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OFFICE OF THE INSPECTOR GENERAL
MATTHEW L. CATE, INSPECTOR GENERAL

ACCOUNTABILITY AUDIT
REVIEW OF AUDITS OF THE
CALIFORNIA DEPARTMENT OF CORRECTIONS
AND REHABILITATION
ADULT OPERATIONS AND ADULT PROGRAMS
2000 – 2004

VOLUME I

APRIL 2006
STATE OF CALIFORNIA

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CONTENTS
VOLUME I
PAGE
EXECUTIVE SUMMARY ------------------------------------------------------------------------------- ES-1
SUMMARY OF FINDINGS AND RECOMMENDATIONS ---------------------------- ES-9
INDEX TO FINDING SUMMARIES------------------------------------------------- ES-55
INTRODUCTION ---------------------------------------------------------------------------------------------1
BACKGROUND ----------------------------------------------------------------------------1
OBJECTIVES, SCOPE, AND METHODOLOGY ------------------------------------------2
FINDINGS AND RECOMMENDATIONS --------------------------------------------------------------------5
CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY
AND STATE PRISON, CORCORAN -------------------------------------------------------7
PHARMACEUTICAL EXPENDITURES --------------------------------------------------------------- 53
OFFICE OF INVESTIGATIVE SERVICES ------------------------------------------------------------ 65
EMPLOYEE DISCIPLINARY PROCESS ------------------------------------------------------------- 89
OFFICE OF COMPLIANCE, AUDIT FUNCTIONS --------------------------------------------------- 99
MEDICAL CONTRACTING PROCESS --------------------------------------------------------------111
EDUCATION PROGRAMS AT LEVEL IV INSTITUTIONS ----------------------------------------121
RICHARD A. MCGEE CORRECTIONAL TRAINING CENTER ----------------------------------133
CALIFORNIA STATE PRISON, SOLANO -----------------------------------------------------------143
CALIFORNIA STATE PRISON, SACRAMENTO ----------------------------------------------------165

VOLUME II
FINDINGS AND RECOMMENDATIONS, CONTINUED
HIGH DESERT STATE PRISON ---------------------------------------------------------------------183
VALLEY STATE PRISON FOR WOMEN -----------------------------------------------------------209
SIERRA CONSERVATION CENTER ----------------------------------------------------------------237
LEO CHESNEY COMMUNITY CORRECTIONAL FACILITY -------------------------------------267
LOCAL ASSISTANCE PROGRAM-------------------------------------------------------------------293
INMATE APPEALS BRANCH ------------------------------------------------------------------------301
SALINAS VALLEY STATE PRISON, INMATE APPEALS AND DISCIPLINARY PROCESSES ---305
CALIFORNIA REHABILITATION CENTER, INMATE APPEALS PROCESS ---------------------315
DEUEL VOCATIONAL INSTITUTION, INMATE APPEALS PROCESS ---------------------------323
CORRECTIONAL FACILITY MAIL PROCESSING ------------------------------------------------329
PRISON INDUSTRY AUTHORITY, OPTICAL PROGRAM AT RICHARD J. DONOVAN --------349
KONOCTI CONSERVATION CAMP NO. 27 -------------------------------------------------------355
RESPONSE FROM THE CALIFORNIA DEPARTMENT OF CORRECTIONS
AND REHABILITATION --------------------------------------------------------------- ATTACHMENT

2006 ACCOUNTABILITY AUDIT

EXECUTIVE SUMMARY

EXECUTIVE SUMMARY

T

his report presents an assessment of the progress made by the California Department of
Corrections and Rehabilitation in implementing past recommendations affecting the
department’s adult operations and programs. The recommendations resulted from 22
audits and reviews conducted by the Office of the Inspector General between 2000 and 2004.
The report represents the third and final component of a comprehensive follow-up review — an
accountability audit — of 33 previous reviews and audits of entities comprising the former
Youth and Adult Correctional Agency (now the California Department of Corrections and
Rehabilitation). In addition to the 22 audits and reviews conducted by the Office of the Inspector
General between May 2000 and September 2004 represented here, the original audits in the
accountability audit included nine audits and reviews of the former California Youth Authority
(now the Division of Juvenile Justice) and two reviews of the Board of Prison Terms (now the
Board of Parole Hearings). The two previous follow-up reviews in the accountability audit were
released in January and July 2005, respectively.
The follow-up review of the California Department of Corrections and Rehabilitation’s adult
operations and programs determined that of 394 recommendations issued in the 22 previous
audits and reviews, 241 (61 percent) have been fully implemented; 53 (14 percent) have been
substantially implemented; 45 (11 percent) have been partially implemented; 39 (10 percent)
have not been implemented; and 16 (4 percent) are no longer applicable. The Office of the
Inspector General has issued 91 new recommendations, listed in the body of this report, to
address remaining deficiencies.
The review revealed two broad findings. The first is that the staff and management of individual
institutions have been highly responsive to recommendations resulting from past audits and
reviews and have taken numerous steps to improve operations and security at the state’s prisons.
The second is that the department itself has been less responsive to past recommendations and,
although it has markedly improved its internal affairs operation, has yet to address three of its
other most troubling and long-standing problems — the need to overhaul its antiquated
information technology system; the need to provide inmates with adequate medical care in a
fiscally sound manner; and the need to fulfill its broader public safety mission by better
preparing inmates for release. Achieving these goals is the responsibility of department
administrators. At the same time, it must be recognized that efforts to address the problems in
these areas are severely hampered by inmate population pressures that have prisons straining at
nearly twice design capacity, spreading staff resources thin and leaving little facility space
available for programming and other purposes. Developing sustainable solutions will require the
department, state policymakers, and the public to collectively address the available options:
increasing prison capacity; examining sentencing and parole policies; investing additional
resources in reducing recidivism; or a combination of all three.

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2006 ACCOUNTABILITY AUDIT

EXECUTIVE SUMMARY

IMPROVEMENTS BY THE INSTITUTIONS
Overall, the 2006 follow-up review determined that recommendations directed to prison wardens
and chief medical officers at individual institutions were more often implemented than those
directed toward department administrators, even though in some instances, the department has
had as long as five years to take action. Of 175 recommendations directed to wardens, 84 percent
(148) have been fully or substantially implemented. In contrast, only 69 percent (98) of the 143
recommendations directed to non-medical administrators in the department have been fully or
substantially implemented. Worst of all, of the 31 recommendations directed to headquarters
medical administrators, only 15 (48 percent) have been fully or substantially implemented. The
table shown below illustrates these results.
TABLE 1
IMPLEMENTATION STATISTICS
BY RESPONSIBLE ENTITY
Responsible
Entity

Totals

Fully
Implemented

Substantially
Implemented

Partially
Implemented

Not
Implemented

Not Applicable

Number

Percent

Number

Percent

Number

Percent

Number

Number

Percent

Percent

Department
Non-medical

143

78

55%

20

14%

22

15%

15

10%

Department
Medical

31

10

32%

5

16%

7

23%

9

29%

175

128

73%

20

11%

10

6%

9

5%

43

23

53%

8

19%

6

14%

6

14%

0%

2

2

100%

0%

0%

394

241

61%

Warden
Chief Medical
Officer
Department of
Forestry and Fire
Protection
Totals

0%
53

14%

0%
45

11%

39

10%

8

6%
0%

8

16

5%

4%

Institutions have implemented improvements in a wide range of operations, including security
requirements, employee disciplinary actions, staff training, and the inmate appeals process. For
example:
•

Sierra Conservation Center. A May 2001 audit of the Sierra Conservation Center
resulted in 53 recommendations to address a range of deficiencies in safety and security,
the inmate disciplinary process, staff training, employee grievances, equal employment
opportunity complaints, adverse personnel actions, and the reporting of inmate deaths.
The follow-up review determined that the institution has fully or substantially
implemented 92 percent of the recommendations, making important improvements in its
physical plant and operational procedures.

•

California State Prison, Solano. A March 2003 audit of California State Prison, Solano,
resulted in 24 recommendations relating to deficiencies in such areas as the tracking of
inmates with tuberculosis; the awarding of sentence reduction credits for classes that

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2006 ACCOUNTABILITY AUDIT

EXECUTIVE SUMMARY

were not held; the reporting of inmate deaths; the retention of inmates in administrative
segregation units for periods longer than justified; documentation of employee
disciplinary proceedings; and prompt implementation of medical modification orders.
The follow-up review determined that the institution has fully or substantially
implemented 88 percent of the recommendations.
•

Leo Chesney Community Correctional Facility. An audit of the Leo Chesney
Community Correctional Facility, released in October 2001, found deficiencies related to
the use of monies from inmate telephone revenues and the inmate welfare fund, as well as
deficiencies in staff training, the inmate adult education program, and the processing of
inmate appeals. The follow-up review determined that the facility has fully or
substantially implemented 73 percent of the 22 recommendations resulting from the
audit.

•

California State Prison, Sacramento. A September 2000 audit of California State Prison,
Sacramento resulted in 17 recommendations to address deficiencies related to financial
management; internal control weaknesses in the handling of inmate trust funds; failure to
process inmate appeal forms in a timely manner; the failure to comply with a mandate to
remove underground storage tanks; inconsistent handling of inmate rules violation
reports; and the failure to complete employee probation and performance reports on time.
The follow-up review determined that the institution has fully or substantially
implemented 82 percent of the recommendations.

IMPROVEMENTS BY THE DEPARTMENT
The follow-up review determined that the most important improvements affecting the
department have occurred in the internal affairs and employee disciplinary process as a result of
earlier reviews and the Madrid v. Woodford litigation. Reviews by the Office of the Inspector
General in October 2001 and March 2002 had found significant deficiencies that prevented
internal affairs investigations from being completed within the statutory one-year time limit,
which in turn prevented the department from disciplining peace officers found to have engaged
in misconduct. The March 2002 review found, for example, that 43 percent of a sample of
investigations completed during fiscal years 1999-2000 and 2000-01 in which misconduct
allegations were sustained were not completed within one year and therefore did not result in
disciplinary action. The department also has been criticized in the past for alleged failure to
sufficiently investigate misconduct and to impose discipline in a fair and consistent manner.
Under reforms developed through the Madrid Remedial Plan, however, a central intake panel
made up of representatives from the Office of Internal Affairs, Office of Legal Affairs, and other
department staff now reviews all requests for investigation and either accepts the request as an
internal affairs investigation or sends it back to the hiring authority for disposition. The Office of
the Inspector General’s Bureau of Independent Review monitors the central intake and internal
affairs process, and also monitors the investigations. A new electronic case management system
tracks the entire employee discipline continuum from the request for investigation to the final
hearing and disposition of action. Although deficiencies remain, such as the inability to use the
system to identify trends and pervasive problems, the Office of the Inspector General found that
as a result of these and other changes, only two percent of 94 investigations with sustained
findings conducted by the Office of Internal Affairs for the period December 1, 2004 through
May 31, 2005 exceeded the one-year statutory limit.
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CONTINUING DEPARTMENT FAILURES
Where institutions have not fully or substantially implemented recommendations, often the
reason has been the failure of the department to implement department-level solutions by
establishing the necessary statewide policies and procedures or investing in needed resources.
The department also has not effectively used its internal audit function and other tools to identify
systemic problems. Again, the most significant deficiencies are seen in information technology,
medical care, and inmate programming.
Information technology. The department’s outdated information technology, with its antiquated
mainframes and stand-alone databases lacking integration with other system components,
impedes processes at every level. The absence of efficient modern technology — to automate
routine procedures, to organize records and make them readily available to designated staff —
echoes through programs and institutions and causes inefficiency and waste. Worse, the
deficiencies reduce critical procedures to the manual handling of paper documents and
sometimes leaves the custody and medical staff at risk of making important decisions based on
paper records in files that may not be up-to-date. These deficiencies have been fueled by a long
history on the part of the department of poor information technology planning, poor project
implementation, and failure to fund needed improvements. Only 42 percent of the Office of the
Inspector General’s past recommendations relating to information technology covered in this
follow-up review, for example, have been fully or substantially implemented. To bring about
solutions, the administration, policymakers, the courts, labor representatives, inmate advocates,
and other corrections stakeholders should work together to invest in needed improvements and
resolve these long-standing problems.
Examples of areas affected by the failures in information technology include the following:
•

1

Pharmaceutical expenditures. The department continues to waste millions of dollars
annually by not implementing recommendations that it replace its outdated, inefficient,
20-year-old pharmacy management system. A July 2003 survey by the Office of the
Inspector General found the department’s pharmaceutical expenditures were projected to
increase 111 percent between 1999-2000 and 2002-03, even though the inmate
population decreased two percent and the national consumer price index for
pharmaceutical drugs increased only 22 percent during that time.1 To remedy the
problems, the Office of the Inspector General’s survey and four comprehensive audits
and studies by other entities identified the need for the department to replace the
pharmacy management system with an automated health care management system
capable of performing essential functions to control costs and prevent waste, fraud, and
abuse. Following the July 2003 survey, the Office of the Inspector General estimated that
by replacing the system and implementing other management controls, the department
could reduce its annual pharmaceutical expenditures— which totaled $122.4 million in
fiscal year 2002-03 — by as much as $26 million. In response to the 2006 follow-up
review, the department reported that it has made progress toward launching a new
automated health care management system, but that statewide implementation has not yet

The actual increase in the department’s pharmaceutical expenditures was later reported to have been 94 percent.

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been accomplished. The department reported, however, that it nonetheless achieved “cost
avoidance” between 2002-03 and 2003-04 because its pharmaceutical expenditures
increased only 6 percent, compared to the 18 percent average annual increase over the
three preceding fiscal years. Yet, Bureau of Labor Statistics data show that between July
2003 and June 2004, pharmacy prices nationwide increased only 3.3 percent. Meanwhile,
the department's pharmaceutical expenditures in fiscal year 2003-04 rose to $129.7
million —an increase of $7.3 million over the previous year. Because of these problems,
in March 2006, the U. S. District Court ordered a comprehensive financial and
operational audit of the department’s pharmaceutical services. That audit will be
conducted by a private specialty firm with expertise in correctional pharmaceutical
operations.
•

Inmate appeals. The department’s Inmate Appeals Branch still has not obtained the
information technology needed to enable it to efficiently analyze information from all
levels of the inmate appeals process in order to identify systemic problems in the
department’s operations and practices. The inmate appeals process provides inmates with
a means of resolving grievances concerning a range of issues, including requests for
reasonable accommodation under the Americans with Disabilities Act and the alleged
failure to obtain medical services. The Office of the Inspector General found from a
February 2001 review that the department had no automated process for analyzing the
appeals to identify deficiencies in policies, procedures, or practices even though the
department’s operations manual identifies the inmate appeals process as a vehicle for that
purpose. In a September 2004 follow-up review, the Inmate Appeals Branch reported that
it had developed a new inmate appeals tracking system for use at the institutions and was
in the planning stages to extend the reporting capability of the new system to include data
that could be used as a tool for identifying systemic problems. In the 2006 follow-up
review, however, the Inmate Appeals Branch reported that enhancements scheduled to
take place in November 2004 had been delayed because of other department priorities. In
December 2005, the Inmate Appeals Branch reported that it was working on a feasibility
study for the enhancements, which was scheduled to be completed by December 21,
2005. But the department had not completed the study when the Office of the Inspector
General’s fieldwork on this issue ended in December 2005.

•

Local assistance. The department’s Local Assistance Program, which reimburses local
jurisdictions for the costs of detaining state parolees in local facilities, lacks the
information technology needed to efficiently verify information on the invoices submitted
for those costs. The department reports that its parole revocation scheduling and tracking
system cannot be programmed to allow continuous tracking of the movements of
individual parolees. As a result, the parole staff cannot confirm that a parolee was
detained in the local jurisdiction on an active parole hold during the period claimed. The
department reports that it is using a tracking system developed only for Parole Region III,
which encompasses Los Angeles County, but has not estimated when such a system
might be available statewide. The 2005 state budget for local assistance payments totaled
$81.5 million.

Medical services for inmates. Because of the department’s long-standing failings in providing
inmate medical services, a federal receiver appointed by the U. S. District Court will take over
the department’s health care operations on April 17, 2006 to create a sustainable health care
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system capable of providing constitutionally adequate medical care to inmates. Under the terms
of the court’s action, the receiver will have broad powers to restructure day-to-day operations
and to direct the department’s medical administrative, personnel, financial, accounting,
contractual, legal, and other operational functions. In working with the receiver, the department
should endeavor to address the following long-term deficiencies:
•

The California Substance Abuse Treatment Facility. The second-largest prison in the
state system, the California Substance Abuse Treatment Facility and State Prison at
Corcoran, reports that a critical shortage of staff physicians to treat its more than 7,300
inmates has prevented the institution from implementing many of the Office of the
Inspector General’s past recommendations affecting medical services. The institution
continues to fail to ensure that inmates see physicians promptly after requesting medical
services, and inmates with chronic medical conditions are not adequately monitored.
Because of the physician shortage, inmate appeals concerning medical services at the
institution are backlogged, creating a domino effect as new appeals are filed to complain
that earlier appeals have not been answered. Repeated turnover in other key medical
positions also contributes to the deficiencies. The institution reports that six different
individuals filled its chief medical officer position between September 2002 and June
2005 when the present incumbent was hired and that since September 2002 its chief
dental officer, chief psychologist, chief psychiatrist, director of nurses, and medical
records supervisor have all resigned, retired, or transferred. The use of outside medical
specialists at the institution also has not been brought under control. In fiscal year 200102, the institution exceeded its budget for contracted medical services by more than $5
million — an 81 percent overage. The Office of the Inspector General recommended in
January 2003 that the institution establish a process to review all referrals to outside
providers, and the institution reports that it did establish an authorization committee to
review specialist referrals, but that the physician shortage has limited the review to a
cursory examination by the chief medical officer.

•

Contracting for outside medical services. An October 2002 special review by the Office
of the Inspector General found the department lacked a comprehensive statewide policy
for managing medical services contracts and, because of deficiencies in its medical
contracting process, had paid for services not performed and for services with an outside
physician that had not been authorized. In response to the Office of the Inspector
General’s review, the department established a health contract services unit to assist
institutions with all medical services contracts. In addition, the department required
institutions to solicit medical providers and to prepare market surveys before initiating a
contract. Meanwhile, expenditures for medical contracts rose 58 percent between fiscal
years 2000-01 and 2004-05 from $200 million to more than $315 million, largely because
of medical staff vacancies requiring contracted personnel to fill the void.
In response to two subsequent audits issued by the California State Auditor in 2004, the
Department of General Services tightened the procedures used by the department to
contract with outside community hospitals, physicians, nurses, pharmacists and other
medical professionals to provide needed services and fill temporary medical staff
vacancies and required the department to obtain competitive bids on clinical contracts.
According to a correctional expert appointed by the U. S. District Court, however, due in
part to insufficient staffing and training necessary to properly implement the new

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contracting procedures as well as to the complexity of the procedures, the department has
fallen $58 million behind in paying provider claims. The new bidding process instituted
to replace single-source contracting also has resulted in a shortage of specialty providers.
Because of these developments, on March 30, 2006 the court ordered the department to
pay all valid outstanding department-approved claims within 60 days and to establish
new medical contracting procedures within 180 days.
Preparing inmates for release. California’s prison population grew by 8,245 inmates between
2000 and 2006, tracking almost exactly with the state’s annual population growth rate. In
February 2000, the total inmate population stood at 160,846 and by March 2006 it had increased
to 169,091, making California’s prison system among the largest in the world and filling the
state’s prisons to nearly double design capacity. The department’s adult operations budget grew
over the same period from $4.4 billion in fiscal year 2000-01 to $5.3 billion in 2003-04 and to a
proposed $7.5 billion for fiscal year 2006-07. As the inmate population increases, the
department’s problems — controlling violence, offering education, delivering health care,
managing overcrowding, and controlling costs — become more difficult. While numerous
factors are driving the numbers, the department has done little to control recidivism.
Examples of the deficiencies in rehabilitation efforts:
•

Substance abuse treatment. According to the department, 21 percent of the state’s more
than 169,000 inmates are presently serving prison terms for drug offenses and the oneyear recidivism rate for drug offenders is 37 percent. Yet, the effectiveness of the
department’s largest substance abuse treatment program is still unproven. A September
2002 study by the University of California, Los Angeles of the California Substance
Abuse Treatment Facility’s 1,478-bed substance abuse treatment program — the largest
custody-based substance abuse treatment program, not only in the state correctional
system, but also in the United States — showed no difference in recidivism rates between
program participants and a control group of inmates from another prison who did not
receive treatment. No comprehensive effectiveness studies comparable to the September
2002 study have been conducted. A January 2003 audit by the Office of the Inspector
General of the program found numerous problems that impaired the program’s
effectiveness. The program is administered by the department’s Office of Substance
Abuse Programs, which screens inmates for the program, and is run by two private
contractors. From January 2002 through June 2006, the Office of Substance Abuse
Programs contracted to pay each private contractor approximately $29 million for
substance abuse program services, for a total of $58 million. Key among the deficiencies
identified was the placement of large numbers of inmates into the program who were not
suited to the treatment model, including sex offenders and inmates suffering from mental
illness. Other deficiencies included a shortage of trained counselors to run the interactive
therapeutic community — a proven treatment modality for substance abusers — and the
fact that treatment group sizes exceeded contract limits. The department has made
improvements since the January 2003 audit by reducing the number of sex offenders and
mental health patients in the program, yet the problems of large group size and the
shortage of counselors remain. The 2006 follow-up review found that more than 400
general population inmates had been moved into the substance abuse housing units in
response to a department-wide bed shortage, causing the substance abuse treatment group

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clusters to increase to up to 100 inmates —exceeding the professionally recommended
standard for therapeutic communities of 50 to 75 participants per cluster. The follow-up
review also found that program staffing was 19 percent short of contract requirements,
with only 59 counselors, instead of the 73 entry-level and journey-level counselors
provided for under the contracts. The deficiencies appear to result from the continuing
failure of the department to adequately monitor program contractors or to include
provisions in the contracts that would allow the state to impose sanctions for
noncompliance.
•

Education. To its credit, the department has taken steps to institute new education
methods for inmates at Level IV institutions, where classroom education models have
proven to be unworkable, but the effectiveness of the new programs has not yet been
evaluated. A July 2003 survey by the Office of the Inspector General found that
delivering academic and vocational classes through a classroom model was ineffective
and expensive for Level IV maximum security inmates because frequent institution
lockdowns caused classes to be cancelled more than 60 percent of the time. The Office of
the Inspector General also found that even if the classes were held 100 percent of the
time, they would be able to accommodate only a small percentage of inmates eligible for
the programs, in part because of the small number of budgeted teaching positions at
Level IV institutions. State law requires the department to make literacy programs
available to at least 60 percent of eligible inmates with the goal of ensuring that inmates
achieve a ninth-grade reading level by the time they parole, and a survey by the
Department of Corrections in November 1996 found that 68 percent of the inmate
population scored below the ninth grade level in reading. Yet, at the time of the Office of
the Inspector General’s July 2003 survey, only 21 percent of eligible inmates at the five
Level IV institutions covered in the survey were assigned to education classes. Since the
survey, the department reports that it has developed new program models incorporating
self-paced independent study, distance education, and other education services to increase
inmate participation. It is too early to assess the effectiveness of the new education
programs, however, and the department has not developed an effective monitoring
system to ensure that institutions are complying with its education policies and
procedures. Prison reform advocates have also suggested that the new programs may be
too shallow to be effective, but again, population pressures appear to make it difficult to
provide more comprehensive educational opportunities, at least in a classroom setting.

Failure to use internal auditing tools. The Department of Corrections and Rehabilitation has
failed to make effective use of its own internal auditing function to identify systemic
deficiencies and effect needed changes in programs and institutions. An October 2002 audit
by the Office of the Inspector General of the Office of Compliance, which is the entity
responsible for the department’s internal auditing activity, found numerous weaknesses. For
example, the office did not target internal audits toward areas of the highest risk; did not
monitor audit projects to make sure they were completed in a proper and timely manner; and
used a rigid checklist auditing approach that had the potential to miss important issues. The
Office of Compliance reports that it has taken preliminary steps toward correcting
deficiencies. But, more than three years after the October 2002 audit, the Office of
Compliance still has not addressed most of the audit findings and has still not appointed a
chief of internal audits with the training and experience to manage an internal auditing unit.

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EXECUTIVE SUMMARY

SUMMARY OF FINDINGS AND RECOMMENDATIONS
Following is a summary of the findings from each of the 22 follow-up reviews comprising this
accountability audit of the California Department of Corrections and Rehabilitation’s adult
operations and programs. An index to the summaries is included following that section.

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2006 ACCOUNTABILITY AUDIT

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY
AND STATE PRISON AT CORCORAN

EXECUTIVE SUMMARY

IMPLEMENTATION REPORT CARD

Previous recommendations: 72
The California Substance Abuse Treatment Facility and
State Prison at Corcoran has developed needed
Fully implemented: 38 (53%)
improvements to policies and procedures affecting
Substantially implemented: 11 (15%)
medical services, but the institution has not
implemented numerous recommendations from a
Partially implemented: 10 (14%)
January 2003 audit, citing a shortage of medical
Not implemented: 12 (17%)
personnel and turnovers in its management ranks as
major impediments. In addition, the Office of Substance
Not applicable: 1 (1%)
Abuse Programs has not significantly improved its
processes for monitoring contracts with private
providers of in-prison substance abuse treatment
programs, and drug treatment providers continue to fail to provide the number of
counselors required under the contracts. Independent evaluations of the effectiveness of the
facility’s in-prison substance abuse treatment program are inconclusive.

The Office of the Inspector General issued a management review audit of the California
Substance Abuse Treatment Facility and State Prison at Corcoran in January 2003. The audit
identified numerous problems at the institution, including inadequate management of medical,
dental, and pharmacy services; deficiencies in the substance abuse treatment program that
prevented the institution from reducing recidivism by helping inmates overcome drug
dependency; and the failure of a significant number of staff and managers to fulfill annual
training requirements.
The January 2003 management review audit identified numerous problems that impaired the
effectiveness of the institution’s substance abuse treatment program. Key among these was the
placement into the program of large numbers of inmates not suited to the treatment model,
including sex offenders and inmates suffering from mental illness. Other deficiencies included a
shortage of trained counselors to run the interactive therapeutic community — a proven
treatment modality for modifying the behavior of substance abusers — and the fact that
treatment group sizes for the therapeutic community exceeded contract limits.
A September 2002 study of the institution’s substance abuse treatment program by the
University of California, Los Angeles, showed no difference in recidivism rates between
program participants and a control group of inmates at another prison who received no treatment.
The study raised questions about the advisability of paying contractors millions of dollars for inprison substance abuse programs not demonstrated to be effective.
As a result of the January 2003 management review audit, the Office of the Inspector General
made 72 recommendations to the Department of Corrections, the Health Care Services Division,
and the California Substance Abuse Training Facility and State Prison at Corcoran.

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EXECUTIVE SUMMARY

BACKGROUND
The California Substance Abuse Treatment Facility and State Prison at Corcoran, which opened
in August 1997, houses approximately 7,300 male inmates and has a staff of about 1,700
employees, making it one of the largest prisons in the western world. It is designed for inmates
ranging from Level II (low medium security) through Level IV (maximum security), and also
includes a small number of Level I (minimum security) inmates. The institution includes a
correctional treatment center, which provides medical treatment and recovery, mental health
assessment and care, and clinical services. Clinics affiliated with the correctional treatment
center provide medical and dental services inside each of the prison’s seven facilities.
Pharmaceuticals are provided by a pharmacy located in the correctional treatment center.
Medical services for the California Department of Corrections and Rehabilitation inmates are the
responsibility of the department’s Division of Correctional Health Care Services. The health care
manager at the Substance Abuse Treatment Facility and State Prison at Corcoran acts as the onsite administrator of health care services for the institution and is responsible for overall
management of the institution’s medical, mental health, and dental programs.
In addition to its mission of providing custody for state prison inmates remanded to the custody
of the Department of Corrections and Rehabilitation, the institution includes a 1,478-bed
substance abuse treatment program — the largest custody-based substance abuse treatment
facility in the United States. The Department of Corrections and Rehabilitation’s Office of
Substance Abuse Programs is responsible for administering the substance abuse program, which
is run by two private contractors. The Office of Substance Abuse Programs has employees on
site to monitor daily program operations and to screen inmates eligible for the substance abuse
program to ensure that the program operates at full capacity. The office is also responsible for
monitoring the private contractors for compliance with the terms of the contracts to provide
treatment services. The institution staff provides custody, security, drug testing, classification
reviews, and administrative support to the Office of Substance Abuse Programs and the
contractors. From January 2002 through June 2006, the Office of Substance Abuse Programs
contracted to pay each private contractor approximately $29 million for substance abuse program
services.
SUMMARY OF THE 2006 FOLLOW-UP RESULTS
In the 2006 follow-up review, the Office of the Inspector General found that although there have
been some improvements, the California Substance Abuse Treatment Facility has made generally
disappointing progress in implementing needed changes in the three years since the January 2003
management review audit. The institution has been successful in identifying and recruiting a
higher proportion of program-eligible inmates into the program, while reducing the proportion of
sex offenders and mental health patients. Of the 1,456 inmates assigned to the program on
October 20, 2005, less than seven percent were mental health patients and less than one percent
of those who were mental health patients were also sex offenders. In comparison, the January
2003 audit found the proportion of sex offenders and mental health patients in the program to be
as high as 50 percent.

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The Office of the Inspector General also found, however, that the Office of Substance Abuse
Programs continues to fail at effectively monitoring its contracts with the private providers of
substance abuse program services at the prison. In reviewing the on-site monitoring reports for
each provider in the substance abuse program for the 11-month period from December 2004 to
October 2005, the Office of the Inspector General found that the monitoring reports continued to
lack detail, did not focus on the contractors’ compliance with contractual expectations, and did
not reflect evidence of substantive review of the providers’ records and operations.
The Office of the Inspector General noted in addition that the program providers continue to
supply an inadequate number of counselors. During an October 2005 site visit, the Office of the
Inspector General found that program staffing was 14 counselors short of the 73 entry-level and
journey-level counselors required under the state contracts — a 19 percent shortfall. Moreover,
the Office of Substance Abuse Programs still has no language in its provider contracts permitting
the state to withhold payment or to exercise other sanctions short of contract cancellation for
instances of non-compliance.
The Office of the Inspector General also found that an influx of more than 400 general
population inmates into the substance abuse housing units in response to a department-wide bed
shortage caused the treatment group cluster sizes to increase from 62 inmates to up to 100
inmates —levels that exceed the professionally recommended standard of 50 to 75 participants
for therapeutic community programs and further detract from program effectiveness.
Treatment also appears to be frequently interrupted. On two separate visits in October and
November 2005, the Office of the Inspector General attempted without success to observe
therapeutic community groups and evaluate group sizes at the institution. On the first visit, all
counseling had been suspended for the programs’ annual “Sports Week,” and on the second visit
nearly all group sessions had been suspended to accommodate population movements among the
housing units. This inactivity, coupled with recent lockdowns reported by counselors, raises
concerns about the continuity of therapeutic community treatment at the institution. It is
noteworthy that, with the exception of the lockdowns, none of the monitoring reports by the
Office of Substance Abuse Programs discussed the continuing problems found by the Office of
the Inspector General during its six days of fieldwork.
The Office of the Inspector General reviewed three subsequent evaluations by the University of
California, Los Angeles, of the institution’s substance abuse treatment program conducted since
the September 2002 evaluation. Although the more recent evaluations, which were issued in
September 2003, September 2004, and January 2006, made positive assessments of the
effectiveness of post-prison aftercare, none were bona-fide effectiveness studies like the 2002
evaluation because they did not compare the recidivism rates of in-prison program participants
against those of inmates from another prison who had not received treatment. Without a
comparison of the subject group to a control group, it is not possible to conclude that the
institution’s program is successful in lowering recidivism.
Medical care. The Office of the Inspector General found that although the institution has made
efforts to implement recommendations affecting the institution’s medical services and
operations, many of the problems identified in the January 2003 management review audit have
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not been adequately addressed. The remaining deficiencies include a continuing backlog of
inmate medical appeals; lack of an effective means of ensuring that physicians work a full 40hour-a-week schedule; failure to ensure that inmates see a physician in a timely manner; lack of
review of the need for inmate treatment by specialists; and inadequate monitoring of chronic care
patients. The institution points to repeated turnover in the chief medical officer position as one
cause of the continuing deficiencies. Six different individuals served in the position between
September 2002 and June 2005, when the present incumbent was hired. The institution also
reports that since September 2002 its chief dental officer, chief psychologist, chief psychiatrist,
director of nurses, and medical records supervisor have all resigned, retired, or transferred. The
institution further cites a critical shortage of physicians and other medical staff as a barrier to full
implementation of the Office of the Inspector General’s recommendations. For example:
•

The institution reports that it has established an expectation that physicians complete all
administrative duties, including notifying the chief medical officer of medical appeals
approaching delinquent status, but maintains that the physician shortage precludes
aggressive focus on appeals.

•

The institution reports it established a medical authorization review committee to review
the medical necessity for procedures referred to outside medical providers, but that the
committee process has fallen victim to the physician shortage and reviews are limited to a
cursory examination by the chief medical officer.

•

While physicians’ hours and workloads have been adjusted to permit doctors to see more
patients, the requirement that inmates see doctors within 14 days after a request for
contact as mandated by the Plata v. Schwarzenegger court decision is not being met
because the institution does not have enough physicians to meet that workload.

In addition, the Office of the Inspector General found that despite establishing a system of
accountability for medical personnel, the institution’s medical management team has been lax in
enforcing a directive that medical personnel log in and out of the correctional treatment center
each day by signing the log and recording the actual times of arrival and departure. Instead of
recording the time of day, physicians simply sign the log and indicate a status of “in” or “out.”
Pharmacy operations. The Office of the Inspector General noted significant improvements in
the institution’s pharmacy operations. The institution developed improved policies and
procedures for control of medications and quality control over prescriptions, as well as for intrafacility transfers of inmate medications. Spending for pharmaceuticals also decreased. As the
Office of the Inspector General reported in the January 2003 management review audit, the
institution spent $5.4 million in fiscal year 2001-02 for drugs and pharmaceutical supplies, but in
fiscal year 2004-05, the institution’s reported spending decreased to $3.7 million — a 31 percent
reduction. The Department of Corrections and Rehabilitation, however, has still has not made a
significant effort to develop an automated pharmaceuticals inventory system for the institutions.
The Office of the Inspector General also found that the Substance Abuse Treatment Facility has
made significant progress in staffing its pharmacy with permanent state employees. At the time
of the Office of the Inspector General’s January 2003 audit, the institution’s pharmacy was
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staffed entirely by contract employees, but now the pharmacy employs only two contract
employees among its full-time staff of nine. The positions currently filled by the two contract
employees have been advertised as state civil service job openings since October 30, 2002, and
the institution says the current state salary for pharmacists is lower than that offered in the
industry, making recruitment difficult.
FOLLOW-UP RECOMMENDATIONS
As a result of the 2006 follow-up review, the Office of the Inspector General is providing 23
recommendations to the Office of Substance Abuse Programs. The main recommendations
are listed below, and the remainder are presented in the full report.
•

Conduct systematic, in-depth monitoring of treatment providers for compliance with
contract terms. Monitoring reports should reflect all substantive details of the
provider’s records and operations. The reports should also include the Office of
Substance Abuse Programs’ analysis and evaluation of the provider’s operations.

•

When drafting contracts for substance abuse treatment services, include provisions for
fiscal sanctions to address instances of non-compliance with contract terms, including
failure to provide the required number of counselors.

•

Whether performed by UCLA or by another contractor, ensure that future studies of
the effectiveness of the substance abuse program at the institution include a comparison
of the treatment group to a control group of similar inmates who did not receive
treatment.

•

Return to using smaller clusters of inmates to conform to the Office of National Drug
Control Policy’s recommendation that therapeutic community program clusters consist
of no more than 50 to 75 inmates.

The Office of the Inspector General recommends that the Substance Abuse Treatment
Facility and State Prison at Corcoran continue to work with the Division of Correctional
Health Care Services’ department-wide efforts to address the shortage of physicians and
other medical staff.

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PHARMACEUTICAL EXPENDITURES
IMPLEMENTATION REPORT CARD

The Office of the Inspector General found that the
Department of Corrections and Rehabilitation has made
some progress in reducing its pharmaceutical
expenditures. The department, however, has
accomplished only the preliminary steps required to
replace its outdated management information system.

Previous recommendations: 7
Fully implemented: 0 (0%)
Substantially implemented: 1 (14%)
Partially implemented: 2 (29%)

Not implemented: 3 (43%)
In July 2003, the Office of the Inspector General conducted
a survey to examine the Department of Corrections
Not applicable: 1 (14%)
pharmaceutical expenditure trends over the four preceding
fiscal years and to evaluate the department’s efforts to
implement changes recommended by previous audits and
studies. The survey revealed that the department’s pharmaceutical expenditures increased 94
percent, from $63 million in fiscal year 1999-2000 to $122.4 million in 2002-03 despite a slight
decrease in inmate population and in stark contrast to a 22 percent increase in the national
consumer price index for pharmaceutical drugs during the same period. The department’s perinmate pharmaceutical expenditures also increased, more than quadrupling from $142 in 1997 to
$642 in 2002. The survey further identified four comprehensive audits and studies that had
previously identified problems in the department’s pharmacy program and included specific
recommendations to remedy the deficiencies. Particularly critical was the indicated need for the
department to replace its Pharmacy Prescription Tracking System, a badly outdated 20-year-old
information system that lacked essential functions to control costs and prevent pharmaceutical
waste, fraud, and abuse. In its July 2003 survey, the Office of the Inspector General
recommended that the department act promptly to implement the recommendations of previous
audits and studies of its pharmacy program, noting the department could reduce its annual
pharmaceutical expenditures by up to $26 million by doing so. The Office of the Inspector
General also recommended that if it appeared that the department would be unable to carry out
the implementation on its own, that it consider contracting with a private vendor to institute the
necessary improvements.

SUMMARY OF THE 2006 FOLLOW-UP RESULTS
In the 2006 follow-up review, the Office of the Inspector General found that the department has
failed to fully implement the recommendations from the 2003 survey. Until it implements past
recommendations in this area, the department continues to waste millions of dollars annually in
pharmaceutical expenditures.
The department reported it has developed a strategic plan incorporating recommendations from
private consulting, regulatory, and oversight agencies. It also reported that it has revised its
statewide procedures for medication administration and distribution; trained personnel on
formulary rules; and organized management workgroups. The department rejected
recommendations to contract with a private firm to manage pharmacy operations and to
centralize its pharmacy distribution system.

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Although the department reported it has made progress in launching a project to replace its
outdated and inefficient pharmacy management system with an automated health care
management system, statewide implementation of that system has not been accomplished. The
department reported, however, that it achieved a “cost avoidance” of $14.3 million between
projected pharmaceutical expenditures for fiscal year 2003-04 ($144 million) and actual
expenditures for that period. The department’s actual pharmaceutical expenditures for fiscal year
2003-04 were $129.7 million — a $7.3 million (6 percent) increase over the previous year,
compared to an 18 percent average increase experienced in the three preceding fiscal years. Yet,
Bureau of Labor Statistics data show that between July 2003 and June 2004, pharmaceutical
prices nationwide increased only 3.3 percent.
Because of these problems, in March 2006, the U. S. District Court ordered a comprehensive
financial and operational audit of the department’s pharmaceutical services, to be conducted by a
private specialty firm with expertise in correctional pharmaceutical operations. In addition, the
U. S. District Court-appointed receiver scheduled to take over all aspects of the department’s
health care system on April 17, 2006, will have authority to acquire and modernize information
technology.
FOLLOW-UP RECOMMENDATIONS
As a result of its 2006 follow-up review, the Office of the Inspector General recommends
that the Department of Corrections and Rehabilitation take the following actions:
•

Continue the project to replace the outdated and inefficient Pharmacy Prescription
Tracking System with the automated Health Care Management System and implement
the new system statewide as soon as practicable.

•

In light of the flexible options likely to be available under the February 2006 federal
court order appointing a receiver over the department’s medical health care delivery
system, reconsider the option of contracting with a private pharmacy services
management firm to implement the recommendations submitted in the reports and
studies conducted since 2000.

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OFFICE OF INVESTIGATIVE SERVICES

EXECUTIVE SUMMARY

IMPLEMENTATION REPORT CARD

The Department of Corrections and Rehabilitation has
Previous recommendations: 37
reorganized and significantly improved its internal
Fully implemented: 19 (52%)
affairs operation since an October 2001 special review.
The Office of Investigative Services—renamed the Office
Substantially implemented: 2 (5%)
of Internal Affairs1—is now responsible for all of the
department’s internal affairs investigative functions.
Partially implemented: 8 (22%)
Many of the Office of the Inspector General’s previous
Not implemented: 6 (16%)
recommendations were implemented in the course of the
reorganization and as a result of a federal court-ordered
Not applicable: 2 (5%)
remedial plan. Other recommendations are no longer
applicable in the wake of these changes. Yet, several
deficiencies identified in the Office of the Inspector General’s 2001 review remain,
including the lack of a system for prioritizing investigations; inadequacies in completing
employee background investigation; and failure to use the department’s internal audits
function to help identify pervasive problems.
In October 2001 the Office of the Inspector General issued a special review of the management
practices and administrative operations of the Office of Investigative Services, which is
responsible for all of the department’s internal affairs investigative functions. The special review
centered on the Office of Investigative Services’ effectiveness, its compliance with required
procedures, and the quality of its operational practices, identifying numerous deficiencies that
impaired the ability of the office to meet its responsibilities. In particular, the review found that a
rapidly expanding caseload, coupled with deficient management practices, prevented the Office
of Investigative Services from completing investigations within required time limits. That
deficiency limited the ability of the department to take appropriate administrative action against
employees when misconduct allegations were sustained. The Office of the Inspector General
presented 37 recommendations to remedy the deficiencies identified in the October 2001 special
review.
SUMMARY OF THE 2006 FOLLOW-UP RESULTS
The Office of the Inspector General’s 2006 follow-up review found that the Office of Internal
Affairs has significantly improved its investigative process through creation of a central intake
panel that brings consistency to the process of determining whether to accept or reject cases for
investigation. In another improvement, the investigative classification system has been
streamlined, allowing cases involving minor supervisory issues requiring no additional
investigation to be addressed directly by the hiring authorities, while those requiring
investigation are conducted or closely supervised by the Office of Internal Affairs. In addition,
the former case management information system has been replaced by a new system providing
not only for tracking and monitoring active cases, but also for tracking the entire employee
discipline continuum from the initial request for investigation to its final disposition. The system
1

Depending on the context and time-frame discussed, both names — Office of Investigative Services and Office of
Internal Affairs — are used in this report.

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EXECUTIVE SUMMARY

is being installed at California Department of Corrections and Rehabilitation investigative
offices, legal offices, and hiring authorities throughout the state.
Many of the Office of the Inspector General’s recommendations from the October 2001 special
review were implemented in the course of reorganizing the entities now under the Department of
Corrections and Rehabilitation, and also as a result of a federal court-ordered remedial plan.
Other recommendations are no longer applicable in the wake of these changes. However, several
deficiencies identified in the Office of the Inspector General’s 2001 review remain. These
include a lack of a system for prioritizing investigations; inadequate management of overtime
use; inadequacies in completing background investigations of employees and borrowed
investigators; inadequate control over access to the case management information system;
deficiencies in evidence handling; and failure to use the department’s internal audits function to
help identify pervasive problems.
FOLLOW-UP RECOMMENDATIONS
The Office of the Inspector General’s 2006 follow-up review makes ten additional
recommendations to the Office of Internal Affairs, including the following:
•

Develop policies and procedures for prioritizing investigative cases.

•

Assign each region a monthly allocation of budgeted overtime and prepare a monthly
log for each regional office that begins with monthly allotted hours and is adjusted for
each usage. When overtime is granted, the supervisor should immediately e-mail the
agent and the overtime timekeeper for the purpose of adjusting monthly balances and
providing evidence of previous overtime approval. In order to provide regional
supervisors flexibility in managing cases, the Office of Internal Affairs should consider
rolling over unused office balances from one month to the next.

•

Refrain from using investigative services unit investigators until their supplemental
background investigations are complete.

•

Formalize the process for verifying that case management information system access is
limited to only authorized users. The process should define the frequency of reviews,
require a reconciliation of beginning and ending authorized users for the period, and
specify the date when users are added or deleted. Included in this process should be a
requirement that an exit document be prepared by the departing staff’s supervisor that
instructs the information technology staff to remove the user’s access.

•

Prepare a supervisory quality control review sheet that ensures that the investigative
package is complete, the investigative plan was followed, all key witnesses were
interviewed, required notices were performed, and the final report represents a clear,
fair, and unbiased representation of the facts.

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•

EXECUTIVE SUMMARY

Use the Department of Corrections and Rehabilitation internal audit staff to perform
field audits to identify trends in complaints against staff so that resources can be
focused on the most pervasive problems.

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EMPLOYEE DISCIPLINARY PROCESS
The Office of the Inspector General found that the
Department of Corrections and Rehabilitation has
improved its employee disciplinary process and has fully or
substantially implemented all previous recommendations.
In March 2002, the Office of the Inspector General conducted a
review of the Department of Corrections employee disciplinary
process. The purpose of the review was to identify any
administrative or procedural weaknesses in the disciplinary
process that might affect the department’s ability to take
appropriate adverse action against employees found to have
engaged in misconduct.

EXECUTIVE SUMMARY

IMPLEMENTATION REPORT CARD
Previous recommendations: 9
Fully implemented: 6 (67 %)
Substantially implemented: 3 (33%)
Partially implemented: 0 (0%)
Not implemented: 0 (0%)
Not applicable: 0 (0%)

The review found that needless complexity sometimes delayed or even impaired disciplinary
actions against employees. In addition, there were no clear guidelines defining the one-year
period for investigating misconduct and imposing disciplinary action against peace officers. The
review found that 43 percent of a sample of investigations completed during fiscal years 1999-00
and 2000-01 in which misconduct allegations were sustained were not completed within one year
and therefore did not result in disciplinary action. Further, employee relations officers at
institutions were not adequately trained, departmental legal staff were often uninvolved in
disciplinary actions, and the department lacked policies and procedures governing settlements
with employees. The Office of the Inspector General made nine recommendations to the
department to address these findings. Subsequent to the March 2002 review, a special master
appointed by the U. S. District Court, Northern District of California has been monitoring efforts
to reform the disciplinary process through what is known as the Madrid Remedial Plan. Many of
the plan’s provisions are consistent with the Office of the Inspector General’s March 2002
recommendations.
SUMMARY OF THE 2006 FOLLOW-UP RESULTS
In its 2006 follow-up review, the Office of the Inspector General found that the Department of
Corrections and Rehabilitation has significantly improved its administration of the employee
disciplinary process. The department has developed a case management system to monitor and
track disciplinary cases from start to finish to ensure that cases meet statutory deadlines. It has
also implemented a new central intake process that provides for representatives from the Office
of Internal Affairs, office of Legal Affairs, and other department staff to review requests for
investigations and determine appropriate action. The Office of the Inspector General’s Bureau of
Independent Review monitors the central intake and internal affairs process and also monitors
the investigations. The department has also updated its policies and procedures for employee
discipline and has provided formal training to its employee relations officers statewide. As a
result of these and other changes, only two percent of 94 investigations with sustained findings
conducted by the Office of Internal Affairs for the period December 1, 2004 through May 31,
2005 exceeded the one-year statutory limit. No follow-up recommendations are made.

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OFFICE OF COMPLIANCE, AUDIT FUNCTIONS
The Office of the Inspector General found that the
Department of Corrections and Rehabilitation has
consolidated its audit functions into a single unit and
elevated the chief of the unit to report directly to the
undersecretary. Yet, more than three years after an
October 2002 review by the Office of the Inspector
General, the department still has not corrected most of
the deficiencies identified in that review.

EXECUTIVE SUMMARY

IMPLEMENTATION REPORT CARD
Previous recommendations: 4
Fully implemented: 2 (50 %)
Substantially implemented: 0 (0%)
Partially implemented: 2 (50%)
Not implemented: 0 (0%)
Not applicable: 0 (0%)

In October 2002, the Office of the Inspector General issued a
report resulting from a review of the audit functions of the
Department of Corrections Office of Compliance. The Office of the Inspector General found that
the Office of Compliance did not adhere to appropriate professional standards in performing its
internal audit work. The Office of the Inspector General identified several specific weaknesses in
the department’s management of the Office of Compliance, all of which resulted from the failure
of the office to comply with internal auditing standards. The deficiencies included poor
communication with executive staff and unresponsiveness to executive requests for audits. As a
result of the deficiencies, the Office of the Inspector General questioned the ability of the Office
of Compliance to accomplish its objectives and meet its assigned responsibilities. As a result of
the October 2002 review, the Office of the Inspector General recommended that the Department
of Corrections consolidate all of its auditing activities into a professional internal auditing unit
consistent with standards prescribed in Standards for the Professional Practice of Internal
Auditing. The Office of the Inspector General recommendations specified that the chief of
internal audits should possess the training, knowledge, and experience necessary to manage an
internal auditing unit and should report to the chief deputy director for Support Services.
SUMMARY OF THE 2006 FOLLOW-UP RESULTS
In its 2006 follow-up review, the Office of the Inspector General found that more than three
years after the initial audit in October 2002, the department has not addressed most of the audit
findings. The department has consolidated its internal audit activities into the Office of Audits
and Compliance, which reports directly to the department’s undersecretary. That change should
allow the department to better coordinate its varied audit activities and provide the appropriate
level of organizational independence, as prescribed by the Institute of Internal Auditors.
According to the department, once the Office of Audits and Compliance is fully operational, it
will address most of the remaining issues raised in the October 2002 review.
Because the Office of Audits and Compliance is not yet fully operational, however, the
department has not yet addressed several issues and recommendations raised in the review
including:
•

The department stated that it has not yet begun to adhere to Standards for the Professional
Practice of Internal Auditing.

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•

The department reported that it has not yet developed a quality assurance and improvement
program for its internal auditing activity.

•

The department stated that it is currently not using a risk-based plan to determine the
priorities of its internal audit activity.

•

The department acknowledged that the two units that perform audits of internal operations
are still not receiving substantive input from senior management in developing their audit
plans.

•

The department has not yet appointed a permanent assistant secretary as the chief of internal
audits who possesses the training, knowledge, and experience to manage an internal auditing
unit.

Not only appropriate auditing standards, but also sound business principles require the
department to incorporate the features described above into its audit operations. By not
adequately addressing the findings of the Office of the Inspector General’s October 2002 report,
the department has limited the value of its internal audit unit as a tool for identifying department
operations needing improvement.
FOLLOW-UP RECOMMENDATIONS
As a result of its 2006 follow-up review, the Office of the Inspector General makes six
recommendations, including:
•

The department should continue its efforts to recruit a permanent assistant secretary
for the Office of Audits and Compliance, ensuring that the person selected possesses the
training, knowledge, and experience to manage an internal auditing unit.

•

The department should ensure that the Office of Audits and Compliance continues to
develop operating policies and procedures that will ensure that its audit activity is
consistent with the standards prescribed in the Standards for the Professional Practice of
Internal Auditing.

•

The policies and procedures should include a process for effective communication with
the department’s executive staff in planning annual audit activities and reporting audit
performance, and a process by which to develop a risk-based comprehensive annual
plan for identifying the priorities of the internal audit activity.

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EXECUTIVE SUMMARY

MEDICAL CONTRACTING PROCESS
IMPLEMENTATION REPORT CARD

The Office of the Inspector General found that the
Department of Corrections and Rehabilitation has
implemented several of the recommendations resulting
from an October 2002 special review, but because of
continuing problems with its medical contracting
procedures, is under court order to develop new
procedures within 180 days.

Previous recommendations: 7
Fully implemented: 5 (72 %)
Substantially implemented: 1 (14%)
Partially implemented: 1 (14%)
Not implemented: 0 (0%)

In October 2002, the Office of the Inspector General
Not applicable: 0 (0%)
conducted a special review of the processes and controls
used by the department’s Health Care Services Division to
procure and pay for contract medical services to inmates. In
order to provide adequate medical services to the growing inmate population, the department
contracts with outside community hospitals, physicians, nurses, pharmacists, and other medical
professionals to obtain specialized services its staff and facilities cannot provide. In some
instances, the department also contracts with medical professionals to fill temporary staff
vacancies in medical classifications where recruitment is difficult. The review determined that
the division did not effectively manage its medical services to inmates and that it should adopt
statewide policies and procedures to ensure cost-effective contracts, quality case management,
and continuity of care.
The October 2002 review found the department lacked a comprehensive statewide policy for
managing medical services contracts and had paid for services not performed and for services
with an outside physician that had not been authorized because of deficiencies in its medical
contracting process. The review found that the process was vulnerable to potentially serious
conflicts of interest because the person selecting the contractor was also authorized to approve
invoices and payments under the contract, and that these deficiencies in the process may have led
to problems in the quality and continuity of inmate medical care.
SUMMARY OF THE 2006 FOLLOW-UP RESULTS
In its 2006 follow-up review, the Office of the Inspector General found that the Department of
Corrections and Rehabilitation has made a number of changes to its medical contracting process.
In response to the Office of the Inspector General’s review, the department established a health
contract services unit to assist institutions with all medical services contracts. In addition, the
department required institutions to solicit medical providers and to prepare market surveys
before initiating a contract. Meanwhile, expenditures for medical contracts rose 58 percent
between fiscal years 2000-01 and 2004-05 from $200 million to more than $315 million, largely
because of medical staff vacancies requiring contracted personnel to fill the void.
In response to two subsequent audits issued by the California State Auditor in 2004, the
Department of General Services tightened the procedures used by the department to contract
with outside community hospitals, physicians, nurses, pharmacists and other medical
professionals to provide needed services and fill temporary medical staff vacancies and required
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EXECUTIVE SUMMARY

the department to obtain competitive bids on clinical contracts. According to a correctional
expert appointed by the U. S. District Court, however, due in part to insufficient staffing and
training necessary to properly implement the new contracting procedures as well as to the
complexity of the procedures, the department has fallen $58 million behind in paying provider
claims. The new bidding process instituted to replace single-source contracting also has resulted
in a shortage of specialty providers. Because of these developments, on March 30, 2006 the court
ordered the department to pay all valid outstanding department-approved claims within 60 days
and to establish new medical contracting procedures within 180 days.
FOLLOW-UP RECOMMENDATION
As a result of its 2006 follow-up review, the Office of the Inspector General recommends
that the Department of Corrections and Rehabilitation develop a more effective and
efficient system for processing and monitoring medical service invoices, including
validation that contractors have performed all services invoiced prior to issuing payment.

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EXECUTIVE SUMMARY

EDUCATION PROGRAMS AT LEVEL IV INSTITUTIONS
IMPLEMENTATION REPORT CARD

The Office of the Inspector General found that the
Department of Corrections and Rehabilitation has made
progress in developing alternative education programs for
Level IV inmates, but the effectiveness of the new
programs has not yet been evaluated.

Previous recommendations: 6
Fully implemented: 1 (17%)
Substantially implemented: 2 (33%)
Partially implemented: 3 (50%)

In July 2003, the Office of the Inspector General conducted a
Not implemented: 0 (0%)
survey of education programs at the Department of
Corrections Level IV institutions. The survey was prompted
Not applicable: 0 (0%)
by management review audits conducted by the Office of the
Inspector General showing that inmates in state correctional
institutions received only limited classroom instruction
because classrooms were closed for significant periods of time due to lockdowns, teacher
vacancies, and other program disruptions.

The survey revealed the classroom education model to be an inefficient and expensive means of
delivering education to Level IV inmates because frequent lockdowns cause academic and
vocational classes to be closed down more than 60 percent of the time. At the five Level IV
institutions locked down for the largest percentages of time, education programs operated an
average of only 25 percent of the time. And even with the classes closed for long periods, the
survey found that inmates continued to receive day-for-day sentence reduction credits as though
they had attended class, and teachers continued to be paid as though they had provided
instruction. Meanwhile, the survey also found that institutions had no systematic means of
accounting for teachers’ activities during lockdown periods or of temporarily assigning them to
other duties, and labor agreements hampered the redirection of teachers to other functions during
those periods. When lockdowns and other program disruptions were taken into account, the
annual per-inmate cost of the education programs at Level IV institutions greatly exceeded the
annual per-inmate cost budgeted.
The Office of the Inspector General also found despite the statutory requirement that the
Department of Corrections and Rehabilitation make literacy programs available to at least 60
percent of eligible inmates — and even though a statewide survey conducted by the Department
of Corrections in November 1996 found that 68 percent of the inmate population scored below
the ninth grade level in reading — only 20.8 percent of eligible inmates at the level IV
institutions surveyed were assigned to education classes at the time of the survey. Lastly, the
Office of the Inspector General found that even if the classes were held 100 percent of the time,
they would have been able to accommodate only a small percentage of inmates eligible for the
programs, in part because of the small number of budgeted teaching positions at Level IV
institutions. The Office of the Inspector General recommended that the Department of
Corrections re-evaluate education programs at Level IV institutions to determine whether they
warrant continued operation and investigate other methods of delivering academic and
vocational instruction. Among the options considered should be eliminating formal classroom
instruction and retaining a small educational staff to coordinate in-cell study courses for inmates.

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SUMMARY OF THE 2006 FOLLOW-UP RESULTS
In its 2006 follow-up review, the Office of the Inspector General found that the Department of
Corrections and Rehabilitation has made some progress in developing alternative education
programs for its Level IV inmates. In response to a $34.8 million reduction to its education
budget, the department evaluated its existing programs and prioritized them to determine those
that warranted continued operation. Upon completion of the evaluation, the department
eliminated 129 education positions, including many of the Level IV vocational programs, due to
their ineffectiveness. The department has since developed alternative education program models
designed to increase overall inmate participation through non-traditional methods. The new
programs include more self-paced independent study, such as the new Bridging Education
Program recently implemented in the reception centers and general population facilities. This
new program allows inmates to begin participating in self-paced education programs when they
arrive at a reception center. Other programs include short-term vocational certification classes,
half-day assignments with a homework component, delivery of educational services via distance
education methodologies, and delivery of educational services in the living units. The department
recently implemented the majority of the new alternative delivery education models. Therefore,
only minimal data is available at this time to evaluate the effectiveness of these programs. Prison
reform advocates have suggested that the new programs may be ineffective, but inmate
population pressures appear to make it difficult to provide more comprehensive educational
opportunities, at least in a classroom setting.
Although the department has made progress in developing new education programs, it still has
not developed an effective monitoring system to ensure that institutions are complying with its
education policies and procedures.
FOLLOW-UP RECOMMENDATIONS
As a result of its 2006 follow-up review, the Office of the Inspector General recommended
that the Department of Corrections and Rehabilitation take the following actions:
•

Systematically evaluate the effectiveness of the new alternative education delivery
models. The evaluation should include inmate participation rates, progress in
achieving educational goals, and the impact of the programs on recidivism.

•

The new Office of Correctional Education should dedicate staff to perform periodic
on-site reviews to ensure compliance with department policies and procedures. The
on-site reviews should include, but not be limited to, verification of educational
representatives participating in classification committees, verification of class
closures for teacher vacancies beyond 30 days, and the verification of the accuracy
of timekeeping for inmate program participation.

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RICHARD A. MCGEE CORRECTIONAL TRAINING CENTER
IMPLEMENTATION REPORT CARD

The Office of the Inspector General found that the
Richard A. McGee Correctional Training Center has
significantly improved its cadet training program. The
academy instituted guidelines for course development that
include instructor input, cadet feedback, and Commission
on Correctional Peace Officer Standards and Training
program approval. Lesson plans for the now-expanded
academy are complete and were approved by the
commission. Cadet testing protocols are also complete, as
are operational procedures governing test results
retention.

Previous recommendations: 12
Fully implemented: 11 (92%)
Substantially implemented: 0 (0%)
Partially implemented: 0 (0%)
Not implemented: 1 (8%)
Not applicable: 0 (0%)

In April 2000 the Office of the Inspector General conducted an unannounced special review
audit of the Richard A. McGee Correctional Training Center (now known as the Richard A.
McGee Academy), which conducts the basic correctional officer academy program for all
correctional officers training in California. The review was prompted by numerous serious
allegations that were reported to the Office of the Inspector General in late March 2000. The
allegations called into question the integrity of test results for recent graduates of the basic
correctional officer academy located at the center and the overall preparedness of correctional
officers graduating from the academy.
As a result of the May 2000 review, the Office of the Inspector General made eight specific
findings, including:
•

Cadets being trained under the expanded ten-week curriculum even though a significant
number of the lesson plans had not been completed.

•

Many of the 46 lesson plans, including those for highly essential courses, had not received
provisional approval from the Commission on Correctional Peace Officer Standards and
Training.

•

The department’s Staff Development Center and the training center staff failed to coordinate
efforts in developing the lesson plans.

•

The training center did not maintain the instructor-to-cadet ratios specified in the lesson plans
approved by the Commission on Correctional Peace Officer Standards and Training.

SUMMARY OF THE 2006 FOLLOW-UP RESULTS
In its 2006 follow-up review, the Office of the Inspector General found that the Richard A.
McGee Correctional Training Center has significantly improved its cadet training program. The
academy implemented guidelines for course development that include instructor input, cadet
feedback, and Commission on Correctional Peace Officer Standards and Training approval.
Lesson plans for the now-expanded academy are complete and have been approved by the

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Commission on Correctional Peace Officer Standards and Training (now the Corrections
Standards Authority). Cadet testing protocols and test retention policy also have been completed.
The Office of the Inspector General makes no follow-up recommendations.

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CALIFORNIA STATE PRISON, SOLANO
IMPLEMENTATION REPORT CARD

The Office of the Inspector General found that the
California State Prison, Solano has improved certain of its
operations since a March 2003 management review audit.
The facility more closely monitors inmates’ tuberculosis
status, better manages sentence reduction credits granted
to inmates, and has improved its management of both
inmates placed in administrative segregation and those
taking psychotropic medications. Although it has made
significant progress, the facility has only partially
implemented recommendations to properly house inmates
taking anticonvulsant medications and has not taken steps
to monitor its pharmacy inventory.

Previous recommendations: 24
Fully implemented: 19 (79%)
Substantially implemented: 2 (9%)
Partially implemented: 2 (8%)
Not implemented: 1 (4%)
Not applicable: 0 (0%)

In March 2003, the Office of the Inspector General conducted a management review audit of
California State Prison, Solano to assess the essential functions of the facility. As a result of the
review, the Office of the Inspector General found that California State Prison, Solano was not
adequately tracking inmates with tuberculosis, creating the potential of exposing inmates
throughout the state to the disease and presenting a risk to the correctional staff and the general
public. In addition, the institution allowed inmates to earn sentence reduction credit through
education and training classes even when classes were not actually held, and maintained
inadequate pharmacy record keeping and physical controls over prescription medications stored
in the infirmary and clinics to prevent unauthorized access and theft. The Office of the Inspector
General also found that a significant number of inmates taking psychotropic medications were
inappropriately housed in buildings lacking air conditioning and some inmates who were taking
anticonvulsant medications were not assigned to lower bunks to lessen the possibility of injury in
the event of a seizure, and makeshift partitions in the institution’s administrative segregation unit
buildings created blind spots that limited the view of the control booth officers, compromising
the safety and security of correctional staff and inmates. Furthermore, when inmate deaths
occurred, the institution did not examine the cause and circumstances surrounding the deaths in a
timely manner and the people the institution assigned to conduct the reviews may have had a
direct interest in the results. The Office of the Inspector General presented 24 recommendations
in its March 2003 report to remedy the findings.
SUMMARY OF THE 2006 FOLLOW-UP RESULTS
In its 2006 follow-up review, the Office of the Inspector General found that the California State
Prison, Solano has made significant progress in implementing the recommendations made in the
March 2003 report. Specifically, the Office of the Inspector General made the following
findings:
•

The facility has improved its monitoring of inmates who have tested positive for tuberculosis
by adding staff and increasing follow-up assessments of those inmates.

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•

In closing classes with no assigned instructors, the facility has reduced the rate at which it
grants sentence-reduction credits to inmates who otherwise did not attend classes.

•

The facility installed mirrors that improved visibility in its administrative segregation units.

•

The facility has implemented procedures to ensure that inmates taking psychotropic
medications—which increase inmates’ susceptibility to heat-related illnesses—are
appropriately housed and monitored when temperatures are higher than 90 degrees. The
facility should, however, improve its monitoring of inmates taking anti-seizure medications
to ensure that those inmates are assigned to lower bunks to protect their safety.

•

The department implemented new procedures in December 2005 relative to reporting inmate
deaths and submitting specific documents related to each death to headquarters for analysis.

•

The pharmacy at California State Prison, Solano has improved its security over non-narcotic
medications, but still does not have a method to monitor their inventory.

•

The department obtained additional resources to improve statewide dental care.

FOLLOW-UP RECOMMENDATIONS
As a result of its 2006 follow-up review, the Office of the Inspector General recommends
that the California State Prison, Solano take the following actions:
•

Conduct periodic evaluations of the housing assignments of inmates who have been
prescribed seizure medications to ensure that those inmates are housed appropriately.

•

Develop a method to reconcile the types and quantities of pharmaceuticals shipped
from its pharmacy to its clinics and the correctional treatment center with the types and
quantities of medications prescribed to inmates.

In addition, the Office of the Inspector General recommends that the California
Department of Corrections and Rehabilitation assess whether additional dental staffing
and equipment have improved the availability of dental examinations to inmates across all
institutions.

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CALIFORNIA STATE PRISON, SACRAMENTO
The Office of the Inspector General found that California
State Prison, Sacramento has corrected various deficiencies
identified in a September 2000 management review audit.
Financial management has improved, in that actual
expenditures are closer to budget allotments; underground
storage tanks have been removed, thus avoiding fines and
penalties; and internal control weaknesses in the handling
of inmate trust funds have been corrected.

EXECUTIVE SUMMARY

IMPLEMENTATION REPORT CARD
Previous recommendations: 17
Fully implemented: 12 (70%)
Substantially implemented: 2 (12%)
Partially implemented: 1 (6%)
Not implemented: 2 (12%)
Not applicable: 0 (0%)

In September 2000, the Office of the Inspector General issued
a management review audit report of California State Prison,
Sacramento focusing on personnel, training, communications, inmate programming, security,
and finances. The audit found deficiencies in financial management and internal control
weaknesses in the handling of inmate trust funds. Other areas found to be deficient included the
institution’s electronic security clearance system designed to track the arrival and departure of
employees and visitors, inmate dental examinations, the failure to process inmate appeal forms in
a timely manner, failure to comply with a mandate to remove underground storage tanks in a
timely manner, inconsistent handling of inmate rules violation reports, and the failure to
complete employee probation and performance reports on time. The Office of the Inspector
General presented 17 recommendations to remedy the deficiencies identified in the September
2000 review.
SUMMARY OF THE 2006 FOLLOW-UP RESULTS
In its 2006 follow-up review, the Office of the Inspector General found that the California State
Prison, Sacramento has substantially improved its financial management, keeping expenditures
aligned with budget allotments and resolving internal control weaknesses relative to inmate trust
funds. The institution has also implemented processes improving monitoring of the following:
inmate and parolee appeals, the correctional peace officer apprenticeship program, equal
employment opportunity case files, and inmate rules violation reports. The institution still needs
improvement in tracking institution staff and visitors, providing timely inmate dental
examinations, and completing staff performance evaluations.
FOLLOW-UP RECOMMENDATIONS
As a result of its 2006 follow-up review, the Office of the Inspector General makes five
recommendations to the department and California State Prison, Sacramento, including:
•

Explore options for a cost-effective electronic system that effectively tracks the entry
and departure of staff and visitors at the institution.

•

Barring a change in Title 15, California Code of Regulations, comply with the
requirement to provide dental examinations to inmates within 14 days of their arrival
at the institution.

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•

EXECUTIVE SUMMARY

Ensure that employee performance and probationary reports are completed in a timely
manner.

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HIGH DESERT STATE PRISON
IMPLEMENTATION REPORT CARD

The Office of the Inspector General found that High
Desert State Prison has addressed most of the
recommendations from a November 2001 audit that were
under its control, but the Department of Corrections and
Rehabilitation has not implemented several
recommendations to provide the institution with needed
resources or to take other actions affecting both High
Desert State Prison and other institutions.

Previous recommendations: 31
Fully implemented: 18 (58%)
Substantially implemented: 4 (13%)
Partially implemented: 3 (10%)
Not implemented: 5 (16%)

Not applicable: 1 (3%)
In November 2001, the Office of the Inspector General
conducted a management review audit of High Desert State
Prison. The audit determined that the institution was generally
well run, but identified a number of deficiencies affecting safety and security, the inmate appeals
process, the inmate disciplinary system, employee performance reports, and inmate medical and
dental care. The audit also identified issues affecting safety and security and inmate dental care
that required action from the Department of Corrections.

Specifically, the Office of the Inspector General noted a number of health care deficiencies,
including poor documentation of chronically ill inmates, inmates taking psychotropic
medications not being properly managed for heat risks, a risk that inmate medications could be
tampered with before administration and were not adequately documented in the medical files,
that inmates were not receiving required dental services, and poor controls over prescription
drugs. Additionally, problems were found in institutional programs, such as the inmate appeals
process, administrative segregation housing units, and inmate discipline process. As a result of
the November 2001 audit, the Office of the Inspector General made 31 recommendations to the
management of High Desert State Prison and to the Department of Corrections.
SUMMARY OF THE 2006 FOLLOW-UP RESULTS
The Office of the Inspector General found in its follow-up audit that High Desert State Prison
has made significant progress in implementing recommendations affecting areas under the
warden’s control, but a number of issues requiring additional funding and policy direction from
the Department of Corrections and Rehabilitation central office have not been addressed. The
institution has addressed the timeliness of the inmate appeals process, monitoring of inmate
modification orders, and ensuring that inmates comply with administrative segregation policies.
The institution has also made improvements in the inmate disciplinary process, in documenting
services provided during lockdowns, in completing staff performance reports, and in completing
mandated training requirements. In contrast, the Department of Corrections and Rehabilitation
has made minimal progress in performing security modifications, including installing security
cameras on the main yards, and in pursuing additional release allowance funding for inmates
paroling from rural areas.
A number of the recommendations affecting the health care program, which is under the
direction of the health care manager, have also been addressed. In particular, the institution has

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made progress in documenting inmate medical histories before issuing medications; in providing
additional escorts for dental services; and in implementing policies and procedures to improve
distribution and tracking of inmate medications. But the institution’s medical department still has
not developed a system to ensure that inmates on psychotropic medications are included in the
mental health care delivery system. Also, the department has not eliminated inconsistencies in
regulations concerning minimum dental service requirements and has not developed an
automated system to schedule and track dental services.
FOLLOW-UP RECOMMENDATIONS
As a result of its 2006 follow-up review, the Office of the Inspector General made six
recommendations, including the following:
•

The High Desert State Prison medical department develop a system to ensure that
inmates requiring psychotropic medications are included in the mental health delivery
system before they receive the medications.

•

The Department of Corrections and Rehabilitation eliminate inconsistencies between
California Code of Regulations, Title 15 and the Department of Corrections and
Rehabilitation Operations Manual concerning inmate dental care.

•

The Department of Corrections and Rehabilitation implement an automated inventory
system to track and monitor prescription drugs.

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VALLEY STATE PRISON FOR WOMEN
The Office of the Inspector General found that Valley
State Prison for Women has improved employee morale
and the timeliness and completion of important
administrative processes, such as Category I
investigations, inmate appeals, and rules violation
reports. The institution remains deficient in areas
involving employee performance and probation reports,
weapons qualification for armed staff, drug disposal, and
drug interdiction training.

EXECUTIVE SUMMARY

IMPLEMENTATION REPORT CARD
Previous recommendations: 35
Fully implemented: 24 (68%)
Substantially implemented: 2 (6%)
Partially implemented: 5 (14%)
Not implemented: 1 (3%)
Not applicable: 3 (9%)

The Office of the Inspector General conducted a January
2001 management review audit of Valley State Prison for Women focused on institutional
processes relating to communications, personnel, investigations, training, security, and financial
matters. As a result of the review, the Office of the Inspector General found that poor morale
among the institution staff was pervasive. The Office of the Inspector General also found a
number of administrative deficiencies, such as incomplete and untimely investigations of
employee misconduct and rules violation reports involving inmate conduct, untimely completion
of inmate appeals and employee performance and probation reports, and inadequate control over
drug disposal.
SUMMARY OF THE 2006 FOLLOW-UP RESULTS
The Office of the Inspector General’s 2006 follow-up review found that Valley State Prison for
Women has taken measures to improve employee morale and various important administrative
procedures, including investigations of employee misconduct, rules violation reports, inmate
appeals, adverse personnel actions, and equal employment opportunity complaints. The
institution has improved its tracking systems for these administrative processes and has
established bi-monthly employee advisory council meetings. However, the institution remains
deficient in preparing timely employee performance and probation reports; ensuring that staff
assigned to armed posts meet quarterly weapons qualification requirements; providing drug
interdiction training; and complying with Department of Corrections and Rehabilitation drug
disposal guidelines.
FOLLOW-UP RECOMMENDATIONS
As a result of its 2006 follow-up review, the Office of the Inspector General makes seven
additional recommendations to Valley State Prison for Women, including:
•

Hold staff members with responsibility for preparing performance and probation
reports accountable for completing and submitting the reports on the required date and
use progressive discipline to ensure compliance.

•

Follow the updated evidence control procedure for the destruction of drugs.

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•

EXECUTIVE SUMMARY

Conduct a quarterly audit of staff members assigned to armed posts to ensure
compliance with the quarterly range qualifications.

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EXECUTIVE SUMMARY

SIERRA CONSERVATION CENTER
IMPLEMENTATION REPORT CARD

The Office of the Inspector General found that the Sierra
Conservation Center has successfully addressed nearly all
of the deficiencies identified in a May 2001 management
review audit. The institution has enhanced the safety and
security of its physical plant and has improved procedures
relating to inmate appeals, the inmate disciplinary
process, staff training, adverse personnel actions,
employee grievances, equal employment opportunity
complaints, and the reporting of inmate deaths.

Previous recommendations: 53
Fully implemented: 38 (71%)
Substantially implemented: 11 (21%)
Partially implemented: 1 (2%)
Not implemented: 1 (2%)
Not applicable: 2 (4%)

The Office of the Inspector General issued a May 2001
management review audit report of Sierra Conservation
Center, which is situated on 420 acres near Jamestown, California, and one of only two
institutions in the state responsible for the training and placement of inmates into the
conservation camp program. While the institution’s principal mission is to provide housing,
programs, and services for minimum and medium custody inmates, it also administers 22
conservation camps — 19 camps for male inmates and three camps for female inmates —
located in rural and wilderness areas. The audit identified safety and security deficiencies
focused on physical conditions of the institution such as the use of privacy curtains by inmates in
their living areas, gun coverage on a recreational yard, physical deterioration of prison
dormitories, the need for an additional strip search facility, and the need to secure utility closets
in the administrative segregation unit. The audit also found deficiencies related to the
institution’s inmate appeals process, inmate disciplinary system, employee grievance process,
equal employment opportunity complaints, inmate death reporting, staff training, and the
tracking of adverse personnel actions. As a result of its May 2001 management review audit, the
Office of the Inspector General made 53 recommendations to the management of the Sierra
Conservation Center.
SUMMARY OF THE 2006 FOLLOW-UP RESULTS
The Office of the Inspector General’s 2006 follow-up review found that the Sierra Conservation
Center made improvements in its physical plant and operational procedures, thereby limiting the
use of privacy curtains in inmate living areas, enhancing gun coverage of the recreational yard,
constructing a strip search area, securing utility closets in the administrative segregation unit; and
making needed repairs to inmate dormitories. The institution has also developed monitoring tools
to ensure that inmate appeals and inmate disciplinary actions are processed in a timely fashion,
taken steps to ensure that staff training requirements are fulfilled, improved monitoring and
tracking of adverse personnel actions and employee grievances, improved organization of equal
employment opportunity complaints, and improved reporting of inmate deaths.
FOLLOW-UP RECOMMENDATIONS
The Office of the Inspector General’s 2006 follow-up review makes five recommendations
to the Sierra Conservation Center, including:

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•

Continue to enforce the order that the staff remove all sheets and makeshift privacy
curtains in housing units that would obstruct the view of officers.

•

Hold managers and supervisors accountable for failure to follow through with their
responsibilities.

•

Ensure that letters of instruction are issued when merited.

•

Maintain a tracking log with complete and up-to-date information on the disposition of
letters of instruction.

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2006 ACCOUNTABILITY AUDIT

LEO CHESNEY COMMUNITY CORRECTIONAL FACILITY
The Office of the Inspector General found that most of
the recommendations from a 2001 audit of the Leo
Chesney Community Correctional Facility have been
fully implemented, but that the Department of
Corrections and Rehabilitation has not addressed
deficiencies identified in the audit relating to the need for
written policies governing investigations into alleged
misconduct at community correctional facilities by nondepartment employees.

EXECUTIVE SUMMARY

IMPLEMENTATION REPORT CARD
Previous recommendations: 22
Fully implemented: 15 (68%)
Substantially implemented: 1 (5%)
Partially implemented: 2 (9%)
Not implemented: 1 (5%)
Not applicable: 3 (13%)

In October 2001, the Office of the Inspector General issued
an audit report of the Leo Chesney Community Correctional Facility, operated by Cornell
Corrections of California, Inc. under a contract with the Department of Corrections and
Rehabilitation. The California Penal Code authorizes the California Department of Corrections
and Rehabilitation to establish, operate, and contract for “community correctional centers” for
the housing, supervision, and counseling of inmates. The Leo Chesney Community Correctional
Facility, the only facility for female inmates in the community correctional facility program, is
located in the community of Live Oak, approximately 50 miles north of Sacramento.
The audit identified problems with the facility’s operations and with the department’s
management of the facility, the most significant of which included an absence of formal policies
and procedures for investigating inmate and staff misconduct; failure by the department’s Office
of Investigative Services to adequately respond to allegations of sexual misconduct; and a lack of
clear guidelines governing the use of revenues generated from inmate telephone calls.
SUMMARY OF THE 2006 FOLLOW-UP RESULTS
The Office of the Inspector General’s 2006 follow-up review found that Cornell Corrections has
improved the investigative process by developing procedures for investigating allegations of
inmate or employee misconduct. These improved procedures provide for investigations of inmate
misconduct to be conducted jointly by Cornell Corrections and the Department of Corrections
and Rehabilitation’s Office of Internal Affairs. But the department still does not have clear
policies to guide the investigative process in cases of misconduct involving the contractor’s
employees.
The Office of the Inspector General’s follow-up review also found that the Community
Correctional Facility Administration provided for better approval and control of inmate
telephone revenues earned by the contractor by negotiating an amendment to its contract. The
amendment addresses how revenues may be spent, but does not address the ownership of any
unspent balance that may remain at the end of the contract period. The department reported that
this important issue will be addressed in an arrangement that will cover all future contracts.
Under that arrangement, inmate telephone services will be provided through a statewide contract
that will result in the state general fund being paid the telephone revenues generated under the
contracts.
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FOLLOW-UP RECOMMENDATIONS
As a result of its 2006 follow-up review, the Office of the Inspector General makes three
recommendations to the Department of Corrections and Rehabilitation which include the
following:
•

Develop and implement clear policies to guide the investigative process for
investigations of misconduct at community correctional facilities by individuals who are
not department employees.

•

Continue to use the new statewide Inmate Telephone System agreement to provide
inmate telephone services for all future community correctional facility contracts.

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EXECUTIVE SUMMARY

LOCAL ASSISTANCE PROGRAM
IMPLEMENTATION REPORT CARD

The Office of the Inspector General found that the Parole
and Community Services Division has made significant
improvements in its oversight of the Local Assistance
Program, but still lacks the information technology
needed to efficiently verify information on invoices
submitted to reimburse local jurisdictions for services
provided to state parolees.

Previous recommendations: 6
Fully implemented: 4 (66 %)
Substantially implemented: 0 (0%)
Partially implemented: 0 (0%)
Not implemented: 1 (17%)

In January 2002, the Office of the Inspector General
Not applicable: 1 (17%)
conducted a special review of the Parole and Community
Services Division’s Local Assistance Program, which
reimburses local jurisdictions for the costs of detaining state
parolees in local facilities. The review determined that the program had overpaid local
jurisdictions $8.2 million in the previous two fiscal years by reimbursing for services at rates
exceeding the maximum daily rate allowed under the State Budget Act. The review also found
that the program did not adequately monitor non-routine medical services provided to state
parolees in Los Angeles County and that the department’s procedures for processing invoices
from local jurisdictions were deficient. The Office of the Inspector General made six
recommendations to the Department of Corrections to address these findings.
SUMMARY OF THE 2006 FOLLOW-UP RESULTS
The Office of the Inspector General’s 2006 follow-up review found that the Parole and
Community Services Division has improved its monitoring of the Local Assistance Program.
The Department of Corrections cooperated with the Department of Finance and the California
Sheriffs’ Association to revise the method for calculating the daily jail rate and to amend the
state budget act language for reimbursement to local jurisdictions. The resulting agreement
excludes non-routine medical costs from the daily jail rate calculation, while the amended budget
language resolves previous confusion over interpretation of California Penal Code requirements
for calculating reimbursements to local jurisdictions. The Parole and Community Services
Division has also improved its procedures and monitoring efforts to reduce associated nonroutine medical costs. The Parole and Community Services Division’s information system,
however, needs further improvement to efficiently verify and process invoices from local
jurisdictions. The State Budget Act of 2005 provides for expenditures of up to $81.5 million in
payments for local assistance. The department reports that its parole revocation scheduling and
tracking system cannot be programmed to allow continuous tracking of the movements of
individual parolees. As a result, the parole staff cannot confirm that a parolee was detained in
the local jurisdiction on an active parole hold during the period claimed. The department reports
that it is using a tracking system developed only for Parole Region III, which encompasses Los
Angeles County, but has not estimated when such a system might be available statewide.

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EXECUTIVE SUMMARY

FOLLOW-UP RECOMMENDATION
As a result of its 2006 follow-up review, the Office of the Inspector General recommends
that the Department of Corrections and Rehabilitation continue to pursue development of
an information system to improve the Local Assistance Program’s invoice verification
process.

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EXECUTIVE SUMMARY

INMATE APPEALS BRANCH
IMPLEMENTATION REPORT CARD

The Office of the Inspector General found that the
Department of Corrections and Rehabilitation Inmate
Appeals Branch has made efforts to enhance its inmate
appeals tracking system to integrate appeals at the thirdlevel review but other department priorities have
hampered its efforts.

Previous recommendations: 1
Fully implemented: 0 (0 %)
Substantially implemented: 0 (0%)
Partially implemented: 0 (0%)

A special review of the Department of Corrections Inmate
Not implemented: 1 (100%)
Appeals Branch, issued by the Office of the Inspector General
Not applicable: 0 (0%)
in February 2001, identified serious deficiencies in the thirdlevel inmate appeals process. The problems had caused
unacceptable delays in the processing of inmate appeals and
had created a significant and growing backlog of appeals that had not been completed within the
60-day time frame required by California Code of Regulations, Title 15, which provides inmates
with a system and process for filing complaints.
The process usually begins with an informal attempt to resolve the issue but can escalate to a
three-step formal appeal process beginning with the institution’s appeals office, which logs
appeals into a database before assigning the appeal to a staff member for action. Second level
appeals are typically decided by the warden or chief medical officer and third level appeals are
decided by the Inmate Appeals Branch in Sacramento. In addition, the inmate appeals process is
intended to serve as a vehicle for improving department policies and procedures. The California
Department of Corrections and Rehabilitation Operations Manual specifies that the appeals
process is designed to audit the internal practices and operation of the Department of Corrections
and Rehabilitation to “identify, modify, or eliminate practices which may not be necessary or
may impede the accomplishment of correctional goals.”
In September 2004, the Office of the Inspector General conducted a follow-up review that
determined the Inmate Appeals Branch had made significant progress in addressing the
deficiencies identified in the February 2001 review. In particular, the follow-up review found
that the Inmate Appeals Branch was meeting required deadlines in responding to third-level
appeals; had virtually eliminated its former backlog of overdue appeals; and had developed a
formal training manual and written guidelines for new appeals examiners. The Inmate Appeals
Branch also had developed a system for tracking inmate appeals for use at all institutions, but at
the time of the follow-up review, online interconnectivity between the prisons and the Inmate
Appeals Branch was still in the planning stage. After its 2004 review, the Office of the Inspector
General recommended that the Inmate Appeals Branch continue to work with the Information
Systems Division to develop and enhance the new inmate appeals tracking system to include
third-level appeals and statewide reporting of first- and second-level appeals. These
enhancements are also needed to provide for a review of institution appeals and elevation of
granted and partially granted appeals as a vehicle for identifying department policies and
procedures needing revision.

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SUMMARY OF THE 2006 FOLLOW-UP RESULTS
The Office of the Inspector General completed a follow-up review in 2006 and found that the
Inmate Appeals Branch has made continuous efforts to enhance its inmate appeals tracking
system. As recently as December 2005, the Inmate Appeals Branch reported that it was working
on a feasibility study for the enhancements, which was scheduled to be completed by December
21, 2005. But the department had not completed the study when the Office of the Inspector
General’s fieldwork ended in December 2005. Notwithstanding the passage of six years, the
Information Systems Division continues to assign a low priority to this project.
FOLLOW-UP RECOMMENDATION
As a result of its 2006 follow-up review, the Office of the Inspector General recommends
that the Department of Corrections and Rehabilitation require the Information Systems
Division to either integrate the inmate appeals tracking system with the third-level appeals
or contract with a private firm to do so.

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SALINAS VALLEY STATE PRISON, INMATE APPEALS AND
DISCIPLINARY PROCESSES
The Office of the Inspector General found that the number
of overdue inmate appeals at Salinas Valley State Prison
has increased since a September 2003 review, primarily
because of a significantly higher volume of appeals from
inmates. In addition, although the institution has improved
its inmate disciplinary process, it has not developed a
corrective action plan to address deficiencies in the process
identified in the September 2003 review.

EXECUTIVE SUMMARY

IMPLEMENTATION REPORT CARD
Previous recommendations: 7
Fully implemented: 3 (44%)
Substantially implemented: 1 (14%)
Partially implemented: 1 (14%)
Not implemented: 1 (14%)
Not applicable: 1 (14%)

In September 2003, the Office of the Inspector General
conducted a follow-up review of the inmate appeals and disciplinary processes at Salinas Valley
State Prison. Since its opening, the institution has had problems with staff turnover and inmate
unrest. Problems with inmates have led to a significant number of total or partial lockdowns,
impairing the institution’s ability to provide academic and vocational programs. In response to
the problems, the Office of the Inspector General conducted an audit of the inmate appeals and
inmate disciplinary processes at the institution in March 2000. The audit found significant
deficiencies in both processes and made recommendations to correct the problems. In response to
an inmate’s complaint, the Office of the Inspector General returned to Salinas Valley State
Prison during January 2003 to initiate an investigation of certain aspects of the inmate
disciplinary process. As a result of that investigation, the Office of the Inspector General found
that the prison had violated the rights of more than 80 inmates in administering the inmate
disciplinary process following an inmate work stoppage in October 2002. The Office of the
Inspector General subsequently conducted a follow-up review of the March 2000 audit to assess
the institution’s progress in addressing the earlier findings. The results of the follow-up review
were published in September 2003.
The September 2003 review found that the institution had significantly improved the inmate
appeals process since the earlier audit, but that problems remained in the inmate disciplinary
process. Specifically, the Office of the Inspector General found that the inmate appeals process
had significantly improved but the Salinas Valley State Prison had made little progress in
improving its inmate disciplinary process. The Office of the Inspector General made seven
recommendations to the management of Salinas Valley State Prison for improving the inmate
disciplinary process.
SUMMARY OF THE 2006 FOLLOW-UP RESULTS
In its 2006 follow-up review, the Office of the Inspector General found that Salinas Valley State
Prison has improved its inmate disciplinary process by requiring chief disciplinary officers to
maintain independent registry logs and to regularly audit the logs for compliance. However, the
institution has not developed a corrective action plan to address the deficiencies in the
disciplinary process identified in the September 2003 follow-up review, and the disciplinary
system procedures developed by the institution still fail to hold staff members accountable for
the quality of their work. Moreover, the Office of the Inspector General found that the number of
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overdue appeals has increased since the March 2000 follow-up review. The rise in the number of
overdue appeals is attributable to a significantly higher volume of appeals from inmates, the
process of logging informal appeals, and a lack of staffing to handle the increase in appeals.
FOLLOW-UP RECOMMENDATIONS
As a result if the 2006 follow-up review, the Office of the Inspector General recommended
that Salinas Valley State Prison take the following actions:
•

Develop an alternative method of tracking informal inmate appeals instead of logging
each informal appeal in the appeals tracking system.

•

Provide for staff accountability in the inmate disciplinary system procedures.

•

Prepare and execute a corrective action plan to address deficiencies in the inmate
disciplinary process.

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2006 ACCOUNTABILITY AUDIT

CALIFORNIA REHABILITATION CENTER,
INMATE APPEALS PROCESS
The Office of the Inspector General found that the
California Rehabilitation Center has improved its process
for handling inmate appeals by maintaining adequate
staffing in the inmate appeals office, providing orientation
on the appeals process to new inmates, and having
management monitor inmate complaints against staff. The
institution continues to experience problems with
transferring inmate property.

EXECUTIVE SUMMARY

IMPLEMENTATION REPORT CARD
Previous recommendations: 5
Fully implemented: 4 (80 %)
Substantially implemented: 0 (0%)
Partially implemented: 1 (20%)
Not implemented: 0 (0%)
Not applicable: 0 (0%)

In August 2000, the Office of the Inspector General
completed its review of the inmate appeals process at the
California Rehabilitation Center. The inmate appeals process is prescribed under Title 15 of the
California Code of Regulations to provide inmates with a system and process for filing
complaints. The process usually begins with an informal attempt to resolve the issue but can
escalate to a three-step formal appeal process beginning with the institution’s appeals office,
which logs appeals into a database before assigning the appeal to a staff member for action.
Second level appeals are typically decided by the warden or chief medical officer and third level
appeals are decided by the Inmate Appeals Branch in Sacramento.
As a result of the August 2000 review, which was prompted by a letter from an inmate reporting
a backlog in the inmate appeals process, the Office of the Inspector General found that the
institution had taken action to significantly reduce the number of overdue appeals and that the
backlog was manageable. The review also found that a high percentage of inmate appeals at the
institution concerned the forwarding of inmate property and trust funds to other institutions. The
Office of the Inspector General made five recommendations to the California Rehabilitation
Center, including that it review and analyze a representative sample of appeals categorized as
complaints against staff to determine the cause of their frequency and implement corrective
action. In addition, the Office of the Inspector General recommended that the institution
discontinue its practice of waiting for an inmate appeal from a transferred inmate before sending
property to the new institution.
SUMMARY OF THE 2006 FOLLOW-UP RESULTS
In its February 2006 follow-up review, the Office of the Inspector General found that the
California Rehabilitation Center has fully implemented the recommendations to adequately staff
the inmate appeals office, incorporate inmate appeals information in its orientation process,
investigate increased staffing for the inmate trust fund office, and review and analyze staff
complaints to identify systemic problems. The Office of the Inspector General found, however,
that the California Rehabilitation Center has not adequately addressed the timely transfer of
inmate property when an inmate is transferred to another institution.

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FOLLOW-UP RECOMMENDATION
As a result of its 2006 follow-up review, the Office of the Inspector General recommends
that the California Rehabilitation Center consider initiating procedures to transfer inmate
property at the time of the inmate’s relocation rather than waiting for the inmate to return
a form once he or she is permanently housed at another institution.

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2006 ACCOUNTABILITY AUDIT

DEUEL VOCATIONAL INSTITUTION, INMATE APPEALS
PROCESS
The Office of the Inspector General found that Deuel
Vocational Institution has improved its inmate appeals
process by implementing both of the Office of the
Inspector General’s recommendations from a September
2000 review. Specifically, the institution upgraded the
software used for the inmate appeals tracking system and
began including informal level inmate appeals in the
tracking system.

EXECUTIVE SUMMARY

IMPLEMENTATION REPORT CARD
Previous recommendations: 2
Fully implemented: 2 (100 %)
Substantially implemented:0 (0%)
Partially implemented:0 (0%)
Not implemented: 0 (0%)
Not applicable: 0 (0%)

The September 2000 review of the inmate appeals process at
Deuel Vocational Institution by the Office of the Inspector
General determined that the process was generally efficient and well-run, but that the computer
system in the inmate appeals office needed to be upgraded with the most recent version of the
inmate appeals tracking system software. The Office of the Inspector General also noted that the
institution was not tracking informal inmate appeals. The inmate appeals process is prescribed
under Title 15 of the California Code of Regulations to provide inmates with a system and
process for filing complaints. The process usually begins with an informal attempt to resolve the
issue but can escalate to a three-step formal appeal process beginning with the institution’s
appeals office, which logs appeals into a database before assigning the appeal to a staff member
for action. Second level appeals are typically decided by the warden or chief medical officer and
third level appeals are decided by the Inmate Appeals Branch in Sacramento.
The Office of the Inspector General made the following two recommendations as a result of the
September 2000 findings:
•

The California Department of Corrections should consider upgrading the computer system
used by the institution’s inmate appeals office with the most recent version of the inmate
appeals tracking system software. The inmate appeals office staff also should be provided
with training and manuals for the new version of the software.

•

Although the institution had strong management controls that mitigated the need for a
tracking system for informal appeals, the inmate appeals staff and the warden should
continue to diligently monitor all informal appeals to ensure that the informal process works
as designed and that a tracking system remains unnecessary.

SUMMARY OF THE 2006 FOLLOW-UP RESULTS
The Office of the Inspector General’s 2006 follow-up review found that both recommendations
issued by the Office of the Inspector General in September 2000 concerning the Deuel
Vocational Institution’s inmate appeals process have been fully implemented, with the institution
upgrading the inmate appeals tracking system software to the current version, and instituting
tracking of informal inmate appeals. Accordingly, the Office of the Inspector General makes no
follow-up recommendations.

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CORRECTIONAL FACILITY MAIL PROCESSING
IMPLEMENTATION REPORT CARD

The Office of the Inspector General found that the
California Department of Corrections and Rehabilitation
has reported making significant progress in implementing
the recommendations from the July 2002 review of
correctional facility mail processing. Eighty-eight percent
of the recommendations have been reported as either fully
or substantially implemented.

Previous recommendations: 27
Fully implemented: 14 (51%)
Substantially implemented: 10 (37%)
Partially implemented: 1 (4%)
Not implemented: 1 (4%)

In July 2002, the Office of the Inspector General conducted a
Not applicable: 1 (4%)
review to determine whether mail handling procedures and
processes could be changed to improve efficiency and reduce
costs while maintaining mandated service levels and
institution security. Department of Corrections and Rehabilitation inmates and staff send and
receive millions of pieces of mail through the U.S. Postal Service each year. Inmates consider
mail a vital link to family, friends, and the outside world, as well as a vehicle for communicating
with legal advisers, government officials, and clergy.
The Office of the Inspector General reviewed the California Code of Regulations, Title 15 and
the correctional facility plans of operations for mail handling for nine institutions, and conducted
in-depth site visits to the California State Prison, Solano; the California Institution for Men; and
the California Institution for Women. As a result of its July 2002 review, the Office of the
Inspector General found a number of problems, including that institutions were not taking
advantage of services provided by U.S. Postal Service, some prisons were inefficient in
searching incoming mail, and standard mail was often delayed by mail requiring special
processing. The Office of the Inspector General estimated that implementing the
recommendations at all of the department’s institutions could generate $1.3 million in
operational savings and provide timelier mail delivery.
SUMMARY OF THE 2006 FOLLOW-UP RESULTS
In January 2006, the Office of the Inspector General completed a follow-up audit of the 27
recommendations issued in July 2002. The Office of the Inspector General found that
implementation of the recommendations had been delayed because the previous departmental
administration neglected to provide direction to the institutions on implementing the needed
improvements. It was only after the Office of the Inspector General’s follow-up audit that
instructions and guidelines were issued to the institutions.
FOLLOW-UP RECOMMENDATIONS
As a result of its 2006 follow-up review, the Office of the Inspector General makes eight
recommendations, including the following:
•

The Department of Corrections and Rehabilitation ensure that California State Prison,
Sacramento use automatic letter openers and that the California Institution for Men

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and Salinas Valley State Prison develop a list of acceptable publications that can be
immediately placed in housing unit mailbags.

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PRISON INDUSTRY AUTHORITY OPTICAL PROGRAM AT THE
RICHARD J. DONOVAN CORRECTIONAL FACILITY
The Office of the Inspector General found that the optical
program laboratory at the Richard J. Donovan
Correctional Facility resumed operations during August
2000. The Prison Industry Authority also implemented a
process to confirm that inmates applying for jobs in the
optical laboratory meet the eligibility requirements set
forth in Penal Code section 5071.

EXECUTIVE SUMMARY

IMPLEMENTATION REPORT CARD
Previous recommendations: 2
Fully implemented: 2 (100 %)
Substantially implemented: 0 (0%)
Partially implemented: 0 (0%)
Not implemented: 0 (0%)

Not applicable: 0 (0%)
The Office of the Inspector General’s May 2000 audit of the
Prison Industry Authority optical program at the Richard J.
Donovan Correctional Facility found that in May 1999, the
California Department of Corrections closed the optical laboratory operation at the Richard J.
Donovan Correctional Facility because inmate workers had gained access to the personal
information of Medi-Cal beneficiaries. The department also closed the remaining optical
laboratories until corrective action was taken and then authorized the re-opening of each optical
laboratory, except the Richard J. Donovan optical laboratory, soon after the Prison Industry
Authority developed new policies and procedures to prevent inmate access to sensitive
information. The Office of the Inspector General evaluated the corrective action taken by the
Prison Industry Authority and found that it developed new policies and procedures that could
effectively prevent inmate access to Medi-Cal beneficiary information in all areas of the optical
program. The Office of the Inspector General recommended that the optical laboratory at the
Richard J. Donovan Correctional Facility resume full operations and that inmate workers should
be screened to ensure they meet eligibility requirements.

SUMMARY OF THE 2006 FOLLOW-UP RESULTS
The Office of the Inspector General’s 2006 follow-up review found that both of the
recommendations made in May 2000 have been fully implemented and that the optical
laboratory program at the Richard J. Donovan Correctional Facility re-opened during August
2000. No follow-up recommendations are made.

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KONOCTI CONSERVATION CAMP NUMBER 27
The Office of the Inspector General found that the
Department of Corrections and Rehabilitation has
clarified rules and procedures governing the use of
inmate labor for conservation camp work projects; has
improved accountability over reimbursements for work
projects; and has instituted limits on reimbursement
amounts.

EXECUTIVE SUMMARY

IMPLEMENTATION REPORT CARD
Previous recommendations: 8
Fully implemented: 5 (63%)
Substantially implemented: 0 (0%)
Partially implemented: 2 (25%)
Not implemented: 0 (0%)

In April 2001, the Office of the Inspector General conducted
Not applicable: 1 (12%)
a special review into allegations of misappropriation of state
funds and inappropriate use of inmates on work projects and
in the vocational auto body program at the Konocti
Conservation Camp, which was operated by the former Department of Corrections. The
department jointly operates 31 fire-fighting conservation camps with the California Department
of Forestry and Fire Protection. Sixteen of the camps, including Konocti, are under the direct
supervision of the California Correctional Center in Susanville, which receives, houses, and
trains minimum-custody inmates for placement into one of the Northern California conservation
camps. As a result of the 2001 review, the Office of the Inspector General found that some of the
work projects conducted by the Konocti Conservation Camp violated state laws, regulations, and
department policy and that the camp had received inappropriate reimbursements for those
projects. The review also determined that the management of the Konocti Conservation Camp
circumvented fiscal controls, failed to maintain proper accounting for reimbursements obtained
through inmate labor, and failed to observe requirements governing the vocational auto body
program. The Office of the Inspector General made eight recommendations to the Department of
Corrections and the Department of Forestry and Fire Protection.
SUMMARY OF THE 2006 FOLLOW-UP RESULTS
In its 2006 follow-up review, the Office of the Inspector General found that the Department of
Corrections and Rehabilitation has clarified rules and procedures governing the use of inmate
labor for conservation camp work projects; has improved accountability over reimbursements for
work projects; and has instituted limits on reimbursement amounts. No follow-up
recommendations are made.

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INDEX TO FINDING SUMMARIES
California Rehabilitation Center, Inmate Appeals Process ---------------------------------ES-48
California State Prison, Sacramento -----------------------------------------------------------ES-32
California State Prison, Solano-----------------------------------------------------------------ES-30
California Substance Abuse Treatment Facility and State Prison, Corcoran-------------ES-11
Correctional Facility Mail Processing---------------------------------------------------------ES-51
Deuel Vocational Institution, Inmate Appeals Process -------------------------------------ES-50
Education Programs at Level IV Institutions -------------------------------------------------ES-26
Employee Disciplinary Process ----------------------------------------------------------------ES-21
High Desert State Prison ------------------------------------------------------------------------ES-34
Inmate Appeals Branch -------------------------------------------------------------------------ES-44
Konocti Conservation Camp Number 27 -----------------------------------------------------ES-54
Leo Chesney Community Correctional Facility ---------------------------------------------ES-40
Local Assistance Program ----------------------------------------------------------------------ES-42
Medical Contracting Process -------------------------------------------------------------------ES-24
Office of Compliance, Audit Functions -------------------------------------------------------ES-22
Office of Investigative Services----------------------------------------------------------------ES-18
Pharmaceutical Expenditures-------------------------------------------------------------------ES-16
Prison Industry Authority Optical Program at the Richard J. Donovan
Correctional Facility ------------------------------------------------------------------------ES-53
Richard A. McGee Correctional Training Center--------------------------------------------ES-28
Salinas Valley State Prison, Inmate Appeals and Disciplinary Process ------------------ES-46
Sierra Conservation Center ---------------------------------------------------------------------ES-38
Valley State Prison for Women ----------------------------------------------------------------ES-36

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2006 ACCOUNTABILITY AUDIT

INTRODUCTION

INTRODUCTION

T

his report presents the results of a comprehensive follow-up audit of 22 previous
audits and reviews conducted by the Office of the Inspector General of the former
California Department of Corrections (now Adult Operations and Adult Programs
of the California Department of Corrections and Rehabilitation) between 2000 and 2004.
The purpose of the audit was to assess the progress of the California Department of
Corrections and Rehabilitation in implementing the Office of the Inspector General’s
previous recommendations. The audit was performed pursuant to California Penal Code
section 6126, which assigns the Office of the Inspector General responsibility for
oversight of the California Department of Corrections and Rehabilitation.
BACKGROUND

The stated mission of the California Department of Corrections and Rehabilitation is to
“improve public safety through evidence-based crime prevention and recidivism
reduction strategies.” The department operates 33 prisons for adult offenders, oversees 12
community correctional facilities, and supervises state parolees in local communities. In
February 2000, the state prison inmate population totaled 160,846; by February 2004, the
population had increased to 161,449; and as of March 2006, the population stood at
169,091— an increase of 8,245 over the February 2000 total. At present, the institutions
are filled to nearly twice design capacity. Department staff consists of 55,050 employees,
including 46,759 employees assigned to institutions, 3,126 assigned to parole, and 4,513
assigned to department administration. The department’s budget for adult operations and
programs increased from $4.4 billion in fiscal year 2000-01 to $5.3 billion in 2003-04,
and the governor’s proposed budget for adult operations and programs for fiscal year
2006-07 is approximately $7.5 billion.
Effective July 1, 2005, the Youth and Adult Correctional Agency was dissolved and its
former entities were reorganized under the new Department of Corrections and
Rehabilitation. The department now consists of Adult Operations and Programs (formerly
the Department of Corrections); the Division of Juvenile Justice (formerly the California
Youth Authority); the Corrections Standards Authority (formerly the Board of
Corrections and the Commission on Correctional Peace Officer Standards and Training);
the Board of Parole Hearings (formerly the Youthful Offender Parole board, the Board of
Prison Terms, and the Narcotic Addict Evaluation Authority); the State Commission on
Juvenile Justice; the Prison Industry Authority; the Prison Industry Board; and the
California Council on Mentally Ill Offenders.
The Department of Corrections and Rehabilitation has come under consistent criticism
for its prison overcrowding; in-prison violence; failure to provide constitutionally
adequate medical care and mental health services to inmates; failures in employee
discipline; and for a recidivism rate that is one of the highest in the country. A series of

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INTRODUCTION

class-action lawsuits have been filed against the department as a result of some of those
problems, addressing in particular, health care services and employee discipline.
The department’s failure to provide adequate medical services to inmates was the subject
of the class-action lawsuit, Plata v. Schwarzenegger. The case resulted in a settlement
agreement that required the department to implement specified changes in inmate
medical services over an eight-year period beginning in 2003. In February 2006,
dissatisfied with the department’s progress in implementing improvements, the U. S.
District Court appointed a receiver over the department’s health care operations. Under
the terms of the court’s action, the receiver, who is scheduled to assume duties on April
17, 2006, will have broad powers for “restructuring day-to-day operations and
developing, implementing, and validating a new, sustainable system that provides
constitutionally adequate medical care to all class members as soon as practicable.” The
receiver’s powers include the duty to control and direct “all administrative, personnel,
financial, accounting, contractual, legal, and other operational functions of the medical
delivery component of the department.”
A federal civil rights lawsuit, Madrid v. Hickman, filed by inmates at Pelican Bay State
Prison, alleging misconduct by correctional officers and corruption in internal affairs
investigations, has resulted in the court-ordered Madrid Remedial Plan to correct
deficiencies in the internal affairs process. The Office of the Inspector General’s Bureau
of Independent Review was established in 2004 as part of that plan to monitor the
department’s internal affairs investigations.
OBJECTIVES, SCOPE AND METHODOLOGY
To conduct the follow-up review, the Office of the Inspector General performed the
following procedures:
•

Reviewed 22 audits and reviews conducted by the Office of the Inspector General of
California Department of Corrections programs and institutions between 2000 and
2004.1

•

Reviewed statutes, regulations, lawsuits, and other documents pertinent to the
California Department of Corrections and Rehabilitation’s current operating
environment.

•

Contacted the California Department of Corrections and Rehabilitation and requested
information and documentation on the department’s progress in implementing the
Office of the Inspector General’s recommendations.

1

Audits of discontinued programs were not included in the follow-up review.

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INTRODUCTION

•

Based on its assessment of the information and documents received, the Office of the
Inspector General either conducted site visits to conduct interviews, make
observations, and review records––performing tests as necessary using audit sampling
techniques — or relied on the documents and other information provided by the
department to assess the department’s progress in implementing the Office of the
Inspector General’s recommendations.

•

Evaluated the information developed from the audit procedures and classified the
progress of the department and the institutions in implementing each recommendation
into one of the following five categories:
¾ Fully implemented: The recommendation has been implemented and no further
corrective action is necessary.
¾ Substantially implemented: More than half of the corrective actions necessary to
fulfill the recommendation have been implemented.
¾ Partially implemented: Half or less than half of the corrective actions necessary
to fulfill the recommendation have been implemented.
¾ Not implemented: The recommendation has not been implemented.
¾ Not applicable: The recommendation is no longer applicable.

In some instances, the department has successfully addressed the problems by
implementing alternative solutions, and wherever that has occurred, those achievements
are acknowledged in the report. The original 22 reports covered in this follow-up
accountability audit had dates of issue ranging from May 2000 through September 2004.
The California Department of Corrections and Rehabilitation, therefore, had a significant
amount of time to implement the Office of the Inspector General’s recommendations
before the follow-up audit was conducted. The large number of audits and
recommendations that required follow-up for the accountability audit caused the
fieldwork completion dates for this follow-up audit to range from August 2005 through
March 2006. (The specific completion date for fieldwork is indicated in each chapter.) It
is therefore possible that in some cases the California Department of Corrections and
Rehabilitation took action to address some of the Office of the Inspector General’s
recommendations after completion of the follow-up audit fieldwork. In such cases, the
corrective action would not be reflected in this report.

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FINDINGS AND RECOMMENDATIONS

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2006 ACCOUNTABILITY AUDIT

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND
STATE PRISON AT CORCORAN

IMPLEMENTATION REPORT CARD
Previous recommendations: 72

The California Substance Abuse Treatment
Fully implemented: 38 (53%)
Facility and State Prison at Corcoran has
Substantially implemented: 11 (15%)
developed needed improvements to policies and
procedures affecting medical services, but the
Partially implemented: 10 (14%)
institution has not implemented numerous
recommendations from a January 2003 audit,
Not implemented: 12 (17%)
citing a shortage of medical personnel and
Not applicable: 1 (1%)
turnovers in its management ranks as major
impediments. In addition, the Office of Substance
Abuse Programs has not significantly improved its
processes for monitoring contracts with private providers of in-prison substance
abuse treatment programs, and drug treatment providers continue to fail to provide
the number of counselors required under the contracts. Independent evaluations of
the effectiveness of the facility’s in-prison substance abuse treatment program are
inconclusive.
The Office of the Inspector General issued a management review audit of the California
Substance Abuse Treatment Facility and State Prison at Corcoran in January 2003. The
audit identified numerous problems at the institution, including inadequate management
of medical, dental, and pharmacy services; deficiencies in the substance abuse treatment
program that prevented the institution from reducing recidivism by helping inmates
overcome drug dependency; and the failure of a significant number of staff and managers
to fulfill annual training requirements.
BACKGROUND
The California Substance Abuse Treatment Facility and State Prison at Corcoran, which
opened in August 1997, houses approximately 7,300 male inmates and has a staff of
about 1,700 employees, making it one of the largest prisons in the western world. It is
designed for inmates ranging from Level II (low medium security) through Level IV
(maximum security), but houses a small number of Level I (minimum security) inmates
as well.
Medical, dental, mental health, and pharmacy services. The institution’s correctional
treatment center is the hub of medical, dental, and mental health services. Located inside
the institution’s secured perimeter, the correctional treatment center is responsible for
medical treatment and recovery, mental health assessment and care, and clinical services.
The correctional treatment center is used for providing in-patient care, treating respiratory
illnesses, and providing care to inmates with mental health problems. Clinics affiliated
with the correctional treatment center provide medical and dental services within each of
the prison’s seven facilities. Pharmaceuticals are provided by a pharmacy located in the
correctional treatment center.
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CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

Medical services for the California Department of Corrections and Rehabilitation’s
inmates are the responsibility of the department’s Division of Correctional Health Care
Services. The health care manager at the Substance Abuse Treatment Facility and State
Prison at Corcoran reports to the regional health care administrator of the Division of
Correctional Health Care Services and acts as the on-site administrator of health care
services for the institution, with responsibility for overall management of the institution’s
medical, mental health, and dental programs. Division personnel, along with various
contract employees, operate the correctional treatment center.
In addition to the health care manager, the medical management team consists of a chief
physician and surgeon, a chief psychiatrist, a chief dental officer, and the director of
nursing, who collectively supervise a staff of physicians, dentists, psychiatrists,
psychologists and other medical employees.
Substance abuse program. In addition to its mission of providing custody for state prison
inmates remanded to the custody of the Department of Corrections and Rehabilitation,
the institution includes a 1,478-bed substance abuse treatment program — the largest
custody-based substance abuse treatment facility in the United States. The Department of
Corrections and Rehabilitations’ Office of Substance Abuse Programs is responsible for
administering the substance abuse program, which is run by two private contractors. The
Office of Substance Abuse Programs has employees on site to monitor daily program
operations and to screen inmates eligible for the substance abuse program to ensure that
the program operates at full capacity. The office is also responsible for monitoring the
private contractors for compliance with the terms of the contracts to provide treatment
services. The institution staff provides custody, security, drug testing, classification
reviews, and administrative support to the Office of Substance Abuse Programs and the
contractors. From January 2002 through June 2006, the Office of Substance Abuse
Programs contracted to pay each private contractor approximately $29 million for
substance abuse program services.
In recent years, providing adequate health care to inmates has been increasingly
problematic for the Department of Corrections and Rehabilitation. In February 2006, the
U.S. District Court for the Northern District of California appointed a receiver over the
department’s health care operations in connection with a class action suit, Plata v.
Schwarzenegger. Under the terms of the court’s action, the receiver has broad powers to
achieve the goal of “restructuring day-to-day operations and developing, implementing,
and validating a new, sustainable system that provides constitutionally adequate medical
care to all class members as soon as practicable.” The receiver’s powers include the duty
to control and direct “all administrative, personnel, financial, accounting, contractual,
legal, and other operational functions of the medical delivery component” of the
department.
SUMMARY OF PREVIOUS FINDINGS AND RECOMMENDATIONS
As a result of the January 2003 management review audit, the Office of the Inspector
General identified 10 findings encompassing a wide array of the institution’s operations.
The findings included observations of deficiencies in the substance abuse treatment
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program, medical and dental care, pharmacy operations, staff training, safety and
security, and hiring procedures. Among the most significant findings from the January
2003 management review audit were the following:
•

Deficiencies in the substance abuse treatment program were preventing the institution
from reducing recidivism by helping inmates overcome drug dependency.

•

Inadequate management of the institution’s medical, dental, and pharmacy services
placed the health of inmates and safety of staff at risk and exposed the state to
possible legal liability.

•

A significant number of staff and managers were not fulfilling annual training
requirements.

As a result of the January 2003 management review audit, the Office of the Inspector
General made 72 recommendations to the Department of Corrections, the Health Care
Services Division, and the California Substance Abuse Training Facility and State Prison
at Corcoran to address these and other findings.
OBJECTIVES, SCOPE, AND METHODOLOGY
The purpose of the 2006 follow-up review was to determine the extent to which the
Department of Corrections and Rehabilitation, the Division of Correctional Health Care
Services, and the California Substance Abuse Training Facility and State Prison at
Corcoran had implemented the recommendations from the Office of the Inspector
General’s January 2003 management review audit. To conduct the follow-up review, the
Office of the Inspector General provided the department, the institution, and the Division
of Correctional Health Care Services with a table listing the January 2003 findings and
recommendations and asked management to provide the implementation status of each
recommendation. The Office of the Inspector General reviewed the responses, along with
supplementary documentation provided, and evaluated the degree of compliance or
noncompliance with the recommendations. The Office of the Inspector General
completed follow-up field work at the institution in November 2005. The results are
presented in the tables following this narrative.
SUMMARY OF THE 2006 FOLLOW-UP RESULTS
Of the 72 recommendations issued by the Office of the Inspector General in January 2003
concerning the California Substance Abuse Treatment Facility and State Prison at
Corcoran, 38 have been fully implemented, 11 have been substantially implemented, 10
have been partially implemented, 12 have not been implemented, and one is no longer
applicable.
Substance abuse treatment program. The Office of the Inspector General’s January 2003
management review audit identified numerous problems that impaired the effectiveness
of the institution’s substance abuse treatment program. Key among these was the
placement into the program of large numbers of inmates not suited to the treatment
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model, including sex offenders and inmates suffering from mental illness. Other
deficiencies included a shortage of trained counselors to run the interactive therapeutic
community — a proven treatment modality for modifying the behavior of substance
abusers — and the fact that group sizes for the therapeutic community exceeded contract
limits.
A September 2002 UCLA study of the institution’s substance abuse treatment program,
cited in the Office of the Inspector General’s audit report, showed no difference in
recidivism rates between program participants and a control group of inmates at another
prison who received no treatment. The study raised questions about the advisability of
paying contractors millions of dollars for in-prison substance abuse programs not
demonstrated to be effective.
In the 2006 follow-up review, the Office of the Inspector General found that the
California Substance Abuse Treatment Facility has made generally disappointing
progress in implementing needed changes in the three years since the January 2003
management review audit, although there have been some improvements. The institution
has been successful in identifying and recruiting a higher proportion of program-eligible
inmates into the program, while reducing the proportion of sex offenders and mental
health patients. Of the 1,456 inmates assigned to the program on October 20, 2005, fewer
than seven percent were mental health patients and fewer than one percent of those who
were mental health patients were also sex offenders. In comparison, the January 2003
audit found the proportion of sex offenders and mental health patients in the program to
be as high as 50 percent.
The Office of the Inspector General also found, however, that the Office of Substance
Abuse Programs continues to fail at effectively monitoring its contracts with the private
providers of substance abuse program services at the prison. In reviewing the on-site
monitoring reports for each provider in the substance abuse program for the 11-month
period from December 2004 to October 2005, the Office of the Inspector General found
that the monitoring reports continued to lack detail, did not focus on the contractors’
compliance with contractual expectations, and did not reflect evidence of substantive
review of the providers’ records and operations.
The Office of the Inspector General noted in addition that the program providers continue
to supply an inadequate number of counselors. During an October 2005 site visit, the
Office of the Inspector General found that program staffing was 14 counselors short of
the 73 entry- and journey-level counselors required under the state contracts —a 19
percent shortfall. Contributing to this condition, the Office of Substance Abuse Programs
still has no language in its contracts with the providers permitting the state to withhold
payment or exercise other sanctions short of contract cancellation for such instances of
non-compliance.
The Office of the Inspector General also found that an influx of more than 400 general
population inmates into the substance abuse housing units in response to a departmentwide bed shortage caused the treatment “cluster” sizes to increase from 62 inmates to up
to 100 inmates. The higher population clusters exceed the professionally recommended
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standard of 50 to 75 participants for therapeutic community programs and further detract
from program effectiveness.
Treatment also appears to be frequently interrupted. On two separate visits in October
and November 2005, the Office of the Inspector General attempted without success to
observe therapeutic community groups and evaluate group sizes at the institution. On the
first visit, all counseling had been suspended for the programs’ annual “Sports Week,”
and on the second visit nearly all group sessions had been suspended to accommodate
population movements among the housing units. This inactivity, coupled with recent
lockdowns reported by counselors, raises concerns about the continuity of therapeutic
community treatment at the institution. It is noteworthy that, with the exception of the
lockdowns, none of the monitoring reports by the Office of Substance Abuse Programs
discussed the continuing problems found by the Office of the Inspector General during its
six days of fieldwork.
The Office of the Inspector General reviewed three subsequent evaluations by UCLA of
the institution’s substance abuse treatment program conducted since the September 2002
evaluation. Although the more recent evaluations, which were issued in September 2003,
September 2004, and January 2006, made positive assessments of the effectiveness of
post-prison aftercare, none were bona-fide effectiveness studies like the 2002 evaluation
because they did not compare the recidivism rates of in-prison program participants
against those of inmates from another prison who had not received treatment. Without a
comparison of the subject group to a control group, it is not possible to conclude that the
institution’s program is successful in lowering recidivism.
Medical care. The Office of the Inspector General found that although the institution has
made efforts to implement recommendations affecting the institution’s medical services
and operations, many of the problems identified in the January 2003 management review
audit have not been adequately addressed. The remaining deficiencies include a
continuing backlog of inmate medical appeals; lack of an effective means of ensuring that
physicians work a full 40-hour-a-week schedule; failure to ensure that inmates see a
physician in a timely manner; lack of review of the need for inmate treatment by
specialists; and inadequate monitoring of chronic care patients. The institution points to
repeated turnover in the chief medical officer position as one cause of the continuing
deficiencies. Six different individuals served in the position between September 2002 and
June 2005, when the present incumbent was hired. The institution also reports that since
September 2002, its chief dental officer, chief psychologist, chief psychiatrist, director of
nurses, and medical records supervisor have all resigned, retired, or transferred. The
institution also cites a critical shortage of physicians and other medical staff as a barrier
to full implementation of the Office of the Inspector General’s recommendations. For
example:
•

The institution reports that it has established an expectation that physicians
complete all administrative duties, including notifying the chief medical officer of
medical appeals approaching delinquent status, but maintains that the physician
shortage precludes aggressive focus on appeals.

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•

The institution reports it established a medical authorization review committee to
review the medical necessity for procedures referred to outside medical providers,
but that the committee process has fallen victim to the physician shortage and
reviews are limited to a cursory examination by the chief medical officer.

•

While physicians’ hours and workloads have been adjusted to permit doctors to
see more patients, the requirement that inmates see doctors within 14 days after a
request for contact as mandated by the Plata v. Schwarzenegger court decision is
not being met because the institution does not have enough physicians to meet
that workload.

In addition, the Office of the Inspector General found that despite establishing a system
of accountability for medical personnel, the institution’s medical management team has
been lax in enforcing a directive that medical personnel log in and out of the correctional
treatment center each day by signing the log and recording the actual times of arrival and
departure. Instead of recording the time of day, physicians simply sign the log and
indicate a status of “in” or “out.”
Pharmacy operations. The Office of the Inspector General noted significant
improvements in the institution’s pharmacy operations. The institution developed
improved policies and procedures for control of medications and quality control over
prescriptions, as well as for intra-facility transfers of inmate medications. Spending for
pharmaceuticals also decreased. As the Office of the Inspector General reported in the
January 2003 management review audit, the institution spent $5.4 million in fiscal year
2001-02 for drugs and pharmaceutical supplies, but in fiscal year 2004-05, the
institution’s reported spending decreased to $3.7 million — a 31 percent reduction. The
Department of Corrections and Rehabilitation, however, has still has not made a
significant effort to develop an automated pharmaceuticals inventory system for the
institutions.
The Office of the Inspector General also found that the Substance Abuse Treatment
Facility has made significant progress in staffing its pharmacy with permanent state
employees. At the time of the Office of the Inspector General’s January 2003 audit, the
institution’s pharmacy was staffed entirely by contract employees, but now the pharmacy
employs only two contract employees among its full-time staff of nine. The positions
currently filled by the two contract employees have been advertised as state civil service
job openings since October 30, 2002, and the institution says the current state salary for
pharmacists is lower than that offered in the industry, making recruitment difficult.
Dental services. The institution’s dental management has instituted systems for tracking
dentists’ productivity and for monitoring patient backlog, showing improvements in both
areas, but has still not updated the chief dental officer’s duty statement or provided
formal management training. In addition, while the Office of the Inspector General found
improvement in the institution’s local management of dental operations, it found no
evidence of regular site inspections by the Division of Correctional Health Care Services.

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Administration and custody. The Office of the Inspector General found improvement in
the institution’s procedures and controls over evidence storage, as well as in its system
for administering and monitoring mandatory employee training. But the institution still
had not implemented the Office of the Inspector General’s recommendations to conform
to departmental regulations concerning recording inmate movements and other
significant events in the administrative segregation units.
FOLLOW-UP RECOMMENDATIONS
The Office of the Inspector General recommends that the Office of Substance
Abuse Programs take the following actions:
•

Conduct systematic, in-depth monitoring of treatment providers for
compliance with contract terms. Monitoring reports should reflect all
substantive details of the provider’s records and operations. The
reports should also include the Office of Substance Abuse Programs’
analysis and evaluation of the provider’s operations.

•

When drafting contracts for substance abuse treatment services,
include provisions for fiscal sanctions to address instances of noncompliance with contract terms, including failure to provide the
required number of counselors.

•

Whether performed by UCLA or by another contractor, ensure that
future studies of the effectiveness of the substance abuse program at
the institution include a comparison of the treatment group to a
control group of similar inmates who did not receive treatment.

•

Return to using smaller clusters of inmates to conform to the Office of
National Drug Control Policy’s recommendation that therapeutic
community program clusters consist of no more than 50 to 75 inmates.

The Office of the Inspector General recommends that the Substance Abuse
Treatment Facility and State Prison at Corcoran continue to work with the
Division of Correctional Health Care Services’ department-wide efforts to
address the shortage of physicians and other medical staff.
Within the framework of that limitation the Office of the Inspector General
recommends that the Substance Abuse Treatment Facility and State Prison
at Corcoran take the following actions:
•

Develop methods to reduce or eliminate inmate medical appeal
backlogs without placing inmates at risk.

•

Hold medical staff responsible for completing administrative
activities, including responding to inmate medical appeals in a timely
manner.

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•

Review all medical procedures currently referred to contracted
specialist clinics or outside providers to identify those that could be
performed by institution doctors.

•

Establish procedures and systems to ensure that all inmate requests
for reasonable accommodation and medical verification of disabilities
under the Americans with Disabilities Act are processed in a timely
manner and that all appropriate accommodations or modifications
are implemented without delay.

•

Track pending actions on Americans with Disabilities Act requests to
ensure completion within established time limits and ensure that
medical chronologies or modifications are implemented without delay.

•

Systematically identify inmates with chronic medical conditions and
ensure that those inmates are monitored through regular
appointments with institution doctors.

•

Establish policies and procedures to require periodic laboratory work
and measurement of vital signs for chronic care inmates. Ensure that
this information is available to doctors at the time of examinations so
they may adequately assess chronic medical conditions.

The Office of the Inspector General further recommends that the California
Substance Abuse Treatment Facility and State Prison at Corcoran take the
following actions:
•

Enforce the August 2004 memorandum from the health care manager
instructing medical personnel to sign in and out of the institution and
record actual times of arrival and departure.

•

Establish procedures to comply with Title 15 of the California Code of
Regulations, requiring that dentists examine inmates within 14 days
of the date inmates arrive at the assigned institution from the
reception center, and develop a reporting and monitoring system to
track compliance.

•

Review the chief dental officer’s duty statement and either require the
chief dental officer to devote 40 percent of his or her time to clinic
work as described in the current duty statement, or revise the duty
statement as necessary.

•

Provide management training to on-site dental management staff,
including training on planning and goal setting; performance
measurement; interpersonal communication; and principles of
supervision.

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•

Continue efforts to reduce the dental backlog.

•

Have the health care manager and the chief dental officer establish
policies and procedures for local operation of dental services.

•

The Office of the Inspector General recommends that the California
Substance Abuse Treatment Facility and State Prison at Corcoran
record inmate movements, unusual incidents, and other noteworthy
conditions in the administrative segregation isolation log (CDC-Form
114) as they occur.

The Office of the Inspector General recommends that the Department of
Corrections and Rehabilitation take the following actions:
•

Continue to develop an automated system combining individual
patient medical records with pharmacy tracking information.

•

Develop a barcode system for tracking the inventory and movement of
pharmaceutical products within the institutions.

•

Work with the receiver recently appointed by the federal court to
develop a competitive salary structure for pharmacy professionals,
while continuing efforts to hire full-time pharmacy staff at present
salary levels.

•

Improve support of the dental function at the California Substance
Abuse Treatment Facility and State Prison at Corcoran by conducting
site visits, both scheduled and unannounced, to inspect dental
operations, provide guidance, and meet with the institution’s dental
management to discuss areas of concern.

The following table summarizes the results of the follow-up review.

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ORIGINAL FINDING NUMBER 1
The Office of the Inspector General found that deficiencies in the substance abuse treatment program were preventing the
institution from reducing recidivism by helping inmates overcome drug dependency.
ORIGINAL RECOMMENDATIONS

STATUS

COMMENTS

The Office of the Inspector General
recommended that the Department of
Corrections take the actions listed below to
improve the substance abuse treatment
program at the Substance Abuse Treatment
Facility and State Prison at Corcoran.
Develop a process for recruiting eligible
inmates from other institutions into the
program, including those who may be
receiving fire camp, facilities maintenance,
and similar assignments in lieu of substance
abuse treatment program assignments.

FULLY
IMPLEMENTED

The Office of Substance Abuse Programs reported that it has developed a
number of strategies to recruit eligible inmates into the program. For example,
contracts that began April 1, 2005 enable the Office of Substance Abuse
Programs to screen, assess, and orient inmates with a history of substance abuse
at intake. Program staff members then recommend participants to the most
appropriate treatment option. Center Point, Inc., was the successful competitor
for the in-reception-center substance abuse programs at North Kern State Prison
(200 slots) and Wasco State Prison (300 slots).
The Office of the Inspector General contacted the Office of Substance Abuse
Programs staff member assigned to the reception center substance abuse
programs at North Kern and Wasco State Prisons and requested information on
inmates the representatives have endorsed to the substance abuse program at the
Substance Abuse Treatment Facility and State Prison at Corcoran.
The Office of the Inspector General verified that between May 3, and October 9,
2005, the staff endorsed 89 participants to the program at the Substance Abuse
Treatment Facility and State Prison at Corcoran. The Office of the Inspector
General also verified that 61 of the 89 participants (69 percent) were actually
participating in the substance abuse program as of October 9, 2005.

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The Office of Substance Abuse Programs reported that as of January 2004, the
substance abuse treatment program at the Substance Abuse Treatment Facility
and State Prison in Corcoran also serves as the alternate placement site for
disabled in-custody drug treatment program parolees who volunteer for treatment
in lieu of parole revocation.
The Office of Substance Abuse Programs reported that as of May 22, 2003,
inmates eligible for work-furlough are also eligible for placement in substance
abuse treatment programs and for subsequent transition into community
treatment. Previously, such inmates were ineligible, and were assigned to fire
camps, facilities maintenance, and similar assignments.
The Office of the Inspector General verified that 314 work furlough inmates (22
percent of the 1,456 inmates assigned to the program) were participating in the
institution’s substance abuse treatment program as of October 20, 2005.
Cease the policy of requiring inmates to
participate in the substance abuse treatment
program involuntarily.

NOT
IMPLEMENTED

The Office of Substance Abuse Programs informed the Office of the Inspector
General that it does not agree with this recommendation and will not pursue a
policy change, citing clinical research supporting the effectiveness of involuntary
program participation.

Develop alternative methods of providing
substance abuse treatment to sex offenders,
perhaps by grouping them into specially
designated clusters.

PARTIALLY
IMPLEMENTED

The Office of Substance Abuse Programs reported that it is exploring funding
options for establishing in-prison programs for sex offenders and correctional
clinical case management system inmates in fiscal year 2007-08.
The Office of Substance Abuse Programs also reported that since May 14, 2004,
inmates convicted of Penal Code section 288 sex offenses are excluded from
placement in substance abuse treatment programs. According to the Office of
Substance Abuse Programs, the deputy director of institutions implemented the
exclusion because there are virtually no continuing care facilities in the state for
individuals convicted of such offenses.
The Office of the Inspector General determined that 87 inmates identified as sex
offenders were assigned to the substance abuse treatment program at the

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Substance Abuse Treatment Facility and State Prison at Corcoran as of October
20, 2005. The Office of the Inspector General also reviewed the commitment and
controlling offenses of each of these inmates and found that eight of the 87
inmates had received a Penal Code section 288 conviction. According to the May
14, 2004 exclusionary policy, only inmates assigned to the substance abuse
treatment program before that date could remain in the program. The Office of
the Inspector General verified that two of the eight inmates were assigned to the
program before May 14, 2004. Six of the eight inmates were assigned to the
program after May 14, 2004, and therefore should not have been included in the
program.
Limit the percentage of correctional clinical
case management system inmates and sex
offenders that contractors must accept into the
substance abuse treatment program.

FULLY
IMPLEMENTED

The Office of Substance Abuse Programs reported that the percentage of
correctional clinical case management system (mental health) inmates continues
to average eight percent of the substance abuse treatment program participants at
the Substance Abuse Treatment Facility and State Prison at Corcoran. The Office
of Substance Abuse Programs also reported that it will move these special
groups to the aforementioned new programs if they are implemented, thus
minimizing the need to include these groups in existing substance abuse
treatment programs.
The Office of the Inspector General obtained a list of the correctional clinical
case management system inmates assigned to the substance abuse treatment
program at the California Substance Abuse Treatment Facility and State Prison
at Corcoran as of October 20, 2005 and found 93 of these inmates, including 12
who were also “R” suffix inmates. Of the 1,456 inmates assigned to the program
on October 20, 2005; therefore, 6.4 percent were correctional clinical case
management system inmates and fewer than one percent were also “R” suffix
inmates. In comparison, the Office of the Inspector General’s January 2003 audit
found the proportion of sex offenders and correctional clinical case management
system inmates to be as high as 50 percent, demonstrating that the Office of
Substance Abuse Programs has been successful in reducing the number of such
inmates assigned to the program.

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2006 ACCOUNTABILITY AUDIT

Conduct systematic, in-depth monitoring of
providers for contract compliance.
Deficiencies noted should require corrective
action plans with deadlines and include
follow-up monitoring to verify that satisfactory
corrective action has been taken.

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

NOT
IMPLEMENTED

The Office of Substance Abuse Programs reported that it has a number of indepth tracking and technical assistance efforts in place to monitor contract
compliance. These efforts include the development of a monitoring handbook to
address standards for program services; a monitoring instrument for the drug
treatment furlough program; an audit tool to assess classification, security, and
contractual compliance of substance abuse program sites; and a Continuing
Quality Improvement Subcommittee comprised of Office of Substance Abuse
Programs and treatment provider executives.
The Office of Substance Abuse Programs also reported that it conducts a
minimum of one site visit per month at the Substance Abuse Treatment Facility
and State Prison at Corcoran’s substance abuse treatment program to evaluate
program operations and provider compliance with contract terms. The staff
member conducting the site visit prepares a report on observations as well as on
areas of concern and accomplishments. The Office of Substance Abuse Programs
allows each provider sufficient time to correct any deficiencies noted in the
report and develops a corrective action plan if the provider does not resolve
deficiencies within the timeframes allowed. The Office of Substance Abuse
Programs monitors the corrective action plan and conducts monthly meetings
until the providers resolve all areas of concern.
The Office of the Inspector General obtained and reviewed the on-site
monitoring reports of each of the substance abuse treatment program providers at
the Substance Abuse Treatment Facility and State Prison at Corcoran for the
period December 2004 to October 2005. During the period, Phoenix House had
site visit reports prepared for visits during December 2004 and January, June,
July, August, and October 2005. Walden House, had site visit reports completed
for visits during December 2004 and March, April, May, and September 2005.
The Office of the Inspector General concluded that monitoring by the Office of
Substance Abuse Programs of providers for contract compliance continues to
lack evidence of systematic, in-depth analysis of contract compliance. The
reports the Office of the Inspector General reviewed continued to lack detail and
did not reflect substantive review of provider records and operations.

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2006 ACCOUNTABILITY AUDIT

Investigate methods of helping providers retain
counselors and other staff members.

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

PARTIALLY
IMPLEMENTED

The Office of Substance Abuse Programs reported that it has taken steps to
ensure higher minimum pay for entry-level counselors by specifying a minimum
and maximum bid amount in the competitive request for proposal. Career paths
are built into contractors’ budgets so that entry-level counseling staff with the
requisite education and experience can progress to journey-level counselors and
into management positions.
The Office of Substance Abuse Programs reported in addition that its Continuing
Quality Improvement Subcommittee studied staff retention strategies as an
example of ‘best practices” during a visit to the substance abuse treatment
program at the Substance Abuse Treatment Facility and State Prison at Corcoran
and intended to share its findings with other treatment providers. The Office of
Substance Abuse Programs also reported that it provides workforce development
training and cross-training for treatment, institution, and headquarters staff and
enables contractors to budget for on-going staff training.
Despite these steps by the Office of Substance Abuse Programs, the Office of the
Inspector General found there continues to be an inadequate number of
counselors working for the providers of the substance abuse treatment program
at the Substance Abuse Treatment Facility and State Prison at Corcoran. The
Walden House contract stipulates that Walden House should have 19 entry-level
counselors, nine journey-level I counselors, and 13 journey-level II counselors.
As of November 15, 2005, Walden House employed the required number of
journey-level I and II counselors, but three entry level counselor positions were
vacant. Similarly, the Phoenix House contract requires Phoenix House to employ
12 entry-level counselors and 20 journey-level counselors. As of October 21,
2005, Phoenix House employed three entry-level counselors and 18 journeylevel counselors —11 counselors fewer than the required number. Executives
from both providers informed the Office of the Inspector General that a number
of counselors transferred to the substance abuse treatment program at the newly
opened Kern Valley State Prison and they have not yet been able to fill the open
positions at the Substance Abuse Treatment Facility and State Prison at
Corcoran. The Office of the Inspector General interviewed various Walden
House counselors and learned that while the counselors generally liked their
jobs, they were dissatisfied with the low pay.

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Evaluate all possible means of increasing
aftercare participation, including possible
legislation to mandate aftercare as a condition
of parole for substance abuse treatment
program inmates.

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

FULLY
IMPLEMENTED

The Office of Substance Abuse Programs reported that it met with the new
Board of Parole Hearings to open discussions about moving civil addicts into
drug treatment furlough programs 120 days before the end of their commitment
terms. In the drug furlough program, inmates serve the final days of their
commitment term in a residential-type setting where substance abuse treatment is
provided. The Office of Substance Abuse Programs noted that the furlough
program is less restrictive than an institution and therefore more closely
resembles the aftercare experience. According to the Office of Substance Abuse
Programs, the discussions included requiring mandatory aftercare for those in the
drug treatment furlough programs as well as mandating aftercare as a condition
of parole for in-prison substance abuse treatment program participants.
The Office of Substance Abuse Programs reported that the drug treatment
furlough program for non-serious, non-violent substance abuse treatment
program inmates was activated on January 26, 2004. The program opened up
1,500 slots in community-based residential treatment facilities, enabling inmates
to volunteer to transition from the in-prison substance abuse treatment program
to the drug treatment furlough program 120 days before their release on parole.
Fifty percent of the participants are budgeted to receive up to 150 days of
aftercare following parole from the drug treatment furlough program.
The Office of Substance Abuse Programs reported in addition that it has
collaborated with the Parole and Community Services Division on a program in
which parolees volunteer to participate in a 30-day jail-based drug education
program in lieu of parole revocation. Participating parolees must agree to
complete 90 days of non-residential aftercare upon release from the jail program.

In future contracts with providers, include
withholding of payments or other fiscal
sanctions as alternatives to contract
termination in the event of non-compliance.
Review and evaluate the recommendations of
the UCLA evaluation of the substance abuse

OFFICE OF THE INSPECTOR GENERAL

NOT
IMPLEMENTED

PARTIALLY
IMPLEMENTED

The Office of Substance Abuse Programs reported that the contract monitoring
handbook under development will include graduated sanctions for contractor
non-compliance.

The Office of Substance Abuse Programs reported that it will be working jointly
with UCLA on controlled studies of the program participants at the Substance

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treatment program.

Abuse Treatment Facility and State Prison at Corcoran. The Office of Substance
Abuse Programs has a formal process for reviewing contracted evaluations and
recommendations and adopts those recommendations that are based on sound
findings and appropriate for implementation in a correctional facility. According
to the office, UCLA studies have identified significant reductions in return-tocustody rates for substance abuse treatment program parolees who complete at
least 90 days of aftercare, preferably in residential treatment. As a result, on June
25, 2003, the chief of the Office of Substance Abuse Programs directed
substance abuse treatment providers to take the steps necessary to place program
graduates in residential treatment within 90 days of release from prison.
The Office of Substance Abuse Programs provided studies of the substance
abuse treatment program performed by UCLA in September 2003, September
2004, and January 2006 for review by the Office of the Inspector General. The
Office of the Inspector General’s review determined, however, that unlike the
September 2002 evaluation described in the original audit report, the more recent
studies did not compare recidivism rates of parolees who completed the
substance abuse treatment program with those of inmates from another prison
who did not receive substance abuse treatment. While the more recent
evaluations did report lower recidivism rates than those reported in the
September 2002 evaluation, without such a comparison, it is not possible to
conclude that the substance abuse treatment program at the Substance Abuse
Treatment Facility and State Prison at Corcoran has succeeded in lowering
recidivism rates.
The Office of Substance Abuse Programs also reported that it disagrees with a
conclusion by the UCLA study authors that the treatment clusters at the
Substance Abuse Treatment Facility and State Prison at Corcoran are too large.
The Office of Substance Abuse Programs reported that the two contract
substance abuse treatment program providers each have three housing units
consisting of 246 inmates divided into four treatment clusters of approximately
62 inmates each. That cluster size would be consistent with the Office of
National Drug Control Policy’s suggestion that large therapeutic community
programs be subdivided into clusters no larger than 50 to 75 inmates.

OFFICE OF THE INSPECTOR GENERAL

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2006 ACCOUNTABILITY AUDIT

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

The Office of the Inspector General determined, however, that some of the
treatment clusters at the institution exceed the recommended limits because
general population inmates not participating in the program have been placed in
the substance abuse treatment housing units in response to a department-wide
bed shortage. As of mid-June 2005, 431 general population inmates were
occupying five of the substance abuse treatment program’s 24 treatment clusters.
As of October 20, 2005, 1,456 inmates were participating in the substance abuse
treatment program and were occupying the remaining 19 treatment clusters. In
site visits to the substance abuse treatment program housing units on October 24,
2005 and November 14, 2005, the Office of the Inspector General verified that
instead of the 62 inmates per treatment cluster reported by the Office of
Substance Abuse Programs, some clusters had between 84 to 100 inmates.
The Office of Substance Abuse Programs also reported that it disagrees with
findings by UCLA researchers that there was no significant difference in returnto-custody rates between Substance Abuse Treatment Facility treatment subjects
and Avenal State Prison subjects who did not receive treatment. According to the
Office of Substance Abuse Programs, further analysis by its staff determined that
the population of non-treatment subjects was over-represented by drug
traffickers compared to the treatment subjects’ higher population of drug
possession offenders, arguing that drug traffickers generally return to prison at a
lesser rate than drug possession offenders.
The Office of the Inspector General discussed this argument with the principal
investigator who worked on the September 2002 UCLA evaluation. According to
the principal investigator, the Office of Substance Abuse Programs raised this
argument during the drafting of the UCLA report. Accordingly, the final UCLA
report specifically addressed the issue, finding that while the control group of
non-treatment inmates convicted of drug offenses did have a higher percentage
of drug traffickers than the treatment group, the one-year return-to-custody
percentages between the treatment and control groups, sorted by type of offense,
was not statistically significant. UCLA, therefore, stands by its findings.

OFFICE OF THE INSPECTOR GENERAL

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2006 ACCOUNTABILITY AUDIT

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

FOLLOW-UP RECOMMENDATIONS
The Office of the Inspector General recommends that the Office of Substance Abuse Programs take the following actions:
•

Conduct systematic, in-depth monitoring of treatment providers for compliance with contract terms. Monitoring
reports should reflect all substantive details of the provider’s records and operations. The reports should also include
the Office of Substance Abuse Programs’ analysis and evaluation of the provider’s operations.

•

When drafting contracts for substance abuse treatment services, include provisions for fiscal sanctions to address
instances of non-compliance with contract terms, including failure to provide the required number of counselors.

•

Whether performed by UCLA or by another contractor, ensure that future studies of the effectiveness of the substance
abuse program at the institution include a comparison of the treatment group to a control group of similar inmates who
did not receive treatment.

•

Return to using smaller clusters of inmates to conform to the Office of National Drug Control Policy’s recommendation
that therapeutic community program clusters consist of no more than 50 to 75 inmates.

ORIGINAL FINDING NUMBER 2
The Office of the Inspector General found serious deficiencies in the medical care provided to inmates at the Substance Abuse
Treatment Facility and State Prison at Corcoran, placing the health of inmates and staff at risk and exposing the State to
possible legal action.
ORIGINAL RECOMMENDATIONS

STATUS

COMMENTS

The Office of the Inspector General
recommended that the Department of
Corrections and the medical management of
the California Substance Abuse
Treatment Facility and State Prison at
Corcoran take the actions listed below to
improve medical services and operations.

OFFICE OF THE INSPECTOR GENERAL

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2006 ACCOUNTABILITY AUDIT

Develop a plan for re-activating medical
operations at the institution. The plan should
include the following: a component for
recruiting, training, and retaining adequate
professional staff; written department and
institution-specific policies and procedures
covering all areas of operation, including
nursing; and provisions for regular on-site
monitoring and assistance by the Health Care
Services Division.

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

PARTIALLY
IMPLEMENTED

The institution noted that since September 2002 its chief medical officer,
chief dental officer, chief psychologist, chief psychiatrist, director of nurses,
and medical records supervisor have resigned, retired, or transferred. Health
care management remains problematic, with the institution experiencing a
succession of six different chief medical officers since September 2002 until
the present incumbent was hired in June 2005. The institution reports hiring a
chief dental officer in July 2005. Meanwhile, according to the institution,
recruitment for all health care classifications has been assigned to the
Selections and Standards Branch.
The institution reported that policies and procedures for its correctional
treatment center have been revised; the inmate medical services program
(known informally as the “Plata” decision) has been activated; appropriate
local operating procedures have been implemented; and staff training has
been completed.
As part of its overall quality management program, the institution says it has
established an inmate medical services subcommittee that meets monthly to
advise the quality management committee regarding ongoing medical issues.
Issues that cannot be resolved locally are addressed through the local
governing body meeting (institution staff and headquarters staff are
members).
The institution reported a continuing critical shortage of physicians at the
institution.

Develop a plan to bring the institution’s
correctional treatment center into compliance
with all licensing requirements. The institution
medical management team should establish
and staff all required committees and ensure
that the committees meet as required. The

OFFICE OF THE INSPECTOR GENERAL

SUBSTANTIALLY
IMPLEMENTED

The institution reports that its correctional treatment center underwent a full
licensing survey by the Department of Health Services in February 2003,
which resulted in a corrective action plan being submitted to the Department
of Health Services. This process was repeated in April 2005.
The Office of the Inspector General confirmed that the Department of Health

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2006 ACCOUNTABILITY AUDIT

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

medical management team should also ensure
that the functions of the pharmacist-in-charge
and the radiology physician are being
performed.

Services April 2005 survey shows fewer corrective action items than the
February 2003 survey. The correctional treatment center remains licensed,
subject to renewal in June 2006.
Required licensing committees are being held as required and records
maintained. The duties of both the pharmacist-in-charge and radiology
physician are being performed through contractual agreements.

Obtain the resources to establish a
management information system by which to
track and monitor backlogs in pharmacy,
radiology, medical records, specialist clinics,
and medical appeals. The system should
prioritize backlogged items according to
urgency.

FULLY
IMPLEMENTED

The institution reported that it put a system in place in May 2003 to track and
monitor backlogs for laboratory, radiology, medical records, medical appeals
and specialty clinics. The system generates a monthly backlog report that is
reviewed by health care management. Areas identified as problematic or
showing a significant increase in backlogs are addressed with health care
management and additional resources are directed to the problem.

Develop methods to reduce or eliminate
backlogs without placing inmates at risk.

PARTIALLY
IMPLEMENTED

The institution reported that its expectation is that physicians see 25
scheduled patients and five additional sick call patients per day, with daily
statistics recorded and maintained. Due to a critical shortage of physicians,
however, the institution reported that it has been unable to meet the
timeframes for seeing patients required by the Plata decision, and that
medical appeals have fallen behind. The Office of the Inspector General noted
that the institution’s physicians averaged 16 patients per day in September
2005. The institution asserted that it has nonetheless resolved backlogs in xray, labs, pharmacy, and specialty clinics.

PARTIALLY

According to the institution, the current work schedule for physicians is eight
hours per day, five days per week, and a sign-in/sign-out log has been
implemented for accountability. In addition, the institution reported that it
compiles daily statistics to provide productivity information to the chief
medical officer.

Ensure that doctors work required hours and
are fully productive during working hours.

OFFICE OF THE INSPECTOR GENERAL

IMPLEMENTED

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2006 ACCOUNTABILITY AUDIT

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

The Office of the Inspector General’s examination of the sign-in log for
February through October 2005 revealed minimal compliance by the
institution’s doctors in adhering to the health care manager’s August 2004
memorandum instructing medical personnel to sign in and out of the
institution. Instead of recording their actual times of arrival and departure as
instructed, doctors were simply signing the log and indicating a status of “in”
or “out.”
Review the number of hours scheduled for
doctors’ lines to ensure that enough time is
scheduled to address inmate medical needs.

Establish a quality control procedure to ensure
that entries into inmate medical files are
complete, accurate, and timely.
Hold the medical staff responsible for
completing administrative activities, including
responding to inmate medical appeals, in a
complete and timely manner.

Foster effective communication and
coordination of medical activities between
medical and custody staff.

OFFICE OF THE INSPECTOR GENERAL

SUBSTANTIALLY
IMPLEMENTED

FULLY
IMPLEMENTED

NOT
IMPLEMENTED

FULLY
IMPLEMENTED

The institution reports that it changed physicians’ work schedules from four
10-hour days to five eight-hour days to allow more consistent coverage and
provide an extra day on which physicians see patients. The chief medical
officer used to hold a weekly physicians’ meeting in an open forum as an
avenue for communication and problem resolution, but the critical shortage of
physicians currently precludes these meetings.
The institution reported that it stresses the importance of timely, complete,
and accurate documentation through physician’s meetings, monthly nursing
meetings, pharmacy meetings, and health record reviews, with relevant
findings reported to health care management.
While the institution reports having established an expectation that physicians
complete all administrative duties in a timely manner and that procedures for
notifying the chief medical officer of medical appeals that will become
delinquent at the end of each week, the physician shortage precludes
aggressive focus on appeals and contributes to a continuing backlog of
appeals.
The institution reported that implementation of a quality management
program provides an avenue for ongoing communication, problem
identification, and resolution of common issues between medical staff and
custody staff.

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2006 ACCOUNTABILITY AUDIT

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

Actively manage the medical function by
establishing goals, setting priorities, defining
expectations, and communicating these to the
medical staff.

SUBSTANTIALLY
IMPLEMENTED

With the January 2004 implementation of the inmate medical services
program, the institution reports that policies and procedures for delivery of
health care are in place, with audits performed to ensure compliance with the
program and Title 22 requirements. Audit findings are reported to health care
management at supervisor meetings, held twice per month, and at monthly
nursing meetings.

Perform periodic audits and reviews of all
medical activities, including nursing, to
monitor compliance with policies, procedures,
and regulations.

FULLY
IMPLEMENTED

The institution reports that nursing audits are performed to ensure compliance
with medication management policy and procedures (Operating Procedure
430). Other nursing audits performed include evaluation of physician orders,
nursing assessment, and charting content.

Ensure that all staff members, including
temporary nursing registry staff, are
thoroughly trained in delivering health care in
a custody environment.

FULLY
IMPLEMENTED

According to the institution, all staff members, including registry nursing
staff, are required to attend orientation classes on institutional safety and
security as well as an overview of correctional health care. Training is
documented and records maintained.

Provide resources to allow clinics to remain
open for more hours per day and more days
per week for sick call and doctors’ lines to
allow more inmates to receive care.

FULLY
IMPLEMENTED

According to the institution, physicians’ work schedules changed from four
10-hour days to five eight-hour days per week, allowing for more consistent
coverage and an extra day on which to see additional patients. Physicians are
expected to see 25 scheduled patients, leaving time to see at least five sick
call patients each day. The Office of the Inspector General confirmed the
improvement to physicians’ work schedules, but noted that the physicians
averaged 16 patients per day during September 2005.

Ensure that treatment in the emergency room
meets minimum standards of care before
inmates are released to housing facilities with
instructions to return to facility doctor’s lines.

FULLY
IMPLEMENTED

According to the institution, a tracking procedure has been implemented to
ensure that all inmates returning from outside medical facilities receive
appropriate follow-up care pursuant to the inmate medical services program
(“Plata”) guidelines and the correctional treatment center policies and
procedures. Because the June 2004 Plata review identified this as an area of
concern, the institution notes that follow-up care is closely monitored and
additional staff training has been conducted.

OFFICE OF THE INSPECTOR GENERAL

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2006 ACCOUNTABILITY AUDIT

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

Establish an automated on-line medical
records system to allow the medical staff
access to inmate pharmaceutical records and
medical histories. The system should also
record and track follow-up appointments to
ensure that these appointments occur.

NOT
IMPLEMENTED

Although an automated on-line medical record system incorporating
pharmaceutical data has not been established, the institution reported that
medical staff can obtain inmate pharmaceutical records by contacting the
pharmacy and that patient medication profiles are provided to staff before all
scheduled appointments. A computer-based appointment scheduling and
tracking system is in place, and the institution reports that the Department of
Corrections and Rehabilitation is developing an automated system that will
incorporate each patient’s medical records and pharmacy tracking
information.

Review all medical procedures currently
referred to contracted specialist clinics or
outside providers in order to evaluate which of
those procedures can be performed by
institution doctors.

NOT
IMPLEMENTED

The institution reported that a medical authorization review committee was
implemented in April 2004 to review the medical necessity of procedures
referred to contracted specialists or outside providers of medical treatment.
With the current critical shortage of physicians at the institution, however,
such review is limited to a cursory examination by the chief medical officer,
who does not formally document the decision process.

Review current backlogs of cases referred to
specialist clinics to assess the appropriateness
of providing specialist clinics more often.

FULLY

Establish procedures and systems to ensure
that all inmate requests for reasonable
accommodation and medical verification of
disabilities under the Americans with
Disabilities Act are processed in a timely
manner and that all appropriate
accommodations or modifications are
implemented without delay.

OFFICE OF THE INSPECTOR GENERAL

IMPLEMENTED

SUBSTANTIALLY
IMPLEMENTED

According to the institution, the chief medical officer is provided with a
monthly report of the number of inmates awaiting specialty services
appointments (optometry, orthotics, surgery, urology, etc.), allowing
management to request additional clinics or provide other resources to prevent
excessive treatment delays.
The institution reported that its administrative staff closely monitors appeals
to ensure compliance with requirements for timely responses to appeals filed
under the Americans with Disabilities Act. The institution further reported
that it has assigned an appeals coordinator to work with medical appeals and
to complete all of the institution’s second-level appeals filed under the
Americans with Disabilities Act. As a result, according to the institution, the
improvement has caused third-party monitoring groups (“Armstrong”
monitors) to put the institution on “paper tour” status for the next scheduled
review, although the recent critical shortage of physicians has made it difficult
to meet the response deadlines required by the Armstrong litigation.

PAGE 29

2006 ACCOUNTABILITY AUDIT

Track pending actions on Americans with
Disabilities Act requests to ensure completion
within established time limits and follow up on
medical chronologies or modifications to
ensure that these are implemented without
delay.

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

SUBSTANTIALLY
IMPLEMENTED

Systematically identify inmates with chronic
medical conditions and ensure that these
inmates are monitored through regular
appointments with institution doctors.

PARTIALLY
IMPLEMENTED

Establish policies and procedures to require
periodic laboratory work and measurement of
vital signs for chronic care inmates. Ensure
that this information is available to doctors at
the time of examinations so they may
adequately assess chronic medical conditions.

PARTIALLY

(See above)

The institution reported that its chronic care program was established as part
of the inmate medical services program in September 2004, and that its
“SATSLITE” scheduling and tracking system tracks and monitors chronic
care appointments. However, the institution advised the Office of the
Inspector General that the critical shortage of physicians has impaired the
institution’s ability to meet program time frames for care of inmates with
chronic medical issues.
(See above).

IMPLEMENTED

FOLLOW-UP RECOMMENDATIONS
The Office of the Inspector General recommends that the institution continue to work with the Division of Correctional
Health Care Services’ department-wide efforts to address the shortage of medical staff as cited by a federal court monitor.
The Office of the Inspector General also reiterates the following recommendations to the institution:
•

Develop methods to reduce or eliminate inmate medical appeal backlogs without placing inmates at risk.

OFFICE OF THE INSPECTOR GENERAL

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2006 ACCOUNTABILITY AUDIT

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

•

Hold medical staff responsible for completing administrative activities, including responding to inmate medical appeals
in a timely manner.

•

Review all medical procedures currently referred to contracted specialist clinics or outside providers to identify those
that could be performed by institution doctors.

•

Establish procedures and systems to ensure that all inmate requests for reasonable accommodation and medical
verification of disabilities under the Americans with Disabilities Act are processed in a timely manner and that all
appropriate accommodations or modifications are implemented without delay.

•

Track pending actions on Americans with Disabilities Act requests to ensure completion within established time limits
and ensure that medical chronologies or modifications are implemented without delay.

•

Systematically identify inmates with chronic medical conditions and ensure that those inmates are monitored through
regular appointments with institution doctors.

•

Establish policies and procedures to require periodic laboratory work and measurement of vital signs for chronic care
inmates. Ensure that this information is available to doctors at the time of examinations so they may adequately assess
chronic medical conditions.

•

Enforce the August 2004 memorandum from the health care manager instructing medical personnel to sign in and out
of the institution and record actual times of arrival and departure.

Finally, the Office of the Inspector General recommends that the Department of Corrections and Rehabilitation continue to
develop an automated system combining individual patient’s medical record with pharmacy tracking information.
ORIGINAL FINDING NUMBER 3
The Office of the Inspector General found that pharmacy operations at the Substance Abuse Treatment Facility and State
Prison at Corcoran were seriously deficient.

OFFICE OF THE INSPECTOR GENERAL

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2006 ACCOUNTABILITY AUDIT

ORIGINAL RECOMMENDATIONS

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

STATUS

COMMENTS

The Office of the Inspector General
recommended that the medical management
Team at the institution take the actions listed
below to improve administrative controls over
pharmacy operations.
Develop written institution policies and
procedures, consistent with Title 22 of the
California Code of Regulations, governing the
institution’s pharmacy operations and comply
with existing department policies and
procedures. The institution policies and
procedures should include the physical
controls and accounting controls necessary to
correct the problems identified by this audit.

FULLY
IMPLEMENTED

Consider implementing an automated barcode
system for tracking the inventory and
movement of pharmaceutical products within
the institution. Bar-coding improves accuracy
in identifying items and in determining
quantities on hand, thus increasing efficiency
by reducing the staff time required to prepare
replenishment orders.

NOT

Develop a systematic means of transferring
inmate medications when inmates change
housing assignments at the institution.

OFFICE OF THE INSPECTOR GENERAL

IMPLEMENTED

FULLY
IMPLEMENTED

The institution reported, and the Office of the Inspector General confirmed, that
policies and procedures consistent with Title 22 of the California Code of
Regulations for pharmacy services are in place and that the institution’s
pharmacy services committee meets quarterly to address pharmacy issues and
review the quarterly pharmacy report.

The institution reported that the Division of Correctional Health Care Services
is working to obtain a more sophisticated automated pharmacy system for
implementation statewide, but that no such system presently exists.

The institution reported that Operating Procedure 418 concerning intra-facility
inmate medication transfer was implemented in October 2003. The policy
governs the method for transferring medications with inmates between yards
within the facility, and has contributed to a reduction in the institution’s
pharmacy expenditures of more $1 million from fiscal year 2002-03 to fiscal

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2006 ACCOUNTABILITY AUDIT

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

year 2004-05. Audits are performed to ensure compliance.
Staff the pharmacy with full-time employees
hired by the Department of Corrections in
order to minimize the turnover in those
positions and enhance the quality of service.

SUBSTANTIALLY
IMPLEMENTED

The institution reported that it currently employs two state pharmacists, five
pharmacy technicians, two contract pharmacists, and a contracted pharmacistin-charge. This represents an improvement over conditions found in the January
2003 audit when the pharmacy was staffed entirely by contract employees.
While recruitment of pharmacists has proven difficult throughout the state’s
correctional institutions, the Substance Abuse Treatment Facility and State
Prison at Corcoran has two pharmacist vacancies that have been advertised for
more than 40 months. The institution said the current salary levels offered by
the state are not competitive with those of private industry.

Ensure that the current pharmacist-in-charge is
present at the pharmacy as required until a
permanent pharmacist-in-charge can be hired.

FULLY
IMPLEMENTED

According to the institution, the current pharmacist-in-charge works a 40-hourper-week schedule under contract with a private agency, while recruitment
efforts to hire a permanent state employee continue.

Develop management information systems,
on-site monitoring methods, and management
reports to more directly monitor pharmacy
operations.

SUBSTANTIALLY
IMPLEMENTED

The institution reports that it has established a pharmacy services committee to
be responsible for overall direction of pharmacy services, along with a
standards compliance coordinator to audit pharmacy services for compliance
with Title 22 regulations. Deficiencies noted by the audits are brought to the
attention of the pharmacy services committee and health care management for
resolution. The institution reports that these actions have resulted in
improvements noted by a recent Plata monitoring tour. The improvements
depend primarily on manual processes, however.

FOLLOW-UP RECOMMENDATIONS
The Office of the Inspector General recommends that the Division of Correctional Health Care Services take the following
actions:

OFFICE OF THE INSPECTOR GENERAL

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2006 ACCOUNTABILITY AUDIT

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

•

Continue to develop and implement an automated barcode system for tracking the inventory and movement of
pharmaceutical products within the institutions.

•

Work with the court-appointed federal receiver to develop a competitive salary structure for pharmacy professionals,
while continuing efforts to hire full-time pharmacy staff at present salary levels.

ORIGINAL FINDING NUMBER 4
The Office of the Inspector General found that the dental care program at the Substance Abuse Treatment Facility and State
Prison at Corcoran was seriously deficient and that inmates were not receiving dental services required under state
regulations.
ORIGINAL RECOMMENDATIONS

STATUS

COMMENTS

The Office of the Inspector General
recommended that the Division of Correctional
Health Care Services take the actions listed
below to improve dental services at the
California Substance Abuse Treatment Facility
and State Prison at Corcoran.
Develop a plan for “re-activating” the dental
operation at the institution. The plan should
provide the dental function with the number of
dental professionals necessary to provide a
minimum standard of care consistent with
Title 15 of the California Code of Regulations.
The plan should also include detailed policies
and procedures for the efficient delivery of
dental services. To this end, the policies and
procedures should include methods for
ensuring that dentists examine inmates within
14 days of arrival at the institution and for

OFFICE OF THE INSPECTOR GENERAL

PARTIALLY
IMPLEMENTED

The institution reported that policies and procedures for dental services have
been developed and approved.
According to the institution, dental management has been a problem because the
chief dental officer position was vacant from September 2002 until July 2005.
The institution reported that meanwhile, dental department meetings are held
monthly, and a dental program subcommittee reports its significant findings to
the Quality Management Committee for resolution.
The institution reported that its dentists continue to make an effort to examine
inmates within 14 days of arrival by using a process that notifies dentists of new

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2006 ACCOUNTABILITY AUDIT

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

developing individual treatment plans, based
on regular examinations, within the framework
of preventative dentistry.

arrivals, but the institution also asserted its belief that the 14-day requirement in
Title 15 pertains to reception centers only and not to other institutions. The
Office of the Inspector General notes, however, that Title 15 of the California
Code of Regulations clearly states, in section 3355.1(b), “Each newly
committed inmate shall within 14 days following transfer from a reception
center to a program facility receive a complete examination by a dentist who
shall develop an individualized treatment plan for the inmate.”
The Office of the Inspector General noted that the institution had six dentists
and six dental assistants at the time of the audit fieldwork — only one fewer in
each category than the institution’s staffing allotment for these positions.

Improve communication with and support of
the institution’s dental function by conducting
scheduled as well as unannounced site visits to
monitor and inspect dental operations, and by
holding regular meetings with on-site
managers to discuss issues of concern to both
headquarters and on-site staff.

PARTIALLY
IMPLEMENTED

As noted above, the institution reports that it has established a dental program
subcommittee as part of its quality management program, and that the
subcommittee meets monthly and forwards any concerns to the quality
management committee for resolution. Issues that cannot be resolved by
institution personnel alone are addressed through the local governing body,
which is comprised of institution staff and headquarters staff.
Although the institution has internal communication and monitoring processes
for its dental operations, the Office of the Inspector General found no evidence
of regular site visits by the Division of Correctional Health Care Services to
inspect dental operations.

Address and resolve the issue of institution
dentists not reviewing or using the dental
assessments completed by reception center
dentists. Institution dentists should either use
the screening as part of the continuum of care
or the Health Care Services Division should
eliminate the screening and its attendant costs.
Obtain the resources to develop a management

OFFICE OF THE INSPECTOR GENERAL

FULLY
IMPLEMENTED

SUBSTANTIALLY

According to the institution, dental assessments performed during the reception
center screening process are reviewed if they are in the unit health record at the
time dental services are performed.

The institution reported that a monthly report on dental services is provided to

PAGE 35

2006 ACCOUNTABILITY AUDIT

information and reporting system to monitor
key indicators of the efficiency and
effectiveness of the dental function. These
indicators should include, but not be limited to,
the following: backlogs in inmate requests for
dental services at the various clinics; number
of patients seen by dentists; number of patients
examined (and not examined) within the 14day limit established by Title 15; number of
individual treatment plans developed; number
of fillings and other preventive procedures
compared to the number of extractions and
denture procedures.

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

IMPLEMENTED

institution and headquarters management. The report provides statistics on the
number of patients to whom services were provided, the percentage of the total
inmate population seen, and details about the types of services provided, such
as restorative procedures, extractions, periodontal, prosthodontics, and
endodontics, in relation to the total number of patients scheduled for
appointments. According to the institution, sick call is held each morning in all
clinics to handle dental emergencies.

Develop a strategy to eliminate the backlog
within a reasonable period based on the
urgency of each request.

SUBSTANTIALLY
IMPLEMENTED

The Office of the Inspector General noted that the institution maintains weekly
statistics for dental workload, including patient backlog, and found that the
backlog during September and October 2005 was approximately three months,
compared to the five-month backlogs the Office of the Inspector General
observed in the January 2003 audit. In addition, the institution has taken steps to
enhance the productivity of its dental operations, as discussed below.

Hold the health care manager and the chief
dental officer accountable for managing dental
operations at the correctional treatment center,
including the following: ensuring that dentists
work appropriate hours and are fully
productive during scheduled working hours;
reviewing the number of hours scheduled for
dental sick call and clinics to ensure sufficient
time is allotted to address inmate dental
problems; establishing a quality control
procedure to ensure that entries into inmate
medical files are complete and accurate;

SUBSTANTIALLY
IMPLEMENTED

The institution reports that its dentists, who work five days per week, are
required to sign in and out daily, that management reviews their productivity
using the monthly dental report and daily appointment lists, and that any
problems are discussed at monthly dental department meetings. The institution
noted again that it has formed a dental program subcommittee that reports to the
institution’s quality management committee, and that dental appeals are
handled in a timely manner under the monitoring of the Correctional Health
Services Administrator II.

OFFICE OF THE INSPECTOR GENERAL

The Office of the Inspector General noted a slight improvement in the
productivity of the institution’s dentists since the January 2003 audit. Dentists
saw an average of 11 patients per day during February and March 2005,

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2006 ACCOUNTABILITY AUDIT

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

ensuring that staff respond to inmate medical
appeals in a complete and timely manner.

compared to only eight patients per day for the same months in 2002.

Review the chief dental officer’s duty
statement and either require him to devote
40% of his time to clinic work or change the
duty statement.

NOT
IMPLEMENTED

The institution advised the Office of the Inspector General that since the chief
dental officer was hired in July 2005, the duty statement for that position has
not been revised since the January 2003 management review audit.

Provide management training to the on-site
dental management staff. The training should
include: planning and goal setting;
performance measurement; interpersonal
communication; and principles of supervision.

NOT
IMPLEMENTED

According to the institution, the chief dental officer has not been scheduled to
attend management training since being hired in July 2005.

Require the health care manager and the chief
dental officer to develop policies and
procedures for local operation of dental
services. These policies and procedures should
include the following:

NOT
IMPLEMENTED

The institution reported that formal policies and procedures are being developed
at department headquarters and have not been officially released, although final
approval and distribution is expected soon. According to the institution, the
institution’s chief dental officer, meanwhile, is working on local policies and
procedures.

•

Longer and more frequent hours of
clinic operations, and the posting of
these hours in the facilities.

•

A system of accountability for the
time worked by dentists, dental
assistants, and other dental staff.

•

Alignment of the work schedules of
dentists and dental assistants to
maximize the efficiency of clinic
operations.

OFFICE OF THE INSPECTOR GENERAL

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2006 ACCOUNTABILITY AUDIT

•

Use of benchmarking and minimum
standards of productivity for dental
staff, including number of patients
seen daily, weekly, and monthly by
dentists.

•

Use of progressive discipline for
employees who fail to comply with
policies, procedures, and minimum
productivity standards.

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

FOLLOW-UP RECOMMENDATIONS
The Office of the Inspector General recommends that the California Substance Abuse Treatment Facility and State Prison at
Corcoran take the following actions:
•

Establish procedures to comply with Title 15 of the California Code of Regulations, requiring that dentists examine
inmates within 14 days of the date inmates arrive at the assigned institution from the reception center, and develop a
reporting and monitoring system to track compliance.

•

Review the chief dental officer’s duty statement and either require the chief dental officer to devote 40 percent of his or
her time to clinic work as described in the current duty statement, or revise the duty statement as necessary.

•

Provide management training to on-site dental management staff, including training on planning and goal setting;
performance measurement; interpersonal communication; and principles of supervision.

•

Continue efforts to reduce the dental backlog.

•

Have the health care manager and the chief dental officer finalize the policies and procedures for local operation of
dental services.

OFFICE OF THE INSPECTOR GENERAL

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2006 ACCOUNTABILITY AUDIT

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

In addition, the Office of the Inspector General recommends that the Division of Correctional Health Care Services improve
its support of the dental function at the institution by conducting site visits, both scheduled and unannounced, to inspect dental
operations, provide guidance, and meet with the institution’s dental management to discuss areas of concern.
ORIGINAL FINDING NUMBER 5
The Office of the Inspector General found that a projected deficit of $8.4 million in the 2002-03 budget for the Substance
Abuse Treatment Facility and State Prison, Corcoran could significantly affect institution operations.
ORIGINAL RECOMMENDATIONS

STATUS

COMMENTS

The Office of the Inspector General
recommended that the California Department
of Corrections take the actions listed below to
better manage the operating budgets of the
institutions.

Continue to request resources to address the
issues driving deficits in the institutions.

FULLY
IMPLEMENTED

The department reported that it has been aggressively pursuing additional
resources to address structural deficiencies and was successful in receiving
additional funding for the following:
Sick leave for posted positions. In fiscal year 2003-04, the department
received $4.8 million in funding to increase its posted sick leave relief factor.
The sick leave relief factor is now funded at the employee’s accrual rate. In
fiscal year 2004-05, additional funding was received to fully fund absences
under the Family Medical Leave Act /California Family Rights Act.
Workers’ compensation. The department reported that it has received base
budget augmentations of $158.3 million over the last three fiscal years to
cover its annual workers’ compensation deficits.

OFFICE OF THE INSPECTOR GENERAL

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CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

Medical guarding and transportation. The department reported that it
received approval for a fiscal year 2004-05 budget augmentation of 114.9
positions and $18.1 million to meet increased costs of medical guarding and
transportation, increasing the base overtime funding for medical guarding and
transportation costs to $9.9 million.
Overtime for posted positions. The department reported that it received an
augmentation of $36.6 million in overtime funding for fiscal year 2001-02
and that provisions were included in the budget bill specifying that the
funding is available only for expenditures for overtime and temporary help to
reduce holiday and vacation leave credits and for costs associated with filling
authorized positions. The funding can be converted to 504 permanent
positions when excess vacancies are filled. The initial allocation of 124.28
positions was distributed to the various institutions in July 2003 and the
remaining 379.61 positions were allocated in August 2004 to reduce overtime
use. An approved budget change proposal for fiscal year 2004-05 addressed
the unfunded relief needed to cover posted positions.
Administrative segregation overflow. For fiscal year 2004-05, the department
reported receiving an augmentation of 195.6 positions and $16.8 million in
funding to provide additional staffing for administrative segregation unit
overflow. The augmentation was based on the minimum overflow levels
experienced during calendar year 2003, and future adjustments were expected
to be addressed after the fall population projection and May 2006 budget
revision.
Utilities costs. For fiscal year 2002-03, the department reported that it
received additional funding of $13.1 million through various policy proposals
and population related adjustments. For fiscal year 2003-04, the department’s
utilities base was increased, with permanent funding of $27.8 million and
one-time population-related adjustments.
Population increases. The department reports that it uses data from its
Offender Information Services Branch in conjunction with any legislative
changes to estimate the fiscal impact of population changes. Through the fall

OFFICE OF THE INSPECTOR GENERAL

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2006 ACCOUNTABILITY AUDIT

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

population projection and the May budget revision process, the department
adjusts its projections of funding required to accommodate population
changes.
New base budget methodology. The department reports that its Financial
Services Division, in conjunction with the Department of Finance, developed
a new budget allotment methodology to align funding with expenditure levels
more realistically and continues to work on refinements. While budgets are
tight, the department reports that it continues to submit requests addressing
the need for additional resources.
Prepare cost estimates of all changes to
employee bargaining unit contracts before
committing to changes in the contracts.

FULLY
IMPLEMENTED

The department reports that its budget management branch is instructed to
estimate the impact of labor agreements that have been negotiated by the
department in consultation with the Department of Finance and the
Department of Personnel Administration. In addition, the department director
issued a memorandum in July 2002, requiring that any labor agreements
having a fiscal impact on either local operations or the department’s budget
must have the prior approval of the budget management branch.

Request additional funding to mitigate the
effect of increased sick leave usage in future
fiscal years.

FULLY
IMPLEMENTED

For fiscal year 2004-05, the department reports that it received approval for
$99.5 million and 1,238.8 positions to address insufficient funding for relief
coverage for absences caused by training, bereavement leave, military leave,
jury duty, the Family Medical Leave Act, and the Family-School Partnership
Act.

Provide institutions with adequate resources
before initiating policy changes, such as
designating an institution for dialysis
treatment.

FULLY

The department notes that its existing policies prohibit implementation of any
new program before appropriate funding is secured. In the specific case of
hemodialysis, the department reports that it has budgeted, funded, and
constructed an on-site hemodialysis unit at the California Substance Abuse
Treatment Facility and State Prison at Corcoran, which is pending activation,
The unit will involve a contract with a private vendor to operate dialysis
chairs.

OFFICE OF THE INSPECTOR GENERAL

IMPLEMENTED

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2006 ACCOUNTABILITY AUDIT

Assist the institution in improving the control
and monitoring of pharmaceuticals.

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

FULLY
IMPLEMENTED

The department reported that its Division of Correctional Health Care
Services has provided the following services to institutions to assist in
managing pharmacy and pharmaceutical operations:
Management Systems
• Imposed a quality management structure to facilitate continuous
improvement, information management and analysis, and corrective
action. The quality management structure involves institutional and
departmental pharmacy improvement teams, pharmacy and
therapeutics subcommittees, quality management committees,
governing bodies, and associated reporting systems.

•

Developed a process to monitor the utilization and costs of certain
drug categories that produces both institution-specific and aggregate
management reports. The reports were disseminated for use in the
quality management process, with quarterly reports, including an
executive summary and analysis available.

•

Procured the Health Care Management System to replace the
outdated Pharmacy Prescription Tracking System. The Health Care
Management System was piloted at the California Medical Facility in
September 2004 with statewide implementation anticipated to occur
over the next two to three years. The system includes a
comprehensive modern pharmacy prescription information
management capability and is designed to assist institutions with
tracking and managing pharmacy operations more easily and rapidly.
The department will provide field training to staff at its institutions as
the system is implemented statewide over the next two to three years.

Contract and Formulary Management
• Developed and distributed formularies and updates to guide
appropriate drug purchases and prescriptions. Non-formulary drug
requests are reviewed for appropriateness and policy compliance by
the institution; and in certain cases, department management. The
Division of Correctional Health Care Services generates, reviews, and

OFFICE OF THE INSPECTOR GENERAL

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2006 ACCOUNTABILITY AUDIT

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

distributes a monthly formulary compliance report through the quality
management process.

•

Developed and distributed monthly contract compliance reports that
facilitate cost-effective purchasing by identifying non-contract
purchases that are generally more expensive than items purchased
through a contract. The Division of Correctional Health Care Services
produces and analyzes these reports and provides them to the
institutions through the quality management process.

•

Developed and distributed periodic discount and rebate reports to
ensure that institutions are taking advantage of available
pharmaceutical discounts and rebates. The Division of Correctional
Health Care Services provides information regarding available
discounts and rebates and advises institution on corrective measures
as necessary through informational e-mail bulletins and the quality
management process.

Medication Utilization and Disease Management
• Developed and implemented the Hepatitis C Virus Clinical
Management Program to assist the institution in improving control
and monitoring of related antiviral drug costs. The program includes a
utilization management database to assist with monitoring hepatitis-C
treatment and tracking.

•

Developed protocols and provided training to appropriate health care
staff in March 2004 on the utilization and management of the five
high-volume/high-cost drug categories that are responsible for more
than 50 percent of the department’s pharmaceutical expenses.

Pharmacy Operations and Medication Management
• Developed and completed the first turn-rate report in 2003 to
determine how frequently pharmacies replace their stock, with a high
turn-rate generally reflective of efficient inventory management. The
department requested that institution pharmacies measure turn rates

OFFICE OF THE INSPECTOR GENERAL

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2006 ACCOUNTABILITY AUDIT

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

while the department conducts annual turn-rate reviews.

•

Facilitated inventory management training for pharmacy field staff in
August and September of 2004, and scheduled annual inventories of
institution pharmacies.

•

Implemented comprehensive transfer and medication management
policies in 2003 that improved continuity of care and reduced waste.

According to the department, as a result of the initiatives noted above, the rate
of increase in the department’s pharmaceutical expenditures slowed to six
percent during fiscal year 2003-04 from a 17.7 percent average over the
previous three years. The department interprets this declining trend as a “cost
avoidance” in excess of $14 million, noting that it is 50 percent less than the
industry standard rate of increase of 12 percent.1 The Office of the Inspector
General did not audit these figures, but, if they are accurate, recognizes them
as a commendable trend. The Office of the Inspector General believes the
department can achieve further savings if it fully implements past
recommendations to replace outdated information technology systems that
lack the capacity to control costs and manage waste.
1

The 12 percent industry standard rate is stated in Hoffman, Nilay, et al. “Projecting Future Drug
Expenditures-2004.” American Journal of Health-System Pharmacy (2004): 61:145-157.

FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 6
The Office of the Inspector General found that a significant percentage of employees and managers of the Substance Abuse
Treatment Facility and State Prison at Corcoran were not fulfilling annual training requirements.
1

OFFICE OF THE INSPECTOR GENERAL

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2006 ACCOUNTABILITY AUDIT

ORIGINAL RECOMMENDATIONS

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

STATUS

COMMENTS

The Office of the Inspector General
recommended that the management of the
California Substance Abuse Treatment Facility
and State Prison at Corcoran take the actions
listed below to ensure that employees receive
required training.
The in-service training unit should periodically
review each employee’s training records to
ensure that all employees meet departmental
training requirements and should notify
appropriate supervisors of instances of noncompliance. For those employees consistently
not attending “7k” training, the in-service
training unit should determine the cause of the
employee’s inability to attend and make
training schedule adjustments if necessary.
As a part of the annual performance evaluation
process, supervisors should work with
employees to include specific plans to meet
training requirements for the following year.
Develop a systematic means of acquiring the
training records of newly arrived employees
from the sending institution or agency.

OFFICE OF THE INSPECTOR GENERAL

FULLY
IMPLEMENTED

The Office of the Inspector General confirmed a statement from the institution
that a block training program was implemented for all department employees in
September 2004, with training months designated for every employee two
months before the employee’s birth month. A 40-hour block of required and sitespecific training is offered weekly during that month. In addition, employees
receive a 12-hour self-study packet, which they are required to complete to
supplement the 40 hours of block training. The in-service training unit
automatically provides each employee with a training audit during the
employee’s birth month, and the personnel department sends the audit results to
the employee’s supervisor for evaluation and follow up.

NOT
APPLICABLE

Under the annual block training process, it is no longer necessary for supervisors
to meet with employees to plan training. Each employee’s training evaluation is
provided to the employee’s supervisor upon completion of training.

FULLY

According to the institution, the in-service training unit and the personnel office
implemented a process in August 2003 in which a listing of all new employees is
sent to the in service training office weekly to assist in tracking and obtaining
new employees’ training files.

IMPLEMENTED

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2006 ACCOUNTABILITY AUDIT

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 7
The Office of the Inspector General found that the Investigative Services Unit was not following proper procedures for the
temporary storage of evidence.

ORIGINAL RECOMMENDATIONS

STATUS

COMMENTS

The Office of the Inspector General
recommended that the management of the
California Substance Abuse Treatment Facility
and State Prison at Corcoran take the actions
listed below to improve the integrity of
temporary evidence storage at the institution.
Re-locate the sub-evidence area to a separate
room, unexposed to extraneous pedestrian
traffic. All persons entering the room should
be required to sign the logbook documenting
the date, time, and purpose of their visit. The
storage refrigerator should be fitted with a lock
if it cannot be moved to a secured and locked
room.
Replace the current loose-leaf evidence log
with hardbound logbooks with pre-numbered
pages. The logbook for urinalysis samples
should be separate from the logbook used for

OFFICE OF THE INSPECTOR GENERAL

FULLY
IMPLEMENTED

FULLY
IMPLEMENTED

The Office of the Inspector General verified that the sub-evidence lockers and
the refrigerator have been relocated to the central services building. Anyone
entering the room is required to sign the logbook documenting the date, time,
and purpose of the visit.

The Office of the Inspector General noted during a follow-up tour that the
logbooks are now manufactured by the investigative services unit staff using a
durable plastic spiral binding, with sequentially-numbered pages, allowing for
individual books unique to an incident number. Separate urinalysis logbooks are

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2006 ACCOUNTABILITY AUDIT

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

other evidence. Information recorded in the
logs should include date and time of access,
the badge number (or other identification),
name of the person submitting the evidence,
the subject’s name and identifying number, a
description of the evidence, and the locker
number in which it is stored. When an
evidence officer retrieves the evidence, the log
entry should include the date and time
evidence was removed from the sub-evidence
locker, the name of the evidence officer, and
the final disposition of the evidence.

being used and information recorded in the logs includes date and time of access,
the badge number (or other identification) and name of the person submitting the
evidence, the subject’s name and identifying number, a description of the
evidence, and the locker number in which it is stored. When an evidence officer
retrieves the evidence, the log entry includes the date and time evidence was
removed from the sub-evidence locker, the name of the evidence officer, and the
final disposition of the evidence.

FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 8
The Office of the Inspector General found that the institution was not properly documenting inmate activity in the
administrative segregation units.

ORIGINAL RECOMMENDATION

STATUS

COMMENTS

The Office of the Inspector General
recommended that the management of the
California Substance Abuse Treatment Facility
and State Prison at Corcoran require the
administrative segregation unit staff to take the
actions listed below to comply with
regulations and policies governing inmate
activity in the administrative segregation unit.

OFFICE OF THE INSPECTOR GENERAL

PAGE 47

2006 ACCOUNTABILITY AUDIT

Record inmate movements and other activities
in the CDC-114 as they occur, rather than
waiting for the first watch administrative
segregation floor officer to update the log.

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

NOT
IMPLEMENTED

The institution reported that training has been provided to all staff in the
administrative segregation units and that all unusual incidents and inmate
movements are documented contemporaneously on the inmate’s individual
CDC- 114D, as well as in the administrative segregation isolation log . In
discussing the matter with institutional management, however, the Office of the
Inspector General learned that supervisors responsible for implementing the
original recommendation misinterpreted it, believing that the recommendation
focused on the CDC-Form 114A, which is the record of activity for an individual
inmate (used for recording such events as feeding, showers, and medical
treatment). Accordingly, the institution’s training was directed toward improving
records in the individual inmate files rather than toward the isolation log (Form
CDC-Form 114).

NOT
IMPLEMENTED

Institution management acknowledged that inmate movement is not consistently
being recorded in the isolation log as it occurs and that this will become a subject
of training.

.

Record unusual incidents and other noteworthy
conditions in the CDC-114 instead of
exclusively in the sergeant’s log.

FOLLOW-UP RECOMMENDATIONS
The Office of the Inspector General recommends that the California Substance Abuse Treatment Facility and State Prison at
Corcoran record inmate movement in the administrative segregation isolation log (CDC-Form 114) as it occurs and that this
document also be used to record unusual incidents and other noteworthy conditions.
ORIGINAL FINDING NUMBER 9
The Office of the Inspector General found that the institution had not consistently followed required state hiring procedures.

OFFICE OF THE INSPECTOR GENERAL

PAGE 48

2006 ACCOUNTABILITY AUDIT

ORIGINAL RECOMMENDATIONS

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

STATUS

COMMENTS

The Office of the Inspector General
recommended that the institution management
take the actions listed below to improve
employee hiring.
In consultation with the department’s Office of
Personnel Management, develop a policies and
procedures manual for the hiring process. The
manual should incorporate the applicable
provisions of the California Department of
Corrections Operations Manual, department
policy memoranda, and state laws and
regulations.

FULLY
IMPLEMENTED

The institution reports that it has in place a recruitment and hiring process that
will ensure that all State Personnel Board rules and regulations are observed. The
Office of the Inspector General examined records at the institution and noted
evidence of improved compliance with each of the elements discussed below.

Advertise all vacancies for at least 14 days in
accordance with the Department Operations
Manual and other department policy
memoranda.

FULLY
IMPLEMENTED

The institution advised the Office of the Inspector General that all vacancies are
advertised for the required 14 days and that the advertisement bulletin is
maintained as part of the recruitment file.

Provide training to appropriate managerial
personnel on the hiring process and on the
responsibilities and duties of interview panel
members.

FULLY
IMPLEMENTED

According to the institution, an orientation is provided to panel members and the
panelists’ acknowledgment forms are maintained in the recruitment file.

For each examination, have all members of
interview panels document the candidates’
interview performance and rate each candidate
using a pre-determined scoring system and a
standardized scoring sheet.

FULLY
IMPLEMENTED

According to the institution, a standardized rating format is used for all
interviews, and the ratings are reflected on the interview questions sheet.

OFFICE OF THE INSPECTOR GENERAL

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2006 ACCOUNTABILITY AUDIT

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

Use interview panels consisting of at least
three members whenever possible.

FULLY
IMPLEMENTED

The institution reported that interview panels consist of at least three members
approved by the staff services manager I when feasible, and a note is made to the
file if there is a deviation from this requirement.

Interview a minimum of three candidates for
each vacancy whenever possible.

FULLY
IMPLEMENTED

According to the institution all interviews consist of at least three candidates
unless fewer than three candidates respond to the notice.

Have the warden date all documents at the
time of signature.
In addition, the Office of the Inspector General
recommended that the Department of
Corrections conduct periodic reviews of
institution hiring policies and procedures to
ensure they are used consistently.

FULLY
IMPLEMENTED

FULLY
IMPLEMENTED

The institution reports that the warden’s executive assistant and the staff services
manager I confirm that documents are dated when the signature is obtained.
The department reported that the institution’s delegated testing office conducts
monitoring reviews of all interview packets for evidence that all requirements of
the hiring process are met.

FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 10
The Office of the Inspector General found while institution employees generally regarded the warden’s communication and
management skills to be satisfactory, some described his management style as “reactive,” and said that he does not
communicate adequately with managers and line staff.

OFFICE OF THE INSPECTOR GENERAL

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2006 ACCOUNTABILITY AUDIT

ORIGINAL RECOMMENDATIONS

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

STATUS

COMMENTS

To improve communication among the
warden, his executive staff, employees, and
inmates, the Office of the Inspector General
recommended that the warden take the actions
listed below.
Conduct regularly scheduled staff meetings
with employees, permitting them to identify
and define important issues.

Within the framework of institution security
and existing policy, respond promptly to as
many employee and inmate concerns as
practicable. When the warden’s commitment
to an action is made, ensure that a “tickler
system” is used to monitor implementation of
the commitment.
Form a committee of representatives from
various employee areas (administration,
custody, facilities, programming, etc.) to
provide a forum for identifying factors relating
to employee morale, recommending solutions,
and monitoring the effectiveness of the
solutions implemented.
Conduct regular walking tours of the
institution, visiting all work sites to talk with

OFFICE OF THE INSPECTOR GENERAL

FULLY
IMPLEMENTED

According to the institution, the warden hosts informal open forums scheduled
at various times throughout the day to allow all interested staff members an
opportunity to attend and ask questions or voice concerns. In addition, the
institution reports that monthly meetings are scheduled with collective
bargaining unit representatives to address issues and concerns.

FULLY

According to the institution, all assignments are currently tracked by an office
technician, and pending issues are continuously monitored for follow-up, with
the office technician generating weekly due lists and overdue reports for use by
the warden during morning briefings. The warden’s administrative assistant
tracks issues resulting from inmate council meetings.

IMPLEMENTED

FULLY
IMPLEMENTED

FULLY
IMPLEMENTED

The institution reported that several committees comprised of managerial staff,
union representatives, and non-custody personnel are in place to address
employee concerns. According to the institution, the warden has an “open door”
policy, allowing an employee to communicate concerns directly to the warden
after exhausting remedies available through the appropriate chain-of-command.

According to the institution, the warden or chief deputy wardens conduct
weekly tours as time and schedules permit.

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2006 ACCOUNTABILITY AUDIT

CALIFORNIA SUBSTANCE ABUSE TREATMENT FACILITY AND STATE PRISON AT CORCORAN

employees about the institution’s mission and
to receive feedback directly from employees
responsible for carrying out that mission.
Meet with the inmate advisory councils at least
once a month.

FULLY
IMPLEMENTED

The institution reports that the associate wardens meet with the inmate advisory
councils monthly, while the warden meets with the councils quarterly. Issues
raised during these meetings are followed-up through the appropriate facility
captain. The warden’s administrative assistant routinely monitors unresolved
issues.

Arrange with facility captains to provide the
inmate advisory councils access to dedicated
office space and the necessary office
equipment and supplies to conduct approved
council activities and business.

SUBSTANTIALLY
IMPLEMENTED

The institution reported that although there is no permanent workspace
dedicated exclusively for the purpose, office space, supplies. and equipment are
provided to the inmate advisory councils as available.

Have an appropriate staff person appointed as
the institution’s inmate advisory council
coordinator.

FULLY
IMPLEMENTED

In addition, the Office of the Inspector General
recommended that the warden take the actions
listed below.

According to the institution the associate warden of each complex has been
designated to serve as the inmate advisory council coordinator.

FOLLOW-UP RECOMMENDATIONS
None.

OFFICE OF THE INSPECTOR GENERAL

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2006 ACCOUNTABILITY AUDIT

PHARMACEUTICAL EXPENDITURES

PHARMACEUTICAL EXPENDITURES
IMPLEMENTATION REPORT CARD

The Office of the Inspector General found that the
Department of Corrections and Rehabilitation has
made some progress in reducing its pharmaceutical
expenditures. The department, however, has
accomplished only the preliminary steps required
to replace its outdated management information
system.

Previous recommendations: 7
Fully implemented: 0 (0%)
Substantially implemented: 1 (14%)
Partially implemented: 2 (29%)
Not implemented: 3 (43%)

Not applicable: 1 (14%)
In July 2003, the Office of the Inspector General
conducted a survey to examine the department’s
pharmaceutical expenditure trends over the four
preceding fiscal years to analyze practices contributing to those trends and to evaluate the
department’s efforts to implement changes recommended by previous audits and studies.

The survey revealed that despite a two percent decrease in inmate population between
fiscal years 1999-2000 and 2002-03, the department’s pharmaceutical expenditures
increased 94 percent, from $63 million in 1999-00 to $122.4 million in 2002-03. During
the same period, the national consumer price index for pharmaceutical drugs increased
only 22 percent. The Office of the Inspector General found that the department’s
pharmaceutical expenditures were also significantly higher than those of two comparably
sized prison systems—the U.S. Bureau of Prisons and the Texas state prison system—and
had increased at a much faster rate.
Problems contributing to the department’s high pharmaceutical expenditures had been
well-documented in four comprehensive audits and studies conducted by the Bureau of
State Audits, by the California State Senate Advisory Commission on Cost Control in
State Government, and by a private consulting firm, FOX Systems, Inc., under a contract
with the department. All of these audits and studies identified similar problems in the
department’s pharmacy program and included specific recommendations to remedy the
deficiencies. Particularly critical was the indicated need for the department to replace its
Pharmacy Prescription Tracking System, a badly outdated 20-year-old information
system without the capacity to perform essential functions to control costs and prevent
pharmaceutical waste, fraud, and abuse.
Although the Legislature mandated in July 2001 that the department implement the
recommendations contained in the 117-page FOX Systems, Inc. report, the Office of the
Inspector General found that, as of July 2003, the department had made only minimal
progress in carrying out the implementation.
The Office of the Inspector General recommended that the department act promptly to
implement the recommendations of previous audits and studies of its pharmacy program
and, if it appeared that the department would be unable to carry out the implementation
on its own, that it consider contracting with a private vendor to institute the necessary
improvements.
OFFICE OF THE INSPECTOR GENERAL

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2006 ACCOUNTABILITY AUDIT

PHARMACEUTICAL EXPENDITURES

BACKGROUND
The California Department of Corrections and Rehabilitation is required to provide health
care services, including pharmaceutical services, to inmates incarcerated in state
correctional institutions. Each institution operates its own pharmacy under the direction
of the department’s Division of Correctional Health Care Services (formerly the Health
Care Services Division), which is responsible for administering health care services to
inmates. Until January 2003, however, when the division hired three pharmacy service
managers, no individual at the department level was assigned to actively manage the
pharmacy program. As a result, pharmacy operations at the institutions lacked
standardization because purchasing, dispensing, and administrative processes varied
significantly. Each institution also maintained an independent pharmacy database using
the Pharmacy Prescription Tracking System, a severely outdated information system with
limited capabilities.
In February 2006, the U.S. District Court for the Northern District of California
appointed a receiver over the department’s health care operations in connection with a
class action suit, Plata v. Schwarzenegger. Under the terms of the court’s action, the
receiver has broad powers of “administration, control, management, operation, and
financing” over all aspects of the department’s health care system, including the power to
acquire and modernize information technology.
SUMMARY OF PREVIOUS FINDINGS AND RECOMMENDATIONS
The Office of the Inspector General’s survey indicated that, although the department
could have reduced its annual pharmaceutical expenditures by up to $26 million by
implementing such management controls as those recommended in the four previous
audits and studies, it had, in fact, made only minimal progress in implementing the
recommendations.
As a result, despite a decrease in inmate population during the period covered by the
Office of the Inspector General’s survey, the department’s pharmaceutical expenditures
continued to grow dramatically. Between fiscal years 1999-2000 and 2002-03, the
department’s pharmaceutical expenditures increased 94 percent, from $63 million to
$122.4 million, while inmate population declined two percent, from 162,000 to 159,000,
and the national consumer price index for prescription drugs increased only 22 percent.1
Similarly, between fiscal years 1996-97 and 1998-99, pharmaceutical expenditures
increased from $24 million to $51 million — an annual growth rate of 28 percent —
while the inmate population grew by about six percent and the cost of prescription drugs
increased only 13 percent. The department’s per-inmate pharmaceutical expenditures also
increased, more than quadrupling from $142 in 1997 to $642 in 2002.

1

At the time of the July 2003 survey, the department’s pharmaceutical expenditures were projected to increase 111
percent between 1999-2000 and 2002-03.
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The Office of the Inspector General issued seven recommendations to the department in
its July 2003 survey addressing these and other findings.
OBJECTIVES, SCOPE, AND METHODOLOGY
The purpose of the 2006 follow-up review was to determine the extent to which the
Department of Corrections and Rehabilitation, through its Division of Correctional
Health Care Services, has implemented the seven recommendations from the Office of
the Inspector General’s July 2003 survey of pharmaceutical expenses. To conduct the
follow-up review, the Office of the Inspector General provided the department and the
Division of Correctional Health Care Services with a table listing the July 2003 findings
and recommendations and asked management to provide the implementation status of
each recommendation. The Office of the Inspector General reviewed the department’s
responses, along with documentation provided by the department, and evaluated the
degree of compliance or noncompliance with the recommendations. The results are
presented in the tables following this narrative and reflect the department’s responses as
of September 2005, when the Office of the Inspector General completed its fieldwork.
SUMMARY OF THE 2006 FOLLOW-UP RESULTS
Of the seven recommendations issued by the Office of the Inspector General in July 2003
concerning the department’s pharmaceutical expenditures, one recommendation has been
substantially implemented; two recommendations have been partially implemented; three
recommendations have not been implemented; and one is no longer applicable.
The Department of Corrections and Rehabilitation reported it has developed a strategic
plan that incorporates recommendations from private consulting, regulatory, and
oversight agencies. The department also reported that it has revised its statewide
procedures for medication administration and distribution; trained personnel on
formulary rules; and organized management workgroups. The department rejected
recommendations to contract with a private firm to manage pharmacy operations and
centralize its pharmacy distribution system.
Although the department reported it has made progress in launching a project to replace
its outdated and inefficient pharmacy management system with an automated health care
management system, statewide implementation of that system has not been
accomplished. The department reported, however, that it achieved a “cost avoidance” of
$14.3 million between projected pharmaceutical expenditures for fiscal year 2003-04
($144 million) and actual expenditures for that period. The department’s actual
pharmaceutical expenditures for fiscal year 2003-04 were $129.7 million — a $7.3
million (6 percent) increase over the previous year, compared to an 18 percent average
increase experienced in the three preceding fiscal years. Yet, Bureau of Labor Statistics
data show that between July 2003 and June 2004, pharmaceutical prices nationwide
increased only 3.3 percent.
Until the department implements past recommendations in this area, it continues to waste
millions of dollars annually in pharmaceutical expenditures. Because of these problems,
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in March 2006, the U. S. District Court ordered a comprehensive financial and
operational audit of the department’s pharmaceutical services, to be conducted by a
private specialty firm with expertise in correctional pharmaceutical operations. In
addition, the U. S. District Court-appointed receiver scheduled to take over all aspects of
the department’s health care system on April 17, 2006, will have authority to acquire and
modernize information technology.
FOLLOW-UP RECOMMENDATIONS
The Office of the Inspector General recommends that the Department of
Corrections and Rehabilitation take the following actions:
•

Continue the project to replace the outdated and inefficient Pharmacy
Prescription Tracking System with the automated Health Care
Management System and implement the new system statewide as soon
as practicable.

•

In light of the flexible options likely to be available under the
February 2006 federal court order appointing a receiver over the
department’s medical health care delivery system, reconsider the
option of contracting with a private pharmacy services management
firm to implement the recommendations submitted in the reports and
studies conducted since 2000.

The following table summarizes the results of the follow-up review.

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ORIGINAL OBSERVATION NUMBER 1
The Office of the Inspector General found that the Department of Corrections has failed to implement recommendations from
four recent audits and studies at a cost of millions in potential pharmaceutical expenditure savings.

ORIGINAL OBSERVATION NUMBER 2
The Office of the Inspector General estimates that the Department of Corrections could reduce its annual pharmaceutical
costs by at least 20 percent—saving upwards of $26 million a year—by implementing effective management controls such as
those recommended in recent audits and studies.

ORIGINAL RECOMMENDATION

STATUS

COMMENTS

The Office of the Inspector General
recommended that the Department of
Corrections begin immediate
implementation of the recommendations
made by FOX Systems, Inc. To accomplish
the implementation, the department was to
select one of the following two options.
Option 1
Direct the Health Care Services Division to
begin implementing the FOX Systems, Inc.
recommendations.

SUBSTANTIALLY
IMPLEMENTED

The California Department of Corrections and Rehabilitation reported that it has
developed a strategic plan incorporating audit recommendations advocated by the
Bureau of State Audits, the Senate Advisory Commission on Cost Control in State
Government, FOX Systems Inc., and recent legislative mandates to improve
pharmacy management. The department reported that it had completed the
following FOX Systems, Inc. recommendations:
•

OFFICE OF THE INSPECTOR GENERAL

Appointed three pharmacy services managers.

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•

Reorganized the Division of Correctional Health Care Services.

•

Revised and distributed the department’s formulary.

•

Established pharmacy and therapeutics subcommittees.

•

Participates in the inter-agency Common Drug Formulary Committee and
Pharmacy Advisory Board.

•

Secured a rebate for a high-cost atypical antipsychotic medication.

•

Implemented a tier structure for atypical antipsychotic medications.

•

Implemented a Hepatitis C Clinical Management Program.

•

Revised and distributed medication management and intra-system
medication transfer policies.

•

Completed e-mail and Internet connectivity in all pharmacies.

•

Completed local area network and wide-area network connectivity in all
institution administration buildings.

•

Acquired the Veterans Affairs Information System and Technology
Architecture (VISTA) system from the U. S. Department of Veterans
Affairs to improve pharmacy and clinical management operations.
Designated as the Health Care Management System, it will be integrated
with the Clinical Management System (a system developed by staff at the
California Medical Facility) and the Parole Division’s Transitional Case
Management Program-Mentally Ill (TCMP-MI) to provide
comprehensive pharmaceutical information management and ancillary
functions.

•

Initiated implementation of the Health Care Management System by
linking the Division of Correctional Health Care Services and all

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institutional pharmacies, including those at Division of Juvenile Justice
facilities, through a central file server.
Reduce the fiscal year 2003-04 budget of
the Health Care Services Division by an
amount equal to 20 percent of its annual
pharmaceutical expenses.

NOT
IMPLEMENTED

The department reported that it did not reduce the Division of Correctional Health
Care Services budget by an amount equal to 20 percent of its annual
pharmaceutical expenses because the reduction could not be achieved without
jeopardizing statutory- and court-mandated inmate health care services. The
department reported, however, that it had completed several initiatives to
accomplish the Office of the Inspector General’s recommendation. According to
the department, these achievements include over $14 million in “pharmaceutical
cost avoidance” for fiscal year 2003-04.
The department reported that its pharmaceutical expenditures exhibited significant
cost avoidance between fiscal years 2002-03 and 2003-04. Total expenditures
reportedly increased by only six percent, considerably less than both the 17.7
percent average increases over the three previous years and the industry standard
increase of 12 percent. As a result, the department maintains that it has avoided
over $14 million in pharmaceutical expenses by slowing the rate of increase from
17.7 percent to six percent.
Moreover, despite court-mandated levels of patient care, a high concentration of
such diseases as the hepatitis C virus, and mental illnesses that require expensive
treatments, the department asserted that this cost avoidance trend will continue to
be evidenced through the following managed care initiatives: monitoring, review,
and quality management of the drug formulary; prescription protocols for highvolume/high-cost pharmaceuticals; utilization management reporting; health
transfer processes; chronic care programs; and compliance auditing.

Reallocate a sufficient portion of the
budgetary reduction to pay for specific
information technology improvements.

OFFICE OF THE INSPECTOR GENERAL

NOT
IMPLEMENTED

The department reported that its pharmacy program’s budget was reduced by $8
million in fiscal year 2002-03 and by a subsequent $4.8 million in fiscal year
2003-2004 because of negative-impact budget change proposals directed at
reducing pharmaceutical expenditures through more efficient prescription
procedures.
The department reported that it is currently requesting funding to implement the
two-phase pilot of the Health Care Management System. The department acquired

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the program technology at no cost from the U.S. Department of Veteran’s Affairs
and will allocate the funding to staff time, system consultants, program
adaptation, and hardware. The department reported that it is also requesting
funding to complete statewide implementation of the Health Care Management
System.
Provide appropriate support to the Health
Care Services Division to expedite the
required technology procurement.

PARTIALLY
IMPLEMENTED

The department reported that it continues to pursue a modern information
technology infrastructure for its pharmacy operations and that it is aggressively
implementing the Health Care Management System — which combines integral
elements of existing software applications obtained from the U.S. Department of
Veteran’s Affairs, the California Medical Facility, and the Parole and Community
Services Division — to meet the department’s needs in a cost-effective manner.
The department reported that it had launched the Health Care Management
System at the California Medical Facility and that it intends to complete statewide
system implementation.
The department also reported that, to meet pressing needs within the budgetary
constraints, the Division of Correctional Health Care Services has proactively
developed several interim data applications, completed e-mail and Internet
connectivity for all institutional pharmacies, and linked all 33 institutions on a
wide area network or local area network in May 2004. Although the interim data
applications enable tracking, monitoring, and reporting of medication errors; of
physician prescribing practices; and of targeted high-cost and high-risk drugs, the
applications are presently dependent on data that emanates from the problematic
Pharmacy Prescription Tracking System, which the new Health Care Management
System is designed to replace.
The department reported that it will achieve central file server connectivity
between prison pharmacies and the Division of Correctional Health Care Services
with implementation of the Health Care Management System.

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Ensure that the Health Care Services
Division establishes specific goals and
objectives to implement the FOX Systems,
Inc. recommendations, and that the Health
Care Services Division management
adequately monitors the implementation.

PHARMACEUTICAL EXPENDITURES

PARTIALLY
IMPLEMENTED

The department reported that it has improved overall pharmacy management by
using a matrix management structure to implement its strategic plan. The plan’s
purpose is to enhance operations through more effective and efficient
pharmaceutical procurement and delivery. The department reported that it has
used a systematic approach to achieve the following five goals:
1. Secure a fully integrated medication management information system.
2. Improve pharmacy operations by instituting centralized pharmacy
management and maintaining a community standard.
3. Improve negotiated discounts for high-cost, high-volume pharmaceuticals.
4. Optimize prescribing targeted high-cost medications.
5. Reduce medication waste through improved distribution and inventory
controls.
The department reported that it has implemented several mechanisms to monitor
overall initiative progress, including a project management matrix, management
reports to track drug utilization, and contract and inventory management.

Option 2 (preferred)
Contract with a private pharmacy services
management firm to implement the FOX
Systems, Inc. recommendations. The
contractor would perform the following
functions:
•

Assume management of the day-today operations of the Health Care
Services Division pharmacy
operations.

NOT
APPLICABLE2

The department reported that it reviewed this option and determined that the most
effective course of action was to permit the Division of Correctional Health Care
Services to implement a managed care model, drug use controls, and a quality
management structure to replicate the recommendations of FOX Systems, Inc.

2

Because the Division of Correctional Health Care Services elected to implement Option 1, the Office of the Inspector General has listed this recommendation as
“Not Applicable.” As noted in the follow-up recommendations, however, the Office of the Inspector General recommends that the Division of Correctional
Health Care Services reconsider implementing Option 2.
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•

Assume responsibility for promptly
implementing the information
technology improvements
recommended by FOX Systems,
Inc.

•

Begin the business process reengineering activities recommended
by FOX Systems, Inc.

Regardless of the option chosen, the
department should also change the
pharmacy program structure from a
decentralized system with pharmacies in
each prison to a system with two or three
regional pharmacies or one large central
pharmacy, consistent with the model used in
other states. That change would provide the
following benefits:
•

Allow more efficient operations,
using automated dispensing
machines.

•

Reduce inventory shrinkage and
spoilage.

•

Increase standardization of
operations and prescribing
practices.

•

Reduce the impact of staff turnover
and vacancies in hard-to-recruit
pharmacist positions located in

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PHARMACEUTICAL EXPENDITURES

According to the department, three Division of Correctional Health Care Services
pharmacy services managers, supported by the quality management structure,
control day-to-day pharmacy operations. A multidisciplinary Pharmacy Focus
Improvement Team provides issue-targeted analysis and planning, concurrent
with multidisciplinary and administrative review from the Pharmacy and
Therapeutics Subcommittee. A parallel quality management structure exists at
each correctional institution.

NOT
IMPLEMENTED

The department reported that it had reviewed options that included mail-order
pharmacy services and regional pharmacies serving several prisons. The
department maintained that it had found these options impractical, given the
remote locations of some institutions and the specific pharmacy service
requirements set by the state Department of Health Services for licensed health
care facilities within most corrections institutions. The department reported,
however, that it was still reviewing other alternatives.
The department reported that it has made progress through other methods and
cited as an example its participation since April 2003 in activities of the
Pharmaceutical Prime Vendor Technology Committee, a subcommittee of the
California Pharmacy Advisory Board, through which it has worked with the
Department of General Services to improve prime vendor contract specifications,
mail-order prescription services, automated dispensing systems, and operations
consolidation.
The department reported that it installed an automated dispensing system in one
of its prisons in October 2000 to increase efficiency and reduce waste. The
department has determined that automated dispensing systems should be tailored
to the needs of individual institutions and to permissible medication packaging for
the inmate populations served.
The department reported that it had implemented a second automated dispensing
system in 2002 in another institution to evaluate the project’s effectiveness.

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remote geographic areas.
•

Reduce prescription errors.

The department reported that it had distributed a revised statewide pharmacy
services policy and procedures for medication administration and distribution,
prescribing practices, intra-system transfers, and inventory control in August
2003.
The department reported that it had also developed a lesson plan and audit tool in
May 2004 to train pharmacy staff in pharmacy operations.
The department reported that it has developed formulary and drug use guidelines,
forms, and protocols and has:
Implemented an ongoing training program for the updated formulary and
formulary compliance in April 2003.
Provided policy training on videoconference pharmacy services to field
medical staff in February 2004.
Developed a lesson plan and audit tool to train pharmacy staff in
pharmacy operations in May 2004.
The department reported that, in November 2003, it had implemented the
Hepatitis C Clinical Management Program, which standardizes hepatitis C virus
(HCV) medication management through a court-approved protocol to ensure
effective and efficient application of costly HCV drug therapies. By using a
scientifically based, data-driven approach to identify those individuals likely to
benefit from testing and treatment, the department maintains that it has reduced
the margin for unnecessary and potentially dangerous therapies, while at the same
time providing quality care where such testing and treatment are appropriate.
The department reported that it initiated a pharmacist recruitment mailer program
in February 2003, prepared a salary adjustment package for the appropriate
control agencies in February 2004, and continues to actively recruit to fill fulltime pharmacy positions.

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The department reported that it began implementation of its Department of Health
Services-approved medication error reduction plan on July 17, 2003 to comply
with California Health and Safety Code section 1339.63, which mandates
medication error reduction plans at general acute care hospitals. The plan includes
processes for collecting and reviewing data on medication errors and corrective
actions to eliminate or substantially reduce medication errors.
In addition, the department has reported implementation of the new clinical
management software at the California Medical Facility. This Clinical
Management System enables physicians to write orders on-line, monitors
appropriate dosage rates, and averts duplicate therapies and potential drug
reactions—resulting in more efficient patient care and fewer prescription errors. It
will eventually be used by correctional institutions statewide.

FOLLOW-UP RECOMMENDATIONS
The Office of the Inspector General recommends that the Department of Corrections and Rehabilitation take the following
actions:
•

Continue the project to replace the outdated and inefficient Pharmacy Prescription Tracking System with the automated
Health Care Management System and implement the new system statewide as soon as practicable.

•

In light of the flexible options likely to be available under the February 2006 federal court order appointing a receiver over
the department’s medical health care delivery system, reconsider the option of contracting with a private pharmacy
services management firm to implement the recommendations submitted in the reports and studies conducted since 2000.

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OFFICE OF INVESTIGATIVE SERVICES

OFFICE OF INVESTIGATIVE SERVICES

IMPLEMENTATION REPORT CARD

Previous recommendations: 37
The Department of Corrections and Rehabilitation
has reorganized and significantly improved its
Fully implemented: 19 (52%)
internal affairs operation since an October 2001
special review. The Office of Investigative
Substantially implemented: 2 (5%)
Services—renamed the Office of Internal
Partially implemented: 8 (22%)
Affairs1—is now responsible for all of the
department’s internal affairs investigative
Not implemented: 6 (16%)
functions. Many of the Office of the Inspector
Not applicable: 2 (5%)
General’s previous recommendations were
implemented in the course of the reorganization
and as a result of a federal court-ordered remedial
plan. Other recommendations are no longer applicable in the wake of these changes.
Yet, several deficiencies identified in the Office of the Inspector General’s 2001
review remain. These include a lack of a system for prioritizing investigations;
inadequate management of overtime use; inadequacies in completing background
investigations of employees and borrowed investigators; inadequate control over
access to the case management information system; deficiencies in evidence
handling; and failure to use the department’s internal audits function to help
identify pervasive problems.

In October 2001 the Office of the Inspector General issued a special review of the
management practices and administrative operations of the Office of Investigative
Services. At the time of the special review, the Office of Investigative Services was
responsible for investigating allegations of serious employee misconduct only within the
Department of Corrections. Since renamed the Office of Internal Affairs, the office is
now responsible for conducting employee misconduct investigations for all entities
within the new Department of Corrections and Rehabilitation. The October 2001 review,
which centered on the effectiveness of the office, compliance with required procedures,
and the quality of operational practices, identified numerous deficiencies that impaired
the ability of the Office of Investigative Services to meet its responsibilities. In particular,
the review found that a rapidly expanding caseload and deficient management practices
prevented the Office of Investigative Services from completing investigations within
required time limits. That deficiency limited the ability of the department to take
appropriate administrative action when misconduct allegations were sustained. The
Office of the Inspector General noted that some of the issues raised in the review were
beyond the control of the Office of Investigative Services and required action by the
Department of Corrections management.

1

Depending on the context and time-frame discussed, both names — Office of Investigative Services and Office of
Internal Affairs — are used in this report.

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BACKGROUND
The Office of Investigative Services was established in July 1997 by the California
Department of Corrections for the purpose of investigating allegations of serious
employee misconduct within the department. Until that time, local hiring authorities —
prisons and parole regions — conducted most internal investigations. That arrangement
raised questions from the Legislature and the public about the appropriateness of hiring
authorities investigating their own employees. The Office of Investigative Services was
therefore created to fulfill the following responsibilities:
•

Perform fair and impartial investigations;

•

Ensure the consistent application of policies and procedures throughout the
Department of Corrections;

•

Provide highly trained staff with specialized skills to perform administrative and
criminal investigations, particularly those related to incidents involving the use of
force, officer-involved shootings, and sexual assaults; and

•

Provide oversight for investigations of less serious misconduct performed by the
institutions.

With the July 2005 reorganization of the former Youth and Adult Correctional Agency
into the newly created Department of Corrections and Rehabilitation, the Office of
Investigative Services was renamed the Office of Internal Affairs and assigned
responsibility for internal affairs investigative functions for all organizations inside the
new department. Additional organizational and operational changes have resulted in the
implementation of some of the Office of the Inspector General’s October 2001
recommendations, or have altered operations so significantly that other recommendations
are no longer applicable. The department has made additional changes under a remedial
plan developed to address deficiencies in the employee disciplinary process identified by
a U. S. District Court special master in connection with the Madrid v. Schwarzenegger
case. The Madrid Remedial Plan presently forms the basis for significant changes
affecting employee discipline in the Department of Corrections and Rehabilitation.
SUMMARY OF PREVIOUS FINDINGS AND RECOMMENDATIONS
The Office of the Inspector General made the following specific findings as a result of
the October 2001 special review:

• The Office of Investigative Services could not effectively manage its caseload with its
existing staffing levels without significant changes to its management practices.

• The management information system for the Office of Investigative Services was
inaccurate and unreliable and did not contain information needed for the agency to
effectively manage its resources and caseload.
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• The Office of Investigative Services lacked adequate controls to prevent overtime
abuse.

• Background checks of Office of Investigative Services agents were inadequate
because of a departmentally imposed 11-hour limit on conducting background
investigations.

• The Office of Investigative Services did not conduct background checks of staff
borrowed to conduct internal affairs investigations.

• The Office of Investigative Services did not have a formalized plan for training
special agents.

• The Office of Investigative Services case tracking system did not have adequate
controls to prevent unauthorized access.

• The Office of Investigative Services investigations lacked sufficient documentation to
show that investigations were conducted in accordance with established guidelines.

• The Office of Investigative Services did not have procedures to ensure that the
regional offices processed Category II case rejections consistently and properly.

• The Office of Investigative Services was not adequately fulfilling its responsibility
for overseeing Category I investigations.

• Procedures used by the Office of Investigative Services for handling evidence did not
comply with regulatory requirements or the agency’s own guidelines.

• The Office of Investigative Services was not in compliance with prescribed armory
policies and procedures.
The Office of the Inspector General presented 37 recommendations to remedy the
deficiencies identified in the October 2001 special review.
OBJECTIVES, SCOPE, AND METHODOLOGY
The purpose of the 2006 follow-up review was to determine the extent to which the
Office of Internal Affairs has implemented the 37 recommendations from the Office of
the Inspector General’s October 2001 special review. To conduct the follow-up review,
the Office of the Inspector General provided the Office of Internal Affairs with a table
listing the October 2001 findings and recommendations and requested the
implementation status of each recommendation. The Office of the Inspector General
reviewed the responses, along with documentation provided by the Office of Internal
Affairs, and evaluated the degree of compliance or noncompliance with the
recommendations. Fieldwork for the follow-up review concluded in March 2006. The
results are presented in the tables following this narrative.
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SUMMARY OF THE 2006 FOLLOW-UP RESULTS
Of the 37 recommendations issued by the Office of the Inspector General in October
2001, 19 recommendations have been fully implemented; two have been substantially
implemented; eight have been partially implemented; six have not been implemented;
and two recommendations are no longer applicable.
The Office of the Inspector General found that the Office of Internal Affairs has
significantly improved its investigative process. No longer are requests for investigations
considered at each regional office; instead, nearly all requests are forwarded to a central
intake panel for review. Before creation of the central intake panel, each of the Office of
Internal Affairs regions decided which cases were accepted and which were rejected.
Establishment of the central intake panel brings consistency to the decision. In another
improvement, the investigative classification system, which formerly designated minor
offenses as Category I investigations and allegations of serious offenses as Category II
investigations, has been eliminated. Instead, cases involving minor supervisory issues
requiring no additional investigation are addressed directly by the hiring authorities,
while those that require investigation are conducted or closely supervised by the Office of
Internal Affairs. In addition, the former case management information system has been
replaced by a new system that provides not only for the tracking and monitoring of active
cases, but also for tracking the entire employee discipline continuum from the request for
investigation to the final hearing and disposition of action. The system is being installed
at California Department of Corrections and Rehabilitation investigative offices, legal
offices, and hiring authorities throughout the state.
Despite these important improvements, several deficiencies identified in the Office of the
Inspector General’s October 2001 special review remain. The deficiencies include the
lack of a system for prioritizing investigations, inadequate management of overtime use;
inadequacies in completing employee background investigations and background
investigations of borrowed investigators; inadequate control over access to the case
management information system; inadequate documentation of supervisory review of
investigations; failure to ensure that case rejection letters are issued in a timely manner;
deficiencies in policies and procedures for the handling of evidence; physical deficiencies
in the evidence room; and failure to use the department’s internal audits function to assist
in identifying systemic and pervasive problems and in focusing resources accordingly.
FOLLOW-UP RECOMMENDATIONS
The Office of the Inspector General recommends that the Office of Internal
Affairs take the following additional actions:
•

Develop policies and procedures for prioritizing investigative cases.

•

Assign each region a monthly allocation of budgeted overtime and
prepare a monthly log for each regional office that begins with
monthly allotted hours and is adjusted for each usage. When overtime

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is granted, the supervisor should immediately e-mail the agent and the
overtime timekeeper for the purpose of adjusting monthly balances
and providing evidence of previous overtime approval. In order to
provide regional supervisors flexibility in managing cases, the Office
of Internal Affairs should consider rolling over unused office balances
from one month to the next.
•

Reevaluate whether the proposed budget increase to 40 hours per
background investigation for potential employees of the Office of
Internal Affairs is justified, given that investigators are obtaining 75
percent of the required information using only 11 hours per
investigation.

•

Ensure that background investigation files contain evidence that
potential employees of the Office of Internal Affairs have not been the
subject of past or pending adverse actions, as mandated by California
Penal Code sections 6065(b)(1) and 6126.2.

•

Refrain from using investigative services unit investigators until their
supplemental background investigations are complete.

•

Formalize the process for verifying that case management
information system access is limited to only authorized users. The
process should define the frequency of reviews, require a
reconciliation of beginning and ending authorized users for the
period, and specify the date when users are added or deleted.
Included in this process should be a requirement that an exit
document be prepared by the departing staff’s supervisor that
instructs the information technology staff to remove the user’s access.

•

Prepare a supervisory quality control review sheet that ensures that
the investigative package is complete, the investigative plan was
followed, all key witnesses were interviewed, required notices were
performed, and the final report represents a clear, fair, and unbiased
representation of the facts.

•

Establish procedures to ensure that case rejection letters are issued
within the prescribed 10-day time-frame.

•

Use the Department of Corrections and Rehabilitation internal audit
staff to perform field audits to identify trends in complaints against
staff so that resources can be focused on the most pervasive problems.

•

Install a dedicated alarm system for the southern regional office
evidence room.

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The Office of the Inspector General also recommends that the California
Department of Corrections and Rehabilitation standardize evidence
policy and procedures throughout the department and include the
standards in the Office of Internal Affairs’ Investigation Policy and
Procedures Manual, and train staff to ensure that the policies and
procedures are properly implemented and followed.
The following table summarizes the results of the follow-up review.

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ORIGINAL FINDING NUMBER 1
The Office of the Inspector General found that the Office of Investigative Services could not effectively manage its caseload
with its existing staffing levels without significant changes in its management practices.
ORIGINAL RECOMMENDATIONS

STATUS

COMMENTS

In order for the agency/department to take
appropriate administrative action when
allegations are sustained and effectively fulfill
its responsibilities, the Office of the Inspector
General recommended that the California
Department of Corrections and the Office of
Investigative Services take the actions listed
below.
Address the present inability of the Office of
Investigative Services to fulfill its
responsibilities. As part of this effort, reassess
the mission and responsibilities of the Office
of Investigative Services and, from that
reassessment, allocate sufficient resources to
the Office of Investigative Services to allow it
to meet its mandate.

FULLY
IMPLEMENTED

The Office of Internal Affairs reported that it has undergone several changes in
leadership since the October 2001 special review and that the employee
disciplinary process has been the focus of legislative hearings, audits by external
parties, recommendations by the California Independent Review Panel, and
scrutiny by the U. S. District Court special master. To respond to the deficiencies
reported by these entities, the department was required by the federal court to
develop a corrective action plan, known as the “Madrid Remedial Plan” to rectify
problems in the department’s disciplinary continuum – including the
investigative process. The Office of the Inspector General’s recommendation to
reassess the mission and responsibilities of the Office of Internal Affairs is
incorporated in the Madrid Remedial Plan. Many of the Madrid Remedial Plan
objectives provide for the reassessment of the roles and responsibilities of the
Office of Internal Affairs and for specific processes by which to meet those
objectives.
To fulfill its revised mission, the Office of Internal Affairs hired seven additional
special agents, two information technology employees, and two office
technicians. It also reported that a budget change proposal was submitted for
fiscal year 2006-07 to align staffing levels with proposed structural and
functional changes resulting from the California Department of Corrections and
Rehabilitation’s reorganization plan and consolidation of investigative functions.

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The Office of the Inspector General reviewed the remedial plan and concluded
that the department has initiated a significant reassessment of the Office of
Internal Affairs.
Review the Office of Investigative Services’
organizational structure and administrative
processes to ensure standardization in the
operation of the regional offices. As a part of
the process, develop a formalized system for
prioritizing cases.

SUBSTANTIALLY
IMPLEMENTED

The Office of Internal Affairs reported that it has established a central intake
process that alleviates the former disparities among accepted and rejected cases
when the regional offices acted autonomously in vetting investigation requests.
The new system also ensures consistency in the type and severity of allegations
accepted for investigation and ensures the sufficiency of the evidence used to
determine whether or not to proceed.
The Office of Internal Affairs also reported that its new case management system
promotes case prioritization by including a classification field that identifies a
case as “high” or “normal” priority. The case management system also allows
case activity to be monitored by Office of Internal Affairs administrators in
headquarters and identifies specific categories of cases for monitoring.
Implementation of the new case management system also contributes to the
standardization of operations throughout the regional offices.
The Office of the Inspector General noted that while the new case management
system allows for case prioritization, and the central intake process has improved
the organizational structure, the Office of Internal Affairs has not developed
policies and procedures to provide for consistency in the prioritization process.

FOLLOW-UP RECOMMENDATION
The Office of the Inspector General recommends that the Office of Internal Affairs develop policies and procedures for
prioritizing investigative cases.
ORIGINAL FINDING NUMBER 2
The Office of the Inspector General found that the management information system of the Office of Investigative Services was
inaccurate and unreliable and did not contain the information needed for the agency to effectively manage its resources and
caseload.

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ORIGINAL RECOMMENDATION
In order to ensure that the system fully meets
management information needs and
department requirements, the Office of the
Inspector General recommended that the
Office of Investigative Services, in concert
with the Information Systems Division, review
and modify the case-tracking system. The
recommendation specified that if system
modification was not feasible, the Office of
Investigative Services should replace the
system.

OFFICE OF INVESTIGATIVE SERVICES

STATUS
FULLY
IMPLEMENTED

COMMENTS
The Office of Internal Affairs reported and the Office of the Inspector General
verified that, as of July 2004, the Office of Internal Affairs had implemented a
new case management system in each of its regional offices, headquarters, and
various institutions. Implementation of the case management system will provide
needed information for all stakeholders in the employee disciplinary process to
facilitate tracking of cases from start to finish.

FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 3
The Office of the Inspector General found that the Office of Investigative Services lacked adequate controls to prevent
overtime abuse.
ORIGINAL RECOMMENDATION

STATUS

COMMENTS

In order to prevent overtime abuse, the Office
of the Inspector General recommended that the
Office of Investigative Services implement
appropriate control measures governing
overtime payments. The process should
require prior authorization of overtime,
supervisor approval before payment, and
management oversight through review of
payment trends and patterns. Management
should also investigate discrepancies and take
appropriate action to rectify problems.

PARTIALLY

According to the Office of Internal Affairs, overtime is approved by supervisors
in the regional offices. The Office of the Inspector General confirmed that these
approvals are largely in place, but the approvals are granted and documented
after the overtime is incurred. The Office of the Inspector General also observed
a variety of processes for authorizing overtime at the various regional offices.
For example, one regional office used standard state overtime authorization
forms and maintained the highest level of compliance of all regions — 43
percent. Another regional office, where none of the overtime hours met the
“prior authorization standard,” used the employee timesheet for overtime
authorization.

IMPLEMENTED

Oversight monitoring at regional offices also varied. One regional office

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prepared a monthly tracking schedule that allocated 100 hours of overtime for
the entire office, with the 100 hours based upon earlier budget-based overtime
estimates. The tracking log was adjusted for overtime incurred and provided a
method for monitoring overtime on a daily basis. No other regional office used
such a tool.
In lieu of individual regional offices reporting monthly overtime, the budget
officer monitors monthly overtime reports prepared by the California Department
of Corrections and Rehabilitation personnel office. Any unusual trends or usages
are reported to Office of Internal Affairs management. This provides for
centralized oversight of overtime usage.

FOLLOW-UP RECOMMENDATIONS
The Office of the Inspector General recommends that the Office of Internal Affairs assign each region a monthly allocation of
budgeted overtime and prepare a monthly log for each regional office that begins with monthly allotted hours and is adjusted
for each usage. When overtime is granted, the supervisor should immediately e-mail the agent and the overtime timekeeper
for the purpose of adjusting monthly balances and providing evidence of previous overtime approval. In order to provide
regional supervisors flexibility in managing cases, the Office of Internal Affairs should consider rolling over unused office
balances from one month to the next.
ORIGINAL FINDING NUMBER 4
The Office of the Inspector General found that background checks of Office of Investigative Services agents were inadequate
because of a departmentally imposed 11-hour limit on conducting background investigations.

ORIGINAL RECOMMENDATIONS

STATUS

COMMENTS

In order to improve the quality of the
background checks, the Office of the Inspector
General recommended that the California
Department of Corrections take the actions
listed below.

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Remove the 11-hour limit on performing
background investigations.

OFFICE OF INVESTIGATIVE SERVICES

NOT
IMPLEMENTED

According to the Office of Internal Affairs, the Department of Corrections and
Rehabilitation is considering preparing a budget change proposal to increase the
background investigation time-frame to 40 hours for all peace officer staff; but
no increase in the allotted time for background checks has been implemented.
The Office of the Inspector General’s testing of background investigations
concluded that 75 percent of the required investigation elements were fulfilled
within the 11-hour budget. Consequently, the Office of Internal Affairs should
be able to conduct complete and thorough background investigations with
budgets of between 11 and 40 hours per candidate.

Require background investigations to be
conducted in accordance with Commission on
Peace Officer Standards and Training
guidelines.

SUBSTANTIALLY
IMPLEMENTED

The Office of Internal Affairs reported that to the extent possible within the 11
hour limit, the background investigations are conducted in accordance with the
guidelines set by the Commission on Peace Officer Standards and Training. If
funding for this activity is provided in the future, the department will be able to
spend 40 hours for each background investigation, increasing compliance with
the guidelines.
The Office of the Inspector General reviewed the six most recent background
investigations for Office of Internal Affairs hires and found deficiencies similar
to those reported in the 2001 special review. The investigations reviewed still
failed to include credit checks and face-to-face contacts with personal
references, neighbors, or landlords. Despite those deficiencies, however, two
background investigations contained 95 percent of the investigative elements
required by the Commission on Peace Officer Standards and Training
guidelines. The six background investigations collectively contained 75 percent
of the applicable elements from the Commission on Peace Officer Standards
and Training guidelines. Improvements were noted in preparation of
background reports and evidence of medical and psychological examinations.

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Require background investigation files to
contain evidence to verify that candidates have
not been the subject of past or pending serious
adverse actions as mandated by California
Penal Code sections 6065(b)(1) and 6126.2.

OFFICE OF INVESTIGATIVE SERVICES
PARTIALLY
IMPLEMENTED

Review by the Office of the Inspector General of hiring packages for six recent
special agent hires determined that four files did not contain evidence of testing
for compliance with California Penal Code section 6126.2 and that three files
lacked evidence of testing for compliance with California Penal Code section
6065(a)(1). California Penal Code section 6126.2 prohibits the hiring of any
internal affairs investigator candidate who is indirectly or directly involved in
an open internal affairs investigation, and California Penal Code section 6065
(a) (1) prohibits the hiring of an internal affairs investigator candidate who has
ever had allegations sustained pertaining to a serious disciplinary action.

FOLLOW-UP RECOMMENDATIONS
The Office of the Inspector General recommends that the Office of Internal Affairs take the following additional actions:
•

Reevaluate whether the proposed budget increase to 40 hours per background investigation for potential employees of
the Office of Internal Affairs is justified, given that investigators are obtaining 75 percent of the required information
using only 11 hours per investigation.

•

Ensure that background investigation files contain evidence that potential employees of the Office of Internal Affairs
have not been the subject of past or pending adverse actions, as mandated by California Penal Code sections 6065(b)(1)
and 6126.2.

ORIGINAL FINDING NUMBER 5
The Office of the Inspector General found that the Office of Investigative Services did not conduct background checks of staff
borrowed to conduct internal affairs investigations.

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ORIGINAL RECOMMENDATION
To comply with statutory requirements and
improve the integrity of investigations, the
Office of the Inspector General recommended
that the California Department of Corrections
conduct background checks on employees
borrowed to conduct internal affairs
investigations. The recommendation noted that
because of the time and cost associated with
background investigations, the Office of
Investigative Services could identify a pool of
employees borrowed for internal affairs
investigations and perform background checks
for those employees.

OFFICE OF INVESTIGATIVE SERVICES

STATUS
NOT
IMPLEMENTED

COMMENTS
In July 2005, the Office of Internal Affairs reported that the recommendation is
no longer applicable because it no longer uses borrowed staff to perform
internal affairs investigations.
The Office of the Inspector General determined, however, that in September
2005, the Office of Internal Affairs began delegating case assignments to prison
investigative services units. Of 10 investigative services unit investigators
reviewed by the Office of the Inspector General, none had had a supplemental
background investigation completed, although nine were reportedly in the
process of receiving such an investigation.

FOLLOW-UP RECOMMENDATION
The Office of the Inspector General recommends that the Office of Internal Affairs refrain from using investigative services
unit investigators until their supplemental background investigations are complete.
ORIGINAL FINDING NUMBER 6
The Office of the Inspector General found that the Office of Investigative Services did not have a formalized plan for training
special agents or sufficient means to monitor and track the training progress of special agents to ensure compliance with
prescribed training policies.
ORIGINAL RECOMMENDATIONS

STATUS

COMMENTS

In order to improve the training program for
Office of Investigative Services special agents
and ensure compliance with prescribed training
policies, the Office of the Inspector General
recommended that the California Department
of Corrections and the Office of Investigative
Services take the actions listed below.

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Allow the Office of Investigative Services to
develop and manage its own training budget.

OFFICE OF INVESTIGATIVE SERVICES
FULLY
IMPLEMENTED

According to the California Department of Corrections and Rehabilitation, the
Office of Internal Affairs now has its own training budget. The Budget
Management Branch reported that the training budget for the Office of Internal
Affairs in fiscal year 2005-06 totaled $84,573.
The Office of the Inspector General confirmed that the Office of Internal Affairs
now maintains it own training budget.

Allow Office of Investigative Services staff
members to comply with the 40-hour training
requirement on a calendar year or fiscal year
basis instead of basing compliance on each
staff member’s performance appraisal period.

NOT
APPLICABLE

The Office of Internal Affairs reported that although it may seem easier to track
employee training on a calendar year basis, the California Department of
Corrections and Rehabilitation Operations Manual requires that training plans
be created and updated during an employee’s annual appraisal period, which
coincides with the employee’s birthday. The Office of Internal Affairs reported
that further discussion is planned to determine whether the policy should be
changed or an exception provided for Office of Internal Affairs employees.
Upon further review, the Office of the Inspector General concluded that the
training review cycle based on the employee’s birth date is adequate.

Establish minimum training requirements for
each job classification to ensure that
employees possess the minimum skills needed
to perform assigned duties and to ensure
comparability in the proficiency of staff
members among various offices.

FULLY
IMPLEMENTED

The Office of Internal Affairs issued a memorandum in November 2001 that
outlines the recommended training requirements for sworn and non-sworn staff
and prescribes the frequencies with which courses must be repeated. The Office
of Internal Affairs management also developed a training program in
accordance with the Madrid Remedial Plan.
The Office of the Inspector General reviewed the draft training plan submitted
to the federal court in October 2005 and noted that it provides detailed training
requirements by classification, time-frames for completion of training, and an
organizational structure to monitor and direct training requirements.

Prepare an annual training plan that identifies
and summarizes training needs by employee,
office, and topical area.

IMPLEMENTED

Establish a separate training database for
Office of Investigative Services staff members

FULLY
IMPLEMENTED

OFFICE OF THE INSPECTOR GENERAL

FULLY

As part of the Madrid Remedial Plan, the Office of Internal Affairs has
completed a training assessment to align its training with the "industry
standard." The training plan was completed and submitted to the federal court in
October 2005.
According to the Office of Internal Affairs, each regional office implemented a
staff training database in January 2002. The Office of the Inspector General

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and maintain the training database at the Office
of Investigative Services headquarters.

confirmed that each regional office maintains a training database and that these
databases can be merged at Office of Internal Affairs headquarters as needed.
In accordance with the proposed training plan, the Office of Internal Affairs will
select a training advisory committee, a training manager, and regional training
coordinators. The regional coordinators maintain training records and are
responsible for ensuring that training mandates are fulfilled at the local level.
Each year regional coordinators will prepare a training needs assessment for
development of the annual training plan.

FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 7
The Office of the Inspector General found that the internal affairs case tracking system did not have adequate controls to
prevent unauthorized access.
ORIGINAL RECOMMENDATIONS

STATUS

COMMENTS

In order to reduce the inherent risk associated
with unauthorized access and improve controls
over access to the internal affairs case tracking
system, the Office of the Inspector General
recommended that the California Department
of Corrections and the Office of Investigative
Services take the actions listed below.
Purge log-on identifications for employees no
longer working for the Office of Investigative
Services or not otherwise required to have
access to the office network and systems.
Once the system is purged of unauthorized logon identifications, the office should formalize a
process for purging log-on identifications as

OFFICE OF THE INSPECTOR GENERAL

PARTIALLY
IMPLEMENTED

According to the Office of Internal Affairs, log-on identifications were purged
in response to the Office of the Inspector General’s report. The Office of
Internal Affairs also reported that when employees leave the Office of Internal
Affairs, their network accounts are deleted. Yet the Office of Internal Affairs
does not have a formalized process for the elimination of unauthorized users. In
particular, there is no checkout process to eliminate system user identifications
when an employee departs the Office of Internal Affairs. Instead the network

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administrators access the user list as part of their daily activities, and in so
doing, according to the Office of Internal Affairs, would recognize the name of
an unauthorized user. The process assumes that the system administrator is
immediately aware of any employees, including regional staff, who leave Office
of Internal Affairs. It was the failure to remove former staff members from user
lists that resulted in the initial finding and recommendation. Because the process
is not formalized, the potential for failures continues.

part of the standard separation process when
employees leave.

Require the Office of Investigative Services
system administrator to meet monthly or
quarterly with the network manager from the
Information Services Division to reconcile the
list of authorized users maintained by the
Information Services Division to the list of
authorized users maintained by the Office of
Investigative Services.

PARTIALLY
IMPLEMENTED

While the case information system has changed since the 2001
recommendation, the need for reconciliation of authorized users still exists. The
Office of Internal Affairs reported in July 2004 that the system administrator
was working with the network management team for the Information Systems
Division to develop a quarterly reconciliation process for all authorized users.
The first reconciliation was anticipated to be complete by September 30, 2004.
The Office of Internal Affairs reported, however, that the Information Services
Division had not prepared a listing of authorized users by July 2004 and that,
consequently, the Office of Internal Affairs had not completed a user
reconciliation. In January 2006, the Office of Internal Affairs claimed that
audits of users accessing their domain, servers, and computers were conducted
several times a month. A log of monthly reconciliations provided by the Office
of Internal Affairs dated back to September 2005. The Office of the Inspector
General learned, however, that staff from the Department of Corrections and
Rehabilitation’s Information Services Division monitors user accounts that have
no activity and coordinate with the Office of Internal Affairs only when unusual
activity is observed.
In summary, the Office of Internal Affairs took no action to implement the
Office of the Inspector General’s recommendation to conduct access
reconciliations until four years had passed. Furthermore, the Office of Internal
Affairs still has no formal policy specifying frequency, procedures, or reporting
to keep unauthorized users from accessing confidential information assets.

Require separate passwords for the network
and the case tracking system.

OFFICE OF THE INSPECTOR GENERAL

FULLY
IMPLEMENTED

Since the October 2001 special review, the Office of Internal Affairs has
undergone numerous changes and revisions to its case management systems and

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in security measures to protect information assets. Initially the Office of Internal
Affairs disagreed with the recommendation, stating that Microsoft did not
recommend dual passwords (one for the network and another for the case
management system) for its Windows authentication software. As technology,
computer security software and the complexity of the case management system
evolved, however, the Office of Internal Affairs chose to abandon Microsoft
Windows authentication software for SQL authentication software. With the
deployment of SQL authentication software, the dual password format is now in
place.
Establish expiration dates for both network and
case tracking system passwords.
Retain at least a 30-day history of user access
to the system.

FULLY
IMPLEMENTED
FULLY
IMPLEMENTED

According to the Office of Internal Affairs, its network now requires staff to
change computer passwords on a quarterly basis.
With the implementation of the new case management system, the Office of
Investigative Service now has the capability of permanently tracking and
archiving all users who access the system.

FOLLOW-UP RECOMMENDATIONS
The Office of the Inspector General recommends that the Office of Internal Affairs formalize the process for verifying that
case management information system access is limited to only authorized users. The process should define the frequency of
reviews, require a reconciliation of beginning and ending authorized users for the period, and specify the date when users are
added or deleted. Included in this process should be a requirement that an exit document be prepared by the departing staff’s
supervisor that instructs the information technology staff to remove the user’s access.

ORIGINAL FINDING NUMBER 8
The Office of the Inspector General found that a significant number of investigation files lack sufficient documentation to
show that the investigation was conducted in accordance with established guidelines.
ORIGINAL RECOMMENDATION

STATUS

In order to ensure uniformity in the
maintenance and documentation of

PARTIALLY
IMPLEMENTED

OFFICE OF THE INSPECTOR GENERAL

COMMENTS
The Office of Internal Affairs reported it did not conclude that a checklist is the
best method to ensure that investigations are conducted in accordance with

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investigative case files, the Office of the
Inspector General recommended that the
Office of Investigative Services establish a
managerial review checklist. The
recommendation specified that the checklist
should be signed and dated by the senior
special agent responsible for reviewing the
case files.

established guidelines and instead will develop a policy and procedure manual
and an investigator’s manual and review adherence to these standard practices.
The Office of the Inspector General disagrees with that position. While a policy
and procedure manual and supervisory review are important, a methodical and
carefully prepared quality control guide for case file reviews would provide a
helpful tool for the reviewer, thus ensuring a level of consistency among all
investigation files. Further, a checklist would create a record that the case file
was reviewed for key attributes required by the policy and procedure manual.
A review by the Office of the Inspector General of case files in the Office of
Internal Affairs southern region office determined that a checklist is being used
in that office. The checklist delineates standard investigative documents with a
date completed and a line for agent initials.

FOLLOW-UP RECOMMENDATION
The Office of the Inspector General recommends that the Office of Internal Affairs prepare a supervisory quality control
review sheet that ensures that the investigative package is complete, the investigative plan was followed, all witnesses were
interviewed, required notices were performed, and the final report represents a clear, fair, and unbiased representation of the
facts.

ORIGINAL FINDING NUMBER 9
The Office of the Inspector General found that the Office of Investigative Services did not have procedures in place to ensure
that the regional offices process Category II case rejections consistently and properly.
ORIGINAL RECOMMENDATIONS

STATUS

COMMENTS

In order to ensure consistency in accepting and
rejecting Category II cases and to improve the
processing of Category II investigation
requests, the Office of the Inspector General
recommended that the California Department
of Corrections and the Office of Investigative
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Services take the actions listed below.
Amend the California Department of
Corrections Operations Manual to provide for
centralized review and acceptance or rejection
of investigation requests.
Adopt a policy and procedures for assigning
priority for case acceptance or rejection.

Provide refresher training for special agents incharge and senior special agents on the
definitions of Category I and Category II
misconduct.

Establish procedures to ensure that case
rejection letters are issued within the
prescribed 10-day timeframe.

FULLY
IMPLEMENTED

PARTIALLY
IMPLEMENTED

The Department of Corrections and Rehabilitation has instituted a central intake
process in which all requests for investigations are directed to the Office of
Internal Affairs headquarters and presented before a panel of agents, attorneys,
management representatives, and the Office of the Inspector General’s Bureau
of Independent Review.
The new case management system does provide for identifying cases as
“normal” or “high” priority once the case is accepted by central intake. The
criteria for determining priority include whether a subject is on administrative
time off, the subject is high profile, or the statute completion time-frame is
short. The case management system allows monitoring of high priority cases
through specialized management reports. The Office of the Inspector General
notes, however, that while the Office of Internal Affairs has developed a case
management system that allows for prioritizing cases, it has not developed
policies and procedures to provide for consistency in the prioritization process.

NOT
APPLICABLE

The Office of Internal Affairs has eliminated the Category I and Category II
case distinctions. Consequently, the recommendation no longer is relevant. All
requests for investigations are handled through the central intake process, which
provides a thorough assessment of the allegations and specific violations of
policy or law. Because the process eliminated the subjectivity of Category I and
II determination, the need for definition training is no longer applicable.

NOT
IMPLEMENTED

According to the Office of Internal Affair, no procedures have been
implemented that would ensure compliance with the California Department of
Corrections and Rehabilitation Operations Manual required 10-day time-frame.
Rather, the Office of Internal Affairs will consider adding audit procedures to
periodically monitor compliance.
The Office of the Inspector General conducted a test of the turn-around timeframes for 36 rejection letter and found that 47 percent of the responses did not
meet the 10-day criterion. The late rejection letters averaged 19 days between
receipt and response.

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2006 ACCOUNTABILITY AUDIT

Implement a review process providing for
independent review of the rejection letters to
ensure that the letters adequately explain why
the case was rejected.

OFFICE OF INVESTIGATIVE SERVICES

FULLY
IMPLEMENTED

The Office of the Inspector General reviewed nine rejection memoranda and
found they were thorough in presenting specific details about the reasons the
case was rejected. Rejection letters are now prepared by the central intake unit
— a change that contributes to a more consistent level of detail in the rejection
letters.

FOLLOW-UP RECOMMENDATION
The Office of the Inspector General recommends that the Office of Internal Affairs establish procedures to ensure that case
rejection letters are issued within the prescribed 10-day time-frame.
ORIGINAL FINDING NUMBER 10
The Office of the Inspector General found that the Office of Investigative Services was not adequately fulfilling its
responsibility for overseeing Category I investigations.
ORIGINAL RECOMMENDATIONS

STATUS

COMMENTS

In order to effectively oversee Category I
investigations, the Office of the Inspector
General recommended that the Office of
Investigative Services take the actions listed
below.
Perform an analysis of the workload and
resources necessary to implement an effective
tracking system, perform data analysis, and
conduct audits of the Category I investigations.
The office should also develop a work plan to
identify the initial objectives and timelines for
implementing a legitimate oversight process.

OFFICE OF THE INSPECTOR GENERAL

FULLY
IMPLEMENTED

The Office of Internal Affairs no longer classifies investigations as Category I
and Category II. All requests for investigations are reviewed by a panel in the
central intake unit at the Office of Internal Affairs headquarters. Accepted
requests are assigned to an Office of Internal Affairs regional office. As with the
former Category I cases, the regional office can assign investigations to an
Office of Internal Affairs special agent or delegate them to an institution’s
investigative services unit. Cases assigned to the institution’s investigative
services unit are supervised by a senior special agent at the Office of Internal
Affairs and are monitored on the new case management system.

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The case management system also provides a periodic case aging report that
allows the senior special agent to monitor the age of a case. This feature
prevents cases from exceeding statutory completion time-frames without
sufficient warning to management.
If additional resources cannot be obtained, the
Office of Investigative Services should use the
information developed to determine the best
way to provide at least minimal oversight of
Category I investigations using existing
resources. Potential improvements include the
following:

FULLY
IMPLEMENTED

The Office of Internal Affairs has obtained additional manpower and electronic
data processing resources. The new case management system is a database
system that provides a single source for monitoring requests for investigations,
investigations, and employee disciplinary actions. The system incorporates
hiring authorities, employee relations officers, institutional investigative
services units, the Office of Internal Affairs, legal affairs staff, and the Office of
the Inspector General’s Bureau of Independent Review.

Develop an improved management
information system to track and monitor
investigations and identify trends so as to focus
resources on the most pervasive problems.

FULLY

The case management system classifies approximately 43 different types of
offenses for the purpose of stratifying and trending allegations. The system can
sort by allegation, providing such information as the case region, institution,
subject, statutory completion date, and case conclusion. As of February 2006,
all requests for investigation and all direct employee actions for the California
Department of Corrections and Rehabilitation are reviewed by the central intake
panel. These requests are posted into the case management system, which
provides a mechanism for monitoring the decisions to investigate allegations or
to proceed with direct corrective or adverse actions. All hiring authorities post
their activities to the case management system, which allows for proper
monitoring of employee actions imposed.

IMPLEMENTED

Centralize the oversight function and redirect
staff to perform oversight.

IMPLEMENTED

Perform reviews on a sample basis. Perform
both desk reviews and field reviews.

FULLY
IMPLEMENTED

Use Department of Corrections internal audit

NOT

OFFICE OF THE INSPECTOR GENERAL

FULLY

According to the Office of Internal Affairs, the case management system will be
expanded to all California Department of Corrections and Rehabilitation hiring
authorities to provide proper monitoring of investigations and employee
disciplinary processes.
The Office of Internal Affairs reported that it established an administrative
support unit to help monitor and track investigations and identify trends. The
administrative support unit will also develop a self-audit process and perform
reviews.
The Office of Internal Affairs reported that it will consider using the
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staff to perform field audits.

OFFICE OF INVESTIGATIVE SERVICES
IMPLEMENTED

department’s internal audit staff in conjunction with the reorganization
proposed by the Corrections Independent Review Panel to evaluate the merits of
this recommendation.

FOLLOW-UP RECOMMENDATION
The Office of the Inspector General recommends that the Office of Internal Affairs Use the Department of Corrections and
Rehabilitation internal audit staff to perform field audits to identify trends in complaints against staff so that resources can be
focused on the most pervasive problems.
ORIGINAL FINDING NUMBER 11
The Office of the Inspector General found that the procedures used by the Office of Investigative Services for handling
evidence did not comply with regulatory requirements or the agency’s own guidelines.
ORIGINAL RECOMMENDATIONS

STATUS

COMMENTS

In order to ensure compliance with regulatory
and agency requirements, the Office of the
Inspector General recommended that the
Office of Investigative Services, at a minimum
take the actions listed below.
Provide training to all staff on general
evidence-handling policies and procedures.

NOT
IMPLEMENTED

In response to this recommendation, the Office of Internal Affairs reported that
the evidence handling problem identified by the Office of the Inspector General
was isolated at one regional office and was rectified immediately. The Office of
Internal Affairs also reported that as part of the Madrid Remedial Plan, it would
rewrite the Policy and Procedures Manual and Investigator’s Guide (tasks 2.5.2
and 2.5.3), which will also clarify evidence handling policies and procedures.
A review by the Office of the Inspector General of the original policy and
procedures manual, however, failed to identify any reference to evidence
handling. Furthermore, the proposed training plan drafted for the U. S. District
Court failed to cite any courses specifically addressing evidence handling. A

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review of numerous staff in-service training reports from all regional offices
revealed that 24 special agents at one regional office received preservation of
evidence training consisting of a 30-minute in-house training session.
Provide specialized training for evidence
custodians and alternates.

NOT
IMPLEMENTED

The Office of the Inspector General reviewed the training records of the
evidence officers for the office referred to in the Office of Internal Affairs’
response, the southern regional office. While these special agents participated in
training for some general investigation topics, the Office of the Inspector
General could not locate training records that satisfy the recommendation for
specialized training for evidence custodians and alternates. Furthermore,
documents show that repeated requests for formal evidence handling training
dating back to 1999 have been denied.

Make physical modifications, as necessary, to
the regional evidence rooms to ensure that they
meet all requirements.

PARTIALLY
IMPLEMENTED

The Office of Internal Affairs stated that the evidence handling procedures were
isolated to one regional office and were rectified.
The Office of the Inspector General confirmed that, while some minor physical
modifications were made, the southern regional office has not installed an alarm
system dedicated to the evidence room.

Re-key evidence rooms to limit access to the
evidence custodian, the alternate, and the
regional special agent in-charge.

IMPLEMENTED

Use bound evidence logs that provide space for
all mandatory information.

FULLY
IMPLEMENTED

The Office of Internal Affairs reported, and the Office of the Inspector General
confirmed, that the deficiency reported existed in only one regional office and
was corrected at that location.

Perform periodic audits at each of the regions
to ensure compliance with policies and
procedures.

PARTIALLY
IMPLEMENTED

The Office of Internal Affairs had not conducted any internal audits at the time
the Office of the Inspector General conducted its fieldwork, but had assembled
a self-audit program. This recommendation has also been incorporated into the
federal court remedial plan.

OFFICE OF THE INSPECTOR GENERAL

FULLY

The Office of Internal Affairs reported, and the Office of the Inspector General
confirmed, that the deficiency reported existed in only one regional office and
was corrected at that location.

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OFFICE OF INVESTIGATIVE SERVICES

FOLLOW-UP RECOMMENDATIONS
The Office of the Inspector General recommends that the California Department of Corrections and Rehabilitation
standardize evidence policy and procedures throughout the department and include the standards in the Office of Internal
Affairs’ Investigation Policy and Procedures Manual, and train staff to ensure that the policies and procedures are properly
implemented and followed.
The Office of the Inspector General also recommends that the Office of Internal Affairs install a dedicated alarm system for
southern regional office evidence room.
ORIGINAL FINDING NUMBER 12
The Office of the Inspector General found that the Office of Investigative Services was not in compliance with prescribed
armory policies and procedures.
ORIGINAL RECOMMENDATION
In order to ensure compliance with armory
policies and procedures, the Office of the
Inspector General recommended that the
Office of Investigative Services review the
operations of the armories at all of its regional
offices and address all areas of noncompliance, including those related to physical
design, fire safety, and record maintenance and
retention.

STATUS
FULLY
IMPLEMENTED

COMMENTS
The Office of the Inspector General conducted a follow-up site review of the
regional office that was responsible for the October 2001 finding and found that
the areas of non-compliance previously identified have been corrected.

FOLLOW-UP RECOMMENDATIONS
None.

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EMPLOYEE DISCIPLINARY PROCESS
The Office of the Inspector General found that the
Department of Corrections and Rehabilitation has
improved its employee disciplinary process and has
fully or substantially implemented all previous
recommendations.

EMPLOYEE DISCIPLINARY PROCESS

IMPLEMENTATION REPORT CARD
Previous recommendations: 9
Fully implemented: 6 (67 %)
Substantially implemented: 3 (33%)
Partially implemented: 0 (0%)

In March 2002, the Office of the Inspector General
Not implemented: 0 (0%)
conducted a review of the Department of Corrections
employee disciplinary process. The purpose of the
Not applicable: 0 (0%)
review was to identify any administrative or procedural
weaknesses in the disciplinary process that might affect
the department’s ability to take appropriate adverse action against employees found to
have engaged in misconduct. The review found a number of systemic deficiencies in the
department’s disciplinary process that jeopardized the department’s ability to administer
appropriate adverse action against peace officers within the one-year statutory deadline.
BACKGROUND

The Department of Corrections and Rehabilitation employs a workforce of approximately
50,000 to fulfill its responsibility for more than 165,000 state prison inmates and 114,000
parolees. Ensuring appropriate conduct of employees and taking disciplinary action
against those found to have engaged in misconduct is one of the department’s essential
functions.
The department’s employee disciplinary process has been the subject of a lawsuit,
Madrid v. Woodford, and as a result, a special master appointed by the U. S. District
Court, Northern District of California has been monitoring efforts to reform the
disciplinary process through the Madrid Remedial Plan. Many of the plan’s provisions
are consistent with the Office of the Inspector General’s March 2002 recommendations.
SUMMARY OF PREVIOUS FINDINGS AND RECOMMENDATIONS
As a result of the March 2002 review, the Office of the Inspector General made the
following specific findings:
•

The needless complexity of the employee disciplinary process caused delays that
impaired the ability of the Department of Corrections to take appropriate action
against employees found to have engaged in misconduct.

•

Forty-three percent of a sample of investigations completed during fiscal years 19992000 and 2000-01 in which misconduct allegations were sustained were not
completed within one year and therefore did not result in disciplinary action.

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•

There were no clear guidelines for defining the prescribed one-year period for
investigating alleged misconduct and imposing disciplinary action against peace
officers or for identifying the required 30-day notification period.

•

Employee relations officers at institutions did not receive adequate training and often
lacked the experience necessary to properly handle employee disciplinary actions.

•

Most of the employee disciplinary actions proceeded all the way through settlement
and hearing before the State Personnel Board without advice or assistance from the
department’s legal staff.

•

There were no established policies or procedures governing settlement of employee
disciplinary actions and the department had no means of monitoring or evaluating the
settlement process.

The Office of the Inspector General issued nine recommendations as a result of the
March 2002 review.
OBJECTIVES, SCOPE, AND METHODOLOGY
The purpose of the 2006 follow-up review was to determine the extent to which the
California Department of Corrections has implemented the nine recommendations from
the Office of the Inspector General’s March 2002 review of the employee disciplinary
process. To conduct the follow-up review, the Office of the Inspector General provided
the Department of Corrections and Rehabilitation with a table listing the March 2002
findings and recommendations and asked the department to provide the implementation
status of each recommendation. The Office of the Inspector General reviewed the
responses, along with documentation provided by the department, and evaluated the
degree of compliance or noncompliance with the recommendations. Review fieldwork
was completed on January 30, 2006. The results are summarized in the table that follows
this section.
SUMMARY OF THE 2006 FOLLOW-UP RESULTS
Of the nine recommendations issued by the Office of the Inspector General in March
2002 concerning the employee disciplinary process, six recommendations have been fully
implemented and three have been substantially implemented.
The Office of the Inspector General found that the Department of Corrections and
Rehabilitation has significantly improved its administration of the employee disciplinary
process. The department has developed a case management system to monitor and track
disciplinary cases from start to finish to ensure that cases meet statutory deadlines. It has
also implemented a new central intake process that provides for representatives from the
Office of Internal Affairs, Office of Legal Affairs, and other department staff to review
requests for investigations and determine appropriate action. The Office of the Inspector
General’s Bureau of Independent Review monitors the central intake and internal affairs
process and also monitors the investigations. The department has also updated its policies
and procedures for employee discipline and has provided formal training to its employee
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relations officers statewide. As a result of these and other changes, only two percent of 94
investigations with sustained findings conducted by the Office of Internal Affairs in the
period December 1, 2004 through May 31, 2005 exceeded the one-year statutory limit.
The Office of the Inspector General makes no follow-up recommendations.

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ORIGINAL FINDING NUMBER 1
The Office of the Inspector General found that the needless complexity of the employee disciplinary process caused delays that
impaired the ability of the Department of Corrections to take appropriate action against employees found to have engaged in
misconduct.
ORIGINAL RECOMMENDATIONS
The Office of the Inspector General
recommended that the Department of
Corrections establish a centralized system to
monitor and track the status of employee
disciplinary cases. The Office of the Inspector
General recommended that the department
consider modifying either the personnel
operations information management system or
the Employment Law Unit information
management system to include this tracking
capability and that the system include an early
warning mechanism for cases in danger of
exceeding statutory time limits.

STATUS
SUBSTANTIALLY
IMPLEMENTED

COMMENTS
The California Department of Corrections and Rehabilitation has developed a
centralized case management system that monitors and tracks the status of
employee disciplinary cases. When the system is fully implemented, it will
incorporate information from the information management systems of both the
Employment Law Unit and department personnel operations. The system will
include an early warning mechanism for cases in danger of exceeding statutory
time limits.
Most of the department’s hiring authorities, including the Office of Internal
Affairs and the Employment Advocacy and Prosecution Team, now have access
to the case management system. Efforts to give all hiring authorities access are
continuing. Under the Madrid Remedial Plan, full rollout of the case
management system is scheduled for June 2006.
The Office of the Inspector General reviewed the timeliness of investigations
conducted by the Office of Internal Affairs for the period December 1, 2004
through May 31, 2005 and found that only two (2 percent) of the 94 sustained
cases reviewed exceeded the one-year statute, preventing the hiring authority
from taking disciplinary action against the employee. By comparison, the
original Office of the Inspector General review found 43 percent of the sustained
cases reviewed exceeded the one-year statute.

FOLLOW-UP RECOMMENDATIONS
None.

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ORIGINAL FINDING NUMBER 2
The Office of the Inspector General found that the California Department of Corrections had no clear guidelines for defining
the prescribed one-year period for investigating alleged misconduct and imposing disciplinary action against peace officers or
for identifying the required 30-day notification period.
ORIGINAL RECOMMENDATION
The Office of the Inspector General
recommended that the Department of
Corrections issue clear guidelines defining
what constitutes the date of discovery, who is
“authorized to initiate an investigation,” and
the date the department makes its decision to
impose discipline.

STATUS
SUBSTANTIALLY
IMPLEMENTED

COMMENTS
The Department of Corrections and Rehabilitation Operations Manual, section
3, article 22, covering employee discipline, has been revised and was accepted by
the federal district court on December 22, 2005. Article 22 outlines sections
relating to employee misconduct investigations and employee discipline.
The department has implemented a central intake process that includes
representatives from the Office of the Inspector General’s Bureau of Independent
Review and the department’s Legal Affairs Division and Office of Internal
Affairs to review requests for investigations and determine whether to authorize
internal affairs investigations. More than half of the department’s hiring
authorities use the central intake process, and the department achieved statewide
implementation on January 30, 2006. Auditors from the Office of the Inspector
General observed and participated in the central intake process during the followup review. Under the new process, central intake examines requests for
investigations and reviews the supporting documentation provided by the
requestor. Central intake then either accepts the request as an internal affairs
investigation or returns the request for direct disciplinary or corrective action at
the hiring authority level. Central intake can also return the request if it identifies
no misconduct. The process allows the department to concentrate investigative
resources on cases that have merit while requiring the hiring authorities to take
direct corrective action in matters that do not warrant a formal investigation.
According to the department, specific guidelines governing the date of discovery
and internal affairs investigations will be included in the Department of
Corrections and Rehabilitation Operations Manual, article 14 – Employee
Misconduct Investigations/Inquiries. Revisions to article 14 have been completed
and are part of the Madrid Remedial Plan. The department consulted with the

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Office of the Inspector General Bureau of Independent Review to develop the
following mutually agreed-upon definition of investigatory timeframes: “The
CDC shall normally conclude all of its investigations of peace officer misconduct
and provide notice of its proposed disciplinary action within one year. This time
period shall begin on the date that an uninvolved supervisor learns facts, which if
true, would constitute employee misconduct.” At the end of the fieldwork,
October 18, 2005, the Department of Corrections and Rehabilitation had received
an extension from the court to have article 14 completed by December 9, 2005.

FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 3
The Office of the Inspector General found that employee relations officers at institutions did not receive adequate training and
often lacked the experience necessary to properly handle employee disciplinary actions.
ORIGINAL RECOMMENDATIONS
The Office of the Inspector General
recommended that the Department of
Corrections establish a formalized training
program for employee relations officers at the
institutions.

OFFICE OF THE INSPECTOR GENERAL

STATUS
FULLY
IMPLEMENTED

COMMENTS
The Department of Corrections and Rehabilitation has developed a formalized
training program for employee relations officers that consists of fourteen lesson
plans covering the following topics:
Overview of employee relations officer advocacy curriculum
Analysis of investigations
Drafting adverse actions
Rejection during probation and non-punitive actions
Serving adverse actions
Skelly hearings and due process
Settlements
Administrative time off
Subpoenas and witness preparation
Evidence
Order of evidence at SPB hearings, discovery, and pre-hearing motions
Examination of witnesses
Argument
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Case preparation
The Office of the Inspector General reviewed training records and confirmed that
as of July 27, 2005, 54 employees had completed formal training. The total
included at least one employee from each of the 33 institutions, one from each of
the four parole regions, and seven from the central office. The department
reported it will continue to provide formal training to ensure that newly hired
employee relations officers receive the required training. The department is also
developing a computer-based training program for employee relations officers
and anticipates the new training to be available to employees by April 2006.
The Office of Internal Affairs, the Employment Advocacy and Prosecution
Team, and the Bureau of Independent Review also provided training to employee
relations officers and investigative services unit staff in September and October
2005. The training covered the following topics:
New central intake process
Investigator training plans
Providing assistance to outside agencies
Peace Officers Bill of Rights
Overview of the Bureau of Independent Review
Overview of the vertical advocate program
Investigative review and initiation of discipline
Hiring authority review of investigation
Justification of penalty
The Office of the Inspector General
recommended that the department convert the
employee relations officer positions from
temporary training assignments to permanent
positions.

OFFICE OF THE INSPECTOR GENERAL

SUBSTANTIALLY
IMPLEMENTED

The Department of Corrections and Rehabilitation received approval through the
budget process to establish 20 correctional sergeant positions for four-year
rotations as disciplinary officers (formerly referred to as employee relations
officers). The department reported to the court monitor in October 2005,
however, that it had reached agreement with the Department of Personnel
Administration to use the staff services manager I classification for the
disciplinary officer positions in order to establish permanent assignments. The
department informed the court it may continue to use the training and
development process as necessary to hire a correctional sergeant or to extend an
existing assignment for up to four years in cases where using a staff services
manager I candidate is not feasible.

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FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 4
The Office of the Inspector General found that most of the employee disciplinary actions at the Department of Corrections
proceeded all the way through settlement and hearings before the State Personnel Board without advice or assistance from the
department legal staff.
ORIGINAL RECOMMENDATIONS

STATUS

COMMENTS

The Office of the Inspector General
recommended that the Department of
Corrections establish formalized policies and
procedures to expand the role and
responsibility of the Employment Law Unit in
the preparation of employee disciplinary
actions.

FULLY
IMPLEMENTED

The Department of Corrections and Rehabilitation Operations Manual, section
3, article 22, Employee Discipline, now implemented statewide, has been revised
to include the vertical advocacy model. The vertical advocacy model establishes
formalized policies and procedures to expand the role and responsibility of the
Employment Advocacy and Prosecution Team in the preparation of employee
disciplinary actions. Vertical advocates will assist with disciplinary actions, draft
the adverse action, and prosecute most cases involving staff integrity or
dishonesty, abuse of authority, sexual misconduct, use of force in which an
inmate suffers death or serious injury, use of deadly force, serious allegations
against supervisors, high-profile cases, and any case for which the penalty is
dismissal. Vertical advocates were assigned and attended training concurrently
with the respective hiring authorities on the vertical advocacy model and
disciplinary procedures.

The Office of the Inspector General
recommended that as part of that effort, the
department implement a process for
monitoring court decisions and State Personnel
Board rulings affecting employee disciplinary
actions.

FULLY
IMPLEMENTED

According to the department, court decisions, State Personnel Board rulings, and
employee disciplinary actions are monitored using the following systems and
processes:
•
•
•

Case management system
Vertical advocacy policy
PROLAW database

Vertical advocates use the PROLAW database to monitor disciplinary actions
and State Personnel Board decisions. The PROLAW database has been installed
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statewide and all vertical advocates have been trained on its use.
The Office of the Inspector General also
recommended that the department provide
Internet access to employee relations officers
and conform to standard management practices
by instituting a comprehensive e-mail system
to improve communication between
headquarters staff and institution employees.

FULLY
IMPLEMENTED

According to the department, all employee relations officers at the adult
institutions have been provided with Internet access and have e-mail capability to
communicate with headquarters employees.

In addition, the Office of the Inspector General
recommended that the department review its
policies and procedures for evaluating and
appealing cases to ensure that it vigorously
defends its right to discipline employees guilty
of serious misconduct.

FULLY
IMPLEMENTED

The revised Department of Corrections and Rehabilitation Operations Manual,
section 3, article 22, Employee Discipline, outlines the procedure for appealing
State Personnel Board decisions to the Superior Court. Employees from the
Office of the Inspector General’s Bureau of Independent Review participate in
the new process.

FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 5
The Department of Corrections had not established policies and procedures governing settlement of employee disciplinary
actions and had no means of monitoring or evaluating the settlement process.
ORIGINAL RECOMMENDATION
The Office of the Inspector General
recommended that the Department of
Corrections establish policies and procedures
governing employee disciplinary action
settlements and require that the necessary
documentation be maintained for monitoring
and evaluating the settlement process.

OFFICE OF THE INSPECTOR GENERAL

STATUS
FULLY
IMPLEMENTED

COMMENTS
The revised Department of Corrections and Rehabilitation Operations Manual,
section 3, article 22, Employee Discipline, now includes a settlement policy that
requires documentation, monitoring, and evaluation throughout the process. The
case management systems and PROLAW database will be used to document and
monitor the settlement process.

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FOLLOW-UP RECOMMENDATIONS
None.

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OFFICE OF COMPLIANCE, AUDIT FUNCTIONS
The Office of the Inspector General found that the
Department of Corrections and Rehabilitation has
consolidated its audit functions into a single unit
and elevated the chief of the unit to report directly
to the undersecretary. Yet, more than three years
after the Office of the Inspector General issued its
initial report, the internal audit organization still
does not adhere to appropriate internal auditing
standards in performing its work.

OFFICE OF COMPLIANCE, AUDIT FUNCTIONS

IMPLEMENTATION REPORT CARD
Previous recommendations: 4
Fully implemented: 2 (50 %)
Substantially implemented: 0 (0%)
Partially implemented: 2 (50%)
Not implemented: 0 (0%)
Not applicable: 0 (0%)

In October 2002, the Office of the Inspector General
issued a report resulting from a review of the audit functions of the Department of
Corrections’ Office of Compliance. The Office of the Inspector General found that the
Office of Compliance did not adhere to appropriate professional standards in performing
its internal audit work. The Office of the Inspector General identified several specific
weaknesses in the department’s management of the Office of Compliance, all of which
resulted from the failure of the office to comply with internal auditing standards. The
deficiencies included poor communication with executive staff, unresponsiveness to
executive requests for audits, and inadequate monitoring of the audit status. As a result of
the deficiencies, the Office of the Inspector General questioned the ability of the Office
of Compliance to accomplish its objectives and meet its assigned responsibilities.
BACKGROUND
When the Office of the Inspector General issued its October 2002 report, the Office of
Compliance was comprised of three organizational units: The Program and Fiscal Audits
Branch, the Inmate Appeals Branch, and the Information Security Unit. The primary
audit functions of the department were established within the Program and Fiscal Audits
Branch. The department established these audit activities to fulfill the requirements of
California Penal Code, section 5057, which provides:
Subject to the powers of the Department of Finance under Section 13300 of the
Government Code, the director must establish an accounting and auditing system for all
of the agencies and institutions including the prisons which comprise the department,
except the Youth Authority, in such form as will best facilitate their operation, and may
modify the system from time to time.

In addition, California Department of Corrections and Rehabilitation Operations
Manual, section 11010.26.1 provides as follows:
The Program and Fiscal Audits Branch exists to independently audit program contracts
for compliance to terms and conditions of the contract. And review, evaluate, and better
assure that institutions, parole regions, and headquarters are operated in accordance
with department standards, state and federal law, and court mandates.
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The Department of Corrections and Rehabilitation reorganized its audit functions into the
Office of Audits and Compliance in July 2005
State law requires all state agencies having their own internal auditors to adhere to the
Standards for the Professional Practice of Internal Auditing of the Institute of Internal
Auditors. The Institute of Internal Auditors promulgates these standards to provide
guidance for conducting internal auditing. It divides the standards into two groups:
attribute standards, which address the characteristics of organizations and parties
performing internal audit activities; and performance standards, which describe the nature
of internal audit activities and provide criteria against which the performance of these
services can be evaluated. In addition, the Institute of Internal Auditors maintains a third
set of standards–implementation standards––which apply only to specific types of audit
activity.
In response to the Office of the Inspector General’s October 2002 report, the department
disagreed with the Office of the Inspector General’s conclusion that the activities of the
department’s Program and Fiscal Services Branch were internal audit activities, and were
therefore subject to the state law that requires it to adhere to the Standards for the
Professional Practice of Internal Auditing. Rather, the department asserted that alternate
auditing standards promulgated for external auditors were the appropriate auditing
standards for it to follow.
The Institute of Internal Auditors describes internal auditing as follows:
Internal auditing is an independent, objective assurance and consulting activity
designed to add value and improve an organization’s operations. It helps an
organization accomplish its objectives by bringing a systematic, disciplined approach to
evaluate and improve the effectiveness of risk management, control, and governance
processes.

The Office of the Inspector General continues to maintain that the department’s audit
activities are consistent with the Institute of Internal Auditors’ description of internal
auditing, and that the department therefore should ensure that its audits are conducted in
accordance with the Standards for the Professional Practice of Internal Auditing.
SUMMARY OF PREVIOUS FINDINGS AND RECOMMENDATIONS
The Office of the Inspector General made the following specific findings as a result of
the October 2002 review:
•

The Office of Compliance did not adhere to appropriate professional standards,
calling into question its ability to accomplish its objectives and meet its assigned
responsibilities.

•

Audit planning and communication with the department executive staff was
inadequate.

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•

The management of the Program and Fiscal Audits Branch did not target internal
audit activity toward issues posing the highest risk.

•

The Program and Fiscal Audits Branch of the Office of Compliance was not
responsive to executive management requests for special audits.

•

The Office of Compliance did not adequately monitor the status of audit projects.

•

The Program Compliance Unit of the Program and Fiscal Audits Branch used a
highly structured auditing approach that could fail to reveal important issues relating
to the entities under audit.

•

The audit functions of the California Department of Corrections were fragmented,
with a lack of coordination of audit activities and incomplete coverage of areas
requiring audit, resulting in a failure to comply with state law governing financial
accountability.

As a result of the October 2002 review, the Office of the Inspector General recommended
that the Department of Corrections consolidate all of its auditing activities into a
professional internal auditing unit consistent with standards prescribed in Standards for
the Professional Practice of Internal Auditing. The recommendations specified that the
chief of internal audits should possess the training, knowledge, and experience necessary
to manage an internal auditing unit and should report to the chief deputy director for
Support Services.
OBJECTIVES, SCOPE, AND METHODOLOGY
The purpose of the 2006 follow-up review was to determine the extent to which the
California Department of Corrections and Rehabilitation has implemented the
recommendations from the Office of the Inspector General’s October 2002 review. To
conduct the follow-up review, the Office of the Inspector General provided the
Department of Corrections and Rehabilitation with a table listing the October 2002
findings and recommendations and asked the department to provide the implementation
status of each recommendation. The Office of the Inspector General reviewed the
responses, along with documentation provided by the department, and evaluated the
degree of compliance or noncompliance with the recommendation. The fieldwork for the
follow-up review was completed in August 2005. The results are presented in the tables
following this narrative.
SUMMARY OF THE 2006 FOLLOW-UP RESULTS
The department has fully implemented two of the four recommendations issued by the
Office of the Inspector General in October 2002 concerning the audit functions of the
Office of Compliance, and has only partially implemented the two remaining
recommendations.

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The Office of the Inspector General found that more than three years after the initial audit
in October 2002, the department has not addressed most of the audit findings. The
department has consolidated its internal audit activities into the Office of Audits and
Compliance, which reports directly to the department’s undersecretary. That change
should allow the department to better coordinate its varied audit activities and provide the
appropriate level of organizational independence, as prescribed by the Institute of Internal
Auditors. According to the department, once the Office of Audits and Compliance is fully
operational, it will address most of the remaining issues raised in the October 2002
review. Because the Office of Audits and Compliance is not yet fully operational,
however, the department has not yet addressed several issues and recommendations
raised in the review. Specifically:
•

The department stated that it has not yet begun to adhere to Standards for the
Professional Practice of Internal Auditing, but asserts that where applicable, the new
office will be operated consistent with these standards.

•

The department reported that it has not yet developed a quality assurance and
improvement program for its internal auditing activity. However, it also reports that
the Office of Audits and Compliance will include a quality assurance and
improvement function that will evaluate the effectiveness of the internal audit
activity.

•

The department stated that it is currently not using a risk-based plan to determine the
priorities of its internal audit activity, but asserts that its new Office of Audits and
Compliance will develop a comprehensive annual work plan based on input from
senior management. The department adds that it plans to assign the Office of Risk
Management responsibility for developing a risk analysis plan for the department,
which senior management will use in determining the priorities of the internal audit
activity.

•

The department acknowledged that the two units that perform audits of internal
operations –– the Correctional Business Audit Unit and the Program Compliance Unit
–– are still not receiving substantive input from senior management in developing
their audit plans. However, the department stated that the deputy director of the Risk
Management Division does provide a semi-annual report of auditing activities to the
executive staff. The department reported that its new Office of Audits and
Compliance will develop a comprehensive annual work plan that will be based on
substantive input from senior management through a process it has yet to develop,
and will provide reports of auditing activities to a new executive management team.

•

Although the department reported completing 19 audits as part of its biennial internal
control certification as required by the State Administrative Manual, it did not
conduct these audits in accordance with appropriate internal auditing standards, as
required by state law.

•

The department has not yet appointed a permanent assistant secretary as the chief of
internal audits who possesses the training, knowledge, and experience to manage an
internal auditing unit. It has assigned an acting chief of internal audits who has some
narrowly focused auditing experience. The acting chief does not have experience in

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applying internal auditing standards, procedures and techniques, however, and has not
demonstrated such proficiency by obtaining an appropriate professional certification,
such as the Certified Internal Auditor designation. Therefore, the Office of the
Inspector General questions whether that person is qualified for the position of chief
of internal audits.
Not only appropriate auditing standards, but also sound business principles require the
department to incorporate the features described above into its audit operations. By not
adequately addressing the findings of the Office of the Inspector General’s October 2002
report, the department has limited the value of its internal audit unit as a tool for
identifying department operations needing improvement.
FOLLOW-UP RECOMMENDATIONS
The Office of the Inspector General recommends that the California
Department of Corrections and Rehabilitation continue its efforts to recruit a
permanent assistant secretary for the Office of Audits and Compliance,
ensuring that the person selected possesses the training, knowledge, and
experience to manage an internal auditing unit.
In addition, the department should ensure that the Office of Audits and
Compliance continues to develop operating policies and procedures that will
ensure that its audit activity is consistent with the standards prescribed in
the Standards for the Professional Practice of Internal Auditing. The policies
and procedures should include the following:
•

A process for effective communication with the department’s executive
staff in planning annual audit activities and reporting audit performance.

•

A process by which to develop a risk-based comprehensive annual plan
for identifying the priorities of the internal audit activity.

•

A process for entering into the audit monitoring system the data
necessary to adequately monitor the status of audits.

•

A system to monitor the amount of time the staff spends on audits.

The following table summarizes the results of the follow-up review.

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ORIGINAL FINDING NUMBER 1:
The Office of the Inspector General found that the Program and Fiscal Audits Branch did not adhere to professional
standards for internal auditing.
ORIGINAL FINDING NUMBER 2:
The Office of the Inspector General found that the Program and Fiscal Audits Branch, which performed most of the
department’s audit work, was not effectively communicating with the department’s executive staff in planning annual audit
activities and in reporting audit performance.
ORIGINAL FINDING NUMBER 3:
The Office of the Inspector General found that the management of the Program and Fiscal Audits Branch did not target
internal audit activity toward issues posing the highest risk.
ORIGINAL FINDING NUMBER 4:
The Office of the Inspector General found that the Program and Fiscal Audits Branch was not responsive to executive
management requests for special audits.
ORIGINAL FINDING NUMBER 5:
The Office of the Inspector General found that the Office of Compliance did not monitor the status of audit projects.
ORIGINAL FINDING NUMBER 6:
The Office of the Inspector General found that the Program Compliance Unit of the Program and Fiscal Audits Branch used a
highly structured auditing approach that could fail to reveal important issues relating to the entities under audit.
ORIGINAL FINDING NUMBER 7:
The Office of the Inspector General found that the audit functions of the California Department of Corrections were
fragmented, with a lack of coordination of audit activities and incomplete coverage of areas requiring audit, resulting in a
failure to comply with state law governing financial accountability.

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ORIGINAL RECOMMENDATIONS

OFFICE OF COMPLIANCE, AUDIT FUNCTIONS

STATUS

COMMENTS

The Office of the Inspector General
recommended that the California Department
of Corrections take the actions listed below.
Consolidate all department auditing activities
into a professional internal auditing unit.

FULLY
IMPLEMENTED

As part of its recent restructuring, the department created an Office of Audits
and Compliance. According to the department, the coordination and
performance of all department audits, reviews, and quality assurance
functions have been consolidated into this office.

The audit unit should be operated consistent
with standards prescribed in Standards for the
Professional Practice of Internal Auditing.

PARTIALLY
IMPLEMENTED

The department reported that it has not yet begun to adhere to Standards for
the Professional Practice of Internal Auditing, but stated that as the new
Office of Audits and Compliance is developed, it will be operated consistent
with these standards where applicable.
The Office of the Inspector General’s original report addressed a number of
specific standards with which the Program and Fiscal Audits Branch of the
Office of Compliance was not complying. A discussion of each of the specific
standards addressed in the Office of the Inspector General’s October 2002
report follows.
Organizational Independence — This standard requires that the chief audit
executive report to a level within the organization that allows the internal
audit activity to fulfill its responsibilities. As discussed below, the department
has reorganized its audit activities to provide the appropriate level of
organizational independence.
Proficiency — This standard states that internal auditors, including the chief
audit executive, should possess the knowledge, skills, and other competencies
needed to perform their individual responsibilities. As discussed later in this
matrix, the department has not yet appointed a permanent assistant secretary
as chief of its internal audits.
Quality Assurance and Improvement Program — This standard requires the
chief audit executive to develop and maintain a quality assurance and

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improvement program that covers all aspects of internal audit activity and
continuously monitors its effectiveness.
The department reported that a quality assurance and improvement program
has not yet been developed and implemented. However, the department stated
that the Office of Audits and Compliance will include a quality assurance and
improvement function that will evaluate the effectiveness of the internal audit
activity.
Managing the Internal Audit Activity — This standard requires the chief audit
executive to effectively manage the internal audit activity to ensure it adds
value to the organization. As part of these responsibilities, the standards
require the chief audit executive to establish risk-based plans to determine the
priorities of the internal audit activity, consistent with the organization’s
goals.
The department stated that it is currently not using a risk-based plan to
determine the priorities of its internal audit activity. The department added,
however, that its new Office of Audits and Compliance will develop a
comprehensive annual work plan based on input from senior management.
The department plans to assign its Office of Risk Management the task of
developing a risk analysis plan for the department, which senior management
will use in determining the priorities of the internal audit activity.
Resource Management — This standard requires the chief audit executive to
ensure that internal audit resources are appropriate, sufficient, and effectively
deployed to achieve the audit plan. The Office of the Inspector General found
in its October 2002 report that the Program and Fiscal Audits Branch lacked
an adequate audit tracking system.
The department reported that it has developed and implemented an audit
tracking system called the Standardized Correspondence Control System. It
describes the system as one that tracks each audit, including various milestone
dates, and provides a weekly report for audit management.

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The Office of the Inspector General reviewed a sample management report
produced by the tracking system and found that with some modification, the
system would provide information the department could use to monitor the
status of audits. However, the sample report reviewed revealed that key
information had not been entered into the tracking system’s data fields and
that there was no field for time spent on each audit. For example, several
audits listed on the sample report did not have a date in the “Date Assigned”
field, even though the report showed that the audit had been completed––
signified by a date in the “Date Approved” field. According to the deputy
director, the “Date Assigned” field reports the date the audit was commenced
and the “Date Approved” field is the date the final audit report was signed by
the chief of the audits branch. Therefore, several audits on the sample report
showed that even though the audit had not been commenced, the audit had
been completed and the final report signed by the chief of the audits branch.
In addition, the department acknowledged that the system does not track the
time spent on audits by staff. As a result, the department is still unable to
determine whether assignments are completed within designated budgetary
timeframes. Unless and until all key data is entered into the system and the
system tracks time spent on audits, the report’s usefulness to department
management is limited.
Reporting to the Board and Senior Management — This standard requires the
chief audit executive to report periodically to senior management on the
internal audit activity’s purpose, authority, responsibility, and performance
relative to its plan.
According to the department, the two units that perform audits of internal
department operations are not receiving substantive input from senior
management in developing their audit plans. The department also reported
that the deputy director of the Risk Management Division provides a semiannual report of auditing activities to the department’s executive staff. The
department added that the new Office of Audits and Compliance will develop
a comprehensive annual work plan that will be based on substantive input
from senior management through a process it has yet to develop and will
provide reports of auditing activities to a new executive management team.

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The chief of internal audits should possess the
training, knowledge, and experience to manage
an internal auditing unit.

PARTIALLY
IMPLEMENTED

The department reported that it has not yet appointed a permanent chief of
internal audits, adding that when it selects a chief, the person will possess the
training, knowledge, and experience to manage an internal auditing unit. It
has assigned an acting chief of internal audits who has some narrowly focused
auditing experience. However, the acting chief does not have experience in
applying internal auditing standards, procedures, and techniques, and has not
demonstrated such proficiency by obtaining an appropriate professional
certification, such as the Certified Internal Auditor designation. Therefore, the
Office of the Inspector General questions whether that person is qualified for
the position of chief of internal audits.

The chief of internal audits should report to the
chief deputy director for Support Services.

FULLY
IMPLEMENTED

As part of its recent restructuring, the department created an Office of Audits
and Compliance. According to the department’s July 2005 organization chart,
this office reports directly to the department’s undersecretary. That reporting
relationship should provide the appropriate level of organizational
independence, as prescribed by the Institute of Internal Auditors.

FOLLOW-UP RECOMMENDATIONS
The Office of the Inspector General recommends that the California Department of Corrections and Rehabilitation continue
its efforts to recruit a permanent assistant secretary for the Office of Audits and Compliance, ensuring that the person selected
possesses the training, knowledge, and experience to manage an internal auditing unit.
In addition, the department should ensure that the Office of Audits and Compliance continues to develop operating policies
and procedures that will ensure that its audit activity is consistent with the standards prescribed in the Standards for the
Professional Practice of Internal Auditing. The policies and procedures should include the following:
•

A process for effective communication with the department’s executive staff in planning annual audit activities and
reporting audit performance.

•

A process by which to develop a risk-based comprehensive annual plan for identifying the priorities of the internal
audit activity.

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•

A process for entering into the audit monitoring system the data necessary to adequately monitor the status of audits.

•

A system to monitor the amount of time the staff spends on audits.

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2006 ACCOUNTABILITY AUDIT

MEDICAL CONTRACTING PROCESS

MEDICAL CONTRACTING PROCESS

IMPLEMENTATION REPORT CARD

The Office of the Inspector General found that the
Department of Corrections and Rehabilitation has
remedied nearly all of the deficiencies in its medical
contracting process but must continue to take steps
to control its medical contract expenditures.

Previous recommendations: 7
Fully implemented: 5 (72 %)
Substantially implemented: 1 (14%)
Partially implemented: 1 (14%)

In October 2002, the Office of the Inspector General
Not implemented: 0 (0%)
conducted a special review of the processes and
Not applicable: 0 (0%)
controls used by the department’s Health Care
Services Division to procure and pay for contract
medical services to inmates. The review determined
that the division did not effectively manage its medical services to inmates and that it
should adopt statewide policies and procedures to ensure cost-effective contracts, quality
case management, and continuity of care.
BACKGROUND
The Department of Corrections and Rehabilitation established the Health Care Services
Division in 1992 to manage and oversee the delivery of health care services to inmates.
In order to provide adequate medical services to the growing inmate population, the
department contracts with outside community hospitals, physicians, nurses, pharmacists,
and other medical professionals to obtain specialized services its staff and facilities
cannot provide. In some instances, the department also contracts with medical
professionals to fill temporary staff vacancies in medical classifications where
recruitment is difficult.
As shown in the chart below, the total cost for contracted medical services continues to
rise annually, from $200 million in fiscal year 2000-01 to more than $315 million in
fiscal year 2004-05—an increase of 58 percent.
Contract Medical Expenditures ($ millions)

$400
$300

$200

$239

$279

$315

$200
$100
$0

2001-02

2002-03

2003-04

2004-05

Fiscal Year

The Health Care Services Division has oversight responsibility for all medical contracts.
In response to external audits, the division established the Health Contract Services Unit
to establish new contract policies, assist with contract negotiations, and provide support

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to institutions for all medical service contracts. Until recently, the Department of
Corrections and Rehabilitation was not required to competitively bid the majority of its
medical service contracts and often it contracted with a sole provider. Prompted by the
Bureau of State Audits, the Department of General Services issued Management
Memorandum 05-04 on January 26, 2005, which requires competitive bids for all medical
services except those in which departments can justify the need for an exemption.
SUMMARY OF PREVIOUS FINDINGS AND RECOMMENDATIONS
As a result of the October 2002 review, the Office of the Inspector General made the
following specific findings:
•

The Department of Corrections lacked a comprehensive statewide policy for
managing its medical services contracts.

•

Lack of sound contract management by the Department of Corrections resulted in
payments of more than $77,000 for clinical services not performed and of more than
$1 million for services not authorized under a California Medical Facility contract
with an outside physician.

•

The contracting process of the Department of Corrections was vulnerable to
potentially serious conflicts of interest because the person selecting the contractor
was also authorized to approve invoices and payments under the contract.

•

The deficiencies identified in the department’s contracting process may have led to
problems in the quality and continuity of inmate medical care.

As a result of the October 2002 review, the Office of the Inspector General made the
following seven recommendations:
•

The Office of the Inspector General recommended that the Department of Corrections
adopt statewide policies and procedures for contract management, including but not
limited to advertising and soliciting proposals; and awarding, monitoring, and
enforcing contracts to provide cost-effective medical services to inmates. The
recommendation specified that the policies and procedures should include the
following:
¾ A requirement that institutions advertise the need for medical service providers
and solicit proposals from their local communities.
¾ A requirement that institutions document their efforts to advertise and solicit
proposals before approving any contract.
¾ Implementation of a statewide survey every three to four years to determine what

constitutes a reasonable hourly fee for various medical specialties in selected
regions of the state. The results of this survey can be used to develop reasonable
contract expenditures for specific services in various geographical regions.

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¾ A requirement that the cost of custody and support staff be included in

calculations of the cost of providing medical care to inmates outside an
institution, and that the cost be applied in developing a “reasonable” rate for care
inside the institution.
•

The Department of Corrections establish tight controls to ensure compliance with
contract provisions, including monitoring and authorizing payment. The controls
should be effectively communicated to staff through special training in contract
language and the proper procedures for authorizing payments. The department
should also strengthen its procedures for amending existing contracts to avoid
confusion and misunderstanding.

•

The Department of Corrections include provisions in its contracting policies to ensure
that the individual who selects and approves a contractor does not also authorize
payment by approving invoices under that contract.

•

Pending resolution of contract issues, the Department of Corrections take any
necessary interim steps to ensure that inmates receive good-quality medical care that
is uninterrupted by contract problems.

OBJECTIVES, SCOPE, AND METHODOLOGY
The purpose of the 2006 follow-up review was to determine the extent to which the
California Department of Corrections and Rehabilitation has implemented the seven
recommendations from the Office of the Inspector General’s October 2002 special review
of the medical contracting process. To conduct the follow-up review, the Office of the
Inspector General provided the Department of Corrections and Rehabilitation with a table
listing the October 2002 findings and recommendations and asked the department to
provide the implementation status of each recommendation. The Office of the Inspector
General reviewed the responses, along with documentation provided by the department,
and evaluated the degree of compliance or noncompliance with the recommendations.
Review fieldwork was completed on November 7, 2005. The results are summarized in
the table that follows this section.
SUMMARY OF THE 2006 FOLLOW-UP RESULTS
Of the seven recommendations issued by the Office of the Inspector General in October
2002 concerning the medical contracting process, five recommendations have been fully
implemented; one has been substantially implemented; and one has been partially
implemented.
As a result of the 2006 follow-up review, the Office of the Inspector General found that
the Department of Corrections and Rehabilitation has made a number of changes to its
medical contracting process. In response to the Office of the Inspector General’s 2002
review, the department established a health contract services unit to assist institutions
with all medical services contracts. In addition, the department required institutions to
solicit medical providers and to prepare market surveys before initiating a contract.

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Meanwhile, expenditures for medical contracts rose 58 percent between fiscal years
2000-01 and 2004-05 from $200 million to more than $315 million, largely because of
medical staff vacancies requiring contracted personnel to fill the void.
In response to two subsequent audits issued by the California State Auditor in 2004, the
Department of General Services tightened the procedures used by the department to
contract with outside community hospitals, physicians, nurses, pharmacists and other
medical professionals to provide needed services and fill temporary medical staff
vacancies and required the department to obtain competitive bids on clinical contracts.
According to a correctional expert appointed by the U. S. District Court, however, due in
part to insufficient staffing and training necessary to properly implement the new
contracting procedures as well as to the complexity of the procedures, the department has
fallen $58 million behind in paying provider claims. The new bidding process instituted
to replace single-source contracting also has resulted in a shortage of specialty providers.
Because of these developments, on March 30, 2006 the court ordered the department to
pay all valid outstanding department-approved claims within 60 days and to establish
new medical contracting procedures within 180 days.
FOLLOW-UP RECOMMENDATION
The Office of the Inspector General recommends that the Department of
Corrections and Rehabilitation develop a more effective and efficient system
for processing and monitoring medical service invoices, including validation
that contractors have performed all services invoiced prior to issuing
payment.
The following table summarizes the results of the follow-up review.

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ORIGINAL FINDING NUMBER 1
The Department of Corrections lacked a comprehensive statewide policy for managing its medical services contracts.
ORIGINAL RECOMMENDATIONS

STATUS

COMMENTS

The Office of the Inspector General
recommended that the Department of
Corrections adopt statewide policies and
procedures for contract management,
including but not limited to advertising and
soliciting proposals and awarding, monitoring,
and enforcing contracts to provide costeffective medical services to inmates. The
policies and procedures should include the
following:
A requirement that institutions advertise the
need for medical service providers and solicit
proposals from their local medical
communities.

SUBSTANTIALLY
IMPLEMENTED

According to the department, the Health Care Services Division has
implemented new procedures that require completing market surveys for the
majority of its medical services contracts. The division conducted meetings with
all institutions except Pelican Bay State Prison, California State Prison,
Corcoran, and the California Substance Abuse Treatment Facility and State
Prison at Corcoran to discuss the new contract procedures. Institution contract
analysts, health care cost and utilization program analysts, and health care
managers attended the meetings for an understanding of how to complete market
surveys for medical contracts. The department reported that the remaining three
institutions will receive contract training as part of the new statewide contract
negotiation training to be completed by May 2006.
Under the January 2005 Management Memorandum 05-04 issued by the
Department of General Services, all departments are now required to bid for
medical services, with the exception of emergency hospital and ambulance
provider services. When it is difficult to obtain services, such as in rural
locations or for specific medical specialties, departments can submit a special

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category request/non-competitive bid exemption request to the Department of
General Services. The Department of Corrections and Rehabilitation has
prepared 16 special category requests and had received approval for 14 at the
time review fieldwork was completed on November 7, 2005.
According to the department, the Health Contract Services Unit also uses the
following as benchmarks for determining the reasonableness of potential
contract provisions:
¾ Department sector rates for Relative Value for Physicians
¾ Medicare Diagnostic Related Group code information
¾ Data reflecting cost-to-change ratios obtained from the Office of
Statewide Health Planning and Development
The department provided the Office of the Inspector General with draft
procedures addressing hospital negotiations, completion of physician contracts,
contract renewal requests, and contract approval. The Health Contract Services
Unit had not presented the procedures for approval at the time fieldwork was
completed.
A requirement that institutions document their
efforts to advertise and solicit proposals
before approving any contract.

FULLY
IMPLEMENTED

The department reported that it implemented a process effective July 1, 2004
requiring all non-bid contract requests to be submitted to the Health Contract
Services Unit for approval. The Health Contract Services Unit maintains all
documentation relating to solicitation and now-mandatory market surveys. The
unit also prepares solicitation letters targeting areas in which preferred provider
master contracts are desirable and performs cost analyses, including such factors
as medical guarding and inmate transportation, for each proposal received under
preferred provider master contracts. All negotiation efforts are documented in
Health Contract Services Unit contract files. The department continues to
develop policies and procedures to address contract issues.
The Office of the Inspector General reviewed eight contract requests that
institutions had submitted to the Health Contract Services Unit to verify
completion of market surveys; all eight were in compliance with this
requirement.

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Implementation of a statewide survey every
three to four years to determine what
constitutes a reasonable hourly fee for a range
of medical specialties in selected regions of
the state. The results of the survey could be
used to develop equitable contract
expenditures for specific services in various
geographical regions.

FULLY
IMPLEMENTED

A requirement that the cost of custody and
support staff be included in calculations of the
cost of providing medical care to inmates
outside an institution and that the cost be
applied in developing a reasonable rate for
care inside the institution.

FULLY
IMPLEMENTED

According to the department, the Health Contract Services Unit has completed a
survey of four specialty services the department frequently uses—cardiology,
neurology, orthopedics, and gastroenterology—to determine the current rates for
these services and identify whether patients can be directed to providers with
favorable rates. The Health Contract Services Unit reported that it will employ
the surveys to determine the reasonableness of proposed rates.
The department provided the Office of the Inspector General with documentation
of its neurology survey.
The Health Contract Services Unit provided the Office of the Inspector General
with a medical guarding cost analysis worksheet it had prepared with input from
the Institutions Division. The analysis identifies the costs associated with
medical guarding in both medical-guarded and non-medical-guarded hospital
units. Medical-guarded units have correctional officers permanently assigned to
provide ongoing security coverage for inmates receiving medical care, while
non-medical-guarded facilities must temporarily assign correctional staff to the
hospital while an inmate receives treatment. The Health Contract Services Unit
completed the project in December 2003 but continued to work with the
Institutions Division in updating the worksheet to include necessary revisions.
According to the department, the unit employees use the worksheet routinely to
establish appropriate rates.

FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 2
Lack of sound contract management by the Department of Corrections resulted in payments of more than $77,000 for clinical
services not performed and of more than $1 million for services not authorized under a California Medical Facility contract
with an outside physician.

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ORIGINAL RECOMMENDATION
The Office of the Inspector General
recommended that the Department of
Corrections establish stringent controls for
monitoring and authorizing payments for
contract health care services. The controls
should be effectively communicated to staff
through special training on contract language
and the proper procedures to be followed
when authorizing and processing invoices for
payment. The department should also
improve the procedures for amending existing
contracts to avoid confusion and
misunderstanding.

MEDICAL CONTRACTING PROCESS

STATUS
PARTIALLY
IMPLEMENTED

COMMENTS
At the time the Office of the Inspector General conducted its original review, the
Health Care Services Division had disbanded the contract unit due to budget
reductions. After audits by the Office of the Inspector General and the Bureau of
State Audits revealed deficiencies in the department’s medical contracting
procedures, however, the department received additional funding to re-establish
the unit, now known as the Health Contract Services Unit. The unit assists
institutions with medical contract negotiations, develops contracting policies and
procedures specific to health care contracts, and performs contract-monitoring
services for the department. The unit is comprised of 15 positions, including three
managers and 12 analysts. Most of the analysts in the unit have attended training
related to cost benefit analysis and analytical skills development, and those new to
the unit will attend training in the near future. According to the department, in
April 2005 it awarded Managed Care Consulting Inc. a contract to provide
contract negotiation skills training to the Health Contract Services Unit. The
contractor is currently reviewing staff skill levels to determine training needs.
The Health Care Services Division distributed a memorandum to all institutions
on June 29, 2004 outlining the new contract procedures for institutional health
care services. The memorandum covers procedures for contract requests, renewal
of exiting contracts, and the new “medical and return” process (when an inmate
must be transferred to another facility to receive appropriate medical services).
According to the Health Contract Services Unit, the staff meets with institutions
and medical contractors on a regular basis to monitor the quality of services and
resolve any contractual issues.
The department reported that it has contacted various providers and is considering
contracting out the medical invoice review. Currently, the health care cost and
utilization analysts at the institutions perform medical invoice reviews, but they
are able to perform detailed audits only on a limited sample due to the high
volume of medical invoices and the absence of an automated system. The
department stated that it is still in the early planning stages of transferring the
invoice review function to an automated system and the costs of doing so have not
yet been determined.

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FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 3
The contracting process of the Department of Corrections was vulnerable to potentially serious conflicts of interest because
the person selecting the contractor was also authorized to approve invoices and payments under the contract.
ORIGINAL RECOMMENDATION
The Office of the Inspector General
recommended the department include
provisions in its contracting policies to ensure
that the individual who selects and approves a
contractor does not also authorize payment by
approving invoices under that contract.

STATUS
FULLY
IMPLEMENTED

COMMENTS
The new procedures provided on June 29, 2005 to all institution health care
managers require that initial and renewal contract requests be submitted to the
Health Contract Services Unit for approval. In addition, the unit reviews market
surveys and utilization data before recommending approval of a specific
contractor. The new medical contract procedures have eliminated the previous
potential for conflicts of interest.

FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 4
The current deficiencies in the department’s contracting process may lead to problems in the quality and continuity of inmate
medical care.
ORIGINAL RECOMMENDATION
Pending resolution of contract issues, the
Office of the Inspector General recommended
that the Department of Corrections take any
necessary interim steps to ensure that inmates
receive good-quality, fundamental medical
care that is uninterrupted by contract issues.

STATUS
FULLY
IMPLEMENTED

COMMENTS
The department reported that it instructed all institutions to transfer patients to
other facilities if services were not readily available because of contract issues. In
addition, the Health Contract Services Unit has developed a network of service
providers and affirms that it provides ongoing assistance to the institutions in
determining the availability of medical services.
The memorandum submitted on June 29, 2004 advises all department health care

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managers to contact the Health Contract Services Unit for assistance if there is no
existing local or regional contract for a particular medical service. Through its
network, the unit can determine if services are available at another institution.
The department can then transfer the inmate to the appropriate location for
medical services (“medical and return process”).

FOLLOW-UP RECOMMENDATION
The Office of the Inspector General recommends that the Department of Corrections and Rehabilitation develop a more
effective and efficient system for processing and monitoring medical service invoices, including validation that contractors
have performed all services invoiced prior to issuing payment.

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EDUCATION PROGRAMS AT LEVEL IV INSTITUTIONS

EDUCATION PROGRAMS AT LEVEL IV INSTITUTIONS
The Office of the Inspector General found that the
Department of Corrections and Rehabilitation has
made progress in developing alternative education
programs for Level IV inmates.

IMPLEMENTATION REPORT CARD
Previous recommendations: 6
Fully implemented: 1 (17%)
Substantially implemented: 2 (33%)

In July 2003, the Office of the Inspector General
Partially implemented: 3 (50%)
conducted a survey of education programs at the
Not implemented: 0 (0%)
Department of Corrections Level IV institutions. The
survey was prompted by management review audits
Not applicable: 0 (0%)
conducted by the Office of the Inspector General
showing that inmates in state correctional institutions
received only limited classroom instruction because classrooms are closed for significant
periods of time due to lockdowns, teacher vacancies, and other program disruptions. The
survey revealed the classroom education model to be an inefficient and expensive means
of delivering education to Level IV inmates because frequent lockdowns cause academic
and vocational classes to be closed down more than 60 percent of the time. At the five
Level IV institutions locked down for the largest percentages of time, education programs
operated an average of only 25 percent of the time. And even with the classes closed for
long periods, the survey found that inmates continued to receive day-for-day sentence
reduction credits as though they had attended class, and teachers continued to be paid as
though they had provided instruction. The Office of the Inspector General also found that
even if the classes were held 100 percent of the time, they would be able to accommodate
only a small percentage of inmates eligible for the programs, in part because of the small
number of budgeted teaching positions at Level IV institutions. The survey found in
addition that institutions had no systematic means of accounting for teachers’ activities
during lockdown periods or of temporarily assigning them to other duties.
BACKGROUND
Declaring that “there is a correlation between prisoners who are functionally literate and
those who successfully reintegrate into society upon release,” the Legislature in 1987
enacted the Prisoner Literacy Act, which required the Department of Corrections to
provide literacy programs at every state prison. Codified as California Penal Code section
2053 et seq., the act required the department to make the programs available to at least 60
percent of eligible inmates in the state prison system by January 1, 1996, with the goal of
ensuring that inmates achieve a ninth-grade reading level by the time they parole.
Accordingly, the Department of Corrections provides an education program consisting of
both academic classes and vocational training for inmates at state correctional
institutions. A November 1996 survey by the Department of Corrections found that 68
percent of the inmate population scored below the ninth grade level in reading.
The budget for the Department of Corrections for fiscal year 2004-05 included $12.3
million for academic and vocational education for the five Level IV institutions that were

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part of the Office of the Inspector General’s original survey. As of April 30, 2005, there
were 20,059 inmates, 18 percent of the eligible population, enrolled in academic and
vocational education programs statewide.
SUMMARY OF PREVIOUS FINDINGS AND RECOMMENDATIONS
The Office of the Inspector General made the following specific observations as a result
of the July 2003 survey:
•

Only 21 percent of eligible inmates at the five Level IV institutions covered in the
survey were enrolled in education classes and the classes were closed a large
percentage of the time because of lockdowns and other disruptions.

•

The low level of inmate participation is explained partly by budget constraints. In
fiscal year 2002-03, the number of academic teaching positions budgeted at the five
Level IV institutions surveyed averaged 16, with an average of only 13 of those
positions actually filled. At a ratio of one teacher for every 27 students, therefore, the
academic program were able to accommodate an average of only 351 inmates at each
of the institutions — 11.8 percent of the eligible inmate population (with “eligible”
defined as those able to participate in a classroom setting).

•

The Department of Corrections and the institutions had no means of accounting for
the activities of teachers during lockdowns, and labor agreements hampered the
redirection of teachers to other functions during those periods.

•

When lockdowns and other program disruptions were taken into account, the annual
per-inmate cost of the education programs at Level IV institutions greatly exceeded
the annual per-inmate costs budgeted.

As a result of the July 2003 survey, the Office of the Inspector General recommended
that the Department of Corrections re-evaluate education programs at Level IV
institutions to determine whether they warrant continued operation and investigate other
methods of delivering academic and vocational instruction. Among the options
considered should be eliminating formal classroom instruction and retaining a small
educational staff to coordinate in-cell study courses for inmates. Instruction through cable
television and correspondence courses could also be developed to assist inmates in
achieving educational goals.
OBJECTIVES, SCOPE, AND METHODOLOGY
The purpose of the 2006 follow-up review was to determine the extent to which the
Department of Corrections and Rehabilitation has implemented the six recommendations
from the Office of the Inspector General’s July 2003 survey of education programs at
Level IV institutions. To conduct the follow-up review, the Office of the Inspector
General provided the Department of Corrections and Rehabilitation with a table listing
the July 2003 findings and recommendations and asked the department to provide the
implementation status of each recommendation. The Office of the Inspector General

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reviewed the responses, along with documentation provided by the department, and
evaluated the degree of compliance or noncompliance with the recommendations.
Fieldwork for the review was completed in September 2005. The results are presented in
the tables following this narrative.
SUMMARY OF THE 2006 FOLLOW-UP RESULTS
Of the six recommendations issued by the Office of the Inspector General in July 2003
concerning the education programs at Level IV institutions, one recommendation has
been fully implemented; two recommendations have been substantially implemented; and
three recommendations have been partially implemented.
The Office of the Inspector General found that the Department of Corrections and
Rehabilitation has made some progress in developing new education methods for Level
IV inmates, but the effectiveness of the new programs has not yet been evaluated. In
response to a $34.8 million reduction to its education budget, the department evaluated its
existing programs and prioritized them to determine those that warranted continued
operation. Upon completion of the evaluation, the department eliminated 129 education
positions, including many of the Level IV vocational programs, due to their
ineffectiveness. The department has since developed alternative education program
models designed to increase overall inmate participation through non-traditional methods.
The new programs include more self-paced independent study, such as the new Bridging
Education Program recently implemented in the reception centers and general population
facilities. This new program allows inmates to begin participating in self-paced education
programs when they arrive at a reception center. Other programs include short-term
vocational certification classes, half-day assignments with a homework component,
delivery of educational services via distance education methodologies, and delivery of
educational services in the living units. The majority of the new alternative education
delivery models have only recently been implemented; therefore, only minimal data is
available at this time to evaluate the programs’ effectiveness. The department also has not
developed an effective monitoring system to ensure that institutions are complying with
its education policies and procedures. Prison reform advocates have also suggested that
the new programs may be too shallow to be effective, but inmate population pressures
appear to make it difficult to provide more comprehensive educational opportunities, at
least in a classroom setting.
FOLLOW-UP RECOMMENDATIONS
The Office of the Inspector General recommends that the Department of
Corrections and Rehabilitation take the following actions:
•

Systematically evaluate the effectiveness of the new alternative
education delivery models. The evaluation should include inmate
participation rates, progress in achieving educational goals, and the
impact of the programs on recidivism.

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•

EDUCATION PROGRAMS AT LEVEL IV INSTITUTIONS

The new Office of Correctional Education should dedicate staff to
perform periodic on-site reviews to ensure compliance with
department policies and procedures. The on-site reviews should
include, but not be limited to, verification of educational
representatives participating in classification committees, verification
of class closures for teacher vacancies beyond 30 days, and the
verification of the accuracy of timekeeping for inmate program
participation.

The following table summarizes the results of the follow-up review.

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ORIGINAL OBSERVATION NUMBER 1
The Office of the Inspector General found that only a small percentage of inmates at Level IV institutions were enrolled in
education classes and that the classes were closed a large percentage of the time because of lockdowns and other disruptions.
ORIGINAL OBSERVATION NUMBER 2
The Office of the Inspector General found that the department and institutions had no means of accounting for the activities
of teachers during lockdowns and that labor agreements hampered the redirection of teachers to other functions during those
periods.
ORIGINAL OBSERVATION NUMBER 3
The Office of the Inspector General found that when lockdowns and other program disruptions were taken into account, the
annual per-inmate cost of the education programs at Level IV institutions greatly exceeded the annual per-inmate cost
budgeted.
ORIGINAL RECOMMENDATIONS
The Office of the Inspector General
recommended that the Department of
Corrections re-evaluate education programs at
Level IV institutions to determine whether
they warrant continued operation and
investigate other methods of delivering
academic and vocational instruction.

STATUS
FULLY
IMPLEMENTED

COMMENTS
According to the department, the Education and Inmate Programs Unit
evaluated all Level IV institutions as part of a $34.8 million reduction to the
department’s education budget. The evaluation included inmate program
participation, program viability, teacher assignments, inmate assignments, and
waiting lists. In addition, the department looked at the Ten-Year Employability
Outlook published by the Employment Development Department to determine
the projected employment growth for vocational programs. The evaluation
completed by the department noted that Level IV institutions of 180- design1
and Level IV institutions of 270-design2 evidenced the following:
•
•
•

1
2

Excessive class closures averaging 77 percent
Low enrollment of approximately 20 percent
Fifteen percent of the teachers assigned to programs other than those for
which they were hired to teach

High Desert State Prison, Pelican Bay State Prison, California State Prison, Sacramento, and Salinas Valley State Prison.
California State Prison, Los Angeles County and Salinas Valley State Prison.

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•
•

Seventeen vocational programs deemed as low growth by the Ten-Year
Employability Outlook
Programs not well suited as correctional education vocational programs

Upon completion of the evaluation, the Education and Inmate Programs Unit
recommended that the department eliminate 129 education positions at the
Level IV institutions. The department approved the recommendations and
eliminated the positions and programs effective March 1, 2004.
The Office of the Inspector General
recommended that among the options
considered should be eliminating formal
classroom instruction and retaining a small
educational staff to coordinate in-cell study
courses for inmates.

SUBSTANTIALLY
IMPLEMENTED

Along with the recommended position cuts noted above, the Education and
Inmate Programs Unit, now renamed the Office of Correctional Education, also
reported that it had developed alternative means of delivering educational
services. These alternatives include short-term vocational certification, half-day
assignments with homework, delivery of educational services during lockdowns
via distance education methodologies, and delivery of educational services in
living units. The Office of Correctional Education had expected to fully
implement these new programs by October 2005. The department was still
negotiating with labor union representatives on the implementation of the new
alternative education delivery models during the Office of the Inspector
General’s fieldwork. The new alternative delivery models include both distance
education and independent study. According to the department, these models
are appropriate for higher-level learners, and teachers will be assigned 90 to 120
students, thereby greatly expanding educational services.
In response to the ongoing security measures under lockdown and modified
program conditions, the alternative education delivery model has a component
that includes providing educational services during lockdowns and modified
programs. According to the department, each institution has developed a plan
for how it will deliver services during lockdowns and modified programs.
The Office of Correctional Education reported that it has recently implemented
industry certification in all of the vocational construction trade programs, using
the National Center of Construction Education and Research text and
instructional materials. This curriculum addresses short-term vocational
certification and is delivered in modules that run from three to six weeks.
Completion of the program results in industry certification. The program

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complements the aforementioned half-time educational programs that are part
of the alternative education and delivery model. The Office of Correctional
Education continues to support traditional classroom instruction as a viable
method of instructional delivery when it is feasible.
The Office of the Inspector General reviewed the inmate participation statistics
provided by the Department of Corrections and Rehabilitation for fiscal year
2004-05 and found the following:
Institution
California State Prison,
Sacramento
Calipatria State Prison
High Desert State Prison
Pelican Bay State Prison
Salinas Valley State
Prison
Totals/average
percentage

Inmate
Participation3

Total Hours
Possible4

Percentage of
Participation

159,174
221,697
266,784
113,568

260,022
527,355
673,539
237,273

61%
42%
40%
48%

139,677

483,811

29%

900,900

2,182,000

41%

The original survey of the above institutions indicated an average participation
rate of 25 percent. Although the department has improved, the 41 percent
participation rate ultimately results in the closure of education programs 59
percent of the time. It is too early to evaluate the effectiveness of the new
alternative delivery models because the department only recently implemented
these programs. Nevertheless, the data clearly demonstrates that the department
must continue to improve its delivery of education services to the Level IV
inmate population.

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The Office of the Inspector General
recommended that instruction through cable
television and correspondence courses could
also be developed to assist inmates in
achieving educational goals.

EDUCATION PROGRAMS AT LEVEL IV INSTITUTIONS
SUBSTANTIALLY
IMPLEMENTED

According to the department, every institution is connected to the corrections
learning network. The corrections learning network is a distance learning
initiative, administered by Educational District 101 and funded through the
United States Department of Education. The network provides free interactive
instructional programming for the nation’s correctional facilities. Educational
programming is available through satellite/television downlink for the offender
population (youth and adult) and to correctional employees. The department
reported that it uses the corrections learning network to supplement curricula in
the traditional classroom programs and in its Bridging Education Program. The
institutions distribute the network programming to the housing units, where
inmates can directly connect with the correctional learning network. Each
institution has been permitted program flexibility in its distribution.
The department stated that it has obtained more traditional and distance college
courses. The department considered budget change proposals to improve the
infrastructure for reception centers in order to accommodate additional electrical
and cable connections and thereby make available more television units in
housing units/cells to receive educational and self-help information through
distance learning models. The department reported, however, that the excessive
cost of providing the additional cable connections became evident. As an
alternative, the department decided to concentrate on purchasing television sets
and video cassette recorders for use in the reception center dayrooms to
facilitate the distance learning efforts. The department stated that it is currently
ordering television carts to enable staff to secure the equipment when not in use
and provide mobility to different locations as needed.
The department affirmed that it has significantly increased the availability of
college programs to the inmate population, including some Level IV
institutions, without additional allocations from the state general fund. The
department stated that it has cooperated fully with the California community
colleges to expand the availability of college programs.
The department also provided the following examples of new educational
programs now being offered at level IV institutions:
•

OFFICE OF THE INSPECTOR GENERAL

Pelican Bay State Prison operates a small television studio that records
teacher classroom lectures for distribution across the institutional
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television network, allowing inmates who are unable to attend school to
continue their studies. The network also provides other programs,
including general educational development, community college courses,
and self-help programming.

OFFICE OF THE INSPECTOR GENERAL

•

Salinas Valley State Prison provides re-entry information through
educational packets, which include anger management and substance
abuse videos. In addition, the adjunct teacher coordinates general
education development and the corrections learning network
programming. The institution recently installed computer labs with
educational software in all four yards.

•

California State Prison, Sacramento uses an adjunct teacher who
coordinates general education development and corrections learning
network programming for inmates who cannot attend traditional
classrooms. In addition, the institution gives inmates access to re-entry
and general education development materials through educational
packets.

•

High Desert State Prison coordinates with the work of its television
specialist and two academic teachers, who manage coursework offered
through the corrections learning network. Inmates who complete the
course receive completion certificates.

•

Calipatria State Prison uses the corrections learning network to offer
general education development coursework to all institution inmates.
After completing the course, inmates may sign up through the education
department to take the general education development exam.

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If the department decides to continue formal
classroom instruction, the Office of the
Inspector General recommended that the
department take the following actions:
Ensure that classification committees include
an education representative for the purpose of
evaluating appropriate education placement for
inmates.

PARTIALLY
IMPLEMENTED

The Department of Corrections and Rehabilitation provided the Office of the
Inspector General with a memorandum entitled “Student Class Assignment
Policy,” dated February 7, 2003 and signed by W. A. Duncan, former Deputy
Director, Institutions Division. The purpose of the memorandum, which was
sent to all institutions, was to reiterate departmental policy and to ensure that an
education representative was present at initial classification committee and unit
classification committee hearings. The memorandum also provided guidelines
for appropriate inmate education placement, assessment, and equal access to
inmates with special needs. The Office of Correctional Education affirmed that
it has never deviated from its position — that inmates receive an education
appropriate to their individual needs. In addition, the new Bridging Education
Program mandates that an educational representative be part of the classification
committee to directly interview participants and ensure their appropriate
placement.
The Office of the Inspector General recognizes that the Department of
Corrections and Rehabilitation has officially notified the institutions of the
policy requiring educational representatives to participate in classification
committee hearings. The department, however, could not provide evidence to
indicate that it has monitored whether educational representatives actively
participate in classification committee hearings, as required. Moreover, the
department stated in its response that, because of budget cuts, it no longer
retains staff to perform on-site compliance reviews.

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Develop a more efficient process for removing
from classes inmates who are disruptive or
who fail to attend class and for removing
inmates from classes that are closed because of
teacher vacancies and other reasons.

EDUCATION PROGRAMS AT LEVEL IV INSTITUTIONS
PARTIALLY
IMPLEMENTED

According to the department, it has convened with the teachers’ and vocational
instructors’ union pursuant to an understanding of the existing sections of the
California Code of Regulations, Title 15 and the Department of Corrections and
Rehabilitation Operations Manual, which delineate the discipline process and
define education staff authority to effectively handle classroom discipline
problems. The department also states that it will continue training supervisors of
correctional education programs to ensure that education staff members are
aware of the disciplinary process. Recommended changes to the California
Code of Regulations are being sought relative to the section that reads, “A
classification committee action shall not be required to remove inmates from
Bridging Education Programs if no other changes in work/training group,
privilege group, custody designation or work waiting list is required.”
The department stated that the Title 15 revisions encompass new classification
and disciplinary processes with the implementation of the Bridging Education
Program. The Office of the Inspector General reviewed the revisions to Title 15
and found no significant changes that constitute a more efficient process for
teachers to remove disruptive inmates from education programs.
The department also stated that it notified wardens and supervisors of
correctional education programs in writing of the policy regarding class
closures. The policy requires that inmates be temporarily unassigned from
classes in which the teacher or instructor is unavailable beyond 30 days.

Institute quality-control measures to ensure
that inmate class attendance is accurately
reported.

OFFICE OF THE INSPECTOR GENERAL

PARTIALLY
IMPLEMENTED

The Department of Corrections and Rehabilitation stated that each instructor is
required to keep a permanent class record on inmate attendance. In addition, the
department stated that all instructors are required to follow timekeeping policies
as articulated in the California Code of Regulations, Title 15, Crime Prevention
and Corrections, Article 3.5. The supervisors of academic instruction and
vocational instruction at each institution review the permanent class record for
accuracy and apply proper corrective action procedures if an inmate fails to
attend. The supervisor of correctional education program maintains all
permanent class records in the education office. The assignment office is
provided copies to maintain accountability under the department’s new
timekeeping system.

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According to the department, the new education strategic plan it has adopted
includes a mandated accountability model. In addition, the department will hire
an associate governmental program analyst at each institution for education data
collection and reporting needs. The department states that it is also developing
a new monthly report that will provide better enrollment accountability.
The Office of the Inspector General recognizes that the Department of
Corrections and Rehabilitation has made efforts to officially notify institutions
of the policy requirements. Nevertheless, without performing periodic on-site
institution audits, the department cannot ensure compliance with its policies.

FOLLOW-UP RECOMMENDATIONS
The Office of the Inspector General recommends that the Department of Corrections and Rehabilitation take the following
actions:
•

Systematically evaluate the effectiveness of the new alternative education delivery models. The evaluation should
include inmate participation rates, progress in achieving educational goals, and the impact of the programs on
recidivism.

•

The new Office of Correctional Education should dedicate staff to perform periodic on-site reviews to ensure
compliance with department policies and procedures. The on-site reviews should include, but not be limited to,
verification of educational representatives participating in classification committees, verification of class closures for
teacher vacancies beyond 30 days, and verification of the accuracy of timekeeping for inmate program participation.

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RICHARD A. MCGEE CORRECTIONAL TRAINING CENTER

RICHARD A. MCGEE CORRECTIONAL TRAINING CENTER
IMPLEMENTATION REPORT CARD

The Office of the Inspector General found that the
Richard A. McGee Correctional Training Center
has significantly improved its cadet training
program. The academy instituted guidelines for
course development that include instructor input,
cadet feedback, and Commission on Correctional
Peace Officer Standards and Training program
approval. Lesson plans for the now-expanded
academy are complete and were approved by the
commission. Cadet testing protocols are also
complete, as are operational procedures governing
test results retention.

Previous recommendations: 12
Fully implemented: 11 (92%)
Substantially implemented: 0 (0%)
Partially implemented: 0 (0%)
Not implemented: 1(8%)
Not applicable: 0 (0%)

In April 2000 the Office of the Inspector General conducted an unannounced special
review audit of the Richard A. McGee Correctional Training Center. The review was
prompted by numerous serious allegations that were reported to the Office of the
Inspector General in late March 2000. The allegations called into question the integrity of
test results for recent graduates of the basic correctional officer academy located at the
center and the overall preparedness of correctional officers graduating from the academy.
BACKGROUND
Established in the early 1970s, the Richard A. McGee Correctional Training Center (now
known as the Richard A. McGee Academy) conducts the basic correctional officer
academy program for all correctional officers training in California. Cadets who complete
the training are credentialed by the academy as certified correctional peace officers. In
addition to basic correctional officer training, the center provides advanced peace officer
and correctional officer training, parole agent training, management training, and a
leadership institute.
Before the Office of the Inspector General’s 2000 audit, the basic correctional officer
certification training program consisted of a six-week course given at the academy in
Galt, California. In fiscal year 1999-00, the Department of Corrections obtained a $5
million budget increase to expand the program to a ten-week course. The ten-week
curriculum required developing 77 new lesson plans, all of which were to have been
launched in January 2000. (Effective September 30, 2000, legislation further expanded
the ten-week course to 16 weeks.)
The Office of the Inspector General’s May 2000 audit reported a range of deficiencies in
the implementation of the new ten-week academy. Among other findings, it revealed
incomplete lesson plans, lesson plans that failed to receive Commission on Correctional
Peace Officer Standards and Training approval, academy courses that did not adhere to
specified lesson plan instructor-to-cadet ratios, testing and cadet evaluations that lacked
strict controls, and academy instructors who were insufficiently qualified.

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RICHARD A. MCGEE CORRECTIONAL TRAINING CENTER

Effective July 1, 2005, the Commission on Correctional Peace Officer Standards and
Training was dissolved and responsibility for academy oversight was transferred to the
Corrections Standards Authority. Legislated by Senate Bill 737, this transfer of authority
included the oversight to “develop, approve, and monitor standards for the selection and
training of state correctional peace officers.” The bill also renamed the training center the
Richard A. McGee Academy.
Although the Corrections Standards Authority is accountable for oversight of the
academy, the Department of Corrections and Rehabilitation is still required to design and
deliver training programs, conduct validation studies, and provide program support—
areas in which critical deficiencies were found in the May 2000 audit. These deficiencies
are the focus of this follow-up review.
SUMMARY OF PREVIOUS FINDINGS AND RECOMMENDATIONS
As a result of the May 2000 review, the Office of the Inspector General made the
following specific findings:
•

Cadets were being trained under the expanded ten-week curriculum even though a
significant number of the lesson plans had not been completed. The Department of
Corrections was able to completely develop only 46 of the required 77 new lesson
plans before January 2000, the start of the ten-week curriculum.

•

Many of the 46 lesson plans, including those for highly essential courses, had not
received provisional approval from the Commission on Correctional Peace Officer
Standards and Training. At the start of the January 2000 academy, only 23 completed
lesson plans had been submitted to the commission for approval, and only a portion
of the 23 had received provisional approval.

•

The Department of Corrections Staff Development Center and the training center
staff failed to coordinate efforts in developing the lesson plans. The training center
staff members informed the Office of the Inspector General that their suggestions for
lesson plans were consistently ignored. Consequently, the training staff found some
of the commission-approved training plans to be unacceptable and significantly
modified the plans without the knowledge of either the Staff Development Center or
the commission.

•

The training center did not maintain the instructor-to-cadet ratios specified in the
lesson plans approved by the Commission on Correctional Peace Officer Standards
and Training.

•

Guidelines for presenting lesson plans and administering tests were not prepared. No
written guidelines were developed for administering the lesson plans, presenting them
to a class, or evaluating their effectiveness. Likewise there were no written guidelines
for administering and securing the tests associated with each lesson plan.

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RICHARD A. MCGEE CORRECTIONAL TRAINING CENTER

•

The academy’s process for testing and certifying cadets under the ten-week
curriculum was seriously flawed. For example, the overall passing score for cadets
was, without justification, arbitrarily lowered from 85 percent to 80 percent; cadets
were permitted to retake tests more than once to increase scores; cadets were not
administered comprehensive examinations required by the California Department of
Corrections Operations Manual; the training center nullified a particular quiz because
the failure rate was too high; test questions were altered without commission
approval; students who failed firearms testing were allowed to graduate; written
evaluations of cadets by company commanders were not specific to individual cadets,
as intended; and cadets received disparate treatment relative to opportunities to
improve performance and to disciplinary actions for similar offenses.

•

Except for the quiz on radio communications, test results had not been destroyed. The
staff at the training center’s examination unit initially informed the Office of the
Inspector General that all test and quiz results had been destroyed at the completion
of the first ten-week course. However, other training center staff members later
produced test and quiz results, except for those pertaining to the radio
communications class. According to the training center staff, the radio
communications quiz was destroyed because the quiz was nullified.

•

Instructor qualifications and class preparation time were deficient. Because
certification of many of the instructors at the academy had not been evaluated by an
objective certifying agency, some may not have been qualified in the subjects they
taught. Also, they were required to teach eight to 12 hours a day on a variety of
subjects, and the Staff Development Center was often tardy in supplying lesson plans.
As a result, instructors had inadequate time for class preparation. These factors were
further exacerbated by the academy’s overall instructor shortage. The training center
estimated that nine additional instructors were needed to effectively institute the
lesson plans.

As a result of the May 2000 review, the Office of the Inspector General recommended
that the Richard A. McGee Correctional Training Center, in consultation with the Staff
Development Center and the Commission on Correctional Peace Officer Standards and
Training, take the following actions:
•

Complete all lesson plans.

•

Obtain lesson plan approval from the Commission on Correctional Peace Officer
Standards and Training.

•

Develop lesson plans in a collaborative effort between the Staff Development
Center and the Correctional Training Center.

•

Adhere to lesson plan staff-to-cadet ratios.

•

Prepare guidelines for presenting lesson plans and administering tests.

•

Establish a clearly defined testing protocol that measures cadet performance.

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RICHARD A. MCGEE CORRECTIONAL TRAINING CENTER

•

Handle and dispose of test results appropriately.

•

Develop an action plan.

•

Provide instructors with approved lesson plans and written guidelines.

•

Follow prescribed guidelines in administering tests.

•

Ensure that instructors are fully qualified.

•

Determine the need for remedial training of cadets who had recently completed
the new ten-week curriculum.

OBJECTIVES, SCOPE, AND METHODOLOGY
The purpose of the 2006 follow-up review was to determine the extent to which the
Richard A. McGee Academy has implemented the 12 recommendations from the Office
of the Inspector General’s May 2000 review. To conduct the follow-up review, the Office
of the Inspector General provided the California Department of Corrections and
Rehabilitation Office of Departmental Training and the Richard A. McGee Academy
with a table listing the May 2000 findings and recommendations and requested the
implementation status of each recommendation. The Office of the Inspector General
reviewed the responses, along with documentation provided by the academy, and
evaluated the degree of compliance or noncompliance with the recommendations.
Review fieldwork was completed in November 2005. The results are presented in the
table that follows this section.
SUMMARY OF THE 2006 FOLLOW-UP RESULTS
Of the 12 recommendations issued by the Office of the Inspector General in May 2000
concerning the academy’s administration of its correctional cadet training program, 11
recommendations have been fully implemented and one recommendation, relating to the
possible need for remedial training of cadets who had recently completed the ten-week
curriculum, has not been implemented.
The Office of the Inspector General found that the Richard A. McGee Academy has
significantly improved its cadet training program. The academy implemented guidelines
for course development that include instructor input, cadet feedback, and Commission on
Correctional Peace Officer Standards and Training approval. Lesson plans for the nowexpanded academy are complete and have been approved by the Commission on
Correctional Peace Officer Standards and Training (now the Corrections Standards
Authority). Cadet testing protocols and test retention policy also have been completed.
FOLLOW-UP RECOMMENDATIONS
None.
The following table summarizes the results of the follow-up review.

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ORIGINAL FINDING NUMBER 1
The Office of the Inspector General found that cadets were being trained under the expanded ten-week curriculum even
though a significant number of the lesson plans had not been completed.
ORIGINAL RECOMMENDATION
The Office of the Inspector General
recommended that the California Department
of Corrections Staff Development Center
complete all lesson plans.

STATUS
FULLY
IMPLEMENTED

COMMENTS
According to the Department of Corrections and Rehabilitation Office of Training
and Professional Development, the ten-week curriculum was expanded to 16
weeks and all lesson plans were completed as of June 11, 2003.

FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 2
The Office of the Inspector General found that many of the lesson plans, including those for highly essential courses, had not
received provisional approval from the Commission on Correctional Peace Officer Standards and Training.
ORIGINAL RECOMMENDATION
The Office of the Inspector General
recommended that the California Department
of Corrections Staff Development Center, in
consultation with the training center, obtain
Commission on Correctional Peace Officer
Standards and Training approval of lesson
plans.

STATUS
FULLY
IMPLEMENTED

COMMENTS
The Department of Corrections and Rehabilitation Office of Training and
Professional Development reported that all lesson plans comprising the 16-week
Basic Correctional Officer Academy curriculum were approved by the
Commission on Correctional Peace Officer Standards and Training as of June 11,
2003. The approval is still valid under the new Corrections Standards Authority.

FOLLOW-UP RECOMMENDATIONS
None.

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ORIGINAL FINDING NUMBER 3
The Office of the Inspector General found that the Department of Corrections Staff Development Center and the training
center staff failed to coordinate efforts in developing the lesson plans.
ORIGINAL RECOMMENDATION

STATUS

COMMENTS

The Office of the Inspector General
recommended that the California Department
of Corrections Staff Development Center and
the Correctional Training Center develop
lesson plans in a collaborative effort.

FULLY
IMPLEMENTED

With the July 1, 2005 reorganization of the Department of Corrections and
Rehabilitation, instructional designers have been relocated to the Basic Peace
Officer Institute at the Richard A. McGee Academy. According to the Office of
Training and Professional Development, as lesson plans are developed and
revised, designers will rely on instructor and cadet evaluations, classroom
visitation, and pilot testing to coordinate materials used in the lesson plans.
Academy instructors have been apprised of this process and have been
encouraged to provide input.

FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 4
The Office of the Inspector General found that the training center did not maintain the instructor-to-cadet ratios specified in
the approved lesson plans.
ORIGINAL RECOMMENDATION
The Office of the Inspector General
recommended that the California Department
of Corrections Staff Development Center
ensure adherence to lesson plans and written
guidelines including maintaining specified
lesson plan ratios.

OFFICE OF THE INSPECTOR GENERAL

STATUS
FULLY
IMPLEMENTED

COMMENTS
According to the Office of Training and Professional Development, one of the
chief priorities of the basic academy’s scheduling office is to ensure that courses
are in compliance with required staff-to-cadet ratios specified by approved lesson
plans.

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FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 5
The Office of the Inspector General found that guidelines for presenting lesson plans and administering tests were not
prepared.
ORIGINAL RECOMMENDATION
The Office of the Inspector General
recommended that the California Department
of Corrections Staff Development Center
prepare guidelines for presenting lesson plans
and administering tests.

STATUS
FULLY
IMPLEMENTED

COMMENTS
The Department of Corrections Staff Development Center informed the Office of
the Inspector General that guidelines for presenting lesson plans are complete and
were approved by the Commission on Correctional Peace Officer Standards and
Training.
All academy instructors receive a Correctional Sergeant/Instructor Handbook
containing instructional guidelines that include the following:
•
•
•
•
•
•
•
•
•
•
•
•

Course length
Prerequisites
Recommended maximum number of students
Related courses
Required resources
Instructional goal
Core tasks
Learning objectives
Learning activities
Evaluation methodology
Outline of the course presentation
PowerPoint slides used, if applicable

In addition, guidelines were established for administering basic academy tests.
Testing falls into two categories: written objective testing and skills
demonstration testing. The Curriculum Testing and Evaluation Section at the
academy administers all written examinations; skills testing is predicated on
individual lesson plans.

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FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 6
The Office of the Inspector General found that the academy’s process for testing and certifying cadets under the ten-week
curriculum was seriously flawed.
ORIGINAL RECOMMENDATION
The Office of the Inspector General
recommended that the California Department
of Corrections Staff Development Center
establish and clearly define a testing protocol
that measures cadet performance.

STATUS
FULLY
IMPLEMENTED

COMMENTS
According to the Office of Training and Professional Development, the basic
academy uses five separate instruments to gauge cadet performance: practice
exercises, major exams, performance tests, the California Penal Code 832 test,
and on-the-job observation. The protocol sets guidelines for the development of
each of these measuring instruments, including establishing pass points,
continuous improvement, test administration procedures, and test security.

FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 7
The Office of the Inspector General found that except for the quiz on radio communications, test results had not been
destroyed.
ORIGINAL RECOMMENDATION
The Office of the Inspector General
recommended that the Richard A. McGee
Correctional Training Center handle and
dispose of test results appropriately.

OFFICE OF THE INSPECTOR GENERAL

STATUS
FULLY
IMPLEMENTED

COMMENTS
On August 22, 2005 the academy approved Operational Procedure #B-038, which
mandates that all hard copies of cadet tests and scantrons be destroyed upon
graduation, unless a cadet is involved in any administrative action relative to poor
academics or testing irregularities, whereupon those tests and scantrons will be

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maintained on-site for two years. The records will then be archived off-site for
three years. Cadet academic scores, range scores, participation logs, and related
class materials are securely maintained on-site for two years in the testing office
and three years at the off-site archives location. After five years’ storage, the
documents are confidentially shredded. At the conclusion of each academy, a
password-protected copy of the testing files for each class is created and archived.
A chronological electronic history of academy classes is maintained indefinitely
in the testing office.

FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 8
The Office of the Inspector General found that instructor qualifications and class preparation time were deficient.
ORIGINAL RECOMMENDATIONS

STATUS

COMMENTS

The Office of the Inspector General
recommended the actions listed below.

The California Department of Corrections
Staff Development Center, in consultation with
the training center and the Commission on
Correctional Peace Officer Standards and
Training develop an action plan.

FULLY
IMPLEMENTED

The California Department of Corrections
FULLY
IMPLEMENTED
Staff Development Center should provide
approved lesson plans and written guidelines to
academy instructors.

OFFICE OF THE INSPECTOR GENERAL

The academy developed an action plan following the Office of the Inspector
General’s May 2000 report. The latest version of the action plan submitted to the
Office of the Inspector General, dated September 16, 2000, indicated that 35 of
the 37 action items had been completed. The remaining two action items were not
related to the Office of the Inspector General's recommendations.
The Office of the Inspector General was informed that copies of approved lesson
plans have been provided to basic correctional academy instructors. Further, in
March 2005 the academy revised its Correctional Sergeant/Instructor Handbook
to include guidelines for training cadets.

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The Richard A. McGee Correctional Training
Center follow prescribed guidelines in
administering tests.

FULLY
IMPLEMENTED

Operational procedures applying to major exam administration and scoring
instructions were approved in March 2005. According to the academy, the center
administration will review these procedures annually for any necessary
amendments.

The Richard A. McGee Correctional Training
Center ensure that instructors are fully
qualified.

FULLY
IMPLEMENTED

The academy reported that it maintains training files for all instructors. According
to the academy, every basic academy instructor’s in-service training file has been
analyzed and a complete accounting of instructor certification training has been
made. A certification spreadsheet has been created and the academy’s scheduling
office uses the spreadsheet to ensure that instructors are assigned to teach only
courses for which they have the necessary certificates.

The California Department of Corrections
should determine the need for remedial
training of cadets recently completing the new
ten-week curriculum.

NOT
IMPLEMENTED

The academy observed that several years have elapsed since the last class of the
Basic Correctional Officer Academy graduated under the circumstances identified
by the May 2000 audit. There is no documentation of follow-up work to
determine the need for remedial training. Further, the academy suggests that any
deficiencies in the training of cadets in the original ten-week academy would
likely have been addressed by corrective action tied to performance problems or
by ongoing service training.

FOLLOW-UP RECOMMENDATIONS
None.

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CALIFORNIA STATE PRISON, SOLANO

CALIFORNIA STATE PRISON, SOLANO

IMPLEMENTATION REPORT CARD

Previous recommendations: 24
The Office of the Inspector General found that the
California State Prison, Solano has improved
Fully implemented: 19 (79%)
certain of its operations since a March 2003
Substantially implemented: 2 (9%)
management review audit. The facility more closely
monitors inmates’ tuberculosis status, better
Partially implemented: 2 (8%)
manages sentence reduction credits granted to
inmates, and has improved its management of both
Not implemented: 1 (4%)
inmates placed in administrative segregation and
Not applicable: 0 (0%)
those taking psychotropic medications. Although it
has made significant progress, the facility has only
partially implemented recommendations to
properly house inmates taking anticonvulsant medications and has not taken steps
to monitor its pharmacy inventory.

In March 2003, the Office of the Inspector General conducted a management review
audit of California State Prison, Solano pursuant to its authority under California Penal
Code, section 6051. The review was conducted to assess the essential functions of the
facility. As a result of the review, the Office of the Inspector General found deficiencies
in tracking inmate tuberculosis status, improper assignment of sentence reduction credits,
ineffective monitoring of the length of time inmates spend in administrative segregation,
unsafe modifications to the administrative segregation buildings, and inappropriate
housing for inmates taking psychotropic and anticonvulsant medications.
BACKGROUND
California State Prison, Solano opened in August 1984 and is a medium-security
institution covering 146 acres in Vacaville, California. The prison was initially
administered by the warden of the California Medical Facility, the adjacent institution,
but beginning in January 1992 it was administered as a separate institution under its own
warden. California State Prison, Solano was designed to house 2,658 inmates, but it
currently houses about 5,800 Level II and Level III inmates. The prison provides a
comprehensive work/training program that offers academic and vocational training as
well as industry assignments.
SUMMARY OF PREVIOUS FINDINGS AND RECOMMENDATIONS
As a result of the March 2003 review, the Office of the Inspector General made the
following specific findings:
•

California State Prison, Solano was not adequately tracking inmates with
tuberculosis, creating the potential of exposing inmates throughout the state to the
disease and presenting a risk to the correctional staff and the general public.

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CALIFORNIA STATE PRISON, SOLANO

•

California State Prison, Solano inmates were allowed to earn sentence reduction
credit through education and training classes even when classes were not actually
held.

•

Makeshift partitions in the institution’s administrative segregation unit buildings
created blind spots that limited the view of the control booth officers, compromising
the safety and security of correctional staff and inmates.

•

A significant number of inmates taking psychotropic medications were
inappropriately housed in buildings lacking air conditioning and some inmates who
were taking anticonvulsant medications were not assigned to lower bunks to lessen
the possibility of injury in the event of a seizure.

•

When inmate deaths occurred, the cause and circumstances surrounding the deaths
were not examined in a timely manner and those assigned to conduct the reviews may
have had a direct interest in the results.

•

California State Prison, Solano retained inmates in administrative segregation units
longer than justified.

•

California State Prison, Solano was not complying with state regulations governing
inmate dental care and as a result may have been exposed to the risk of litigation.

•

California State Prison, Solano did not adequately document employee disciplinary
proceedings, and the warden inappropriately served as the Skelly hearing officer in
appeals of adverse action decisions.

•

Pharmacy record keeping and physical controls over prescription medications stored
in the infirmary and clinics were inadequate to prevent unauthorized access and theft.

•

California State Prison, Solano did not promptly implement medical modification
orders and many were significantly overdue at the time of the audit.

•

The institution was not properly documenting inmate activity in the administrative
segregation units and in some instances events were logged before they occurred.

•

California State Prison, Solano prepared an excessive number of daily meals for
inmates, resulting in unnecessary added costs for food and related services.

The Office of the Inspector General presented 24 recommendations to remedy the
deficiencies identified in the March 2003 review.
OBJECTIVES, SCOPE, AND METHODOLOGY
The purpose of the 2006 follow-up review was to determine the extent to which the
California State Prison, Solano has implemented the 24 recommendations from the Office
of the Inspector General’s March 2003 management review audit. To conduct the followOFFICE OF THE INSPECTOR GENERAL

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CALIFORNIA STATE PRISON, SOLANO

up review, the Office of the Inspector General provided the California State Prison,
Solano with a table listing the March 2003 findings and recommendations and asked
management to provide the implementation status of each recommendation. The Office
of the Inspector General reviewed the responses, along with documentation provided by
the facility, and evaluated the degree of compliance or noncompliance with the
recommendations. In addition, the Office of the Inspector General visited the facility in
October 2005 to conduct on-site verification and interviews with staff members. The
fieldwork for the follow-up review was completed during February 2006. The results are
presented in the table following this narrative.
SUMMARY OF THE 2006 FOLLOW-UP RESULTS
Of the 24 recommendations issued by the Office of the Inspector General in March 2003
concerning the California State Prison, Solano, 19 recommendations have been fully
implemented; two have been substantially implemented; two have been partially
implemented; and one has not been implemented.
The Office of the Inspector General found that the California State Prison, Solano has
made significant progress in implementing the recommendations made in the March 2003
report. Specifically, the Office of the Inspector General made the following findings:
•

The facility has improved its monitoring of inmates who have tested positive for
tuberculosis by adding staff and increasing follow-up assessments of those inmates.

•

In closing classes with no assigned instructors, the facility has reduced the rate at
which it grants sentence-reduction credits to inmates who otherwise did not attend
classes.

•

The facility installed mirrors that improved visibility in its administrative segregation
units.

•

The facility has implemented procedures to ensure that inmates taking psychotropic
medications—which increase inmates’ susceptibility to heat-related illnesses—are
appropriately housed and monitored when temperatures are higher than 90 degrees.
The facility should, however, improve its monitoring of inmates taking anti-seizure
medications to ensure that those inmates are assigned to lower bunks to protect their
safety.

•

The department implemented new procedures in December 2005 relative to reporting
inmate deaths and submitting specific documents related to each death to
headquarters for analysis.

•

In July 2005, the department obtained additional resources to improve statewide
dental care. It is too early, however, for the Office of the Inspector General to
determine whether those additional resources will improve inmate dental care.

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•

CALIFORNIA STATE PRISON, SOLANO

The pharmacy at California State Prison, Solano has improved its security over nonnarcotic medications, but still does not have a method to monitor their inventory.
FOLLOW-UP RECOMMENDATIONS
The Office of the Inspector General recommends that the California State
Prison, Solano take the following additional actions:
•

Conduct periodic evaluations of the housing assignments of inmates who
have been prescribed seizure medications to ensure that those inmates are
housed appropriately.

•

Develop a method to reconcile the types and quantities of
pharmaceuticals shipped from its pharmacy to its clinics and the
correctional treatment center with the types and quantities of
medications prescribed to inmates.

The Office of the Inspector General recommends that the California
Department of Corrections and Rehabilitation take the following additional
actions:
•

Assess whether the increased dental staffing and equipment have
improved the availability of dental examinations to inmates across all
institutions.

The following table summarizes the results of the follow-up review.

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CALIFORNIA STATE PRISON, SOLANO

ORIGINAL FINDING NUMBER 1
The Office of the Inspector General found evidence that California State Prison, Solano was not adequately tracking inmates
with tuberculosis, creating the potential of exposing inmates throughout the state to the disease and presenting a risk to the
correctional staff and the general public.
ORIGINAL RECOMMENDATIONS

STATUS

COMMENTS

The Office of the Inspector General
recommended that California State Prison,
Solano take the actions listed below to
improve the identification and tracking of
inmate tuberculosis status.
Allocate additional personnel resources to the
task of monitoring and recording inmate
tuberculosis status.

FULLY
IMPLEMENTED

California State Prison, Solano reported that the medical department has
provided additional resources to assist the public health nurse and infection
control nurse in monitoring inmates’ tuberculosis (TB) status. Specifically, it
assigned a TB manager to oversee the project, updated its TB policies and
procedures, and assigned additional clerical staff to medical records. It also
assigned a staff physician to oversee auditing of the TB alert program. The
facility also reports that nursing supervisors daily review TB testing of
incoming inmates.
The Office of the Inspector General interviewed the chief medical officer and
verified that additional staff members have been assigned to oversee the
facility’s TB alert program. According to the chief medical officer, a
physician oversees the TB alert program and two public health nurses work
nearly full-time monitoring TB alert program information in inmate medical
records. Additionally, an infection control nurse and a health program
coordinator work part-time on the TB alert program.

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Require the public health nurse to collect all
records for inmates who have completed a
tuberculosis treatment regimen to ensure that
those inmates receive a post-treatment
evaluation by a physician.

CALIFORNIA STATE PRISON, SOLANO

SUBSTANTIALLY
IMPLEMENTED

The facility reported that the public health nurse is required to monitor and
ensure that all inmates, including new arrivals, are processed, evaluated, and
receive a post-treatment physician evaluation and follow-up. This process is
audited by a staff physician and nursing supervisors.
The Office of the Inspector General interviewed the chief medical officer,
who stated that the institution is closely monitoring 186 inmates who
previously tested positive for the TB skin test. In addition, the physician who
monitors the TB alert program stated that, beginning in March 2006, all
inmates previously testing positive, but who refused to take or stopped taking
medication, will be counseled and strongly advised to begin or complete the
prophylactic medication series. According to the chief medical officer,
inmates who test positive for the TB skin test have a 50 percent chance of
developing infectious TB within two years. The physician further informed
the Office of the Inspector General that inmates receive evaluations over the
course of treatment to ensure that there is no adverse reaction to the
medication, although post-treatment evaluation is not administered in all
cases. Alternatively, post-treatment evaluation typically occurs in light of a
separate clinical need, such as if the inmate has other medical issues that
require follow-up.
The chief medical officer also affirmed that the facility will shortly initiate
new procedures to assess the clinical need for a chest x-ray for new inmates
who had previously tested positive for TB but who had either refused to take
or had not completed taking the prophylactic medication series. For these
inmates, a chest x-ray would be considered if the inmate’s previous chest xray had been taken more than three months earlier and if such clinical
symptoms as night sweats, coughing, fever, or recent weight loss were
evident.

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Require the public health nurse to ensure that
tuberculosis codes are properly updated in
inmate medical records and in the
department’s system-wide database and that a
CDC Form 128-C (medical chrono) is
forwarded to the central records staff for
inclusion in the inmate’s central file.

CALIFORNIA STATE PRISON, SOLANO

FULLY
IMPLEMENTED

The facility reported that the department’s Division of Correctional Health
Care Services developed a standardized statewide inmate TB alert system.
The facility’s public health nurse monitors the system daily for compliance
and ensures that a completed CDC Form 128-C (medical chrono) is
forwarded to the records office for inclusion in the inmate’s central file.
The physician who oversees the TB alert system at the facility also affirmed
to the Office of the Inspector General that, between January and June 2005,
she audited medical records monthly to ensure that inmates’ TB status
(coding) and TB-related documents concur with their medical records. She
reported further that she had observed a substantial improvement in recordkeeping monitored by the public health nurses. In addition, the chief medical
officer reported that the public health nurse has fully reconciled the TB codes
recorded in inmate medical records with those in the system-wide database.

FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 2
The Office of the Inspector General found that California State Prison, Solano inmates were allowed to earn sentencereduction credit through education and training classes even when classes were not actually held.

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ORIGINAL RECOMMENDATIONS

CALIFORNIA STATE PRISON, SOLANO

STATUS

The Office of the Inspector General
recommended that California State Prison,
Solano refer all inmates currently assigned to
programs without instructors to the
classification committee for reassignment in
accordance with the May 16, 2002
memorandum from the Department of
Corrections Institutions Division and
discontinue awarding “S” time to these
inmates.

FULLY
IMPLEMENTED

The Office of the Inspector General also
recommended that California State Prison,
Solano immediately identify which classes
should be closed and take formal steps to do
so.

FULLY

COMMENTS
California State Prison, Solano reported that the education supervisor is
monitoring these issues. When long-term class closures are anticipated, they
are communicated to the inmate assignment lieutenant for temporary
deactivation. Additionally, monthly education reports itemize specific reasons
for “S” time to guide supervisors in rectifying deficiencies.
The Office of the Inspector General found that the facility closed eight classes
in 2005. The facility also reduced the percentage of inmate “S” time credits.
(Regulations authorize the department to award inmates sentence-reduction
credit under certain circumstances, such as when instructors are absent and no
relief instructor is available. These time credits are referred to as “S” time
credits.) In fiscal year 2001-02, 62 percent of the time credits granted for
education were “S” time hours, whereas in fiscal year 2004-05, the percentage
of “S” time hours decreased to 46 percent.

IMPLEMENTED

California State Prison, Solano reported that inmates assigned to education
classes identified as permanently closed are referred to the work incentive
coordinator for reassignment as appropriate. The classes are then documented
as closed and inmates are no longer assigned to those classes.
The Office of the Inspector General found that the facility closed eight classes
in 2005.

FOLLOW-UP RECOMMENDATIONS
None.

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CALIFORNIA STATE PRISON, SOLANO

ORIGINAL FINDING NUMBER 3
The Office of the Inspector General found that makeshift partitions in the institution’s administrative segregation unit
buildings created blind spots that limited the view of the control booth officers, compromising the safety and security of
correctional staff and inmates.
ORIGINAL RECOMMENDATION
The Office of the Inspector General
recommended that California State Prison,
Solano remove the makeshift barriers in the
administrative segregation unit and develop
alternatives for creating meeting space.

STATUS
SUBSTANTIALLY
IMPLEMENTED

COMMENTS
California State Prison, Solano reported that the floors have been painted with
a red line, convex mirrors have been installed, partitions are currently secured
to the floor, and obstructions have been removed from cabinet tops. In
addition, the facility reported that the institutional staff reviewed the Office of
the Inspector General’s recommendation to remove the partitions and decided
to retain them because they furnish privacy for inmate mental health and
medical evaluation interviews.
Although the partitions still present blind spots to the control booth officer,
the Office of the Inspector General believes that the facility’s modifications
have improved control booth officers’ visibility and are the most feasible
solution to the original recommendation.

FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 4
The Office of the Inspector General found that a significant number of inmates taking psychotropic medications were
inappropriately housed in buildings lacking air conditioning and that some inmates who were taking anticonvulsant
medications were not assigned to lower bunks to lessen the possibility of injury in the event of a seizure.

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ORIGINAL RECOMMENDATION
The Office of the Inspector General
recommended that the institution conduct
periodic evaluations of the housing
assignments of inmates who have been
prescribed psychotropic medications or whose
medical conditions indicate particular housing
needs. When a housing assignment is found to
be incompatible with an inmate’s medical
condition, the institution should take
immediate measures to reassign the inmate to
appropriate housing.

CALIFORNIA STATE PRISON, SOLANO

STATUS
PARTIALLY
IMPLEMENTED

COMMENTS
California State Prison, Solano reported that its extreme weather plan
(institutional operations plan CSPS-CS/AD-04-015) requires specific staff
procedures to minimize health risks to inmates who could be adversely
affected if exposed to high ambient temperatures. In addition, the facility
reported that inmates who suffer from seizure disorders are required to be
identified by unit staff to ensure compliance with lower bunk requirements.
The Office of the Inspector General reviewed the extreme weather plan and
related documents. The Office of the Inspector General found that the facility
medical staff generates a daily list of heat-risk inmates, and that custody staff
monitors inside and outside air temperatures hourly. Further, the facility
extreme weather plan outlines specific steps to be followed when
temperatures exceed 90 and 95 degrees. When inside temperatures exceed 95
degrees, medical staff members visually monitor heat-risk inmates every two
hours and must contact the chief medical officer for a diagnosis when a heatrisk inmate appears to be suffering from heat exposure.
The Office of the Inspector General also analyzed pharmacy records for
September 2005 and identified eight inmates who had been prescribed seizure
medications, yet records indicated that the inmates were not assigned to lower
bunks, putting them at risk of a fall-related injury in the event of a seizure.
The Office of the Inspector General requested that the chief medical officer
assess whether these inmates had health conditions that required placement in
lower bunks; according to the chief medical officer, five of the eight did
require lower bunks. In response, the Office of the Inspector General alerted
the warden’s office, which determined that two of the five were currently
housed in lower bunks, leaving three remaining inmates in upper bunks.

FOLLOW-UP RECOMMENDATION
The Office of the Inspector General recommends that the institution conduct periodic evaluations of the housing assignments
of inmates who have been prescribed seizure medications to ensure that these inmates are housed appropriately.

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CALIFORNIA STATE PRISON, SOLANO

ORIGINAL FINDING NUMBER 5
The Office of the Inspector General found that when inmate deaths occurred, the cause and circumstances surrounding the
deaths were not examined in a timely manner and that those assigned to conduct the reviews may have had a direct interest in
the results.
ORIGINAL RECOMMENDATIONS

STATUS

COMMENTS

The Office of the Inspector General
recommended that the Department of
Corrections develop procedures to require the
Health Care Services Division to take the steps
listed below to improve review of inmate
deaths.
Coordinate review of inmate deaths with the
warden and the institution’s chief medical
officer. The procedures should provide for
communication throughout the review process
to coordinate the assignment of staff and
collection of evidence by the investigative staff
when necessary.

FULLY
IMPLEMENTED

On December 30, 2005, the department’s director over the Division of
Correctional Health Care Services issued a directive requiring that all inmate
death-related documents be submitted to the division within seven calendar
days following the date of death. Division staff also told the Office of the
Inspector General that, beginning January 2006, all inmate deaths are
reviewed by a headquarters-based death review committee comprised of
division staff, medical professionals, and representatives from the Office of
Internal Affairs. At present, the death review committee is monitored by the
Office of the Inspector General’s Bureau of Independent Review. The
committee meets every two weeks and can issue referrals for peer reviews
and/or internal affairs investigations. Referrals for internal affairs
investigations related to inmate deaths can also be initiated by the institution’s
chief medical officer or the warden.
Because the death review process and peer review process are new, the Office
of the Inspector General did not assess their effectiveness during this audit. It,
anticipates, however, that it will provide comments to the division and

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appropriate departmental officials as part of its ongoing monitoring of the
death review process.

Forward pertinent information gathered by the
investigations unit of the institution to the
morbidity and mortality review committee.

FULLY
IMPLEMENTED

According to the director of the division’s medical program implementation,
the morbidity and mortality review committee has been replaced. Inmate
deaths are now reviewed by the death review committee described above, and
inmate suicides are reviewed by staff members who have clinical,
psychological, and custodial expertise. The December 30, 2005 directive
provides that all information related to inmate deaths is forwarded to the
division. As noted above, the death review committee includes representatives
from the Office of Internal Affairs and is presently monitored by the Office of
the Inspector General’s Bureau of Independent Review.

Ensure that those conducting peer reviews are
independent of the incident and the individuals
involved.

FULLY
IMPLEMENTED

According to the division’s director of medical program implementation, peer
reviews are now coordinated through the regional medical directors and the
professional practice executive committee. These peer reviews can be initiated
by the death review committee or health care managers, and are conducted
either by regional staff or external University of California experts.

Ensure that peer reviews are completed in a
timely manner.

FULLY
IMPLEMENTED

The division reported to the Office of the Inspector General that, because they
are now coordinated through headquarters division staff, peer reviews are
monitored for timely completion by headquarters staff.

FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 6
The Office of the Inspector General found that California State Prison, Solano retained inmates in administrative segregation
units longer than justified.

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ORIGINAL RECOMMENDATIONS

CALIFORNIA STATE PRISON, SOLANO

STATUS

COMMENTS

The Office of the Inspector General
recommended that the warden take the actions
listed below.
Develop a standard tracking system for use by
all of the housing facilities to monitor inmates
retained in administrative segregation. The
tracking system should record all critical
actions, including communication with
employees and other units within the
institution, to ensure that casework is
completed in a timely manner.
Emphasize the importance of completing
casework before presenting cases at the
institution classification committee hearing or
submitting cases to the classification services
representative for review and approval.

Provide training to correctional counselors and
other members of the institution staff to ensure
that all actions required in administrative
segregation cases are completed and the results
documented and communicated to the
appropriate staff.
Identify all cases that have been deferred
pending action or returned by the classification
services representative for completion of
additional casework and monitor these cases

OFFICE OF THE INSPECTOR GENERAL

FULLY
IMPLEMENTED

FULLY
IMPLEMENTED

FULLY
IMPLEMENTED

FULLY
IMPLEMENTED

The institution reported that its inmate classification information system is
currently being used to monitor inmates retained in administrative
segregation. This local information system tracks all critical actions, including
communication with employees and other units, to ensure that casework is
completed in a timely manner.

The institution reported that caseworkers can now prepare the appropriate
documentation before presenting cases to the institutional classification
committee by using the inmate classification information system. The Office
of the Inspector General’s review of institutional classification committee
actions relative to administrative segregation inmates confirmed that casework
is completed before cases are presented to the institution classification
committee.
The institution reported that it provides training to correctional counselors and
other institutional staff weekly or monthly. It furnished the Office of the
Inspector General with copies of weekly agenda meeting topics supported by
sign-in sheets for training conducted in 2004 and 2005, indicating that the
topic of administrative segregation had been included.
The institution generates a deferral list of administrative segregation inmates
whose institution classification committee hearings have been deferred
pending results from investigations, parole hearings, district attorney requests,
rules violation reports, or other administrative issues. This list is provided to

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closely to ensure that tasks are completed by
the institution staff in a timely manner.
The Office of the Inspector General further
recommended that the Department of
Corrections follow the procedural requirements
for amending regulations as required by the
California Government Code.

the chief deputy warden for review and forwarded to division heads to ensure
that the pending circumstances are monitored.
FULLY
IMPLEMENTED

The Department reported that it follows the procedural requirements for
amending regulations as required by the California Government Code. The
Office of the Inspector General originally found that the department’s
Institutions Division disseminated a department-wide memo in November
2001, directing institutions to re-evaluate an inmate’s retention in
administrative segregation every 90 to 180 days, depending on the reason for
the retention, instead of the mandate of at least every 30 days. Since the
Office of the Inspector General’s original audit, the department’s Regulation
and Policy Management Branch processed the formal regulation change, and
effective December 15, 2005, the regulation change became permanent.

FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 7
The Office of the Inspector General found that California State Prison, Solano was not complying with state regulations
governing inmate dental care and as a result may have been exposed to the risk of litigation.

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ORIGINAL RECOMMENDATION
The Office of the Inspector General
recommended that the California Department
of Corrections examine policies and regulatory
requirements governing inmate dental care and
consider revising requirements to a level
achievable under present conditions.

CALIFORNIA STATE PRISON, SOLANO

STATUS
PARTIALLY
IMPLEMENTED

COMMENTS
The department reported that it is examining its policies and regulatory
requirements in the course of drafting a dental policy and procedure manual.
The department also reported its submission of a fiscal year 2005-06 finance
letter to secure additional positions and equipment specifically for
department-wide dental care.
The Office of the Inspector General found that inmates did not receive the
required dental examinations under California Code of Regulations, Title 15,
which requires that inmates receive an initial dental examination within 14
days of arrival from the reception center. Further, inmates under age 50 are to
receive a dental examination every two years; all other inmates are to receive
a dental examination annually.
The Office of the Inspector General also found that the drafted dental policy
and procedure manual does not address the inmate dental care issues
identified in the audit. Also, the department does not offer any proposed or
pending changes to Title 15 that would alter the frequency of inmate dental
examinations.
The finance letter to increase department-wide dental care was approved in
July 2005, adding 63 positions and $13.3 million. It is too early, however, for
the Office of the Inspector General to determine whether these additional
resources will improve the availability of inmate dental care examinations.

FOLLOW-UP RECOMMENDATION
The California Department of Corrections and Rehabilitation should assess whether the increased dental staffing and
equipment have improved the availability of dental examinations to inmates across all institutions.

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ORIGINAL FINDING NUMBER 8
The Office of the Inspector General found that California State Prison, Solano did not adequately document employee
disciplinary proceedings and that the warden inappropriately served as the Skelly hearing officer in appeals of adverse action
decisions.
ORIGINAL RECOMMENDATIONS

STATUS

COMMENTS

The Office of the Inspector General
recommended that California State Prison,
Solano take the actions listed below.

Take steps to ensure that the employee
relations officer and all others involved in
possible employee disciplinary proceedings
document their actions thoroughly and
completely in the adverse action files to
provide a complete and accurate history of
critical steps in the disciplinary process and
assist the employee relations officer in
developing consistent disciplinary
recommendations in future cases.

OFFICE OF THE INSPECTOR GENERAL

FULLY
IMPLEMENTED

California State Prison, Solano reported that the employee relations officer
uses a checklist contained within each adverse action file for an overview of
the critical steps taken in employee disciplinary proceedings, ranging from a
review of circumstances for possible adverse action to taking adverse action
through the appeal process. The completed adverse action files also contain
supporting documentation.
As part of its follow-up review, the Office of the Inspector General examined
samples of adverse action files and found that they were supported by
documentation of the disciplinary steps taken.

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Discontinue the practice of the warden acting
as the Skelly hearing officer in personnel
matters involving California State Prison,
Solano.

CALIFORNIA STATE PRISON, SOLANO

FULLY
IMPLEMENTED

California State Prison, Solano reported that it no longer engages the warden
or chief deputy warden to conduct Skelly hearings. Alternatively, associate
wardens who are not within the chain of command of the affected employee
conduct these hearings.
As part of its follow-up review, the Office of the Inspector General reviewed
samples of adverse action files and found that the hearing officer was a noninvolved manager.
In addition, as discussed in the chapter of this audit which relates to the
employee disciplinary process, the Office of the Inspector General’s followup review to its initial March 2002 review of the department’s employee
disciplinary process found that the Department of Corrections and
Rehabilitation has made significant improvements in administering the
employee disciplinary process by updating its policies and procedures for
employee discipline, providing formalized training to its statewide employee
relations officers, and developing a case management system to monitor the
comprehensive stages of disciplinary cases. It has also implemented a new
central intake process that includes legal representatives from both the
Department of Corrections and Rehabilitation and the Office of the Inspector
General’s Bureau of Independent Review to review requests for investigations
and determine appropriate action.

FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 9
The Office of the Inspector General found that pharmacy record keeping and physical controls over prescription medications
stored in the infirmary and clinics were inadequate to prevent unauthorized access and theft.

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ORIGINAL RECOMMENDATIONS

CALIFORNIA STATE PRISON, SOLANO

STATUS

COMMENTS

The Office of the Inspector General
recommended that the health care manager at
California State Prison, Solano take the actions
listed below to improve control over
pharmaceuticals.
Institute measures to ensure that medications
are securely stored at all times consistent with
their value and potential for misuse.
Medications in the infirmary and clinics should
be stored in secured areas under a supervisor’s
control.

FULLY
IMPLEMENTED

Record the quantity of pharmaceuticals
shipped to the infirmary and clinics and
periodically compare these records to the
quantities prescribed by doctors. Investigate
any material variations between the two
amounts. Physical inventories of drugs should
be conducted periodically and compared to
perpetual inventory records maintained by the
health care manager.

NOT
IMPLEMENTED

OFFICE OF THE INSPECTOR GENERAL

California State Prison, Solano reported that narcotic medications are stored
in secured containers in the pharmacy, clinics, and the correctional treatment
center. In addition, licensed pharmacists monitor the handling and storage of
narcotics and perform routine audits of these functions.
During its follow up review, the Office of the Inspector General observed that
both narcotic and non-narcotic medications are stored in secured containers
and that medications in the correctional treatment center and clinics are
secured under a supervisor’s control.
California State Prison, Solano reported that the pharmacy maintains both
individual binders with accountability log sheets for each medication and a
controlled medication log for narcotics. For narcotics secured in locked
cabinets, a running inventory log is also updated whenever medications are
added or removed and an inventory of each cabinet is conducted at every shift
change.
The Office of the Inspector General verified that the pharmacy maintains a
medication log for narcotics, but that a similar perpetual inventory system is
not maintained for non-narcotic medications. According to the pharmacy
manager, the current pharmacy computer system is incapable of generating
inventory records, making a reconciliation between physical inventory
amounts and perpetual inventory records unfeasible.

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FOLLOW-UP RECOMMENDATION
The Office of the Inspector General recommends that the California State Prison, Solano develop a method to reconcile the
types and quantities of pharmaceuticals shipped from its pharmacy to its clinics and the correctional treatment center with the
types and quantities of medications prescribed to inmates.
ORIGINAL FINDING NUMBER 10
The Office of the Inspector General found that California State Prison, Solano did not promptly implement medical
modification orders and that many were significantly overdue at the time of the audit.
ORIGINAL RECOMMENDATION
The Office of the Inspector General
recommended that the chief medical officer at
California State Prison, Solano assign a staff
member to monitor the timely completion of
medical modification orders, with priority on
resolving the oldest orders first. That staff
member should also periodically reconcile the
information on the overdue modification
orders list with information in the inmate
appeals office records to ensure accuracy of
the list.

STATUS
FULLY
IMPLEMENTED

COMMENTS
California State Prison, Solano reported that a medical appeals coordinator is
assigned to monitor the timely completion of medical modification orders.
The medical appeals coordinator reconciles this information monthly with the
inmate appeals office, which prepares a weekly overdue list that is distributed
to the warden, chief deputy warden, and division heads.
In its October 2005 follow-up review, the Office of the Inspector General
examined a list of medical modification orders and found that the facility had
no overdue orders.

FOLLOW-UP RECOMMENDATIONS
None.

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ORIGINAL FINDING NUMBER 11
The Office of the Inspector General found that the institution was not properly documenting inmate activity in the
administrative segregation units and that in some instances events were logged before they occurred.
ORIGINAL RECOMMENDATION
The Office of the Inspector General
recommended that administrative segregation
custody personnel institute a practice of
recording inmate movements in CDC Form
114 and CDC Form 114-A as they occur,
rather than waiting for the first watch
administrative segregation floor officer to
update the movements after the fact or
recording events before they take place.

STATUS
FULLY
IMPLEMENTED

COMMENTS
California State Prison, Solano reported that it had trained all administrative
segregation custody personnel to record inmate movements as they occur on
the CDC Form 114, Disciplinary Detention Log, and the CDC Form 114-A,
Detention/Segregation Record. The administrative segregation lieutenant
additionally monitors this practice.

FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 12
The Office of the Inspector General found that California State Prison, Solano prepared an excessive number of daily meals
for inmates, resulting in unnecessary added costs for food and related services.

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ORIGINAL RECOMMENDATION
The Office of the Inspector General
recommended that the warden and the food
manager review the food service process at the
institution to identify areas in which controls
should be established or strengthened. Controls
should include an accurate cost accounting
system to record actual meals served, recycled, and wasted to assist in estimating
future daily meal requirements and in
controlling associated costs. The institution
should also strengthen custody controls over
food service operations to lessen opportunities
for inmates to obtain more than one meal.

CALIFORNIA STATE PRISON, SOLANO

STATUS
FULLY
IMPLEMENTED

COMMENTS
California State Prison, Solano reported that it is difficult to predict exactly
how many inmates will be participating in each meal because such factors as
the menu, weather conditions, sports events, and inmate incidents can affect
meal participation. The facility further reported that its food services
department developed a tracking system reflecting daily meals prepared
versus wasted; this data—including dates, menus, and events suspected to
have contributed to food waste fluctuations—is submitted monthly to
management and is also evaluated in food services supervisory and staff
meetings. The facility also took measures to reduce inmates’ ability to
“double back” through food lines to receive more than one meal and in
addition modified the feeding system to minimize inmates’ opportunities to
request extra portions of food.
The Office of the Inspector General reviewed monthly monitoring sheets
prepared by the food services manager for January through August 2005.
During this period, the monthly food waste ranged between 2 and 5.4 percent
and averaged 3.1 percent—a significant improvement over the 7.5 percent
average noted by the Office of the Inspector General in its 2003 audit.

FOLLOW-UP RECOMMENDATIONS
None.

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2006 ACCOUNTABILITY AUDIT

CALIFORNIA STATE PRISON, SACRAMENTO
The Office of the Inspector General found that
California State Prison, Sacramento has corrected
various deficiencies identified in a September 2000
management review audit. Financial management
has improved in that actual expenditures are closer
to budget allotments; underground storage tanks
have been removed, thus avoiding fines and
penalties; and internal control weaknesses in the
handling of inmate trust funds have been
corrected.

CALIFORNIA STATE PRISON, SACRAMENTO

IMPLEMENTATION REPORT CARD
Previous recommendations: 17
Fully implemented: 12 (70%)
Substantially implemented: 2 (12%)
Partially implemented: 1 (6%)
Not implemented: 2 (12%)
Not applicable: 0 (0%)

In September 2000, the Office of the Inspector General issued a report presenting the
results of a management review audit of California State Prison, Sacramento. The audit
focused on personnel, training, communications, inmate programming, security, and
finances. The review found several deficiencies in financial management, including
budgeting and staffing issues. Other areas found to be deficient included security, inmate
dental examinations, and tracking and filing systems pertaining to various operational
areas.
BACKGROUND
California State Prison, Sacramento, which opened in 1986, covers 1,200 acres adjacent
to Folsom State Prison. When it first opened, the institution was administered by the
Folsom warden and was called New Folsom. In October 1992, the institution’s name was
changed to the California State Prison, Sacramento and it began operating as a separate
institution with its own warden.
California State Prison, Sacramento is a multi-mission institution that houses maximum
security inmates serving long-term sentences and other inmates who have proved to be
management problems at other institutions. The institution also serves as a medical hub
for northern California institutions, with a psychiatric services unit, an enhanced
outpatient unit, and an enhanced outpatient administrative segregation unit. The
institution currently operates an outpatient housing unit and a correctional treatment
center, the latter of which was licensed in February 2003. The institution also provides
Prison Industry Authority inmate work programs, inmate academic and vocational
education programs, and other inmate programs.
At present, the institution houses approximately 2,900 Level IV (high-security) inmates
and 400 Level I (low-security) inmates. For fiscal year 2005-06, the institution has an
operating budget of approximately $161 million and 1,420 staff positions.

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SUMMARY OF PREVIOUS FINDINGS AND RECOMMENDATIONS
The Office of the Inspector General made the following specific findings as a result of
the September 2000 review:
•

The institution’s budget deficit continued to increase. This trend was expected to
continue unless the institution’s budget was adjusted to reflect its realistic needs.

•

Inmate and parolee appeal forms were not processed in a timely manner.

•

There was inadequate documentation to demonstrate that the apprentices in the
Correctional Peace Officer Standards and Training apprentice program fully complied
with prescribed standards.

•

The warden’s busy schedule limited time spent in custody areas.

•

The Identix Touchlock II System did not work properly and, apparently, some of the
institution staff members did not use it.

•

The institution faced potentially highly significant fiscal liability for failing to remove
underground storage tanks in a timely manner.

•

The institution was not in compliance with the regulatory requirement for providing
dental examinations to inmates.

•

The equal employment opportunity complaint and investigation case files contained
inadequate documentation.

•

Employee probation and performance reports were not completed in a timely manner.

•

The emergency operations plan was not submitted in a timely manner.

•

The various facilities did not manage and process the inmate rules violation reports in
a consistent manner.

•

California State Prison, Sacramento incurred high costs in workers’ compensation
expenditures and related service fees paid to the State Compensation Insurance Fund.

•

There were internal control weaknesses in accounting for the inmate trust funds.

The Office of the Inspector General presented 17 recommendations to remedy the
deficiencies identified in the September 2000 review.

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OBJECTIVES, SCOPE, AND METHODOLOGY
The purpose of the 2006 follow-up review was to determine the extent to which
California State Prison, Sacramento has implemented the 17 recommendations from the
Office of the Inspector General’s September 2000 audit. To conduct the follow-up
review, the Office of the Inspector General provided the California State Prison,
Sacramento with a table listing the September 2000 findings and recommendations and
asked the institution to provide the implementation status of each recommendation. The
Office of the Inspector General reviewed the responses, along with documentation
provided by the institution, and evaluated the degree of compliance or noncompliance
with the recommendations. Additional field work was completed in September 2005. The
results are presented in the table following this narrative.
SUMMARY OF THE 2006 FOLLOW-UP RESULTS
Of the 17 recommendations issued by the Office of the Inspector General in the
September 2000 management review audit, 12 recommendations have been fully
implemented; two have been substantially implemented; one has been partially
implemented; and two have not been implemented.
The Office of the Inspector General found that the California State Prison, Sacramento
has substantially improved its financial management. The institution has kept
expenditures aligned with budget allotments; avoided fines and penalties by removing
underground storage tanks in a timely manner; and resolved internal control weaknesses
relative to inmate trust funds. The institution has also benefited from departmental
changes that have increased funding and staff levels to address high workers’
compensation expenditures. The institution has implemented processes that have
improved timely monitoring of the following: inmate and parolee appeals, the
correctional peace officer apprenticeship program, equal employment opportunity case
files, and inmate rules violation reports. In addition, the institution has improved custody
operations by providing the appropriate level of warden involvement and updating its
emergency operations plan. The institution still needs improvement in the following
areas: tracking institution staff and visitors, providing timely inmate dental examinations,
and completing staff performance evaluations.
FOLLOW-UP RECOMMENDATIONS
The Office of the Inspector General recommends that the California
Department of Corrections and Rehabilitation take the following additional
action:
•

In conjunction with the institution wardens, implement measures to
lower workers’ compensation costs through enhanced case
monitoring, thereby minimizing service fees paid to the State
Compensation Insurance Fund.

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The Office of the Inspector General recommends that the warden of
California State Prison, Sacramento take the following additional actions:
•

Explore options for a cost-effective electronic system that effectively
tracks the entry and departure of staff and visitors at the institution.

•

Barring a change in Title 15, California Code of Regulations, comply
with the requirement to provide dental examinations to inmates
within 14 days of their arrival at the institution.

•

Ensure that performance and probationary reports are completed in
a timely manner.

•

In conjunction with the California Department of Corrections and
Rehabilitation, implement measures to lower workers’ compensation
costs through enhanced case monitoring, thereby minimizing service
fees paid to the State Compensation Insurance Fund.

The following table summarizes the results of the follow-up review.

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ORIGINAL FINDING NUMBER 1
The Office of the Inspector General found that the institution’s budget deficit continued to increase. The trend was expected
to continue unless the institution’s budget was adjusted to reflect its realistic needs.
ORIGINAL RECOMMENDATION
The Office of the Inspector General
recommended that the Department of
Corrections perform a custody staffing audit to
determine the appropriate level of staffing
required to maintain the safety and security of
the institution and the programming needs of
the institution’s specialized population.
It was further recommended that the
Department of Finance and the Legislature
should participate in the audit to ensure that
the institution’s budget is balanced
permanently and safely. Until this is
accomplished, it is difficult to hold the warden
solely accountable for the budget deficit.

STATUS
SUBSTANTIALLY
IMPLEMENTED

COMMENTS
The Office of the Inspector General reviewed budgetary and expenditure
reports to determine whether the institution has continued to incur a budget
deficit. The reports concentrated on the program 21 budget, which is the
portion of the institution’s budget controlled by the warden. Review of the
last fiscal year (2004-05) expenditures indicated that the institution exceeded
its mid-year projected expenditures of $118.4 million by only $289,000,
which amounts to one-quarter of a percent, a deficit that was incurred after
the mid-year fiscal review adjustment had reduced the budget allotment by
$453,000.
The California Department of Corrections and Rehabilitation administration
reported that staff from the department’s headquarters worked with staff from
the Department of Finance to develop a new base budget methodology to
fund institutions based on their individual missions and functions. The goal
was to develop an achievable budget for each institution and to hold
institution management accountable for operating within that budget. The
department also reported that it would continue to seek additional funding for
inmate population-related issues and operating cost adjustments.
The department administration reported that it received $450,000 during
fiscal year 2003-04 to initiate a standardized institutional staffing study. It
affirmed, however, that due to contractual freezes, the project was delayed
and the funding was subsequently re-appropriated in fiscal year 2004-05
when the Standardization Review Unit was established. It also reported that
the Standardization Review Unit has gathered preliminary data to complete
the staffing and operations reviews and contracted with the California State
University, Sacramento for consultation services. According to the
administration, department need dictates that the reviews begin in the

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institution case records office and mailrooms statewide and that project
funding has been extended through fiscal year 2006-07, although it is
anticipated that project funding and completion will continue through fiscal
year 2007-08.
The Office of the Inspector General reviewed the Standardization Review
Unit’s work plan, which identified that preliminary data collection for the
custody review was to take place January 2006 through May 2006. The
custody review site visits are scheduled to begin June 2006, with findings and
recommendations to be completed by October 2006. The review of those
areas in the custody operations not included in the initial review is scheduled
to begin November 2006.

FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 2
The Office of the Inspector General found that inmate and parolee appeal forms were not processed in a timely manner.
ORIGINAL RECOMMENDATIONS

STATUS

COMMENTS

The Office of the Inspector General
recommended that the warden take the actions
listed below.
Implement effective monitoring processes to
ensure that inmate/parolee appeals are
processed promptly. The warden should
review the status of the appeal reports weekly
until the appeal backlog is eliminated. Once
the appeal backlog is eliminated, the warden
should continue to periodically review the
OFFICE OF THE INSPECTOR GENERAL

SUBSTANTIALLY
IMPLEMENTED

California State Prison, Sacramento reported that the inmate appeals process
is monitored and reviewed weekly by the warden and that an updated overdue
appeals list is prepared and distributed weekly to each division head, the chief
deputy warden, and the warden. The appeals status or backlog is addressed by
the warden during the Monday executive staff meeting with managers. The
institution also reported that a correctional sergeant’s position had been
reclassified to a correctional counselor II specialist to better address the
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status of appeals and ensure timely resolution.
If additional resources are necessary, the
warden should address this issue either
through redirection of staff or through the
budgetary process.

Ensure that a standard informal appeals log
book is developed to define information
required to be used consistently by all
facilities.

appeals workload and that the appeals office has added a second appeals
coordinator to the staff.
The Office of the Inspector General reviewed an overdue appeals report
dated, August 4, 2005. The report identified 50 overdue appeals, with 39 at
the first level and 11 at the second level. Eleven of the overdue appeals,
however, were medically related, cases in which ultimate oversight
responsibility lies with the chief medical officer. Nine of the overdue appeals
had been generated by other institutions from which inmates had transferred.
Nonetheless, 50 overdue appeals demonstrate a clear improvement over the
108 overdue inmate appeals found in the original audit.
FULLY
IMPLEMENTED

California State Prison, Sacramento reported that a designated staff member
in each facility collects daily appeals and maintains the informal appeals
logbook, after which the appeals are either forwarded to the appeals
coordinator or logged and assigned to the appropriate staff member with an
expected due date. Informal appeals are returned through the designated staff
member to document the response date in the logbook and are also returned to
the inmate. The standard logbooks are used to maintain the informal logs.
The institution further reported that the informal appeals logbooks are not
required by department procedures or law; that notwithstanding, staff
continues to collect and track informal appeals to ensure their appropriate and
timely management. Essential information is maintained in the logs by all
facilities. Although the logs themselves are not identical across all facilities,
the information gathered is the same.

Provide additional training, if necessary, in
California State Prison, Sacramento’s policies
and procedures for processing inmate appeals.

FULLY
IMPLEMENTED

California State Prison, Sacramento reported that inmate appeals training had
been provided annually to all staff during the 7K training schedule. The 7K
training has now been eliminated and the inmate appeals training is conducted
on the job by the supervisors.

FOLLOW-UP RECOMMENDATIONS
None.
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ORIGINAL FINDING NUMBER 3
The Office of the Inspector General found there was inadequate documentation to demonstrate that the apprentices in the
Correctional Peace Officer Standards and Training apprentice program fully complied with prescribed standards.
ORIGINAL RECOMMENDATION
To mitigate the potential for exposing the
institution and the department to civil liability,
the Office of the Inspector General
recommended that the institution’s in-service
training unit develop policies, procedures, and
controls to monitor apprentices’ progress and
completion of the Correctional Peace Officer
Standards and Training apprenticeship
program.
The procedures should provide for the
reconciliation of apprentice time sheets with
total reported program hours. The procedures
should also ensure that documentation of all
required program milestones (probation
reports, for example) is included in the
apprentice files in accordance with statute and
with the terms of the memorandum of
understanding for Bargaining Unit 6.

STATUS
FULLY
IMPLEMENTED

COMMENTS
California State Prison, Sacramento reported that the apprenticeship program
and all participant information is tracked by an apprenticeship tracking and
maintenance computer program used by the department and the institutions.
Apprentice progress is monitored through data in the computer program as
well as through hard copies of monthly reports in apprentice files. In the
capacity of the Local Apprenticeship Subcommittee chairperson, the inservice training manager maintains the apprenticeship program. The
subcommittee secretary documents the monthly meetings.
The Office of the Inspector General reviewed a copy of a monthly meeting
report, which includes the status of enrollees by classification and the activity
of each classification. It also provides current information on individuals who
have completed, been terminated from, or resigned from the program since
the last meeting. The report identified one correctional officer who had
completed the mandatory hours in the following categories: (a) maintaining
security, (b) supervising inmates, (c) escorting/transporting inmates, (d) report
writing/record keeping, and (e) additional experience. It also identified an
individual who had resigned because of a disability.
The institution reported that the reconciliation of apprentice time sheets
occurs monthly and that the generated reports reflect current work hours.
Apprentice files and related information are housed in the in-service training
manager’s office.
Although the original finding identified deficiencies in the verification of
training hours and documentation of probation reports, reconciling apprentice

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time sheets and maintaining apprentice training documentation should resolve
those issues.

FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 4
The Office of the Inspector General found that the warden's busy schedule limited time spent in custody areas.
ORIGINAL RECOMMENDATION
The Office of the Inspector General
recommended that the warden prioritize the
workload to allow for greater involvement in
custody matters.

STATUS
FULLY
IMPLEMENTED

COMMENTS
California State Prison, Sacramento reported that the warden is intimately
involved in all of the institution’s custody operations. The warden
participates in two weekly executive staff meetings and two weekly lockdown
meetings; chairs weekly institutional classification committees; attends most
major program meetings; and regularly tours the institution and
communicates with staff. The warden has made active involvement in custody
operations a top priority.

FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 5
The Office of the Inspector General found that the Identix Touchlock II System did not work properly and, apparently, some
of the institution staff members did not use it.
ORIGINAL RECOMMENDATION
The Office of the Inspector General
recommended that the warden continue to

OFFICE OF THE INSPECTOR GENERAL

STATUS
FULLY
IMPLEMENTED

COMMENTS
California State Prison, Sacramento reported in its initial response to the audit
that it was working with department headquarters to resolve the problem.

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work cooperatively with the Department of
Corrections to make the necessary corrective
changes to the Identix Touchlock II system to
ensure that it is fully operational at California
State Prison, Sacramento.

Trans Tech was commissioned to address the software and equipment
failures. The software was subsequently sent to Oregon but the problem could
not be remedied. Since that time, the institution reported that the Identix
Touchlock II system has been discontinued.
Although the institution worked with the department in attempting to resolve
the problem, the ultimate resolution was to terminate the system’s operation.
Nevertheless, an electronic system to track the entry and departure of staff
and visitors remains critical to enhance the institution’s safety and security
operations.

FOLLOW-UP RECOMMENDATION
The Office of the Inspector General recommends that California State Prison, Sacramento explore options for a cost-effective
electronic system that effectively tracks the entry and departure of staff and visitors at the institution.
ORIGINAL FINDING NUMBER 6
The Office of the Inspector General found that the institution faced potentially highly significant fiscal liability for failing to
remove underground storage tanks in a timely manner.
ORIGINAL RECOMMENDATION
The Office of the Inspector General
recommended that California State Prison,
Sacramento continue to expedite the
underground fuel storage tank filling and
removal process. At the same time, the
institution should negotiate with Sacramento
County to either extend the final deadline by
approximately one month or waive all fines
and penalties to mitigate their impact on an
already significant budget deficit.

OFFICE OF THE INSPECTOR GENERAL

STATUS
FULLY
IMPLEMENTED

COMMENTS
In its initial response to the audit, California State Prison, Sacramento
reported that its ability to comply with the mandates for removing the
underground fuel storage tanks was limited. It also reported that the process
would be completed by November 2000 and that its compliance with
Sacramento County requirements appeared to preclude the imposition of any
fines or penalties. Since that time, the institution reported that the
underground storage tank filling and removal process was completed.

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FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 7
The Office of the Inspector General found that the institution was not in compliance with the regulatory requirement for
providing dental examinations to inmates.
ORIGINAL RECOMMENDATION
The Office of the Inspector General
recommended that California State Prison,
Sacramento comply with the requirement to
examine inmates within 14 days of their
transfer from the reception center to the
institution. Although the chief medical officer
would be directly responsible for
implementing this finding, the warden should
monitor progress in resolving the problem.

STATUS
NOT
IMPLEMENTED

COMMENTS
The California Department of Corrections and Rehabilitation reported that the
Division of Correctional Health Care Services has developed dental policies
and procedures to standardize dental services at all correctional facilities. The
proposed dental policies and procedures will require the dental examinations
to be completed within 90 days of the inmate’s arrival at the assigned
institution, which will necessitate a revision to the 14-day mandate in the
California Code of Regulations, Title 15.
The Office of the Inspector General reviewed the draft dental policies and
procedures dated October 2003. It determined that the chapters related to
dental issues retain the 14-day requirement for dental examinations.
Specifically, chapter nine, which covers inmate dental care, requires that a
comprehensive dental examination be completed within 14 days of
assignment to a given facility.
The Office of the Inspector General reviewed the California Code of
Regulations, Title 15, section 3355.1 regarding dental examinations and
determined that, as of February 10, 2006, the institution is still required to
provide a complete dental examination to inmates within 14 days of their
transfer from a reception center. The California State Prison, Sacramento
provided no evidence to indicate that it is complying with this requirement.
The California Department of Corrections and Rehabilitation also reported
that additional resources to augment staffing of the statewide dental program

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had been acquired through a fiscal year 2005-06 finance letter.
The Office of the Inspector General reviewed the fiscal year 2005-06 finance
letter, wherein the department had requested a total of 88.5 positions and
$17.3 million to correct the base dental staffing deficiencies, assess the dental
staffing and operational deficiencies, and begin the planning activities to
implement major policy changes in the dental program. Review of the Final
Change Book for fiscal year 2005-06 showed that the Legislature had reduced
the finance letter amount by $4 million to accommodate the purchase of
equipment over a two-year period. Given that 50.0 of the positions authorized
by the Legislature were to have been instituted January 1, 2006, an
assessment of the benefits afforded by these additional resources would be
premature, as would assessment of the potential effects of the protracted delay
in equipment funding. The California State Prison, Sacramento was
scheduled to acquire three office technicians and one dental assistant.

FOLLOW-UP RECOMMENDATION
Barring a change in Title 15, California Code of Regulations, the Office of the Inspector General recommends that California
State Prison, Sacramento comply with the requirement to provide dental examinations to inmates within 14 days of their
arrival at the institution.
ORIGINAL FINDING NUMBER 8
The Office of the Inspector General found that the equal employment opportunity complaint and investigation case files
contained inadequate documentation.
ORIGINAL RECOMMENDATION
The Office of the Inspector General
recommended that the institution’s equal
employment opportunity coordinator develop a
system to track and monitor equal employment
opportunity cases to assure that cases are
resolved in a timely fashion, and that all
OFFICE OF THE INSPECTOR GENERAL

STATUS
FULLY
IMPLEMENTED

COMMENTS
California State Prison, Sacramento reported that the equal employment
opportunity coordinator deploys a system for tracking equal employment
opportunity cases to assure that cases are resolved in a timely manner and that
critical information is complete. The coordinator regularly monitors the
caseload to identify and apprise the warden of those cases requiring
immediate attention.
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critical documentation is complete.

The Office of the Inspector General reviewed an excerpt from an equal
employment opportunity log and found the information documented to be
appropriate for case monitoring.

FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 9
The Office of the Inspector General found that employee probation and performance reports were not completed in a timely
manner.
ORIGINAL RECOMMENDATION
The Office of the Inspector General
recommended that the warden should take
steps to ensure that performance and
probationary reports are completed on time.

STATUS
NOT
IMPLEMENTED

COMMENTS
California State Prison, Sacramento reported that the completion of
performance evaluations outside of overtime remains a challenge. The current
overdue list is unacceptable and the process for tracking performance
evaluations is flawed. The personnel officer has been instructed to prepare a
plan that ensures timely tracking and completion of performance evaluations.
The personnel section generates the report notices, which the in-service
training and personnel assignment sections forward through the division
heads to the appropriate supervisors. The personnel officer has implemented
a tracking system report to monitor the progress and completion of
performance and probationary reports.
The Office of the Inspector General reviewed a current report of outstanding
performance evaluations. The list identified 668 employees whose
performance evaluations were delinquent. With a budget for approximately
1,420 positions, this amounts to a delinquency rate of 47 percent.

FOLLOW-UP RECOMMENDATION
The Office of the Inspector General recommends that the warden take steps to ensure that performance and probationary
reports are completed in a timely manner.

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ORIGINAL FINDING NUMBER 10
The Office of the Inspector General found that the institution’s emergency operations plan was not submitted in a timely
manner.
ORIGINAL RECOMMENDATION
The Office of the Inspector General
recommended that the warden should
implement procedures to ensure that the
emergency operations plan is updated and
ready to be submitted to the Department of
Corrections for review each January.

STATUS
FULLY
IMPLEMENTED

COMMENTS
California State Prison, Sacramento reported that the emergency operations
plan is current. A report from the Emergency Operations Unit of department
headquarters indicates that the plan had been submitted and contained all the
required resource supplements. The headquarters report also identified
specific areas that require further clarification. The administration reported
that the follow-up work was being completed and that its plan had been
approved by headquarters.
The Office of the Inspector General reviewed a copy of the report from
headquarters and found that California State Prison, Sacramento’s emergency
operations plan was consistent with the requirements set forth in the
California Department of Corrections and Rehabilitation Operations Manual
and encompassed all required resource supplements. The headquarters report
did not indicate that the institution’s emergency operations plan was
delinquent.

FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 11
The Office of the Inspector General found that the various facilities did not manage and process the inmate rules violation
reports in a consistent manner.

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ORIGINAL RECOMMENDATIONS

CALIFORNIA STATE PRISON, SACRAMENTO

STATUS

COMMENTS

The Office of the Inspector General
recommended that the warden’s office
implement a monitoring system to ensure that
CDC-115 forms are processed promptly and
uniformly among the facilities.
Specifically, the Office of the Inspector
General recommended that the warden take the
actions listed below.
The inmate disciplinary process requires due
process and consistency in disposition. On a
weekly basis, either the warden or the chief
deputy warden should review the status of the
reports with Facilities A, B, and C, taking
appropriate action when necessary to ensure
prompt resolution of inmate disciplinary cases.

FULLY
IMPLEMENTED

California State Prison, Sacramento reported that the chief disciplinary
officers—the associate wardens assigned to each facility—are responsible for
the disciplinary systems within those facilities. Under the supervision of the
facility lieutenants, the chief disciplinary officers track and maintain
disciplinary processes. Staff utilizes the standardized facility logbooks to
monitor the progress of each CDC-115, Rules Violation Report. Facility
captains review and approve all rules violation reports and also monitor,
review, and approve the logbooks.
The institution reported that the warden and chief deputy warden conduct spot
reviews of the logbooks during institution tours, classification committee
hearings, and inmate appeals reviews. The institution also reported that the
warden, chief deputy warden, and associate wardens are complying with the
current mandates relative to disciplinary process.

A written explanation should be required of
any official authorizing the voiding of a CDC115 form. Furthermore, for proper monitoring
and auditing purposes, copies of all voided
CDC-115 forms must be forwarded to the
chief disciplinary officer for the institution
register and files.

OFFICE OF THE INSPECTOR GENERAL

FULLY
IMPLEMENTED

California State Prison, Sacramento reported that a written explanation is
required of any official who voids a rules violation report. All rules violation
reports are forwarded to the appropriate chief disciplinary officer for the
institution register files.

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2006 ACCOUNTABILITY AUDIT

Copies of completed CDC-115 and 115-A
forms should be delivered to inmates within
five working days of the chief disciplinary
officer’s review.

CALIFORNIA STATE PRISON, SACRAMENTO

FULLY
IMPLEMENTED

California State Prison, Sacramento reported that copies of the completed
rules violation reports are delivered to inmates within five working days of
the chief disciplinary officer’s review.

FOLLOW-UP RECOMMENDATIONS
None.
ORIGINAL FINDING NUMBER 12
The Office of the Inspector General found that California State Prison, Sacramento incurred high costs in workers’
compensation expenditures and related service fees paid to the State Compensation Insurance Fund.
ORIGINAL RECOMMENDATION
The Office of the Inspector General
recommended that the Department of
Corrections should increase the workers’
compensation staff at California State Prison,
Sacramento.

STATUS
PARTIALLY
IMPLEMENTED

COMMENTS
The warden had submitted a budget concept statement to department
headquarters requesting additional staff to manage the workers’ compensation
caseload. The California State Prison, Sacramento reported that the request
was denied but that it continued to explore options to manage its workers’
compensation caseload, including requesting additional staff through the
budget process. The department indicated that its budget for fiscal year 200405 had been fully funded for workers’ compensation costs.
The institution also reported that, as a result of the department’s
reorganization and consequent departmental assumption of responsibility for
workers’ compensation cases, the need for additional institution staff to
manage the caseload no longer exists. It reported that the workers’
compensation costs for the institution were to have been $5.3 million in fiscal
year 2002-03, $6.0 million in fiscal year 2003-04, and $5.2 million in fiscal
year 2004-05.
The Office of the Inspector General reviewed information obtained from the

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department’s fiscal services unit and verified that the department had received
a $115.8 million increase to its base budget in fiscal year 2003-04 to fund
additional workers’ compensation expenses unrelated to any employee
population adjustments that might have altered the base budget’s level of
workers’ compensation funding. The fiscal services unit reported that,
although the institution is not allocated a specific increase in its base
allotment, its annual needs are based initially on personnel year expenditures,
which may be reassessed periodically and at year-end. It also reported that the
department had redirected two positions to start addressing cost containment
and that legislative action subsequently added six positions to implement the
workers’ compensation suspicious activity program. The fraud investigation
program assists the department in managing claims through a fraud referral
program. The department has also developed a workers’ compensation cost
containment strategy action plan to more effectively manage workers’
compensation processes.
While the specific recommendation to increase institution staff was not
implemented, the department reported that it has increased staff at the
department level to address workers’ compensation expenditures issues.
Although funding for workers’ compensation costs has increased, it is not
evident that the department has either decreased or stabilized workers’
compensation expenditures. It is also not apparent that the changes made by
the department have reduced service fees levied by the State Insurance
Compensation Fund.

FOLLOW-UP RECOMMENDATION
The Office of the Inspector General recommends that the California Department of Corrections and Rehabilitation and the
warden implement measures to lower workers’ compensation costs through enhanced case monitoring, thereby minimizing
service fees paid to the State Compensation Insurance Fund.

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ORIGINAL FINDING NUMBER 13
The Office of the Inspector General found that there were internal control weaknesses in accounting for the inmate trust
funds.
ORIGINAL RECOMMENDATION
The Office of the Inspector General
recommended that in the future, if vacancies
occur in the trust accounting office and
internal controls are compromised, the warden
should take action to redirect resources to this
area.

STATUS
FULLY
IMPLEMENTED

COMMENTS
California State Prison, Sacramento reported that, given its current staffing
level, internal controls are not compromised. The institution reported that the
warden would continue to redirect resources to comply with department
mandates.

If necessary, staff from other accounting units
in the California Department of Corrections
should be used to assist with the inmate trust
accounting system.

FOLLOW-UP RECOMMENDATIONS
None.

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