REPORT OF
THE
STATE AUDITOR

Department of Corrections
Internal Health Care Provided to Inmates
Performance Audit
September 2005

LEGISLATIVE AUDIT COMMITTEE
2005 MEMBERS
Representative Val Vigil
Chair

Senator Norma Anderson
Vice-Chair

Representative Fran Coleman
Senator Deanna Hanna
Representative David Schultheis
Senator Stephanie Takis
Senator Jack Taylor
Representative Al White

Office of the State Auditor Staff
Joanne Hill
State Auditor

Cindi Stetson
Deputy State Auditor

Becky Richardson
Tobin Bliss
Mette Boes
John Conley
Legislative Auditors

STATE OF COLORADO
OFFICE OF THE STATE AUDITOR
303.869.2800
FAX 303.869.3060

JOANNE HILL, CPA
State Auditor
Legislative Services Building
200 East 14th Avenue
Denver, Colorado 80203-2211

September 14, 2005

Members of the Legislative Audit Committee:
This report contains the results of a performance audit of the Department of
Corrections. The audit was conducted pursuant to Section 2-3-103, C.R.S., which
authorizes the State Auditor to conduct audits of all departments, institutions, and agencies
of state government. The report presents our findings, conclusions, and recommendations,
and the responses of the Department of Corrections.

TABLE OF CONTENTS
PAGE
REPORT SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Recommendation Locator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
OVERVIEW OF INTERNAL HEALTH CARE
PROVIDED TO INMATES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
FINDINGS AND RECOMMENDATIONS
CHAPTER 1. QUALITY OF CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Health Intake Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Medical Record Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Management Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
CHAPTER 2. COST CONTAINMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Copayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Prescription Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

STATE OF COLORADO
OFFICE OF THE STATE AUDITOR

REPORT SUMMARY

JOANNE HILL, CPA
State Auditor

Internal Health Care Provided to Inmates
Performance Audit
September 2005
Authority, Purpose, and Scope
This performance audit was conducted pursuant to Section 2-3-103, C.R.S., which authorizes the
Office of the State Auditor to conduct performance audits of all departments, institutions, and
agencies of state government. The audit work, performed between February 2005 and May 2005,
was conducted in accordance with generally accepted governmental auditing standards. During this
audit we reviewed the medical services provided internally to inmates at state-run adult correctional
facilities. As part of the audit, we engaged the services of the Caley Gordon Group to evaluate the
quality of medical care being provided by the Department at its on-site clinics. The audit did not
review dental and optometry services, substance abuse, mental health, or sex offender treatments,
nor did the audit evaluate the services provided by the Department’s external health care
administrator, which were evaluated in the April 2005 Performance Audit of External Health Care
Services Provided to Inmates.

Overview
The Department of Corrections’ (Department) Division of Clinical Services (Division) is responsible
for ensuring that inmates receive health care services during their incarcerations at state-run adult
correctional facilities. The Division’s clinical staff provide primary and emergency care on-site at
clinics located in 20 of 21 state-run correctional facilities. In addition to the 20 clinics, the Denver
Reception & Diagnostic Center and the Colorado Territorial Correctional Facility have infirmaries.
In Fiscal Year 2005 the Division provided medical services to a total of about 21,700 inmates and
each inmate visited the clinics and infirmaries an average of about seven times.
The Division’s funding derives almost entirely from the State’s General Fund. In Fiscal Year 2005
the Division spent almost $61 million to provide health care services to inmates. Of this total,
almost $33 million was spent on the internal medical services provided at its clinics and infirmaries.

For further information on this report, contact the Office of the State Auditor at 303.869.2800.

-1-

SUMMARY
2

Internal Health Care Provided to Inmates Performance Audit - September 2005

Summary of Audit Comments
Quality of Care
The first contact inmates have with clinical staff is upon entry or reentry into the State’s correctional
system. It is at this point the Department conducts intake screenings and examinations. After
inmates are transferred to their assigned facilities, medical care (with the exception of emergency
and inpatient care) is provided on-site at the facilities’ clinics and infirmaries. We evaluated both
the medical intake and ongoing medical care provided at the facilities and found:
•

Health intake procedures are not being completed for all inmates in a timely and
comprehensive manner. Statutes require the Department to conduct an assessment of each
inmate’s mental health, substance abuse, and medical treatment needs upon entry or reentry
into the correctional system. The Department has established standards and time frames
outlining the medical screening and examination activities that are to occur during this
process. We sampled a total of 99 male and female inmates and found that 51 inmates did
not receive the complete series of necessary screenings and examinations. Further, for the
48 inmates who did receive all of the required screenings and examinations, only 12 received
these within the required time frames. We provided this information to the Department. As
of September 2005, the Department reports that screenings for 36 of the 51 inmates have
been completed, screenings for 3 inmates are pending, and the remaining 12 inmates are no
longer in the Department’s custody.

•

Greater uniformity and consistency is needed to deliver quality care at the clinics. We
reviewed a sample of 236 inmate clinical visits that occurred during the first nine months of
Fiscal Year 2005 and found quality-of-care concerns in 86 of the records (36 percent).
Further, we identified almost 100 actions, inactions, or underlying causes at the
Department’s clinics that led to these quality-of-care concerns. To address these issues, the
Department needs to ensure staff apply all standards, guidelines, and protocols consistently.
Additionally, the Department needs to standardize drug treatments across facilities by
incorporating drug therapies into disease management and chronic care guidelines and
protocols. Finally, the Department needs to ensure inmates’ medical records contain all
relevant information on the care received both at the clinics and from external providers.

Management and Oversight
We evaluated the Department’s oversight and management of the systemwide delivery of internal
health care services and found:
•

Critical components are lacking in the Quality Management Program. We found flaws
in the design and operation of the Quality Management Program that have, for the most part,
diminished its effectiveness. Specifically, the Program operates as a fragmented system of

Report of The Colorado State Auditor

SUMMARY
3

numerous committees that meet inconsistently. Further, quality management reviews have
focused primarily on retrospective reviews of complaints, incidents, or deaths and generally
have not included prospective ongoing reviews, such as reviewing the routine medical
decisions made by staff.
•

Available data are not being used sufficiently for management decision-making. The
Department does not routinely analyze or access basic programmatic data, such as medical
grievances related to health care services, lawsuits resulting from clinical activities, and
numbers of emergency room visits. Additionally, the Department does not routinely compile
and analyze information from inmate medical records to assess trends.

•

Documented evidence of systemwide staffing analysis is lacking. During our audit we
found wide variability in staffing levels and costs among the Department’s clinics. During
Fiscal Year 2005 clinic costs per inmate ranged from about $500 to $5,800, depending on
the clinic. According to Department staff, these and other differences in costs, staff-toinmate ratios, and other workload measures can be explained by the distinct characteristics
of each facility. Department staff report they distribute clinical staff among the facilities
based on various factors, such as the number of inmates with chronic conditions, the number
of facility lock downs, and the ratio of the various staffing levels to inmates. However, the
Department lacked analysis demonstrating how these factors led to the staffing levels and
mixes currently in place at each clinic. Without systematic and comprehensive staffing
analyses, the Department does not have a sound basis upon which to support permanent
staffing decisions and cannot determine whether its clinics are performing optimally within
the resources available.

Cost Containment
Many factors contribute to rising health care costs in correctional facilities, including a growing
inmate population, increasing numbers of female inmates, longer incarcerations, aging inmates,
expensive services for chronic and communicable diseases, and costly prescription medications. We
reviewed measures available to the Department to generate revenue and contain costs, and found:
•

Contrary to statutory intent, copayments are not assessed for all clinic encounters.
Statutes require the Department to charge consistent copayments for every medical, mental
health, dental, and optometric service provided to inmates. We found that the Department’s
regulations categorically exclude about one-half of all encounter types, including follow-up
appointments, from copayment charges. In Fiscal Year 2005 only 26 percent of all medical
encounters (39,800 of 153,300) were assessed a copayment due to these exclusions. Medical
encounters have increased by 70 percent (in comparison to a 1 percent increase in the inmate
population) from Fiscal Years 2004 through 2005, raising questions about the effectiveness
of the Department’s application of copayments. Further, if the Department had charged the

SUMMARY
4

Internal Health Care Provided to Inmates Performance Audit - September 2005

$5 copayment on all medical encounters in Fiscal Year 2005, it could have collected about
$766,400, or more than three times the $209,900 that it actually collected.
•

The formulary is outdated and an ineffective management tool. The formulary has not
been updated since 2002 and consequently, does not include some drugs shown to be
effective in treating certain medical conditions at a lower cost. For example, we found the
Department could have saved about $22,800 by replacing Zomig with Midrin, a nonformulary migraine medication that is effective and less costly. An outdated formulary also
forces physicians to prescribe many off-formulary medications, which creates additional
administrative work for the pharmacy and unnecessary delays in dispensing. Over a threemonth period, the pharmacy manager approved all but 9 of the approximately 260 nonformulary medication requests, for an approval rate of 97 percent. Further, 80 of these nonformulary requests (31 percent) were for the same five medications.

•

Sufficient controls are lacking for drug inventories. The Division uses an electronic
Medication Administrative Record system to track the types and quantities of medications
dispensed to inmates through the clinics. However, we found that clinic staff enter data in
the electronic system inconsistently and therefore, data are not accurate or reliable.
Additionally, the Department lacks controls over the destruction of medications. Clinic staff
do not consistently record the exact amount of medications destroyed, use secure methods
of destroying medications, or obtain a witness when medications are destroyed.

Our recommendations and the responses of the Department of Corrections can be found in the
Recommendation Locator and in the body of this report.

RECOMMENDATION LOCATOR
Rec.
No.

Page
No.

Recommendation
Summary

Agency
Addressed

Agency
Response

Implementation
Date

1

19

Meet health intake standards for all inmates by (a) reassessing current intake
processes and procedures and developing appropriate strategic and
contingency plans for completing all mandatory screenings and
examinations; (b) communicating any changes to intake and clinical staff;
and (c) developing a mechanism for tracking completion of the intake
process and any subsequent clinical followup.

Department of
Corrections

Agree

July 2006

2

25

Ensure the consistent application of current standards of care by (a)
evaluating and updating current standards, guidelines, and protocols; (b)
developing checklists and flow sheets for use by staff and for inclusion in
inmates’ medical records; and (c) conducting more routine and
comprehensive reviews of medical records.

Department of
Corrections

Agree

January 2006

3

28

Improve medication management policies and practices by (a) developing
and ensuring compliance with drug treatment protocols; (b) making
additional, easily accessible drug-drug interaction and drug-disease
information available for use by clinical staff; (c) reevaluating policies and
establishing a formal process for approving over-the-counter medications for
sale through Canteen Services; and (d) adopting a medication alert system
to notify clinical staff of medical conditions or over-the-counter medications
that could be contraindicated for certain inmates.

Department of
Corrections

Agree

July 2006

4

30

Ensure inmate medical records are complete and current by (a) adopting
procedures for periodic review of medical records to ensure compliance with
established policies and formats and (b) developing methods to ensure
external provider information is received and appropriate follow-up care and
treatment is provided in a timely manner.

Department of
Corrections

Agree

July 2006

-5-

RECOMMENDATION LOCATOR
Rec.
No.

Page
No.

Recommendation
Summary

Agency
Addressed

Agency
Response

Implementation
Date

5

34

Develop and implement a comprehensive and proactive quality management
program by (a) reassessing and revising the current structure to ensure
committees are multidisciplinary, that they meet and report regularly, that
responsibility and accountability are clearly assigned; (b) routinely
identifying and reviewing programs, activities, and quality-of-care issues at
both clinic and staff levels as well as systemwide; and (c) developing and
measuring outcomes related to the quality of care provided to inmates.

Department of
Corrections

Agree

July 2006

6

37

Improve use and management of critical decision-making information by
periodically reviewing key operating data, developing additional data
sources, ensuring the accuracy and reliability of data, taking steps to
minimize data discrepancies among facilities, and monitoring for
compliance among clinics and clinic staff.

Department of
Corrections

Agree

July 2006

7

40

Ensure clinic staffing levels are appropriate and provide efficient, quality
health care by (a) identifying all critical factors needed to establish optimal
staffing levels; (b) conducting and documenting regular staffing analyses;
and (c) making permanent and temporary staffing changes based on the
annual analysis.

Department of
Corrections

Partially
Agree

January 2006

8

47

Ensure copayment policies and practices comply with statutory intent by
either assessing copayments for every type of clinic encounter or proposing
legislation to include current regulatory exclusions in statute.

Department of
Corrections

Agree

January 2006

-6-

RECOMMENDATION LOCATOR
Rec.
No.

Page
No.

Recommendation
Summary

Agency
Addressed

Agency
Response

Implementation
Date

9

51

Ensure the cost-effectiveness of prescription drug practices by (a)
conducting a systematic and comprehensive review and update of the current
formulary; (b) including a date-specific time for the establishment of an
updated formulary in the contract with an outside provider; (c) establishing
and maintaining a schedule for monitoring prescription patterns and drug
utilization, including adherence to a regular calendar of review committee
meetings; and (d) controlling non-formulary requests through the use of
prior authorization approval and monitoring.

Department of
Corrections

Agree

March 2006

10

53

Take immediate steps to improve drug inventory management practices by
(a) ensuring staff are consistently and accurately entering data into the
electronic medication inventory system; (b) adopting a standard drug
destruction policy for implementation at the clinics; and (c) regularly
monitoring staff and clinic compliance with the drug inventory management
policies.

Department of
Corrections

Agree

March 2006

-7-

9

Overview of Internal Health Care
Provided to Inmates
Background
The Department of Corrections’ (Department) Division of Clinical Services
(Division) is responsible for ensuring that inmates receive health care services during
their incarcerations at state-run adult correctional facilities. The Division’s mission
is to deliver cost-effective, quality health care comparable with community
standards. To fulfill this mission, the Division provides medical, optometry, and
dental services as well as substance abuse, mental health, and sex offender treatment
to an average daily population of about 14,000 inmates housed in state-run facilities.
Division clinical staff provide primary and emergency care on-site at clinics located
in the Department’s correctional facilities throughout the State. In addition, as
described in our April 2005 Performance Audit of External Health Care Services
Provided to Inmates, the Division provides inpatient hospital services, outpatient
tests and procedures, specialty physician consultations, and ancillary services
through a contractual arrangement with an external health care administrator. The
Division does not administer the health care provided to the approximately 2,800
inmates housed in Colorado’s six private prisons. Health care for these inmates is
provided by the private prisons’ operators and overseen by the Department, as
explained in our Performance Audit of Private Prisons, also released in April 2005.
Our current audit focuses on the internal medical services provided by the
Department at its on-site clinics.

Services
All but one of the Department’s 21 state-run correctional facilities operate on-site
medical clinics. The Colorado Correctional Center, a minimum security facility
located in Golden, usually transports its inmates to the Denver Reception &
Diagnostic Center (DRDC) for their health care needs. In addition to the 20 clinics,
two facilities – DRDC and the Colorado Territorial Correctional Facility (CTCF) in
Canon City – house infirmaries. Most clinics operate between 16 and 18 hours a
day, while the infirmaries are staffed around the clock. The clinics and the
infirmaries are capable of treating inmates with acute and chronic medical
conditions. However, unlike the clinics, the infirmaries have permanent beds for the
chronically ill, as well as for inmates recovering from surgery performed at outside
hospitals.

10

Department of Corrections
Internal Health Care Provided to Inmates Performance Audit - September 2005

The Department staffs its clinics and infirmaries with full-time equivalent (FTE)
employees and some contractual personnel. When needed, staff physicians refer
inmates for external diagnosis or treatment at local hospitals or specialty clinics.
Programmatically, the Division administers the following:
•

Reception and diagnostic. The Division oversees the intake and initial
health assessment of all inmates upon entry or reentry into the correctional
system. Male and female inmates are assessed at DRDC and the Denver
Women’s Correctional Facility (DWCF), respectively. The initial health
assessment includes medical, mental health, dental, and substance abuse
evaluations. See Chapter 1 for details and findings related to the health
intake process.

•

Clinic visits. Physicians, physician assistants, licensed nurse practitioners,
certified practical nurses, and regular nurses staff the clinics and provide a
range of services, including emergency and non-emergency treatment,
medication distribution, optometry, mental health, and dental care. See
Chapter 1 for details and findings related to the quality of care.

•

Infirmary. As previously mentioned, the Division provides skilled nursing
care at the DRDC and CTCF infirmaries. The infirmaries provide pre- and
post-hospital care, special testing, and treatment of low resource-intensive
and acute and chronic conditions. The CTCF infirmary also offers licensed
hospice services. See Chapter 1 for details and findings related to the quality
of care.

•

Ancillary. For most ancillary services, such as laboratory screenings, the
Department contracts with outside providers. However, some clinics provide
radiology services, and prescription medications are currently provided to all
facilities through the Department’s pharmacy in Pueblo. See Chapter 2 for
details and findings related to pharmacy services.

The American Correctional Association (ACA) has accredited all but four of the
Department’s clinics and infirmaries. To be accredited by ACA, the entire
operations of a correctional facility must meet the standards, including physical
plant, security, programming, and health care services. According to Department
staff, the Department has not sought ACA accreditation for the Buena Vista,
Colorado Territorial, Fort Lyon, and Fremont correctional facilities because the
overall age and physical condition of these facilities prevent them from meeting the
standards. Therefore, for these four clinics and infirmaries to be accredited, the
entire facilities in which they are located would first have to be brought up to ACA
standards. In addition to ACA accreditation, all of the Department’s clinics and

Report of The Colorado State Auditor

11

infirmaries are licensed as “community clinics” by the Colorado Department of
Public Health and Environment.

Usage
On any given day in Fiscal Year 2005, the Department housed an average of about
14,000 inmates in its state-run adult correctional facilities. Throughout the year,
many more inmates than the average daily population of approximately 14,000 enter
and leave the State’s correctional system. Therefore, in Fiscal Year 2005 the
Division provided medical services to a total of about 21,700 different inmates. As
seen in the table below, these inmates visited the clinics and infirmaries a total of
approximately 153,300 times. This means that each inmate who resided in one of
Colorado’s state-run correctional facilities, at some time during Fiscal Year 2005,
visited a clinic or infirmary an average of about seven times. Furthermore, the
Department’s infirmaries have a total of 68 beds. In Fiscal Year 2005, on average,
about 67 percent of the infirmary beds at DRDC and 84 percent of the beds at CTCF
were occupied.
Department of Corrections
Encounters per Inmate
Fiscal Years 2002 Through 2005
Fiscal Year
2002
Total Encounters
Total Inmates Served
Encounters per Inmate

Fiscal Year
2003

Fiscal Year
2004

Fiscal Year
2005

Percent Change
Fiscal Years
2002 – 2005

118,600

108,400

90,300

153,300

29%

18,000

18,100

18,400

21,700

21%

6.6

6.0

4.9

7.1

8%

Source: Office of the State Auditor’s analysis of Department of Corrections’ data.

Fiscal Overview
In Fiscal Year 2005 the Division spent a total of about $61 million for internal and
external health care services, and employed more than 420 full-time equivalent
(FTE) positions. The Division’s funding derives almost entirely (99 percent) from
the General Fund. The remaining 1 percent is cash funds ($224,700) and cash funds
exempt ($114,200). The source for cash funds is copayments for health care
services, which we discuss later in Chapter 2. The source for cash funds exempt is
federal funds transferred from the Division of Criminal Justice for the purchase of

12

Department of Corrections
Internal Health Care Provided to Inmates Performance Audit - September 2005

computers at the facility clinics. Of the total $61 million expended during Fiscal
Year 2005:
•

$33 million (54 percent) was spent on internal medical services, including
purchasing medications and contract staff to supplement staffing vacancies.

•

$25 million (41 percent) was spent on external medical services, including
inpatient and outpatient hospital services provided through an external health
care administrator.

•

$3 million (5 percent) was spent on other health care services, such as dental.

The costs for providing internal medical services has increased by 12 percent
between Fiscal Years 2002 and 2005. Since Fiscal Year 2002 these increases in
internal costs have been primarily in personal services and prescription medications.

Audit Scope
Our audit focused on the medical services provided internally to inmates at state-run
adult correctional facilities. Our current audit did not include a review of external
services; dental and optometry services; or substance abuse, mental health, and sex
offender treatments. As part of the audit, we collected and analyzed data,
interviewed management and staff, surveyed other states, and analyzed relevant
national data and research literature. We conducted site visits to clinics located
within the Arkansas Valley, Arrowhead, Buena Vista, Colorado State Penitentiary,
Denver Women’s, Four Mile, Fremont, Limon, San Carlos, and Sterling correctional
facilities. We also visited the intake clinic and infirmary at DRDC and the pharmacy
at Pueblo. During our visits we toured the clinics, observed their daily operations,
interviewed staff, and reviewed a sample of inmate medical records.
In addition, we contracted the services of the Caley Gordon Group, whose staff
included both a Colorado-licensed physician and a pharmacist. The purpose of these
services was to evaluate the quality of medical care being provided by the
Department at its on-site clinics. Included in the evaluation was a review of inmate
medical records and an analysis of encounter data from the Department and its
external health care administrator. The findings of this review are discussed in detail
in Chapter 1.

13

Quality of Care
Chapter 1
Overview
Inmates have a well-established constitutional right to health care. In 1976 the
Supreme Court ruled in Estelle v. Gamble that an inmate’s right to health care is
embodied in the Constitutional protection from “cruel and unusual punishment.”
Since that time, three basic rights have emerged in the case law: (1) the right to
access health care, (2) the right to care that is ordered, and (3) the right to a
professional medical judgment. According to the U.S. Department of Justice’s
National Institute of Corrections (NIC), to provide for constitutional care and to
protect against litigation, correctional administrators must adopt procedures to
protect inmates’ basic rights, including:
...a functioning sick call system..., a means of addressing medical
emergencies, a priority system so that those most in need of care
receive it first, the development and maintenance of adequate medical
records, liaison with outside resources for specialist and hospital care
when needed, a system for staff development and training, and an
ongoing effort at quality control.
Achieving these goals in a correctional setting presents many unique challenges not
necessarily present in the general population. First, inmates have a higher incidence
of chronic and communicable diseases. According to the National Commission on
Correctional Health Care, the prevalence of infectious diseases, such as active
Hepatitis-C infection, HIV/AIDS, and active tuberculosis, is significantly greater
among the inmate population than among the population as a whole. Second, many
inmates suffer from years of alcohol and substance abuse. For example, according
to the Government Accountability Office, 74 percent of female inmates used drugs
regularly before incarceration. Third, many inmates have had little or no health
care prior to incarceration. Moreover, correctional systems have additional
considerations, including transportation, security, and recruiting and retaining
qualified medical personnel.
In this chapter we present our findings and recommendations related to the quality
of medical care provided internally to inmates at clinics located in 20 of Colorado’s
state-run adult correctional facilities. We begin our review with the initial contact
the Department of Corrections’ (Department) clinical staff have with inmates at the

14

Department of Corrections
Internal Health Care Provided to Inmates Performance Audit - September 2005

time of their entry or reentry into the correctional system. We then discuss the
ongoing care inmates receive after they arrive at their assigned facilities, and make
recommendations specific to the care provided at the clinics and infirmaries. Finally,
we present our findings related to systemwide oversight and management.

Health Intake Process
By statute, the Department is required to conduct an assessment of each inmate’s
mental health, substance abuse, and medical treatment needs upon entry or reentry
into the correctional system. This initial health appraisal is crucial because it
addresses immediate and potentially life threatening medical conditions, identifies
communicable diseases, and establishes health benchmarks for each inmate.
According to the National Institute of Corrections, the intake health screening may
be the single most important health standard for correctional facilities to meet.
The Department conducts its health-related intake assessments at two facilities: male
inmates are evaluated at the Denver Reception & Diagnostic Center (DRDC) and
female inmates at the Denver Women’s Correctional Facility (DWCF). According
to data provided by the Department, about 8,700 inmates were processed through
intake in Fiscal Year 2005. On average, DRDC received about 29 male inmates per
business day and DWCF received about 4 female inmates per business day.
The Department has established standards outlining the medical screening and
examination activities that are to occur during intake. According to Department
management, the standards are based on national protocols established by health care
organizations, such as the American Cancer Society, American Diabetes Association,
and the National Institute of Health. In addition to requiring certain screenings and
examinations, the Department has adopted time frames within which the various
intake activities are to be completed, as follows:
•

First day. Inmates complete a self-reported medical history and a basic
medical interview, and undergo laboratory and diagnostic screenings for
communicable diseases and blood abnormalities. The first day is an
opportunity for clinical staff to gather basic, but vital, health information
from each inmate. Clinical staff report that based upon the results of the
medical interview, they separate inmates with emergency and nonemergency
conditions. Inmates with medical emergencies are immediately referred for
further examination. Clinical staff estimate that about 5 percent of incoming
inmates require immediate emergency care.

Report of The Colorado State Auditor

15

•

Third day. Inmates receive a complete physical examination, vision
screening, and a statutorily required blood draw for the Colorado Bureau of
Investigation’s DNA database.

•

Additional mandatory screenings. Based on an inmate’s age, gender, or
certain preexisting medical conditions, he or she must undergo additional
screenings. These include diabetic blood sugar screenings, prostate and
colon cancer screenings for men over the age of 50, and breast examinations
for all women. According to the Department’s Clinical Standard and
Procedure for Preliminary Screenings and Periodic Health Examinations,
some of these additional screenings are to be performed on the first day at
DRDC. Others may be completed at DRDC or, later, at the inmate’s
assigned facility.

Finally, after an inmate is transferred from DRDC or DWCF to his or her assigned
facility, clinical staff at that facility are required to review the inmate’s medical
record within 72 hours.
We evaluated the Department’s medical intake activities to determine whether
inmates are receiving the required screenings and examinations within the specified
time frames. We sampled a total of 99 male and female inmates who entered the
State’s correctional system from September 2004 through March 2005. We found
the Department did not complete the health intake procedures for 51 of these 99
inmates. Further, for the 48 inmates who did receive all of the required screenings
and examinations, only 12 received these within the required time frames. Upon
completion of our intake review, we provided the Department with the details so that
staff could take appropriate follow-up action, as needed. According to the
Department, staff reviewed and followed up on the 51 inmates who did not receive
the complete series of necessary screenings. As of September 2005, the screenings
for 36 of these 51 inmates have been completed, screenings for 3 inmates are
pending, and the remaining 12 inmates are no longer in the Department’s custody.
Overall, we found that the Department does not sufficiently prioritize those inmates
with greater health needs. Rather, inmates who are generally healthy or who have
fewer preexisting medical needs are more likely to receive complete and timely
health intake assessments, as described in the following sections.

Comprehensive Intake
As previously described, depending upon inmates’ preexisting medical conditions
or certain personal characteristics, additional screenings and examinations are
required. We found that the Department is not administering these additional

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Department of Corrections
Internal Health Care Provided to Inmates Performance Audit - September 2005

screenings to all of the inmates requiring them. Of the 99 inmates in our sample, 66
had characteristics requiring additional mandatory screenings and examinations. Of
these 66 inmates, 51 (77 percent) did not receive the complete series of necessary
screenings. Inmates required as many as nine additional screenings and
examinations. For example, inmates over 40 years of age are to receive a cholesterol
screening to identify the risk of heart disease. As the following table shows, staff did
not administer the required cholesterol screenings to 76 percent of inmates requiring
them. Clinical staff also did not administer the required colon cancer screenings to
9 of the 13 inmates over 50 years of age.
Department of Corrections
Additional Mandatory Screenings and Examinations
September 1, 2004 Through March 31, 2005

Type of Screening or
Examination

Number of Inmates
Requiring
Screening1

Number of
Inmates Not
Receiving
Required
Screening

Percent of
Inmates Who Did
Not Receive
Required
Screening

Cholesterol

34

26

76

Hypothyroid

30

8

27

Thyroid Function

27

10

37

Blood Sugar

26

18

69

Psychiatric

19

4

21

Hepatitis Panel

17

9

53

Breast

17

2

12

Urinalysis

15

4

27

Colon Cancer

13

9

69

Nutrient & Electrolyte

13

4

31

Chest X-Ray

10

9

90

EKG

10

2

20

Prostate Cancer

10

2

20

Sickle Cell

7

7

100

Diabetes

3

0

0

Source: Office of the State Auditor’s analysis of Department of Corrections’ inmate
medical records.
1
Many inmates are recorded in more than one category because they required multiple
screenings and/or examinations.

Report of The Colorado State Auditor

17

Timely Intake
From our sample of 99 inmates, we identified 48 who received complete intake
screenings and examinations. However, only 12 of these 48 inmates received all of
the mandatory screenings and examinations within the time frames specified in the
Department’s Clinical Standards and Procedures. Although most of the inmates’
screenings and examinations were completed within one to two weeks, some were
delayed by more than one month, as described below:
•

Forty percent (19 of 48) did not receive physicals on the third day of intake.
Additionally, 6 of these 19 inmates (32 percent) did not receive their
physicals within the American Correctional Association’s (ACA), the
Department’s accrediting body, national standard of 14 days. The longest an
inmate waited for a physical exam was 32 days after arriving at DRDC.

•

Twenty-three percent (11 of 48) did not receive the required psychiatric
examinations and mandatory screenings, including those for tuberculosis and
hepatitis, within the specified time frames. One inmate waited 82 days for
a hepatitis screening.

•

Thirty-eight percent (18 of 48) did not have their medical records reviewed
by staff within 72 hours after arriving at their assigned facilities.
Additionally, during the period of our review we found that staff did not
review the medical records for 2 of these 18 inmates. The records for the
other 16 inmates were reviewed within six weeks of their arrival at their
assigned facilities.

When clinical staff are unable to conduct all of the physical examinations on the
third day of intake, staff told us they informally prioritize the overdue physicals for
completion as soon as possible. According to clinical staff, this prioritization is
based on the inmates’ medical needs. However, we did not always find this to be the
case. For example, two inmates arrived at DRDC within a day of one another. One
inmate had a family history of cancer, multiple health problems including two prior
heart surgeries, chronic hypertension, and lower back problems. This inmate did not
undergo a physical for six days. The other inmate, with no identified health risks,
was examined on the third day. A wait of six days for a physical exam may not
appear to be excessive especially when compared with the length of time members
of the general public sometimes wait for medical appointments. However, there are
several critical distinctions in a closed institutional setting that make timeliness an
issue.
First, there is a higher risk of infectious or communicable disease in a prison setting.
Second, inmates are the responsibility of the Department. As such, a comprehensive

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Department of Corrections
Internal Health Care Provided to Inmates Performance Audit - September 2005

and timely medical intake serves as the foundation for meeting inmates’ medical
needs and for ensuring a level of quality health care during their incarcerations. By
not administering all mandatory screenings, the Department cannot ensure that all
chronic conditions are identified. According to the Department’s standards, delays
in diagnosis and treatment can result in “permanent material impairment, permanent
loss of function, or unmanageable pain.” Unidentified or untreated chronic
conditions, such as hypertension or diabetes, can lead to congestive heart failure,
stroke, renal failure, and even death. Additionally, failure to conduct screenings and
examinations increases the Department’s legal liability. Finally, in addition to the
individual and public health benefits from timely and complete health assessments,
the cost savings resulting from early detection and treatment are well documented
in the medical community.

Intake Process Improvements
The problems we identified are not new or isolated occurrences. Rather, they are the
result of a continuing combination of factors that show no signs of changing unless
the Department takes action to address them. Overall, the Department needs to
strengthen its intake process by undertaking the following corrective measures:
•

Planning. According to DRDC staff, when more than 35 inmates arrive at
the facility per day, it is difficult to process all of them through intake in
accordance with the established time frames. Resource limitations, including
an insufficient number of private rooms for physical and psychiatric
examinations, lessen staff’s ability to complete intake in a timely manner.
Although the Department has taken temporary steps to address backlogs,
such as occasionally transferring in staff from other facilities to assist, it has
not developed long-term solutions for this problem.

•

Prioritization. As previously mentioned, one of the standards correctional
administrators need to establish and achieve is a system of prioritization, or
triage, so that those most in need of care receive it first. Administering
intake based on need provides greater assurance that inmates with chronic or
more serious medical conditions or risks receive more timely access to
medical care.

•

Communication. Within a nine-month period, the Department changed
components of its intake standards three times without effectively
communicating the changes to clinical staff. In addition, staff at both DRDC
and the clinics we visited were unclear about where responsibility lay for
follow-up and completion of screenings begun or never performed at DRDC.
According to Joint Commission Resources, an affiliate of Joint Commission
on Accreditation of Healthcare Organizations (JCAHO), communication is

Report of The Colorado State Auditor

19

a critical component in delivering quality care. The JCAHO reports that
communication problems were the primary cause of about two-thirds of all
events reported to it, including medication errors and delays in treatment.
•

Compliance monitoring. The Department does not review inmate medical
records to ensure all essential screenings and examinations are completed in
a timely manner. In addition, no tracking mechanism exists to ensure that
appropriate follow-up occurs after the inmates arrive at their assigned
facilities. The Department needs to develop the necessary mechanisms to
monitor and track intake procedures, such as checklists and sign-off sheets,
and hold staff and clinics accountable for incomplete and untimely intakes.

The Department needs to improve its health intake process to ensure that standards
are met and inmates receive complete and timely assessments. According to
Department management, completion of some of the current mandatory tests and
screenings is not necessarily critical within the existing time frames. If this is the
case, the Department needs to revise its intake standards and time frames, and
communicate changes to all clinical staff. Responsibility for completing intake
screenings and examinations and follow-up should be clearly assigned, whether at
DRDC or at the facilities. If shifting responsibility for some screenings and
examinations to the facilities results in an increased burden on facility staff, the
Department should adjust the intake time frames and staffing levels accordingly. A
system for prioritizing inmates’ medical conditions must be implemented, and longrange plans for addressing overflow and backlogs need to be developed. Finally, the
Department should adopt a mechanism for tracking the intake process to ensure
continuity of care across facilities and for all inmates.

Recommendation No. 1:
The Department of Corrections should ensure it meets health intake standards for all
inmates in a timely and comprehensive manner by:
a. Reassessing current intake processes and procedures, and developing
appropriate strategic and contingency plans for completing all mandatory
screenings and examinations.
b. Communicating any changes to intake and clinical staff.
c. Developing a mechanism for tracking completion of the intake process and
any subsequent clinical follow-up.

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Department of Corrections
Internal Health Care Provided to Inmates Performance Audit - September 2005

Department of Corrections Response:
Agree. Implementation date: July 2006. The Denver Reception &
Diagnostic Center (DRDC) was designed and built in 1989. At that time,
DRDC could accommodate a maximum intake of 15 inmates per day.
Currently, DRDC is processing 35 inmates or more per day and, at times, has
had to increase the number to 45 inmates a day to decrease jail backlog.
Plans were once developed to expand the intake area at DRDC, but had to be
dropped due to budget restrictions. In an attempt to accommodate this
physical resources challenge, the Department is in the process of creating
another examination room to be utilized for the midlevel providers, by
moving the mental health providers out of an existing room to another
building at DRDC. The Department is optimizing the resources and space
allotted, but the Department also realizes its resource limitations and many
variables that intermittently have an impact on operations.
The Department is developing a long-term solution to this problem. As a
result of its action, the Department is now fully staffed with clinical
managers. Currently, there is only one vacancy for a midlevel at DRDC.
The Department has increased the hours for the intake physician and is
currently keeping up with the backlog. The Department has reassessed its
strategy, and has decided to place a full time physician in the infirmary.
The Department agrees that there are opportunities for improving
communications and improving a mechanism for tracking completion of the
intake process, and any subsequent clinical follow-up. The Department will
further investigate the feasibility of checklists and other forms to improve
this process. In addition, the Department recently implemented a Quality
Management Program in October 2004 and is in the process of developing
the mechanisms for ensuring the completion of the required medical tests.

Medical Record Review
After inmates arrive at their assigned facilities, their medical needs are handled
through the clinics located in the Department’s facilities across the State. We
reviewed a sample of 236 inmate clinical visits that occurred during the first nine
months of Fiscal Year 2005 (July 1, 2004, through March 31, 2005). The purpose
of the review was to determine the quality of care provided, by assessing factors such
as the timeliness and appropriateness of care, Department oversight of care, and
standards of care. Our review was conducted by both a Colorado-licensed physician

Report of The Colorado State Auditor

21

and a pharmacist. Inmate medical records were randomly selected from the
categories below. We chose these categories because they represent situations in
which the clinical outcome, such as an emergency room or inpatient admission,
could have been positively or negatively affected by the care provided during the
clinic encounters. The categories chosen were:
•
•
•
•

Inmates with four or more external emergency room visits.
Inmates with an inpatient hospital admission.
Inmates with a hospital readmission within 30 days.
Inmates with an ambulatory clinic encounter.

In reviewing the medical records, if we identified a quality-of-care concern, we then
assigned a level of severity to the concern using the Department’s severity index.
The Department’s regulations outline several levels of severity when a quality issue
is identified and the actions to be taken in response to each of the levels. The
regulations also state that severity codes will be assigned by the chair and co-chair
of the Quality Management Committee “based on the circumstances of the incident,
including the potential for, or actual adverse outcome.” However, the regulations are
vague regarding the types of incidents, or potential or real adverse outcomes that are
to be associated with each level. Other health care providers or provider-related
groups, such as Mississippi’s Medicaid Peer/Utilization Review Organization, South
Dakota’s Medicare Peer Review and Quality Improvement Organization, and the
largest federally qualified health maintenance organization in Nevada, provide
greater direction to their reviewers for assigning severity levels or defining the
quality concerns identified. For example, Mississippi’s Medicaid quality-of-care
reviews use three levels of severity that define the levels as confirmed quality
problems with “minimal potential for significant adverse effect,” “potential for
significant adverse effect,” and “significant adverse effect.” Additional descriptors
and examples for each level are also provided to reviewers. South Dakota’s
Medicare review organization has developed a guide for reviewers that focuses more
on quality improvement than on the severity of concerns. Nonetheless, the reviewer
guide details severity levels and provides definitions for the specific types of
concerns identified, such as improper diagnosis, failure to establish an appropriate
treatment plan, or inappropriate assessment of laboratory tests. As we describe in
more detail later in this chapter, we believe the Department should adopt more
explicit criteria for assigning severity levels and the actions to be taken as part of its
quality management and review processes.
Because the Department’s regulations are vague about the types of quality concerns
to be assigned to each severity level, our physician and pharmacist reviewers used
their clinical expertise in determining the appropriate assignment of severity levels
for each quality-of-care concern they identified. Overall, as the following table

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Department of Corrections
Internal Health Care Provided to Inmates Performance Audit - September 2005

shows, we found that 64 percent of the inmate health records we reviewed had no
quality-of-care issues (150 of 236). For the other 86, or 36 percent of records, we
did identify quality-of-care concerns.
Department of Corrections
Quality of Care Concerns
Severity
of Concern
No Quality Issue

Number of
Records

Percent
of Total

150

64

80

34

Serious Quality Issue2

6

2

Death3

0

0

Totals

236

Quality Issue1

100%

Source: Office of the State Auditor’s review of 236 of the Department of Corrections’
inmate medical records for the period July 1, 2004, through March 31, 2005.
1
According to the Department of Corrections’ regulations, depending upon the severity
level of the concerns categorized here as “quality issues,” staff are either to collect and
monitor data for possible future intervention or to notify the medical provider or other
staff central to the issue.
2
Serious quality issues require a written statement to the Department of Corrections’
Quality Management Committee.
3
All deaths are to be referred to the Department of Corrections’ Peer Review Mortality/
Morbidity Committee to determine whether a quality-of-care issue contributed to the
death.

To identify opportunities for improving care, we further analyzed the quality and
serious quality concerns. We identified almost 100 actions or inactions at the
Department’s clinics associated with the 86 quality and serious quality issues shown
above. We grouped all of these actions, inactions, or underlying causes into various
categories, as illustrated in the following table. The three most frequently identified
categories were missed opportunities, lack of documentation, and lack of
comprehensive physical examinations by clinical staff.

Report of The Colorado State Auditor

23

Department of Corrections
Types of Quality Concerns
Number

Percent
of Total

Missed opportunities

25

26

Lack of documentation

20

21

Lack of comprehensive examinations by clinical staff

14

14

Lack of proper medication and monitoring

10

10

Inappropriate prescription of nonsteroidal antiinflammatory drugs

8

8

Delay in diagnosis or treatment

5

5

No evidence of following guidelines or nursing
protocols

5

5

Inmate noncompliance with prescribed care

4

4

Service unavailability

4

4

Inability of clinics to handle acuity of care

3

3

98

100%

Type of Concern

Totals

Source: Office of the State Auditor’s review of 236 of the Department of Corrections’ inmate
medical records for the period July 1, 2004, through March 31, 2005.

Again, we provided the Department with the details of our medical record review so
that staff could take appropriate follow-up action, as needed. According to the
Department, the six incidents that were identified as having serious quality-of-care
concerns are currently under review by the Quality Management Committee.
We believe the Department should do more to ensure its clinical staff provide a
uniform, consistent level of quality care. As a direct result of our medical record
review, we identified several specific areas in which improvements could be made
to reduce the number and frequency of quality concerns originating at the clinics.
These areas are detailed below.

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Department of Corrections
Internal Health Care Provided to Inmates Performance Audit - September 2005

Standards and Protocols
Clinical standards are requirements that correctional health care facilities must
achieve and maintain to ensure the delivery of quality health care. According to the
ACA, protocols are written instructions and procedures that guide implementation
of expected practices. The Department has adopted clinical standards, care
guidelines, and protocols. However, we found the need for improvement in a
number of areas:
•

Existing standards and protocols. The Department needs to expand its
clinical standards, particularly as they relate to chronic and common
conditions and diagnoses. Also, the Department should incorporate best
practices, such as Milliman recommendations, community standards, and
evidence-based medicine into its care management protocols and patient flow
sheets. Furthermore, use of the Department’s established standards varies
among clinics. For example, some clinics follow the comprehensive Clinical
Standard and Procedure for Hepatitis-C completely, while others do not.
Compliance with this standard, in particular, is important because hepatitis-C
is about 10 times more prevalent among inmates than among the general
population. In another example, we found that staff do not always comply
with the Clinical Standard and Procedure for Laboratory Services regarding
the review and sign-off of laboratory results. We found laboratory results
with no initials or dates, and delays of more than 30 days before staff
reviewed laboratory results.

•

Clinical assessments. We noted differences in the clinical assessments
performed and documented by clinical staff. Generally, clinical staff
documented physical examinations, clinical observations, and assessments
of vital signs, such as blood pressure, temperature, and pulse. However,
some physicians, mid-level practitioners, and nurses performed limited
exams, conducted incomplete or inadequate assessments to support diagnoses
or complaints, and did not record vital signs. We found that limited
examinations contributed to delays in diagnosis and treatment. In a few
cases, more costly treatment could have been avoided had complete work-ups
been performed and documented. For example, an inmate came into a clinic
with complaints of dizziness and black stools. Clinical staff did not perform
a hemoccult and delayed ordering blood tests for at least one additional day,
despite the inmate’s recent hospitalization for esophageal varices (an uneven,
permanent dilatation of the vein) and bleeding. Because the medical work-up
for this inmate was incomplete, treatment was delayed, resulting in his fiveday hospital stay.

Report of The Colorado State Auditor

•

25

Checklists and flow sheets. Using checklists and flow sheets helps ensure
clinical staff follow the appropriate evidence-based treatment steps and
provides a tool for monitoring compliance. In cases in which the Department
has developed flow sheets, such as for diabetes and coronary patients, we
could not always locate the sheets in the medical records for inmates with
these conditions. In other cases, such as for inmates with pulmonary
conditions, the Department has not developed disease-specific patient care
or peak flow assessment sheets for use by staff. In addition, even in medical
records that contained chronic care flow sheets, we found that staff did not
consistently or completely follow the guidelines or record all necessary
information.

The Department has adopted the national Milliman Care Guidelines and developed
the Clinical Standards and Procedures Manual to govern the care provided at the
clinics. However, the Department has not done enough to ensure clinical staff apply
these standards, guidelines, and protocols consistently. To ensure an adequate and
comparable level of care for all of its clinics, the Department needs to assess its
current standards to ensure they are up to date; incorporate additional reference tools,
such as community standards and evidence-based medicine, into its standards,
protocols, and patient care flow sheets; improve compliance with the required
standards by developing checklists and flow sheets for inclusion in inmates’ medical
records; and increase its compliance monitoring. This last step could be
accomplished through regular, random reviews of inmate medical records. The
reviews should assess the comprehensiveness of physical examinations, whether
ordered care occurred, and whether all pertinent clinical information is documented
in records.

Recommendation No. 2:
The Department of Corrections should ensure the consistent and complete
application of current standards of care throughout its clinics and among its clinical
staff by:
a. Evaluating its current standards, guidelines, and protocols, and making
changes or additions where needed.
b. Improving compliance by developing checklists and flow sheets for use by
staff and for inclusion in inmates’ medical records.
c. Monitoring for compliance by conducting more routine and comprehensive
reviews of medical records.

26

Department of Corrections
Internal Health Care Provided to Inmates Performance Audit - September 2005

Department of Corrections Response:
Agree. Implementation date: January 2006. The Department agrees that
improvements can be made to the system. Developing checklists and flow
sheets for use by staff and conducting more routine and comprehensive
reviews of medical records to monitor for compliance are areas the
Department will continue to investigate and implement changes where
needed. As previously stated, a Quality Management Program was initiated
in October 2004 followed by the development of a peer review process in the
Spring of 2005. In addition, one of the projects on our formal documented
agenda is developing a more official chronic care program, which will
include checklists and flow sheets. This project will be completed in the next
six to nine months.
The Department has taken steps to evaluate its current standards, guidelines,
and protocols. The Department has a policy and procedure committee that
meets monthly to review and revise existing standards and/or develop new
standards. This committee has been in effect for over a year and has
reviewed all of the existing policies and procedures. All of our existing
policies and procedures were revised this year. After each standard has been
reviewed and revised, it is sent to the Chief Medical Officer and the Chief of
Clinical Services for final approval and signature. One of the Department’s
projects this past year was to combine all of the existing nursing and provider
standards into one manual. This was accomplished in addition to writing an
entirely new infectious disease management program with all of the
associated new polices to include such topics as HIV, scabies, MRSA,
chickenpox, etc. All of the nursing protocols are in the process of being
reviewed and revised, and this project should be completed in the next 60-90
days.
The Department believes that the real issues are compliance of the providers
with the standards and improving clinical assessments. The Department is
already implementing peer review as a component of the Quality
Management Program and has an active project to formalize chronic care
along with the associated checklist and flow sheets. During the past six
months, all of the clinics have developed Continuous Quality Improvement
Committees. The committees can also be utilized for monitoring compliance
as well as outcomes.

Report of The Colorado State Auditor

27

Medication Management
Broadly defined, medication management is the system health care providers use to
handle medications effectively, including ordering and prescribing; procuring and
storing; preparing and dispensing; and administration and monitoring. During our
review of medical records, we identified several concerns related to the dispensing
of medications to, and the use of medications by, inmates that diminish the
effectiveness of the Department’s management of inmate medication. First, we
found that clinical staff do not always adjust drug therapy according to disease states.
That is, many drugs require lower dosages or adjusted dosing frequencies to avoid
drug toxicity. For example, we identified one inmate who had compromised renal
function. Doses for two drugs were not adjusted for this inmate based on his renal
function. We also identified a total of ten inmates who had histories of, or were
hospitalized for, gastrointestinal (GI) bleeding and had taken or were prescribed
nonsteroidal anti-inflammatory drugs (NSAID). These drugs can cause GI bleeding
and should not be taken by individuals with a known history of GI bleeding. Inmates
may also purchase some NSAIDs, such as Aleve and Motrin, over the counter,
through the Department’s canteens. In Fiscal Year 2004 Motrin was the third most
frequently purchased over-the-counter medication at the northern canteen and the
sixth most frequently purchased medication at the central canteen.
We did not find any instances of drug toxicity related to emergency room or hospital
admissions. However, failure to adjust drug therapy or to adequately monitor
inmates’ use of over-the-counter medications, increases the likelihood for adverse
drug reactions and other quality-of-care concerns. We believe the Department needs
to take action to improve its medication management policies and practices. First,
the Department should standardize drug treatment across facilities by incorporating
drug therapies into disease management and chronic care guidelines and protocols.
Second, although clinical staff have access to online drug-drug interaction
information, we found they do not always use this available resource. Additional
information on drug-disease states, such as for renal and liver diseases, could
augment patient care, particularly given the higher prevalence of certain diseases and
conditions among the inmate population. Third, inmates’ medical records often do
not contain sufficient information to determine the reason(s) for drug and/or dosage
choices, and a system for alerting staff of contraindications does not exist. Using a
simple notification process like color-coded markers on the front of inmates’ medical
records could alert clinical staff to drug allergies and other potentially serious
situations. Finally, the policies and practices for making over-the-counter
medications available at the canteens should be strengthened. The process for
adding or deleting medications from the list of available over-the-counter
medications has not been standardized. All of these factors contribute to an

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Department of Corrections
Internal Health Care Provided to Inmates Performance Audit - September 2005

increased risk that existing medical conditions may be exacerbated, resulting in
avoidable emergency room or hospital admissions.

Recommendation No. 3:
The Department should improve its medication management policies and practices
by:
a. Developing and ensuring compliance with drug treatment protocols.
b. Making additional, easily accessible drug-drug interaction and drug-disease
information available for use by clinical staff.
c. Reevaluating policies and establishing a formal process for approving overthe-counter medications for sale through Canteen Services.
d. Adopting a medication alert system to notify clinical staff of medical
conditions or over-the-counter medications that could be contraindicated for
certain inmates.

Department of Corrections Response:
Agree. Implementation date: July 2006. The Department agrees with the
basic concept of improving the management of medications. These are long
standing problems that are now being addressed through a partnership with
an outside vendor to correct many of the problems. Drug interaction
information is available to every provider entering prescriptions into the
system. This information automatically presents on the computer screen
every time a provider enters a prescription and to override it takes conscious
intent.
The Department agrees with the recommendation related to compliance with
drug treatment protocols. In addition, the Department believes this is only
one aspect of disease management. The Department has already begun the
first step in this process with the implementation of the Milliman Care
Guidelines available online internally to all DOC providers for the past year.
All providers have had training on the use of the guidelines. The second step
is to complete the project on chronic care previously discussed, which could
include drug treatment protocols for these disease processes. The third step
is reviewing and revising the formulary to ensure efficacy and costeffectiveness consistent with chronic care guidelines and Milliman Care

Report of The Colorado State Auditor

29

Guidelines. The final phase is to ensure that all providers are fully trained
and educated in disease management. Clinical Services now has a trainer and
will be part of this process including onsite presentations and training.
The Department agrees that a system of medication alerts be developed and
that this notification system be used by Departmental staff regarding the
contraindications for allergies. The Department is developing an electronic
medical records system that will incorporate a drug contraindication alert
system.
The Department currently has representation on the canteen committee and
a process is in place for approving over-the-counter medications for sale
through the canteen. Other than for security reasons, the right to purchase
items off canteen is considered to be an inmate right by the Attorney
General’s Office. Clinical staff will continue to work with the Canteen
Committee to investigate areas to strengthen current practices and policies.

Documentation and Record Keeping
In its 2001 report on Correctional Health Care, the National Institute of Corrections
(NIC) states that courts have held that “maintenance of adequate medical records is
a necessity.” According to the NIC, at a minimum, medical records should include
a medical history and problem list; notations of patient complaints; treatment
progress notes; and laboratory, X-Ray, and specialists’ findings. Proper medical
records promote continuity of care across correctional facilities and from outside
providers, and protect the health and safety of inmates. They also provide
correctional administrators with treatment documentation in the event inmates sue,
alleging care was not provided.
During our review we found that the Department does not ensure inmates’ medical
records contain all relevant information on the care received both at the clinics and
from external providers. We found missing chart notes; incomplete, out-of-date, or
absent problem lists; missing medication administration records; and missing
emergency room and hospital discharge summaries in 14 percent of the total records
we reviewed (33 of 236). According to regulations, this information should be
contained in the records. We also found that patient care information coming into
the Department from external providers is not date-stamped, so there is no way to
determine whether treatment plans were followed or updated in a timely manner.
This is especially problematic for inmates with chronic medical conditions. Inmates
with multiple emergency room visits or inpatient hospital stays for certain medical
conditions, such as uncontrolled hypertension, diabetes, and asthma, are high-risk

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Department of Corrections
Internal Health Care Provided to Inmates Performance Audit - September 2005

patients in need of active medical management and timely monitoring. Incomplete
or missing medical information can result in failures or delays in diagnosis and
treatment. Further, failure to document recommendations by specialists or hospital
providers can result in unnecessary or repeated emergency room or hospital stays.
Documentation of the care provided in external settings also serves as a record for
payment purposes. We found numerous instances related to one external hospital
provider in which discharge summaries were not included in inmates’ medical
records. In one case, claims data from the external health care administrator showed
that an inmate had an emergency room visit. However, there were no chart notes,
chest pain protocols, or discharge summaries from the hospital in the inmate’s
medical record. Therefore, it is not clear whether the emergency room visit actually
occurred.
Although the Department has a regulation outlining the format to be followed in
recording and documenting clinical assessments and treatment, we found wide
variability in compliance among the clinics and staff. Possibly, revising the format
to include Milliman Care and chronic disease guidelines; chronic care flow sheets;
and responses to laboratory results, diagnostic procedures, or speciality consults
could serve to improve the continuity of care. The Department’s medical records
staff should establish procedures for date-stamping external provider data and for
following up when information is not received in a timely manner. The Department
should also consider online physician consultations to reduce the lag time in
receiving critical information. Finally, the Department should create checklists
and/or other forms to document actions or treatment plan adjustments based on
external provider recommendations.

Recommendation No. 4:
The Department of Corrections should ensure inmate medical records are complete
and current by:
a. Adopting procedures for periodic review of medical records to ensure
compliance with established policies and formats.
b. Developing methods to ensure external provider information is received and
appropriate follow-up care and treatment is provided in a timely manner.

Report of The Colorado State Auditor

31

Department of Corrections Response:
Agree. Implementation date: July 2006. The Department agrees that
compliance is an issue and is aware of the need to adopt procedures for
periodic review of medical records to ensure compliance with established
policies and formats through the quality management program. Three steps
have been taken thus far to improve in this area. These steps include the
implementation of an in-house electronic encounter system used by all
providers each time they deliver medical care to an inmate. This system is
set up in the correct format and has improved the quality of the
documentation compared to the handwritten forms that were previously
utilized. The second step taken was a series of educational talks presented
at provider meetings by personnel from the Attorney General’s Office and
the Chief Medical Officer regarding the important components of
documentation from a medical-legal perspective. The third step was the
initiation of the peer review process which was initiated approximately six
months ago and is in the process of refinement.
The Department agrees improvement must be made in the area of developing
methods to ensure external provider information is received and appropriate
follow-up care and treatment is provided in a timely manner. The
Department is working with the external provider, Physician Health Partners,
in developing an implementation plan for this task.
The internal electronic medical record has been developed, but it is not
comprehensive enough to meet the needs of the Department. A major project
in progress is bringing to completion the development of a comprehensive
electronic medical record project (M-Track). Once this system is
implemented, the scanning of these consults into the record will be a
possibility, and will assure the prompt entry into the system. In the
meantime, as the team is established for the centralized scheduling unit,
manual systems will be implemented to improve the current process.

Management Oversight
The National Institute of Corrections reports that the continuous review of policies,
procedures, practices, material, and people will result in continual improvement in
correctional health care. In the following sections of this chapter, we discuss our
findings and recommendations related to the Department’s oversight and
management of the systemwide delivery of internal health care services. In our 1996

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audit we found the Department did not adequately monitor some of the medical
functions of its Division of Clinical Services (Division). In our current audit we
continue to have concerns about the adequacy of oversight. Our findings in this
section address three functions – quality assurance, information management, and
staffing – that are central to the delivery of cost-effective health care services.

Quality Management
Quality management, or assurance, has been defined as a “process of ongoing
monitoring and evaluation to assess the adequacy and appropriateness of the care
provided and to institute corrective action as needed.” It is an essential component
of any well-run health care system. For some time, the Department has had a Quality
Management Program (Program). However, we found flaws in the design and
operation of the Program that have, for the most part, diminished its effectiveness.
Some of these include:
•

Fragmented structure. The Department’s Program has not functioned as
a cohesive or comprehensive program but rather as a fragmented system of
numerous committees lacking a central systemwide focus. Specifically, the
Department has eight quality management committees and groups that
review deaths, infectious diseases, resource utilization, and practice patterns.
Some committee members serve on as many as five or six different
committees. This can overburden individual workloads and lead to
scheduling difficulties. In fact, we found that not all designated members
attend meetings, as required, and not all meetings are held as frequently as
specified in the Department’s regulations.

•

Retrospective in nature. Quality management programs must be
sufficiently proactive so that actions can be taken before serious quality-ofcare issues arise. Although reviewing or investigating particular events
retrospectively is appropriate, it should not be the primary purpose of a
quality management program. We found, however, that the Department’s
efforts, to date, have been more retrospective than prospective in nature. The
quality management committees’ reviews typically have been based on
complaints, incidents, deaths, or concerns identified at the clinics. According
to regulations, the clinics are supposed to perform more prospective, regular
reviews of the quality of care. However, according to staff at the clinics we
visited, they currently perform these reviews informally and sporadically, and
generally do not document their results.

•

Lack of documentation. We reviewed minutes from the various quality
management committees’ meetings for Fiscal Years 2004 and 2005 and

Report of The Colorado State Auditor

33

found that two committees do not keep minutes of their activities and
decision-making processes. This lack of documentation is a concern on
several levels. Most importantly, there is no permanent record of
management’s decisions. We also found that for the committees and groups
that do document their meetings, the minutes consist largely of narrative
commentary. There is no clear delineation of the steps to be taken or to
whom responsibility for action has been assigned. Further, there is no
evidence that follow-through on previous business has occurred and that staff
and the Department are held accountable.
Recognizing the weaknesses in its quality management, Division management
recently began revamping its Program. Management expects the new program to be
fully operational in June 2006. We commend the Division for undertaking this
considerable task. However, we believe more needs to be done to ensure the new
program contains critical components that, at present, do not appear to be included.
Specifically, the Department needs to determine the activities related to inmate
health care to be reviewed and identify those activities that are the most crucial in
terms of potential problems, frequency, or risk. Data then need to be tracked and
analyzed for these activities and evaluated to determine if opportunities exist for
improvement. The Department also needs to provide greater guidance to reviewers
for determining the severity of the quality issue(s) identified. The Quality
Management committees need to be more multidisciplinary, and records need to be
maintained of their activities and decisions.
Recently the Division began conducting peer reviews of physicians and psychiatrists.
This is a step in the right direction. However, peer reviews should not be limited to
only these two staff levels. Reviews of other clinical staff positions need to be
included in this process. Routine reviews or audits of inmate medical records,
similar to the review conducted during our audit, need to take place. The state of
Georgia prospectively audits its correctional system’s clinical operations to
determine compliance with standard operating procedures, evaluate the quality of
care, and monitor inmates’ access to care. Georgia’s clinics are then required to
provide corrective plans for any resulting recommendations. Finally, the Department
needs to continually evaluate its performance against established measures or “best
practices.”

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Recommendation No. 5:
The Department of Corrections should develop and implement a comprehensive and
proactive quality management program by:
a. Reassessing and revising the current structure to ensure committees are
multidisciplinary, that they meet and report regularly, and that responsibility
and accountability are clearly assigned.
b. Routinely identifying and reviewing programs, activities, and quality-of-care
issues at the individual clinic and staff levels as well as systemwide.
c. Developing and measuring outcomes related to the quality of care provided
to inmates.

Department of Corrections Response:
Agree. Implementation date: July 2006. The Quality Management Program
began in October 2004, meets ACA standards, and has improved the quality
of care being provided to the population. The program includes the
multidisciplinary oversight Quality Management Committee, the active subcommittees as well as ad-hoc committees to address and improve systems
and other quality issues. The Department will continue to reassess and revise
the committees and continue to monitor scheduling and committee
accountability.
The Department has implemented an even more progressive quality
partnership. With the assistance of our new managed care partner, Physician
Health Partners, the Department will become much more sophisticated in the
development and measurement of outcome information and audit
capabilities. The Department expects to be developing the ability to perform
predictive modeling regarding high cost patients within the next 12-24
months. In addition, the Department also agrees that the administrative
regulation for its quality management program can be improved upon in the
delineation of the levels of severity regarding quality issues.
As a component of its Quality Management Program, the Department has
implemented a Continuous Quality Improvement (CQI) program at all
clinical health care facilities. The Department will integrate these
committees into reporting to the multidisciplinary departmentwide
committee. The CQI program is proactive, concurrent and retrospective in

Report of The Colorado State Auditor

35

nature based on the specific components at each facility. This full integration
will prevent fragmentation as well as the ability to assure proper
implementation of individual quality programs and systemwide quality
initiatives. The Department anticipates that within the next six months all
facilities will have the CQI program fully implemented at its facilities, and
that by the end of Fiscal Year 2006 a quality improvement study will have
been completed.
As noted previously, the Department agrees with identifying and reviewing
programs, activities, and quality-of-care issues at the individual clinic and
staff levels within our current structure. We perform this function as a
responsibility of our quality program.

Information Management
Few activities are more necessary than collecting and managing data. Decisions
regarding the numbers and types of clinical staff needed, the services to be provided,
the location and design of clinics, the choice of equipment, and the quality
improvements to be made all depend on the data available to and used by
management. The Department collects or has access to significant quantities of data.
However, the Department has not placed a sufficiently high priority on compiling
and analyzing these and other data for use in management decision making.
This issue is not new to our audits of the Department’s health care services. In our
1996 Performance Audit of Inmate Health Care, we reported that in order for the
Department to manage its services and costs effectively, it needed comprehensive
and accurate information, such as the types of and costs for resources being used to
deliver inmate health care. Although the Department has made progress in
developing databases, such as the electronic Encounter System, its analysis of data
is still problematic. Consequently, it is unclear how the Department arrives at
important management decisions. For example, during our audit we found that the
Department does not routinely analyze or have easy access to reliable data on the
following:
•

The most common medical services provided to inmates internally at the
clinics, and the costs for each service.

•

Costs and workloads per clinic, per staff, and per inmate.

•

The most frequent reasons for inmates’ clinic encounters, the number of
inmates with chronic conditions, and the most common chronic conditions.

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•

The number and types of medications refused by inmates and destroyed by
clinical staff.

•

Medical grievances related to health care services and any lawsuits resulting
from clinical activities.

•

The amount of copayments collected and amount of refunds granted at each
facility.

•

The costs to transport inmates to and from outside consultations.

•

The number of emergency room visits and the modes of transportation to and
from outpatient settings.

Additionally, the Department has not developed or accessed other available data
sources. For example, we intended to compare the results of our intake and medical
record reviews with similar data collected and trended by the Department. However,
we found the Department does not routinely compile and analyze information from
inmate medical records. Neither does the Department use inmate grievances as a
source of information for analysis. In our 1996 audit, the Department reported that
grievances served a valuable function by alerting management to potential situations
that could cause serious problems. In our current audit, we found the grievance
database contains only rudimentary information and is not useful for analysis
purposes. For example, grievances are broadly grouped into categories, including
“medical,” “mental health,” “banking,” and “canteen services.” However, for the
most part, there is no detailed information to describe the specific type of medical
grievance, such as treatment delays, provider complaints, or medications. Other
states have found that analyzing grievances helps identify potential problems with
the provision of care and improve the overall quality of their correctional health care
systems.
Finally, we found that data collected are not always accurate or reliable. For
example, during our medical record review we found improper coding in 3 percent
of the total records reviewed (7 of 236). We identified instances in which there was
evidence of care provided for a condition that was different from the medical
condition coded in the medical record. For example, we found no evidence of
treatment for the coded conditions, including headache, backache, and prostate
hyperplasia. Although a 3 percent error rate may not appear significant, these errors
indicate a need for the Department to improve controls over data accuracy.
By not routinely compiling and analyzing data, the Department lacks a critical tool
for planning, developing, and monitoring its services. For example, although the

Report of The Colorado State Auditor

37

Department does not evaluate wait times for clinic visits, we found considerable
variation among the clinics. Specifically, the average statewide wait time for an
appointment is 10 days, with inmates waiting as little as 1 day and as long as 22
days. Department staff may have explanations for these and other variations in
services; however, these explanations typically are anecdotal. Therefore, they do not
provide a sound or reliable basis upon which comprehensive or costly decisions
should be made. Further, without reliable data and routine analysis, the Department
cannot establish whether variations are justified or whether they are indicators of
inefficient or substandard operations.
To accomplish its constitutional and statutory responsibilities, the Department must
manage the quality of care provided to its inmates. To improve the quality of its
program information, the Department must define the data needed for making
operational and other decisions, ensure that data are accurate and reliable, and
identify and develop additional data sources. The Department should investigate
anomalies in data and take steps to minimize discrepancies systemwide. Finally, the
Department should trend quality-of-care data to identify and address other systematic
changes.

Recommendation No. 6:
The Department of Corrections should improve its use and management of critical
decision-making information by periodically reviewing key operating data,
developing additional data sources, ensuring the accuracy and reliability of data,
taking steps to minimize data discrepancies among facilities, and monitoring for
compliance among clinics and clinic staff.

Department of Corrections Response:
Agree. Implementation date: July 2006. The Department believes there is
a need to improve the use and management of critical decision-making
information. This could be accomplished by periodically reviewing key
operating data, developing additional data resources, ensuring the accuracy
and reliability of data, developing additional data sources, ensuring the
accuracy and reliability of data, taking steps to minimize data discrepancies
among facilities, and to monitor for compliance among clinics and clinic
staff. In addition, the Department realizes that its current system is not
always reliable or accurate and this issue is currently being addressed by
management.

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The Department recognizes the need to improve information systems that
will enable the review, analysis, and accuracy of the data collected.
Currently, the Clinical Services User Board (CSUB) is in place and meets
monthly to address technology strategies to ensure accurate and timely
information with respect to data collection. The board is constantly
prioritizing which projects will bring the most benefit to Clinical Services.
The board also coordinates the development and implementation of the new
electronic medical record (M-Track). However, the Department, like many
other state departments is resource driven, and is being resourceful given the
current allocation of funding and personnel.
The Department’s Clinical Services Management team has developed an
organized project management system to approach resolving these issues in
a priority manner. One example of this is that the board recently made the
decision to implement current coding systems to correct the issue of incorrect
coding.

Staffing
According to the National Institute of Corrections, the effectiveness of any
correctional health care system is largely dependent on staffing considerations.
Additionally, expenditures for staff represent the biggest portion of most health care
budgets. In Fiscal Year 2005 expenditures for the Department’s approximately 420
FTE clinical staff represented about 64 percent ($21 million) of the $33 million spent
on internal medical services. Most of the FTE, or about 380 (90 percent), are
assigned to the clinics and infirmaries around the State. They include physicians,
physician assistants, licensed nurse practitioners, certified practical nurses, and
regular nurses. The remainder of staff are assigned to the Division’s administrative
sections, including the Department’s headquarters office in Colorado Springs. In
addition to its appropriated FTE, the Department contracts with outside agencies to
supplement its staffing vacancies on both short- and long-term bases.
Historically, the Department’s clinical staffing levels have been based on the
facilities’ inmate populations. This was the situation in our 1996 performance audit
of Inmate Health Care in which we found that the Department did not know whether
its staffing patterns and workloads were appropriate. During our current audit the
Department reported that it recently began analyzing staffing models and levels.
According to Department staff, when they distribute clinical staff among the
facilities they use staffing models that consider various factors, such as the medical
acuity of inmates, the security level of the facility, and the ratio of various staffing
levels to inmates. We agree that the use of such staffing models is appropriate.

Report of The Colorado State Auditor

39

Other states, such as Ohio, use numerous factors, including the age and gender of the
inmate population, the number of inmates referred to specialty clinics, and the
number of unscheduled medical assessments when developing staffing plans for their
correctional clinics.
During our audit we found wide ranges in the expenditures per inmate for internal
health care services at the Department’s 20 clinics. For example, in Fiscal Year 2004
the Pueblo Minimum Center spent about $500 per inmate, while the San Carlos
Correctional Facility spent about $5,800 per inmate. According to the Department,
these and other differences in costs, staff-to-inmate ratios, the mix of staff at each
facility, and other workload measures can be explained by the distinct characteristics
of each facility. For example, San Carlos exclusively houses mentally ill inmates.
As such, the clinical costs at San Carlos and other specialized facilities are likely to
be higher. By contrast, other facilities have significantly fewer inmates with serious
medical needs which would likely be reflected in lower costs. However, the
Department could not provide documentation of the models developed and the ways
in which these models have been applied to the staffing allocations at each facility.
Consequently, we were unable to determine whether the differences we found among
the facilities are the result of the Department’s comprehensive, systematic
application of its staffing models.
According to the Department, staffing shortfalls exist at all of the clinics. In
addition, staff told us they regularly review staffing at the clinics, and make
adjustments, such as shifting staff from one facility to another as needs arise. Also,
according to the Department, it has difficulty recruiting and retaining clinical staff
to work in correctional facilities. We believe these types of conditions make the need
for systematic and comprehensive staffing analyses essential. Without such analyses
and a record of it, the Department does not have a sound basis upon which to support
permanent staffing decisions. Furthermore, the Department cannot show whether
clinic facilities with the lowest costs are operating optimally or simply providing a
level of service below that of others. Conversely, the Department cannot show
whether clinics with the highest costs are inefficient or provide excessive care, and
thus present opportunities for potential savings.

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Recommendation No. 7:
The Department of Corrections should ensure clinic staffing levels are appropriate
and provide efficient, quality health care by:
a. Identifying all critical factors needed to establish optimal staffing levels
given the resources at each clinic.
b. Conducting and documenting regular staffing analysis at a minimum as part
of the annual budget process.
c. Making permanent and temporary staffing changes based on the annual
analysis.

Department of Corrections Response:
Partially agree. Implementation date: January 2006. The Department agrees
with the overall concept that there should be assurances that clinical staffing
levels are appropriate and that they provide efficient, quality health care.
Based on the current fiscal environment, the Department’s position is to staff
at a minimally safe level. Two years ago, Clinical Services was challenged
to abolish 73 clinical positions and the management team had to make
decisions on how to absorb the workload. This reality goes against the
philosophy of establishing optimal staffing levels. However, over the past
few years, the Department has had to undertake massive restructuring and
reorganizations to maintain workload levels to provide basic health care
services.
The Department does not agree that it does not conduct and document regular
staffing analysis. The Department has conducted weekly and monthly
staffing analyses, which has been massive and on-going just to maintain
minimal staffing levels. The Chief of Clinical Services and the three
Regional Health Services Administrators meet at least twice a month, and the
team reviews components of staffing. Numerous changes and adjustments
from the level of the individual clinic to major system changes have been
made to ensure access to medical care and safety in the clinics. One example
is reducing the number of hours most clinics are open from 24 to 16 hours.
The Department also analyzed the infirmary staffing levels and as a result
decided to staff them with physicians rather than physician assistants.

Report of The Colorado State Auditor

41

Auditor Addendum:
This audit identified weaknesses in the Department’s ability to document and
justify the systemwide variances that exist in clinic staffing levels, workload
measures, and costs per inmate. We emphasize that in a tight budget environment,
documented staffing analyses and standards are key to controlling staffing costs
while maintaining sufficient levels of service.

43

Cost Containment
Chapter 2
Background
The costs for health care in the United States have increased significantly over the
past two decades, at a rate exceeding inflation. Rising health care costs are not
limited to the general population. They also impact prison populations. In fact,
health care costs are a leading contributor to the increase in prison costs nationwide.
For example, between Fiscal Years 2002 and 2005, internal medical expenditures for
the Division of Clinical Services (Division) increased by 12 percent, while overall
expenditures for the Department of Corrections (Department) increased by 4 percent.
As discussed in the Overview Chapter, the Division spent almost $33 million in
Fiscal Year 2005 to provide medical services internally at its clinics.
In addition to the rise in health care costs generally, a number of factors particularly
impact correctional health care budgets. These factors include a growing inmate
population, increasing numbers of female inmates, longer incarcerations, aging
inmates, expensive services for chronic and communicable diseases, and costly
prescription medications. Although the Department cannot control these factors, it
can and should, to the extent possible, ensure its costs are contained while
maintaining quality health care for the State’s inmates.
We reviewed several cost containment measures available to the Department. In this
chapter we discuss our findings and recommendations related to copayments and the
purchase of prescription medications. We found that although the Department has
implemented some measures, such as reducing clinic hours of operation, it has not
been as effective as it could be in containing its health care costs. This is due
primarily to the Department’s failure to adequately communicate and monitor the
implementation and consistent application of cost containment measures throughout
the clinics.

Copayments
By statute, in 1987 the Division began charging inmates a user fee, or copayment,
for health care services. In the following years, the General Assembly made
statutory changes that excluded several services from the copayment requirement.
For example, for a time, copayments were not statutorily required for follow-up

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Department of Corrections
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appointments. In 1998, however, the General Assembly eliminated all of the
statutory exceptions. Since that time, Section 17-1-113, C.R.S., has required the
Department’s clinics to assess consistent copayments for “all medical, [mental
health], dental, and optometric service rendered to or on behalf of inmates”
(emphasis added).
Statutes also authorize the Department to set the copayment amounts in regulation.
Prior to August 2004, the Department charged inmates a $3 copayment for clinical
visits (encounters) with physicians, dentists, and optometrists, and 50 cents for visits
with physician assistants, licensed nurse practitioners, and nurses. In August 2004
the Department changed the copayment amounts. Now, according to current
regulations, inmates are to be assessed the following:
•
•
•

$5 when an inmate schedules and keeps a clinic appointment.
$10 when an inmate declares he or she cannot wait for an appointment
through routine clinic scheduling and must be seen immediately.
$5 for a “no show” or failure to keep an appointment.

Contrary to statutory intent, the Department does not charge a copayment when an
inmate visits the clinic for scheduled follow-up care or when the Department
schedules an inmate’s visit, such as for intake or to prevent the spread of infectious
diseases. When an inmate visits the clinic, staff select the reason for the visit in the
Department’s clinical Encounter System. Depending upon the type of visit staff
select, the system will, or will not, electronically debit the inmate’s bank account the
applicable copayment amount. In Fiscal Year 2005 the Department collected about
$209,900 in copayments. This total includes 1 month of revenue collections based
upon the lower copayment rates and the remaining 11 months at the higher $5 rate.
The use of copayments in correctional health care settings serves two purposes. First
and foremost, copayments are used as a means of controlling costs by reducing the
number of unnecessary encounters. Second, copayment revenue can be used to
offset a portion of the inmate health care costs. We reviewed the Department’s
copayment policies and practices and found that they have not been effective in
reducing encounters or in maximizing revenue. First, we found that despite the
increase in the copayment charge to $5, the total number of clinic encounters has not
declined. From Fiscal Years 2004 through 2005, total clinic encounters increased
by 70 percent (90,300 to 153,300). By contrast, during this period the average daily
inmate population increased by only 1 percent (13,800 to 13,900). Further, the
increase in encounters was not isolated to a few clinics. Rather, three-fourths of the
clinics (15 of 20) had increases in the number of inmate encounters in Fiscal Year
2005.

Report of The Colorado State Auditor

45

Second, we found that the amount of revenue generated from the copayment is not
optimal. As stated previously, in Fiscal Year 2005 the Department collected about
$209,900 in copayment revenue. However, if the Department had charged the $5
copayment on all clinic encounters, we estimate it could have collected more than
three times that amount, or about $766,400. In other words, for every encounter in
which the Department charged the copayment, regulations exempted about three
encounters from the copayment. Consequently, the Department did not generate
additional revenue that could have offset some costs, including the costs for three
clinical staff, as specified in the Fiscal Year 2005 Long Bill.

Legal Issues
More than three-fourths of the states and the federal government charge inmates
copayments for health care services. Despite the prevalent use nationwide, debate
exists about the fairness and constitutionality of the practice, and there have been
some legal challenges. However, courts generally have held that charging inmates
a fee for health care can be constitutional, provided certain safeguards are in place.
From a review of data compiled by the Colorado Office of the Attorney General, we
found that since Fiscal Year 2004, two inmates have brought charges against the
Department regarding copayments. In both cases, the courts dismissed the charges.
We examined central arguments for and against charging inmates copayments for
health care services to assess whether the Department’s policies and practices
provide necessary safeguards. We found the following:
•

Access to care. We found no evidence that the Department has denied any
inmates access to health care due to an inability to pay. Even if inmates have
insufficient funds to cover the copayment amount, Department regulations
allow them to carry negative account balances. In addition, upon entry into
the correctional system, the Department informs all inmates of its policy to
provide health care in the absence of sufficient funds. Each inmate is given
a copy of the Department’s Clinical Services Patient Handbook, which
clearly states that “no one will be denied health care because of inability to
pay.” Inmates may also request refunds if they believe they were wrongly
assessed copayments.

•

Use of care. Determining whether copayments discourage inmates from
requesting necessary health care is more difficult than determining whether
access has been denied. However, from our review of inmate grievances,
cases filed with the Attorney General’s Office, and other data, we found no
evidence that copayments have discouraged inmates from seeking medical

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attention. In fact, the increase in inmate clinic visits indicates that inmates
have not been deterred from seeking health care.
•

Lack of funds. One criticism of assessing copayments for health care is
related to inmates’ financial resources or their ability to earn sufficient
incomes. We obtained inmate bank records to examine account balances and
found that the average inmate account balance during the period of our
review was more than $25. We also sampled canteen purchases and found
that during the same month inmates visited the clinic – January 2005 – they
also purchased various items from the canteen, such as snacks, a radio, sports
equipment, clothes, and personal hygiene items.

Improvements
Section 17-1-113(5), C.R.S., requires the Department to monitor the information
collected during a clinic encounter to ensure copayments are being assessed
consistently. We found that although the Department has adopted policies
mandating the assessment of copayments, these policies are neither consistently
applied nor regularly enforced. Further, policies that delineate copayment charges
are not consistent with the statutory intent that all medical services rendered to
inmates be subject to a copayment. Specifically, Department regulations
categorically exclude about one-half of all encounter types, including intake
examinations, follow-up appointments, and referrals to specialists, from copayment
charges. In Fiscal Year 2005 only 26 percent (39,800 of 153,300) of all encounters
were assessed a copayment due to these exclusions. Additionally, staff do not
consistently assess copayments, even when regulations specify a copayment is
required, because they may choose to classify an encounter as a type that is not
subject to the copayment. This type of misclassification can lead to an inequitable
treatment of inmates and a reduction in the amount of revenue due the Department
from this source.
This is not the first time we have identified concerns with the use of copayments. In
two prior audits – our 1992 Performance Audit of the Department of Corrections and
1996 Performance Audit of Inmate Health Care – we recommended the Department
monitor facilities to ensure copayments were applied to clinic encounters
consistently and appropriately. We believe as long as statutes mandate the use of
copayments for all clinic visits, the Department has a duty to comply. Uniform
application of the copayment will eliminate inconsistencies and confusion among
clinics and staff, ensure equitable treatment of all inmates, and lessen administrative
duties. If the Department determines there are circumstances for which the
copayment would serve as a deterrent to treatment, then it should seek statutory
change or clarification. Another option would be for the Department to lower the $5

Report of The Colorado State Auditor

47

copayment and apply the lower amount, across the board, to all health care services.
This would reduce the real or perceived financial burden on inmates and, possibly,
be more effective at controlling utilization and costs.

Recommendation No. 8:
The Department of Corrections should ensure its copayment policies and practices
comply with statutory intent by either assessing copayments for every type of clinic
encounter or proposing legislation to include current regulatory exclusions in statute.

Department of Corrections Response:
Agree. Implementation date: January 2006. The Department increased the
amount of the copayment and collected over 6.5 times the amount from the
prior year. Prior to the decision being made to change the copayment, the
Department contemplated charging $5.00 for all visits. The Department
instead decided that the new policy would not charge a copayment for
follow-up visits and other specific appointments. The Department has
devoted significant IT resources to an electronic “encounter” to track its
encounters. Although the new copayment policy leads to better consistency
and standardization, it did not go far enough. The Department anticipated
adjusting the policy after the first full year of implementation. As a result,
discussions have already taken place regarding lowering the copayment to
$3.00 and charging for each and every visit, regardless of the type of visit.
The Department will investigate proposing new legislation regarding
copayments. Lowering the copayment will involve the revision of the
current copayment regulation. The Department anticipates collecting the
same or a larger amount which would allow the Department to fund
additional FTE.
The Department has analyzed the encounter data from Fiscal Year 2002 to
Fiscal Year 2005 and has determined that individual facility clinics have not
been keeping accurate encounter data prior to the implementation of the
electronic encounter system. For example, the Colorado Territorial
Correctional Facility recorded less than 2,000 encounters in Fiscal Year 2004
and over 17,500 encounters in Fiscal Year 2005. The new electronically
captured data suggests that Fiscal Year 2005 may be the baseline year for
accurately tracking encounters.

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Department of Corrections
Internal Health Care Provided to Inmates Performance Audit - September 2005

Prescription Medications
In Fiscal Year 2005 the Department filled about 262,200 inmate prescriptions. On
average, more than 1,000 individual prescriptions are filled each business day. The
most commonly prescribed medications are cardiovascular, psychotropic,
nonsteroidal anti-inflammatory, and gastrointestinal medications. Currently, all
prescriptions are filled through the Department’s only pharmacy located in Pueblo.
Prior to November 2004 the Department operated a second pharmacy in Denver.
According to staff, due to difficulties in filling vacant pharmacist positions, the
Department consolidated the services and functions of the Denver pharmacy with
those of the Pueblo pharmacy.
For an inmate to be prescribed a medication, he or she must see a physician. The
physician diagnoses the inmate’s condition and then orders the prescription(s)
electronically. The electronic prescription is transmitted to the Pueblo pharmacy for
review. Upon receipt, pharmacy staff fill the prescription and send the medication(s)
back to the originating facility via a delivery service. Clinical staff then dispense the
medications to the inmates. In Fiscal Year 2005 the Division spent $8.4 million on
medications.
At the time of our audit, the Division was negotiating a contract for an outside
pharmacy services vendor to replace the operations of the Pueblo pharmacy. The
contracted services are to include prescription medication ordering, dispensing and
delivery, formulary and inventory management, billing, and quality assurance. The
Division anticipates awarding the contract and having services fully operational by
November 2005.

Formulary Utilization
Pharmaceutical industry standards define a formulary as a list of medications that a
committee of practicing physicians and clinical pharmacists has reviewed and
selected based on quality, cost savings, and effectiveness. Drug formularies may
also provide physicians with dosing information, indicated precautions, restrictions,
and cost indicators. Physicians and pharmacists are expected to follow an approved
drug formulary when writing, ordering, and filling prescriptions. At the Department,
responsibility for approving a drug formulary has been assigned to the Pharmacy and
Therapeutics Committee (P&T Committee). By regulation, the P&T Committee’s
members consist of the Chief Pharmacist, Chief Medical Officer, Operations
Manager (this position no longer exists) or designee, and other appointed staff. In
addition to developing, approving, and revising the formulary, the P&T Committee
is responsible for meeting quarterly, achieving maximum drug therapy at the lowest

Report of The Colorado State Auditor

49

possible cost, and evaluating drug usage. The Department’s current formulary
consists of approximately 320 medications.
To be an effective management tool for standardizing cost-effective drug
prescription practices, a formulary must be updated regularly. We reviewed the
Department’s drug formulary and found that it has not been updated since 2002. As
a result, the formulary does not include some drugs shown to be effective in treating
certain medical conditions at a lower cost. We reviewed several medications on the
Department’s formulary that, according to pharmacy staff, have less expensive
alternatives or could be taken off the formulary entirely. For example, Zomig, a
formulary medication for treating migraines, could be replaced by Midrin, a nonformulary migraine medication that is effective and less costly. During a one-year
period, the Department spent almost $22,900 on about 1,700 pills of Zomig. If
Midrin had been on the formulary and prescribed instead of Zomig, the cost would
have been about $100 for the same number of pills; a savings of about $22,800. We
also reviewed utilization and costs for Prilosec and Zantac, two comparable
formulary medications for treating stomach ulcers and heartburn. Prilosec costs the
Department about 55 cents per tablet. By contrast, Zantac costs 5 cents per tablet,
or about 50 cents less. We recognize that less costly but effective alternatives to
Zomig, Prilosec, and the other approximately 320 medications on the formulary are
not appropriate or available in every case or for every inmate. However, in the
absence of regular formulary reviews and updates, the Department cannot ensure
overall maximum drug therapy at the lowest possible cost.
Finally, we reviewed the frequency of physician requests for non-formulary drugs.
When a physician prescribes a formulary medication, there is no need for additional
review by the pharmacist and the order is processed with minimal effort. If,
however, the prescription is for an off-formulary drug, the pharmacy manager must
review and approve it prior to its being filled. An outdated formulary forces
physicians to prescribe many off-formulary medications. This, in turn, creates
additional administrative work for the pharmacy and unnecessary delays in
dispensing. In the three month period between January and March 2005, physicians
treating the Department’s inmates prescribed about 260 non-formulary medications,
excluding psychotropics. Each of these requests requires review and approval by the
pharmacy manager in Pueblo. Of the approximately 260 requests, the pharmacy
manager approved all but nine, for an approval rate of 97 percent. Further, 80 of
these requests (31 percent) were for the same five medications. The percentage of
requests for identical medications and the high approval rate are strong indicators
that the current formulary is in need of revision.

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Department of Corrections
Internal Health Care Provided to Inmates Performance Audit - September 2005

Formulary Updates
The P&T Committee, which is to meet quarterly to conduct formulary management
and evaluate drug usage, has not met in almost a year. Since that time, the U.S. Food
and Drug Administration has approved about 80 new medications. Some of these
medications and others that have been approved since the Department last updated
its formulary in 2002 could be appropriate and cost-effective additions to the existing
formulary. Correspondingly, other medications could be deleted.
Currently, the Department does not have an established timetable for regularly
updating its drug formulary. We surveyed four other states’ correctional departments
to determine the frequency with which they update their formularies. We found that
all four conduct reviews and updates more frequently than is the case in Colorado.
For example, Oregon updates its formulary monthly and Oklahoma does so twice
each quarter. The Department needs to formally adopt a timetable for updates and
ensure its adherence. Determining the frequency of updates is just one in a series of
steps the Department should undertake to ensure its drug formulary functions as an
effective management tool. First, the Department needs to conduct a systematic,
comprehensive review of its outdated formulary. This should include compiling and
analyzing data on the costs, efficacy, prescription patterns, and appropriateness of
every drug on the formulary list. Information on comparable drugs should be studied
and then deletions, substitutions, and additions should be made to establish an
updated and cost-effective formulary. The Department should also ensure a new
formulary is developed as a part of its contract with an outside provider. According
to the Request for Proposal (RFP) for outside pharmacy services, the contractor will
maintain an up-to-date prescription formulary. However, this formulary will initially
be based upon the Division’s current, outdated formulary. The RFP does not include
a process or timeline for updating the formulary. We believe the Department needs
to specify a deadline for updating the formulary in its contract.
Second, regular review committee meetings need to be scheduled. As stated
previously, the P&T Committee is responsible for managing the formulary, but it has
not met in almost one year. Regular meetings of the P&T Committee are critical for
timely monitoring of prescription patterns and drug utilization. Finally, the
Department should continue regulating deviations from the formulary. Requiring
prior authorization or approval from another individual, such as a qualified
pharmacist or physician, for non-formulary drugs is a sound internal control. In
addition, monitoring requests for non-formulary medications can serve as another
source of information for use in evaluating the existing formulary.

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51

Recommendation No. 9:
The Department of Corrections should ensure the cost-effectiveness of prescription
drug practices by developing and updating its formulary on a regular basis. This
should include:
a. Conducting a systematic and comprehensive review and update of its current
formulary.
b. Including a date-specific time for the establishment of an updated formulary
in its contract with an outside provider.
c. Establishing and maintaining a schedule for monitoring prescription patterns
and drug utilization, including adherence to a regular calendar of review
committee meetings.
d. Controlling non-formulary requests through the use of prior authorization
approval and monitoring.

Department of Corrections Response:
Agree. Implementation date: March 2006. The Department became aware
of significant pharmacy issues and called for an internal financial audit. The
results of the audit were completed in June 2004. Based on the audit results,
as well as knowledge of the issues, the clinical management team undertook
a very detailed initiative to determine the best solution for the issues
identified. Based on these deliberations and a mass exodus of pharmacy
staff, including the pharmacy manager, a Request for Proposal (RFP) for
external pharmacy services was issued in April 2005. The Department
received three responses, which were from the three largest national
companies. The Department analyzed possible internal scenarios against the
best external proposal and made the decision to partner with Secure
Pharmacy in June 2005. The Department is currently awaiting final approval
from the Department of Personnel & Administration based on the reorganization plan and will begin contract negotiations soon after plan
approval. The audit recommendations have been previously identified
internally and this independent audit supports our decision. The Department
is aware of the management issues with the formulary and, by March 2006,
the Department will update the drug formulary in conjunction with Secure
Pharmacy. The formulary will be reviewed and updated on an annual basis.
The Department anticipates that all of this audit recommendation, as well as

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Department of Corrections
Internal Health Care Provided to Inmates Performance Audit - September 2005

performance measures, will be incorporated into the new pharmacy contract
with Secure Pharmacy.

Drug Inventory Management
According to the American Pharmacists Association and the U.S. Department of
Justice, a good medication inventory system is important for making purchasing
decisions, reducing waste, and preventing abuse. In addition, it can provide needed
information on drug usage for developing and maintaining a cost-effective drug
formulary. Currently, the Division uses an electronic Medication Administrative
Record (MAR) system to track the types and quantities of medications dispensed to
inmates through the clinics. We reviewed the use of this system and of other drug
inventory practices at the clinics and identified two areas of concern:
•

Inventory data are not accurate or reliable. We reviewed the process for
documenting the administering of medications at six clinics and found
problems with the accuracy of the data being entered. Specifically, staff at
some clinics enter the number and type of medications dispensed to inmates
directly into the Department’s electronic MAR system. Other staff manually
record the information for later entry. There are no controls, however, to
ensure staff follow through and transfer the manually recorded data into the
electronic system. Compounding this problem are inconsistencies in the data
staff actually enter into the system. For example, if an inmate is prescribed
three pills once a day, some clinics enter a quantity of three. Other clinics’
staff will enter a dose of one. When tabulating the number of pills
administered, the electronic system cannot distinguish a count of one pill
from a count of one dose. Therefore, the MAR counts the one dose as one
pill, rather than the three actually dispensed.

•

Drug destruction practices. According to the Department’s Protocol for
Returning Drugs to the Pharmacy, medications are not supposed to be
destroyed at the clinics. However, staff at the six clinics we visited report
that they destroy medications on-site if an inmate refuses his or her
medications. The refused medication is coded into the system with the letter
“R” and is destroyed by clinic staff. However, staff do not enter the quantity
of medication destroyed. Therefore, no record of the exact number of pills
destroyed exists. Further, the clinics employ various methods for destroying
medications. For example, one facility crushes the medication and pours it
down the sink drain. Another facility places the medication in a trash
receptacle that is handled by an inmate porter. In both cases, no witness is
required when the medication is disposed of or destroyed.

Report of The Colorado State Auditor

53

As mentioned earlier, the Department is currently negotiating a contract for its
pharmacy services. One of the services the contractor is expected to provide is a
complete medication inventory tracking system for each clinic. Whether provided
by an outside contractor or internally, the Department needs a drug inventory
tracking system to accurately and automatically record all received, dispensed, and
returned medications at each clinic. The lack of adequate control over drug
inventory was discussed in our 1999 Statewide Single Audit of the Department. We
consider this issue a critical one because the risk for fraud and abuse is high. The
Department should establish standard data codes, educate clinic staff on their
consistent and accurate use, and monitor compliance by staff and by the clinics.
Finally, the Department needs to adopt a standard drug destruction policy. Included
in this policy should be requirements for the proper ways in which to destroy unused
medications and a method for recording the numbers and types of drugs destroyed.

Recommendation No. 10:
The Department of Corrections should take immediate steps to improve its drug
inventory management practices by:
a. Ensuring staff are consistently and accurately entering data into the electronic
medication inventory system.
b. Adopting a standard drug destruction policy for implementation at the
clinics.
c. Regularly monitoring staff and clinic compliance with the drug inventory
management policies.

Department of Corrections Response:
Agree. Implementation date: March 2006. As previously described in the
Department’s response to Recommendation No. 9, and as a component of the
comprehensive pharmacy audit and review, the Department identified the
need for a complete redesign of the pharmacy management drug inventory
system. One aspect of the redesign will include developing processes to
ensure that staff are accurately and consistently entering data into the
electronic medication system. Therefore, as a section within the new
pharmacy management contract with Secure Pharmacy, the Department will
develop, in conjunction with Secure Pharmacy, a sophisticated inventory
management system. This system will be able to track individual
medications completely from the point of ordering, to facility receipt, to

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Department of Corrections
Internal Health Care Provided to Inmates Performance Audit - September 2005

patient delivery, and potential return to the Pharmacy and/or its destruction
based on non-use or expiration, and state laws. A component of the
inventory system will include a policy for drug destruction. The new system
will provide the ability to report and audit pharmacy information, and thereby
improving pharmacy utilization and cost efficiency, and providing high
quality management of the Department’s pharmaceutical usage. The
Department will also develop and implement a process to regularly monitor
clinic compliance with the new drug inventory management policies.

The electronic version of this report is available on the Web site of the
Office of the State Auditor
www.state.co.us/auditor

A bound report may be obtained by calling the
Office of the State Auditor
303.869.2800
Please refer to the Report Control Number below when requesting this report.

Report Control Number 1688