Orange County Ca Audit Correctional Medical Care 2009

• Topics: Misconduct/Corruption, Corrections Audits, Medical

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FINAL REPORT

PERFORMANCE AUDIT
OF
HCA/CORRECTIONAL MEDICAL SERVICES

Office of the
Performance Audit Director
MARCH 2009

FINAL REPORT

Table of Contents
Executive Summary ......................................................................................................................... iv
Preface ......................................................................................................................................... iv
Introduction.................................................................................................................................. v
Background Information .............................................................................................................. v
Key Audit Findings ...................................................................................................................... vii
Summary of Key Recommendations ......................................................................................... xiv
Estimated Cost Savings/Revenue Enhancements ................................................................... xviii
Introduction..................................................................................................................................... 1
Audit Scope and Objectives ............................................................................................................. 2
Audit Methodology ..................................................................................................................... 3
Information Reviewed ................................................................................................................. 3
Interviews .................................................................................................................................... 4
Data Review and Analysis ............................................................................................................ 4
Report Preparation and Review .................................................................................................. 5
Background Information ................................................................................................................. 5
Responsible Party for County Inmate Health Care...................................................................... 5
County Jail Facilities and Inmate Population............................................................................... 6
Two Departments, Two Missions ................................................................................................ 7
Accreditation ............................................................................................................................... 7
CMS Overview ............................................................................................................................. 8
Services Provided Directly by CMS .......................................................................................... 8
Services Provided by Contract ................................................................................................. 8
CMS Organization Chart .......................................................................................................... 9
CMS Revenue/Expense Summary ......................................................................................... 10
What Works Well at CMS .......................................................................................................... 12
Recent Accomplishments .......................................................................................................... 12
Findings & Recommendations....................................................................................................... 14

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CMS Organizational Culture ...................................................................................................... 14
Organizational Structure Issues................................................................................................. 15
Management ............................................................................................................................. 16
Nursing ...................................................................................................................................... 20
Nurse Staffing Levels/Schedules ........................................................................................... 21
Daily Medication Passes ........................................................................................................ 26
County Physicians and Nurse Practitioners ............................................................................... 27
Background Information ....................................................................................................... 27
Residency Programs .............................................................................................................. 29
Utilization Review .................................................................................................................. 29
Medication Orders................................................................................................................. 30
Pharmacy-Related Issues........................................................................................................... 32
Controlled Substances ........................................................................................................... 32
Undistributed Medications.................................................................................................... 35
Medication Packaging ........................................................................................................... 36
Self-Carry Medication Documentation.................................................................................. 38
Perpetual Inventory of Non-Controlled Substances ............................................................. 39
Administrative Issues................................................................................................................. 39
Funding .................................................................................................................................. 39
Contract Administration ........................................................................................................ 40
Hospital/Clinic Scheduling of Inmates for Medical Care ....................................................... 51
Information Technology ........................................................................................................ 54
Risk Management .................................................................................................................. 60
Human Resource Issues......................................................................................................... 61
Purchasing/Supplies .............................................................................................................. 61
Sheriff—HCA Coordination........................................................................................................ 63
Outpatient Clinics .................................................................................................................. 64
Jail Physical Plant ................................................................................................................... 68
Charging Inmates Modest Fees ............................................................................................. 72
Benchmarking Results ............................................................................................................... 74
Issue Prioritization ......................................................................................................................... 75

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Short Term Priorities ................................................................................................................. 75
Long Term Priorities .................................................................................................................. 76
Estimated Cost Savings/Revenue Enhancements ......................................................................... 78
Other Potential Savings ............................................................................................................. 79
Concluding Remarks ...................................................................................................................... 82
Exhibit 1: CMS Board Resolution ................................................................................................... 83
Exhibit 2: CAO Analysis of CMS Options ........................................................................................ 86
Exhibit 3: Recommended CMS Organizational Chart .................................................................... 98
Exhibit 4: CMS Budget vs. Actual Expenditure Detail, FY 2000/01 to FY 2007/08 ........................ 99

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Executive Summary
Preface

The Orange County Board of Supervisors’ (Board) decision to conduct a
performance audit of the Health Care Agency’s Correctional Medical Services
(CMS) program affords an important opportunity to address an inherently highrisk function that has received significant public attention over the past several
years. The audit team wishes to thank both the Health Care Agency (HCA) and
the Orange County Sheriff-Coroner Department (OCSD) for their cooperation
during this audit and their willingness to address the issues identified.
HCA has been delegated the responsibility by OCSD and the Board for
providing County inmates with adequate and timely medical care. HCA fulfills
this responsibility through its CMS program, a large, highly complex and multifaceted operation.

Since the 2002 State budget deficit, which resulted in

significant program reductions, CMS has had difficulty fulfilling its mission in an
efficient and effective manner. This conclusion has been documented in various
internal and external studies. Quality inmate health care is generally achieved,
however, it is provided in an environment laden with management, operational,
and administrative deficiencies, the cumulative effect of which increases risk
exposure to the County. These issues need to be sufficiently addressed before
any significant staffing resource decisions, such as those requested in the 2008
Strategic Financial Plan, can be made.
On the positive side, recent leadership and operational changes at both CMS and
OCSD have opened the door for improvement. At strategic points during the
course of this review, the audit team met with both HCA and OCSD Executive
staff to inform them of our findings and recommendations. As a result, both
agencies have taken immediate first steps to remedy the issues noted in this
report by planning for and implementing system improvements.

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Introduction

Audit Scope and Objectives

The scope of this audit is limited to the CMS section of the HCA/Medical and
Institutional Health Services Division. Specifically excluded from audit are the
other portions of Medical and Institutional Health Services, such as: Correctional
Mental Health Services, Juvenile Health Services, and the Conditional Release
Program. Correctional Dental Services was also not included in this analysis, but
is included in some summary information.
The objectives of the audit are to:
1. Examine and document potential risks and operational deficiencies in the
CMS program.
2. Identify improved business processes and operating efficiencies that will
assist CMS in achieving its stated goals and objectives.

Audit Methodology

The audit included a detailed analysis of multiple data sets; review and
observation of various systems and workflow processes used by CMS that
impact organizational effectiveness; interviews with current/retired CMS staff;
review of regional and national correctional medical reports and industry
standards; examination of contractor operations; and a review of State
regulations and inspections of jail inmate health operations.

Background Information

According to Titles 15 and 24 of the California Code of Regulations, OCSD is the
responsible party for ensuring that adequate health care is provided to the
inmates in its facilities. OCSD has chosen, with the 1975 concurrence of the

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Board, to have its inmate health care administered by HCA/CMS. Having two
separate agencies (HCA and OCSD), with two different missions, involved in the
provision of health care to County inmates is a unique challenge that will be
addressed later in this report.
CMS utilizes both County and contract resources. Internally, CMS has County
staff in the following professional areas: Nursing, Physician, Pharmacy, and
Administration.

Contracted services include:

hospital and clinic facilities

through Western Medical Center – Anaheim (WMC-A); a multi-specialty
physician group (Correctional Managed Care) that provides medical treatment
such as surgical services and specialty consultations and minor procedures at
WMC-A; fiscal intermediary services to track and manage expenses for
emergency care situations in which inmates are sent to a hospital other than
WMC-A; part-time contract physicians, nurses, and pharmacists that cover
weekends, holidays, vacations and sick relief in all jail facilities; and outpatient
dialysis services from Davita via a pass through agreement with WMC-A.
The FY 2008/09 budget for CMS is $36,869,377. In the past, HCA utilized both
County General Funds and State Realignment funds to finance the CMS
operation. However, several years ago, HCA made the decision to only utilize
County General Funds in order to clarify the full program cost and to potentially
trigger OCSD to contribute financial resources to cover the CMS budget, in total
or in part. This decision highlights a discussion which continues today over who
should bear fiscal responsibility for the CMS program.

What Works Well at CMS

The audit team identified the following areas where CMS is providing quality
services:
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Basic inmate health care
Initial health screening during inmate booking
Medication supply and distribution
An overall commitment to inmate care on the part of line staff

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Recent CMS Accomplishments

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In response to the 2007 Grand Jury Report, CMS enhanced emergency
medical response capabilities through increased training, drills, and new
equipment.
In 2008, the Board of Supervisors approved an HCA request to establish
the Institutional Health Quality Assurance Panel to systematically assess,
evaluate, and make recommendations regarding adult correctional
healthcare in Orange County Jail facilities.
In late 2008, CMS was successful in filling the long-vacant Director of
Nursing position.
HCA recabling of jails to provide CMS staff with access to internet and
email service.
Appointment of new Institutional Health Division Manager.
In response to discussions with the audit team, HCA has formed a Task
Force, which is currently addressing the recommendations included in
this report.

Key Audit Findings

The audit team comprehensively examined all aspects of the CMS operation in
both County jail facilities and those services provided externally by contractors.
This examination yielded a considerable number of issues (some 48 findings), the
more significant of which are summarized below.

CMS Organizational Culture

Nearly all staff interviewed during this audit identified several problems within
the CMS organization that impede program efficiency and effectiveness.

consistent theme expressed to the audit team by CMS line and management staff
was “nothing can be done; nothing will change.” This attitude has limited the
opportunities for initiative, innovation and lasting change within the

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FINAL REPORT

organization. This assessment is substantiated by the many audit findings that
follow.

Addressing these cultural issues is vital to ensuring that the more

concrete recommendations that follow are accomplished.

Organizational Structure

The administrative program support function has become increasingly and
inappropriately enmeshed in medical line operations due to a management
vacuum created by a long-term vacancy in the Director of Nursing position
(which was recently filled). This environment has been a source of considerable
frustration among staff and, in part, led to the cultural issues described in the
previous section. The Nursing operation, which is the backbone of the daily
medical care service delivery in the jails, should have under its structural
authority as many of the tools and resources as necessary to perform their daily
line responsibilities.

Management

Two primary findings illustrate the core of CMS management issues:
1. Though inmate health care is a priority, it is a secondary priority for
OCSD, and a non-core service for HCA. This status stems from OCSD’s
primary mission in the jails of ensuring the safety of the inmates and staff
inside the jail facilities. In regard to HCA, correctional medical services
were a County obligation that was assigned to the County Health
Department (the pre-cursor to HCA) back in 1975.

As a result, the

provision of inmate health care predictably receives less attention than
other parts of both OCSD and HCA.
2. CMS staff has generally not been held accountable for poor or nonperformance, which is demonstrated by the following:

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a. Some operational problems have continued for years without
meaningful attention.
b. Employees with known, significant performance issues have been
allowed to pass probation.
c. HCA authorized a consultant review during the course of this
performance audit that addressed several staffing and scheduling
issues already under review by the audit team.
d. It is common knowledge among CMS management that much of
the statistical data collected and aggregated is unreliable.
e. The administration of CMS contracts has been inadequate and
subsequently has not allowed CMS to properly manage contractor
performance or fully prepare for effective contract negotiations
with vendors.
f. There are a handful of conflicts of interest within CMS that have
been left to linger for several years.
g. There are examples of recalcitrance among some CMS line staff.
This was both conveyed to us by CMS management and observed
during the audit team interviews.

Nursing

CMS nursing staff levels have been the subject of considerable scrutiny over the
past several years.

The nurses’ employee association, the Orange County

Employee’s Association (OCEA), began raising concerns over staffing levels in
FY 2003/04 after HCA cut a variety of CMS positions in order to address State
budget shortfalls at that time.

These staffing concerns and other issues

culminated in an October 2007 “vote of no confidence” in the program’s
management, and several subsequent newspaper articles that amplified nursing
staff’s criticism of CMS leadership.

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This audit reviewed both nursing staff levels and work schedules with the
following findings:
There is an excessive number of Supervising Nurse positions.
There is an insufficient number of Senior Nurse positions to meet jail
facility coverage needs.
The current Licensed Vocational Nurse (LVN) work schedules are
inefficient, resulting in staffing overlaps and a mix of nursing schedules,
which makes it difficult to provide adequate supervision.
The bi-weekly master nursing schedule and its development are the
source of considerable frustration among nursing staff.
There are four medication passes that occur every day at every jail facility.
This number of daily medication passes consumes significant staff
resources and may not all be necessary.

Physicians and Nurse Practitioners

CMS employs both in-house County as well as contract physicians to cover the
five jail facilities.

In addition, contract doctors are used to provide medical

services at the WMC-A clinic and hospital. Significant findings in this area
include:
The contract hospital (WMC-A) and physicians (CMC) do not perform
meaningful hospital or physician Utilization Reviews of services provided
according to contract requirements.
As a result, neither contract
requirements nor best practices are followed, nor is the County formally
assured that inmates are receiving quality care or that physician/hospital
expenses are reasonable for the services provided.
Medications prescribed by contract physicians at the hospital/clinic are not
always properly reviewed by a CMS physician before the prescription is
processed.

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Pharmacy-Related Issues

The following are the more significant pharmacy-related findings:
Controlled substance (i.e., potentially addictive substances/medications
that are usually prescribed for mental health treatment or to substance
abusers for withdrawal purposes) documentation and disposal
procedures are not always followed.
There is no validation that undistributed medications are properly
returned to Jail Pharmacies to be destroyed.
There is no inventory of routine, non-controlled medications maintained
outside of the Pharmacy.

Administrative Issues

There are a myriad of administrative issues within CMS that must be addressed.
Some of the more significant findings, by functional area, include:

Funding

OCSD currently does not contribute any financial resources to offset the
cost of medical services provided by HCA, other than transportation of
inmates to hospital/clinic facilities.
Contract Administration

CMS contract administration and program monitoring roles are not
clearly defined, resulting in ineffective contract oversight.

CMC contract physicians do not input discharge planning orders into the
CMS electronic medical record system when an inmate leaves WMC-A.

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Profit and Loss Statements submitted by both CMC and WMC-A are not
in compliance with the contract terms. In addition, the expense amounts
in profit and loss statements could not be fully verified by the audit team.
CMC’s profit margin from the CMS contract far exceeds industry
standards.
The physician and hospital custody database maintained by CMC is
incomplete, inaccurate, and largely unutilized by CMS for contract
monitoring and program management purposes.
CMS management is unable to definitively explain why there is a
sustained increased in the daily census of inpatient inmates at WMC-A,
that began in late 2007.
Hospital/Clinic Scheduling of Inmates for Medical Care

The audit team reviewed the outpatient clinic scheduling process and found that
improvements are required to ensure that all inpatient hospital and outpatient
clinic visits are properly authorized by the CMS Medical Director or Assistant
Medical Director and all inmates receive timely specialty care in line with
community practice.

Information Technology

IT issues pertain to CMS’ electronic inmate medical record system (CHART).
CHART was implemented in 1992 to document and manage inmate health
records and to ensure that the record is available to health professionals in a
timely manner. Significant issues include:

The CHART system is underutilized resulting in significant system-wide
inefficiencies.

The CHART system is written in an outdated programming language and
its future system maintenance and support is limited.

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FINAL REPORT

CMS does not coordinate with HCA/IT or follow change management
best practices when modifying the CHART system application.

Risk Management

Over the last five fiscal years, approximately $1.2 million has been spent settling
or defending CMS lawsuits. Specifically, from July 1, 2003 to June 30, 2008, there
were a total of 55 inmate lawsuit claims filed against CMS for a variety of
reasons, all pertaining to the medical care received while in custody. Of these 55
claims, 18 resulted in either settlements and/or the incursion of outside legal
expenses in defending the suit (six of the 18 were settled for a total of $513,500,
and 17 of the 18 required the expenditure of funds for outside legal counsel,
totaling $748,870); and 37 resulted in no legal or settlement costs to the County.

Human Resource Issues

Over the past decade, the recruitment of quality applicants for physician,
pharmacy, and nursing positions has been a nation-wide challenge, especially in
a correctional environment. In addition, the time required to perform security
background checks by OCSD has further complicated recruiting efforts.

CMS Statistical Data

Statistical summary information of medical services delivered to inmates is not
accurately prepared by health care staff. This information is required by Title 15
and provides the facility/system administrator (i.e., OCSD) with a basis of
accountability, and ideally should be used by CMS to enhance performance and
monitor productivity.

The primary reason for inaccurate information is the

manual processes used to track and summarize data.

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FINAL REPORT
Sheriff-HCA Coordination

The provision of quality inmate health care requires a cooperative effort between
both OCSD and CMS management and line staff.

This relationship was

unproductive between prior management staffs in terms of addressing
challenges and implementing innovations that would result in more efficient and
effective inmate health care services. Examples include:
The transportation of inmates from jail facilities to the clinic/hospital is
expensive, taxes limited deputy resources, has security-related concerns,
and often results in inmates missing their scheduled hospital or clinic
appointments.
During the booking process, inmates at the Intake & Release Center
medical screening area are not afforded assurance of privacy while
providing personal medical information, as suggested by best practices.
There are physical improvements that need to be made within each of the
five jail facilities to improve the quality of care provided to inmates.
OCSD could charge modest fees to inmates for some medical services
provided as is common to other law enforcement agencies. Specific
examples include: 1) charging a fee for inmate requests for routine
medical examination, and (2) for common over-the-counter medications.
Currently, neither is done.

Summary of Key Recommendations

Remove all organizational and personnel barriers to change within the
CMS organization. Set in place a leadership team that is willing and able
to promote an environment of performance and optimism that will ensure
that the findings in this audit are implemented in a timely manner. A
formal audit action plan should be established that is supported by the
resources necessary to bring about lasting improvement, and CMS
management’s progress should be actively monitored by HCA Executive
Management.

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FINAL REPORT

Due to the risks inherent in a correctional medical operation (i.e., financial,
ethical, legal, public/political sensitivity), CMS should be elevated to a first
tier priority for both OCSD and HCA.
HCA should create a Task Force of high-performance HCA employees to
comprehensively address the deficiencies identified in this audit.
Throughout CMS, performance standards should be established,
communicated, and enforced. When basic performance expectations are
not met, employee training, counseling, and then discipline should occur.
Appropriately address all conflict of interest situations within CMS.
Reduce the number of Supervising Nurses to two, with one responsible
for nursing activities at the Theo Lacy and James Musick jail facilities, and
one responsible for the Central Jail Complex. Each supervisor should be
on site Monday through Friday to assist Senior Nurses with the day-today operations and facilitate problem solving.
Transition all LVN positions to either an eight-hour or a twelve-hour shift
in order to eliminate the unnecessary staff overlap that currently exists
with the hybrid “4-10” and “9-80” schedule.
CMS Physician and Pharmacy staff should perform a formal evaluation of
the 1:00 p.m. medication pass to assess the feasibility of discontinuing the
pass in the future, or limiting the pass to include only those medications
that must be given between the 9:00 a.m. and 7:00 p.m. passes.
CMS and OCSD should create a committee to work toward the
development of a partnership with a local medical school to establish a
physician residency program within the jails.
CMS should ensure that adequate utilization review procedures exist and
are followed with regard to the effective and efficient provision of contract
physician and hospital services.

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CMS should immediately enforce the regulations and procedures related
to controlled substances.
CMS should evaluate the current Pharmacy work schedule with the goal
of closer coordination between medication packaging timelines and
medication distribution schedules in order to reduce the amount of
wasted medications.
OCSD should begin to contribute financial resources to cover at least some
of the fiscal burden of providing inmate medical services. Immediate
contribution opportunities exist with some much needed capital and
infrastructure improvements such as, (1) refurbishing medical observation
units at the jails, (2) an electronic medical record system, and (3) building
out clinic space at the jails.
HCA/Contract Administration and CMS should delineate the
responsibilities for contract administration and contract program
monitoring.
Once this occurs, CMS should ensure that contract
monitoring is performed as required.
HCA should require by contract that CMC and WMC-A obtain
independent audits of their annual Profit and Loss Statements to ensure
that the statements accurately represent their profit.
HCA should (1) request that CMC reduce their rates for the remainder of
the current contract term (June 2009), and (2) ensure that future negotiated
physician contracts provide appropriate profit margins in accordance with
industry standards and are in line with other government entities
contracting for correctional medical services.
HCA needs to renegotiate with CMC to eliminate the $100,000 charge for
inputting data that is already necessary for CMC to conduct its own
internal billing and claims processing. This information should be
provided to the County at minimal or no cost as part of normal contract
monitoring.
CMS management needs to specifically determine whether the increase in
the inmate inpatient population is a permanent shift, or one that can be

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mitigated through operational changes on the part of both CMS and
OCSD.
CMS should complete its efforts to fully interface outpatient/inpatient
approval/scheduling process in the CHART system to include
electronically created, sequentially numbered Treatment Authorization
Requests with the online priority/approval function, outpatient
scheduling, and reporting queries that provide CMS management
information to monitor the process.
CMS should work with OCSD to find solutions that will ensure that
inmates are transported to scheduled clinic/hospital appointments.
CMS should move forward immediately to purchase a new fully
automated medical records information system. In the interim, CMS
should more fully utilize the CHART system and establish a cross-over
timeline for moving hard copy components to the electronic medical
record in CHART until a new medical record system is available. In the
near term, CMS should delete 2-3 medical records positions, and in the
long run aim to eliminate 10-15 positions.
CMS should work with HCA/IT to implement ongoing adequate IT
change management procedures in accordance with best practices.
In the short term, CMS should establish procedures to ensure that
statistical summary information is accurately compiled by staff.
OCSD and HCA should begin an in-depth analysis of the feasibility of
implementing outpatient clinic(s) in its jail facility(ies).
Work with OCSD to ensure that a deputy is present at all times during
inmate sick call at the James Musick jail facility.
OCSD and CMS should work together to determine the feasibility of
charging inmates for sick call and/or the selling of over-the-counter
medications through the Sheriff Commissary.

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Estimated Cost Savings/Revenue Enhancements

The audit team calculated an estimate of cost savings and revenue enhancements
from the implementation of all audit recommendations.

Conservative

assumptions and reasonable estimates were utilized. While some savings are
readily measureable, others will not be known until they are implemented.
Moreover, much of the estimated value added will not be achieved immediately,
but rather over time as HCA and OCSD phase in the recommended operational
changes. In addition, although the mitigation of risk, specifically liability risk, is
difficult to value, it is clear that the recommendations provided in this report will
significantly enhance risk protection for the County. Our minimum estimate of
measureable annual value added (cost savings, revenue enhancements, increased
productivity and staff time), contingent upon both HCA and OCSD operational
changes, is approximately $2,740,860 for a one year period, or $13.7 million if
measured over a five year period. In addition, our estimate of other potential,
but less certain, savings is $790,102 for a one year period. The details of these
estimates are provided in the Estimated Cost Savings/Revenue Enhancements
section of the full report.

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PERFORMANCE AUDIT
OF
HCA/CORRECTIONAL MEDICAL SERVICES
Introduction
Over the past several years, a number of events have significantly impacted the
Health Care Agency’s (HCA) Correctional Medical Services (CMS) operation.
These events include:
The 2002 State Budget deficit which reduced funding to CMS and resulted
in significant staffing cuts, impacting program operational capabilities

CMS Staffing, FY 93/94 to FY 07/08
250
200

194

209 210
179

173

189

179

172
155

150
100
50
0

High profile custodial health events which have resulted in increased
scrutiny of inmate medical care
Retirement of key CMS managers and its impact on program operations

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Employee association efforts to publicize CMS deficiencies and a 2007
“no-confidence” vote taken by CMS line nursing staff against CMS
management
2007 Grand Jury Report : “Man Down, Will He Get Up?” detailing
circumstances surrounding an inmate death and subsequent findings
related to nurse staffing and morale issues

These events, as well as the inherent risk from providing health care within a
custodial environment, resulted in the CMS operation being ranked the 5th
highest audit priority in the Office of the Performance Audit Director’s (Office)
Risk Assessment process. This process was used by the Board of Supervisors
(Board) and the Office as a basis to determine which County operational areas
have the highest risk potential and therefore should be examined.
The Office began the CMS audit in May 2008. It was, however, placed on hold
by the Board in June 2008 when they directed the Office to commence an
overtime audit of the Orange County Sheriff-Coroner Department (OCSD). The
overtime audit was subsequently completed in late October 2008, and the CMS
audit resumed.

Audit Scope and Objectives
The scope of this audit is limited to the CMS section of the Medical and
Institutional Health Services Division of the HCA. Specifically excluded from
this audit are other portions of Medical and Institutional Health Services, such
as:

Correctional Mental Health Services, Juvenile Health Services, and the

Conditional Release Program.

Correctional Dental Services was also not

included in this analysis, but is included in some summary information.
The objectives of the CMS audit are to:
1. Examine and document potential risks and operational deficiencies in the
CMS program

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2. Identify improved business processes and operating efficiencies that will
assist CMS in achieving its stated goals and objectives

Audit Methodology
The audit included a detailed analysis of multiple data sets; review and
observation of various systems and workflow processes used by CMS that
impact organizational effectiveness; review of regional and national correctional
medical reports and industry standards; examination of contractor operations;
and a review of State regulations and inspections of jail inmate health operations.

Information Reviewed
Information gathered included:
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Business Plans from 2001-2008
Annual Budgets FY 2000/01 to FY 2008/09
Budget detail worksheets prepared by HCA
California Code of Regulations Titles 15 and 24
CMS historical documents
National Commission on Correctional Health Care Standards
The Institute for Medical Quality (IMQ) Accreditation Standards
Orange County Grand Jury Annual Jail Reports
Pertinent inmates’ medical records and hospital survey information
Hospital and Physician contracts and expense and billing information
CMS operating statistics
Benchmarking data from other California counties
Nursing position class specifications
OCSD/Transportation statistics regarding inmate transportation
State Inspection Reports of inmate medical care
HCA and CMS Organizational structures
Pharmacy records
CHART electronic medical records system
HCA/HR Investigation records of CMS
Consultant staffing reports on CMS
Conflict of Interest information
Newspaper articles related to CMS
Nursing and Physician work schedules

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Fair Labor Standards Act information related to nursing schedules
Treatment Authorization Forms (TARS) approving inmate medical care offsite
Hospital and Physician Utilization Review meeting minutes
Claims/Lawsuits filed against CMS
County Counsel analysis of providing clinic services in jail facilities
Crout and Sida Jail Staffing Assessment for OCSD
Nursing training requirements

Interviews
Interviews/discussions/correspondence with:
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HCA Executive Management
Sheriff Jail Command staff
CMS Administrative Management
CMS Physicians
CMS Pharmacy staff
CMS Nurses
Contract Physician Group
Contract Hospital Management
County Counsel
HCA/Budget staff
HCA/Human Resource staff
HCA/Contract Administration staff
HCA/Information Technology staff
Benchmark Counties
Consultants retained by CMS
Retired CMS staff
Orange County Employee’s Association
OCSD/Transportation staff
OCSD/Administration staff
Institute for Medical Quality staff

Data Review and Analysis
Substantial efforts were made to review, analyze and validate all data received.
At several points during the engagement, audit staff met with HCA and Sheriff
staff to ask questions, verify information, and to discuss findings. In addition,

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audit staff examined data sets and conducted internal checks of all quantitative
information to evaluate the accuracy and integrity of the data provided.

Report Preparation and Review
A confidential preliminary draft report was presented to HCA and to OCSD for a
review of factual accuracy on January 15, 2009.

Comments received and

concurred with by the Office are included in this Final Draft Report, which has
been distributed to HCA, OCSD, the County Executive Office, and the Board of
Supervisors. Upon receipt of formal written responses to this Final Draft Report
by HCA and OCSD (if desired), a Final Report will be agendized on the Board
calendar with any responses included as attachments.

Background Information

Responsible Party for County Inmate Health Care
According to Titles 15 and 24 of the California Code of Regulations (CCR), OCSD
is the responsible party for ensuring that adequate medical care is provided to
the inmates in its facilities. These regulations are minimum standards for local
detention facilities and, as such, provide general guidelines for compliance.
Specific methods utilized to comply with these regulations are left to the
discretion of each Law Enforcement Agency.
OCSD has chosen to have its health care responsibility administered by the
County of Orange Health Care Agency/CMS.

This arrangement was

recommended by the County Administrative Office and subsequently approved
in-concept by the Board of Supervisors on June 17, 1975 (see Exhibit 1):
“…this Board hereby approves, in concept, the transfer of Correctional
Medicine functions presently performed by the Sheriff-Coroner and
Probation Departments, including involved personnel, services and
supplies and fixed assets, to the Physician County Correctional Services

FINAL REPORT

budget, under the direction of the County Health Officer, effective July 1,
1975…”
During its analysis, the County Administrative Office considered the following
alternatives for organizational placement of Correctional Medical (See Exhibit 2):
Retain the (then) present Physician County Correctional Services (PCCS)
organizational structure
Contract with a private firm for correctional medical services
Consolidate all correctional medical activities under the Sheriff-Coroner or
the Probation Department
Have PCCS report directly to the Board of Supervisors or the County
Administrative Officer
Consolidate all correctional medical activities under the County Health
Officer (chosen alternative)

This arrangement was formally adopted by Board Resolution on July 29, 1975
after a Memorandum of Understanding was developed and signed by OCSD, the
County Health Department, and the Probation Department.

County Jail Facilities and Inmate Population
There are five 24/7 jail facilities operated by OCSD where medical care is
provided to inmates: the Central Jail Complex (Men’s Jail, Women’s Jail, Intake
& Release Center) in Santa Ana, the Theo Lacy Jail in the city of Orange, and the
Musick Jail in the city of Irvine.
The total inmate population in the Orange County jail system averaged 6,148
inmates in 2008. The health of the inmate population across the country over the
past several years has substantially declined. Borrowing from the recent Orange
County Jail Assessment Report (Crout & Sida): “Jails everywhere are struggling
with the reality that today’s inmate is in poorer health, more drug addicted, more

FINAL REPORT

mentally ill and more prone to violence than were inmates of a decade or more
ago.”

In addition, correctional healthcare brings special challenges, such as

patient access and treatment, patient health education, medical facilities, and the
use of equipment.

Also, the frequent movement of inmates through the

correctional system creates difficulties in identifying and treating illness,
controlling communicable disease, and managing medical risk.

Two Departments, Two Missions
As noted earlier, inmate health care in Orange County is impacted by two
different County agencies (OCSD, HCA), with two different missions.
The primary mission of OCSD related to inmates is maintaining a safe and secure
environment for the inmates and the jail staff. The responsibility for inmate
health care has been delegated to HCA/CMS.

Financially, other than the

transportation of inmates from the jail to required clinic and hospital visits,
OCSD bears no fiscal responsibility for inmate health care. As a result, health
care is a secondary priority for OCSD.
The primary mission of HCA/CMS is to ensure the provision of adequate health
care for the inmates. The accomplishment of this mission is quite complex with a
number of internal and external players involved.
This distinction in mission between OCSD and HCA is important, resulting in
unique challenges that will be addressed later in this report.

Accreditation
CMS is working toward reestablishing its accreditation with the Institute for
Medical Quality (IMQ) Standards. IMQ standards delineate what constitutes
quality inmate health care services. IMQ provides an accreditation service to
verify an institution’s compliance with established industry standards and state
regulations. The U. S. Court of Appeals, Ninth Circuit has recognized IMQ
accreditation standards as meeting the constitutional level of health services for
inmates. The courts found that standards developed and evaluated by IMQ
were appropriate for use as a defendable standard of healthcare.

CMS has

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established an Accreditation Committee with the goal of accreditation in 2009.
IMQ currently has approximately 23 counties in its program that have or are
trying to get accreditation. Almost none of the ten largest California counties
(with the exception of Santa Clara and one facility in San Diego) participate in
IMQ.

CMS Overview
Services Provided Directly by CMS

CMS provides medical services both in-house (in jail facilities) and externally by
contracts with multiple health care providers outside of the jail facilities.
Internally, CMS has County staff in the following professional areas: Nursing,
Physician, Pharmacy, and Administration.

A brief summary of services

provided by County staff to inmates inside the jail facilities includes:
•
•
•
•
•
•
•
•
•
•
•

Initial physical examination once entering the jail system (Triage)
Daily sick call for inmates requesting to be seen by medical staff
Pharmacy and distribution of daily medications
Basic dental services
X-ray
Observation units
Isolated disability care (”sheltered living”)
Medical records
Diabetic care and other chronic illnesses
Coordination of clinic/hospital outpatient/inpatient specialty care
24/7 emergency medical response

Services Provided by Contract

CMS also contracts for a number of services:
•
•

Inpatient hospital and outpatient clinic services from Western Medical
Center – Anaheim (WMC–A)
Fiscal intermediary services to track and manage expenses for emergency
situations in which inmates are sent to a hospital other than WMC-A

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•

A multi-specialty physician group, Correctional Managed Care (CMC),
that provides medical treatment at WMC–A to inpatient and outpatient
inmates.
These services include surgical services and specialty
consultations and minor treatment services (e.g., Orthopedic,
Ear/Nose/Throat, Optometry, Dermatology, OB/GYN)
Part-time contract physicians, pharmacists, nurse practitioners, and
registered nurses that cover weekends, holidays, vacation and sick relief
in all jail facilities. County physicians provide this care Monday through
Friday during regular business hours.
Outpatient dialysis services from Davita, via a pass through agreement
with WMC-A

CMS Organization Chart

Provided below is the organization chart for CMS:
Med. & Inst. Health
Services, Deputy
Agency Director

Inst. Health
Services, Division
Manager

Juvenile Health

Director of
Nursing

CMS Admin. Manager

Supply Staff (3)

CHART Program
Supervisor

X-Ray
Technician

Medical
Records
Supervisors (2)
Medical
Records Staff
(23)

Inmate
Hospital/Clinic
Scheduler

Clinical Educator (0.5)

Conditional Release
Program

Director of
Pharmacy

Nurse
Scheduler
(LVN) (1)

Secretary

Supply Program
Supervisor

Correctional Mental
Health

Correctional Medical
Services

Medical Director

Chief
Pharmacist,
Theo Lacy

Supervising Nurses (4)

Pharmacists (4)

Senior Nurses (8)

Secretary

Assistant Medical
Director

Pharmacy
Technicians (5)

Registered Nurses
(RNs) (53)

Physicians (3)

Nurse
Practitioners (5)

Licensed Vocational
Nurses (LVNs) (46)

Medical Assistants (7)

A brief description of individual CMS units and County medical staff includes:

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Physician Services – provides overall medical policy and direction for the
provision of medical services to inmates; provides diagnostic, minor
medical, and emergency care to inmates in jail facilities utilizing
Physicians and Nurse Practitioners (NPs)
Nursing Services – provides all jail facility nursing services to inmates
utilizing Registered Nurses (RNs), Licensed Vocational Nurses (LVNs),
and Medical Assistants
Pharmacy Services – provides pharmaceutical drug services within the jail
facilities
Program (Administrative) Services – provides a variety of administrative
support services for CMS including budget, purchasing, contract
administration and clerical services. In addition, includes ancillary
support services such as Radiology, CHART electronic and manual
medical records, the operation of jail medical supply rooms, and
coordination of hospital/clinic scheduling of inmates.

CMS Revenue/Expense Summary

The CMS Program is funded exclusively by the County General Fund as part of
the Health Care Agency Budget.

At one point, HCA utilized both State

Realignment funding and County General Purpose Revenues to finance the CMS
Program. However, several years ago HCA made the determination that the
program should be funded only with General Fund money and not with any
State Realignment dollars. HCA indicated that this decision was made in order
to clarify the full cost of the CMS program for the Board of Supervisors and
potentially trigger OCSD contribution of financial resources to cover the CMS
budget, in total or in part. This decision highlights the discussion between HCA
and OCSD over who should bear the financial responsibility for the CMS
Program.
Total Actual Expenditures for the CMS Program have grown from just over $18
million in FY 2000/01 to nearly $34.7 million in FY 2007/08, an increase of 91% in
seven years. As the chart below demonstrates, CMS has consistently spent above
its budget since FY 2003/04, in amounts ranging from only $271,368 in FY 2007/08

FINAL REPORT

to $1,295,017 in FY 2005/06.

The CMS Total Expense Budget for FY 2008/09 is

$36,869,377, which is a $2,179,515 (or 6.3%) increase from the Total Actual
Expenditures in FY 2007/08.

Millions

Budget vs. Actual Expenditures - HCA/Correctional Medical
Services, FY 2000/01 through FY 2008/09
$40
$35
$30
$25
$20
$15
$10
$5
$0
FY 2000/01* FY 2001/02* FY 2002/03

FY 2003/04

FY 2004/05

FY 2005/06

FY 2006/07

FY 2007/08

FY 2008/09

Budget $19,237,480 $22,433,774 $24,730,446 $24,805,545 $25,855,080 $27,101,239 $29,759,520 $34,418,494 $36,869,377
Actuals $18,142,151 $22,216,084 $23,538,387 $25,459,510 $26,979,848 $28,396,256 $30,444,032 $34,689,862

*Note: FY 2000/01 and FY 2001/02 Budgeted Amounts were obtained from HCA/Internal Budget
system that was utilized at that time, which adjusted information after it was downloaded from
BRASS. All other data were obtained from CEO-Budget.

Within FY 2007/08 Total Actual Expenditures, the Total Salaries and Employee
Benefits (S & EB) accounted for $18,040,344 or 52%.

Within Total S & EB,

Overtime and Extra Help costs accounted for $2,224,556 or 12.3%. Retirement
costs accounted for $2,636,739 or 24% of Regular Salaries. Aside from Total S &
EB, the other large expenditure line item is Professional/Specialized Services,
which accounted for $14,205,139 million or 41% of Total Expenditures.

The

primary components of the Professional/Specialized Services category for CMS
include (1) the County’s contract with WMC-A for inpatient and outpatient care
for inmates ($4.76 million), (2) the County’s contract with CMC to provide
physician services for both acute needs inpatients and as specialty clinic
outpatients ($2.75 million), and (3) payments to non-contracted hospitals who

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provide acute inpatient care to inmates ($3.32 million).
Professional/Specialized

Services

line

item

includes

In addition, the
$2.72

million

administrative overhead allocation from HCA. The $16.5 million increase in
Total Actual Expenditures from FY 2000/01 to FY 2007/08 came primarily in three
categories: Professional/Specialized Services ($8.5 million), Retirement ($2.5
million), and Regular Salaries ($2.5 million).

What Works Well at CMS
The audit team identified the following areas where CMS is providing quality
services:
Basic inmate health care – CMS staff generally provides inmate access to
basic quality health care services in a timely manner.
Inmate Booking Triage – All inmates enter the jail system through the
Central Jail Complex (Intake & Release Center) and immediately receive a
basic health assessment before being housed in a jail facility.
Medicine supply and distribution – Inmates generally receive prescribed
medications in a timely manner.
Commitment to Inmate Care -- Medical staff have a strong commitment to
keeping inmates healthy.

Recent Accomplishments
In response to the 2007 Grand Jury Report, CMS enhanced emergency
medical response capabilities through increased training, drills, and new
equipment.
In 2008, the Board of Supervisors approved an HCA request to establish
the Institutional Health Quality Assurance Panel to systematically assess,
evaluate, and make recommendations regarding adult correctional
healthcare in Orange County Jail facilities.
In late 2008, CMS was successful in filling the long-vacant Director of
Nursing position.

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HCA re-cabling of jails to provide CMS staff with access to internet and
email services.
Appointment of new Institutional Health Division Manager.
In response to discussions with the audit team, HCA has formed a Task
Force which is currently addressing the recommendations included in this
report.

FINAL REPORT

Findings & Recommendations
The audit team comprehensively examined all aspects of the County system that
provides health care services to jailed inmates.

The following findings and

recommendations highlight areas are for improving the CMS operation.

CMS Organizational Culture

Finding 1: Negative employee morale impedes meaningful progress.

Nearly all staff interviewed during this audit identified several problems within
the CMS organization that impede program efficiency and effectiveness.

Addressing these cultural issues is vital to ensuring that the more

concrete recommendations that follow are accomplished.
A summary of the specific issue areas that were identified are listed below, each
of which will be discussed later in this report:
Organizational Structure
Management
Nursing
Physician
Pharmacy
Administration
OCSD-CMS Coordination

Recommendation 1: Remove all organizational and personnel barriers to change
within the CMS organization. Set in place a leadership team that is willing and

FINAL REPORT

able to promote an environment of performance and optimism that will ensure
that the findings in this audit are implemented in a timely manner. A formal
audit action plan should be established that is supported by the resources
necessary to bring about lasting improvements, and CMS management’s
progress should be actively monitored by HCA Executive Management.

Organizational Structure Issues

Finding 2: The current CMS Administrative Services structure impedes
operational efficiency and effectiveness.

Each jail facility is the primary service delivery point for inmate health care. At
each facility, there are both line and support staff. Line staff includes direct
service providers such as doctors, nurses, and pharmacists.

Support staff

currently includes medical record personnel, supply room clerks, an X-Ray
technician, and administrative program staff which provide budgetary,
purchasing, information technology, and clerical support.

Support staff is

supervised by a Program Manager who is physically located at the Central Jail
Complex.

The program support function has become increasingly and

inappropriately enmeshed in medical line operations due to a management
vacuum created by a long-term vacancy in the Director of Nursing position. This
environment has been a source of considerable frustration among staff and, in
part, led to the cultural issues described in the previous section. However, with
the recent hiring of a Director of Nursing, there is an opportunity for the
program support function to refocus on strictly administrative issues, which are
discussed in further detail in the Administrative Issues section of this report.
Similarly, the Nursing operation, which is the backbone of the daily medical care
service delivery in the jails, should have under its structural authority as many of
the tools and resources as necessary to perform their daily line responsibilities.

FINAL REPORT

Recommendations:
2.1 : Relocate the CMS Program Manager from the Central Jail Complex to
HCA/Headquarters and assign the following overall administrative
responsibilities for the CMS function: Human Resources Coordination,
Budget,
Contract
Administration,
Purchasing,
and
Medical
Recordkeeping/IT. This position should continue to report to the Institutional
Medical Health Division Manager, but have no line authority over jail
medical staff.
2.2 : Realign the X-Ray Technician and Inmate Hospital/Clinic Scheduler
under the CMS Medical Director.
2.3 : Realign the supply room function under the Nursing authority structure
at each jail facility.
A recommended organizational chart can be found in Exhibit 3.

Management

Finding 3: Inmate health care is a priority, but a secondary priority for OCSD
and a non-core service for HCA.

As previously stated, the mission of OCSD in the jails is to ensure the safety of
inmates and those who work inside the jail facility. Health care responsibilities
have been delegated to HCA/CMS.

In addition, OCSD, except for the

transportation of inmates to the hospital, does not contribute any financial
resources toward the health care services provided to the inmates. As such,
inmate health care delivery is a secondary priority both operationally and
financially.

FINAL REPORT

Although inmate health care has been delegated to HCA by the Board with
OCSD concurrence, HCA management has described CMS as a “non-core
service.”

This view stems from the circumstances surrounding the Board’s

decision in 1975 to have correctional medicine report to the County Public Health
Department (the pre-cursor to HCA).

At that time, the Physician County

Correctional Services (PCCS) group, which provided health care in County
correctional facilities, reported organizationally to the County Medical Center.
When the County transferred ownership of the medical center to UCI, it was
necessary to find an organizational placement for PCCS. Thus, the provision of
correctional medical services has been a County obligation that was handed to
HCA.
As a secondary and non-core service, the provision of inmate health care
predictably receives less attention than other parts of both OCSD and HCA. As a
result, making the time to address the issues within CMS, working through two
different departmental chains of command, and gaining approval for the
allocation of sufficient resources to make improvements has been an on-going
problem.

Recommendation 3: Due to the risks inherent in a correctional medical operation
(i.e., financial, ethical, legal, public/political sensitivity), CMS should be elevated
to a first tier priority for both OCSD and HCA.

Finding 4: There is a lack of accountability with CMS management and line
staff.

Despite the fact that CMS both knows it has deficiencies, and is aware that little
progress has been made in addressing those deficiencies, employees have
generally not been held accountable for poor or non-performance.

This is

confirmed by the following significant findings:

FINAL REPORT

•

Some problems have continued for years without meaningful attention
including: outpatient scheduling of inmates and the assurance of their
actual transportation to the hospital; inadequate utilization of the CHART
electronic medical record system; ongoing issues with lost hard copy
inmate medical records; orderliness and functionality of medical supply
storerooms; accepting responsibility for the administration of contracts
including the meaningful conduct of patient and medical facility
Utilization Reviews; and following documentation and disposal policies
and procedures regarding controlled substances.
Despite the fact that these and other issues have been unresolved for
several years, it was not until September 2008 that CMS put together a
formal action plan that prioritized issues and tracked implementation
progress. In addition, HCA Executive Management was consistently
surprised at the depth of the problems within CMS and the lack of
progress toward addressing their on-going issues. Lastly, this recentlycreated action plan is inappropriately monitored by a staff member in
HCA/Strategic Projects Administration, not by CMS management.

•

Employees with known, significant performance issues have been allowed
to pass probation. In one instance, an employee passed because
management/supervision was unwilling to confront the issues; in another
instance an employee passed because of a failure to complete an
evaluation before the end of the performance period thereby allowing the
employee to pass by default.

•

HCA authorized a consultant review during the course of this
performance audit to address several staffing and scheduling issues
previously covered by a prior consultant report and already under review
by the audit team. In addition, one of the primary tasks of this second
consultant review was to determine the staffing requirements needed to
obtain IMQ Accreditation, despite the fact that several of the prior
consultant’s more pressing operational recommendations had not been
resolved.

•

It is common knowledge among CMS management that much of the
statistical data collected and aggregated is unreliable. Despite this
knowledge, this data was and is still used within CMS to provide

FINAL REPORT

information to Executive Management, and on occasion was/is forwarded
to the California Department of Corrections per state regulations.
•

The administration of CMS contracts has been inadequate and
subsequently has not allowed CMS to properly manage contractor
performance or fully prepare for effective contract negotiations with
vendors.

•

There are a handful of conflicts of interest within CMS that have been left
to linger for several years. These conflicts include the employment of
relatives within the CMS program, and the utilization of at least one
employee in multiple capacities as both a contractor and a County
employee. The continuation of these situations has not only created
unacceptable conflicts of interest, but has generated much animosity
among staff both within CMS and OCSD, and exposed the County to
potential and unnecessary liability.

•

There are examples of recalcitrance among some CMS line staff. This was
both conveyed to us by CMS management and observed during the audit
team interviews. Simply put, some employees do not perform their
required duties and very little, if anything, is done to address it by
supervision/management.

Recommendations:
4.1: HCA should create a Task Force of high-performance HCA employees to
comprehensively address the management/accountability deficiencies identified
in this audit.
4.2:

Throughout

CMS,

performance

communicated, and enforced.

standards

should

established,

When basic performance expectations and

standards are not met, employee training, counseling, and then discipline should
occur.
4.3: Appropriately address all conflicts of interest within CMS.

FINAL REPORT

Nursing
CMS Nursing staff levels have been the subject of considerable scrutiny over the
past several years.

The nurses’ employee association, the Orange County

Employee’s Association (OCEA), began raising concerns over nursing staff levels
in FY 2002-03 after HCA cut a variety of CMS positions in order to address State
budget shortfalls (the total number of nursing positions fell from 125 in FY
2002/03 to 94 in FY 2003/04). It should be noted that these staffing cuts came only
two years after a significant staffing increase in the CMS program (the total
number of nursing positions increased from 109 in FY 2000/01 to 121 in FY
2001/02).

140
120
100
80
60
40
20
0
SUPERVISING RN

FY 99/00

FY 00/01

FY 01/02

FY 02/03

FY 03/04

FY 04/05

FY 05/06

FY 06/07

FY 07/08

FY 08/09

SENIOR RN

LVN

CMS nurses’ concerns with staffing levels and other issues culminated in a
October 2007 “vote of no-confidence” in the program’s management, and several
subsequent newspaper articles that amplified nursing staff’s criticism of CMS
leadership. In addition, in both 2006 and 2007, Grand Jury Reports on CMS
indicated understaffing and a lack of training for nursing personnel after incustody deaths prompted increased scrutiny of the program.

FINAL REPORT

In response to this scrutiny, HCA hired an external consultant to conduct a nurse
staffing review. The review was conducted from late 2007 through April 2008,
with a final report issued to HCA management. Then, in fall 2008, HCA hired a
second consultant to again review nursing staffing levels and identify the
necessary resources to regain accreditation by IMQ which was lost in 2002.
The audit team’s review of the CMS Nursing function resulted in the following
findings:
Nurse Staffing Levels/Schedules

Finding 5: The current allocation of four Supervising Comprehensive Care
Nurse positions is excessive.

Prior to the staffing reductions in FY 2003/04, CMS had three budgeted
Supervising Nurse positions. Starting in FY 2003/04 to FY 2006/07, CMS reduced
its Supervising Nurse positions to two. Then, in FY 2007/08, CMS increased the
number of Supervising Nurse positions to four.

Interviews with CMS

management and staff, as well as detailed job descriptions provided by HCA
management confirm that Supervising Nurses are utilized in a variety of
disparate ways:
•

One Supervising Nurse is primarily responsible for working with
HCA/Human Resources to augment recruiting efforts for staff nurses, and
to provide training once employees are hired.

•

A second Supervising Nurse position, which is currently vacant, was
responsible for collecting and verifying some operational statistics, as well
as creating new and modifying existing policies and procedures in order
to achieve IMQ accreditation.
This second Supervisor was also
responsible for the James Musick Facility, but was rarely on site.

•

The third and fourth Supervising Nurses are utilized consistent with the
responsibilities of their classification, and are responsible for the nursing
operations at the Theo Lacy Facility and the Central Jail Complex,
respectively.

FINAL REPORT

Clearly, only two of the positions are used to meet the supervisory nursing needs
of the organization.

Recommendations:
5.1: Reduce the number of Supervising Nurses to two, with one responsible for
nursing activities at the Theo Lacy and James Musick Facilities, and one
responsible for the Central Jail Complex. Each Supervisor should be on site
Monday through Friday to assist Senior Nurses with the day-to-day operations
and facilitate problem solving.
5.2: Both the vacant Supervising Nurse position and the Supervising Nurse
position currently responsible for recruiting should be reclassified to a Senior
Nurse level and reassigned to either (1) WMC – A as the CMS hospital liaison or
(2) the Theo Lacy Jail Facility to improve Senior Nurse coverage.

Finding 6:

The current allocation of eight budgeted Senior Nurse positions

is insufficient to meet coverage needs.

The Senior Nurses are responsible for providing supervision to all nursing staff
and ensuring the achievement of day-to-day operational tasks and goals at four
of the five jail facilities. Currently, no Senior Nurse is assigned to the James
Musick Facility due to its small size. Five Senior Nurses work the day shifts
(6:30AM to 7:00PM) at the four facilities and four Senior Nurses work the night
shifts (6:30PM to 7:00AM). One of these nine positions is a RN which was
temporarily classified as Senior Nurse.
Based on our review of CMS nursing schedules and interviews with a variety of
staff, there are frequent instances where only one Senior Nurse is on duty to
cover all four jail facilities. In the majority of instances, Theo Lacy is the facility
without a Senior Nurse.

These occurrences are especially problematic as they

FINAL REPORT

also often occur at times when no Supervising Nurse is on site. This results in no
supervisor on site to (a) advise line staff during times of emergency, (b) handle
supervisory problems that arise, and (c) ensure that all operational tasks are
completed satisfactorily.

Recommendation 6: Increase the number of Senior Nurse positions to ten in
order to fill in coverage gaps to ensure day-to-day supervision, especially at the
Theo Lacy Facility. The one temporarily promoted position should be made
permanent, and the second position should come from the reclassification of one
of the Supervising Nurse positions.

Finding 7: The current LVN schedules are inefficient and lead to supervision
difficulty because they are inconsistent with the schedules of other nursing
personnel.

There are three different LVN shifts during a 24-hour period. Both the Day Shift
(6:00AM to 4:30PM) and the PM Shift (1:00PM to 11:30PM) are 10-hour shifts, but
the Night Shift (9:30PM to 7:00AM) is a 9-hour shift. It is important to note that
these LVN shifts differ from the RNs and the Senior Nurses who work 12-hour
shifts from either 6:30AM to 7:00PM (Day Shift) or 6:30PM to 7:00AM (Night
Shift). These different schedules weaken the ability of the Senior Nurses to plan
and manage their respective staffs because of the multiple shift changes that
occur. Similarly, staff cohesion and cooperation during a given twelve-hour
period is limited because of these staggered shifts. Lastly, because the LVN Day
Shift begins thirty minutes before the Senior Nurse Day Shift, Senior Nurses
raised concerns about monitoring punctuality among LVN staff.

FINAL REPORT

In terms of efficiency, the audit team identified a significant amount of idle or
“down”
down” time on each shift created by the overlap of staff (i.e.
(i.e., from 1:00PM
1
to
4:30PM, from 9:30PM to 11:30PM, and from 66:00AM to 7:00AM).
AM). The total hours
of LVN staff overlap under the current schedule for any given position is 6.5
hours in a 24-hour period,
iod, which equates to 2,372.5 hours in a year in which
there is excessive staff coverage (See graphic below).. Staff also indicated that
from midnight to 4:00AM,
AM, there is simply not very much going on at any of the
facilities, with the exception of the IRC
IRC, where inmates are booked into the jail
system on 24/7 basis.

CMS is currently budgeted 49 FTE LVN positions, with three being utilized for
non-nursing
nursing assignments. Thus, the 46 remaining positions are used to cover the
different LVN shifts detailed in the chart below:

Location
IRC
Lacy
Lacy – Mod O
Men's
Women's
Total LVNs

Day
Shift

PM
Shift

Night
Shift

2
2
1
2
1
8

1
1
1
1
1
5

FINAL REPORT

Six months ago, the LVNs and OCEA created a proposal to transition to the “312” schedule that is used for Registered Nurses in order to address these
inefficiencies and create a more consistent working environment. HCA is
currently evaluating this proposal.

Recommendation 7: Transition all LVN positions to either eight-hour shifts or
twelve-hour shifts in order to eliminate the unnecessary staff overlap that
currently exists with either the “4-10” and “9-80” schedule. Implementing this
change would be more efficient, allowing six LVN positions to either be deleted
or reassigned to assist with IMQ accreditation-related tasks (e.g. 14-day health
inventories). The decision between eight and twelve-hour shifts needs to be
made only after a thorough review of shift activities and Fair Labor Standards
Act (FLSA) requirements is completed and any procedural adjustments are made
(e.g. reduction in the number of medication passes).

Finding 8: The bi-weekly master nursing schedule has been the source of
considerable frustration among nursing staff.

Historically, the schedule has been compiled by a full-time Nurse Scheduler, but
due to a leave of absence, a Supervising Nurse is covering this very timeconsuming task.

This temporary change has addressed a concern among staff

that the Nurse Scheduler, historically filled by an LVN, did not have the
authority to review leave and other requests for other LVNs and especially for
the higher-classified RNs. This problem was exacerbated by the fact that the
Director of Nursing (DON) position had been vacant for the last several years,
and the Nurse Scheduler reported directly to the Program Manager, who does
not have nursing management experience or a clinical background.

FINAL REPORT

Though the temporary assignment of a Supervising Nurse to complete the
schedule has addressed some of the aforementioned problems, it has created
another: the use of high-level nurse management resources (i.e., a Supervising
Nurse) to complete a task that substantively and procedurally could be done by
an employee in a lesser paid administrative support role.

Recommendation 8: Utilize an administrative support employee who reports to
the Director of Nursing (DON) to develop the schedule for review by the DON.
This person should also work collaboratively with the Supervising Nurses
assigned to specific facilities to address any problems that arise. This solution
will not only make more effective use of the Supervising Nurse resources, but
will empower the Scheduler to make any schedule-related decisions in
consultation with, and with the authority of, the DON and Supervisors.

Daily Medication Passes

Finding 9: The current number of daily medication passes consumes
significant staff resources and may not all be necessary.

CMS performs four medication passes per day requiring intensive LVN
resources. One of the four medication passes, performed at 5:00 a.m., is required
for providing medications to a relatively small number of inmates, many of
whom are attending court (for the period July 1 through November 30, 2008, an
average of 36 packaged medications were processed by the Pharmacy per day for
the Central Jail Complex).

The largest passes occur at 9:00 a.m. and 7:00 p.m.

and include an average of 1,092 and 1,904 (for the period July 1 through
November 30, 2008) packaged medications for the Central Jail Complex. One
substantially smaller pass with an average of 141 packaged medications occurs at
1:00 p.m. The CMS Director of Pharmacy informed us that a review of the
medications administered at the 1:00 p.m. medication pass was performed

FINAL REPORT

several months ago informally at the direction of the Institutional Health Services
Division Manager. At that time, it was determined that the 1:00PM med pass
was necessary due to the current detoxification protocols established and
medication prescribed for dental needs. The audit team compared the number of
medication passes to other Counties in a benchmark study and found that it is
not uncommon to have two main medication passes, with additional medication
passed only when absolutely necessary or self-carried by inmates.

Recommendation 9: CMS Physician and Pharmacy staff should perform a formal
evaluation of the 1:00PM med pass for the purpose of determining the feasibility
of discontinuing the pass in the future, or limiting the pass to include only those
medications that must be given between the 9:00AM and 7:00PM passes.

County Physicians and Nurse Practitioners

Background Information

CMS employs the following Physician and Nurse Practitioner staffing
complements:
•

Full Time County Physicians
There are currently five full time County Physician positions in CMS:
(1) Medical Director
Per Title 15 of the CCR, this is a mandated position, which is chosen by
both HCA and OCSD, which has the responsibility to:
o Provide overall medical policy direction for the CMS operation
o In consultation with HCA Executive Management, to determine
the level of medical care provided within the jail system
o Be the final arbiter in all medical decisions regarding inmates
o Ensure that contractors providing medical care to inmates both
within and outside the jail do so in an acceptable manner

FINAL REPORT

o In cooperation with OCSD, identify, approve, plan, and
implement improvements in the provision of inmate health care
(1) Assistant Medical Director
This position is responsible for the day-to-day provision of doctor and
nurse practitioner services within the County’s five jail facilities.

addition, both the Medical Director and Assistant Medical Director are
the final approval required for sending inmates for outside clinic or
hospital care.
(3) Physicians
Three County Physician positions (only two are filled) are allocated to
CMS and cover the five jail facilities from Monday through Friday
during regular business hours. Regular duties include: examination of
patients who have been referred for examination by nursing staff;
evaluation of chronic disease patients (e.g., cardiac, asthma, seizure);
rounds for patients temporarily confined to infirmaries for observation
(e.g., oxygen delivered, sleep apnea, alcohol and drug detoxification,
surgical recuperation); care of complex cases, including hepatitis and
HIV.
•

Part-time Extra Help Physicians
Due to the 24/7 nature of jail operations, part-time Extra Help Physicians
are employed on a contract basis to provide medical care to inmates
during nights, weekends, holidays, and for sick/vacation relief of County
full time physicians.

There are currently 11 Extra Help Physicians

working a variety of hours, a cumulative average of about 21 hours per
week.
•

(5) Nurse Practitioners
CMS has five Nurse Practitioner positions that provide important skilled
medical care that can be done at lower expense. Typical duties include:
inmate physicals during Triage, case management of identified illnesses,
sick call for inmates referred by nurses, and treatment of routine illnesses.

FINAL REPORT

All Nurse Practitioners report to the Assistant Medical Director. Four of
the five positions are currently filled.

Residency Programs

Finding 10: Coordination efforts between OCSD and CMS have been
unsuccessful in establishing a physician residency and training partnership
with local medical programs.

The establishment of a Physician Residency program could be a win-win
solution for both the County and new doctors in residence. From the Resident
perspective, it would allow new doctors invaluable experience in a correctional
setting caring for patients whose illnesses are less prevalent than those found in
the public at-large: tuberculosis, HIV, and hepatitis-C. For the County, it could
retain the services of less expensive physician services and assist in long-term
recruiting efforts. CMS physician staff did attempt to establish a partnership
with a local optometry program, but the effort was ultimately dropped due to
background check issues and delays.

Recommendation 10: CMS and OCSD should develop a partnership with a local
medical school residency program.

Utilization Review

Finding 11: WMC-A does not perform meaningful hospital or physician
Utilization Reviews of services provided according to contract
requirements.

FINAL REPORT

The purpose of the utilization review program is to provide a consistent, qualitycontrolled method of assuring cost-effective utilization of health resources. This
is performed by three review methods: 1) a Prospective Review provides for preauthorizing urgent procedures/tests/treatment to ensure it meets established
criteria (i.e. is medically necessary & appropriate), 2) a Concurrent Review is a
program for reviewing the cases of currently hospitalized patients in order to
determine that the level of care is appropriate and the treatment plan is the most
efficient and cost-effective, and 3) a Retrospective Review is for reviewing
historical hospital inpatient and clinic outpatient utilization statistics for the
purposes of education, pattern identification, and quality assurance.
Specific requirements to perform these reviews are documented in WMC-A’s
Utilization Management (UM) Procedures dated November 18, 2008. The audit
team reviewed the utilization plan, inquired with contract staff regarding
procedures performed, and reviewed utilization meeting agenda minutes. Our
examination found that these utilization reviews are not performed as stated in
UM Procedures.

Instead, these reviews have become cursory and less than

meaningful. As a result, neither contract requirements nor best practices are
followed, nor is the County formally assured that inmates are receiving quality
care or that physician/hospital expenses are reasonable for the services provided.
Contractors informed us that the UM procedures, established many years ago,
are outdated and they plan to work with CMS at the beginning of 2009 to review,
update, revise, and follow the procedures by the end of the first quarter.

Recommendation 11: CMS/Physicians should ensure that adequate utilization
review procedures are performed. Any changes to utilization procedures should
be discussed with CMS Management before implemented.

Medication Orders

Finding 12: Telephone orders for medication are not approved electronically in
the CHART electronic medical record system.

FINAL REPORT

All telephone medication orders must evidence documented approval within 72
hours. When a physician is not physically present (on-call), the RN will obtain a
telephone order and enter the medication as a verbal order into the CHART
system and as a telephone order on the Medical Orders form.

CHART

(Correctional Health Assessment, Recording, and Tracking) is an electronic
medical record information system used by CMS. The medical orders form is
faxed to the Pharmacy. Pharmacy ensures the medication order is accurately
recorded in the CHART system. Physicians are required to record authorization
of the medication manually on the hard copy Medical Orders form. Subsequent
documented approval of the telephone order is not required electronically. The
ability to electronically approve telephone orders is a feature that is currently
available in the CHART system and is utilized by HCA Mental Health
Psychiatrists. CMS informed the audit team that they plan to roll-out this feature
in the near future. More specific CHART system findings and recommendations
will be discussed later in the Administrative Issues/Information Technology
Section of this report.

Recommendation 12: CMS should complete its efforts to roll-out the electronic
approval of verbal medication orders in the CHART system.

Finding

13:

Medications

prescribed

contract

Physicians

the

hospital/clinic are not always properly reviewed by a CMS physician before
the prescription is processed.

After an inmate is seen at the hospital, the hospital physician may prescribe a
recommended medication. The County Medical Director has pre-authorized the
transcription of hospital orders onto the CMS medical order sheets under his
name although the prescription portion was not actually reviewed. The RN
enters the order into the CHART system as prescribed by the County Medical
Director although this did not actually occur.

FINAL REPORT

Recommendation 13: All medication orders should be properly reviewed and
approved, at least verbally, and ideally electronically, by a County Physician
before it is entered into the CHART system.

Pharmacy-Related Issues
There are several important findings in this area that have been discussed with
HCA Executive Management so immediate changes could be implemented.

Controlled Substances

Finding 14: Controlled substance documentation and disposal procedures are
not always followed.

There are approximately twelve controlled substances utilized by CMS.
Controlled substances are defined as substances that may be addictive and are
medications that are usually prescribed for mental health treatment or to
substance abusers for alcohol or benzodiazepine withdrawal or detoxification.
CMS Pharmacy policy requires a perpetual inventory of controlled substances
distributed to nurses and maintained at nursing stations.

A sequentially

numbered “Controlled Substances Administration Record” is used by nursing
staff to document an audit trail of each dose.

Further accountability is

established by requiring dual authorization for all medications received and
disposed of as well as to verify substances on hand at the end of each shift. A
Senior Nurse is required to review each record to ensure the form is properly
completed. After each shift, the LVN must update the CHART system to record
whether the inmate received the medication or the reason if it was not
administered (e.g. refused, at court, released). The audit team identified the
following control weaknesses in regard to controlled substances:

FINAL REPORT

•

The “Controlled Substances Administration Record” is not always
adequately updated. The audit team reviewed all Controlled Substances
Administration Records completed and returned to the pharmacy for
three sample months. We found that it is common practice for
medications that are not administered to be returned to inventory without
proper notation on the controlled substance record to clarify that the
inmate did not receive the medication.

•

Dual verification is not always performed as required. During fieldwork,
the audit team observed a LVN document dual verification of a shift count
even though it did not occur. The LVN informed us that it is her
understanding that physically verifying controlled substance information
is not required, and that accountability is established with the nurse that
performed the count.

•

Controlled substances are not always properly destroyed per federal
regulation. Several LVNs stated that in some cases controlled substances
are flushed down the toilet although tamper resistant boxes are available
for disposal. Title 15 requires that controlled substances be disposed of in
accordance with Drug Enforcement Administration (DEA) procedures.
The DEA requires the transfer of controlled substances to a distributer that
is registered with the DEA to destroy drugs. CMS has a contract with a
vendor for these purposes.

•

There is no established verification schedule to confirm the accuracy of
controlled substance records. To ensure controlled substances are
properly accounted for, a periodic review of a sample of doses
administered according to the Controlled Substances Administration
Record should be compared to the inmate’s medication record in the
CHART system or hard copy record to ensure the inmate was prescribed
the medication and there is documentation that the drug was
administered. This is especially important because CMS does not have a
consistent process for documenting medications administered. Examples
include “Stat” doses which are medications determined urgent and are
provided in a rush so they are allowed to be documented on medical
order forms or nurse progress notes; inmates may have two medical
records (medical and mental health records are not combined); or as noted
earlier, substances returned to inventory do not always identify the
inmate that did not receive the medication. For a one sample month (June

FINAL REPORT

2008) period, the audit team examined 45 inmate doses documented on
Controlled Substances Administration Records. For the sample selected,
we compared the controlled substance dose, inmate name, booking #, and
date administered documented on the Controlled Substances
Administration Record, to the substance administered according to the
CHART system or hard copy record. Our review found seven instances (a
16% error rate) where records did not properly account for controlled
substances due to the following reasons:
Three doses administered according to the Controlled Substances
Administration Record did not agree with the dose prescribed in
the CHART system.
Two doses were recorded in the CHART system as not
administered because the inmate was released, although the
Controlled Substances Administration Record indicated that the
dose was administered to the inmates. We discussed this with
CMS and later found that the controlled substances were returned
to inventory but there was no notation to identify the inmate that
did not receive the medication. Due to the incomplete record
keeping, CMS had to review the medication record for all inmates
that received the same controlled substance for the medication pass
in order to provide sufficient evidence to the audit team that the
substances were properly accounted for.
Two doses were recorded in the CHART system as administered.
For one, the Controlled Substances Administration Record
identified that the dose was destroyed because the inmate did not
receive it. For the other, the record did not indicate the controlled
substance was removed from inventory.

•

Pharmacists perform monthly spot-checks, as part of a monthly
Medication Area Inspection report, to confirm that the drug counts
according to the Controlled Substances Administration Record
correspond to the actual count of medication on hand. However, there is
no specific written policy on the part of CMS/Pharmacy that requires
pharmacy staff to complete these counts. As such, there is confusion at

FINAL REPORT

Theo Lacy as to why such inspections are necessary, though they are
completed.

These controlled substance findings are important given the jail environment
where many of the inmates are either chemically or alcohol addicted.
addition,

controlled

substance

documentation

weaknesses

increase

In
the

possibility that these substances could be misused or stolen, and may result in
increased risk to the County.

Recommendations:
14.1: CMS should immediately enforce the regulations and procedures related to
controlled substances.
14.2: CMS Pharmacy should provide additional training to nursing staff on the
proper procedures to account for and dispose of controlled substances.
14.3: The Pharmacy Director should ensure that a specific formal policy and
procedure exists and is enforced to address required spot checks of controlled
substance inventories at all dispensary facilities.
14.4: Additional monitoring procedures should be performed by the Senior
Nurse responsible for ensuring the substance administration record is properly
completed to include a periodic review of the CHART system medication/hard
copy distribution record to the Controlled Substances Administration Record.
Any differences should be immediately addressed.

Undistributed Medications

Finding 15: There is no validation that undistributed medications are properly
returned to Jail Pharmacies to be destroyed.

FINAL REPORT

Many formulary medications (approved stock list of available medications
provided by CMS) cannot be distributed because the inmate is at court,
transferred to another facility, released from custody, refused the medication, or
was discharged. These medications, packaged primarily by the Pharmacy, do not
include controlled substances. LVNs maintain the undistributed medications in
an unsecured Return to Pharmacy Box in the nursing dispensary until the
following day when they pick-up medications for the next medication pass and
return undistributed medications from prior shifts to the Pharmacy to be
destroyed. The Pharmacist does not verify that all medications that were not
distributed, according to the CHART system, were returned. The Pharmacy
Director informed us that due to the number of undistributed medications and
limited system reports available in the CHART system, verification would be
impossible with the current staffing levels.

Recommendation 15: A process to ensure that undistributed medications are
properly returned to the Pharmacy should be evaluated by CMS Management.
That process should include the overnight storage of medications in a secure
location with access only by Pharmacy personnel and the medication nurse.

Medication Packaging

Finding 16: The CMS Pharmacies package medication too far in advance
resulting in a significant number of medications that must be destroyed.

Pharmacy staff informed the audit team that medications must be processed the
previous day for the next day’s 5:00AM, 9:00AM, and 1:00PM medication
distributions. The 7:00PM medication is packaged at 8:30AM the same day. This
is required because the pharmacy closes by 5:00PM and does not open until
7:00AM Theo Lacy processes medication two days in advance for the Monday

FINAL REPORT

medication pass because Pharmacy Technicians, responsible for packaging
medications are not on duty Sunday.

Due to the magnitude of inmate

movement, medication should be packaged closer to the time the medication is
distributed. In light of the fact that CMS spends nearly $1 million per year on
medications, the audit team estimated that addressing this practice would result
in meaningful cost savings.

Recommendation 16:

CMS should evaluate the current Pharmacy work

schedule with the goal to improve medication packaging timelines that are closer
to medication distribution schedules.

Finding 17: Some new medication orders are not included in the inmate’s
medication package when they are filled by the Pharmacy.

Since formulary medications are often packaged the day before they are
distributed, some recent medication orders (new bookings or new medication
orders) entered into the CHART system are not included in the inmate’s
medication package from the pharmacy. As a result, the LVN’s package these
new formulary medications from nursing station stock. LVNs add supplemental
medication orders processed after the medications have already been packaged
by opening the pre-packaged medication packet in order to add the formulary
medication from nurse station inventory. The audit team’s review of manually
prepared medication packaging statistics maintained by CMS found that this
practice has resulted in the LVN’s packaging an average of 2,900 medications per
month at the Theo Lacy facility alone. CMS has planned to implement an update
query in CHART for some time where new medication orders received after the
medications are packaged may be processed through CMS’s automated
medication packaging system, CIPS (Correctional Institution Pharmacy System)
that is interfaced with the CHART system; however this effort has not been

FINAL REPORT

completed. This would dramatically reduce the number of medications handpackaged by the LVNs.

Recommendation 17:

CMS should quickly complete its efforts to create the

required update query in the CHART system in order to reduce the number of
medications packaged by the LVNs.

Self-Carry Medication Documentation

Finding 18: Random spot checks of Musick jail facility self-carry medications
are not always provided weekly to the Pharmacy according to policy.

Pharmacy procedures require a weekly documented spot check of at least ten
inmates to monitor inmate compliance with prescribed medication instructions.
The audit team’s review of the Musick jail facilities “Self Administered
Medication Compliance Monitor” records found that for the period January 1,
2008 through October 31, 2008, approximately 28, or 64% of the 44 required
weekly documented spot checks were not provided to the Pharmacy.
Documented spot checks provide evidence that monitoring of the self-carry
medication program occurred as required.

Recommendation 18: The CMS Pharmacy should monitor self-carry medication
random spot check records to ensure documentation is provided in compliance
with established procedures.

FINAL REPORT
Perpetual Inventory of Non-Controlled Substances

Finding 19: There is no perpetual inventory of formulary medications
maintained outside of the Pharmacy.

Some formulary medications are maintained in the Nursing Station to provide to
inmates that transfer or otherwise miss the regular distribution cycle processed
through CIPS. A manual tracking system was implemented at the women’s jail
to track each non-controlled medication provided to an inmate. However, this
process was never rolled out to other medical locations because the process is
labor intensive.

CMS informed us that dispensing systems are available to

properly track medications but were never purchased due to budget constraints
over the last three fiscal years.

Recommendation 19: CMS should evaluate available dispensing systems that
may be purchased within current budget constraints.

Administrative Issues

There are a number of significant administrative issues within CMS that require
attention. By functional area, they include:

Funding

Finding 20: OCSD currently does not contribute any financial resources to
offset the cost of correctional medical services provided by HCA.

FINAL REPORT

As noted in the background section of this report, the cost of providing health
care to Orange County Jail inmates has nearly doubled in the last eight fiscal
years.

HCA continues to fund the entire program out of its General Fund

allocation. A sample of other California counties indicates that this arrangement
is not uniformly utilized. The audit team noted at least two Southern California
counties (San Diego & San Bernardino) where inmate medical services fall under
the auspices, both organizationally and financially, of the County Sheriff’s
Department. In addition to OCSD General Fund revenues, other counties also
utilize State Mental Health Realignment Funds and Proposition 172 funds to
offset some of the cost of providing inmate medical care where possible. Other
counties also help fund some correctional medical costs through the Inmate
Welfare Program.

Recommendation 20: OCSD should begin to contribute financial resources to
cover at least some of the fiscal burden of providing inmate medical services.
Immediate contribution opportunities exist with some much needed capital and
infrastructure investments, such as: (1) refurbishing medical observation units at
the jails, (2) an electronic medical record system, and (3) building out clinic space
at the jails. In addition, the cost of over-the-counter (OTC) medications sold
through the commissary, when such a program is implemented, should be
funded with Inmate Welfare/Commissary dollars in OCSD.

Contract Administration

CMS has a fixed price contract with CMC to provide physician services at WMCA, and a separate contract with WMC-A for use of the hospital facility.
Responsibility for Contract Administration

Finding 21: CMS contract administration and program monitoring roles are not
clearly defined, resulting in ineffective contract oversight.

FINAL REPORT

HCA/Contract Administration should be responsible for contract solicitation,
negotiations, procurement, and for technical contract language interpretation
once developed.

CMS should be responsible for day-to-day monitoring of

contractor performance and ensuring that required medical expense information
is provided according to contract terms. During the course of this audit, the
audit team found that contract administration duties were not delineated in this
fashion, were uncoordinated when they were performed, and in some cases,
were not performed at all. For instance, as discussed in subsequent findings
related to WMC-A and CMC profit and loss statements, this information is often
inaccurate, unverifiable, and not prepared according to the contract. None of
these issues had been previously identified or addressed by HCA.

Recommendation 21: HCA/Contract Administration and CMS should delineate
the responsibilities for contract administration and contract program monitoring.
Once this occurs, CMS should ensure contract monitoring is performed as
required.

Update of Inmate Medical Records in CHART System

Finding 22: CMC contract physicians do not input discharge planning orders
into the CHART system when an inmate leaves WMC-A.

Inmate patient discharge summary information includes ordered medications
and follow-up appointments. Part IV, Section C of CMC’s contract states that all
physicians or designees shall write legibly in custody patient charts and input
discharge planning recommendations in the CHART system. CMC informed us
that the former CMS Hospital Liaison RN used to input this information directly
into the CHART system for them. This discontinued after CMS changed their
computer system as it was no longer compatible with the hospital system.

FINAL REPORT

The inmate discharge summary is provided to Sheriff Transportation deputies
when an inmate returns to the jail facility (Intake & Release Center).

CMS

medical record clerks are then responsible for sorting these documents and
distributing them to the appropriate jail facility where the inmate is housed. On
many occasions, the discharge summary does not arrive at the appropriate jail
facility for several days.

Recommendation 22: CMS should ensure that County and contractor computer
systems are compatible to allow for electronic access to the medical records.
After this occurs, CMS should require that CMC contract physicians input
discharge planning information into the CHART system in order to achieve a
fully electronic medical record as required by the contract.

CMC Profit and Loss Statements

CMC is required by contract to provide an Expenditure and Revenue report of
the actual cost of custody physician services for the preceding period or portion
thereof, no later than sixty days following each period to HCA for informational
purposes only. The report is to be prepared in accordance with the procedure
that is provided by HCA and in accordance with generally accepted accounting
procedures. CMC has prepared a Profit and Loss Statement annually as the
method to comply with the contract terms.

Our audit of Profit and Loss

Statements resulted in the following findings:

Finding 23.1: Profit and Loss Statements are not prepared according to the
contract period as required.

The CMC contract clearly identifies each contract period as July 1 through June
30 for the period of five years commencing July 1, 2004. However, since 2004,
CMC has provided the statements on a calendar year basis. Per the audit team’s

FINAL REPORT

request, CMC provided revised statements according to the required fiscal year
basis.

Finding 23.2: CMC over-reported expenses included on Profit and Loss
Statements.

Audit team fieldwork included reviewing CMC documentation to support the
amounts reported to HCA on the Profit and Loss Statements. The audit team
was unable, however, to reconcile CMC’s records to amounts reported. As a
result of our analysis, CMC agreed that their statements were incorrect and
subsequently revised their Profit and Loss Statements for the periods July 2005
through June 2007. Per review of the revised completed fiscal year statements, it
appears that expenditures were originally over-reported by approximately
$306,099 and $126,329, respectively. CMC stated that differences were the result
of physician claims received several months after the end of the service month.
This explanation, however, is not reasonable because if claims were missing then
preliminary expense totals should be lower not higher. It should be noted that
since this is a fixed-fee contract, the over-reporting of expenses has no current
financial impact to CMS, but is important information for future contract
negotiations.

Finding 23.3: CMC’s Revised Profit and Loss Expenditures do not agree with
supporting documentation.

CMC allocates “corporate expenses” (indirect overhead expenses) to each
contract they are awarded. According to CMC, the allocation is based on the
contract award amount as a percentage of all CMC contracts. A spreadsheet is
prepared monthly to allocate these overhead expenses to the CMS contract in
order to include it on the Profit and Loss Statements. The audit team’s review of
this practice resulted in the following findings:

FINAL REPORT

1. Since November 2006, CMC has allocated approximately 84% of its
corporate expenses to the CMS contract. Based on the audit team’s
calculation of CMC’s contract awards, CMC should have only allocated
74% of its corporate expenses to the CMS contract. For FY 2005/06 and FY
2006/07, these incorrect allocation percentages resulted in an inaccurate
overhead allocation to the CMS contract of approximately $9,000 and
$45,000, respectively.
2. CMC corporate expenses are recorded onto monthly spreadsheets based
on amounts recorded into a Quickbooks accounting system in order to
allocate them across CMC’s contracts awarded. For a one fiscal year
sample period (July 1, 2006 through June 30, 2007) the audit team
recalculated monthly corporate expenses included on the monthly
spreadsheets and compared them to expense amounts recorded in CMC’s
Quickbooks accounting system and found that the expenses do not agree.
As such, we were unable to confirm the accuracy of corporate expenses
allocated to the CMS contract.

Recommendation 23:

HCA should require by contract that CMC obtain an

independent audit of the Profit and Loss Statement annually to ensure that the
statements accurately present CMC’s profit.

CMC’s Profit Margin

Finding 24: CMC’s profit margin from the CMS contract far exceeds industry
standards.

The audit team compared CMC’s profit margin before taxes to the profit margin
reported by the Risk Management Association (RMA) for offices of physicians.
RMA compiles financial data primarily from audit reports and tax returns. RMA
benchmark data reports average profit before taxes of 9.9% for groups with
balance sheet assets of two to ten million dollars (CMC is in this category). The
audit team confirmed, however, that CMC receives a 36% profit before taxes

FINAL REPORT

from its contract with CMS. This finding should be placed in context by noting
that it has been difficult over the years to find a contractor to provide specialty
physician services to inmates. CMC was the only physician’s firm to bid during
the last solicitation.

Recommendation 24: HCA should (1) request that CMC reduce their rates for
the remainder of the current contract term (June 2009), and (2) ensure that future
negotiated physician contracts provide appropriate profit margins in accordance
with industry standards and are in line with other government entities
contracting for correctional medical services.

WMC-A Profit and Loss Statements

Finding 25.1: WMC-A is unable to provide sufficient documentation to explain
the expenses reported in the Profit and Loss Statements provided to the
County.

On an annual basis, WMC-A is required to provide a profit and loss statement
for the previous fiscal year. WMC-A staff indicated that FY 2004/05 was used as
a baseline to determine the subsequent years’ expenditures, and as such, the
audit team sought documentation to support that fiscal year. However, while
WMC-A was able to provide a total “Usual and Customary Charges” for that
fiscal year, they were not able to sufficiently explain how the information is used
to determine the costs reported to the County on the annual profit and loss
statement. The audit team worked with WMC-A staff for over a month to secure
this documentation, but WMC-A was never able to fully explain or support the
cost allocation methodology used in creating the profit and loss statements.
WMC-A staff indicated that the cost allocation methodology utilized in the FY
2004/05 timeframe would again be used in the creation of the FY 2007/08 profit

FINAL REPORT

and loss statement. While this information is not used for annual billing (this is a
fixed fee contract), the information is vital for subsequent contract negotiations in
order to determine appropriate profit margins. Thus, with the WMC-A contract
due to expire in June of this year, HCA has no verifiable information on the
actual expenses incurred by WMC-A as a result of providing custody hospital
services.

Finding 25.2: Profit and Loss Statements are not provided or prepared
according to the terms of the contract.

The WMC-A contract requires that a report detailing the “actual cost of Custody
Hospital Services” shall be submitted to the County no later than sixty (60) days
following the end of the fiscal year (June 30th) and according to generally
accepted accounting principles. However, the audit team determined that for FY
2005/06 and FY 2006/07, the reports were provided between six and nine months
after the end of the fiscal year. As of the writing of this report, the revenue and
expenditure report for the FY 2007/08 time period has still not been submitted to
the County (now seven months after the end of the fiscal year). In addition, the
audit team determined that for FY 2005/06 and FY 2006/07, the expenses reported
by WMC-A were not prepared using generally accepted accounting principles.
Instead, an arbitrary inflation factor was applied to the FY 2004/05 Total Expense
per Adjusted Patient Day, which, as noted in the previous finding, was itself an
estimated number. Lastly, the arbitrary inflation factor was not applied in a
uniform fashion in the data reported to the County, and as such the profit and
loss statements are not consistently prepared for the two fiscal years, FY 2005/06
and FY 2006/07.

Recommendation 25: HCA needs to hold WMC-A accountable to the terms of
the contract regarding the preparation of annual profit and loss statements. In
addition, HCA needs to work directly with WMC-A to clarify and verify the
actual costs of the Custody Hospital Services that WMC-A provides in order for

FINAL REPORT

both sides to be fully prepared for the upcoming request for proposal (RFP) and
potential contract negotiations. Lastly, HCA should require that WMC-A obtain
an independent audit of their annually-provided profit and loss statements to
ensure that the County has complete and accurate information.

WMC-A Hospital and CMC Physician Expense Databases

Finding 26: The physician and hospital custody database maintained by CMC
is incomplete, inaccurate and largely unutilized by CMS for contract
monitoring and program management purposes.

HCA compensates CMC approximately $100,000 per year to input information
into a County database that tracks services rendered by physicians to inmates as
part of the contract between CMC and the County. This database was created by
HCA/IT and loaded on a computer at CMC’s office, then CMC staff were trained
on how to import the data from their existing internal billing system to the
County’s database. All the pertinent data tracked in this database is already
input by CMC clerical staff into their own claims and billing system in order to
pay their physicians for services rendered.

Thus, HCA unnecessarily

compensates CMC for a process that they already perform in the course of
running their business. WMC-A also compensates CMC $60,000 in order to
manually input the hospital’s claim forms into the County’s custody database.
All of the physician and hospital data is aggregated by CMC and sent on a CD to
HCA/Contract Administration on a monthly basis, where the data is imported
into the historical database maintained by HCA. The purpose of maintaining
this database is to provide HCA, and specifically CMS, with a tool for (1)
monitoring physician and hospital services rendered per the contract, (2)
identifying trends in care, and (3) negotiating subsequent contracts with accurate
utilization data. Because the contracts with both the physician’s group (CMC)
and the hospital (WMC-A) are fixed fee contracts, the utilization database does

FINAL REPORT

not impact current charges or billing, however, as indicated above, its contents
can be useful in a variety of ways.
The audit team interviewed County/contract staff and reviewed the custody
database; the following issues were identified:

•

The FY 2007/08 data set was incomplete. The audit team requested the
Custody database information for the complete FY 2007/08, however the
data received from HCA/Contract Administration was missing several
months of data, which is not in compliance with contract terms. This data
was later appended to include the missing months after HCA/Contract
Administration notified CMC of the audit team’s finding.

•

The database contains multiple entries for the same services rendered to
the same inmate on the same day. CMC staff indicated that at one point
during FY 2006/07, there had been some problems with the importation of
data and that a member of HCA/IT had come to fix the problem.
However, the audit team determined that duplicate entries continued to
show up in the FY 2007/08 data. The audit team identified approximately
$105,000 of duplicate physician charges and $34,000 of duplicate hospital
charges in FY 2006/07, and $36,000 of duplicate physician charges and
$200,000 of duplicate hospital charges in FY 2007/08.

•

The database is often missing charge data for physicians that subcontract
with CMC on a fixed-fee basis. In short, if the physician is compensated
by CMC on a fixed fee basis, his or her billing information is not always
incorporated in the custody database because no payment claim form is
submitted to CMC for processing. Instead, CMC requests, but does not
require, that these fixed-fee physicians provide a claim form as if they
were billing, with the understanding that the form will only be used for
informational purposes. As a result, physicians often choose not to
provide this information in a timely manner, if at all.

•

CMS management does not monitor or utilize the custody database for
any sort of operational or strategic purposes.

•

Prior to this audit, the data in the custody database maintained by CMC
had never been audited for accuracy by an independent party or by the
County.

FINAL REPORT

Recommendations:
26.1:

CMS and HCA/Contract Administration need to articulate the goal for

maintaining the custody database and who is responsible within HCA to ensure
that goal is achieved. Both parties need to work together to determine how this
data, and any additional data that can be captured, will be utilized to improve
CMS from a programmatic and operational standpoint.
26.2:

HCA needs to renegotiate with CMC to eliminate the $100,000 charge for

inputting data that is already necessary for CMC to conduct its own internal
billing and claims processing.

This information should be provided to the

County for minimal or no charge as part of normal contract monitoring. CMC
should be able to provide a data file to the County on a monthly basis with all
relevant information.
26.3:

HCA/Contract Administration should work directly with WMC-A to

import their charge data directly into a database that is maintained in-house by
HCA/Contract Administration or by CMS program management.
26.4:

HCA/Contract Administration or CMS program management needs to

conduct some degree of periodic auditing of this data to ensure accuracy and
completeness.

Based on the audit team’s experience, this objective can be

achieved with minimal time and resources on the part of HCA.

Increase in Inmate Clinic/Hospital Visits

Finding 27: CMS management is unable to definitively explain the reason that
there is a sustained increase in the daily census of inpatient inmates at WMCA, that began in late 2007.

FINAL REPORT

HCA, WMC-A, and OCSD Transportation statistics confirm that the average
daily census at the WMC-A custody unit often exceeded the unit’s capacity
during 2008, forcing inpatient inmates to be housed in other non-secure parts of
the hospital. In these situations, at least one Deputy Sheriff from Theo Lacy must
sit with each inmate on a one-on-one basis, twenty-four hours per day. Such a
situation leads to significant amounts of overtime for OCSD, and strains the
existing contractual arrangement with WMC-A as this sustained impact on the
hospital was not envisioned during negotiations.
There were two theories provided by CMS staff for the increased inpatient
inmate population: (1) the recent implementation of the “R3” classification (i.e.
an inmate charged as a sex offender), which requires that such inmates be
segregated from general population inmates, including at the hospital, and (2)
the reluctance of CMS staff, nurses and managers, to accept patients returning
from the hospital who may need some degree of “skilled nursing” attention in an
observation unit. Such a patient would typically be allowed to return home and
receive in-home care from a family member or friend if they were not in jail.
CMS staff’s reluctance typically stems from either a discomfort with providing a
somewhat higher degree of personal care or from a belief that the observation
units available are not clean, safe or modern enough to accommodate this
“skilled level” of nurse care. Despite these hypotheses, no one from CMS was
able to definitively identify the causes of the significant increase in inpatient
population, which has had significant impacts on both OCSD and WMC-A.
HCA/Contract Administration staff informed the audit team that they are in
discussions with WMC-A to build out a section of the hospital directly adjacent
to the custody unit where eleven more inmate beds can be placed to handle this
increased capacity.

Recommendation 27:

CMS management needs to specifically determine

whether this increase in the inpatient hospital inmate population is a permanent
shift, or one that can be mitigated through operational changes on the part of
both CMS and OCSD. If in fact some of the inmate inpatients at WMC-A can be
moved back to the jail by making some improvements to the observation units at
the jail, and boosting training and initiative on the part of nursing staff, then

FINAL REPORT

HCA and the County may be able to lower the inpatient hospital inmate
population to a level that can be accommodated in the existing unit, thereby
avoiding an expensive build-out of additional custody space. If, however, HCA
and OCSD determine that there are no internal measures to address the
increased inpatient population, then both HCA and OCSD should commit
financial resources for the build-out of the custodial facility at WMC-A, should
the current contract be extended past June 2009. Not only does the responsibility
for care ultimately fall to the Sheriff’s Department, but OCSD also stands to
achieve significant cost savings if they do not have to commit overtime resources
to one-on-one guarding of each inmate patient that is out in the general
population of the hospital.

Hospital/Clinic Scheduling of Inmates for Medical Care

Finding

28:

The

inpatient/outpatient

scheduling

process

requires

improvement.

CMS

Scheduling

Clerk

responsible

for

coordinating

these

outpatient/inpatient services with WMC-A. The Clerk reports organizationally
to the CMS Program Manager (Administration). The audit team reviewed this
scheduling process and found that process improvements are required to ensure
that all inpatient hospital and outpatient clinic visits are properly authorized by
the CMS physician and all inmates receive timely specialty care in line with
community practice. Failure to provide required specialty care, depending on
the circumstances, may result in a significant liability to the County. Examples of
scheduling problems include:
•

The CMS process for tracking inmate Treatment Authorization Request
(TAR) forms is ineffective. As a result, CMS is unable to determine
whether inmates that require outpatient/inpatient specialty care received
those services in a timely manner. A pre-numbered TAR form is required

FINAL REPORT

to be completed by a CMS physician before an inmate may receive
specialty care at the hospital or clinic. The CMS Assistant Medical Officer
is primarily authorizing the TAR and assigning a priority number. The
priority number (Priority 1 is High Priority and 3 is Low Priority)
identifies the urgency of the appointment. Priority numbers came about
as the result of the large number of inmates requiring outpatient/inpatient
services. An Appointment Log was originally created in Excel to track
TAR requests. However, despite this logging process, there is no
verification of whether the inmate was actually seen or if the appointment
should be canceled because it is no longer necessary due to inmate release
or other circumstances. The audit team reviewed the log and found that it
was no longer being used due to the volume of activity, and because the
log was not properly updated to track who was or was not seen by a
physician. We also found that TAR forms are not properly filed within
the hard copy medical record chart.

•

The WMC-A TAR logs are also not always updated. The TAR forms are
provided to a clerk at the hospital for the actual formal scheduling of
inmates for appointments. The hospital clerk receives the TAR and date
stamps the photo copy and enters the TAR onto an Excel spreadsheet.
The spreadsheet is updated once the inmate is actually seen at the
hospital. The audit team, however, observed that the spreadsheet is not
always updated per this procedure. A sample of TAR requests included
on the spreadsheet showed no notation was made that the inmate was
seen. The audit team requested and the clerk was able to provide
evidence that the inmate was actually seen at the hospital, although the
log was not updated. Since the log is not properly updated, WMC-A was
unable to generate a list of all outstanding TAR requests, creating
confusion and increasing the difficulty of auditing this process.

•

The appointment scheduling and monitoring process is ineffective. One
problem, as noted above, is that CMS and the hospital clerk maintain two
separate TAR logs, which are not properly updated. In other cases, TAR
forms are not prepared by CMS when inmates require follow-up
appointments recommended by CMC Physicians. In these cases, the
hospital clerk uses a variety of methods to schedule inmates: maintaining
the hard copy medical record as a tickler file if a TAR was not provided
for a follow-up appointment, reviewing current and prior month TAR
Excel logs, and adding inmates to the appointment schedule upon urgent

FINAL REPORT

requests by CMS. In addition, the current scheduling process is inefficient
as it relies on the hospital clerk’s working knowledge of the schedule, and
CMS has no mechanism to monitor the status of scheduling requests.
These scheduling problems have escalated in the previous year due to
changes in inmate classification categories (e.g., “R3” sexual offenders)
requiring segregation, the significant increase in the number of inmates
requiring specialty services, and the number of required rescheduled
appointments due to the increased backlog. As a result of these issues, at
the time of our audit, approximately 30-40% of inmates scheduled daily
for clinic/hospital visits do not make their appointments. In other
instances, inmates were rescheduled multiple times over several months
or were never seen. Such situations have the potential to result in
significant liability to the County.
•

The CHART system has a scheduling feature; however, it is not utilized.
CMS informed us that they plan to implement the CHART scheduling
function and to prepare an electronic TAR request form with electronic
prioritizing and approval. This will require customization of the CHART
system and coordination with WMC-A.

•

The CMS Scheduling Clerk does not report organizationally to a CMS
physician, but rather to the CMS Program Manager (Administration).
Inmate continuity of care is the primary responsibility of the CMS Medical
Director and physicians. The scheduling clerk job responsibilities require
ongoing coordination with the CMS physicians on a regular basis and
have increased significantly since the CMS hospital liaison position was
eliminated.

Recommendations:
28.1: CMS should complete its efforts to fully interface the outpatient/inpatient
approval/scheduling process in the CHART system to include electronically
created sequentially numbered TARs with online priority/approval function,
outpatient scheduling, and reporting queries that provide CMS Management
information to monitor the process.

FINAL REPORT

28.2: CMS should change its organizational structure to have the CMS
Scheduling Clerk report to the Assistant Medical Director with technical support
from program administrative services.
28.3:

CMS should work with OCSD to find solutions that will ensure that

inmates are transported to scheduled clinic/hospital appointments.

Information Technology

CHART Electronic Medical Record System

Finding 29: The CHART electronic medical record information system is not
fully utilized resulting in significant system-wide inefficiencies.

CHART was implemented in 1992 with the assistance of Insight Enterprises.
Management of health records and ensuring the record is available to health
professionals enhances continuity of care, facilitates early and correct diagnosis
based on review of prior symptoms and findings, and permits coordination of
treatment by multiple clinicians.

IMQ Health Care Accreditation Standards

require that health records maintained be legible, individual, completed, and
stored in a “secure area readily accessible to health care providers, but
inaccessible to custody staff or inmates.” Inaccurate or missing records can create
significant risks for CMS as important medical information must be available
when needed for current treatment options and administration of further
medical services. Use of electronic medical records provides increased operating
efficiency, as well as better medical service for inmates.
The current CHART system capabilities are not being fully utilized resulting in
CMS maintaining both a partial electronic medical record and a hard copy
medical chart. The decision to continue to partially utilize CHART has resulted
in CMS unnecessarily having 23 clerical staff (Office Assistants and Office
Technicians) that manually prepare schedules, locate/pull hard copy charts, and
send medical record documentation to other jail facilities.

Based on the

FINAL REPORT

interviews with medical records staff, a review of the “Duties Overview”
prepared by medical records staff, and process observation, the audit team
determined that these manual processes comprise the bulk of tasks completed by
medical records staff on a daily basis.
The audit team reviewed the CHART system capabilities and found that a
majority of the tasks performed by clerical staff can be eliminated with the
scheduling component of the CHART system, and fully utilizing the system to
document inmate medical visits for such things as: problem lists, diagnosis and
treatments, RN progress notes, and hospital discharge summaries as well as vital
signs, diabetic readings and lab results. All staff interviewed stated that hard
copy charts go missing on many occasions and in some cases cannot be located at
all.

A fully electronic medical record would significantly improve the services

provided and allow for full automation and timely accessibility of statistics
required by Title 15. To implement the fully electronic medical record would
require minimal integration of paper forms with the existing system, such as
inmate medical message slips and inmate consent and refusal forms.

CMS

informed us that they plan to replace the CHART system with the purchase of a
new electronic medical record system. However, even if CMS were to start
today, a new system would not be functional for at least two years. In the short
term, CMS has not expressed a commitment to fully utilize the CHART system
until a new medical record system is available. A commitment to more fully
utilize the CHART system may potentially save CMS between $500,000 and
$750,000 each fiscal year as an estimated 10-15 clerical positions attending to
hard copy charts could be deleted once the significant manual process burden is
eliminated.

Recommendation 29: CMS should move forward immediately to purchase a
new fully automated medical records information system. In the interim, CMS
should more fully utilize the CHART system and establish a cross-over timeline
for moving hard copy components to the electronic medical record in CHART
until a new medical record system is available. A formal on-going training
program is required regardless of which electronic medical record system is in
place. An analysis of hard copy medical records currently used should be
performed to determine if any system customization is required to achieve this

FINAL REPORT

goal. In the near term, CMS should delete 2-3 medical records positions, and in
the long run aim to eliminate 10-15 positions.

Finding 30: The CHART system is written in an outdated programming
language and its future system maintenance and support is limited.

CHART was developed from the COSTAR system and is written in the ANSI
Standard MUMPS (Massachusetts General Hospital Utility Multi-Programming
System) programming language created in the late 1960s for use in the healthcare
industry. COSTAR was customized to meet the special requirements of CMS.
HCA/IT informed the audit team that the programming language is outdated
and as a result system support is difficult to find. Recent efforts to recruit a
MUMPS System Analyst were unsuccessful because there are very few qualified
applicants and the one selected was unable to pass the Sheriff’s background
clearance.
Insight Enterprises currently supports the CHART system through an annual
support agreement costing approximately $47,000 per year. However, Insight
Enterprises has stated that system maintenance and support will only be
provided for the next few years.
HCA has planned for some time to develop a request for proposal (RFP) in order
to purchase a new system to replace CHART. The first stage, in progress, is the
hiring of an IT consultant to assist in specifying the business requirements of a
new system to be included in the RFP. The consultant services are scheduled to
be completed by November 2009, however, HCA has stated that the current
budget situation may delay the project.

Recommendation 30: HCA should continue its efforts to purchase a new system
to replace CHART, especially in light of the short term support available in the

FINAL REPORT

near future, the cost savings to be realized from a reduction in the manual
recording keeping process, and to mitigate potential high-risk operating
deficiencies created by maintaining a semi-manual medical record keeping
system.

Finding 31: CMS does not coordinate with HCA/IT or follow change
management best practices when modifying the CHART system application.

The audit team reviewed CMS’s process for prioritizing and approving CHART
system changes, documentation maintenance, deploying changes, and testing
change programs. Our review found that CMS neither effectively utilizes the
services of HCA/IT nor does it have adequate controls over the modification of
the CHART system in place to ensure program modifications are properly
authorized, tested and approved.

System control weaknesses identified are

noted below:
1. CMS does not have a formal process for prioritizing and authorizing
system change requests. A list of planned system changes/rollout of
existing system functions is maintained electronically in a Word
document by the CMS CHART system Supervisor.
The list has
approximately 21 priority system changes including rollout of existing
CHART system functions that are not currently utilized. Two items on the
list, patient scheduling and electronic approval of treatment request
authorizations (identified as number 1 and 4 on the priority list) are
planned for implementation in early 2009. However, there is no
documented approval of these planned system changes by the
Institutional Health Services Division Manager. And, more importantly,
the majority of CMS staff who would be using the system had no idea that
system changes were being contemplated.
2. A formal process for CHART end-users to convey system change requests
to management, such as a standard change request form, is not used. User
requests should include, at a minimum, the requestor’s name, date of the
request, priority of the request, and thorough description of the change
and expected benefits of the change. User requests should include review

FINAL REPORT

and authorization by management. CMS management indicated that they
are developing a CHART Project Request Form based on HCA/IT’s
Request Form in order to prioritize and approve requests and maintain a
list of the approved CHART projects. CMS plans to implement the
Request Form in early 2009. During fieldwork, the audit team observed
inefficient processes that could be remedied if end-users had a process to
request changes to the CHART system.
3. Documentation of detailed test plans for each system modification is not
prepared. System testing is performed only by the CHART system
Supervisor and Insight Enterprises (vendor/programmer). To be effective,
tests should be conducted in advance of any proposed roll-out and in an
environment that simulates the conditions that are likely to be
encountered when the modification is implemented. Individuals from all
affected business areas should be represented in testing from developing
test cases to reviewing and approving test results. Test plans should be
developed for all levels of testing that define responsibilities of each party
(e.g. end-users, programmers, system analysts, quality assurance) and
approved and signed off by appropriate management. Interviews with
CMS end-users found that staff is not usually aware of the planned system
changes although the changes will significantly affect the workflow of
physician and nursing functions, outpatient scheduling, and medical
record’s staff responsibilities.
4. The Insight Enterprises vendor/programmer is responsible for migrating
CHART changes into production. This is inconsistent with IT best
practices, as programmers should not have write, modify or delete access
to production data.
5. HCA/IT is not involved in the CHART change management process.
HCA/IT utilizes a formal change management process when
implementing changes to other HCA applications, however, these
practices are not utilized to support changes to CMS’s CHART system.
Having all agency IT applications reviewed by HCA/IT ensures agencywide consistency and compatibility, and brings greater resources to bear.
Some of the risks to CMS of not having HCA/IT involved in this process
include unauthorized modifications negatively affecting the CHART
system, or new systems not properly implemented, thus preventing CMS
from having medical information available to staff in a timely manner.

FINAL REPORT

The HCA/IT Support/Software Development manager informed us that
they would like to include the CHART system in the HCA/IT change
management process and to seek approval for CHART changes from the
HCA Change Advisory Board (CAB) prior to moving them into
production.

HCA/IT will work with CMS and the Insight vendor to

prepare the Request for Change and present it to the CAB. This will
ensure that best practices are followed.

Recommendation 31: CMS should work with HCA/IT to implement ongoing
adequate change management procedures in accordance with best practices.

Finding 32: Sheriff AJS (Adult Justice System) inmate demographic
information is not uploaded often enough into the CHART system.

OCSD utilizes the AJS system to perform a variety of inmate record keeping
functions. The CMS CHART application interfaces with the Sheriff’s AJS for
inmate demographic information only.

A batch routine is received by the

CHART system every four hours, which updates information such as where the
inmate is physically located (e.g., what jail facility, in court, etc.). New bookings
are interfaced real time in CHART.

Having real time inmate demographic

information is important since the information included in the CHART system is
transferred to the Pharmacy CIPS (Correctional Pharmacy Software) system for
medication packaging. Due to the regular movement of inmates between jail
facilities and courts, or being released from custody, the four-hour batch update
of the CHART system from AJS is not sufficient and results in a large amount of
medications being destroyed as inmates are not present at their last known
location to receive their packaged medication. Additionally, this information
will be required to effectively utilize the CHART scheduling features as planned
by CMS for inmate sick call and outpatient clinics. Discussion with OCSD found

FINAL REPORT

that the batch routine can occur as often as CMS needs, and just requires
coordination between the two IT groups.

Recommendation 32: CMS Management should work with HCA/IT and
OCSD/IT to receive more frequent updates of AJS information in the CHART
system.

Risk Management

Finding 33: A total of $1.2 million has been spent either settling or defending
CMS lawsuits over the last five fiscal years.

The audit team reviewed inmate claims/lawsuits specifically related to medical
care over a five year period from July 1, 2003 through June 30, 2008. During that
period, there were a total of 55 inmate lawsuit claims filed against CMS for a
variety of reasons, all pertaining to the medical care received while in custody.
Of these 55 claims, 18 resulted in either settlements and/or the incursion of
outside legal expenses in defending the suit (six of the 18 were settled for a total
of $513,500, and 17 of the 18 required the expenditure of funds for outside legal
counsel, totaling $748,870); and 37 resulted in no legal or settlement costs to the
County. Thus a total of approximately $1.2 million has been spent either settling
or defending CMS lawsuits over the last five fiscal years.
Though the elimination of litigation risk is not possible, this data emphasizes the
importance of tightening processes and procedures within CMS in order to
provide the County with as much risk protection as possible. For clarification,
the claims mentioned above do not include those filed by inmates against OCSD
that also have components pertaining to the medical care received while in
custody. CEO/Risk Management is not equipped to electronically search claims
at that level of detail.

FINAL REPORT

Recommendation 33: With the implementation of recommendations included in
this report, CMS should realize greater risk avoidance and liability protection.

Human Resource Issues

Finding 34: Recruiting medical professionals has been challenging for CMS.

Recommendation 34: CMS should address this background issue with OCSD at
their periodic meetings to determine if OCSD could customize its background
check to expedite the hiring process. If this cannot be done, and if finances
permit, CMS should consider partially funding an OCSD background position
whose first priority would be to perform CMS-related background checks.

Purchasing/Supplies

Inventory Tracking System

Finding 35: CMS has not implemented a medical supply inventory tracking
system.

Previous Grand Jury and consultant reports found that the medical supply
storage rooms at the Central Jail Complex were disorganized and poorly

FINAL REPORT

controlled. This audit confirms that these conditions still exist. CMS supply
room staff does not have an accurate count of supplies on hand and supply
replenishment is performed by visually checking the shelves.

HCA/IT

performed an analysis of four different inventory tracking systems and provided
CMS an inventory system recommendation in a report dated August 2008. The
recommendation, to utilize an existing supply vendor, would not require any
additional scanning software or training costs to CMS. The proposal provides
for minimal hardware fees.

CMS is working with HCA/IT to finalize the

agreement and to determine an implementation date.

Recommendation 35: CMS should complete the inventory tracking project as
soon as possible.

Storeroom Staff Reporting Structure

Finding 36: CMS Storeroom/Supply staff report organizationally to the CMS
Program Manager.
Supply rooms house all the items and equipment which directly support CMS
nursing functions and require on-going communication with nursing staff.
Having this function staffed and supervised by non-line and non-medical staff
adds an unnecessary layer of coordination and approval, causing delays in
acquiring supplies and in the motivation to make changes in a timely manner.

Recommendation 36: CMS should assign the supply room function to report
organizationally to the Director of Nursing. Any ancillary purchasing support
needed can be provided by the CMS/Administration function recommended
earlier in this report.

FINAL REPORT

CMS Statistical Data

Finding 37: Statistical summaries of medical services delivered by CMS to
inmates are not accurate and are compiled by the inappropriate organizational
unit.

Statistical summary information of medical services delivered to inmates are not
accurately prepared by health care staff and are entered into an Excel
spreadsheet by the Storeroom Supervisor. This information is required by Title
15 and provides the facility/system administrator (i.e., OCSD) with a basis of
accountability, and ideally should be used by CMS to enhance performance and
monitor productivity. The primary reasons for inaccurate information are that
staff manually track processes performed from memory, and/or errors occur in
transcribing statistics manually to the required hard copy form. This information
is provided to the Storeroom Supervisor who has no basis for verifying the
statistics being collected; is in handwritten, hard copy forms on a daily basis; and
is manually entered into an Excel spreadsheet on the storeroom computer.

Recommendation 37: In the short term, CMS should establish procedures to
ensure that statistical summary data is accurately compiled by staff and assign
the responsibility to compile statistics to CMS Administration. Once CMS has
implemented a fully electronic medical record, statistical data should be
generated from the CHART system automatically.

Sheriff—HCA Coordination

In order for quality inmate health care to be provided, it requires a cooperative
effort between both OCSD and CMS management and line staff.

This

FINAL REPORT

relationship was non-productive between prior management staffs in terms of
addressing challenges and implementing innovations that would result in the
more efficient and effective provision of inmate health care services. Examples
include:

Outpatient Clinics

Finding 38: The transportation of inmates from jail facilities to the
clinic/hospital is expensive, taxes limited deputy resources, has securityrelated concerns, and often does not result in all scheduled inmates getting to
hospital or clinic appointments.

OCSD is responsible for the physical transport and guarding of inmates outside
the jail facilities for medical care, and its corresponding cost in the following
circumstances:
•
•
•

For short-term (a few hours) outpatient care at the clinic
For long-term inpatient care in the hospital (overnight or longer)
For emergency transport of inmates with life-threatening conditions

To provide an indication of the quantity of inmates being transported outside jail
facilities for medical care, the following statistics were provided by OCSD and
the Santa Ana Fire Department/Paramedics.

Reason for Transport
Scheduled Hospital visits
(only weekdays)
Emergency transport:
OCSD
Emergency transport:
Paramedic

2008 Total

2008 Daily
Average

2007 Total

2007 Daily
Average

2,436

9.4

1,761

6.8

468

1.3

686

1.9

N/A

129

0.4

FINAL REPORT

As previously mentioned, outpatient clinic and some inpatient hospital visits are
pre-scheduled, and inmates often miss outpatient clinics and occasionally miss
scheduled inpatient visits.

Reasons include a lack of available deputies to

transport, the time of transport conflicting with other Sheriff responsibilities
(inmate Court transport), and the security classification of individual inmates.
Depending upon the nature of the illness/injury of the inmate, and the time it
takes to reschedule the inmate, this situation increases County exposure to
litigation risk.
OCSD/Transportation allocates three full time Deputy II positions Monday
through Friday for the daily transport of inmates to the clinic/hospital. On a
yearly basis, the straight line salary and benefit projection of three Deputy II
officers in the Transportation Bureau is $414,765. This figure does not include
the various transport costs (vehicle, maintenance, gas, insurance, etc), the
additional cost of emergency transportation visits outside of the Monday
through Friday day time runs to the hospital, or any necessary overtime costs.
Any reduction in the need to transport inmates could result in General Fund
savings for OCSD or the ability to use staff resources for other purposes.
In addition, each transport of an inmate outside the jail system increases security
risks to the community, to the deputies, and to medical staff. To the extent that
this transport can be curtailed would lessen this risk.
To address this issue, clinic(s) could be established within the jail system, saving
the County money, reducing security risks, and eliminating the persistent
problem and potential litigation risk of the non-transport of inmates to medical
care. To clarify, this recommendation is only related to daily outpatient clinic
visits where inmates see medical specialists and on the same day are returned to
the jail system. It does not pertain to inmates who require inpatient hospital
care.
This idea has been discussed periodically over the years between HCA and
OCSD with no progress being made. Common reasons given for not moving
forward with this innovation include: finding sufficient space within the jail
system for the clinic, ensuring that contract physician specialists would work
inside the jail system, and the ability of the jail system to meet any required state

FINAL REPORT

standards for the establishment of a clinic.

As evidenced by other sheriff

departments statewide who do provide clinics within their jail system, each of
the above concerns may be mitigated. For example:

Identifying Sufficient Space

Space has been a constant concern of OCSD jail operations, particularly in the
Central Jail Complex. However, both Theo Lacy and the Musick jail facilities
have adequate space that could be used or developed for use for clinics as the
space required for a clinic is minimal (one room). Theo Lacy has space adjacent
to Mod O that was set aside over a year ago for in-house dialysis services.
However, to date this space has not been utilized for dialysis or other purposes.
In addition, most modules at Theo Lacy have a medical office set aside for sickcall and other treatments. Though staff utilizes this space at certain times of the
day for these purposes, the space is also often vacant. Since inmates are already
transported daily between jail facilities, inmates scheduled for medical clinic
visits could easily be incorporated into these runs.
Availability of Physician Specialists Willing to Work Inside the Jail

An expressed issue over the years has been the ability to find qualified multispecialty groups/individuals who are willing to provide medical care to inmates.
The last solicitation only yielded one vendor, the current contractor (CMC), who
is now in the last year of a five year contract that will expire in June 2009. The
current contract allows the County to require that the physician group provide
these services inside jail facilities. Given that the contract is currently in its last
year, and the current economic climate is distressed, this year’s solicitation for
physician services may attract additional proposers, and again should require
that any physician group chosen should agree to provide clinic services within
jail facilities if necessary.

FINAL REPORT
State Mandates for Clinic Services Provided within Jail Facilities

As stated earlier, other Sheriff agencies provide clinic services within their jail
facilities. Clinic services are akin to basic office visits made by the public to
specialty doctors for diagnoses and minor treatment and prescription
medication. In addition, the Theo Lacy facility has the necessary equipment to
conduct in-house dialysis, a service which is currently provided by a separate
contract outside the jail facility.
CCR Title 14 and 25 Guidelines provide a decision-tree analysis of what a law
enforcement agency with a jail facility must take into consideration when
determining whether or not to establish an on-site clinic. Given that there are
considerable benefits to be gained from establishing a jail clinic (e.g.,
transportation cost savings, staffing cost savings, elimination of off-site clinic
security issues, elimination of inmate scheduling issues, mitigation against
litigation risk from non-transport of inmates for medical care), an in-depth
analysis of this issue should be undertaken.

Recommendation 38: OCSD and HCA should begin an in-depth analysis of how
to implement outpatient clinic(s) in its jail facility(ies).

Finding 39: The clinic schedule often conflicts with OCSD/Transportation’s
court runs.

The current early-morning timing of several outpatient clinics conflicts with the
morning court runs for OCSD/Transportation. Clinics typically begin between
7:30-8:30 a.m., the same time court runs are being made. However, later in the
morning when the morning court runs are complete, more deputies are available
to help with clinic transportation needs.

FINAL REPORT

Recommendation 39: CMS should work with CMC contract physicians to
reschedule clinic times to accommodate OCSD/Transportation and maximize
transportation resources.

Jail Physical Plant

IRC Triage

Finding 40: The IRC medical screening area is not adequately designed to
ensure privacy of medical information.

This issue was discussed in previous consultant reports provided to CMS and
OCSD. Each arrestee is required to answer a series of questions from CMS health
staff relating to their health history prior to beginning the OCSD booking
process. Questions are answered through a speaking device since the area is
secured by glass, which magnifies the arrestee’s responses and may be heard by
anyone within the IRC triage area. This situation is not in compliance with best
practices regarding the confidentiality of personal health information and can
discourage inmates from sharing important medical information.

Recommendation 40: CMS should work with OCSD to make the necessary
adjustments to comply with best practices.

FINAL REPORT
Men’s Jail Observation Unit

Finding 41: Facility improvements are needed in the Men’s Jail Observation
Unit to provide a higher quality of care for inmates who need skilled nursing
care.

The Men’s Jail has approximately 20 beds in an enclosed area for the purpose of
providing infirmary care to inmates with an illness or diagnosis that requires 24hour monitoring or assistance with skilled nursing intervention, or their
conditions

prevent

them

from

returning

the

normal

population.

Improvements to the physical condition of the Observation Unit are needed,
including improvements in bed conditions and cleanliness of the facility. These
improvements will not only enhance the quality of care to convalescing inmates
but also make the Unit better equipped to receive inmates from the hospital
sooner, thus saving costs.

Recommendation 41: OCSD should upgrade the condition of the Men’s Jail
Observation Unit.

Women’s Jail

Finding 42: The physical layout of the area in the Women’s Jail designated as
the Observation Unit does not allow for adequate line-of-sight viewing of the
inmates.

This confinement area is square-shaped with individual cells around its
perimeter which have locked doors with small observation windows at eye level.
The nursing station is in the middle of the square. In this set-up, nursing staff

FINAL REPORT

are unable to observe the inmate’s condition and must physically walk to each
cell at regular intervals.

Recommendation 42: OCSD should investigate placing cameras in each cell that
could be viewed at the nursing station.

Theo Lacy Jail

Finding 43: Frequent maintenance problems with the lone elevator to Mod-O
and the Theo Lacy Pharmacy are a cause for concern with CMS staff.

CMS staff indicated, and OCSD confirmed, that there is only one elevator that
can be utilized to get to both Mod-O and the Theo Lacy Pharmacy. According to
staff, this elevator is frequently broken, causing a variety of problems as the only
other ingress/egress is the stairway. Such problems included the movement of
sick inmates in Mod-O to other parts of the facility or to outside medical
facilities, or the movement of large pharmacy packages being shipped to outside
County facilities, primarily juvenile detention centers.

Pharmacy staff also

indicated that although their current location, which is inside of Mod-O, is
convenient for the medications distributed in Mod-O, these medications
represent only 20% or less of the total medications they package and distribute to
medical staff. Approximately 30% of all medications are given to the Theo Lacy
Dispensary and then passed out by LVNs, and roughly 50% are packaged and
sent out to juvenile facilities.

The somewhat remote location of the current

pharmacy on the 2nd floor of the facility is less convenient and efficient for
meeting the majority of their customer needs.

Recommendation 43: OCSD staff needs to ensure that the elevator to Mod-O
and the Theo Lacy Pharmacy is functioning at all times. In addition, CMS and

FINAL REPORT

OCSD should consider relocating the Theo Lacy Pharmacy to a more central
location, such as at the current Theo Lacy Dispensary. Such a move would give
pharmacy staff easier access to vehicles picking up and dropping off
medications, and would also give doctors, LVNs and RNs easier access to
pharmacy staff for the last-minute procurement and packaging of medications.

Musick Jail

Finding 44: There is not a sustained security presence in the medical area.

As has been documented in the recent Crout & Sida Jail Assessment Study, the
James Musick jail facility in Irvine is reaching the end of its useful life in its
present condition. This includes the medical facility, a double-wide trailer which
is deteriorating and is exposed to some outside environmental conditions.
In addition, the audit team identified a safety concern that needs to be addressed
within the medical trailer. There were instances where no deputy was present
inside the locked medical trailer to provide security to medical staff
administering inmate care. In addition, when a deputy is present, he/she is
usually watching the inmates in the sick call waiting area. This area, due to the
facility layout, does not allow visual access into the inmate treatment area where
medical staff is providing inmate care. There are “panic buttons” within the
medical trailer which will quickly summon deputy assistance, but it is not
sufficient to ensure staff safety.

Recommendation 44: Ensure that a deputy is present at all times during inmate
sick call at the James Musick Facility.

FINAL REPORT
Charging Inmates Modest Fees

Finding 45: OCSD currently does not charge modest fees to inmates for some
medical services provided as is common with other law enforcement agencies.

Two specific examples of fees that could be charged include:
1. Fee for Service for Sick Call
This practice institutes a minor fee (e.g. $3) charged to inmates for inmateinitiated sick call. Any time an inmate requests to see medical staff, they
fill out a “pink slip” and place it in a secure depository which is viewed
every day by the nursing staff. The inmate is then scheduled to be seen by
medical staff within 24 hours. Interviews with both medical and OCSD
staff confirm that not all inmates requesting sick call are indeed ill.
Instituting a minor fee for sick call has been a practice that has been
implemented with success in several other counties. The fee is affordable
to the majority of inmates who carry a monetary balance inside the jail for
the purchase of personal and other commissary items, and cuts down on
the instances of marginal sick call requests.

This proactively reduces

workload in this area, freeing nurses up for other duties. In addition, it
provides a nominal revenue source for OCSD for use in other inmate
areas. Of course, to comply with State regulations, if an inmate does not
have the ability to pay, the service will be provided at no cost.

2. Selling of Over-the-Counter (OTC) Medication via the Commissary
A considerable amount of medical staff time is spent in dispensing of
common OTC medications to inmates such as: Tylenol, Advil, foot and
skin crèmes, powders, etc. in nurse sick call. If these OTC medications
could be provided via the Commissary, CMS would reduce workload for
medical staff and also, by charging a fee for service, OCSD would also
collect a nominal fee. This practice is also being done at many other law

FINAL REPORT

enforcement jurisdictions. In fact, CMS conducted a pilot project to have
LVNs distribute OTC meds in order to reduce unnecessary RN sick call.
However, the project was stopped when it was determined that LVNs are
not legally allowed to pass out OTC medications.

Recommendation 45: OCSD and CMS should work together to determine the
feasibility of charging inmates for sick call and/or the selling of OTC medications
through the Sheriff Commissary.

FINAL REPORT

Benchmarking Results
Benchmarking of medical services and practices provided to inmates was done
with other California sheriff agencies of comparable size. The chart below details
the results of this research:
Variable

Department
Average Adult
Population

Who Funds?
Total Annual
Budget

Total Staff

Orange

Health Care Agency

Health Services Department

Sheriff's Department

6,200 Adults

1,534 Adult, 266 Juveniles

5,500-6,000

Riverside
o
San Diego
Riverside County
Regional Medical
Center Sheriff's Department
3,600 - Adult, 500
Juvenile
5,000 Adults

General Fund

County Health Services Agency (General
Fund), with some juvenile funding from
Juvenile Services, and Inmate Welfare for OTC
medications

General Fund & Inmate
Welfare Fund

General Fund,
Realignment
Revenue, some other
General Fund
minor sources

Approx. $36 million

Approx. $17.3 million

$17 million

$17.5 million

$51 million

Approx. 190 (Not
including Dental or
Mental Health Staff)

52.8-Adult, 11-Juvenile, 63.8-Total (not
including Dental or Mental Health Staff)

126 FTE (not including
administrative staff), 30 per
diem

98
(Not including
mental or dental staff)

278
(includes Dental and
Mental Health Staff)

52 FTE, 20 per diem

N/A

157

N/A

Predominantly 3/12,
but some on 5/8s and
4/10s

RNs - mix of 5/8,
4/10, 2/12 & 2/8,
LVN - 5/8

Yes

N/A

9 passes per day
covering a 24-hour
period that starts at
4am.

Some basic items,
such as creams and
some pain relievers

None. OTC
medications are
passed as prescribed
by attending
physicians.

# of RNs

# of LVNs

Nurse Schedule
MOU with
Sheriff
Department

# of Med. Passes

OTC through
Commissary

Contra Costa

21.2 + Approx $1 million in extra-help, per
diem nurses- Adult, 8 - Juvenile, 29.2 - Total,
(not including Dental or Mental Health Staff)
14.8 - Adult, 2 - Juvenile, 16.8 - Total (not
includig Dental or Mental Health Staff)

San Bernardino

RN - 3/12, LVN 4/10, 9/80

5/8

38 FTE, 10 per diem
RNs work all schedules,
depending on preference
(3/12, 4/10, 5/8), LVNs are
on 3/12

Yes

With Probation, but not the Sheriff's Dept.

N/A

Two main medication rounds, two minor for a
very few medications. Keep as much as
possible on twice daily or "keep on person."

4 passes, but to the extent
possible prescribe
medications that do not
require more than 2 passes.

Tylenol, Tums,
Cough Drops, MultiVitamins

Yes - multivitamins, Vitamin C, Antifungal
cream, hydrocortisone cream, ibuprofen,
medicated foot poweder, nasal decongestant,
cough drops, tylenol, artificial tears, benzyl
peroxide acne lotion, chlorpheniramine,
laratadine, prilosec OTC, stool softener,
hemmorrhoid suppositories, antacid tablets,
petroleum jelly, clotrimazone cream.

Yes and vending machines.
Healthcare also allows for
self carry medications.

Yes, sick call, but
most specialty clinics
done at contract
hospital (UCSD)

Clinics in Jails?

Yes (Obstetrics, Orthopedics,
GastroIntesntinal, Oral
Surgery, HIV, Dermatology,
Optometry, Dialysis)

County hospital?

Yes

Charge Inmates
for Medical
Service

Yes, $3 Sick Call, $3 medications

Yes, $3

FINAL REPORT

Issue Prioritization

One of the primary reasons CMS has made little progress in addressing known
deficiencies has been a lack of issue prioritization. Accordingly, the audit team
has attempted to assist in this area by categorizing issues identified during this
audit as either short or long-term priorities.

It is important that any

prioritization process utilized by CMS should be viewed and decisions made
within the context of achieving program IMQ Accreditation.

Short Term Priorities (in no particular order)
Establish an internal HCA Task Force to prioritize issues, develop strategies
for achieving audit recommendations, and ensure implementation of those
strategies (completed).
Remove conflict of interest situations (in progress)
Prepare for Hospital and Physician contract solicitations (in progress)
Improve monthly meetings between CMS and OCSD (in progress)
Make appropriate personnel and organizational changes (some in progress)
Follow proper documentation and disposal procedures to account for
Controlled Substances
Improve contract administration practices
Conduct appropriate and beneficial Utilization Reviews on Hospital and
Physician contracts
Identify CHART system modules that can be put into production now and
ensure appropriate change management practices are utilized; reduce
medical record positions as these changes are implemented.

FINAL REPORT

Provide clear mission, goals and strategies for CMS staff
Ensure that all employees are evaluated accurately and in a timely manner
Ensure that all statistical information collected and disseminated is accurate
Develop useful management reporting tools for use by CMS management
and supervision
Fully utilize the resources available to CMS from HCA and OCSD
Provide monthly updates on audit recommendation progress to HCA and
OCSD Executive Management
Develop an effective and efficient LVN work schedule that meets the goals of
the organization (in progress)
Ensure that all inmates scheduled for outpatient clinics are transported
Approach CMC to reduce Physician contract rates for the remainder of the
contract term

Long Term Priorities (in no particular order)
OCSD and HCA review of medical services, inmate health goals and service
deliver, and any subsequent revisions to MOU

Study the feasibility of establishing clinics in the jail(s), including the
provision of dialysis services
Go out to bid for a new medical records IT system
Pursue IMQ accreditation once the majority of audit recommendations are
implemented

FINAL REPORT

Reduce the amount of medication runs in each jail facility
Research the feasibility of, plan for, and implement a Doctor Residency
program
Research the feasibility of, plan for, and implement a fee for service and a
OTC medication program
Work with OCSD to make the necessary facility changes to accommodate
medical care improvements
Decrease the processing time and/or background requirement checks for
medical staff
After implementing audit recommendations, examine staffing and resource
levels

FINAL REPORT

Estimated Cost Savings/Revenue Enhancements
The audit team calculated an estimate of the cost savings and/or revenue
enhancements from the implementation of the audit recommendations
provided throughout this report. Conservative assumptions and reasonable
estimates were utilized to provide a minimum level of cost savings or
revenue

enhancements.

While

some

savings/revenues

are

readily

measureable, others will not be known until they are implemented.
Moreover, much of the estimated value added will not be achieved
immediately, but rather over time as HCA and OCSD phase in the
recommended operational changes. Our minimum estimate of measureable
annual value added (cost savings, revenue enhancements, increased
productivity and staff time), contingent upon both HCA and OCSD
operational changes, is approximately $2,740,860 for a one year period, or
$13.7 million if measured over a five year period. In addition, our estimate
of other potential, but less certain, savings is $790,102 for a one year period.
Estimated annual savings of $750,000 from reducing the number of
medical records staff by 15, made possible by more efficient use of
electronic medical record systems (maximization of the existing
CHART system in the near term, and procurement of a new system in
the long term). These savings will be phased in during the near to
mid-term as an increasing number of processes are automated with
CHART.
Savings of 1,095 hours or $37,985 of LVN staff time per year resulting
from reducing the number of medication runs in jail facilities from four
to three times per day.
$432,918/year of cost savings resulting from decreasing LVN staff by
six, due to more efficient LVN scheduling.
$117,000/year of revenue generated from charging a $3 co-pay for sick
call visits. This estimate assumes that of the 130,000 RN sick calls that
occur on an annual basis, that only 30% (39,000) are chargeable and
collectable.

FINAL REPORT

$14,580/year of revenue generated from charging inmates for over-thecounter medications through the Sheriff/Commissary, which are
currently given by RNs or doctors during sick call. This estimate
assumes that of all the sick calls (RN, doctor, and nurse practitioner),
approximately 30% or 48,600 currently result in distributions of such
medication. This estimate also assumes that $1 on average is charged
for such medications and only 30% of charges are collectible.
Savings of 22,750 hours or $1,242,377 of RN staff time resulting from
decreased sick call demand because inmates are (1) charged a co-pay
for inmate-initiated visits, and (2) more OTC medications can be
purchased through the Sheriff-Commissary. Analysis from the prior
CMS pilot projects and from other jurisdictions indicates that total RN
sick call will, conservatively, be reduced by 35% resulting from these
changes (annual decrease of 45,500 sick calls per year). This estimate
assumes that each sick call requires approximately 30 minutes of RN
time to complete all tasks associated with a sick call (e.g. triage,
physical assessment, and charting).
Savings of $16,000/year from reclassifying two existing Supervising
Nurse positions to Senior Nurse positions.

$100,000/year of cost savings due to eliminating the compensation to
Correctional Managed Care (CMC) for unnecessary database
management.
$30,000/year of cost savings from working directly with WMCAnaheim to obtain hospital charge data, rather than through CMC.
This assumes that only 50% of the $60K that WMC-A pays to CMC is
passed along to the County in the total contract amount.

Other Potential Savings

In addition to specific dollar savings, the audit team has identified the following
other areas where savings are available but are more difficult to quantify until

FINAL REPORT

implemented. As such, the savings estimates presented in this section are less
certain than the ones identified in the previous section:
Significantly improved risk avoidance and increased productivity for the
County from improved processes and procedures, management and
oversight. For instance, if the $1.2 million that has been spent settling or
defending CMS lawsuits over the last five years (approx. $240,000/year)
were reduced by 10% as a result of the changes suggested in this report,
the savings to the County would be $24,000/year.
Staff time savings resulting from the discontinuance of the “weekender”
program at the jails and the associated repetitive triage of inmates that
occurs with that program.
Savings of $72,000/year from deletion of one LVN position from the
Central Jail Complex night shift staff if it is determined that the night shift
duties (especially the 5:00 a.m. medication pass) at the three Central Jail
facilities (Men’s Jail, Women’s Jail, IRC) can be handled by two roaming
LVNs, instead of the current three LVNs, with one at each facility.
Savings from performing meaningful Hospital and Physician Utilization
Reviews. Improvements in this area would not only potentially lead to
savings in the hospital contract with WMC-A, but also could open up
more beds at the custody unit at WMC-A, which would, in turn, decrease
the amount of one-on-one coverage provided by Theo Lacy deputies to
watch inmates for whom there is no space in the custody unit. For
example, if such a change lead to a decrease of 4,380 Deputy I hours at the
hospital (12 hours per day multiplied by 365 days per year), which is
highly conservative in light of the amount of deputy resources that are
currently used to watch inmates in the hospital, that would be a savings of
$254,697 per year.
Fewer wasted pharmaceuticals resulting in less medication costs to CMS.
For instance, in FY 2007-08, CMS spent $991,345 on pharmaceuticals. A
conservative 10% reduction in such spending equates to $99,135 in cost
savings.

FINAL REPORT

Savings at the negotiating table with outside vendors resulting from
improved contract administration and monitoring. For instance, reducing
the profit margin for Correctional Managed Care to 25%, instead of the
current 36%, would result in a cost savings of $340,270.
Savings resulting from greater program efficiency and performance
monitoring due to better gathering of data and statistics, both internally
and with respect to external contracts.
Reduction in the use of contract nursing staff to complete training sessions
and exercises, with greater reliance on in-house staff that have similar
training abilities and credentials and can train staff during shift down
time.
Lower cost physician services through the establishment of a partnership
with a local medical school residency program.
Less deputy resources required for transportation to clinics at WMC-A if
more clinics are held within the jail facilities.

FINAL REPORT

Concluding Remarks

Overall, while this audit indicates that inmate health care is generally adequate
and available, the cumulative impact of the system and management-related
deficiencies noted in this report is increased risk to the County.
Due to the high volume of substantial issues identified during this audit, HCA
should form an internal Task Force to prioritize issues, develop specific work
plans, with effective strategies and time schedules to address identified areas,
and provide the group with the necessary authority for seeing the plans through
to completion.
Since the commencement of this audit, HCA Executive Management has been
actively engaged in discussing these many issues, understanding the depth of the
problems, and has begun to make a number of changes to the CMS organization.
In addition, the recent changes in OCSD Jail and CMS management increase the
possibility that real reform of conditions, systems, processes, and the
implementation of important innovations can be made and sustained.
In conclusion, the audit team wishes to thank the Board of Supervisors for their
continued support in its performance auditing efforts, and to the Health Care
Agency and the Orange County Sheriff-Coroner Department for providing us
access to their operations.

FINAL REPORT

Exhibit 1: CMS Board Resolution

FINAL REPORT

Exhibit 2: CAO Analysis of CMS Options

FINAL REPORT

Exhibit 3: Recommended CMS Organizational Chart
Med. & Inst. Health
Services, Deputy
Agency Director

Inst. Health Services,
Division Manager

Director of
Nursing

CMS Admin. Manager

Medical
Records
Supervisors (2)
Medical
Records Staff
(8-13)

Clinical Educator (0.5)

Supervising Nurses (2)

Senior Nurses (10)

Medical Director

Chief
Pharmacist,
Theo Lacy

Supply Program
Supervisor

Hospital Liaison

Supply Staff (3)

Registered Nurses
(RNs) (53)

Conditional Release
Program

Director of
Pharmacy

Assistant/
Scheduler (1)

Assistant

CHART Program
Supervisor

Correctional Mental
Health

Correctional Medical
Services

Juvenile Health

Pharmacists (4)

Pharmacy
Technicians (5)

Secretary

Assistant Medical
Director

Physicians (3)

Nurse
Practitioners (5)

Licensed Vocational
Nurses (LVNs) (40)

X-Ray
Technician

Medical Assistants (7)

Inmate
Hospital/Clinic
Scheduler

FINAL REPORT

Exhibit 4: CMS Budget vs. Actual Expenditure Detail, FY 2000/01 to FY 2007/08

FY 2000/01

FY 2002/03

FY 2003/04

FY 2004/05

FY 2005/06

FY 2006/07

FY 2007/08

Detailed Data Not Available

Budget
Actual
Budget
Actual
Budget
Actual
Budget
Actual
Budget
Actual
Budget
Actual
Budget
Actual
Budget
Actual
N/A $5,676,360
N/A $6,630,552 $7,229,803 $7,304,015 $9,612,248 $9,566,772 $9,343,187 $9,618,781 $10,406,335 $10,552,457 $10,544,919 $10,632,881 $13,681,988 $14,205,139
N/A $8,504,839
N/A $10,015,734 $11,014,055 $10,235,539 $8,489,578 $9,481,173 $9,580,073 $9,653,388 $9,477,739 $9,477,916 $10,003,695 $10,103,717 $10,795,891 $10,995,732
N/A
$91,534
N/A
$128,253
$640,011
$569,004
$758,669
$889,427 $1,165,362 $1,242,494 $1,431,495 $1,516,829 $2,069,409 $2,344,592 $2,453,248 $2,636,739
N/A
$82,839
N/A
$758,103 $1,045,371
$878,206 $1,181,339
$768,905
$934,179
$901,932
$934,179 $1,069,303 $1,267,308 $1,092,136 $1,155,112 $1,151,017
N/A
$379,442
N/A
$418,707
$357,139
$366,613
$369,639
$540,984
$369,639
$949,622
$369,639 $1,075,953
$556,460 $1,169,115
$573,154 $1,073,539
N/A
$754,644
N/A
$829,024
$775,460
$822,556
$986,779
$910,289 $1,059,796 $1,063,209 $1,059,796 $1,104,674 $1,299,987 $1,306,851 $1,399,987
$991,345
N/A
$611,136
N/A
$729,608 $1,022,782
$833,198
$895,284
$928,908 $1,016,208
$911,326 $1,016,676
$898,249 $1,029,093
$893,762 $1,113,804
$937,909
N/A
$772,157
N/A
$736,016
$666,688
$716,215
$644,627
$672,375
$690,627
$642,189
$663,273
$647,440
$676,538
$625,586
$635,732
$665,507
N/A
$369,239
N/A
$478,373
$265,572
$360,684
$280,195
$333,192
$280,195
$423,578
$280,195
$376,053
$369,881
$373,491
$422,057
$369,359
N/A
$11,021
N/A
$17,514
$13,000
$12,103
$11,520
$33,408
$11,520
$15,126
$11,520
$55,478
$187,525
$25,068
$289,944
$215,821
N/A
$127,220
N/A
$158,234
$150,646
$166,955
$118,568
$164,928
$133,659
$169,668
$132,956
$172,268
$129,924
$182,140
$151,835
$194,970
N/A
$0
N/A
$235,618
$327,551
$327,552
$279,667
$276,700
$358,016
$353,391
$352,385
$348,527
$259,336
$259,159
$235,126
$173,172
N/A
$68,652
N/A
$83,803
$0
$104,233
$0
$89,308
$0
$86,806
$0
$62,465
$67,015
$66,784
$69,294
$137,453
N/A
$116,446
N/A
$93,699
$144,603
$107,225
$98,203
$85,030
$98,203
$189,671
$98,203
$128,499
$98,128
$156,349
$117,464
$133,218
N/A
-$52,851
N/A
-$53,786
$44,485
$45,467
$65,463
$58,350
$81,267
$71,430
$91,753
$80,081
$114,542
$93,712
$132,294
$104,334
N/A
$50,190
N/A
$109,212
$124,644
$110,159
$88,920
$99,610
$101,088
$96,737
$102,336
$96,403
$104,368
$92,181
$113,052
$97,168
N/A
$0
N/A
$0
$0
$38,743
$0
$45,609
$0
$37,144
$94,900
$112,650
$96,798
$170,800
$99,702
$94,795
N/A
$84,061
N/A
$79,259
$85,000
$109,177
$98,400
$116,352
$111,254
$93,213
$111,254
$100,807
$109,703
$82,910
$113,433
$77,065
N/A
$15,526
N/A
$18,752
$27,300
$1,396
$28,975
$0
$20,065
$9,502
$20,065
$15,751
$39,724
$86,186
$54,035
$67,801
N/A
$10,143
N/A
$28,199
$114,500
$33,939
$68,632
$25,003
$45,622
$26,037
$45,622
$34,384
$56,786
$32,540
$87,635
$51,198
N/A
$469,555
N/A
$721,211
$681,836
$395,406
$728,839
$373,186
$455,120
$424,602
$400,918
$470,069
$678,381
$654,074
$723,707
$316,584
$19,237,480 $18,142,151 $22,433,774 $22,216,084 $24,730,446 $23,538,387 $24,805,545 $25,459,510 $25,855,080 $26,979,848 $27,101,239 $28,396,256 $29,759,520 $30,444,032 $34,418,494 $34,689,862

Detailed Data Not Available

Exp. Object
PROF/SPEC S
REG SALARIE
RETIREMENT
EXTRA HELP
OVERTIME
PHARMACEUT'
HEALTH INSU
OTHER PAY
MED SUPPLIE
RNTS/LEAS-E
MEDICARE
WORK COM GE
TEL/TG-I/F
MAINT -EQUI
INSURANCE
OTHER INSUR
AN LV PAYOF
AMBUL CONTR
MIN MED EQSPEC DEPT E
OTHER
Grand Total

FY 2001/02

Actual Spending FY 00/01
through FY 07/08
Dollar Change
$8,528,779
$2,490,893
$2,545,205
$1,068,178
$694,098
$236,702
$326,773
-$106,650
$120
$204,800
$67,750
$173,172
$68,801
$16,772
$157,185
$46,978
$94,795
-$6,996
$52,274
$41,055
$296,672
$16,547,712

*Note: FY 2000/01 and FY 2001/02 Budgeted Amounts were obtained from HCA/Internal Budget system that was utilized at that time, which
adjusted information after it was downloaded from BRASS. All other data were obtained from CEO-Budget.

% Change
150.25%
29.29%
2780.62%
1289.47%
182.93%
31.37%
53.47%
-13.81%
0.03%
1858.33%
53.25%
N/A
100.22%
14.40%
-297.41%
93.60%
N/A
-8.32%
336.68%
404.75%
63.18%
91.21%