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Achieving a Constitutional Level of Medical Care in CA Prisons CCHCS 2014

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Achieving a Constitutional Level of
Medical Care in California’s Prisons
Twenty-fifth Tri-Annual Report of the Federal Receiver’s
Turnaround Plan of Action
For September 1 – December 31, 2013

February 1, 2014

California Correctional Health Care Receivership

As soon as practicable, provide constitutionally adequate
medical care to patient-inmates of the California
Department of Corrections and Rehabilitation (CDCR)
within a delivery system the State can successfully
manage and sustain.

Reduce avoidable morbidity and mortality and protect
public health by providing patient-inmates timely access
to safe, effective and efficient medical care, and
integrate the delivery of medical care with mental health,
dental and disability programs.

Table of Contents


Executive Summary……………………………………………………………………………………………. 1


The Receiver’s Reporting Requirements………….................................………...........



Status of the Receiver’s Turnaround Plan Initiatives………………………………



Ensure Timely Access to Health Care Services………………………………….. 4

Objective 1.1

Screening and Assessment Processes…………………...……………………. 4

Objective 1.2

Access Staffing and Processes...………………………………………………….


Objective 1.3

Scheduling and Patient-Inmate Tracking System………………...........


Objective 1.4

Standardized Utilization Management System…………………...........



Establish a Prison Medical Program Addressing the Full Continuum
of Health Care Services…………………………………………………………………….


Objective 2.1

Primary Care……………………………………………………………………………….


Objective 2.2

Chronic Care……………………………………………………………………………….


Objective 2.3

Emergency Response………………………………………………………………….


Objective 2.4

Specialty Care and Hospitalization………………………………………………



Recruit, Train and Retain a Professional Quality Medical Care


Objective 3.1

Physicians and Nurses……………….……………………………………………….. 8

Objective 3.2

Clinical Leadership and Management Structure………….………………


Objective 3.3

Professional Training Program…………………………………………………….


Implement Quality Improvement Program………………………………………



Objective 4.1

Clinical Quality Measurement and Evaluation Program...…………...


Objective 4.2

Quality Improvement Programs………………………………………………….


Objective 4.3

Medical Peer Review and Discipline Process……………………………….


Objective 4.4

Medical Oversight Unit………………………………………….......................


Objective 4.5

Health Care Appeals Process………………………………………………………. 22


Objective 4.6


Out-of-State, Community Correctional Facilities and Re-entry


Establish Medical Support / Allied Health Infrastructure………………….


Objective 5.1

Pharmacy……………………………………………………………………………………. 26

Objective 5.2

Health Records………………………………………………………………………….


Objective 5.3

Imaging/Radiology and Laboratory Services…...………………............


Objective 5.4

Clinical Information Systems……………………………………………………….


Objective 5.5




Provide for Necessary Clinical, Administrative and Housing
Facilities………………………………………………………………………………………….. 28



Objective 6.1

Upgrade Administrative and Clinical Facilities…………………………….. 28

Objective 6.2

Expand Administrative, Clinical, and Housing Facilities……………….

Objective 6.3

Finish Construction at San Quentin State Prison…………………………. 32


Additional Successes Achieved by the Receiver……………………..……..……………………


A. Quality Assurance and Patient-Inmate Administrative Appeals


B. Electronic Health Records System


C. Technical Assistance from the Court Experts on Remaining Systemic Issues


Particular Problems Faced by the Receiver, Including Any Specific Obstacles
Presented By Institutions Or Individuals………………………………..…………………………… 36

CCHCS Activities related to the Court’s June 24, 2013, Order Granting
Plaintiff’s Motion for Relief Re: Valley Fever at PVSP and ASP……………………….



Overcrowding Update…………….……………………………………………………………..……… 37


An Accounting of Expenditures for the Reporting Period……………………………………. 39


Other Matters Deemed Appropriate for Judicial Review..……………………...............



Coordination with Other Lawsuits………………………………………………………………….



Master Contract Waiver Reporting………………………………………………………………… 40


Consultant Staff Engaged by the Receiver….………………………………………………….. 40


Overview of Transition Activities…………………………………………….……………………..



Conclusion…………...……………………………………………………………................................. 48


Section 1: Executive Summary
In our first Tri-Annual report for 2014, the accomplishments for the period of September 1
through December 31, 2013 are highlighted (because of their importance, we have included in
this report certain developments that have occurred in January 2014). Progress continues
toward fully implementing the Vision and Mission outlined in the Receiver’s Turnaround Plan of
Action (RTPA), although the activation of the California Health Care Facility (CHCF) in Stockton
has been a challenge. Highlights for this reporting period include the following:

The CHCF began accepting patient-inmates in July of 2013. Its activation has presented a
number of problems including, but not limited to, problems with the proper
management of the kitchen, a failure to provide nursing staff with appropriate keys to
cells and other spaces, inadequate staffing of access to care officers, inadequate clinical
staffing, and a variety of failures to provide appropriate accommodations for Armstrong
class members. Perhaps the most persistent, fundamental failure has been the inability
to provide adequate basic medical and personal hygiene supplies to the housing units,
what appears to be a complete breakdown in the supply chain system, and a slow initial
response to that problem. The Receiver and his staff are now working with top CDCR
executives and leadership at CHCF to attempt to remediate the situation. The next triannual report will reveal whether our efforts are successful.


The DeWitt Nelson Correctional Annex (DNCA), which is the second of the two major
projects planned for the purpose of adding new medical and mental health beds to the
CDCR system, is nearing completion with a planned date for receiving patient-inmates in
early April 2014. Whether DNCA will be able to open as planned depends largely upon
whether infrastructural systems at CHCF, including the supply chain, can be fixed in time
(since CHCF provides supplies and other infrastructural support to DNCA).


Regarding the Health Care Facility Improvement Program (HCFIP), which includes
upgrades to add/renovate exam rooms and related health care space, as well as
improvements to medication distribution at existing prisons, 22 projects have now
received project approval from the Public Works Board (PWB) and interim funding from
the Pooled Money Investment Board (PMIB). Remaining projects are proceeding on a
sequential submittal schedule to PWB and PMIB. The PWB approved preliminary plans
for statewide medication distribution projects in November 2013, which is a one-month
delay from the previous report. The PWB approved preliminary plans in December 2013
for five projects: California Medical Facility (CMF), California State Prison, Solano (SOL),
California Institution for Men (CIM), California State Prison, Sacramento (SAC), and Mule
Creek State Prison (MCSP). There are now 16 projects in the preliminary planning phase
and six projects, including statewide medication projects, in the working drawings
phase. Construction is expected to begin in spring 2014 for the statewide medication
distribution projects and in mid-2014 for the first HCFIP projects, which will be CMF
and SOL.
Page 1 of 46


The Plata Court Experts visited ten institutions during 2013 to evaluate the quality of
medical care. Their reports identified certain systemic failures in the medical delivery
system. After a series of meetings with the Court Experts and representatives from the
Office of the Inspector General (OIG), we have agreed that progress in the case will be
accelerated by having the Court Experts work directly with CCHCS executives in solving
the identified systemic gaps. In addition, we have agreed to have the Court Experts work
with the OIG and CCHCS’s quality improvement team to develop a common set of
metrics and a common evaluation methodology for OIG audits so that the results of
those audits are closely aligned with our internal dashboard measures and with the
methodology employed by the Court Experts in conducting their reviews. The goal of
this effort is to create an OIG audit instrument that ultimately can be used in lieu of the
Court Expert evaluations. The Receiver believes these efforts, which are consistent with
the spirit of the Court’s orders regarding the role of the Court Experts in evaluating
medical care systems, will lead more quickly to the improvements that are necessary to
bring medical care into compliance with constitutional requirements. The Receiver
recommends this approach for the Court’s consideration.


This reporting period concluded Round One of the Health Care Access operational
monitoring audits. Since the October 26, 2012 Delegation of Authority, each institution
has been audited once and approximately half have been audited twice. Of all Round
One audits, ten institutions scored below the delegation benchmark of 85.0 percent.
The overall average score for Round One is 87.6 percent.


As for the Round Two audits, this Tri-annual period brings the total number of audits
conducted to 16 with the remaining 17 audits scheduled to occur between January and
June of 2014. Of the 14 audit reports published, the average Round Two score is 90.1
percent, which represents a modest overall improvement.

Format of the Report
To assist the reader, this Report provides three forms of supporting data:
Metrics: Metrics that measure specific RTPA initiatives are set forth in this report with the
narrative discussion of each Goal and the associated Objectives and Actions that are not
Appendices: In addition to providing metrics, this report also references documents in the
Appendices of this report.
Website References: Whenever possible website references are provided.
Information Technology Project Matrix
A chart has been created to specifically illustrate the major technology projects and the
deployment of those projects. This document is included as Appendix 1.
Page 2 of 46

Section 2: The Receiver’s Reporting Requirements
This is the twenty-fifth report filed by the Receivership, and the nineteenth submitted by
Receiver Clark Kelso.
The Order Appointing Receiver (Appointing Order) filed February 14, 2006 calls for the Receiver
to file status reports with the Plata court concerning the following issues:
1. All tasks and metrics contained in the Plan and subsequent reports, with degree of
completion and date of anticipated completion of each task and metric.
2. Particular problems being faced by the Receiver, including any specific obstacles
presented by institutions or individuals.
3. Particular success achieved by the Receiver.
4. An accounting of expenditures for the reporting period.
5. Other matters deemed appropriate for judicial review.
(Reference pages 2-3 of the Appointing Order at
In support of the coordination efforts by the three federal courts responsible for the major
health care class actions pending against CDCR, the Receiver files the Tri-Annual Report in three
different federal court class action cases: Armstrong, Coleman, and Plata. An overview of the
Receiver’s enhanced reporting responsibilities related to these cases and to other Plata orders
filed after the Appointing Order can be found in the Receiver’s Eleventh Tri-Annual Report on
pages 15 and 16. (
Court coordination activities include: facilities and construction; telemedicine and information
technology; pharmacy; recruitment and hiring; credentialing and privileging; and space

Page 3 of 46

Section 3: Status of the Receiver’s Turnaround Plan Initiatives
Goal 1: Ensure Timely Access to Health Care Services
Objective 1.1. Redesign and Standardize Screening and Assessment Processes at
Reception/Receiving and Release
Action 1.1.1. By January 2009, develop standardized reception screening processes and
begin pilot implementation
This action is completed.
Action 1.1.2. By January 2010, implement new processes at each of the major reception
center prisons
Based on the Plata Court Expert review of the San Quentin State Prison (SQ) reception center
processes in March 2013, a review of optimizing further reception center processes in light of
redistribution of reception center missions is underway.
Action 1.1.3. By January 2010, begin using the new medical classification system at each
reception center prison.
This action is completed.
Action 1.1.4. By January 2011, complete statewide implementation of the medical
classification system throughout CDCR institutions.
This action is completed.
Objective 1.2. Establish Staffing and Processes for Ensuring Health Care Access at Each
Action 1.2.1. By January 2009, the Receiver will have concluded preliminary assessments
of custody operations and their influence on health care access at each of CDCR’s
institutions and will recommend additional staffing, along with recommended changes to
already established custody posts, to ensure all patient-inmates have improved access to
health care at each institution.
This action is completed.
Action 1.2.2. By July 2011, the Receiver will have fully implemented Health Care Access
Units and developed health care access processes at all CDCR institutions.
This action is completed.
Refer to Appendix 2 for the Executive Summary and Health Care Access Quality Reports for
August 2013 through November 2013.

Page 4 of 46

Objective 1.3. Establish Health Care Scheduling and Patient-Inmate Tracking System
Action 1.3.1. Work with CDCR to accelerate the development of the Strategic Offender
Management System (SOMS) with a scheduling and inmate tracking system as one of its
first deliverables.
This action is substantially complete. The medical, dental, and mental health scheduling
systems have been in production at all of the original 33 institutions since July 2013. Most
aspects of support have been transitioned to IT maintenance and operation.
Progress during this reporting period is as follows:

Medical scheduling system management reports were rolled out to all institutions by
October 2013.


A release of bug fixes and essential change requests to the medical scheduling system
was deployed in early November 2013. There are no other outstanding changes to the
medical scheduling system.


Three releases of change requests to the dental scheduling system and dental reporting
were deployed over the October to December 2013 timeframe. This completes all
outstanding change requests to the dental scheduling system.


The Health Care Scheduling and Tracking System was rolled out to California City (CAC),
in December 2013.

A request has been made to CCHCS IT Governance to close the project at the next governance
meeting in 2014.
Objective 1.4. Establish a Standardized Utilization Management System
Action 1.4.1. By May 2010, open long-term care unit.
This action is completed.
Action 1.4.2. By October 2010, establish a centralized UM System.
This action is completed.

Page 5 of 46

Goal 2: Establish a Prison Medical Program Addressing the Full Continuum of
Health Care Services
Objective 2.1. Redesign and Standardize Access and Medical Processes for Primary Care
Action 2.1.1. By July 2009, complete the redesign of sick call processes, forms, and staffing
This action is ongoing. Progress during this reporting period is as follows:
An interdisciplinary team has reviewed and revised the Primary Care Model. Based on the review,
the team has re-organized the relevant policies and procedures to include:
• Overview of the Health Care Model: Defines and establishes relationship, integration, and
responsibilities for Primary Care, Diagnostic and Therapeutic Services, Urgent Care, Tertiary
Care, Dental Care, and Mental Health Care.
• Primary Care Team: Defines membership in Primary Care Team, responsibilities, continuity
of team, Primary Care Team huddles, care conferences, and primary care panel
• Disease Management (Chronic Care): Defines program for management of enduring
medical conditions, including establishment of clinical guidelines, surveillance and
screening, tracking of conditions, adjustment of therapy, patient-inmate self-management,
tracking of patient-inmate outcomes and populations, continuity of care, and case
• Preventive Primary Care Services: requires established guidelines for preventive services,
infectious disease surveillance, immunizations, screening, patient-inmate education and
support in health maintenance. Includes annual primary care nursing visit focused on
screening and patient-inmate education, as well as season-focused immunization program
for influenza.
• Episodic Primary Care Services: establishes system to respond to symptoms of a new
condition and to exacerbations of pre-existing conditions. Includes method for patientinmates and others to initiate health care visits.
Drafting of the Episodic Primary Care Services module is still in process. The other modules have
been drafted. Once the complete package is drafted it will enter the review and approval process.
The revisions provide for involvement of dental and mental health services in care management
and prepare the Department for transition to the Electronic Health Records System (EHRS).
Action 2.1.2. By July 2010, implement the new system in all institutions.
This action is ongoing. Please see action item 2.1.1.
Objective 2.2. Improve Chronic Care System to Support Proactive, Planned Care
Action 2.2.1. By April 2009, complete a comprehensive, one-year Chronic Care Initiative to
assess and remediate systemic weaknesses in how chronic care is delivered.
This action is completed.
Page 6 of 46

Objective 2.3. Improve Emergency Response to Reduce Avoidable Morbidity and Mortality
Action 2.3.1. Immediately finalize, adopt and communicate an Emergency Medical Response
System policy to all institutions.
This action is completed.
Action 2.3.2. By July 2009, develop and implement certification standards for all clinical staff
and training programs for all clinical and custody staff.
This action is completed.
Action 2.3.3. By January 2009, inventory, assess and standardize equipment to support
emergency medical response.
This action is completed.
Objective 2.4. Improve the Provision of Specialty Care and Hospitalization to Reduce Avoidable
Morbidity and Mortality
Action 2.4.1. By June 2009, establish standard utilization management and care
management processes and policies applicable to referrals to specialty care and hospitals.
This action is completed.
Action 2.4.2. By October 2010, establish on a statewide basis approved contracts with
specialty care providers and hospitals.
This action is completed.
Action 2.4.3. By November 2009, ensure specialty care and hospital providers’ invoices are
processed in a timely manner.
This action is completed.

Page 7 of 46

Goal 3: Recruit, Train and Retain a Professional Quality Medical Care Workforce
Objective 3.1 Recruit Physicians and Nurses to Fill Ninety Percent of Established Positions
For details related to vacancies and retention, refer to the Human Resources Recruitment and
Retention Reports for August 2013 through November 2013. These reports are included as
Appendix 3.
Action 3.1.1. By January 2010, fill ninety percent of nursing positions.
This action is completed.
Action 3.1.2. By January 2010, fill ninety percent of physician positions.
This action is completed.
Objective 3.2 Establish Clinical Leadership and Management Structure
Action 3.2.1. By January 2010, establish and staff new executive leadership positions.
Action 3.2.2. By March 2010, establish and staff regional leadership structure.
These actions are completed.
Objective 3.3. Establish Professional Training Programs for Clinicians
Action 3.3.1. By January 2010, establish statewide organizational orientation for all new
health care hires.
This action is completed.
Action 3.3.2. By January 2009, win accreditation for CDCR as a Continuing Medical
Education provider recognized by the Institute of Medical Quality and the Accreditation
Council for Continuing Medical Education.
The action is completed.

Page 8 of 46

Goal 4: Implement Quality Improvement Programs
Objective 4.1. Establish Clinical Quality Measurement and Evaluation Program
Action 4.1.1. By July 2011, establish sustainable quality measurement, evaluation and
patient safety programs.
This action is ongoing. Progress during this reporting period is as follows:
Patient Safety Program
In May 2012, CCHCS adopted policies and procedures to establish a statewide Patient Safety
Program. Implementation of the new Patient Safety Program requires establishing an
infrastructure statewide, such as a health incident reporting system and oversight committees,
as well as orienting CCHCS staff at all levels of the organization to new concepts and skills. As a
result, CCHCS has adopted a phased approach to program implementation, with updates
provided below.
Annual Patient Safety Plan. Members of the Patient Safety Committee have established a plan
that includes multiple statewide projects intended to advance the new statewide Patient Safety
Program over the next two years. In addition, specific safety strategies and objectives, such as
reducing potentially avoidable hospitalizations, improving laboratory monitoring for patientinmates on psychotropic medications, and addressing polypharmacy risk, have been
incorporated into the CCHCS Performance Improvement Plan for 2013-2015.
Health Care Incident and Medication Error Reporting. During this reporting period, CCHCS staff
continued to report actual and potential adverse events through the Health Care Incident
Reporting System, and a multi-disciplinary group at headquarters met daily to triage the health
incidents, directing institutions to take appropriate follow-up action, as per policy.
A total of 162 incident reports were submitted through the Health Incident Reporting System
during calendar year 2013. Health incident information came from a variety of sources, as
described in Figure 1.
Figure 1. 2013 Health Care Incidents Reported by Source

Reported By Headquarters
Other Referrals

Total Reports= 162


During this reporting period, the Adverse and Sentinel Event Committee (ASEC), which provides
oversight to both the Health Care Incident Reporting System and the statewide root cause
Page 9 of 48

analysis process, began to apply the new taxonomy described in the previous Tri-Annual Report
to ascertain the types of health care incidents submitted, a required first step in the
identification and analysis of trends to understand process problems. Please see Figure 2.
Figure 2. 2013 Health Care Incidents Reported by Event Type


Wrong Medication/Dosing
Missing/Delayed Dose
Patient Self-Harm
Unidentified/Unknown Event
Patient Accident
Medication- Wrong Patient
Other Types of Events
Unusual Occurrence


* Cases may have more than
one Event Type









In addition, the ASEC analyzed and compared data in the health care incidents reports and
monthly medication errors reports to identify potential under-reporting.
The ASEC reports the aforementioned information to the Patient Safety Committee quarterly
and specifies actions taken to address the most prevalent types of health incidents, as well as
improve reporting rates overall.
Root Cause Analysis. The Patient Safety Program Policy and Procedure introduced new
requirements that institutions conduct root cause analyses for a subset of health care incidents
defined as adverse/sentinel events. Root cause analysis is a well-tested approach to effectively
and efficiently identify and fix fundamental system processes. To support institutions in
completing thorough and credible root cause analyses (RCAs) as required by policy, CCHCS
established a standardized RCA procedure and tools, referred to as the RCA Tool Kit; provided
statewide training; and made QM Section staff available to assist institutions with RCA
facilitation upon request. (A recording of the RCA webinar and the RCA Tool Kit is posted for
easy access by all staff on the Patient Safety page on Lifeline, at this link: Patient Safety Page).
By the close of 2013, a total of 14 RCAs had been assigned to institutions or as statewide
aggregate RCAs. Once assigned, institutions have 45 days to complete the RCA process and
submit a report with findings and an improvement plan. The ASEC gives input to the RCA report
and may request clarification or additional work on the analyses. Each RCA report includes
Page 10 of 48

performance metrics to ensure that identified root causes have been effectively addressed by
the proposed improvement activities and the risk of the adverse event recurring is significantly
reduced. After report approval, the institution submits performance measure data to the ASEC,
which monitors progress for four months. If the ASEC deems that sufficient progress has been
made, the RCA is closed. Six of the fourteen analyses in 2013 have been completed and closed.
During this reporting period, the ASEC assigned the first aggregate RCA to address the process
for credentialing licensed independent practitioners of various disciplines, particularly contract
providers. The ASEC assigns aggregate RCAs when the committee receives multiple health care
incidents and adverse events from different institutions linked to the same health care process,
circumstances which suggest a systemic failure, rather than an isolated problem at an individual
For an aggregate RCA, the RCA Team involves representatives from several institutions and
multiple disciplines, including participants from the headquarters program with statewide
oversight responsibilities. Fact-finding is conducted at both the institution and headquarters
level, and the entire team convenes for the brainstorming session used to identify contributing
factors and root causes. In lieu of the action plan submitted for an RCA assigned to an individual
institution, the aggregate RCA team offers a series of recommendations to improve the
statewide process under consideration and performance metrics to assess progress. ASEC
members review the recommendations and work with statewide executives to implement
suggested improvements as appropriate, as well as monitor the effectiveness of interventions.
The report for the aggregate RCA on credentialing was submitted for ASEC review in December
2013, and is pending presentation at the Patient Safety Committee. A second aggregate RCA
was assigned during this reporting period to examine the health care transfer process, including
coordination of care as a patient-inmate moves from one institution to another and transition
of care for clinically high-risk patient-inmates upon parole. Much of the required activity for
that RCA has been completed by the RCA Team. The final report is pending, and will be shared
with appropriate standing and ad hoc workgroups involved with various aspects of care
coordination and care management.
Patient Safety Survey. A key element in increasing health incident reporting, effectively
conducting root cause analyses, acting upon the RCA results – and other important,
foundational aspects of the Patient Safety Program – is to establish a culture of safety and
improvement at institutions statewide. To that end, CCHCS prepared for the implementation of
a statewide Patient Safety Culture Survey that will both educate health care staff about
workplace factors that impact patient-inmate safety and identify strengths and weaknesses in
our current organizational culture, statewide and at individual institutions.
In 2013, the Patient Safety Committee selected a culture survey from the federal Agency for
Healthcare Research and Quality used by health care organizations nationwide. CCHCS made
minor adaptations for application in our organization after testing the survey tool at California
Men’s Colony (CMC), where the leadership team is a strong champion of patient-inmate safety.
Page 11 of 48

The Patient Safety Committee will administer the survey statewide over a three-week period
from mid-February through early March 2014. During this reporting period, Health Care Chief
Executive Officers (CEOs) were briefed on the upcoming survey at a statewide Health Care CEO
conference and during a weekly statewide leadership conference call, culminating in formal
notification via statewide memorandum on January 13, 2014 (please see Appendix 4).
This first survey will offer baseline information about the state of CCHCS’s organizational
culture. The Patient Safety Committee intends to repeat the survey every 12 to 18 months to
assess changes over time.
Sharing Best Practices – Patient Safety Stories. During this reporting period, the Patient Safety
Committee released the first in a series of periodic Patient Safety Stories, in an effort to identify
and disseminate best practices in particularly problematic patient-inmate safety areas.
Each Patient Safety Story is divided into three parts:
o Part 1: Description of an actual patient-inmate’s experience in the prison health care
system, highlighting some of the process pitfalls that can place patient-inmates at risk.
o Part 2: Aggregate data that helps readers understand how the patient-inmate safety issue
impacts institutions and patient-inmates statewide. A broader health care industry
perspective may also be provided.
o Part 3: Practical ways that health care staff can improve performance in the targeted area.
Whenever possible, best practices from CDCR institutions are profiled in this section, with
links to any available resources or tools.
During this reporting period, the Patient Safety Committee distributed a Patient Safety Story
about anticoagulation care, a major patient-inmate safety issue statewide and nationally.
(Anticoagulation is one of the topics covered by the Joint Commission in its 2014 National
Patient Safety Goals for ambulatory care.) The full Patient Safety Story is attached as
Appendix 5.
Headquarters Patient Safety Committee and Adverse/Sentinel Event Committee. Since its
inaugural meeting in August 2012, the Patient Safety Committee has convened
18 times; the Adverse/Sentinel Event Committee met 37 times (some of these meetings were
joint with the Patient Safety Committee). With many of the foundational elements of the
Patient Safety Program now in place, these committees have settled fully into the role
described for them in policy, shifting away from a primary focus on development and approval
of tools and training programs to activities such as implementation of statewide patient-inmate
safety initiatives.
Statewide Patient Safety Initiative – Patient-Inmates at Risk for Coccidioidomycosis (cocci).
In July 2013, CCHCS modified the Medical Classification System (MCS) Policy and Procedures1 to
preclude patient-inmates with certain risk factors, such as history of lymphoma, from

IMSP&P, Volume 4, Chapter 29 and 29.

Page 12 of 48

placement at prisons where cocci is most prevalent – referred to as Cocci Areas 1 and 2.
Patient-inmates who are already housed at a prison in Cocci Area 2 (Avenal State Prison (ASP)
and Pleasant Valley State Prison (PVSP)) may complete a waiver to stay at their current
institution if they meet specific criteria. This program change was prompted in part by a June
2013 federal court order, which mandated removal of certain patient-inmates from the cocci
hyperendemic area within 90 days or by September 21, 2013.
To support appropriate placement of patient-inmates with cocci risk factors, CCHCS released a
Cocci Risk Registry, which allows custody and health care staff to run customized reports
identifying patient-inmates who must transfer out of Cocci Areas 1 and 2, as well as patientinmates who are appropriate to backfill soon-to-be-vacant cells. Please see release
memorandum in Appendix 6 for a detailed description of the Cocci Risk Registry.
In August 2013, CCHCS established a process for reconciling each patient-inmate’s 128C3 with
the Master Patient Registry, providing a mechanism for back-and-forth communication
between institution and headquarters staff about patient-inmate risk factors and ensuring
more accurate risk designations. By comparing clinical documentation against registry data,
health care staff may learn of very recent changes in health status, such as new diagnoses that
impact risk level and placement decisions. Please see the comprehensive description of the
Patient Risk Reconciliation Process presented in Appendix 7.
To support ongoing efforts to appropriately place patient-inmates with cocci risk factors, CCHCS
began reporting weekly on the status of patient-inmates eligible for movement out of the
hyperendemic area during this reporting period. The weekly report provides both aggregate
data (e.g., the number of patient-inmates at a particular institution overdue for transfer) and
patient-inmate-level data (the names and housing information of the specific patient-inmates
who have been identified as overdue for transfer). This level of data assists health care and
custody staff in determining where to focus their energy relative to movement of cocci patientinmates. Please see Figure 3 and 4.

Page 13 of 48

Figure 3. Aggregate Data from Weekly Report: Transfer Status of Cocci Restricted Patient-inmates

Figure 4. Patient-Inmate-Level Report Data: Transfer Status of Cocci Restricted Patient-inmates

Actual Patient Information Redacted

Statewide Patient Safety Initiative – High-Risk Patient-Inmates.
As part of its annual Performance Improvement Plan, CCHCS has set incremental goals for
concentrating the prison systems’ high risk patient-inmates at a subset of Intermediate
Institutions that are resourced specifically to care for the more complex and unstable patientinmates. The goal was to reach 90 percent of high risk patient-inmates at Intermediate
Institutions by the close of 2013.
Page 14 of 48

CCHCS continues to make steady progress toward this goal, through a complex collaboration
between health care and custody staff at institution and statewide levels. On a daily basis,
health care and custody staff use reports and patient-inmate lists to identify high risk patientinmates currently housed at Basic Institutions who may be more appropriately managed at an
Intermediate Institution and initiate moves for these patient-inmates. As of December 2013,
69 percent of high risk patient-inmates were housed at an Intermediate Institution, up from
55 percent at the same time last year. Please see Figure 5.
Figure 5. Percentage of High Risk Patient-Inmates Housed at Intermediate Institutions, May 2012 through
December 2013

Statewide PIP Objective = 90%


Dec 2013: 69%
























Revisions to the Health Care Services Dashboard
During this reporting period, CCHCS initiated an intensive, four-month project to redesign the
monthly Health Care Services Dashboard, which consolidates strategic performance
information across all clinical program areas into a single report.
The new and improved version of the Dashboard, scheduled for release in February 2014, will:
• Allow viewers to create custom reports using Dashboard data, including trending
reports according to a user’s desired parameters.
• Offer detailed sub-reports for many performance measures.
• Incorporate new performance objectives from the statewide Performance Improvement
Plan 2013-2015.
• Include data from the new centralized medical scheduling system.
Beyond the improvements noted above, the Dashboard redesign provided QM Section staff
concentrated time to reconfigure the data infrastructure supporting the Dashboard, re-visit the
methodologies for hundreds of critical health care measures, and update report formats to
make them more user-friendly. This work is required preparation for Electronic Health Record
System implementation.
Patient-Inmate Registries
CCHCS has made it a priority to promote the use of its 24 registries and sub-registries, which
make critical clinical information, such as a patient-inmate’s health risk status, easily accessible
to care teams working to manage an assigned patient-inmate panel. The flags imbedded in the
Page 15 of 48

patient-inmate registries prompt care teams to follow CCHCS guidelines, which both improves
patient-inmate outcomes and helps to reduce costs. Widespread and consistent registry use is
required for full implementation of the Population and Care Management elements of the
CCHCS Primary Care Model, and necessary for compliance with certain IMSP&P.
Statewide, registry usage has steadily increased since the May 2012 release of on-demand
patient-inmate registries, which allow users to select from drop-down menus to customize
registry reports for a particular patient-inmate population, care team, or other data element.
All but seven of the adult institutions have seen improvements in registry usage over the prior
year; more than a third of our institutions had increased the average unique users per day by
100 percent or more by December 2013, as compared with the beginning of the year. Please
see Figure 6.2
Figure 6. Average Unique Registry Users per Day - Percent Change, January 2013 vs. December 2013

WSP (-77%)
MCSP ( -68%)
SAC ( -49%)
DVI ( -43%)
CVSP ( -41%)
CCWF ( -32%)
ISP ( -19%)
CAL ( 14%)
VSP (14%
SVSP (22%)
FSP (30%)
SOL (36%)
ASP (38%)
LAC (41%)
CEN (44%)
PBSP (48%)
SW (57%)
NKSP (82%)
COR (84%
PVSP (101%)
CMF (105%)
HDSP (109%)
CTF (110%)
CCC (141%)
SCC (163%)
SATF (163%)
CIW (167%)
CCI (204%)
KVSP (247%)
RJD (265%)
CMC (305%)
CIM (327%)
CRC (375%)
SQ (450%)


Action 4.1.2. By July 2009, work with the Office of the Inspector General to establish an
audit program focused on compliance with Plata requirements.
This action is completed. However, discussions are continuing with OIG and the Plata Court
Experts to discuss possible refinements to the OIG's inspection program.
Objective 4.2. Establish a Quality Improvement Program
Action 4.2.1.(merged Action 4.2.1 and 4.2.3): By January 2010, train and deploy existing
staff--who work directly with institutional leadership--to serve as quality advisors and
develop model quality improvement programs at selected institutions; identify clinical
champions at the institutional level to implement continuous quality improvement locally;
and develop a team to implement a statewide/systems-focused quality
CHCF is not included in this analysis, as it was not yet fully operational and was not required to complete a PIWP
in 2013.


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monitoring/measurement and improvement system under the guidance of an
interdisciplinary Quality Management Committee.
This action item is ongoing. Progress during this period is as follows:
Quality Management Policy and Procedures
In December 2012, CCHCS issued new Quality Management (QM) Program Policies and
Procedures, replacing outdated program standards from 2002. Incorporated into Volume 3 of
the IMSP&P, the new policy and procedures maintain many of the existing quality management
structures, but also introduces a number of new program elements, such as current nationallyrecognized improvement techniques. Updates on program implementation are provided below.
Statewide Performance Improvement Plan
Three years ago, CCHCS established its first statewide Performance Improvement Plan (PIP),
which outlines the organization’s major improvement priorities, lists statewide performance
objectives, and describes major improvement strategies (please see Appendix 8). The
Performance Improvement Plan is updated periodically as performance objectives are met and
new priorities emerge, and is posted on the Intranet.
After vetting with CCHCS staff at different levels of the organization, the Headquarters Quality
Management Committee (QMC) finalized the Performance Improvement Plan for 2013-2015
during the last reporting quarter. This quarter, QM Section staff worked to develop the
methodology for tracking new PIP objectives on a monthly basis in an updated version of the
Health Care Services Dashboard. In addition to regular Dashboard reporting, the Headquarters
QMC will be reviewing reports on subsets of PIP measures during regularly scheduled meetings
to assess progress and develop interventions as necessary. The first of these executive reports
was released in November, covering scheduling and access to medical services. (Please see
“Statewide Improvement Initiative: Scheduling System”, in this same section, below for more
Institution Performance Improvement Work Plans
Per current policy, institution leadership teams are required to update their local Performance
Improvement Work Plan (PIWP) every 12-15 months. This annual requirement presents an
opportunity for institutions to celebrate the progress they have made to date, identify
improvement initiatives from the prior year's plan that still need work, and consider new
priorities for the coming year. By the close of the PIWP process, institutions establish clear
improvement priorities and a unified purpose for institution health care staff, which is essential
to successful improvement work. In 2014, all institutions must include scheduling and
medication management initiatives in their PIWP, considered two of our most critical patientinmate safety areas statewide.
During this reporting period, CCHCS made new tools available to help institutions create their
PIWP for 2014, including:
• A 2014 PIWP Tool Kit, which describes recommended steps for updating the PIWP and
offers tools to help institutions move through each step.
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"Plug and play" content for a scheduling improvement initiative (a completed initiative
template that can be customized by the institution).
A database of all initiatives submitted by institutions in 2013 PIWPs, which allows
institutions to "shop" for improvement ideas in a variety of categories.

All of these resources can be found at a new PIWP webpage on the QM Portal, at this link: PIWP
Resource Center. Please see Figure 7.
Figure 7. Screenshot of the new PIWP Resource Center on the QM Portal.

Use the PIWP Database to search for
improvement initiatives and action steps
submitted by institutions in 2013

During this reporting period, multiple PIWP orientation sessions were offered to familiarize
institutions with these new resources, and at least one additional session will be offered in
early February 2014. The deadline for institution PIWPs is February 28, 2014.
Institution Performance Management Support Units
In September, a more formal process began at several institutions to reorganize existing
resources into Performance Management Support Units (PMSUs) to better focus on QM and
patient-inmate safety activities in a more integrative, efficient and effective approach across
program areas. Units of staff with systems improvement expertise dedicated full-time to
activities such as performance evaluation and process redesign are commonplace in the
broader health care industry. Typically, the role of these units within the organization is to
support and integrate activities related to prioritizing, planning, designing, testing, and
implementing performance improvement and evaluating performance.

Page 18 of 48

As these institutions established their Units, the demand for specialized training has grown. In
response, the QM Section will hold a special session of the QM Patient Safety Academy in
January and the training schedule will be generally expedited during the next year as much as
possible to provide training to the new Units.
QM Section staff also developed several advanced modules of the QM Patient Safety Academy
during this reporting period. Building upon the broad orientation provided during the two-day
QM Patient Safety Academy, the advanced modules focus intensively on certain topics, with the
intent to promote skills development in areas critical to performance improvement, such as
performance measurement, problem analysis, and development and testing of interventions, as
well as more general skills commonly used by improvement professionals, like project
management, group facilitation, and strategic planning.
Institution PMSUs are a critical part of the effort to build QM capacity enterprise-wide,
establish an organizational culture that promotes continuous performance improvement, and
strengthen the institution, regional, and state-level QM infrastructure. However, the CCHCS
philosophy is that continuous performance improvement is everyone’s job. Core PMSU
resources supplement and support leaders, managers and supervisors who must ultimately
champion and be responsible for quality work and organizational excellence, which are
essential to successful transition of prison health care services to state control, and maintaining
the advances achieved well into the future.
Statewide Improvement Initiative – Scheduling System
Starting in February 2013, CCHCS began rolling out an enterprise-wide Medical Scheduling and
Tracking System (MedSATS) to improve the scheduling process, increase timely access to
medical services, and establish a single centralized and standardized medical scheduling system
for all institutions. As of this reporting period, MedSATS has been successfully deployed at 32 of
34 institutions (Pelican Bay State Prison (PBSP) and CHCF are in progress), and currently
captures approximately 80,000 to 90,000 completed encounters each week.
During the last reporting period, CCHCS launched a Scheduling Process Improvement (SPI)
Initiative to provide institution leadership with a structured process and new tools available
through MedSATS implementation to improve access to care and scheduling efficiency locally.
To apply the new structured process and tools, institution staff learn specific quality
improvement techniques, building institution capacity to improve other critical health care
processes in the future.
Though MedSATS presents a rich source of data to track and improve access to care, it is only as
useful as the data is accurate. During this reporting report, CCHCS began to test the reliability of
MedSATS data, focusing on a subset of performance measures that will be reported monthly in
the Health Care Services Dashboard in February 2014, and began to develop tools to help
institutions increase the accuracy of the new system.

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Over the course of several weeks, a team of analysts under the supervision of clinical staff
matched MedSATS data points against corresponding information in the patient-inmate health
record to ascertain data accuracy. At the conclusion of the data reliability testing, each
institution Health Care CEO received a report with results emphasizing not only areas where
data integrity might be problematic, but areas where the institution may wish to focus access to
care improvements. Please see Figure 8.
Figure 8. Sample Report with Institution Validation Findings

To help institutions improve both data accuracy and actual access to care, CCHCS established a
new webpage on the QM Portal with ready access to a number of resources that can assist
institutions in improving data reliability (see Figure 9), including, but not limited to:
• Proposed step-by-step content for a scheduling initiative that can be customized and
inserted in an institution PIWP.
• A sample Local Operating Procedure for scheduling processes.
• Guide to MedSATS reports that can help institutions manage scheduling process.
• Job aids.
• Work flow diagrams designed by Nursing staff and MedSATS designers.
• Scheduling Process “Do’s and Don’ts”.
• Validation findings for each institution.

Page 20 of 48

Figure 9. Screenshot of New Scheduling Improvement Initiative Webpage on the QM Portal

During this reporting period, CCHCS made a number of changes and enhancements to the
MedSATS system in response to requests by users, which should also improve data reliability.
Prior to release of these system changes in November 2013, CCHCS provided 8 training sessions
in October to provide MedSATS users and executive teams with an overview of the changes.
CCHCS released the first in a series
2013, offering institutions baseline
Performance Improvement Plan for
The “Executive Report: MedSATS
Appendix 9.

of Scheduling Improvement Project reports in November
data on new scheduling objectives from the statewide
2013-2015, including objectives for scheduling efficiency.
and Scheduling Process Improvement” is attached as

Action 4.2.2. By September 2009, establish a Policy Unit responsible for overseeing review,
revision, posting and distribution of current policies and procedures.
This action is completed.
Action 4.2.3. By January 2010, implement process improvement programs at all
institutions involving trained clinical champions and supported by regional and statewide
quality advisors.
This action is combined with Action 4.2.1.

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Objective 4.3. Establish Medical Peer Review and Discipline Process to Ensure Quality of Care
Action 4.3.1. By July 2008, working with the State Personnel Board and other departments
that provide direct medical services, establish an effective Peer Review and Discipline
Process to improve the quality of care.
This action is completed.
Objective 4.4. Establish Medical Oversight Unit to Control and Monitor Medical Employee
Action 4.4.1. By January 2009, fully staff and complete the implementation of a Medical
Oversight Unit to control and monitor medical employee investigations.
This action is completed.
Objective 4.5. Establish a Health Care Appeals Process, Correspondence Control and Habeas
Corpus Petitions Initiative
Action 4.5.1. By July 2008, centralize management overall health care patient-inmate
appeals, correspondence and habeas corpus petitions.
This action is completed.
Refer to Appendix 10 for health care appeals, and habeas corpus petition activity for September
2013 through December 2013.
Action 4.5.2. By August 2008, a task force of stakeholders will have concluded a systemwide analysis of the statewide appeals process and will recommend improvements to the
This action is completed.
Objective 4.6. Establish Out-of-State, Community Correctional Facilities (CCF) and Re-entry
Facility Oversight Program
Action 4.6.1. By July 2008, establish administrative unit responsible for oversight of
medical care given to patient-inmates housed in out-of-state, community correctional or
re-entry facilities.
This action is completed.
The Private Prison Compliance and Monitoring Unit (PPCMU) continues to conduct on-site
compliance reviews of the existing four Out-of-State Correctional Facilities and four In-state
Community Correctional Facilities contracted to provide housing California patient-inmates,
ensuring compliance with the Remedial Plan developed in July 2008 and to meet the court
mandate to provide a constitutional level of medical care.

Page 22 of 48

An accurate and objective review of each facility is critical to ensuring compliance with the
Receiver’s Turnaround plan. To improve the statistical information obtained during each
compliance review, PPCMU developed a new audit tool to measure compliance. To date, the
new audit tool has been utilized to conduct compliance reviews at two of the four contract
facilities; with the expectation of completing audits of all
remaining facilities within the current fiscal year. The new
report affords PPCMU the ability to document an overall
rating for each facility as outlined within the included
chart. To date the overall compliance results for each
facility reflect a demonstrated ability above the required 85 percent.
1. Potential Out-of-State Private Prison Expansion
During the current reporting period, CCHCS staff have completed facility inspections at six
Out-of-State correctional facilities in four different states to gather data and assess the
overall capabilities of the identified sites to provide the required medical services for
patient-inmates should CDCR’s request to increase out-of-state bed capacity be approved.
The correctional facilities surveyed as potential sites for Out-of-state housing of California
patient-inmates included:

Prairie Correctional Facility - Appleton, MN
North Lake Correctional Facility - Baldwin, MI
Diamondback Correctional Facility - Watonga, OK
Great Plains Correctional Facility - Hinton, OK
Hudson Correctional Facility - Hudson, CO
Kit Carson Correctional Facility – Burlington, CO

2. In-State Community Correctional Facilities:
As part of efforts to meet the court mandated inmate capacity of 137.5 percent, CDCR
initiated an effort to redistribute the inmate population housed in and out of state. One
component is reactivating and moving inmates to modified community correctional
facilities (CCF) within California. Adding to the existing capacity at Golden State Modified
CCF, CDCR reactivated three modified CCFs during the reporting period:

Desert View Modified CCF on October 21, 2013
Central Valley Modified CCF on October 21, 2013
Shafter Modified CCF on December 16, 2013

Page 23 of 48

During the reporting period, CDCR also signed contracts to reactivate two additional CCFs
with the following activation dates:

Delano Modified CCF on January 6, 2014
Taft Modified CCF on February 17, 2014

Each CCF is designated a hub institution, one of CDCR’s reception center institutions (see
Figure 10). One of the hub institution’s responsibilities is to facilitate health care services
beyond which the CCF is contractually bound to provide. These types of services are
typically for urgent care situations, lab tests, or an evaluation for mental health, dental,
specialty care referral, or medication.
Under these contracts, patient-inmates from the CCFs are returned to the hub institution
for some health care services provided by CCHCS and CDCR (on any given week, from 20 to
50 patient-inmates are sent back to hub institutions for such services). It appears that
CCHCS’s budget allocation may have been reduced on a pro rata basis for each patientinmate transferred to a CCF even though CCHCS is still providing some health care services
for these patient-inmates. We are working now to quantify this residual burden and will
share this information with the Department of Finance to ensure that any reduction in our
budget reflects only the actual reduction in workload.
Figure 10. CCFs by Hub Institution

California State Prison, Los Angeles County
• Desert View
North Kern State Prison
• Central Valley
• Golden State
• Delano
Wasco State Prison
• Shafter
• Taft


Population 3







3. Contracted Bed Population:
CCHCS utilizes the services of clinical and administrative staff to ensure the medical needs
of the patient-inmate population are addressed in a timely manner within all contract beds.
In a continuing effort by CDCR to reduce the overall patient-inmate population within the
existing state institutions, conversely, the contracted bed population continues to increase.
Figure 11 identifies the total number of patient-inmates housed in contracted beds as of
January 4, 2014.


Population based on count provided by CDCR’s Contract Beds Unit date December 27, 2013.

Page 24 of 48

Figure 11. Total Number of Patient-Inmates Housed in Contracted Beds
Contract beds in other States:
Florence Correctional Center
La Palma Correctional Center
North Fork Correctional Facility
Tallahatchie County Correctional Facility



Contract beds in California:
Central Valley Modified CCF
Desert View Modified CCF
Golden State Modified CCF
Shafter Modified CCF


Contract Beds Total

Population based on count provided by CDCR’s Contract Beds Unit date December 27, 2013.

Page 25 of 48



Goal 5: Establish Medical Support / Allied Health Infrastructure
Objective 5.1. Establish a Comprehensive, Safe and Efficient Pharmacy Program
Action 5.1.1. Continue developing the drug formulary for the most commonly prescribed
This action is completed.
Refer to Appendix 11 for Top Drugs, Top Therapeutic Category Purchases, and Central Fill
Pharmacy Service Level for September 2013 through December 2013.
Action 5.1.2. By March 2010, improve pharmacy policies and practices at each institution
and complete the roll-out of the GuardianRx® system.
This action is completed.
Action 5.1.3. By May 2010, establish a central-fill pharmacy.
This action is completed.
Objective 5.2. Establish Standardized Health Records Practice
Action 5.2.1. By November 2009, create a roadmap for achieving an effective
management system that ensures standardized health records practice in all institutions.
This action has been completed.
Objective 5.3. Establish Effective Imaging/Radiology and Laboratory Services
Action 5.3.1. By August 2008, decide upon strategy to improve medical records, radiology
and laboratory services after receiving recommendations from consultants.
This action is ongoing. Progress during the reporting period is as follows:
Imaging/Radiology Services
The strategy to improve radiology services statewide has been established.
• CCHCS has fully implemented RIS/PACS electronic radiographic equipment statewide.
• Training in use and access has been provided to all affected staff.
• Mobile imaging services are available at all institutions with electronic transmission
capabilities at all locations. (Additional work is needed to ensure reliable connectivity at
a few sites).
• Old imaging records from all institutions are now located in the Imaging Record Center
(IRC) where they are stored and uploaded when needed.
• A single statewide provider (a radiology group) has been contracted to provide radiology
interpretation services, increasing consistency and standardization of protocols, cost
savings, and more effective quality control.
• Report turnaround times are improved with reports available within four hours in most
Page 26 of 48


The statewide radiology service provider provides Radiation Safety Office (RSO)
oversight to all institutions, also ensuring coverage, standardization of practices, and
improvement in quality control activities.

Laboratory Services
Strategies to improve laboratory services statewide have been established. Components
• The previously reported plan to implement a statewide Enterprise Laboratory
Information System (LIS) has been revised. Laboratory results reporting will be
incorporated into the EHRS currently under development. The system will also allow for
logistic tracking of specimens and testing turnaround time, review of services, and other
management reports. A full LIS will be an integral part of the EHRS which is now being
implemented in CCHCS.
• Evaluation of Point of Care (POC) testing practices in the institutions is in progress. In
particular glucose and anticoagulation Point of Care testing devices, as well as any other
POC test devices in use. The goal is to standardize practices in our institutions and to
enhance patient-inmate care and patient-inmate safety.
• Guidelines to assist clinicians in obtaining indicated lab studies for particular conditions
based on CCHCS Care Guides and other recommendations are being created during
development of “order sets” for implementation of the EHRS.
• Since implementation of an electronic order system by our contract referral lab in
February 2013, compliance with use of the electronic order form has increased to
96 percent statewide.
Objective 5.4. Establish Clinical Information Systems
Action 5.4.1. By September 2009, establish a clinical data repository available to all
institutions as the foundation for all other health information technology systems.
This action is completed.
Objective 5.5. Expand and Improve Telemedicine Capabilities
Action 5.5.1. By September 2008, secure strong leadership for the telemedicine program
to expand the use of telemedicine and upgrade CDCR’s telemedicine technology
This action is completed.

Page 27 of 48

Goal 6: Provide for Necessary Clinical, Administrative and Housing Facilities
DNCA, which is the second of the two major projects planned for the purpose of adding new
medical and mental health beds to the CDCR system, is nearing completion. The construction of
CHCF is essentially complete; however, as explained below, on January 27, 2014, the Receiver
halted further transfer of medical patient-inmates to CHCF until various improvements in the
supply chain system and delivery of care are achieved.
Regarding HCFIP, which includes upgrades to add/renovate exam rooms and related health care
treatment space, as well as improvements to medication distribution at existing prisons,
22 projects have now received project approval from PWB and interim funding from PMIB.
Remaining projects are proceeding on a sequential submittal schedule to PWB and PMIB. The
PWB approved preliminary plans for statewide medication distribution projects in
November 2013, which is a one-month delay from the previous report. The PWB approved
preliminary plans in December 2013 for five projects: CMF, SOL, CIM, SAC, and MCSP. There are
now 16 projects in the preliminary planning phase and six projects, including statewide
medication projects, in the working drawings phase. Construction is expected to begin in
spring 2014 for the statewide medication distribution projects and in summer 2014 for the first
HCFIP projects, which will be CMF and SOL.
The new medical and mental health beds added pursuant to Goal 6 will be substantially
completed by 2014. It is possible for HCFIP and medication distribution upgrades at existing
prisons to be substantially completed by 2017, with the priority focus on the upgrades at
intermediate level‐of‐care facilities to be substantially completed by 2016.
Objective 6.1. Upgrade administrative and clinical facilities at each of CDCR’s thirty-three
prison locations to provide patient-inmates with appropriate access to care.
Initial PWB project approvals have been secured for all of the intermediate level‐of‐care
projects, the reception center projects, and seven basic level‐of‐care facilities (Valley State
Prison, California Training Facility (CTF), Salinas Valley State Prison, California Correctional
Institution, Sierra Conservation Center (SCC), Substance Abuse Treatment Facility, and
California State Prison, Corcoran (COR), along with the statewide medication distribution
projects. Submission of the remaining basic level‐of‐care projects will be scheduled through
August 2014 following completion and review of site‐specific plans. The PWB approved
preliminary plans for five projects (CMF, SOL, CIM, SAC, and MCSP) in December 2013.
Action 6.1.1. By January 2010, completed assessment and planning for upgraded
administrative and clinical facilities at each of CDCR’s thirty-three institutions.
This action item is ongoing. Progress during this reporting period is as follows:
CDCR has now received PWB project approvals and PMIB interim loan approvals for 22 projects;
including statewide medication distribution projects, which do not require PMIB financing since
these projects are being funded by State general funds. CDCR is proceeding with sequential
Page 28 of 48

project and interim funding submittals for the remaining projects through August 2014 as
site‐specific plans are developed. These site reviews are now occurring.
Action 6.1.2. By January 2012, complete construction of upgraded administrative and
clinical facilities at each of CDCR’s thirty-three institutions.
This action item is ongoing. Progress during this reporting period is as follows:
The preliminary design for each of the projects by an architectural and engineering (A&E) firm
begins once PWB project and PMIB loan approvals have been obtained. The contracts with A&E
firms for site‐specific preliminary plans for all 22 of the approved projects have been finalized.
The completed preliminary plans must be approved by the PWB and Department of Finance
before the A&E firm can proceed to preparation of the working drawings and bid these projects
for construction. Preliminary designs for the statewide medication distribution projects
received PWB approval in November 2013 and five other projects (CMF, SOL, CIM, SAC, and
MCSP) received approval in December 2013. Construction drawings are currently being
prepared for these six projects. The current schedule shows construction of the first two HCFIP
projects (CMF and SOL) will start in mid-2014 and the last HCFIP project (Chuckawalla Valley
State Prison (CVSP)) will be completed in mid-2017.
Objective 6.2. Expand administrative, clinical and housing facilities to serve up to 10,000
patient-inmates with medical and/or mental health needs.
Construction at CHCF was substantially completed in August 2013 and the first patient-inmates
were received on schedule in July 2013. Department of State Hospital (DSH) patient-inmate
admissions also began in July 2013. To date, approximately 1,200 patient-inmates have been
admitted to CHCF. Construction at DNCA remains on schedule to be substantially complete in
March 2014 with patient-inmates scheduled to arrive in early April 2014.
Unfortunately, as described below, substantial difficulties in properly activating CHCF for its
health care mission have occurred. As of January 27, 2014, the Receiver has decided to cease
transferring any additional medical patient-inmates to CHCF until the problems are corrected
(at present, about 77 percent of CHCF’s medical capacity is in use). Because DNCA will rely upon
many of the systems at CHCF that are, at present, not functioning properly, it is uncertain
whether DNCA will be able to accept patient-inmates in April 2014 as planned. Although efforts
to remediate the problems at CHCF are underway, there is very little time to correct the
deficiencies before DNCA’s scheduled opening.
Action 6.2.1. Complete pre-planning activities on all sites as quickly as possible.
This action item is ongoing. Progress during this reporting period is as follows:
Construction at CHCF has been substantially completed. As with any major construction project,
there are certain construction defects that must be corrected, and the CHCF project is no
different. The most significant defect is related to the system that delivers hot water
throughout the site. CDCR’s construction team is working with its contractors to fix these
Page 29 of 48

problems, and there is a high degree of confidence that the systems can indeed be corrected.
For additional details on construction-related issues, see Section 7, D: Overview of Transition
There have been difficulties in filling clinical and administrative positions at CHCF. The most
serious gap has been in the recruiting and staffing of psychiatrist positions. As a result, DSH has
only been able to activate 12 of 17 units. DSH is making every effort to open the remaining
units as soon as possible. The Receiver’s staff is reevaluating the medical staffing at CHCF in
response to concerns expressed by the Health Care CEO that staffing in certain classifications is
Even if full staffing were achievable, however, there are extremely serious deficiencies in the
activation at CHCF. The Receiver first became aware of these deficiencies as early as July of
2013 when concerns were raised by the Department of Public Health (“DPH”) about whether
problems in the management of the kitchen might block licensing of the facility. DPH ultimately
licensed the facility in August 2013. Unfortunately, the problems that DPH had identified were
never satisfactorily resolved notwithstanding the approval for licensing purposes. The problems
manifested themselves in inadequate supplies of appropriate food, hot meals not being
available, special diet meals not being available as required and general confusion and chaos in
the kitchen operation. A key problem is that there are too many kitchen managers trying to run
the kitchen. Instead of assigning a single manager to run the kitchen, three managers – one
from DSH, one from CDCR and one from CCHCS – were apparently given joint authority to run
the kitchen. With three managers in charge, no one has been in charge. The Receiver’s staff
recommended in October 2013 that a major step forward would be to simply assign a single
manager to run the kitchen. An acting manager from another institution was appointed on a
temporary basis, but that manager is scheduled to return to his institution in the near future. A
permanent appointment needs to be made.
A much more serious set of problems was brought to the Receiver’s attention after
headquarters clinicians visited CHCF in September and October 2013. The reports indicated that
breakdowns in the supply chain – the process by which material is procured, delivered to the
general CHCF warehouse, and then delivered to each housing unit – were so serious that basic
and essential medical and personal hygiene supplies were either not available at all, or not
available in sufficient quantities in the housing units and for use by clinicians and patientinmates. The initial reports included such things as insufficient catheters for patient-inmates
and gloves for nurses. With respect to catheters, the Receiver learned that the Health Care CEO
for the facility became so desperate for supplies and so frustrated that he could not secure
those supplies through CHCF’s supply chain process that he personally drove across town to the
San Joaquin General Hospital to borrow several boxes of catheters.
It is simply inconceivable to the Receiver that the Health Care CEO of CDCR’s health care facility
– supposedly the highest health executive at the institution – was forced to personally borrow
supplies from a local hospital because procurement and warehousing functions at the
institution were unable to deliver the necessary supplies. It was a clear sign of a fundamental
Page 30 of 48

breakdown in processes. As a result, in October and November 2013, the Receiver’s office sent
down to CHCF a small team of experienced executives and clinicians to try to help break
through the bureaucratic logjam and to report progress, or the lack thereof, back to the
It became clear to the Receiver by the end of November 2013 that the situation was not
improving. The reports back from the team of executives who had been sent to CHCF indicated
that the need to address issues impacting health care was, as a practical matter, being treated
as a second-class priority. Stated another way, the institution was being run as just another
prison – where custody issues are typically the highest priority and health care and other
programs are secondary – instead of being run as a health care facility for patient-inmates.
In another effort to change the dynamics at CHCF, on December 2, 2013, the Receiver decided
to transfer the Health Care CEO at CHCF to another institution and appointed as Health Care
CEO Ms. Jackie Clark, one of our most experienced Health Care CEO’s who had successfully
activated the new facilities at SQ. Unfortunately, as of late January 2014, it was clear that the
situation had not improved. Supplies were still short, housing units were hoarding the supplies
that were available, patient-inmates were still not being supplied with basic medical and
personal hygiene necessities, and Ms. Clark was making an emergency order for more supplies
every day. Even her personal intervention did not guarantee results. For example, in December
2013, Ms. Clark had requested a special bed for a patient-inmate only to discover weeks later
that the bed simply had not been ordered by the warehouse.
In mid-January, 2014 the Receiver was informed that shortages in the housing units of soap and
towels resulted in patient-inmates not being allowed to take showers or, if taking a shower,
frequently using dirty socks to dry themselves. This, combined with reports of general
unsanitary conditions in cells, has likely contributed to an outbreak of scabies at the institution.
The Receiver requested a meeting on January 27, 2014 to discuss these unacceptable
conditions with the Warden at CHCF, the Health Care CEO at CHCF, the Receiver’s top clinical
staff, CDCR’s top health care officials, and CDCR’s top custody executives. After reviewing the
myriad problems that exist, there was general agreement that the supply chain problem was
one of the highest priority issues that needed to be addressed immediately, although there
remain other issues that also need remediation. The Warden and Health Care CEO were
directed to produce within five to seven working days a joint list of the most important
problems and a joint plan on how those problems could be resolved (a plan that very likely will
require some immediate, short-term steps combined with more permanent, longer-term fixes).
After the meeting on January 27, 2014, on the advice of his top medical executives, the
Receiver decided to close intake at CHCF to any further medical patient-inmates until the major
deficiencies at CHCF are resolved. Because DNCA will be supplied by CHCF, the Receiver is
reserving judgment as to whether DNCA can be permitted to open as scheduled.

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More broadly, the activation at CHCF highlights the question of whether CDCR is prepared to
manage its health care mission successfully. Given the opportunity to demonstrate its capacity
and leadership at CHCF, it stood up a facility that could not supply basic medical equipment and
personal hygiene material to its clinicians and patient-inmates, a situation that has been
permitted to persist for five months without significant improvement.
The Receiver hopes that, working collaboratively with CDCR over the next weeks and months,
the problems at CHCF will be corrected, and the next tri-annual will be able to give a more
positive report on CHCF’s activation. If that does not happen, the Receiver will consider
alternative solutions.
Action 6.2.2. By February 2009, begin construction at first site.
This action item is ongoing. Progress during this reporting period is as follows:
Construction at CHCF was substantially completed in August 2013 as scheduled.
Action 6.2.3. By July 2013, complete execution of phased construction program.
This action item is ongoing. Progress during this reporting period is as follows:
CHCF construction was substantially completed in August 2013 and the first patient
were received in July 2013.
Objective 6.3. Complete Construction at San Quentin State Prison
Action 6.3.1. By December 2008, complete all construction except for the Central Health
Services Facility.
This action is completed.
Action 6.3.2. By April 2010, complete construction of the Central Health Services Facility.
This action is completed.

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Section 4: Additional Successes Achieved by the Receiver
A. Quality Assurance and Patient-Inmate Administrative Appeals
The Receiver’s office has staff dedicated to responding to patient-inmates’ petitions in various
courts for writs of habeas corpus, at least as such responses are ordered by the court hearing
the petition. The legal process for petitioning a court for such writ relief was not established by
the Receiver as a quality of care improvement program, rather, it is long-standing and widereaching body of law that enables patient-inmates to seek relief from alleged unconstitutional
confinement or conditions of confinement, including constitutionally inadequate medical care.
The Office of the Attorney General may also respond to patient-inmates’ petitions, although the
“jurisdictional” divide between the Receiver’s staff is that the Receiver’s staff addresses
patient-inmate allegations of inadequate medical care, and the OAG addresses all other issues
in an patient-inmate petition that are deemed to be non-medical conditions of custody, if there
are any such issues.
California patient-inmates have a long history of filing such petitions to seek court relief for
what they allege to be instances of constitutionally inadequate care. The habeas process is thus
arguably related to quality assurance, in that it is a patient-inmate driven process causing some
level of court review of aspects of their medical care. If the Receiver’s staff undertakes to
review and respond to a patient-inmate’s petition for a writ of habeas corpus, clinical staff is
available as needed to help understand the subject clinical history and care issues.
The habeas process is also related to patient-inmate administrative appeals in that, technically,
a prerequisite for a patient-inmate to seek court relief is that the issue should have first been
addressed through the administrative appeal process. This prerequisite is known as the
“exhaustion of remedies” doctrine, but it is not absolute and can be waived by the court in a
variety of circumstances, such as if the patient-inmate’s self-described condition and the
change in care being sought by the patient-inmate is deemed a possible emergency.
Appendix 12 provides a data-based view of how patient-inmates have been using petitions for
habeas relief, during 2011, 2012 and 2013, as a means of contending that various aspects of
their care are constitutionally inadequate. This data shows the number of cases in which the
Receiver’s staff has filed a court response to patient-inmate allegations of inadequate care, and
the general nature of the issues being presented by the patient-inmates. The subject care in
any case is almost always specific to an individual patient-inmate.
B. Electronic Health Records System
As part of a multi-stage proposal process for an EHRS an award was made to Cerner
Corporation on June 25, 2013. CCHCS/CDCR will work with Cerner Corporation to plan,
configure, build and rollout to all facilities, a commercial-off-the-shelf (COTS), EHRS solution.

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The implementation of an integrated EHRS will afford CCHCS/CDCR demonstrable and
sustained benefits to patient-inmate safety, quality and efficiency of care, and staff efficiencies
and satisfaction. It will help facilitate policy adherence, as well as monitoring and reporting our
performance in a variety of arenas, including: scheduling and access to care, continuity of care,
medication management, evidence-based health care practices, resource management,
primary care model implementation, effective communication, patient-inmate education, and
system management.
The estimated timeline to implement the technology solution is 18 to 24 months with the first
four facilities “go live” scheduled in November/December of 2014.
C. Technical Assistance from the Court Experts on Remaining Systemic Issues
During 2013, the Court Experts conducted site visits to ten institutions to evaluate the quality of
care. Their comprehensive evaluations concluded that, while care was generally adequate at
two of the ten institutions (subject to certain conditions), care was inadequate at the
remainder. At a meeting with the Court Experts in December 2013 to review the reports, it
became clear from the reports and the discussion with the Court Experts that, while there have
been improvements in many areas of the medical care system, there remained a number of
systemic problems that had not been fully corrected, including problems in the following areas:
intersystem and intrasystem transfers (where frequent gaps in continuity of care persist);
medication management; appropriate sanitation and cleanliness; and routine, on-site oversight
and monitoring of institutions.
We agreed at the December 2013 meeting that it would be a more productive use of the Court
Experts if we took a pause in their institution-by-institution evaluations – which would
undoubtedly have resulted in additional reports identifying the same system-wide gaps and
problems – and instead engage the Court Experts to work directly with CCHCS staff to solve the
remaining systemic problems. At a follow-up meeting in January 2014, we agreed that the
highest priority was for the Court Experts to work closely with the OIG and CCHCS’s quality
improvement team to make substantial improvements to OIG’s audit methodology (with
conforming changes to our quality improvement dashboard) so that the OIG methodology more
closely aligns with the Court Experts’ evaluation methodology. The intent is to improve the OIG
methodology in such a way that the Court (and, later, the State when the case has concluded)
can rely upon that methodology as a valid way of measuring the quality of care being delivered
by the medical care system. The next priority will be for the Court Experts to work with the
newly-appointed regional health care executives to help mentor them in their difficult oversight
and supervision roles. The third priority will be for the Court Experts to work with our staff in
examining the policies associated with inter-system and intra-system transfers. A fourth priority
will be to assist us in designing and implementing the new electronic health record so that it
will properly support the quality improvement and OIG audit programs.
The Receiver anticipates that this engagement with the Court Experts, which is consistent with
the spirit of the various Court orders regarding the roles to be played by the Court Experts, will
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substantially accelerate our progress. The Receiver recommends this approach for the Court’s

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Section 5: Particular Problems Faced by the Receiver,
Including Any Specific Obstacles Presented by Institutions or
A. CCHCS Activities related to the Court’s June 24, 2013, Order Granting Plaintiffs’ Motion for
Relief Re: Valley Fever at Pleasant Valley and Avenal State Prisons
On June 24, 2013, the Court issued its Order Granting Plaintiffs’ Motion for Relief Re: Valley
Fever at PVSP and ASP (“Order”) that, among other actions, requires the Receiver to present
the response to the Order in the Tri-Annual report. On July 10, 2013, CCHCS formally requested
the Centers for Disease Control (CDC) to examine the available epidemiologic data to assess if
the risk based exclusionary policy should be expanded to include other groups, including those
age greater than 55. CDC and the National Institute for Occupational Safety and Health (NIOSH)
have completed their preliminary field assessments of the two institutions. CCHCS is awaiting
the results of the CDC evaluation. The preliminary recommendations were received from the
Health Hazard Evaluation from NIOSH on June 17, 2013, and largely concerned facility
modifications which were referred to CDCR. The recommendations regarding education and
training to employees working at PVSP and ASP are being evaluated for incorporation into
existing workplace health and safety training.
We now await the NIOSH report on recommendations regarding reducing the risk of exposure
to cocci indoors and guidelines on the use of respiratory protection for staff when outdoors.
We also await the CDC report regarding the predicted impact of the use of the cocci skin test to
exclude susceptible patient-inmates from highly endemic areas vs. our current strategy of
exclusion based on risk factors.
Provider education on the diagnosis, treatment, and management of cocci infection was
developed with input from the Plata Court Experts, Plaintiffs’ expert, the public health
community, and CCHCS’ multidisciplinary continuing medical education group resulting in a
comprehensive CCHCS cocci clinical guideline and a web based training utilizing the guideline;
Training was completed for all physicians and nurses per the court order.
In response to the Receiver’s policy, CDCR successfully transferred 885 patient-inmates out of
ASP to appropriate intermediate institutions. Another 378 voluntarily waived; 29 others either
paroled, were released or deceased. For PVSP, the department was successful in transferring
813 patient-inmates to appropriate intermediate institutions with 271 waivers and 36 others
having paroled, released or deceased. All of this movement occurred by September 23, 2013.
There is ongoing surveillance for cocci; the number of cases is low this past fall, consistent with
the drought conditions in California. Training on surveillance and an addendum to the cocci
care guide to formalize our surveillance and reporting for cocci are planned.

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B. Overcrowding Update
As noted in the last report, California’s prisons remain significantly overcrowded. At the end of
this reporting period, California’s prison population stood at 134,249, which was an increase of
almost 1,000 patient-inmates since the last reporting period.
More significantly, CDCR released its Fall 2013 population projections. According to this report,
CDCR is estimating that the prison population will grow to almost 143,000 by June 2019, an
increase of almost 10,000 patient-inmates than what their previous report estimated. Their
report states that the increase in population will be due primarily to a projected increase in
admissions from court. Of great concern is the rise in the number of patient-inmates sentenced
to state prison for “second strikes” in 2012-13, 5,492, which is an astounding 32.6 percent
increase compared to the prior year. This presents the State with a long-term challenge that
demands some immediate attention and planning.
In response to Senate Bill 105 and a filing by the State on September 16, 2013, the Three-Judge
Court ordered the parties to engage in a meet and confer to “explore how defendants can
comply with [the] Court’s June 20, 2013, Order, including means and dates by which such
compliance can be expedited or accomplished and how [the] Court can ensure a durable
solution to the prison crowding problem.” Three-Judge Court, Order to Meet and Confer, p. 2
(September 24, 2013). On October 21, 2013, the Court extended the meet-and-confer process
to November 18, 2013 (Three-Judge Court, Order Extending Meet and Confer Process, p. 1
(October 21, 2013) and then the court further extended the meet-and-confer process to
January 10, 2014. Three-Judge Court, Order Further Extending Meet and Confer Process, p. 1
(December 11, 2013).
Unfortunately, the meet-and-confer process did not result in a
negotiated agreement between the parties. As a result, on January 13, 2014, the court ordered
the parties to file proposed orders by January 23, 2014, to reflect what each party proposes to
be the best way to achieve durable compliance with the Court’s orders to maintain a prison
population of no more than 137.5 percent.
On January 23, 2014 both parties submitted their proposed orders. The State’s order would
seek a two-year extension for reaching 137.5 percent design capacity (until February 28, 2016).
As well, the State proposed the following:

Expanded medical parole process;
New parole process for elderly patient-inmates who have served at least 25 years in
state prison;
Increased credit-earning for non-violent second strike offenders and minimum custody
$81.1 million for various prison recidivism reduction efforts;
$128 million for county probation felony diversion programs;
Cap out-of-state placements at 8,900; and
Appointment of a “compliance officer” empowered to order necessary releases.
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In their proposed order, the Prison Law Office (PLO) proposed that the State be required to
reach 137.5 percent design capacity by May 2014, as well as the following:

Keep in place waivers of state law, as set forth in the previous Court Order (June 20,
Allow for the continued housing of out-of-state patient-inmates;
Bi-monthly reports on specific steps taken towards implementing measures included in
the State’s previous plans; and
Appointment of a “compliance officer” empowered to order necessary releases.

The court has stated it intends to issue an order sometime in mid-February.

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Section 6: An Accounting of Expenditures for the Reporting
A. Expenses
The total net operating and capital expenses of the Office of the Receiver for the four month
period from September through December 2013 were $473,300 and $0 respectively. A balance
sheet and statement of activity and brief discussion and analysis is attached as Appendix 13.
B. Revenues
For the months of September through December 2013, the Receiver requested transfers of
$700,000 from the State to the California Prison Health Care Receivership Corporation (CPR) to
replenish the operating fund of the office of the Receiver. Total year to date funding for the
FY 2013/2014 to CPR from the State of California is $875,000.
All funds were received in a timely manner.

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Section 7: Other Matters Deemed Appropriate for Judicial
A. Coordination with Other Lawsuits
During the reporting period, regular meetings between the three courts, Plata, Coleman, and
Armstrong (Coordination Group) class actions have continued. A Coordination Group meeting
was held on October 2, 2013. Progress has continued during this reporting period and is
captured in meeting minutes.
B. Master Contract Waiver Reporting
On June 4, 2007, the Court approved the Receiver’s Application for a more streamlined,
substitute contracting process in lieu of State laws that normally govern State contracts. The
substitute contracting process applies to specified project areas identified in the June 4, 2007
Order and, in addition, to those project areas identified in supplemental orders issued since
that date. The approved project areas, the substitute bidding procedures and the Receiver’s
corresponding reporting obligations are summarized in the Receiver’s Seventh Quarterly Report
and are fully articulated in the Court’s Orders, and therefore, the Receiver will not reiterate
those details here.
As ordered by the Court, included as Appendix 14 is a summary of the contracts the Receiver
awarded during this reporting period, including a brief description of the contracts, the projects
to which the contracts pertain, and the method the Receiver utilized to award the contracts
(i.e., expedited formal bid, urgent informal bid, sole source).
C. Consultant Staff Engaged by the Receiver
During this reporting period, the Office of the Receiver has not engaged any consultant staff.
D. Overview of Transition Activities
Post Delegation Report for Health Care Access Units
Access Quality Report
The published Access Quality Report (AQR) remains unchanged from the time of delegation.
The Receivership continues to receive the required data from the institutions on a monthly
basis, with one exception: without consultation or notice to the Receiver, CDCR created and
initiated a new time and shift system (i.e., “TeleStaff”) which does not provide certain data
points the institutions are required to report to complete the AQR. As of the conclusion of this
reporting period, approximately half the institutions have transitioned to the new system. It is
anticipated all institutions will transition by May 2014.
Custody Access to Care Success Rate
During this reporting period, an AQR was published for the months of August, September,
October, and November 2013. The average custody Access to Care Success Rate for this period
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was 99.59 percent. This represents an increase of 0.31 percentage points over the previous
reporting period. Figure 11 is a summary by month of the number of institutions failing to attain
the 99.0 percent benchmark established in the delegation. For institutions failing to attain the
benchmark, a total of 12 Corrective Action Plans (CAP) were due to be submitted this reporting
period. All plans were received.
Figure 11. Institutions Failing to Attain the 99.00% Standard for the Custody Access to Care Success Rate
























Operations Monitoring Audits
As outlined in the HCAU Delegation of Authority, Field Operations staff are continuing to
conduct Health Care Access Unit Operations Monitoring Audits (OMA). During this reporting
period, Field Operations staff conducted a total of 23 Health Care Access Unit Operations
Monitoring Audits (OMA); 11 Round One audits, and 12 Round Two audits which occur
180-days after the Round One audit.
This concludes the Round One audit of all 33 institutions. The findings for 31 institutions have
been published to date. Of these reports, the institutions averaged a score of 86.8 percent. Two
institutions scored below the delegation benchmark of 85.0 percent: California State Prison, Los
Angeles County (LAC) and PBSP. A review of the scores achieved for individual chapters of the
audit indicate systemic non-compliance in three areas in that the institutions averaged below
85.0 percent. These chapters are:
• Access to Mental Health Care (74.3 percent)
• Access Quality Report (77.3 percent), and
• Access to Medication (79.6 percent).
As for the Round Two audits, this tri-annual period brings the total number of audits conducted
to 16 with the remaining 17 audits scheduled to occur between January and June of 2014. Of
the 14 audit reports published, the average Round II score is 88.4 percent. Three institutions
scored below the delegation benchmark of 85.0 percent: SCC, SQ and CMC. Although modestly
improved over the Round One average (stated previously), the same three chapters averaged
below 85.0 percent during Round II:

Access to Medication (75.6 percent)
Access to Mental Health Care (78.1 percent), and
Access Quality Report (82.5 percent).

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Failure to Resolve Operations Monitoring Audits Round One CAP Items:
The following institutions’ Round Two audit findings listed CAP items identified during Round
One, which were not resolved or significantly improved. The institutions’ continued noncompliance in these fully correctable areas is considered symptomatic of poor or insufficient
leadership. Please see Figure 12.
Figure 12.


Quantitative Findings
Nursing staff are not being notified by custody staff in a timely manner regarding patient-inmate bed
Staff is not consistently moving the medication and Medication Administration Record (MAR) at the
same time the patient-inmate is transferred between housing units.
Custody staff are not the staff actually transporting the medication and MAR to the new housing
facility for patient-inmate transfers between housing units.
The AQR data for Treatment and Triage Area (TTA) and Code II/III ambulance runs is not accurate.
The AQR data for transportation and/or medical guarding redirected hours is not being recorded
Mental Health Crisis Bed (MHCB) discharge records are not consistently and thoroughly completed.
Suicide cut-down kits do not contain all items required by the MHSDS Program Guide.
Custody tracking sheets are not being consistently utilized for ducat tracking.
Custody attendance at Suicide Prevention and Response Focused Improvement Team (SPR FIT)
meetings is not consistent.
Medical emergency “222” calls are being made frequently to avoid the patient-inmate “co-pay.”
Patient-inmates are not being timely released from work/program assignments for health care
Diabetic patient-inmates do not have access to food within 30 minutes of receiving insulin treatment.
Medical rounds and collection of CDCR Form 7362 not documented in general population housing
units during lockdowns.
Medical rounds and collection of CDCR Form 7362 not documented in CDCR 114 ASU Log Book.
Morning mental health check-in meeting is not consistently taking place in ASU.
Morning mental health check-in meeting is not consistently documented in the CDCR 114 ASU Log
Patient-inmates in restricted housing units do not have access to obtain CDCR Form 7362 health care
requests daily.
Patient-inmates in restricted housing units do not have access to submit CDCR Form 7362 health care
requests daily.
The AQR data for daily health care add-on appointments is not being accurately reported.
The AQR data for number of budgeted correctional officer posts and vacancies is not being accurately
Nursing over-use of “add-on” appointments, circumventing the priority ducating process.
Keep-on-person (KOP) medications are being packaged with patient-inmate personal property for
transports between institutions.
Hora somni (“hours of sleep”, HS) medications are not being administered per statewide pill policy
All custody peace officers are not carrying a CPR mouth barrier on their person at all times while on
Quarterly medical emergency response drills/simulations are not being conducted as required.
The Warden (or other appropriate custody designee) is not consistently attending Emergency
Medical Response Review Committee meetings.
The institution made changes to the HCAU Post Assignment Schedule and/or Master Assignment
Roster without providing notice to the Office of the Receiver.
Suicide cut-down kit inventories are not being conducted daily.
Mental health group sessions are not being scheduled via the priority ducat process.

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The second component to the audit process is a qualitative analysis, which seeks to identify
processes, relationships, and other un-quantifiable factors which nonetheless have a tangible
effect on health care access. The qualitative review process largely consists of interviews with
staff at all levels, and auditor observation of operations having to do with health care access.
During the Round I and II audits, the following qualitative findings were predominant:

Transportation vehicles (onsite and offsite) are accruing high mileage, developing
concerns over reliability. Institutions universally claim difficulty obtaining funding to
maintain, upgrade or replace vehicles as necessary.


The approved custody tracking sheets and/or master pass list are not being utilized for
tracking and reconciling of patient-inmate ducat outcomes. During this reporting period,
this was observed at California Institution for Women (CIW), CMC (MH), CTF, High
Desert State Prison, LAC, PVSP, and SCC.


The custody and health care management teams at specific locations, including Richard
J. Donovan Correctional Facility (RJD), CVSP, LAC and COR, were found to exhibit
significant leadership needs. Frequently these take the form of ideological differences,
lack of cooperation and collaboration, exclusion from information-sharing, and absence
of mutual support. The specifics take many forms, and are not necessarily reflected in
the overall quantitative scoring.

Medical Guarding / Activation of CHCF
With the activation of the CHCF in July 2013, and the resultant shift of high-risk patient-inmates
out of basic institutions, an observable decrease in medical guarding unit/community hospital
bed utilization has taken place at institutions designated as basic acuity level of care. From
May 2013 to November 2013, the monthly medical guarding unit/community hospital bed
census for basic care institutions dropped from 2,155 to 1,491, with some minor fluctuations
In September 2013, Field Operations conducted a staffing utilization review, taking a snapshot
of HCAU custody staff utilization for a one-week period. This review indicated a significant
number of HCAU custody staff being redirected out of medical guarding/community hospital
posts and transportation posts into other institutional vacancies, due to decreased census or
workload. The institutions redirecting staff out of medical guarding/community hospital posts
were comprised of a blend of both basic care and intermediate acuity levels, not neatly aligning
with the observed census trends. However, the bulk of the institutions showing redirects out of
transportation posts were basic-care institutions, supporting the idea that demand/workload
has decreased at such institutions subsequent to the CHCF activation.
Transportation Vehicles
CCHCS staff continued to work with CDCR staff on the monitoring and responsibility for
managing medical transportation vehicles. Accomplishments made during the reporting period
include the following:
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The previous reporting period CDCR agreed to purchase and replace 12 Emergency [Medical]
Response Vehicles (ERVs) that were identified as needing to be replaced. In December 2013
CCHCS was informed by the Office of Business Services within CDCR that the Division of Adult
Institutions (DAI) and the Administrative Service Division have subsequently met and come to
agreement on the purchase of the ERV’s. CCHCS has not been informed of a purchase schedule
or a timeframe in which the vehicles will be available to the requesting institutions.
Prior to previous reporting period, DAI indicated to CCHCS that they would be providing a plan
for managing the medical transportation vehicles. CCHCS still has not received the plan, nor has
CCHCS received any updated data regarding the status and/or condition of the medical
transportation fleet. The data that was compiled in July 2013 reflected that 198 medical
transportation vehicles had a mileage which exceeded the OFA replacement criteria and should
be replaced. To this date, CCHCS has not been notified relative to the intent to purchase or the
actual purchase of replacement vehicles. The above issues will continue to be monitored under
the terms of the delegation.
Post Delegation Report for Facility Planning and Activation Management
The first free‐standing medical facility project activated is CHCF at Stockton. The activation of
CHCF involved extensive coordination among all project disciplines, including construction
contractors, construction management, medical, nursing, allied services, mental health, dental,
licensing, custody, transportation, and support services. Since CHCF includes a DSH facility for
patient‐inmates who require licensed intermediate or acute level of mental health care,
coordination between CDCR, DSH, and CCHCS has been particularly critical for successful
activation. With significant efforts on the part of all team members, the activation of CHCF and
the receipt of the first patient
‐inmates occurred on schedule. As of December 31, 2013,
approximately 1,200 patient-inmates have been admitted to CHCF.
Construction at CHCF was substantially complete in August 2013 as scheduled. However, facility
plant issues most typical of a newly constructed facility continue to be identified and addressed
by CHCF Plant Operations staff and by the design-builder where appropriate. The most
significant issue has been multiple points of failure in the hydronic loop, which provides the
source of heat for the buildings. Some of the points of failure have resulted in the loss of heat in
some housing units, which necessitated the use of temporary heating sources. Facility Planning,
Construction and Management (FPCM) staff, CHCF staff, and the design-builder have all been
working on this problem on a priority basis making repairs, assessing possible causes, and
developing solutions. Staff also continue to monitor building temperatures and temporary
heaters remain onsite as a precautionary measure.
Construction of DNCA is scheduled to be complete in March 2014. An activation schedule has
been drafted based on the current baseline construction schedule. Facility Planning and
Activation Management (FPAM) staff are effectively managing activation activities and
monitoring the procuring and delivery of Group I and Group II equipment and Group III
consumables. FPAM continues to apply sound project management and critical path scheduling
skills and tools to this project.
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Under the delegation of authority, FPAM was required to provide project schedules for the
HCFIP projects. The current schedules show that construction begins in March 2014 with
activation activities starting in August 2015 for the statewide medication distribution projects.
The schedule shows construction starting in July 2014 with activation activities starting in
December 2015 for the first HCFIP project, which is at CMF. According to this schedule,
construction of the last HCFIP project, which is CVSP, will start in May 2016 and be completed
in August 2017.
CDCR Performance Under the October 26, 2012 Revocable Delegation of Authority For FPAM
Since the signing of this revocable delegation, FPAM has continued to perform with the same
rigor, focus, and skills they demonstrated prior to the delegation. The coordination and
collaboration of FPAM with the construction management team and the application of sound
project management tools and skills continues to be effective. To facilitate success, CDCR
created a team environment with active involvement from members of the Project
Management firm (Vanir Construction Management, Inc.), the Construction Management firm
(URS/Lend Lease), CCHCS, and DSH. The team continuously communicates and uses appropriate
project management tools, such as dashboards, critical path schedules, regular team meetings
and reports to maintain open lines of communication and to track and monitor the necessary
activation activities.
Post Delegation Report for Construction Oversight
In order to streamline and coordinate health care construction, on September 21, 2009, the
Receiver and the Secretary of CDCR issued a revocable delegation of their respective authorities
related to the construction of the new Consolidated Care Center, now known as CHCF, and the
HCFIP to CDCR’s Senior Chief of FPCM. Under the direction of the Senior Chief, FPCM became
responsible for the study, planning, design, development, management, and construction of
CHCF (and DNCA) and HCFIP. These projects comprise the elements of Goal 6; to expand
administrative, clinical and housing facilities for patient
‐inmates with medical and/or mental
health needs and to upgrade administrative and clinical facilities at CDCR’s existing prisons.
During the period of this report, the Senior Chief announced his retirement in early 2014. The
responsibilities under the delegation have been transitioned to the Acting Director of FPCM. No
change in commitment, focus, or progress is anticipated.
Expand Administrative, Clinical and Housing Facilities
The two major construction projects to add medical and mental health beds and provide for
necessary clinical, administrative, and housing facilities are the 1,818 bed CHCF and the
conversion of DNCA (located adjacent to CHCF) to serve as a 1,133 bed facility annex to CHCF.
CHCF was substantially completed in August and first patient-inmates were received on
schedule in July 2013. However, facility plant issues most typical of a newly constructed facility
continue to be identified and addressed by FPCM, CHCF Plant Operations staff, and by the
design-builder where appropriate. The most significant issue has been multiple points of failure
in the hydronic loop, which provides the source of heat for the buildings. Some of the points of
failure have resulted in the loss of heat in some housing units, which necessitated the use of
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temporary heating sources. FPCM staff, CHCF staff, and the design-builder have all been
working on this problem on a priority basis making repairs, assessing possible causes, and
developing solutions.
As indicated, the 1,133 bed DNCA is adjacent to and will serve as an annex to CHCF. DNCA will
house intermediate‐care patient‐inmates needing enhanced medical services and Enhanced
Outpatient Program (EOP) patient‐inmates with EOP‐level mental health needs. This project is
continuing under an aggressive construction schedule. To date, construction is approximately
90 percent complete.
Upgrade Administrative and Clinical Facilities in CDCR’s Existing Prisons
The HCFIP projects continue to progress through the PWB approval and PMIB funding
processes. To date, 22 projects have received PWB project
‐level approvals and interim
financing from PMIB. Contracts for developing site‐specific designs for the 22 approved projects
have been finalized. CDCR’s current schedules reflect project authorization and funding
submittals to PWB and PMIB for the remaining projects sequenced through August 2014.
The statewide medication distribution projects received PWB approval in September 2012
(PMIB funding is not required since these are funded with State General Funds). These projects
received PWB approval of preliminary plans in November 2013 and construction drawings are
now being developed.
CDCR Performance under the September 21, 2009 Revocable Delegation of Authority For
Construction Oversight
CDCR continues to demonstrate a high level of commitment, focus, and ability to effectively
manage the health care construction projects. FPCM continues to effectively manage the
facility issues of the CHCF, which are to be expected of a newly constructed facility. FPCM is
demonstrating the same abilities and commitment to a timely and successful completion of the
DNCA project.
Confidence in the HCFIP schedules continues as additional projects are approved by PWB and
funded by PMIB and as preliminary plans for approved projects receive subsequent PWB
approval. To date, of the 32 planned HCFIP projects (including the statewide medication
distribution projects), 6 authorized projects have received PWB approval of preliminary plans
and are now in the working drawings phase; 16 authorized projects are in the preliminary
planning phase; and project authorizations for the remaining projects are in various stages of
development and/or stages of the approval process. Architectural & Engineering contracts have
been executed for all 22 approved projects and contracts for the next two projects have been
negotiated and are in the process of being executed.
Facility Construction
With the exception of SQ, which had physical plant upgrades constructed under the
Receivership to address lack of treatment and clinic space, the Plata Court Experts found that
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all of the facilities they visited had serious physical plant issues. Their observations underscore
the importance of completing the HCFIP program as quickly as possible.

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Section 8: Conclusion
As the above makes clear, we are continuing to make durable improvements to CDCR’s health
care system. Progress has not always been in a straight line, and for every success, we discover
additional room for improvement, some of which we have discovered for ourselves, some of
which is reported by plaintiffs’ counsel, and some of which is discovered by the Plata Court
Experts. We believe that, working collaboratively with CDCR, the OIG and the Court Experts, we
stand a good chance of making significant progress during the coming year.

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