0%10
0%87
%21
.249
Poss
ible P
oints
77
77
77
77
77
77
77
77
711
9Re
ceive
d Poin
ts4.2
61.7
4.64.5
3.66.1
6.42.8
4.13.3
5.93.9
3.63.4
3.45.8
73.3
Scor
e60
%85
%24
%65
%64
%52
%88
%92
%40
%58
%48
%84
%56
%52
%48
%48
%82
%62
%To
tal P
ossib
le Po
ints
174
173
171
155
166
176
166
161
169
159
185
161
177
154
164
177
180
2868
Total
Rec
eived
Poin
ts93
.910
980
.492
.910
2.112
9.611
9.398
.988
.282
.891
.711
2.911
5.810
5.773
.411
7.112
1.217
34.9
Tota
l Sco
re54
%63
%47
%60
%62
%74
%72
%61
%52
%52
%50
%70
%65
%69
%45
%66
%67
%60
%
APPENDIX D-2C
ATE
GO
RY
SC
OR
ES
: Acc
ess
to C
are,
con
tinue
d
State of California • August 2010 Page 129
CAT
EG
OR
Y Q
UE
STI
ON
S: C
ontin
uity
of C
are
02.0
07N
on-r
ecep
tion
cent
er: D
oes
the
heal
th c
are
trans
fer i
nfor
mat
ion
form
indi
cate
that
it w
as re
view
ed a
nd s
igne
d by
lice
nsed
hea
lth
care
sta
ff w
ithin
one
cal
enda
r day
of t
he in
mat
e’s
arriv
al a
t the
inst
itutio
n?
02.0
14N
on-r
ecep
tion
cent
er: I
f the
inm
ate
was
sch
edul
ed fo
r a s
peci
alty
app
oint
men
t at t
he s
endi
ng in
stitu
tion,
did
the
rece
ivin
g in
stitu
tion
sche
dule
the
appo
intm
ent w
ithin
30
days
of t
he o
rigin
al a
ppoi
ntm
ent d
ate?
02.1
11N
on-r
ecep
tion
cent
er: D
id th
e in
mat
e re
ceiv
e m
edic
al a
ccom
mod
atio
ns u
pon
arriv
al, i
f app
licab
le?
02.1
28If
the
inm
ate
had
an e
xist
ing
med
icat
ion
orde
r upo
n ar
rival
at t
he in
stitu
tion,
did
the
inm
ate
rece
ive
the
med
icat
ions
by
the
next
ca
lend
ar d
ay, o
r did
a p
hysi
cian
exp
lain
why
the
med
icat
ions
wer
e no
t to
be c
ontin
ued?
04.0
51D
id th
e pr
imar
y ca
re p
rovi
der (
PC
P) e
valu
ate
the
inm
ate
with
in o
ne c
alen
dar d
ay a
fter p
lace
men
t?04
.052
Did
the
RN
com
plet
e an
initi
al a
sses
smen
t of t
he in
mat
e on
the
day
of p
lace
men
t?05
.108
Did
Rec
eivi
ng a
nd R
elea
se h
ave
the
inm
ate’
s U
HR
and
tran
sfer
env
elop
e?
05.1
09If
the
inm
ate
was
sch
edul
ed fo
r any
upc
omin
g sp
ecia
lty s
ervi
ces,
wer
e th
e se
rvic
es n
oted
on
Form
737
1 (H
ealth
Car
e Tr
ansf
er
Info
rmat
ion)
?
05.1
10D
o al
l app
ropr
iate
form
s in
the
trans
fer e
nvel
ope
iden
tify
all m
edic
atio
ns o
rder
ed b
y th
e ph
ysic
ian,
and
are
the
med
icat
ions
in
the
trans
fer e
nvel
ope?
05.1
71D
id a
n R
N a
ccur
atel
y co
mpl
ete
all a
pplic
able
sec
tions
of F
orm
737
1 (H
ealth
Car
e Tr
ansf
er In
form
atio
n) b
ased
on
the
inm
ate’
s U
HR
?
05.1
72D
id th
e H
ealth
Rec
ords
Dep
artm
ent m
aint
ain
a co
py o
f the
inm
ate’
s Fo
rm 7
371
(Hea
lth C
are
Tran
sfer
Info
rmat
ion)
and
For
m
7231
A (O
utpa
tient
Med
icat
ion
Adm
inis
tratio
n R
ecor
d) w
hen
the
inm
ate
trans
ferr
ed?
07.0
43D
id th
e P
CP
revi
ew th
e co
nsul
tant
’s re
port
and
see
the
inm
ate
for a
follo
w-u
p ap
poin
tmen
t afte
r the
spe
cial
ty s
ervi
ces
cons
ulta
tion
with
in s
peci
fied
time
fram
es?
07.2
70D
id th
e sp
ecia
lty p
rovi
der p
rovi
de ti
mel
y fin
ding
s an
d re
com
men
datio
ns o
r did
an
RN
doc
umen
t tha
t he
or s
he c
alle
d th
e sp
ecia
lty p
rovi
der t
o as
certa
in th
e fin
ding
s an
d re
com
men
datio
ns?
14.0
33D
oes
the
inst
itutio
n ha
ve a
n ad
equa
te p
roce
ss to
ens
ure
inm
ates
who
are
mov
ed to
a n
ew c
ell s
till r
ecei
ve th
eir m
edic
al
duca
ts?
21.2
48U
pon
the
inm
ate’
s di
scha
rge
from
the
com
mun
ity h
ospi
tal,
did
the
triag
e an
d tre
atm
ent a
rea
(TTA
) reg
iste
red
nurs
e do
cum
ent
that
he
or s
he re
view
ed th
e in
mat
e’s
disc
harg
e pl
an a
nd c
ompl
eted
a fa
ce-to
-face
ass
essm
ent o
f the
inm
ate?
21.2
49U
pon
the
inm
ate’
s di
scha
rge
from
the
com
mun
ity h
ospi
tal,
did
the
inm
ate
rece
ive
a fo
llow
-up
appo
intm
ent w
ith h
is o
r her
pr
imar
y ca
re p
rovi
der (
PC
P) w
ithin
five
cal
enda
r day
s of
dis
char
ge?
21.2
50U
pon
the
inm
ate’
s di
scha
rge
from
the
com
mun
ity h
ospi
tal,
did
the
inm
ate’
s P
rimar
y C
are
Pro
vide
r (P
CP
) pro
vide
ord
ers
for
appr
opria
te h
ousi
ng fo
r the
inm
ate?
APPENDIX D-3: Category Questions and Scores - Continuity of Care
cont
inue
d on
pag
e 13
0
Bureau of Audits and Investigations, Office of the Inspector General Page 130
21.2
51U
pon
the
inm
ate’
s di
scha
rge
from
the
com
mun
ity h
ospi
tal,
did
the
regi
ster
ed n
urse
inte
rven
e if
the
inm
ate
was
hou
sed
in a
n ar
ea th
at w
as in
appr
opria
te fo
r nur
sing
car
e ba
sed
on th
e pr
imar
y ca
re p
rovi
der’s
(PC
P) h
ousi
ng o
rder
s?
21.2
81U
pon
the
inm
ate’
s di
scha
rge
from
a c
omm
unity
hos
pita
l, di
d th
e in
stitu
tion
adm
inis
ter o
r del
iver
all
pres
crib
ed m
edic
atio
ns to
the
inm
ate
with
in s
peci
fied
time
fram
es?
CAT
EG
OR
Y S
CO
RE
S: C
ontin
uity
of C
are
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
02.00
7Po
ssibl
e Poin
ts7
77
77
77
77
77
77
798
Rece
ived P
oints
76.5
4.56.3
65.3
6.16.6
6.67
6.66
77
88.5
Scor
e10
0%93
%64
%90
%85
%75
%88
%95
%95
%10
0%95
%85
%10
0%10
0%90
%02
.014
Poss
ible P
oints
77
77
77
42Re
ceive
d Poin
ts7
07
77
735
Scor
e10
0%0%
100%
100%
100%
100%
83%
02.11
1Po
ssibl
e Poin
ts6
66
66
66
66
66
66
78Re
ceive
d Poin
ts4
64.5
26
4.56
64.5
66
36
64.5
Scor
e67
%10
0%75
%33
%10
0%75
%10
0%10
0%75
%10
0%10
0%50
%10
0%83
%02
.128
Poss
ible P
oints
88
88
88
88
88
88
88
88
813
6Re
ceive
d Poin
ts2.7
74
40
3.41
23.3
03.4
1.80
2.42.8
1.91.3
41Sc
ore
33%
88%
50%
50%
0%43
%13
%25
%42
%0%
43%
23%
0%30
%35
%24
%17
%30
%04
.051
Poss
ible P
oints
55
55
55
55
55
50Re
ceive
d Poin
ts4.5
44
54
53.5
44
442
Scor
e90
%80
%80
%10
0%80
%10
0%70
%80
%80
%80
%84
%04
.052
Poss
ible P
oints
55
55
55
55
55
50Re
ceive
d Poin
ts4.5
54
53
54.5
45
4.544
.5Sc
ore
90%
100%
80%
100%
60%
100%
90%
80%
100%
90%
89%
05.10
8Po
ssibl
e Poin
ts7
77
77
77
77
77
77
77
77
119
Rece
ived P
oints
77
77
77
77
77
77
77
77
711
9Sc
ore
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
APPENDIX D-3C
ATE
GO
RY
QU
ES
TIO
NS
: Con
tinui
ty o
f Car
e, c
ontin
ued
State of California • August 2010 Page 131
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
05.10
9Po
ssibl
e Poin
ts8
88
88
88
88
880
Rece
ived P
oints
80
48
08
08
88
52Sc
ore
100%
0%50
%10
0%0%
100%
0%10
0%10
0%10
0%65
%05
.110
Poss
ible P
oints
88
88
88
88
88
88
88
812
0Re
ceive
d Poin
ts8
48
88
88
88
6.48
83.2
88
109.6
Scor
e10
0%50
%10
0%10
0%10
0%10
0%10
0%10
0%10
0%80
%10
0%10
0%40
%10
0%10
0%91
%05
.171
Poss
ible P
oints
77
77
77
77
77
77
77
77
711
9Re
ceive
d Poin
ts5.6
07
77
75.3
5.67
1.41.4
74.2
77
74.2
90.7
Scor
e80
%0%
100%
100%
100%
100%
75%
80%
100%
20%
20%
100%
60%
100%
100%
100%
60%
76%
05.17
2Po
ssibl
e Poin
ts8
88
88
88
88
88
88
88
88
136
Rece
ived P
oints
08
88
88
88
88
08
88
88
812
0Sc
ore
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%0%
100%
100%
100%
100%
100%
100%
88%
07.04
3Po
ssibl
e Poin
ts9
99
99
99
99
99
99
99
99
153
Rece
ived P
oints
22.6
1.73.7
0.71.6
1.12.3
3.23.2
4.23.4
2.16.5
02.1
3.844
.2Sc
ore
22%
29%
19%
41%
8%18
%13
%25
%36
%36
%47
%38
%23
%73
%0%
23%
42%
29%
07.27
0Po
ssibl
e Poin
ts6
66
66
66
66
66
66
66
66
102
Rece
ived P
oints
3.23.5
5.36
4.66
65.6
66
66
66
5.66
693
.8Sc
ore
53%
59%
88%
100%
77%
100%
100%
94%
100%
100%
100%
100%
100%
100%
94%
100%
100%
92%
14.03
3Po
ssibl
e Poin
ts4
44
44
44
44
44
44
44
44
68Re
ceive
d Poin
ts4
44
44
44
44
44
44
24
44
66Sc
ore
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
50%
100%
100%
100%
97%
21.24
8Po
ssibl
e Poin
ts7
77
77
77
77
77
77
77
77
119
Rece
ived P
oints
5.56.3
4.65.3
6.26.4
5.97
6.76.2
6.47
5.96.4
2.23.6
6.297
.8Sc
ore
79%
90%
65%
75%
88%
92%
84%
100%
96%
88%
92%
100%
84%
92%
32%
52%
88%
82%
21.24
9Po
ssibl
e Poin
ts7
77
77
77
77
77
77
77
77
119
Rece
ived P
oints
4.26
1.74.6
4.53.6
6.16.4
2.84.1
3.35.9
3.93.6
3.43.4
5.873
.3Sc
ore
60%
85%
24%
65%
64%
52%
88%
92%
40%
58%
48%
84%
56%
52%
48%
48%
82%
62%
21.25
0Po
ssibl
e Poin
ts7
77
77
77
77
77
77
77
77
119
Rece
ived P
oints
5.15.6
3.57
6.77
77
76.7
76.7
6.77
75
710
9Sc
ore
73%
80%
50%
100%
96%
100%
100%
100%
100%
96%
100%
96%
96%
100%
100%
72%
100%
92%
APPENDIX D-3
cont
inue
d on
pag
e 13
2
CAT
EG
OR
Y S
CO
RE
S: C
ontin
uity
of C
are,
con
tinue
d
Bureau of Audits and Investigations, Office of the Inspector General Page 132
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
21.25
1Po
ssibl
e Poin
ts7
77
77
742
Rece
ived P
oints
70
70
77
28Sc
ore
100%
0%10
0%0%
100%
100%
67%
21.28
1Po
ssibl
e Poin
ts6
66
66
66
66
66
66
66
66
102
Rece
ived P
oints
66
3.54.7
4.75.3
3.82.9
2.30.8
42.8
2.60.6
2.80.4
356
.2Sc
ore
100%
100%
58%
79%
79%
88%
64%
48%
38%
13%
67%
47%
44%
10%
47%
7%50
%55
%To
tal P
ossib
le Po
ints
122
122
112
112
109
9910
410
197
104
122
115
102
106
104
9912
218
52To
tal R
eceiv
ed P
oints
88.3
81.5
78.3
92.6
69.4
82.3
75.2
81.1
75.9
73.4
81.3
97.1
69.6
84.1
76.8
67.4
100.8
1375
.1To
tal S
core
72%
67%
70%
83%
64%
83%
72%
80%
78%
71%
67%
84%
68%
79%
74%
68%
83%
74%
CAT
EG
OR
Y S
CO
RE
S: C
ontin
uity
of C
are,
con
tinue
dAPPENDIX D-3
State of California • August 2010 Page 133
CAT
EG
OR
Y Q
UE
STI
ON
S: P
rimar
y C
are
Pro
vide
r Res
pons
ibili
ties
02.0
22R
ecep
tion
cent
er: I
f the
prim
ary
care
pro
vide
r (P
CP
) ind
icat
ed th
e in
mat
e re
quire
d a
spec
ial d
iet,
did
the
PC
P re
fer t
he in
mat
e to
a
regi
ster
ed d
ietic
ian?
02.2
11R
ecep
tion
cent
er h
isto
ry a
nd p
hysi
cal:
Is th
e “H
isto
ry o
f Pre
sent
Illn
ess”
sec
tion
of F
orm
720
6 (H
isto
ry a
nd P
hysi
cal
Exa
min
atio
n) c
ompl
ete
and
appr
opria
te to
the
chie
f com
plai
nt(s
), if
any?
02.2
12R
ecep
tion
cent
er h
isto
ry a
nd p
hysi
cal:
Are
the
“Pas
t His
tory
” and
“Pas
t Med
ical
His
tory
” sec
tions
of F
orm
720
6 (H
isto
ry a
nd
Phy
sica
l Exa
min
atio
n) c
ompl
ete?
02.2
13R
ecep
tion
cent
er h
isto
ry a
nd p
hysi
cal:
Is th
e “F
amily
and
Soc
ial H
isto
ry” s
ectio
n of
For
m 7
206
(His
tory
and
Phy
sica
l E
xam
inat
ion)
com
plet
e?
02.2
15R
ecep
tion
cent
er h
isto
ry a
nd p
hysi
cal:
Is th
e “R
evie
w S
yste
ms”
sec
tion
of F
orm
720
6 (H
isto
ry a
nd P
hysi
cal E
xam
inat
ion)
co
mpl
ete?
02.2
16R
ecep
tion
cent
er h
isto
ry a
nd p
hysi
cal:
Is th
e “P
hysi
cal E
xam
inat
ion”
sec
tion
of F
orm
720
6 (H
isto
ry a
nd P
hysi
cal E
xam
inat
ion)
co
mpl
ete
and
appr
opria
te to
the
hist
ory
and
revi
ew o
f sys
tem
s?
02.2
17R
ecep
tion
cent
er h
isto
ry a
nd p
hysi
cal:
Is th
e “D
iagn
osis
/Impr
essi
on” s
ectio
n of
For
m 7
206
(His
tory
and
Phy
sica
l Exa
min
atio
n)
appr
opria
te to
the
hist
ory
and
phys
ical
exa
min
atio
n?
02.2
18R
ecep
tion
cent
er h
isto
ry a
nd p
hysi
cal:
Is th
e “P
lan
of A
ctio
n” s
ectio
n of
For
m 7
206
(His
tory
and
Phy
sica
l Exa
min
atio
n)
appr
opria
te to
the
“Dia
gnos
is/Im
pres
sion
” sec
tion
of th
e fo
rm?
02.2
19R
ecep
tion
cent
er h
isto
ry a
nd p
hysi
cal:
Has
requ
ired
inta
ke te
stin
g be
en o
rder
ed?
03.0
77W
ere
key
elem
ents
on
Form
s 74
19 (C
hron
ic C
are
Follo
w-U
p Vi
sit)
and
7392
(Prim
ary
Car
e Fl
ow S
heet
) fille
d ou
t com
plet
ely
for
the
inm
ate’
s tw
o m
ost r
ecen
t vis
its?
03.0
82D
id th
e in
stitu
tion
docu
men
t tha
t it p
rovi
ded
the
inm
ate
with
hea
lth c
are
educ
atio
n?03
.235
Is th
e cl
inic
al h
isto
ry a
dequ
ate?
03.2
36Is
the
focu
sed
clin
ical
exa
min
atio
n ad
equa
te?
03.2
37Is
the
asse
ssm
ent a
dequ
ate?
03.2
38Is
the
plan
ade
quat
e an
d co
nsis
tent
with
the
degr
ee o
f con
trol b
ased
on
the
chro
nic
care
pro
gram
inte
rven
tion
and
follo
w u
p re
quire
men
ts?
03.2
62Is
the
inm
ate’
s P
robl
em L
ist c
ompl
ete
and
filed
acc
urat
ely
in th
e in
mat
e’s
unit
heal
th re
cord
(UH
R)?
04.0
56D
id th
e P
CP
’s p
lan
adeq
uate
ly a
ddre
ss th
e in
itial
ass
essm
ent?
04.1
12W
as th
e P
CP
’s in
itial
eva
luat
ion
adeq
uate
for t
he p
robl
em(s
) req
uirin
g O
HU
pla
cem
ent?
APPENDIX D-4: Category Questions and Scores - Primary Care Provider Responsibilities
cont
inue
d on
pag
e 13
4
Bureau of Audits and Investigations, Office of the Inspector General Page 134
APPENDIX D-4C
ATE
GO
RY
QU
ES
TIO
NS
: Prim
ary
Car
e P
rovi
der R
espo
nsib
ilitie
s, c
ontin
ued
04.2
08W
as th
e le
vel o
f car
e av
aila
ble
in th
e O
HU
app
ropr
iate
to th
e pa
tient
’s c
linic
al p
rese
ntat
ion?
04.2
30W
as th
e P
CP
’s in
itial
ass
essm
ent (
or d
iagn
oses
) app
ropr
iate
for t
he fi
ndin
gs in
the
initi
al e
valu
atio
n?
06.1
91A
ll di
agno
stic
ser
vice
s: D
id th
e P
CP
docu
men
t the
clin
ical
ly s
igni
fican
t dia
gnos
tic te
st re
sults
on
Form
723
0 (In
terd
isci
plin
ary
Pro
gres
s N
otes
)?06
.263
All
diag
nost
ic s
ervi
ces:
Did
the
PC
P ad
equa
tely
man
age
clin
ical
ly s
igni
fican
t tes
t res
ults
?09
.069
Did
med
ical
sta
ff pr
ompt
ly o
rder
ext
ra d
aily
nut
ritio
nal s
uppl
emen
ts a
nd fo
od fo
r the
inm
ate?
09.0
72D
id th
e “P
robl
ems/
Ris
ks Id
entifi
ed” s
ectio
n of
the
Brig
gs F
orm
570
3N (P
rena
tal F
low
Rec
ord)
cor
robo
rate
the
“Pre
nata
l S
cree
ns” a
nd th
e “M
ater
nal P
hysi
cal”
exam
inat
ion
sect
ions
?09
.223
Wer
e th
e re
sults
of t
he in
mat
e’s
spec
ified
pre
nata
l scr
eeni
ng te
sts
docu
men
ted
on F
orm
570
3N?
11.1
00A
fter t
he fi
rst 7
2 ho
urs,
did
a p
hysi
cian
per
form
a p
hysi
cal e
xam
inat
ion
and
orde
r a m
etab
olic
pan
el a
nd a
urin
alys
is o
f the
in
mat
e?
21.2
50U
pon
the
inm
ate’
s di
scha
rge
from
the
com
mun
ity h
ospi
tal,
did
the
inm
ate’
s P
rimar
y C
are
Pro
vide
r (P
CP
) pro
vide
ord
ers
for
appr
opria
te h
ousi
ng fo
r the
inm
ate?
21.2
76W
hile
the
patie
nt w
as in
the
TTA
, was
the
clin
ical
car
e re
nder
ed b
y th
e at
tend
ing
prov
ider
ade
quat
e an
d tim
ely?
21.2
79Fo
r pat
ient
s m
anag
ed b
y te
leph
one
cons
ulta
tion
alon
e, w
as th
e pr
ovid
er’s
dec
isio
n no
t to
com
e to
the
TTA
appr
opria
te?
CAT
EG
OR
Y S
CO
RE
S: P
rimar
y C
are
Pro
vide
r Res
pons
ibili
ties
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
02.02
2Po
ssibl
e Poin
ts4
4Re
ceive
d Poin
ts0
0Sc
ore
0%0%
02.21
1Po
ssibl
e Poin
ts2
22
22
22
14Re
ceive
d Poin
ts1.5
1.82
0.81.8
1.61.2
10.7
Scor
e75
%92
%10
0%40
%89
%82
%60
%76
%02
.212
Poss
ible P
oints
22
22
22
214
Rece
ived P
oints
1.81.2
21.7
21.8
1.812
.3Sc
ore
88%
60%
100%
85%
100%
90%
90%
88%
State of California • August 2010 Page 135
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
02.21
3Po
ssibl
e Poin
ts2
22
22
22
14Re
ceive
d Poin
ts2
22
1.52
1.51.6
12.6
Scor
e10
0%10
0%10
0%75
%10
0%75
%80
%90
%02
.215
Poss
ible P
oints
22
22
22
12Re
ceive
d Poin
ts0
21.4
1.60.4
05.4
Scor
e0%
100%
70%
80%
20%
0%45
%02
.216
Poss
ible P
oints
22
22
22
214
Rece
ived P
oints
1.51.9
22
21.7
1.212
.3Sc
ore
75%
95%
100%
100%
100%
85%
60%
88%
02.21
7Po
ssibl
e Poin
ts2
22
22
22
14Re
ceive
d Poin
ts1.8
1.91.8
22
1.81.1
12.4
Scor
e88
%95
%90
%10
0%10
0%89
%56
%89
%02
.218
Poss
ible P
oints
22
22
22
214
Rece
ived P
oints
21.7
22
22
1.313
Scor
e10
0%85
%10
0%10
0%10
0%10
0%67
%93
%02
.219
Poss
ible P
oints
44
44
44
44
32Re
ceive
d Poin
ts2.8
24
3.83.6
40.8
3.424
.4Sc
ore
70%
50%
100%
95%
90%
100%
20%
85%
76%
03.07
7Po
ssibl
e Poin
ts10
1010
1010
1010
1010
1010
1010
1010
1010
170
Rece
ived P
oints
0.49.1
4.67.4
7.88.5
5.28.5
7.62.4
5.26
7.26
2.87.2
2.898
.7Sc
ore
4%91
%46
%74
%78
%85
%52
%85
%76
%24
%52
%60
%72
%60
%28
%72
%28
%58
%03
.082
Poss
ible P
oints
1212
1212
1212
1212
1212
1212
1212
1212
1220
4Re
ceive
d Poin
ts7.7
8.96.2
96
125.8
10.8
11.5
7.29.6
11.5
10.6
5.39.1
1.46.2
138.8
Scor
e64
%74
%52
%75
%50
%10
0%48
%90
%96
%60
%80
%96
%88
%44
%76
%12
%52
%68
%03
.235
Poss
ible P
oints
1818
1818
1818
1818
1818
1818
1818
1818
1830
6Re
ceive
d Poin
ts10
.813
.36.5
12.6
1212
.68.6
11.7
11.5
7.910
.85.8
12.2
8.65.8
12.2
7.917
0.8Sc
ore
60%
74%
36%
70%
67%
70%
48%
65%
64%
44%
60%
32%
68%
48%
32%
68%
44%
56%
03.23
6Po
ssibl
e Poin
ts19
1919
1919
1919
1919
1919
1919
1919
1919
323
Rece
ived P
oints
16.2
18.2
14.4
15.2
13.7
13.3
12.2
17.1
15.8
13.7
14.4
13.7
15.2
12.9
9.114
.411
.424
0.9Sc
ore
85%
96%
76%
80%
72%
70%
64%
90%
83%
72%
76%
72%
80%
68%
48%
76%
60%
75%
APPENDIX D-4C
ATE
GO
RY
SC
OR
ES
: Prim
ary
Car
e P
rovi
der R
espo
nsib
ilitie
s, c
ontin
ued
cont
inue
d on
pag
e 13
6
Bureau of Audits and Investigations, Office of the Inspector General Page 136
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
03.23
7Po
ssibl
e Poin
ts19
1919
1919
1919
1919
1919
1919
1919
1919
323
Rece
ived P
oints
13.9
17.2
7.619
16.6
1613
.716
14.3
128.4
16.4
16.4
13.5
11.2
17.4
923
8.6Sc
ore
73%
91%
40%
100%
88%
84%
72%
84%
75%
63%
44%
86%
86%
71%
59%
92%
47%
74%
03.23
8Po
ssibl
e Poin
ts19
1919
1919
1919
1919
1919
1919
1919
1919
323
Rece
ived P
oints
1118
.19.5
1717
.717
.915
.616
.918
.216
.813
.616
.216
.314
10.9
17.4
1025
7.1Sc
ore
58%
95%
50%
90%
93%
94%
82%
89%
96%
88%
71%
85%
86%
74%
57%
92%
53%
80%
03.26
2Po
ssibl
e Poin
ts8
88
88
88
88
88
88
88
88
136
Rece
ived P
oints
6.43.8
2.28
6.70.8
6.77.2
2.67.7
4.86.4
6.48
5.16.1
4.893
.7Sc
ore
80%
48%
28%
100%
83%
10%
84%
90%
32%
96%
60%
80%
80%
100%
64%
76%
60%
69%
04.05
6Po
ssibl
e Poin
ts5
55
55
55
55
550
Rece
ived P
oints
54.5
3.83.8
4.44.4
1.93.1
55
40.9
Scor
e10
0%90
%75
%75
%88
%89
%38
%63
%10
0%10
0%82
%04
.112
Poss
ible P
oints
55
55
55
55
55
50Re
ceive
d Poin
ts4.1
4.54
3.93.5
3.51.5
25
436
Scor
e82
%90
%80
%78
%70
%70
%30
%40
%10
0%80
%72
%04
.208
Poss
ible P
oints
99
99
99
99
99
90Re
ceive
d Poin
ts9
99
99
97
99
988
Scor
e10
0%10
0%10
0%10
0%10
0%10
0%78
%10
0%10
0%10
0%98
%04
.230
Poss
ible P
oints
55
55
55
55
55
50Re
ceive
d Poin
ts5
4.55
4.45
55
3.15
547
Scor
e10
0%90
%10
0%89
%10
0%10
0%10
0%63
%10
0%10
0%94
%06
.191
Poss
ible P
oints
77
77
77
77
77
77
77
77
711
9Re
ceive
d Poin
ts5.4
6.14.1
6.15.3
5.64.9
3.91
5.14.7
4.54.8
6.14.3
6.25.1
83.2
Scor
e78
%87
%58
%88
%75
%80
%70
%56
%14
%73
%67
%64
%69
%87
%62
%89
%73
%70
%06
.263
Poss
ible P
oints
1010
1010
1010
1010
1010
1010
1010
1010
1017
0Re
ceive
d Poin
ts9.1
9.27
6.77.7
98.2
7.86.7
1010
8.38.3
105.8
8.99
141.7
Scor
e91
%92
%70
%67
%77
%90
%82
%78
%67
%10
0%10
0%83
%83
%10
0%58
%89
%90
%83
%09
.069
Poss
ible P
oints
55
Rece
ived P
oints
4.34.3
Scor
e86
%86
%
CAT
EG
OR
Y S
CO
RE
S: P
rimar
y C
are
Pro
vide
r Res
pons
ibili
ties,
con
tinue
dAPPENDIX D-4
State of California • August 2010 Page 137
CAT
EG
OR
Y S
CO
RE
S: P
rimar
y C
are
Pro
vide
r Res
pons
ibili
ties,
con
tinue
dRe
f Nu
mber
SAC
CMF
RJD
CEN
DVI
CCW
FCM
CSC
CLA
CPV
SPCC
ICR
CCI
WAS
PHD
SPSQ
CCC
Aver
age
Scor
e09
.072
Poss
ible P
oints
77
Rece
ived P
oints
00
Scor
e0%
0%09
.223
Poss
ible P
oints
55
Rece
ived P
oints
4.34.3
Scor
e86
%86
%11
.100
Poss
ible P
oints
77
77
77
77
77
77
84Re
ceive
d Poin
ts0
00
07
3.53.5
74.7
04.2
736
.9Sc
ore
0%0%
0%0%
100%
50%
50%
100%
67%
0%60
%10
0%44
%21
.250
Poss
ible P
oints
77
77
77
77
77
77
77
77
711
9Re
ceive
d Poin
ts5.1
5.63.5
76.7
77
77
6.77
6.76.7
77
57
109
Scor
e73
%80
%50
%10
0%96
%10
0%10
0%10
0%10
0%96
%10
0%96
%96
%10
0%10
0%72
%10
0%92
%21
.276
Poss
ible P
oints
77
77
77
77
77
77
77
77
711
9Re
ceive
d Poin
ts6.4
76.7
6.36.4
76.4
76.1
6.76.7
5.85.7
4.54.4
5.54.7
103.3
Scor
e91
%10
0%95
%91
%92
%10
0%91
%10
0%87
%96
%95
%83
%81
%64
%63
%79
%67
%87
%21
.279
Poss
ible P
oints
88
88
88
88
88
88
88
812
0Re
ceive
d Poin
ts8
86.7
88
88
88
88
88
88
118.7
Scor
e10
0%10
0%83
%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%99
%To
tal P
ossib
le Po
ints
175
167
173
151
186
167
143
168
169
151
193
168
203
168
169
179
175
2905
Total
Rec
eived
Poin
ts12
3.513
993
.712
115
0.914
0.597
.814
312
911
1.214
6.813
1.215
6.612
1.192
.514
1.311
5.921
55To
tal S
core
71%
83%
54%
80%
81%
84%
68%
85%
76%
74%
76%
78%
77%
72%
55%
79%
66%
74%
APPENDIX D-4
Bureau of Audits and Investigations, Office of the Inspector General Page 138
CAT
EG
OR
Y Q
UE
STI
ON
S: N
urse
Res
pons
ibili
ties
01.0
24R
N F
TF D
ocum
enta
tion:
Did
the
inm
ate’
s re
ques
t for
hea
lth c
are
get r
evie
wed
the
sam
e da
y it
was
rece
ived
?01
.157
RN
FTF
Doc
umen
tatio
n: D
id th
e R
N’s
sub
ject
ive
note
add
ress
the
natu
re a
nd h
isto
ry o
f the
inm
ate’
s pr
imar
y co
mpl
aint
?
01.1
58R
N F
TF D
ocum
enta
tion:
Did
the
RN
’s a
sses
smen
t pro
vide
con
clus
ions
bas
ed o
n su
bjec
tive
and
obje
ctiv
e da
ta, w
ere
the
conc
lusi
ons
form
ulat
ed a
s pa
tient
pro
blem
s, a
nd d
id it
con
tain
app
licab
le n
ursi
ng d
iagn
oses
?
01.1
59R
N F
TF D
ocum
enta
tion:
Did
the
RN
’s o
bjec
tive
note
incl
ude
vita
l sig
ns a
nd a
focu
sed
phys
ical
exa
min
atio
n, a
nd d
id it
ad
equa
tely
add
ress
the
prob
lem
s no
ted
in th
e su
bjec
tive
note
?
01.1
62R
N F
TF D
ocum
enta
tion:
Did
the
RN
’s p
lan
incl
ude
an a
dequ
ate
stra
tegy
to a
ddre
ss th
e pr
oble
ms
iden
tified
dur
ing
the
FTF
triag
e?01
.163
RN
FTF
Doc
umen
tatio
n: D
id th
e R
N’s
edu
catio
n/in
stru
ctio
n ad
equa
tely
add
ress
the
prob
lem
s id
entifi
ed d
urin
g th
e FT
F tri
age?
01.2
44R
N F
TF D
ocum
enta
tion:
Did
the
RN
’s o
bjec
tive
note
incl
ude
alle
rgie
s, w
eigh
t, cu
rren
t med
icat
ion,
and
whe
re a
ppro
pria
te,
med
icat
ion
com
plia
nce?
01.2
46D
id d
ocum
enta
tion
indi
cate
that
the
RN
revi
ewed
all
of th
e in
mat
e’s
com
plai
nts
liste
d on
For
m 7
362
(Hea
lth C
are
Ser
vice
s R
eque
st F
orm
)?
02.0
15W
as a
revi
ew o
f sym
ptom
s co
mpl
eted
if th
e in
mat
e’s
tube
rcul
in te
st w
as p
ositi
ve, a
nd w
ere
the
resu
lts re
view
ed b
y th
e in
fect
ion
cont
rol n
urse
?
02.0
17If
yes
was
ans
wer
ed to
any
of t
he q
uest
ions
on
the
initi
al h
ealth
scr
eeni
ng fo
rm(s
), di
d th
e R
N p
rovi
de a
n as
sess
men
t and
di
spos
ition
on
the
date
of a
rriv
al?
02.0
20D
id th
e LV
N/R
N a
dequ
atel
y do
cum
ent t
he tu
berc
ulin
test
or a
revi
ew o
f sig
ns a
nd s
ympt
oms
if th
e in
mat
e ha
d a
prev
ious
po
sitiv
e tu
berc
ulin
test
?
05.1
09If
the
inm
ate
was
sch
edul
ed fo
r any
upc
omin
g sp
ecia
lty s
ervi
ces,
wer
e th
e se
rvic
es n
oted
on
Form
737
1 (H
ealth
Car
e Tr
ansf
er
Info
rmat
ion)
?
05.1
10D
o al
l app
ropr
iate
form
s in
the
trans
fer e
nvel
ope
iden
tify
all m
edic
atio
ns o
rder
ed b
y th
e ph
ysic
ian,
and
are
the
med
icat
ions
in
the
trans
fer e
nvel
ope?
05.1
71D
id a
n R
N a
ccur
atel
y co
mpl
ete
all a
pplic
able
sec
tions
of F
orm
737
1 (H
ealth
Car
e Tr
ansf
er In
form
atio
n) b
ased
on
the
inm
ate’
s U
HR
?
08.1
85D
id th
e m
edic
al e
mer
genc
y re
spon
der u
se p
rope
r equ
ipm
ent t
o ad
dres
s th
e em
erge
ncy
and
was
ade
quat
e m
edic
al c
are
prov
ided
with
in th
e sc
ope
of h
is o
r her
lice
nse?
09.2
24W
as th
e in
mat
e’s
wei
ght a
nd b
lood
pre
ssur
e do
cum
ente
d at
eac
h cl
inic
vis
it?
APPENDIX D-5: Category Questions and Scores - Nurse Responsibilities
State of California • August 2010 Page 139
11.0
97D
id th
e R
N c
ondu
ct a
face
-to-fa
ce tr
iage
of t
he in
mat
e w
ithin
two
(2) b
usin
ess
days
of r
ecei
pt o
f the
For
m 1
28-B
and
doc
umen
t th
e in
mat
e’s
reas
ons
for t
he h
unge
r stri
ke, m
ost r
ecen
t rec
orde
d w
eigh
t, cu
rren
t wei
ght,
vita
l sig
ns, a
nd p
hysi
cal c
ondi
tion?
14.1
31D
o m
edic
atio
n nu
rses
und
erst
and
that
med
icat
ion
is to
be
adm
inis
tere
d by
the
sam
e lic
ense
d st
aff m
embe
r who
pre
pare
s it
and
on th
e sa
me
day?
15.2
82E
mer
genc
y M
edic
al R
espo
nse
Dril
l: D
id m
edic
al s
taff
arriv
e on
sce
ne in
five
min
utes
or l
ess?
15.2
83E
mer
genc
y M
edic
al R
espo
nse
Dril
l: D
id th
e em
erge
ncy
med
ical
resp
onde
rs a
rriv
e w
ith p
rope
r equ
ipm
ent (
ER
bag
, bag
-val
ve-
mas
k, A
ED
)?15
.285
Em
erge
ncy
Med
ical
Res
pons
e D
rill:
Did
em
erge
ncy
med
ical
resp
onde
rs c
ontin
ue b
asic
life
sup
port?
21.2
48U
pon
the
inm
ate’
s di
scha
rge
from
the
com
mun
ity h
ospi
tal,
did
the
triag
e an
d tre
atm
ent a
rea
(TTA
) reg
iste
red
nurs
e do
cum
ent
that
he
or s
he re
view
ed th
e in
mat
e’s
disc
harg
e pl
an a
nd c
ompl
eted
a fa
ce-to
-face
ass
essm
ent o
f the
inm
ate?
21.2
51U
pon
the
inm
ate’
s di
scha
rge
from
the
com
mun
ity h
ospi
tal,
did
the
regi
ster
ed n
urse
inte
rven
e if
the
inm
ate
was
hou
sed
in a
n ar
ea th
at w
as in
appr
opria
te fo
r nur
sing
car
e ba
sed
on th
e pr
imar
y ca
re p
rovi
der’s
(PC
P) h
ousi
ng o
rder
s?
CAT
EG
OR
Y S
CO
RE
S: N
urse
Res
pons
ibili
ties
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
01.02
4Po
ssibl
e Poin
ts4
44
44
44
44
44
44
44
44
68Re
ceive
d Poin
ts3.8
3.83.7
3.53
2.13.6
1.23.1
3.53.7
1.83.2
3.51.6
0.53.2
48.8
Scor
e96
%96
%93
%87
%76
%52
%90
%30
%77
%87
%92
%45
%80
%89
%40
%11
%80
%72
%01
.157
Poss
ible P
oints
77
77
77
77
77
77
77
77
711
9Re
ceive
d Poin
ts6.4
6.75.8
75.8
6.46.5
5.64.1
3.54.5
3.23.8
4.54
2.25.5
85.5
Scor
e92
%96
%83
%10
0%83
%92
%93
%80
%59
%50
%64
%45
%54
%65
%57
%32
%79
%72
%01
.158
Poss
ible P
oints
66
66
66
66
66
66
66
66
610
2Re
ceive
d Poin
ts5.7
5.34.8
5.45.5
5.85
5.75.4
24.1
5.44.8
4.43.6
1.63.5
78Sc
ore
96%
88%
79%
89%
91%
96%
83%
95%
90%
33%
68%
90%
79%
74%
61%
27%
58%
76%
01.15
9Po
ssibl
e Poin
ts6
66
66
66
66
66
66
66
66
102
Rece
ived P
oints
5.54.6
4.85.4
45.3
4.44.8
3.33.2
4.15.4
4.63.5
33
4.773
.6Sc
ore
91%
77%
80%
90%
67%
88%
73%
80%
55%
53%
68%
90%
76%
59%
50%
50%
79%
72%
APPENDIX D-5C
ATE
GO
RY
QU
ES
TIO
NS
: Nur
se R
espo
nsib
ilitie
s, c
ontin
ued
cont
inue
d on
pag
e 14
0
Bureau of Audits and Investigations, Office of the Inspector General Page 140
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
01.16
2Po
ssibl
e Poin
ts7
77
77
77
77
77
77
77
77
119
Rece
ived P
oints
6.46.6
76.8
6.76.7
6.86.6
74.4
6.47
6.76.6
77
6.311
2Sc
ore
92%
94%
100%
97%
96%
96%
98%
95%
100%
63%
92%
100%
96%
94%
100%
100%
90%
94%
01.16
3Po
ssibl
e Poin
ts5
55
55
55
55
55
55
55
55
85Re
ceive
d Poin
ts3.9
4.74.5
4.73.5
4.84.3
4.54.3
2.84
4.83.5
4.13.2
3.23.2
68Sc
ore
77%
94%
90%
93%
70%
96%
85%
90%
86%
57%
80%
95%
71%
82%
64%
64%
63%
80%
01.24
4Po
ssibl
e Poin
ts3
33
33
33
33
33
33
33
33
51Re
ceive
d Poin
ts2.8
2.82.4
2.82.4
2.42.4
1.51
10.8
0.20.4
1.90.2
0.51.4
26.9
Scor
e92
%94
%80
%93
%79
%80
%80
%50
%35
%33
%28
%5%
12%
65%
7%18
%47
%53
%01
.246
Poss
ible P
oints
55
55
55
55
55
55
55
55
585
Rece
ived P
oints
4.64.6
4.34.5
4.84.8
4.45
4.33.3
3.24.8
43.8
4.34.5
4.573
.7Sc
ore
92%
92%
87%
90%
96%
96%
88%
100%
86%
67%
64%
95%
80%
77%
87%
91%
90%
87%
02.01
5Po
ssibl
e Poin
ts7
77
77
77
77
77
77Re
ceive
d Poin
ts7
77
4.75.3
5.87
2.37
77
67.1
Scor
e10
0%10
0%10
0%67
%75
%83
%10
0%33
%10
0%10
0%10
0%87
%02
.017
Poss
ible P
oints
88
88
88
88
88
88
88
88
128
Rece
ived P
oints
84.4
7.67.5
88
82.3
3.75.6
88
6.98
88
110
Scor
e10
0%56
%94
%93
%10
0%10
0%10
0%29
%46
%70
%10
0%10
0%87
%10
0%10
0%10
0%86
%02
.020
Poss
ible P
oints
66
66
66
66
66
66
66
66
610
2Re
ceive
d Poin
ts5.4
4.25.2
5.46
65.1
5.76
5.14.8
65.4
5.15.8
5.86
93Sc
ore
90%
70%
87%
90%
100%
100%
85%
95%
100%
85%
80%
100%
90%
85%
97%
96%
100%
91%
05.10
9Po
ssibl
e Poin
ts8
88
88
88
88
880
Rece
ived P
oints
80
48
08
08
88
52Sc
ore
100%
0%50
%10
0%0%
100%
0%10
0%10
0%10
0%65
%05
.110
Poss
ible P
oints
88
88
88
88
88
88
88
812
0Re
ceive
d Poin
ts8
48
88
88
88
6.48
83.2
88
109.6
Scor
e10
0%50
%10
0%10
0%10
0%10
0%10
0%10
0%10
0%80
%10
0%10
0%40
%10
0%10
0%91
%05
.171
Poss
ible P
oints
77
77
77
77
77
77
77
77
711
9Re
ceive
d Poin
ts5.6
07
77
75.3
5.67
1.41.4
74.2
77
74.2
90.7
Scor
e80
%0%
100%
100%
100%
100%
75%
80%
100%
20%
20%
100%
60%
100%
100%
100%
60%
76%
APPENDIX D-5C
ATE
GO
RY
SC
OR
ES
: Nur
se R
espo
nsib
ilitie
s, c
ontin
ued
State of California • August 2010 Page 141
Ref
Numb
erSA
CCM
FRJ
DCE
NDV
ICC
WF
CMC
SCC
LAC
PVSP
CCI
CRC
CIW
ASP
HDSP
SQCC
CAv
erag
e Sc
ore
08.18
5Po
ssibl
e Poin
ts7
77
77
77
77
77
77
77
711
2Re
ceive
d Poin
ts3.5
77
75.6
75.6
77
77
75.3
5.37
710
2.3Sc
ore
50%
100%
100%
100%
80%
100%
80%
100%
100%
100%
100%
100%
75%
75%
100%
100%
91%
09.22
4Po
ssibl
e Poin
ts6
6Re
ceive
d Poin
ts4.3
4.3Sc
ore
71%
72%
11.09
7Po
ssibl
e Poin
ts6
66
66
66
66
66
672
Rece
ived P
oints
26
26
66
1.50
04.8
4.80
39.1
Scor
e33
%10
0%33
%10
0%10
0%10
0%25
%0%
0%80
%80
%0%
54%
14.13
1Po
ssibl
e Poin
ts4
44
44
44
44
44
44
44
44
68Re
ceive
d Poin
ts4
44
04
44
44
44
44
44
44
64Sc
ore
100%
100%
100%
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%94
%15
.282
Poss
ible P
oints
22
22
22
22
22
22
22
230
Rece
ived P
oints
02
22
22
22
22
22
02
226
Scor
e0%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
0%10
0%10
0%87
%15
.283
Poss
ible P
oints
11
11
11
11
11
11
11
115
Rece
ived P
oints
01
10
11
11
10
11
11
112
Scor
e0%
100%
100%
0%10
0%10
0%10
0%10
0%10
0%0%
100%
100%
100%
100%
100%
80%
15.28
5Po
ssibl
e Poin
ts1
11
11
11
11
11
11
11
15Re
ceive
d Poin
ts1
11
11
11
11
11
11
11
15Sc
ore
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
21.24
8Po
ssibl
e Poin
ts7
77
77
77
77
77
77
77
77
119
Rece
ived P
oints
5.56.3
4.65.3
6.26.4
5.97
6.76.2
6.47
5.96.4
2.23.6
6.297
.8Sc
ore
79%
90%
65%
75%
88%
92%
84%
100%
96%
88%
92%
100%
84%
92%
32%
52%
88%
82%
21.25
1Po
ssibl
e Poin
ts7
77
77
742
Rece
ived P
oints
70
70
77
28Sc
ore
100%
0%10
0%0%
100%
100%
67%
Total
Pos
sible
Point
s12
211
512
210
411
612
210
710
110
310
711
510
910
186
100
9111
518
36To
tal R
eceiv
ed P
oints
104.1
7910
4.794
.390
.511
4.494
.684
.383
.470
.476
.797
.676
.972
.174
65.7
94.7
1477
.4To
tal S
core
85%
69%
86%
91%
78%
94%
88%
83%
81%
66%
67%
90%
76%
84%
74%
72%
82%
80%
APPENDIX D-5C
ATE
GO
RY
SC
OR
ES
: Nur
se R
espo
nsib
ilitie
s, c
ontin
ued
Bureau of Audits and Investigations, Office of the Inspector General Page 142
California Prison Health Care Receivership Corporation’s Response
State of California • August 2010 Page 143
California Prison Health Care Receivership Corporation’s Response (page 1 of 1)
SPECIAL REPORT
I N M A T E C E L L P H O N E U S E E N D A N G E R S P R I S O N
S E C U R I T Y A N D P U B L I C S A F E T Y
OFFICE OF THE
INSPECTOR GENERAL
D A V I D R . S H A W
I N S P E C T O R G E N E R A L
S T A T E O F C A L I F O R N I A
M A Y 2 0 0 9
SPECIAL REPORT
SUMMARY AND ANALYSIS OF THE FIRST 17 MEDICAL INSPECTIONS OF CALIFORNIA PRISONS
OFFICE OF THE INSPECTOR GENERAL
David R. ShawINSPECTOR GENERAL
Jerry TwomeyCHIEF ASSISTANT INSPECTOR GENERAL
Nancy FaszerDEPUTY INSPECTOR GENERAL, IN-CHARGE
STATE OF CALIFORNIAAUGUST 2010
WWW.OIG.CA.GOV