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CA Inspector General Finds 15 of 17 Prisons Demonstrate Low Adherence to Established Medical Policies and Procedures

by Mike Brodheim

In August 2010, California’s Office of the Inspector General (OIG) issued a report summarizing and analyzing the results of medical inspections at 17 of 33 adult prisons operated by the California Department of Corrections and Rehabilitation (CDCR). The inspections, conducted between September 2008 and January 2010, marked the halfway point of the OIG’s first annual cycle of medical inspections of CDCR facilities.

Using teams of physicians, registered nurses, deputy inspectors general and analysts, the OIG devised 166 questions to assess each prison’s compliance with CDCR’s policies and procedures, as well as with community standards, in 20 key components of medical care. Each facility received a score reflecting its percentage compliance with respect to each component. Some components did not apply at all prisons; for example, prenatal, childbirth and post-delivery care applied only at the California Institution for Women, one of the two women’s prisons inspected during this cycle.

The average score for the 17 prisons profiled in the OIG report was 70%, with individual facility scores ranging from 62% to 78%. Only two prisons had scores above 75% – the Sierra Conservation Center and the Central California Women’s Facility. The facility with the lowest score (62%) was High Desert State Prison.

In individual component categories, the lowest average scores were in the areas of preventive services (37%), prisoner hunger strikes (46%) and access to health care information (59%). The highest average level of compliance was in staffing levels and training (94%). The average score for chronic care services, one of the more important aspects of prison medical care, was 64% (High Desert State Prison had the lowest score for chronic care, at 45%).

In preventive services, the lowest-scoring prison was the California Correctional Institution, with only 7% compliance; ten other facilities scored below 40% for that same component. With respect to preventive services, the OIG report noted “alarmingly low scores in tuberculosis treatment.”

The OIG provided a second, alternative, broader perspective on its results. Working with its lead physician, it identified 100 (of the original 166) questions as fitting into five general categories of medical care: medication management, access to providers and services, continuity of care, primary care provider responsibilities, and nurse responsibilities.

The OIG conducted the inspections at the request of the federal court presiding over Plata v. Schwarzenegger, the class-action suit alleging constitutionally inadequate medical care in California’s adult prisons, and on behalf of the Receiver appointed by the court in 2006 to oversee the delivery of that medical care – described then as “broken beyond repair.”

The Receiver developed scoring criteria to measure adherence to medical policies and procedures, with 75 to 85 percent denoting “moderate” adherence, lower scores denoting “low” adherence, and higher scores denoting “high” adherence. In each component area or question where a prison receives a score of 60% or less, the Receiver requires that the facility develop a corrective plan of action, itemizing how it intends to remedy deficiencies in that area.

The 75% cutoff for moderate adherence, as determined by the Receiver, does not establish a constitutional threshold for adequate medical care. To the extent that unconstitutional care is an issue, the threshold must be determined by the court.

PLN readers should note that the OIG’s inspections dealt only with medical care (the subject of the Plata lawsuit) and not with mental health or dental care (the subjects of other pending lawsuits). The issues being litigated in Plata ultimately led to the convening of a federal three-judge panel, which determined that 1) notwithstanding the Receiver’s intervention, the delivery of medical care in California’s prisons continues to violate the Eighth Amendment; and 2) overcrowding is the primary cause of that ongoing violation.

The three-judge panel concluded that it was necessary to order CDCR to reduce its prisoner population, or more specifically to reduce its level of overcrowding, from approximately 200% to 137.5% of design capacity. This would require the release of around 40,000 prisoners. The case is presently pending before the U.S. Supreme Court. [See: PLN, Aug. 2010, p.1].

Based on the OIG’s findings, only two prisons were able to achieve an average overall score above 75%, reflecting “moderate adherence” to CDCR’s medical policies and procedures. The remaining 15 facilities performed at a level characterized by the Receiver as reflecting “low adherence” to those policies and procedures.

On a more encouraging note, the prisons’ average score exceeded the 75% threshold for “moderate adherence” in 11 of the 20 individual component areas, with scores in five of those 11 components reflecting “high adherence.”

With respect to individual questions, the OIG reported that, while the prisons achieved average scores of 86% or higher on 60 of the inspection program’s 166 questions, they scored consistently poorly, averaging 60% or less, on 42 questions. As a specific example, the OIG noted that 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 that question, the OIG noted, was just 29%.

In every category except nurse responsibilities, the prisons’ scores fell below the 75% threshold for “moderate adherence.” While scores for continuity of care and primary care provider responsibilities were only a point below that threshold, the scores for medication management (58%) and access to providers and services (60%) were cause for greater concern.

The OIG noted two significant, recurring problems. First, nearly all of the prisons were ineffective at ensuring that prisoners actually receive their medications. Second, they were generally ineffective at ensuring timely access to providers and services, regardless of whether for routine, urgent or emergency medical care.

The OIG concluded, based on the wide variation in scores, that the Receiver had yet to implement a system that ensures consistent compliance with CDCR policies and procedures throughout the state’s prison system.

Following the release of the 2010 OIG report summarizing the results of medical inspections at the first 17 prisons, the OIG conducted medical inspections at an additional eight CDCR facilities as of March 30, 2011. Those inspections included evaluations of 17 to 19 component areas, involving 125 to 153 questions.

The eight more-recently inspected facilities fared better than the first 17, with an average score of 77.46%. Individual average scores ranged from a low of 74.1% at Salinas Valley State Prison to 81.4% at the California Institute for Men. Only two of the eight prisons inspected since the OIG’s 2010 summary report scored below the 75% threshold for moderate adherence.

Problems were still noted in several areas, though, including low scores in the areas of preventive services (40% at Mule Creek and 42% at Salinas Valley); clinical care (61.1% at Salinas Valley and 67.1% at CSP Sacramento and the California Medical Facility); and chronic care (61.5% at the California Institute for Men and 51.7% at Wasco State Prison).
The OIG plans to conduct medical inspections of the remaining CDCR facilities over the course of the next year. The report is available on PLN’s website.

Sources: Office of the Inspector General, Summary and Analysis of the First 17 Medical Inspections of California Prisons, Aug. 2010; Associated Press;

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