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Utah Legislative Auditor General - Performance Audit of Healthcare in State Prisons

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REPORT TO THE
UTAH LEGISLATURE
Number 2021-17

A Performance Audit of
Healthcare in State Prisons

December 2021

Office of the
LEGISLATIVE AUDITOR GENERAL
State of Utah

STATE OF UTAH

Office of the Legislative Auditor General
315 HOUSE BUILDING • PO BOX 145315 • SALT LAKE CITY, UT 84114-5315
(801) 538-1033 • FAX (801) 538-1063

Audit Subcommittee of the Legislative Management Committee

KADE R. MINCHEY, CIA, CFE
AUDITOR GENERAL

President J. Stuart Adams, Co–Chair • Speaker Brad R. Wilson, Co–Chair
Senator Karen Mayne • Senator Evan J. Vickers • Representative Brian S. King • Representative Mike Shultz

December 7, 2021

TO: THE UTAH STATE LEGISLATURE

Transmitted herewith is our report, A Performance Audit of Healthcare in
State Prisons (Report #2021-17). An audit summary is found at the front of the
report. The objectives and scope of the audit are explained in the Introduction.
We will be happy to meet with appropriate legislative committees, individual
legislators, and other state officials to discuss any item contained in the report in
order to facilitate the implementation of the recommendations.
Sincerely,

Kade R. Minchey, CIA, CFE
Auditor General

vv

"'

UTAH STATE

~

AUDIT SUMMARY

,11111111
LEGISLATURE
REPORT #2021-17 | DECEMBER 2021
Office of the Legislative Auditor General | Kade R. Minchey, Auditor General

PERFORMANCE
AUDIT
AUDIT REQUEST
The Legislative Audit
Subcommittee requested
that we evaluate the quality,
efficiency, and effectiveness
of healthcare services
administered in Utah’s prison
system and determine if
any medical neglect has
occurred and to what degree.
In addition, we were asked
to review how effectively
COVID-19 concerns were
addressed.

Audit of Healthcare in
State Prisons
KEY
FINDINGS

As part of this audit, our medical consultant reviewed 76 sampled
cases and determined that several inmates were given inappropriate
or inadequate care.
The lack of follow-up and patient monitoring is problematic and
medical charts lack sufficient information.
Inmates with diabetes are not adequately monitored and the amount
of time between insulin distribution and mealtime does not follow
internal protocols or meet professionally recognized standards.
Clinical Services Bureau is not fully compliant with national
accreditation (NCCHC) standards.
Administrative oversight of medical services needs to improve.

Management Needs to Improve Systemic Deficiencies within
Clinical Services

► BACKGROUND
The Clinical Services
Bureau (Bureau) provides
healthcare services to over
5,000 inmates who reside
within the Utah Department
of Corrections (UDC). The
Bureau is responsible for
providing medical, mental
health, dental, and optometry
services to the inmates at
the Utah State Prison (USP
or Draper prison site) and the
Central Utah Correctional
Facility (CUCF or Gunnison
prison site). The Bureau
operates infirmaries at both
locations and a pharmacy is
located at the Draper site.

Our review of the Utah state prison system’s Clinical Services Bureau (Bureau)
found several systemic deficiencies that negatively impacted patient outcomes.
Systemic deficiencies, at times, threaten the level of care provided. In most cases,
inmates received competent medical care. Unfortunately, in other cases, systemic
deficiencies significantly delayed or degraded the level of care provided.

RECOMMENDATIONS
We recommend that management improve systemic deficiencies within
the Clinical Services Bureau.
We recommend that the Bureau ensure that all patients have access to:
(1) Appropriate and timely clinical judgements rendered by a qualified
healthcare professional, and (2) Correct treatments and medications for
corresponding diagnoses.
We recommend that the Bureau follow all internal policies, internal
protocols, professionally recognized standards, and best practices
regarding the administration and application of healthcare to inmates.

Summary continues on back >>

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UTAH STATE

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AUDIT SUMMARY

111111111
LEGISLATURE
CONTINUED

REPORT
SUMMARY
Management Can Improve Its Compliance
With Statute and Standards
The Utah Department of Corrections (UDC)
prison healthcare system needs improvement. In this
audit, we address several areas of concern and provide

•

The Bureau is not following the inmate handbook fee
schedule regarding mental health copays.

Administrative Oversight of Medical Services
Needs to Improve
The primary reason for the Bureau’s systemic deficiencies

recommendations for improvement. The following bullet

is inadequate oversight from multiple levels of personnel.

points summarize our findings:

More specifically, Bureau management:

•

Statutorily required national accreditation standards

•

are not consistently being met.
•

award programs circumvent Administrative Rule.

Bureau management is using EMTs in situations

•

Lacks transparency in funding allocations.

that they have not been adequately trained

•

Reports incorrect performance metric data to the

for. We question whether the use of EMTs in a

Legislature for program performance metrics that do

nonemergency setting places them in situations

not reflect actual program operations.

beyond their limited clinical training and education.
•

Lacks financial controls, as individual incentive

Personal health information is not adequately

•

Has not updated several of the Bureau’s policies,
procedures, and training materials.

protected per state statute and national standards.

Management Needs to Ensure That
Personal Health Information Is
Protected and Unused Medications Are
Secure
We found patient treatment sheets,
pill packets containing personal health

Funds Sent
In Late

information, and a used syringe in two public
dumpsters located outside the prison. Four
weeks later, a second inspection found
more pill packets containing personal
health information and unused medications.
Medications in pill packets that are stamped
“retained” are to be retained by clinical staff
and returned to the pharmacy. These pills, if
unopened, can be reused by the pharmacy.

Funds Sent
Within Two
Weeks

REPORT TO THE
UTAH LEGISLATURE

Report No. 2021-17

A Performance Audit of
Healthcare in State Prisons

December 2021

Audit Performed By:
Audit Manager

Brian Dean, CIA, CFE

Audit Supervisor

David Gibson, CISA

Audit Staff

Nicole Luscher
Amber Edgel

Table of Contents
Chapter I
Introduction ....................................................................................................................... 1
Medical Services Are Provided
By the Department of Corrections ............................................................................. 1
ICRs Are the Main Mechanism Available for
Inmates to Request Medical Services ......................................................................... 2
Bureau Expenses Consistently
Exceed Appropriation Amounts ................................................................................ 4
Statute Requires Accreditation .................................................................................. 6
Audit Scope and Objectives ....................................................................................... 7
Chapter II
Management Needs to Improve Systemic
Deficiencies within Clinical Services ................................................................................... 9
Improved Practices and Oversight
Are Needed to Ensure Quality Care ........................................................................ 11
Prison Medical Needs to Effectively
Regulate Inmates with Diabetes .............................................................................. 15
Oversight of Prison Medical
Regarding COVID-19 Could Improve ................................................................... 20
Recommendations................................................................................................... 21
Chapter III
Management Can Improve Its
Compliance With Statute and Standards ........................................................................... 23
Management Should Ensure that
Statutorily Required Standards Are Followed .......................................................... 24
Management Needs to Ensure Medications Are
Distributed According to Statute and Standards ...................................................... 32
Management Needs to Better Protect
Personal Health Information ................................................................................... 34

Bureau Management Needs to
Follow the Inmate Handbook Fee Schedule ............................................................ 38
Recommendations................................................................................................... 38
Chapter IV
Administrative Oversight of Medical
Services Needs to Improve ............................................................................................... 39
Individual Incentive Awards
Circumvent Administrative Rule ............................................................................. 39
Management Should Be More
Transparent in Funding Allocations ........................................................................ 42
Performance Metrics Need to
Be Improved and Updated ...................................................................................... 44
Policies, Procedures, and Training
Materials Are Outdated ........................................................................................... 47
Recommendations................................................................................................... 48
Appendices .......................................................................................................................49
Appendix A ............................................................................................................. 51
Appendix B ............................................................................................................. 55
Agency Response ............................................................................................................. 87

Chapter I
Introduction
The Clinical Services Bureau (Bureau, or prison medical) provides
healthcare services to more than 5,000 inmates under the jurisdiction
of the Utah Department of Corrections (UDC). The Bureau is
statutorily required to be compliant with National Commission for
Correctional Health Care (NCCHC) standards. The Bureau provides
medical, mental health, dental, and optometry services to inmates at
the Utah State Prison (USP, or Draper prison site) and the Central
Utah Correctional Facility (CUCF, or Gunnison prison site). The
Bureau operates infirmaries at both locations and a pharmacy at the
Draper prison site.

Medical Services Are Provided
By the Department of Corrections
Medical staff at USP and CUCF are responsible for the healthcare
of all Utah state inmates. Both facilities utilize outside medical services
when they do not have the internal expertise to meet the needs of their
patients. For example, USP contracts with the University of Utah
Hospital, and CUCF contracts with the Gunnison Valley Hospital.

USP contracts with the
University of Utah
Hospital and CUCF
contracts with the
Gunnison Valley
Hospital for medical
services.

Because of geographic location, the Draper prison has been
designated to provide medical care to those with more acute medical
needs and, therefore, has more resources available to serve a larger
population of inmates. USP also has access to telemedicine, which
allows inmates to be evaluated by outside specialists in a live-video
conference setting. The telemedicine clinics 1 preserve resources and
reduce the risk of transporting inmates to offsite locations. Figure 1.1
summarizes the number of medical and mental health personnel at
both prison locations.

1

The Wasatch Infirmary, located at the Draper prison site, has 11 telemedicine
specialty clinics including hepatology, nephrology, neurology etc. The telemedicine
system allows inmates to be evaluated and followed by off-site specialists.

Office of the Utah Legislative Auditor General

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Figure 1.1 Medical Personnel at the Draper and Gunnison
Prison Sites. The Draper prison site has more medical personnel
because it has a larger inmate population and has a greater share
of inmates with acute medical needs.
Employee Count 2

The Draper prison site
has more medical
personnel because it
has a larger inmate
population.

Medical & Mental Health
Personnel
Doctor (3 doctors, one
practicing medical director*)
Physician Assistant

Draper

Gunnison

3

1

8

2

42

19

Psychiatrist*

1

-

Psychologist*

2

-

Supervising Psychologist

1

-

Therapist Supervisor

4

1

Clinical Therapist

7

1

Optometrist*

1

-

Physical Therapist*

1

-

Dietician*

1

-

Emergency Medical Technician
(EMT)
TOTAL

22

2

93

26

Nurse

Source: Department of Human Resource Management
* Employees are shared by both facilities.

While Figure 1.1 is not a comprehensive list, it accounts for most
medical and mental health personnel at both facilities.

ICRs Are the Main Mechanism Available for
Inmates to Request Medical Services
Inmates at both the Draper and Gunnison prison sites submit
inmate healthcare requests (ICRs) to request medical, mental health,
dental, or optometry services. ICR forms filled out by inmates can be
submitted to a secure collection box, or directly to UDC staff. The
form allows inmates to request the following services:
•
•

Medical visit
Mental health visit

The employee count includes the number of full-time equivalent (FTE) positions as
of August 23, 2021.

2

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A Performance Audit of Healthcare in State Prisons (December 2021)

•
•
•
•
•

Dental visit
Medication renewal
Mental health medication renewal
Information (questions about a recent test or procedure)
Optometry visit

The form also has space for inmates to write additional notes. The
inmate dates the form and provides their name, inmate number, and
housing unit. Figure 1.2 illustrates the step-by-step process from when
an ICR is submitted to when an inmate is seen by a qualified
healthcare provider.
Figure 1.2 The ICR Process Allows Inmates to Initiate a
Healthcare Request. ICRs can be verbally communicated to UDC
personnel but must be entered into the electronic medical record
system so that an appointment with a healthcare provider can be
scheduled.
7. Healthcare
Appointment
Inmates see a qualified
healthcare provider.

6. Appointment
is Scheduled

1. ICR is
Submitted
Inmates can submit an ICR
themselves, or they can
communicate the issue to UDC
personnel, who can submit a
request on their behalf.

2. ICRis
Collected

Appointments are scheduled
based on their priority rating
(triage value).

ICRs are collected in the
morning and afternoon
each day.

Inmate healthcare
requests (ICRs) can be
verbally communicated
to UDC personnel but
must be entered into
the electronic medical
record system.

5. ICRis
Prioitized
3. Face-to-Face
Encounter

ICRs are prioritized
(triaged) by a nurse.

4. ICR is Entered
into EMR System

When reviewing ICRs,
medical personnel are to
have a face-to-face
encounter with the inmate to
discuss any concerns.

All ICRs are to be entered into
the EMR system exactly as
written.

Source: Auditor generated

ICRs are collected twice daily at pill lines 3 by emergency medical
technician (EMT) staff. Figure 1.3 illustrates the number of monthly
3

Pill lines are designated places in the facility where inmates who require
medications that must be more carefully monitored are given their daily dosages. Pill
lines are held twice daily.

Office of the Utah Legislative Auditor General

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ICRs that were processed at the Draper and Gunnison prison sites
between calendar years 2018 and 2020.
Figure 1.3 Total Number of Monthly ICRs Received by the
Draper and Gunnison Prisons for Calendar Years 2018 to 2020.
The Draper prison site averaged 3,879 ICRs a month in 2020,
whereas the Gunnison prison site averaged 1,490 ICRs a month in
2020.

Draper Prison's ICRs

6000
5000

The Draper prison
receives more ICRs
since they house more
inmates than the
Gunnison prison.

4000
3000

Gunnison Prison's ICRs

2000
1000
0

Jan

Feb

Mar

April

May
2018

June

July

2019

Aug. Sept.

Oct.

Nov.

Dec.

2020

Source: Auditor generated

At the beginning of March 2020, the total inmate population was
just over 3,300 for the Draper prison and 1,700 for the Gunnison
prison. The average number of ICRs per capita is close to one ICR per
person per month at both prison locations. Once an ICR is entered
into the system, it is triaged (or prioritized) by a nurse. 4 After the ICR
is triaged, the inmate will be scheduled to see a provider as needed. 5

Bureau Expenses Consistently
Exceed Appropriation Amounts
The Bureau’s expenses consistently exceed ongoing appropriation
revenues. Over the past five fiscal years (2016 to 2020), the Bureau’s
expenses averaged $34.7 million per year, while ongoing
appropriations averaged $31.3 million per year. The $3.4 million
4

Gunnison prison uses registered nurses to triage ICRs and the Draper prison uses
senior registered nurses to triage ICRs.
5
A provider refers to any medical doctor, mental health doctor, dentist, optometrist,
or physician assistant.

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A Performance Audit of Healthcare in State Prisons (December 2021)

average annual deficit 6 has largely been supplemented by one-time
General Fund appropriations, dedicated credits, and nonlapsing
balances, as illustrated by Figure 1.4.
Figure 1.4 The Bureau’s Expenses (Gray Area) Have
Consistently Exceeded Ongoing Appropriation Amounts (Blue
Bars). Each year, the Bureau requests supplemental funding in the
form of one-time General Fund appropriations (orange) to help
close the funding gap. Additional revenue in the form of dedicated
credits (yellow) and nonlapsing balances (green) also helps to
address funding gaps.
$40
$35
$30

The Bureau has
received one-time
General Fund
appropriations
(orange) for the last
five years.

Millions

$25
$20
$15
$10
$5
$0

2016
■

2017

Expenses

■ General

Fund (One-Time)

2018
■ General

2019

2020

Fund (Ongoing)

■ Dedicated

Credits Revenue

■ Beginning Nonlapsing
Source: Division of Finance

Figure 1.4 shows the contrast between revenues and expenses. The
Bureau has been granted statutory authorization for nonlapsing funds.
In other words, money 7 that is not spent at the close of a fiscal year
may be carried over to the following fiscal year. It is crucial to
6

The average annual deficit of $3.4 million equates to roughly 10 percent of the
Bureau’s total budget.
7
The Utah Legislature authorizes program-specific nonlapsing fund amounts each
year in the Executive Offices and Criminal Justice Base Budget Bill. For example, the
nonlapsing fund amount authorized for prison medical services for fiscal year 2021 is
$2.5 million. On average, the Bureau carries forward a nonlapsing fund balance of
roughly 4 percent of their total budget.

Office of the Utah Legislative Auditor General

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understand carryover funds (nonlapsing funds) and other revenue
streams, such as dedicated credits and one-time supplemental funding
requests since the Bureau relies on this additional income to meet its
expenditures. 8

In 2020, the Bureau
implemented our
office’s 2013 audit
recommendation,
which has resulted in
significant cost
savings.

According to Bureau management, budgeting for medical services
is challenging because medical expenses can be unpredictable.
Management stated that the Bureau asks for a supplemental
appropriation annually to budget for unforeseen medical emergencies
and surgeries. Regarding unforeseen medical necessities, the Bureau
recognized significant costs savings in 2020 by renegotiating one of its
outside medical provider contracts. We are encouraged by this action
as it fulfilled a recommendation that our office gave to the department
in 2013.

Statute Requires Accreditation
The Bureau is required by Utah Code 64-13-39 to apply for and
meet all accreditation requirements set by NCCHC, which the
Gunnison prison successfully completed in 2019 and the Draper
prison successfully completed in 2020. NCCHC assists correctional
and detention facilities to provide effective and efficient healthcare.
NCCHC has 60 standards within the following seven categories:
•
•
•
•
•
•
•

The Bureau is
statutorily required to
be compliant with
National Commission
for Correctional Health
Care (NCCHC)
standards.

Governance and administration
Health promotion, safety, and disease prevention
Personnel and training
Ancillary healthcare services
Patient care and treatment
Special needs and services
Medical–legal issues

Each standard is classified as either “essential” or “important.”
There are 39 essential standards and 21 important standards. NCCHC
accredits facilities that demonstrate 100 percent compliance to
applicable essential standards and 85 percent compliance to applicable
important standards. The accreditation assessment is a week-long
process that occurs once every three years. The onsite assessment
consists of NCCHC sending a survey team to the facility for an
Budgeting practices, and the need for increased transparency in funding allocations,
are discussed in detail in Chapter IV of this report.

8

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A Performance Audit of Healthcare in State Prisons (December 2021)

in-person review. Afterward, the lead surveyor submits a report to
NCCHC for review by the accreditation committee. To be clear, we
did not audit the accreditation process and, therefore, provide no
opinion on NCCHC’s position. Our audit process is separate from the
accreditation process and is designed to give comprehensive and
thorough review of state prison healthcare operations. Our audit
included more than five months of on-site interviewing, observing,
analyzing, and documenting activities within the prison’s Clinical
Services Bureau. Both the Draper and Gunnison prison sites were
evaluated independently and are identified as applicable in the report.

Audit Scope and Objectives
We were asked by the Legislature to evaluate the quality,
efficiency, and effectiveness of healthcare services being administered
in Utah’s prison system and to determine if any medical neglect has
occurred and, if so, to what degree. In addition, we were asked to
review how effectively COVID-19 concerns have been addressed.
To assist with the review of inmate medical cases, we contracted
with Marc Babitz, MD, to serve as a medical consultant. As part of
this audit, Dr. Babitz reviewed 76 sampled medical cases and provided
medical expertise. His conclusions and resume can be found in
Appendix B of this report. One continuing theme throughout the
course of this audit was the poor condition of the data maintained by
the Bureau. Data provided by the Bureau required us to spend a
significant amount of time putting the data into a usable format to
determine compliance. The following chapters address risk areas and
recommendations that we identified throughout the course of this
audit.
•

Chapter II: Primarily discusses the need for
management to improve patient monitoring, patient
follow-up, continuity of care, and more effectively
regulate inmates’ diabetes.

•

Chapter III: Discusses the need for management to
comply with statute and standards involving the inmate
intake process, ICRs, and personal health information.

Office of the Utah Legislative Auditor General

To assist with the
review of inmate
medical cases, we
contracted with Marc
Babitz, MD, to serve as
a medical consultant.

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•

-8-

Chapter IV: Discusses how management can improve
administrative and fiscal oversight as well as general
program operations.

A Performance Audit of Healthcare in State Prisons (December 2021)

Chapter II
Management Needs to Improve Systemic
Deficiencies within Clinical Services
Our review of the Utah state prison system’s Clinical Services
Bureau (Bureau, or prison medical) found several systemic deficiencies
that negatively impacted patient outcomes. We found that prison
medical professionals are generally dedicated employees working to
provide quality care. However, systemic deficiencies, at times, threaten
the level of care provided. In most cases, inmates received competent
medical care. Unfortunately, in other cases, systemic deficiencies
significantly delayed or degraded the level of care provided.
Our audit team spent several months working with and observing
prison medical staff, interviewing staff and inmates, analyzing data,
evaluating compliance, and identifying areas of improvement. To assist
in our review, we consulted with a licensed physician with more than
40 years of clinical experience. Ultimately, we concluded that the
primary reason for the Bureau’s systemic deficiencies is inadequate
oversight from multiple levels of personnel. The following bullet
points summarize our findings.

Systemic deficiencies,
at times, threaten the
level of care provided.

The primary reason for
the Bureau’s systemic
deficiencies is
inadequate oversight
from multiple levels of
personnel.

Chapter II
•

Several inmates were given inappropriate or inadequate
care.

•

Follow-up and patient monitoring are insufficient.

•

Improper monitoring of diabetes presents a serious risk
to some inmates.

•

Oversight of prison medical regarding COVID-19
could improve.
Chapter III

•

Statutorily required national accreditation standards are
not consistently being met.

•

A lack of oversight regarding inmate healthcare requests
(ICRs) has resulted in concerns with face-to-face patient

Office of the Utah Legislative Auditor General

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assessments, delays in internal prioritization timelines,
and ICRs not being entered into the electronic medical
record (EMR) system.

We recommend that
the executive director
of UDC ensure that all
recommendations are
adequately
implemented.

•

Emergency medical technicians (EMTs) do not always
complete their shift requirements. 9

•

Medications are not being distributed according to
statute and standards.

•

Medical staff failing to protect personal health
information.

•

Medical staff failing to secure biohazard waste bins.
Chapter IV

To ensure all concerns
have been sufficiently
addressed, we also
recommend that the
executive director
launch an internal
review.

•

Multiple Administrative Rule violations regarding
individual incentive award programs.

•

A lack of transparency regarding funding allocations and
the use of program funds.

•

Program performance metrics do not reflect actual
program operations.

•

Policies, procedures, and training materials are outdated.

Due to the nature of these findings, we recommend that the
executive director of the Utah Department of Corrections (UDC)
ensure that all recommendations in this audit report are adequately
implemented. Our audit team worked closely with Bureau
management throughout the duration of this audit. While
management responded to audit requests and concerns in a timely
manner, the documentation provided did not always directly address
the concerns we raised or impact audit conclusions. To ensure all
concerns have been sufficiently addressed, we recommend that the
executive director also launch an internal review to determine if
additional changes not addressed in this report are needed regarding
operations and/or staff.

Each shift, EMTs are supposed to complete an inventory of all medical supplies and
fill out a daily log to ensure that supplies are current and available.

9

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A Performance Audit of Healthcare in State Prisons (December 2021)

Improved Practices and Oversight
Are Needed to Ensure Quality Care
The lack of follow-up and patient monitoring is a systemic concern
that extends beyond the COVID-19 pandemic. This conclusion is
based on a medical review of 76 sampled 10 cases (independent medical
issues) for 47 unique inmates. The sample consisted of a variety of
medical issues and concerns that spanned a three-year period. We
contracted with a physician who has more than 40 years of clinical
experience as a medical provider and a public health expert. The
consultant’s full report can be found in Appendix B of this audit
report. The consultant focused on the Draper facility; however, the
review included a small number of medical cases for inmates at the
Gunnison facility. Most cases reviewed by the physician showed no
significant concerns (83 percent). However, the medical review
revealed some substantial concerns that indicate a need to repair key
areas of the deficient healthcare system in Utah prisons. The following
two points summarize these concerns:
•

Inappropriate or inadequate medical care was given in
17 percent of the sampled cases (about one in every six
cases).

•

Lack of follow-up and patient monitoring was identified
in nearly one-third of all cases.

The specific cases identified by our contracted physician are
concerning and should be remedied with immediate action. That said,
we do not characterize the prison healthcare system as deficient based
on these cases alone. Additional clinical and administrative concerns in
need of correction and repair will be demonstrated throughout this
audit report.

The medical review
revealed some
substantial concerns
that indicate a need to
repair key areas of the
deficient healthcare
system in Utah
prisons.

We do not characterize
the prison healthcare
system as deficient
based on the sample
cases alone. Additional
concerns will be
demonstrated
throughout this audit
report.

10

Sampled cases were selected to include medical cases, some COVID-19 cases
(about 26 percent), and cases from inmate and other interviews. The sample was not
designed to be extrapolated to the general prison population.

Office of the Utah Legislative Auditor General

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Several Inmates Were Given
Inappropriate or Inadequate Care
In several cases, the
care provided to
inmates was either
inappropriate or
inadequate.

Prison medical staff
failed to follow a
treatment regimen
provided by a
specialist, thereby
presenting concerns
for the potential
success of the
treatment.

In several cases, the care provided to inmates was either
inappropriate or inadequate. While these cases range in complexity
and severity, the medical care provided in each of these cases should be
improved. General examples of inappropriate or inadequate care
identified in our audit process include, but are not limited to the
following categories:
•

Unreasonable delays and inconsistencies in critical
medications.

•

Administration of wrong medications.

•

Resolved ICRs indicating a provider assessment had
been completed when it had not been.

•

Unreasonable delays in appropriate exams and treatment
plans.

•

Failure to follow national guidelines and internal
protocols.

A specific example of a case that falls into one or more of these
categories involves a critical drug treatment regimen recommended by
a healthcare specialist outside 11 of the prison. In this case, the specialist
provided detailed instructions on the amount, number, and frequency
of medication doses over a specific time frame. We found that the
treatment regimen provided by the specialist was not consistently
followed by prison medical staff, thereby presenting concerns for the
potential success of the treatment. The primary concern in this case
(and in other cases with documented occurrences of inconsistent and
inadequate treatment) is the level of substandard care. Inadequate care
such as this could negatively impact patient health outcomes and incur
additional healthcare-related expenses.

Outside care is any healthcare provided by someone other than department staff.
This includes all appointments, surgeries, tests, X-rays, etc. that are conducted at
outside healthcare clinics and hospitals. Additionally, telemedicine is available in the
Wasatch Infirmary at the Draper prison site, where a camera and a telephone
connection are used to provide live video conferencing with specialists, who are able
to see and converse with inmates.
11

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A Performance Audit of Healthcare in State Prisons (December 2021)

National Accreditation Standards Require Inmates to Receive
the Care That Is Ordered. The National Commission on
Correctional Health Care (NCCHC) has 39 essential standards that
require 100 percent compliance to achieve accreditation. Utah statute
requires UDC to comply with NCCHC standards. The first essential
standard defines access to care as follows:

Utah statute requires
UDC to comply with
NCCHC standards.

Access to care means that, in a timely manner, a
patient is seen by a qualified health care professional,
is rendered a clinical judgment, and receives care that
is ordered. 12
This standard requires the responsible health authority to identify and
eliminate any unreasonable barriers, intentional or unintentional, to
inmates receiving healthcare. The standard also provides examples of
unreasonable barriers, such as having an understaffed, underfunded, or
poorly organized system, resulting in the inability to provide
appropriate and timely access to care. Utah Code 13 requires UDC to
comply with NCCHC standards. NCCHC is also required to conduct
inspections to ensure compliance and accreditation. According to
NCCHC, the on-site survey cycle (inspection) occurs approximately
every three years and typically lasts about a week, depending on facility
size and complexity. Accreditation is a useful tool that provides needed
feedback. However, the purpose of our audit work is not
accreditation; rather, our audit is intended to provide management
with a comprehensive review of where deficiencies exist, so that
improvements and adjustments can be made. Our audit team spent
several months working with and observing medical services,
interviewing clinical staff and inmates, analyzing data, evaluating
compliance, and identifying areas of improvement.

The purpose of our
audit work is not
accreditation; rather,
our audit is intended to
provide management
with a comprehensive
review of where
deficiencies exist.

Lack of Follow-Up and Patient
Monitoring Is Problematic
Insufficient documentation on individual medical charts made
evaluating the quality of care increasingly difficult. For example, 30
percent of medical charts (23 cases) reviewed by our medical
consultant were lacking sufficient information. Of the 23 cases, only 6
were COVID-19 cases. The other 17 cases detailed medical concerns
and chronic conditions such as cancer, stroke, acute injury, and
12
13

NCCHC P-A-01.
Utah Code 64-13-39.

Office of the Utah Legislative Auditor General

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Several patients did
not receive adequate
and timely follow-up
visits or appropriate
patient monitoring.

medication requests. In many instances, the medical provider would
request “monitoring,” or “increased monitoring,” however, these
orders did not contain specific parameters such as the frequency of the
checks or the type of checks (e.g., vital signs, oxygen saturation levels,
etc.). As a result, several patients did not receive adequate and timely
follow-up visits or appropriate patient monitoring.
The lack of follow-up and patient monitoring became especially
concerning throughout the COVID-19 pandemic, which
overwhelmed—as was the case in most healthcare facilities—the
prison’s medical system. The increased workload imposed upon
clinical staff by the pandemic resulted in insufficient numbers of
medical staff to maintain a high quality of clinical care for all patients,
and especially for COVID-19 patients. According to our medical
consultant:

Patients who test positive [for COVID-19] and are high
risk need to be closely monitored, at a minimum, daily
checking of their vital signs, especially their
temperature and their oxygen saturation. When there
is any evidence of a patient’s condition worsening,
those checks should occur more frequently, e.g. 2–4
times/day.
Provider orders for
patients diagnosed
with COVID-19 were
vague and did not
stipulate specific
parameters of care.

For several inmates who were diagnosed with COVID-19, the
provider requested “monitoring,” or “increasing monitoring,” but the
orders were vague and did not stipulate specific parameters of care.
The Lack of Follow-Up and Patient Monitoring Appears to
Be Systemic and Extends Beyond the COVID-19 Pandemic.
During the pandemic, medical staff adopted a record-keeping practice
for COVID-19 patients known as “charting by exception.” Charting
by exception streamlines the documentation process by reducing or
eliminating redundant charting. In some of the COVID-19 specific
cases, care was reportedly given for which no documentation exists.
That said, only 26 percent of the sampled cases reviewed by our
medical consultant were related to the COVID-19 pandemic.
Of the 76 cases reviewed by the medical consultant, 23 cases 14 (30
percent) were not seen in the correct amount of time, based on the

14

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The 23 cases date back to 2018; only six of these cases were COVID-19 cases.

A Performance Audit of Healthcare in State Prisons (December 2021)

medical issue in question. 15 In other cases, resolved ICRs indicated
that a provider assessment had been completed when it had not been.
To verify this, we reviewed patient medical charts and did not find
provider assessments in the corresponding medical charts.
Furthermore, we observed an EMT administering the wrong
medication to an inmate. Although the incident was reported, there
was no evidence of prison medical staff conducting follow-up visits or
increased patient monitoring. The lack of follow-up and patient
monitoring is a contributing factor to the larger issues of
inappropriate and inadequate care.

Prison Medical Needs to Effectively
Regulate Inmates with Diabetes

Resolved ICRs
indicated that a
provider assessment
had been completed
when it had not been.
To verify this, we
reviewed patient
medical charts and did
not find provider
assessments in the
corresponding medical
charts. Furthermore,
we observed an EMT
administering the
wrong medication to
an inmate.

Another factor leading to our conclusion that the prison medical
system is deficient is the problematic care of inmates with diabetes.
Between 8 and 9 percent of inmates at both prison locations have
diabetes. 16 According to the American Diabetes Association (ADA),
inmates with diabetes should be closely monitored. However, we
question whether current practices meet the ADA’s standard of
measuring blood sugar (glucose) levels three or more times daily. Our
conclusion is based on the following:
•

Blood sugar levels are not sufficiently monitored at all
levels of prison security.

•

After receiving insulin, inmates do not always receive
food within the recommended time frames.

At the Draper prison, the amount of time between insulin
distribution and mealtime does not follow internal protocols or meet
the ADA’s recommended timelines. Significant deviations from ADA
guidelines could result in inmates developing complications and longterm damage. Conversely, regular monitoring of blood glucose levels
could mitigate further complications.

At Utah prisons, the
amount of time
between insulin
distribution and
mealtime does not
follow internal
protocols or meet ADA
guidelines.

15

The response timeline and handling of ICRs are discussed in detail in Chapter III.
As of October 2021, the number of inmates diagnosed with diabetes included 132
inmates at the Gunnison prison site (7.8 percent) and 226 inmates at the Draper
prison site (8.6 percent).
16

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Increased Monitoring of Blood Sugar Levels
Is Needed at All Levels of Prison Security
We observed instances
of dangerously low
and dangerously high
blood sugar readings,
which likely could have
been mitigated through
increased monitoring
and proper treatment.

Without a glucometer
to self-monitor or
access to food beyond
routine meals, we are
concerned that some
diabetic inmates are
not receiving adequate
monitoring or proper
treatment.

We observed instances of dangerously low and dangerously high
blood sugar readings, which likely could have been mitigated through
increased monitoring and proper treatment by medical staff. Although
most diabetic inmates reportedly have a glucometer to help them selfmonitor their blood sugar levels, not all inmates are able to selfmonitor due to behavioral and/or custody concerns. ADA guidelines
for diabetes management in correctional institutions state, “Patients at
all levels of custody should have access to medication at dosing
frequencies that are consistent with their treatment plan and medical
direction.” While diabetic inmates have an individual responsibility for
self-management (such as adhering to recommended diets), new
intakes and inmates with behavioral concerns are largely dependent on
prison medical staff for care. Without a glucometer to self-monitor or
access to food beyond routine meals, 17 we are concerned that some
diabetic inmates are not receiving adequate monitoring or proper
treatment. For example, we observed a blood sugar reading of 59
mg/dl 18 at 10:26 pm for a new intake who was not approved for food
beyond scheduled mealtimes.
Failing to maintain a healthy blood sugar level results in
complications such as hypoglycemia (low blood sugar) or
hyperglycemia (high blood sugar). Severe hypoglycemia is a medical
emergency and may include confusion, incoherence, combativeness,
somnolence, lethargy, seizures, and coma. Hyperglycemia weakens
blood vessels and can affect fingers, toes, skin, eyes, kidneys, and the
heart. Our review of patient medical charts revealed a diabetic inmate
who experienced multiple episodes of hypoglycemia within a six-week
period.
The ADA states that patients with type 1 diabetes are at risk for
hypoglycemia and should have their blood glucose levels monitored
three or more times daily. Currently, medical staff at the Draper
prison site monitor blood glucose levels of diabetic inmates twice daily

17

Additional food options such as prison commissary and PM boxes will be
discussed in a later section.
18
A normal blood glucose level is defined by the ADA as greater than 70 mg/dl.

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A Performance Audit of Healthcare in State Prisons (December 2021)

during pill line. 19 The Gunnison prison site likewise provides access to
insulin twice daily. A potential solution to increase patient monitoring
and more closely evaluate inmate diabetes management regimens may
include adding a third pill line.
If Bureau management opts to transition from two to three pill
lines daily, that practice would match what is being done in other
prison healthcare systems. For example, surrounding states including
Colorado, Arizona, Idaho, and Montana all operate pill lines three
times daily. While there may be a variety of reasons these states chose
to operate pill lines three times daily, a third pill line in Utah prisons
would increase access to care and may also prove beneficial to inmates
whose prescribed medications are intended to be taken closer to
bedtime. A third pill line is just one option; the method of ensuring
that diabetic inmates are properly monitored ultimately lies with
Bureau management.

The method of
ensuring that diabetic
inmates are properly
monitored ultimately
lies with Bureau
management.

After Receiving Insulin, Inmates Do Not Always
Receive Food within Recommended Time Frames
Our audit team identified three concerns related to insulin routines
not being appropriately timed with meals:
•

The amount of time between insulin distribution and
meals does not always follow internal protocols or meet
ADA standards.

•

Diabetic protocols are outdated and do not specify how
to manage disruptions or delays to the normal schedule.

•

Significant delays in provider treatment orders and
renewals further complicate diabetic management.

As noted earlier in this chapter, the statutorily enforced NCCHC
standards require inmates to have access to care in a timely manner

NCCHC standards
require inmates to
have access to care in
a timely manner and to
receive the care that is
ordered.

The Bureau operates a pharmacy to provide prescription medications to inmates.
Depending on the type of medication, inmates may receive a “blister pack” of pills
that they can self-administer. Pill lines are held twice daily for medications that must
be more carefully monitored. In addition to the twice daily pill lines, one location at
the Draper prison site holds two more pill lines for critical cases including diabetic
inmates.
19

Office of the Utah Legislative Auditor General

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and to receive the care that is ordered. The following section addresses
each of these three concerns in detail.

Significant deviations
from the 30-minute
standard could result
in complications such
as hypoglycemia and
hyperglycemia.

The Amount of Time Between Insulin Distribution and
Mealtime Does Not Always Follow Internal Protocols or Meet
ADA Standards. The ADA states that regular insulin 20 works best if
taken 30 minutes before eating. Similarly, prison medical staff are
trained to make sure that diabetic inmates are fed within 30 minutes of
receiving regular insulin. Significant deviations from the 30-minute
standard could result in complications such as hypoglycemia and
hyperglycemia. 21 At several locations throughout the Draper prison
site, our audit team observed that the amount of time between insulin
distribution and mealtimes exceeded the 30-minute standard.
Figure 2.1 The Amount of Time Between Insulin Distribution
and Mealtime Exceeds the 30-Minute Standard. The data in this
figure represent seven unique instances where diabetic inmates
waited longer than 30 minutes for their meal. Significant deviations
from the 30-minute standard could result in serious complications
for diabetic inmates.
Location

Insulin Type

Housing Unit A
Housing Unit B
Housing Unit B
Housing Unit C
Housing Unit D
Housing Unit E
Housing Unit F

Regular
Rapid*
Regular
Rapid*
Regular
Regular
Regular

Duration between
Insulin and Meal
64 mins
67 mins
92+ mins
50 mins
92 mins
72 mins
73 mins

Source: Auditor observations
* Rapid insulin, or fast-acting insulin, has a quicker onset than regular insulin.

Regular, or short-acting insulin usually reaches the bloodstream within 30 minutes
after injection, peaks anywhere from two to three hours after injection, and is
effective for approximately three to six hours. Types of regular insulin include
Human Regular (Humulin R, Novolin R, and Velosulin R).
21
The previous section details some of the complications associated with low and
high blood sugar levels.
20

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A Performance Audit of Healthcare in State Prisons (December 2021)

Moreover, our audit team analyzed officer logs 22 from three
different housing units at the Draper prison location over a fourmonth period, from May to August 2021. 23 Using the daily log data,
we created a separate document combining all pill line and mealtime
observations. Once all observations were in one collective location, we
analyzed the time intervals between each pill line and meal delivery.
The analysis of the three Draper housing units revealed that the 30minute standard was met only 7 to 27 percent of the time. Data from
the officer logs suggest that one Draper housing unit failed to provide
food within the 30-minute standard 93 percent of the time.

Data from the officer
logs suggest that one
Draper housing unit
failed to provide food
within the 30-minute
standard 93 percent of
the time.

Related to the extended delays between insulin distribution and
mealtimes, inmates have reportedly skipped taking insulin when it is
offered so far from mealtime. To address this issue, we recommend
that the Bureau follow ADA guidelines and internal protocols by
ensuring that insulin is administered 30 minutes before mealtimes.
Although this recommendation addresses some timeline concerns,
other diabetic chronic care management issues also exist.
Prison Protocols Are Outdated and Do Not Specify How to
Manage Disruptions or Delays to the Normal Schedule. While we
recognize the timing of insulin and meals can be complicated within a
prison setting where “lock downs” and other disruptions occur,
correctional institutions should have response protocols in place as
part of the patient’s medical plan. An ADA publication 24 addressing
diabetes management in correctional settings states:

Should circumstances arise that delay patient access
to regular meals following medication administration,
policies and procedures must be implemented to
ensure the patient receives appropriate nutrition to
prevent hypoglycemia.

22

Officer logs are daily records kept by custody staff. The logs should include all
movements, security checks, counts, case numbers of incidents, visitors on unit, and
any activity deemed appropriate to note. Our audit team used these logs to record
pill line and mealtime observations.
23
Officer logs from the Gunnison prison location were missing essential data,
rendering them unusable for audit purposes.
24
American Diabetes Association. “Diabetes Management in Correctional
Institutions.” Diabetes Care, vol. 31, Supplement 1, Jan. 2008, pp. S90.

Office of the Utah Legislative Auditor General

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Although the Bureau has protocols in place for the identification and
management of chronic diseases such as diabetes, the protocols do not
specify how to manage disruptions to the normal schedule.

Inmates who do not
have access to food
items through prison
commissary are
entirely dependent on
prison mealtimes for
food.

Because treatment
orders expire after one
year, and renewals are
not always timely,
diabetic inmates may
go weeks without
receiving the
necessary food to help
regulate their blood
sugar levels.

Significant Delays in Provider Treatment Orders and
Renewals Further Complicate Diabetic Management. Provider
treatment orders are good for one year only and need to be renewed
annually; however, our audit team identified multiple instances of
diabetic inmates going weeks without a treatment order renewal and,
therefore, without the necessary food for their individual diabetes
management. New intakes and inmates with behavioral concerns may
not have access to food items through prison commissary, 25 which is
considered a privilege based on behavior. Therefore, inmates who do
not have access to food items through prison commissary are entirely
dependent on prison mealtimes for food. Aside from the basic three
meals per day, the prison offers a “PM box,” which is reserved solely
for inmates who qualify. A PM box includes additional food items to
help diabetic inmates regulate their blood sugar levels throughout the
night. To qualify for a PM box, an inmate must receive a treatment
order from a provider. However, because treatment orders expire after
one year, and renewals are not always timely, diabetic inmates may go
weeks without receiving a PM box to help regulate their blood sugar
levels.

Oversight of Prison Medical
Regarding COVID-19 Could Improve
Many lessons have been learned and will continue to be learned
during the COVID-19 pandemic. As discussed previously in this
chapter, we are concerned with the lack of follow-up and patient
monitoring regarding inmates. Specifically, the lack of documentation
for inmates who contracted COVID-19 is concerning. Insufficient
information on individual medical charts made evaluating the level of
care increasingly difficult. In several of the COVID-19 cases, care was
reportedly given for which no documentation exists. Furthermore, we
observed personal protective equipment (PPE) regarding COVID-19
test procedures failing to meet CDC standards. These are examples

25

Commissary offers products for sale such as packaged food items, writing
materials, electronics, additional hygiene products, arts and craft supplies, and
approved clothing items.

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A Performance Audit of Healthcare in State Prisons (December 2021)

where systemic deficiencies caused by poor oversight may have
negatively impacted the care of inmates.
Lastly, we reviewed other aspects of the COVID-19 response and
found that quarantine data from the Draper prison site were poorly
organized and incomplete. Therefore, our audit team was not able to
draw any conclusions as to whether appropriate quarantine guidelines
were followed.

Systemic deficiencies
caused by poor
oversight may have
negatively impacted
the care of some
inmates.

Recommendations
1. We recommend that the executive director of the Utah
Department of Corrections ensure that all recommendations in
this audit are adequately implemented.
2. We also recommend that the executive director of the Utah
Department of Corrections launch an internal review to
determine if additional changes not addressed in this report are
needed regarding operations and/or staff.
3. We recommend that the Clinical Services Bureau ensure that
providers and other medical staff define the term “monitor” in
patient charts with specific parameters on a case-by-case basis.
4. We recommend that the Clinical Services Bureau increase
oversight to ensure that appropriate case-by-case patient
follow-up procedures are being completed.
5. We recommend that the Clinical Services Bureau ensure that all
patients have access to:
a. Appropriate and timely clinical judgments rendered by a
qualified healthcare professional.
b. Correct treatments and medications for corresponding
diagnoses.
6. We recommend that the Clinical Services Bureau follow
internal policies and professionally recognized standards
regarding the administration of insulin and the oversight of
inmates with diabetes.

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7. We recommend that the Clinical Services Bureau create policies
and procedures to effectively manage nutrition and medical
care for diabetic patients during disruptions or delays to the
normal schedule.
8. We recommend that the Clinical Services Bureau develop
policies, where appropriate, that help the organization be more
compliant with CDC standards regarding medical issues such
as the COVID-19 pandemic.

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A Performance Audit of Healthcare in State Prisons (December 2021)

Chapter III
Management Can Improve Its Compliance
With Statute and Standards
As addressed in Chapter II of this report, the Utah Department of
Corrections (UDC) prison healthcare system needs improvement. In
this chapter, we address several areas of concern and provide
recommendations for improvement. The National Commission for
Correctional Health Care (NCCHC) is the official accreditation body
for UDC. Per statute, the Clinical Services Bureau (Bureau, or prison
medical) must follow NCCHC standards to achieve accreditation,
which was successfully accomplished in 2020.
Our audit report is not intended to supersede NCCHC
conclusions or act as an accreditation review. Rather, our review is
intended to help executive leadership at UDC ensure that the Bureau
is functioning in an efficient and effective manner. In this chapter, we
report on four areas in need of improvement. The first two address the
Bureau’s inconsistency in adhering to NCCHC standards and the use
of emergency medical technicians (EMTs) in situations beyond their
training and skill level. The last two areas describe how the Bureau
needs to follow state statute and standards. More specifically:
•

We observed and documented seven NCCHC standards
that are not consistently followed.

•

Bureau management is using EMTs in situations that
they have not been adequately trained for. For example,
EMTs are delivering medication at pill lines and are
assessing routine healthcare requests. We question
whether the use of EMTs in a nonemergency setting
places them in situations beyond their limited clinical
training and education, which is focused on medical
emergencies.

•

This audit is intended
to help executive
leadership at UDC
ensure that the Bureau
is functioning in an
efficient and effective
manner.

We found that the
Bureau is not
consistently complying
with NCCHC
standards.

Personal health information is not adequately protected
per state statute and national standards. We found
inmates’ personal health information in public
dumpsters outside the prison.

Office of the Utah Legislative Auditor General

- 23 -

•

The Bureau is not following the inmate handbook fee
schedule. We found 165 copay charges assessed to
inmates for mental health services from fiscal year 2018
to 2021. These copays for mental health services are not
in line with the inmate handbook.

Management Should Ensure That
Statutorily Required Standards Are Followed

Systemic deficiencies
in prison healthcare
are due to inadequate
oversight from multiple
levels of personnel.

Bureau management needs to improve its oversight and
supervision to ensure that proper medical care is provided to inmates.
We documented and observed that the Bureau is not consistently
meeting statutorily required standards. Again, our audit work is not
intended as an accreditation review, which usually occurs in a week or
less. Rather, our review is a performance and compliance review
consisting of several months of direct, on-site work. In Chapter II, we
conclude that the prison healthcare system is deficient, and that the
primary reason for systemic deficiencies is inadequate oversight from
multiple levels of personnel.
In addition to the standard on access to timely healthcare discussed
in Chapter II, our in-depth audit identified seven essential standards
that we believe are deficient and in need of immediate correction.
Prior to introducing the essential standards and corresponding
deficiencies, it is important to note that the datasets provided to us
were poorly kept, thereby limiting our analysis. That said, we were
able to document a lack of compliance to essential standards by
analyzing the remaining usable data. The following list summarizes
our findings:
•

The initial health
assessment standard
that requires inmates
to be seen within
seven days is not
always being met.

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Standard: NCCHC Essential Standard: P-E-04(1): All
inmates receive an initial health assessment as soon as
possible, but no later than seven calendar days after
admission. Documented Deficiency: We found that
over a three-year period, 180 inmates did not receive
their health assessment within the seven-day standard.
We documented this deficiency by analyzing inmate
intake and refusal data. Additional details are found on
pages 26–28.

A Performance Audit of Healthcare in State Prisons (December 2021)

•

Standard: NCCHC Essential Standard: P-E-05(6):
Mental health evaluations of patients with positive
screens should be completed within 30 days, or sooner
if clinically indicated. Documented Deficiency: Over a
three-year period, 3 qualifying male inmates at the
Draper prison site did not receive a mental health
evaluation within the 30-day standard. Furthermore, we
were not able to verify mental health evaluations for 143
inmates due to poor record keeping. Over a two-year
period, 15 qualifying female inmates at the Draper
prison site did not receive an evaluation within the 30day standard. Gunnison did not provide the requested
data. We documented this deficiency by analyzing
mental health intake and refusal data for male and
female inmates. Additional details are found on pages
26–28.

•

Standard: NCCHC Essential Standard: P-E-06(6): An
oral examination is performed by a dentist within 30
days of admission. Documented Deficiency: Over a
three-year period, 277 male inmates and 31 female
inmates (308 total cases) at the Draper prison site did
not receive an oral examination within the 30-day
standard. It is important to note that 301 of these cases
were identified as noncompliant during calendar year
2020. While we recognize that the COVID-19
pandemic affected clinical operations, 7 cases were
identified as noncompliant prior to 2020. The Gunnison
prison site did not provide the requested data. We
documented this deficiency by analyzing dental intake
and refusal data for male and female inmates. Additional
details are found on pages 26–28.

•

Standard: NCCHC Essential Standard: P-E-07(4): A
face-to-face encounter for a healthcare request is
conducted by a qualified healthcare professional, or the
healthcare liaison (if applicable), within 24 hours of
receipt by health staff. Documented Deficiency: This is
not always occurring at the Draper prison site; however,
face-to-face encounters are occurring at the Gunnison
prison site. We documented this deficiency by observing

Office of the Utah Legislative Auditor General

The mental health
evaluation standard
that requires inmates
to be seen within thirty
days is not always
being met.

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20 pill lines over a five-week period. Additional details
are found on pages 28–29.
•

Standard: NCCHC Essential Standard: P-C-05(2):
Staff administering or delivering prescription
medication should be trained in common side effects.
Documented Deficiency: We are concerned that EMTs
in the prisons are delivering medications beyond their
level of training and lack the proper training with regard
to medication side effects. We observed several examples
of this occurring. This is discussed in more detail on
pages 32–34.

•

Standard: NCCHC Essential Standard: P-A-08(7):
Access to health records and health information is
controlled by the responsible health authority.
Documented Deficiency: We found personal health
information in public dumpsters outside the prison.
This is discussed in more detail on pages 34–37.

•

Standard: NCCHC Essential Standard: P-D-01(3):
The facility maintains records as necessary to ensure
adequate control and accountability for all medications,
except those that may be purchased over the counter.
Documented Deficiency: We found medications that
should have been retained and returned to the pharmacy
in public dumpsters outside the prison. This is discussed
in more detail on pages 34–37.

Personal health
information is not
being protected as
required by NCCHC
standards.

While this audit is not an accreditation review, it is a performance
audit that is meant to be a tool to help executive leadership at UDC
ensure that the Bureau is functioning in an efficient and effective
manner.
Initial Health Assessment Timelines
Do Not Meet NCCHC Standards
Bureau management
needs to improve its
oversight to ensure
that initial health
assessments are being
performed as required
by NCCHC standards.

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Bureau management needs to improve its oversight to ensure that
initial health assessments are being performed as required by NCCHC
standards. The following essential standards focus on the intake
process of new inmates entering the prison:

A Performance Audit of Healthcare in State Prisons (December 2021)

•

Standard: P-E-04(2): All inmates receive an initial
health (medical) assessment as soon as possible, but no
later than seven calendar days after admission.

•

Standard: P-E-05(6): Mental health evaluations of
patients with positive screens are completed within 30
days, or sooner if clinically indicated.

•

Standard: P-E-06(6): An oral examination is performed
by a dentist within 30 days of admission.

Intake assessments are important because medical personnel need
to identify the inmate’s medical, mental health, and dental needs and
establish a plan for meeting those needs.
Bureau Management Needs to Improve Health Intake
Assessments of Inmates. From 2018 to 2020, we found that 180
inmates did not receive an initial health (medical) assessment within
the seven-day NCCHC time frame. Of the 180 inmates, 34 waited
longer than one month for their assessment, with the longest wait
time recorded at 307 days. We documented this deficiency by
analyzing three years (2018 to 2020) of data containing inmate intake
history. We also found that intake records have been poorly
maintained. For example, during the same time frame, 348 inmates
had no recorded assessment dates and no recorded refusals.
Bureau Management Needs to Improve Mental Health and
Dental Intake Assessments to Comply with NCCHC Essential
Standards. A mental health evaluation is to be completed within 30
days if a new inmate answers “yes” to any critical questions during the
mental health screening. Between calendar years 2018 and 2020, a
total of 3 qualifying male inmates at the Draper prison site did not
receive a mental health evaluation within the 30-day standard. We
documented this deficiency by analyzing three years (2018 to 2020) of
mental health intake and refusal data. We also found that the records
have been poorly maintained. For example, during the same time
frame (2018 to 2020) we were not able to determine whether 143
inmates received a mental health evaluation. In several other instances,
there was no recorded evaluation date even though the data indicated
that an evaluation was either scheduled or completed. Between

Office of the Utah Legislative Auditor General

Compliance with
mental health and
dental intake
assessment standards
needs to improve.

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calendar years 2019 and 2020, 26 a total of 15 qualifying female
inmates at the Draper prison site did not receive a mental health
evaluation within the 30-day time frame.
Similarly, oral exams are to be completed by a dentist within the
first 30 days of intake. Between calendar years 2018 and 2020, a total
of 277 male inmates and 31 female inmates at the Draper prison site
did not receive an oral exam within the 30-day timeline. We
documented this deficiency by analyzing three years (2018 to 2020) of
dental intake and refusal data for male and female inmates.
A pattern of
noncompliance was
identified before the
COVID-19 pandemic.

While we recognize that the COVID-19 pandemic affected clinical
operations in calendar year 2020, a pattern of noncompliance was
identified that occurred before the pandemic. Therefore, we
recommend that Bureau management ensure that all inmates receive
their mandatory intake assessments within the time frames required by
NCCHC standards. Management should also ensure that all intake
assessment data are accurately recorded and appropriately maintained.
Oversight of Inmate Healthcare
Requests Needs to Be Improved
Bureau management needs to improve its oversight to ensure that
inmate healthcare requests (ICRs) are handled appropriately and
within a timely manner. According to NCCHC standards, once an
ICR is submitted and collected, medical staff are required to have a
face-to-face encounter with the inmate who submitted the ICR within
24 hours. However, we found that face-to-face encounters are not
always occurring at the Draper prison site. Additionally, the internal
goal of seeing inmates within 15 days of ICR submission is also not
occurring. We observed that the schedulers at the Draper prison site
do not use the ICR triage date (prioritization date), but instead
schedule appointments according to the oldest submission date.

Medical staff at the
Draper prison site are
not always conducting
face-to-face
encounters as required
by NCCHC standards.

NCCHC Standards Require a Face-to-Face Encounter After
ICRs Are Submitted. According to NCCHC standard P-E-07(4), a
face-to-face encounter for a healthcare request is conducted by a
qualified healthcare professional, or the healthcare liaison (if
applicable), within 24 hours of receipt by health staff. This is not
always happening at the Draper prison site. We documented this
2018 mental health assessment data for females at the Draper prison site were not
available. The Gunnison prison site did not provide the requested data.
26

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A Performance Audit of Healthcare in State Prisons (December 2021)

deficiency by observing 20 different pill lines over a five-week period,
both in the morning and in the afternoon. In most instances, we did
not see EMTs conducting face-to-face encounters for ICR
submissions.
At the Draper facility, we observed multiple instances of ICRs
being collected without a face-to-face encounter. For example, a
mental health ICR was submitted by an inmate requesting to see a
mental health provider, but no follow-up questions were asked by the
EMT receiving the ICR. In contrast, at the Gunnison facility, we
observed nurses collect ICRs and personally contact each inmate with
an ICR submission to directly assess their concern(s). We recommend
that Bureau management ensure that both state prison facilities
conduct (or continue to conduct) a face-to-face encounter within 24
hours of ICR receipt by health staff.
Inmates Are Not Being Seen by Providers within the Targeted
Timeline. After ICRs are entered into the electronic medical record
(EMR) system, nurses 27 triage (prioritize) all ICRs, with the exception
of mental health ICRs, which are triaged by mental health supervisors.
According to Bureau management, nurses at the Draper facility assign
each ICR a triage value between 1 and 15 days. 28 For example, a triage
value of 1 means that the inmate should be seen within one day. With
15 as the maximum triage value, all inmates should be seen within 15
days. In contrast, Gunnison uses triage values of 1, 2, and 3. In this
case, a triage value of 1 means the inmate should be seen within one
day; 2 within seven days, and 3 within 15 days. Figure 3.1 shows the
percentage of ICRs that failed to meet the specified triaged time
frame, resulting in inmates having to wait longer than expected for
clinical services.

27

Gunnison prison uses registered nurses to triage ICRs and the Draper prison uses
senior registered nurses to triage ICRs.
28
The ICR forms used by inmates to submit healthcare requests, state that
appointments will be scheduled within 21 days or less, unless medically urgent.
Despite the inconsistency between what is stated on the ICR form and the internal
timeline, the Bureau is held accountable to the 15-day timeline because of its triage
process.

Office of the Utah Legislative Auditor General

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Figure 3.1 Triage Timelines Are Not Being Met at the Draper or
Gunnison Prison Sites. In this chart, any percentage greater than
zero means that the triage time frame is not being met. For
example, in calendar year 2020, the Draper facility failed to meet
the assigned triage date 36 percent of the time for medical
requests.

Gunnison prison does
a better job of meeting
medical and mental
health ICR triage
timelines than the
Draper prison.

100
90
80
70
60
50
40
30
20
10
0

87

87

73

73

40

46

54

50

40

50

82

71

64

61
36

80

44 48

11 __ II __ 111 ..
5 3

6 7

4 4

Draper

Gunnison*

Draper

Gunnison*

Draper

Gunnison*

2018

2018

2019

2019

2020

2020

■ Medical

■ Mental Health

■

Dental

■ Optometry

Source: Auditor analysis
* Roughly 35 percent of Gunnison prison site data were not useable due to poor data entry.

Schedulers are not
using the triage value
when scheduling
appointments for
inmates.

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Those Responsible for Scheduling Appointments at the
Draper Prison Site Are Not Using the Triage Value. After an ICR
is triaged by a nurse, a scheduler (the person in charge of scheduling
appointments) retrieves the ICR report from the EMR system. While
observing medical and mental health schedulers at the Draper prison
site, we noticed that they did not use the internal triage values when
assigning appointment dates. Rather, schedulers prioritized ICRs
according to the oldest recorded submission date. This means that an
ICR submitted two weeks prior could take precedence over an
emergent ICR triaged to be seen within one day. Schedulers follow
this practice unless they are contacted directly by clinical staff
specifically asking that a particular ICR be scheduled sooner. Besides
causing potential delays for inmates in need of medical services, this
practice also negates the efforts of senior nurses who spend time
triaging the ICRs. By contrast, schedulers at the Gunnison prison site
use internal triage values to schedule medical and mental health
appointments for inmates. To prioritize patient care more effectively,
we recommend that Bureau management ensure schedulers are using
internal triage information when scheduling appointments for
healthcare providers.

A Performance Audit of Healthcare in State Prisons (December 2021)

Not All ICRs Are Entered into the Electronic Medical Record
System. Every collected ICR is supposed to be entered in the prison’s
EMR system, word for word, within 24 hours of receipt. After ICRs
are entered into the system, medical staff commonly discard the paper
ICR forms in secure shred bins. To gauge whether staff were entering
ICRs into the EMR system, we collected the contents of shred bins
from three different medical rooms within in the Draper prison
facility. We found a total of 18 ICRs that had not been entered into
the prison’s EMR system. In addition, we found ten ICRs, from two
different locations, that were only partially entered in the EMR
system. We recommend that Bureau management train and supervise
medical personnel to ensure that all ICRs are correctly entered into the
EMR system in their entirety.

All ICRs are to be
entered into the EMR
system within 24 hrs of
receipt. We found 18
discarded ICRs that
had not been entered
and 10 discarded ICRs
that were only partially
entered.

EMTs Are Not Completing
Shift Requirements
EMTs are responsible for ensuring that medical rooms are stocked
with proper medical supplies. There are several medical rooms
throughout the prison that service corresponding inmate housing
units. Therefore, each medical room should be stocked with the
necessary medical supplies for immediate use in an emergency. Each
shift, EMTs are supposed to complete an inventory of all medical
supplies and fill out a daily log to ensure supplies are current and
available. The following items are to be checked daily:
•
•
•
•
•
•
•

Refrigerator temperatures
Jump bags 29 and seal numbers 30
Oxygen tank pressure levels
O2 masks, oral airways, and cannulas31
Insulin medications
Glucometers (every Sunday)
Personal protective equipment

29

A jump bag, or “jump kit,” is the primary trauma bag carried by EMTs and
paramedics. It contains a basic set of emergency supplies and other items.
30
One of the pockets on the jump bag is to be sealed or secured with a zip tie
because it holds syringes and other sharp equipment.
31
Cannulas are used to drain fluid, administer medication, and provide oxygen.

Office of the Utah Legislative Auditor General

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EMTs are not
consistently
completing required
daily inventories of
medical equipment,
which could be
disastrous in the event
of an emergency.

Inventory logs are located in each of the medical rooms and should
be filled out daily. At the Draper prison site, we found multiple
incomplete logs in multiple medical rooms, dating as far back as
January 2021. Furthermore, we found several jump bags that were
missing secure seal tags. These findings are concerning, since a lack of
properly maintained medical supplies could be disastrous in the event
of an emergency. One EMT we spoke with during the audit said that
they bring their own personal bag and keep medical supplies from the
medical room in it, because they do not trust that vital medical
supplies will be available at the facility when needed. We recommend
that Bureau management train and supervise EMTs to ensure that
medical rooms are always stocked with the required medical supplies
and that daily logs are consistently filled out.

Management Needs to Ensure Medications Are
Distributed According to Statute and Standards
We have concerns with using EMTs in a nonemergency setting.
Our medical consultant, who is also the former division director of
Family Health and Preparedness 32 at the Utah Department of Health,
reported:

They [EMTs] do not have patient assessment
education and training beyond emergency situations.
Since the vast majority of medical concerns from the
inmates do not involve the medical emergencies for
which EMTs are trained, they are not appropriately
suited to correctly evaluate these inmates and their
medical concerns.
We have concerns that
EMTs are being used
in nonemergent
situations that may be
beyond their level of
training.

The consultant’s full review can be found in Appendix B of this
report. EMTs have limited clinical training, which focuses heavily on
medical emergencies.
According to the EMS Personnel Licensure Interstate Compact,
which is codified in Utah Code 26-8c-102, an EMT is an individual
licensed with cognitive knowledge and a scope of practice that
corresponds to that level in the National Emergency Medical Services

As division director, our medical consultant oversaw EMT certification and
training requirements.
32

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A Performance Audit of Healthcare in State Prisons (December 2021)

(EMS) Education Standards. Figure 3.2 further explains the National
EMS Education Standards concerning EMTs.
Figure 3.2 Using EMTs to Deliver Medication at Pill Lines and
Perform Face-to-Face Patient Assessments Appears to Exceed
National EMS Education Standards. EMT certification allows
EMTs to operate in an emergency setting. We question whether
regularly delivering medication and conducting nonemergent
patient assessments are within an EMTs’ scope of practice and
level of training.
According to the National EMS Education Standards:

“The primary focus of the Emergency Medical Technician is to
provide basic emergency medical care and transportation for
critical and emergent patients who access the emergency
medical system.”
Source: National EMS Education Standards

Based on our review of the Emergency Medical Services Licensure
Interstate Compact (statute) and the National EMS Education
Standards, we are concerned that the Draper prison facility might be
using EMTs in situations beyond their knowledge and training
capabilities. Our medical consultant agrees. His remarks are found in
Appendix B.
During our interviews and observations at the prisons, an EMT
shared with us that they do not feel adequately trained for some of the
tasks they are asked to perform. For example, the EMT identified
delivering medications at pill lines as a specific task that they feel is
beyond their level of training and scope of practice. We suggest that
the Bureau review its use of EMTs to ensure that they are being used
according to their level of training and scope of practice. In situations
that require the proper dispensing of medications, such as pill lines,
nurses have the education and training to know about medication side
effects (or adverse reactions) and are qualified to conduct patient
assessments.

The Bureau needs to
review its use of EMTs
to ensure they are
being used according
to their level of
training.

In January 2020, NCCHC’s review of the Draper prison facility
expressed concerns that medical staff who administer and deliver
prescription medications were not being trained on the administration
of retained medications or the side effects of medications. The Bureau
responded to NCCHC by stating that all registered nurses (RNs) and

Office of the Utah Legislative Auditor General

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licensed practical nurses (LPNs) at the prison facility had received this
training as part of their orientation and annually at Nursing Skills Day.
We are concerned with the Bureau’s response because, at the Draper
prison, EMTs primarily operate pill lines, not RNs or LPNs.
We found that
Colorado, Montana,
and Wyoming all use
nurses to administer
pills lines and conduct
face-to-face
assessments.

We found that prisons in Colorado, Montana, and Wyoming all
use nurses to administer pill lines and conduct face-to-face assessments
with inmates regarding their ICRs. Likewise, the Gunnison prison
primarily uses nurses to administer pill lines and conduct face-to-face
assessments. While we understand that the Bureau has had a difficult
time recruiting and retaining nurses at the Draper facility,
management needs to be proactive in addressing this problem. One
solution could be for the Bureau to implement an education loan
repayment program for nurses. This program could be used to help
improve recruiting and retention efforts for nurse positions.
We recommend that the Clinical Services Bureau ensure that the
use of EMTs in the prison setting is consistent with state statute and
best practices, and that licensed nurses (or other qualified medical
professionals) are used in situations that require a level of skill and
knowledge beyond what an EMT is certified for.

Management Needs to Better Protect
Personal Health Information
Management needs to improve the protection of inmates’ personal
health information. Additionally, management should ensure that
medical staff return all unused medications to the prison’s pharmacy.
In two different public dumpsters outside the Draper prison site, our
audit team found inmates’ personal health information, along with
hazardous medications that should have been retained and returned to
the pharmacy. Furthermore, management needs to ensure that
biohazard bins are locked and secured.

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A Performance Audit of Healthcare in State Prisons (December 2021)

Management Needs to Ensure That Personal Health
Information Is Protected and Unused Medications Are Secure
Pill packets (blister packs) with medications used at pill lines
contain personal health information and unused medication.
Medications in pill packets that are stamped “retained” are to be
retained by clinical staff and returned to the pharmacy. These pills, if
unopened, can be reused by the pharmacy. All other pill packets are to
be securely shredded after use. As shown in Figure 3.3, we found pill
packets containing personal health information, patient treatment
sheets, a used syringe (which should have been disposed of in a
biohazard waste container), and unused medications (which should
have been retained and returned to the pharmacy) in two public
dumpsters outside the prison. Medical staff are supposed to return all
unopened pill packets to the pharmacy and shred any identifiable
personal health information.

We found patient
treatment sheets, pill
packets containing
personal health
information, and a
used syringe in two
public dumpsters
outside the prison.

Figure 3.3 Personal Health Information Such as Prescriptions,
Treatment Sheets, and Medication Refill Requests Were Found
in Public Dumpsters Outside the Prison. All prescriptions and
treatment sheets are to be securely shredded, and syringes should
be placed in a biohazard waste container.

Source: Auditor generated

Office of the Utah Legislative Auditor General

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According to statute,
all medical records
should be protected.

According to Utah Code 63G-2-302(1)(b), “The following records
are private: records containing data on individuals describing medical
history, diagnosis, condition, treatment, evaluation, or similar medical
data.” Additionally, the Bureau’s training manual states the following:
A public employee or other person who has lawful
access to any private or controlled record and who
intentionally discloses or provides a copy of a private or
controlled record to any person knowing that such
disclosure is prohibited is guilty of a class B
misdemeanor.
When we first found personal health information discarded in the
dumpsters, we alerted Bureau management. Four weeks later, our
audit team checked the public dumpsters a second time and found
more pill packs containing personal health information and unused
medications, as shown in Figure 3.4.

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A Performance Audit of Healthcare in State Prisons (December 2021)

Figure 3.4 A Second Inspection Found Prescriptions and
Retained Medications in a Public Dumpster Outside the Prison.
All prescription information is to be securely shredded, and all
retained medications are to be returned to the pharmacy.

Four weeks later, we
found more pill
packets containing
personal health
information and
unused medications in
a public dumpster
outside the prison.

Source: Auditor generated

We immediately alerted Bureau management a second time to let
them know that personal health information and medications were still
being discarded.
Management Needs to Ensure
Biohazard Bins Are Secure
Besides checking the public dumpsters for discarded personal
health information, we also inspected the biohazard bins at the Draper
prison site and found that one was unlocked. Bureau management
should ensure that biohazard bins are secure.

Office of the Utah Legislative Auditor General

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Bureau Management Needs to
Follow the Inmate Handbook Fee Schedule
The Bureau charges
for mental health
services, which is not
in line with the inmate
handbook.

Lastly, we found that the Bureau has been charging inmates copays
for mental health services, even though the inmate handbook states
that there is no charge for these services. Between fiscal years 2018
and 2021, 165 charges for mental health services, totaling $825, were
recorded. We were able to document this deficiency by analyzing three
years of copay data. Bureau management needs to review its practice
and ensure inmates are not being charged for mental health services;
conversely, the Bureau could change the inmate handbook to allow for
this practice.

Recommendations
1. We recommend that the Clinical Services Bureau ensure
that the use of emergency medical technicians in the prison
is consistent with state statutes and best practices, and that
licensed nurses (or other qualified medical professionals) are
used in situations that require a level of skill and knowledge
beyond what an EMT is certified for.
2. We recommend that executive management at the Utah
Department of Corrections ensure that personnel in the
Clinical Services Bureau fully comply with required
NCCHC standards.
3. We recommend that the Clinical Services Bureau ensure
compliance with statute regarding the protection of
personal health information.
4. We recommend that the Clinical Services Bureau follow the
inmate handbook regarding copays for mental health
services.

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A Performance Audit of Healthcare in State Prisons (December 2021)

Chapter IV
Administrative Oversight of Medical
Services Needs to Improve
As described in Chapter II of this audit report, the primary reason
for systemic deficiencies in delivering medical services to Utah inmates
is inadequate oversight from multiple levels of personnel. The lack of
oversight from the Clinical Services Bureau (Bureau, or prison
medical) management has affected all levels of healthcare operations,
including program administration. Finances lack controls, as
individual incentive award programs circumvent administrative rules.
There is also a need for increased transparency in funding allocations
and for management to be proactive in creating and reporting
meaningful program performance metrics. We also found that several
of the Bureau’s policies, procedures, and training materials are
outdated.

The lack of oversight
from Bureau
management has
affected all levels of
healthcare operations,
including program
administration.

Individual Incentive Awards
Circumvent Administrative Rule
Bureau management is in violation of Administrative Rule in three
ways. First, nurses’ overtime incentives exceed allowable amounts.
Second, emergency medical technician (EMT) retention incentives
lack proper approval. Finally, incentive programs are not in policy.
This section addresses each of the three Administrative Rule violations
in detail.

Bureau management is
in violation of
Administrative Rule in
three ways. This
section addresses
each of the violations
in detail.

Nurses’ Overtime Incentive
Exceeds Allowable Amount
Over the past six fiscal years (2016 to 2021), there have been
multiple violations of Administrative Rule related to employee
incentive programs. Administrative Rule specifies thresholds for
individual incentive award amounts as follows:

Office of the Utah Legislative Auditor General

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Individual awards may not exceed $4,000 per pay
period and $8,000 in a fiscal year, except when
approved by DHRM and the governor. 33
Without having prior
approval from DHRM
and the governor, the
Bureau exceeded the
award thresholds
specified in rule.

Without having prior approval from the Department of Human
Resource Management (DHRM) and the governor, the Bureau
exceeded award thresholds specified in rule. Bureau management
exceeded the threshold of $8,000 per fiscal year in three separate
instances:
•
•
•

2016: One employee received $12,900 in incentive pay.
2017: One employee received $19,200 in incentive pay.
2021: One employee received $12,000 in incentive pay.

Bureau management also exceeded the threshold of $4,000 per pay
period in one instance:
•

We are not
discouraging the use
of incentive programs;
rather, we are
concerned that Bureau
management is not
compliant with state
rules in administering
incentive award
programs.

2016: One employee received $4,800 in incentive pay in one
pay period.

Bureau management created the nurses’ overtime incentive
program to remain competitive in hiring and retaining nurses. As
mentioned in Chapter III, nurses are critical to the proper delivery of
medical services in Utah prisons. These incentive programs are an
important recruiting and retention tool; however, management has
not ensured adherence to Administrative Rule and policy when
considering such programs. The Bureau currently employs
approximately 205 full-time employees, 61 of whom are nurses, and
has collectively awarded more than $570,000 in incentive awards over
the past five fiscal years (2016 to 2020). To be clear, we are not
discouraging the use of incentive programs. Rather, we are suggesting
that Bureau management demonstrate awareness of applicable rules
and provide careful oversight of implemented incentive programs.
As a result of this audit, Bureau management began working with
DHRM to find a compliant solution for addressing compensation
issues. Subsequently, DHRM now recognizes overtime hours worked
as a shift differential 34 rather than an incentive award. Had Bureau
management been more attentive, these issues may have been resolved
Administrative Rule R477-6-7(1)(b).
A shift differential refers to the extra, or premium pay certain employees receive
for working outside normal business hours.
33
34

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A Performance Audit of Healthcare in State Prisons (December 2021)

more quickly, and Administrative Rule violations could have been
avoided. Another entity that uses shift differentials to compensate its
licensed practical nurses and registered nurses is the Utah State
Hospital. Bureau management could have taken the opportunity to
consult with industry professionals and discuss possible solutions for
addressing issues related to recruiting, retention, and compensation.
EMT Retention Incentive
Lacks Approval Documentation
On February 5, 2016, the then executive director of the Utah
Department of Corrections approved a retention bonus pay program
for EMTs. The proposal was intended to be a “short-term fix” for the
Bureau, which was having difficulty retaining EMTs. The Bureau
proposed to offer EMTs a bonus of $250 per paycheck per month, for
a maximum of 18 months. In other words, an EMT could receive up
to $9,750 in bonus pay over an 18-month period. 35 However, after
the program was approved, it did not receive administrative oversight.
This is another example of Bureau management’s lack of careful
oversight.
The 18-month program that was intended to be a short-term fix
was still awarding retention bonuses four years later, with the last
round of bonuses being distributed to EMTs at the beginning of
September 2020. The lack of oversight resulted in multiple EMTs
exceeding the $9,750 maximum. Although the program had received
initial approval, neither DHRM nor the Bureau was able to locate
approval documentation allowing management to extend the program
beyond the original 18-month timeline. Market-based bonuses (such
as retention bonuses) require DHRM approval, according to
Administrative Rule.

The 18-month program
that was intended to be
a short-term fix was
still awarding retention
bonuses four years
later.

An agency may award a cash bonus as an incentive to
acquire or retain an employee with job skills that are
critical to the state and difficult to recruit in the

35

There are 26 pay periods in one calendar year (12 months); therefore, there are 39
pay periods in an 18-month period (26 + (26/2) = 39). A retention bonus of $250
per paycheck, over an 18-month period, equates to a maximum of $9,750 (39 *
$250 = $9,750).

Office of the Utah Legislative Auditor General

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market. Any market-based bonuses shall be approved
by DHRM. 36
If Bureau management had recognized the need to continue EMT
retention incentives beyond the original 18-month mark (July 2017),
management should have sought DHRM’s approval to extend the
program.
Incentive Programs
Are Not in Policy
Neither the nurses’ overtime incentive program nor the EMT
retention incentive program is mentioned in policy, as required by
Administrative Rule. Administrative Rule plainly states the requirement
for agencies to include incentive awards and bonuses in policy:

Only agencies with written and published incentive
award and bonus policies may reward employees with
incentive awards or bonuses. 37
The human resources
field director at DHRM
noted that, at a
minimum, Bureau
policies should make a
general statement
regarding implemented
individual incentive
award programs and
bonuses.

The human resources field director at DHRM noted that, at a
minimum, the policy should make a general statement that the Bureau
will implement bonuses and awards for the nurses’ overtime incentive
program and the EMT retention incentive program. We recommend
that the Bureau follow all aspects of Administrative Rule when
implementing individual incentive award programs and bonuses.

Management Should Be More
Transparent in Funding Allocations
The Bureau has been
consistently
underspending in
personnel services and
redirecting those funds
to pay outside
providers.

Bureau management should be more transparent in how funding is
allocated. Over the past five fiscal years (2016 to 2020), the Bureau
has been consistently underspending in personnel services 38 and
redirecting those funds to pay outside providers. The cumulative total
of redirected funds from personnel services over the five-year period is
$11.3 million. Conversely, outside provider payments required an
additional $9.6 million to satisfy the deficit. We note this pattern for
Administrative Rule R477-6-7(4).
Administrative Rule R477-6-7(1).
38
Personnel services include regular salaries and wages, paid leave, paid overtime,
incentive awards, state retirement, health insurance, dental insurance, long-term
disability insurance, and other personnel-related expenditures.
36
37

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A Performance Audit of Healthcare in State Prisons (December 2021)

two reasons. First, it provides an opportunity for Bureau management
to be more transparent in how program funds are used. Second, it
provides an opportunity for Bureau management to be proactive in
recruiting and retention efforts.
All positions within the Bureau are funded, whether they are filled
or not. For example, Figure 4.1 shows that in fiscal year 2020, the
Bureau budgeted for 202 full-time positions; however, only 172
positions were filled. This means the Bureau received funding for 30
unfilled positions. While the Bureau is authorized to move money
within the medical services line item, our analysis shows that funds
intended for full-time equivalent (FTE) employees are being
redirected to other sources. For example, the outside provider
payment deficit was largely funded by money intended for personnel
services. We recommend that Bureau management be more
transparent with the Legislature in how program funds are being used.

All positions within the
Bureau are funded,
whether they are filled
or not.

Figure 4.1 Actual FTE Counts Are Significantly Lower Than
Budgeted FTE Counts. The blue area represents budgeted and
funded FTEs, whereas the orange area represents actual FTEs.
Over a five-year period, funded positions exceeded actual positions
by an average of 33 FTEs.

207

214
197

176
161
2016

200

2018

In fiscal year 2020, the
Bureau received
funding for 30 unfilled
positions.

180
172

165
2017

202

2019

2020

■ Budgeted ■ Actual
Source: Governor’s Office of Management and Budget

While data show that recruiting efforts for vacant positions are
ongoing, we believe that proactive and creative solutions, such as an

Office of the Utah Legislative Auditor General

- 43 -

education loan repayment program, may help address the gap in
funding as it relates to actual FTEs.

Performance Metrics Need to
Be Improved and Updated
Performance metrics
do not reflect actual
operations, indicating
inadequate oversight
by Bureau
management.

Because the method of
ICR submission is
manual, there are no
available data to
accurately track the
amount of time from
when the ICR is
submitted to when it is
collected.

Performance metrics do not reflect actual operations, indicating
inadequate oversight by Bureau management. For example, in fiscal
year 2020, the Bureau reported five performance metrics to the
Legislature. Two of the five metrics relate to the percentage of inmate
healthcare requests (ICRs) processed within a specified timeframe.
More specifically, the ICR timeline for addressing and closing requests
for medical services is three business days. While interviewing Bureau
staff, we found that nurses, EMTs, schedulers, and providers had never
heard of this performance metric. Additionally, staff reported that the
metric is unreasonable, stating that addressing and closing ICRs
within three business days is not feasible. In addition to the lack of
staff alignment regarding performance measures, we also question the
parameters used to generate this metric, how it is being calculated, and
how it is reported to the Legislature.
Figure 4.2 illustrates how ICR response timelines are calculated.
While ICRs can be submitted in numerous ways, the most common
way is to fill out a request form. When an inmate submits an ICR, the
written request is placed in a secure collection box. Because this
method of submission is manual, there are no available data to
accurately track the amount of time from when the ICR form is
submitted to when it is collected (see step 1 in Figure 4.2). Once the
ICR form is collected by medical staff, it is entered in the prison’s
electronic medical record (EMR) system. After the request is entered
in the EMR system, it is given an electronic time stamp, which
includes the date the request was recorded (see step 2 in Figure 4.2).
Once an inmate sees a provider or receives medication, or the request
is resolved in some other way, the ICR is considered “closed” (see step
3 in Figure 4.2).
When Calculating the ICR Response Timeline, the Utah
Department of Corrections Uses a Generic Calculation, Making
the Metric Appear More Favorable. The amount of time between
receiving an ICR and closing it is referred to as the ICR response
timeline. Rather than calculating the percentage of ICRs addressed

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A Performance Audit of Healthcare in State Prisons (December 2021)

and closed within three business days (the correct response timeline
calculation in Figure 4.2), the Utah Department of Corrections
(UDC) changed the number of business days by subtracting one from
the total (the incorrect response time calculation in Figure 4.2). In
other words, an ICR that actually took four business days to address
and close is represented in the data as three business days (4 – 1 = 3).
Therefore, a four-business day response time is counted as meeting the
three-business day metric and is reported as such. We believe that
calculating and reporting the metric in this way is incorrect and
misleading.

UDC changed the data
when calculating the
ICR response timeline.

Figure 4.2 ICR Data Reported to the Legislature Are Incorrect.
UDC accounts for the unknown window of time in Step 1 by
subtracting one day from the ICR response timeline. We believe
that calculating and reporting the metric in this way is incorrect and
misleading.

UM

ICR Submitted

I

UW

1c R Collect ed and Reco rded j

UM

1CRClosed

I

Uii

Resu lt s Reported

I

■
♦■111;·,► ◄♦·Hddi·l·l:iii&MEIG¥%·@Miiil¥N@i·-◄··ild:liiii%%611F
.,.Mi-1► <,,-iiill····lii·l·l:liiiiii·lii·iiii···E@l·is)-tl:li·iiiiilf§ffEiifi
* UDC acco unts for the un know n t ime in Step 1 by subt racti ng 1 day from t he ICR response timeli ne (Step 3 close date - Step 2 recorde d

da te}. Howeve r, using a ge neric calculat ion as an all-encomp ass ing solution for an unknown t imeframe creates a flawed metric th at gene rates
result s that appear to be more favora ble tha n they actually are.

Source: Auditor generated

Figure 4.3 shows the variation between the correct and incorrect
calculations of this metric. On average, the two calculations differ by
about 12 percentage points.

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Figure 4.3 The Current Method of Calculating the ICR
Response Timeline Is Misleading. The blue line represents the
correct method of calculating the ICR response timeline, whereas
the orange line represents the incorrect method. The Legislature is
being told that a higher percentage of ICRs are addressed and
closed within three-business days than what is actually occurring.
For example, the orange line incorrectly shows that in June 2020,
nearly two-thirds (65 percent) of ICRs were addressed and closed
within three business days.
80%
70%

Using the correct
method of calculation,
we recreated the
metric and found that
the data did not
represent what was
being reported to the
Legislature.

60%
50%
40%
30%
20%
10%
0%

Correct ICR Timeline Calculation

Incorrect ICR Timeline Calculation

Source: Utah Department of Corrections and auditor analysis
* The parameters used to generate this metric exclude 15 percent of usable ICR data.

This performance
metric does not reflect
actual program
operations.

Using the correct method of calculation, we recreated the metric
(blue line) and found that the data did not represent what was being
reported to the Legislature (orange line). Furthermore, this
performance metric does not reflect actual program operations.
Bureau management noted that the target ICR response timeline is 15
days, not three business days. 39 Therefore, we recommend that the
Bureau create meaningful performance metrics that adequately reflect
program activity, and clearly communicate these metrics to all Bureau
staff.

Chapter III of this audit report describes the ICR process in greater detail and
highlights our concerns with these internal practices.
39

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A Performance Audit of Healthcare in State Prisons (December 2021)

Policies, Procedures, and Training
Materials Are Outdated
It is critical that Bureau management regularly review policies,
procedures, and training materials for the proper administration of
inmate healthcare. A regular review ensures the safety and protection
of both medical staff and inmates. There are several internal policies
and procedures that govern medical services at both prison sites.
Additionally, the National Commission on Correctional Health Care
(NCCHC) requires healthcare policies and procedures to be reviewed
at least annually. Bureau management provided us with signed cover
sheets indicating that nursing and EMT protocols had been reviewed
over the last two years; however, upon further examination, we found
that the documents in question were not updated. For example, the
review dates listed throughout the original documents had outdated
coversheets and had not been adjusted to reflect the most current date
calling into question the level of review completed. The following
bullet points summarize the review dates listed on several of the
Bureau’s policies, procedures, and training materials.
•

The last formal approval of the prison’s drug
formulary 40 was in January 2019. Conversely, the state’s
Public Employees Health Program reports updating its
formulary for generic drugs monthly and newly
approved drugs quarterly. Frequent updates ensure that
the most current clinical guidelines are being used and
may result in lower cost-sharing options.

•

Nursing protocols were last updated seven years ago, in
November 2014.

•

EMT orientation materials include training sections that
have not been updated since July 2008, more than 13
years ago.

NCCHC requires
healthcare policies and
procedures to be
reviewed at least
annually.

The review dates listed
on several of the
Bureau’s policies,
procedures, and
training manuals do
not meet NCCHC’s
annual review
threshold.

A formulary is a list of brand name and generic prescription drugs that are
approved to be prescribed by a particular health insurance policy.
40

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Policies and
procedures from
surrounding states had
review dates within the
last year and were
updated as necessary.

We also reviewed policies and procedures from surrounding states
such as Arizona and Nevada. The policies and procedures from these
states had review dates within the last year and were updated as
necessary. To better protect medical staff and ensure that inmates are
receiving consistent and appropriate care, we recommend that Bureau
management review and update all policies, procedures, and training
materials.

Recommendations
1. We recommend that the Clinical Services Bureau follow
Utah Administrative Rule when implementing incentive
programs.
2. We recommend that the Clinical Services Bureau be
transparent with the Legislature in how program funds are
being used.
3. We recommend that the Clinical Services Bureau create
meaningful performance metrics that reflect program
activity.
4. We recommend that the Clinical Services Bureau ensure
that its formulary, procedures, policies, and training
materials are all up to date.

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A Performance Audit of Healthcare in State Prisons (December 2021)

Appendices

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A Performance Audit of Healthcare in State Prisons (December 2021)

Appendix A

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A Performance Audit of Healthcare in State Prisons (December 2021)

Recommendations
This report made the following 16 recommendations. The number convention assigned to each
recommendation consists of its chapter followed by a period and recommendation number
within that chapter.
Recommendation 2.1

We recommend that the executive director of the Utah Department of Corrections ensure that
all recommendations in this audit are adequately implemented.
Recommendation 2.2

We also recommend that the executive director of the Utah Department of Corrections launch
an internal review to determine if additional changes not addressed in this report are needed
regarding operations and/or staff.
Recommendation 2.3

We recommend that the Clinical Services Bureau ensure that providers and other medical staff
define the term “monitor” in patient charts with specific parameters on a case-by-case basis.
Recommendation 2.4

We recommend that the Clinical Services Bureau increase oversight to ensure that appropriate
case-by-case patient follow-up procedures are being completed.
Recommendation 2.5

We recommend that the Clinical Services Bureau ensure that all patients have access to:
a. Appropriate and timely clinical judgments rendered by a qualified healthcare
professional.
b. Correct treatments and medications for corresponding diagnoses.
Recommendation 2.6

We recommend that the Clinical Services Bureau follow internal policies and professionally
recognized standards regarding the administration of insulin and the oversight of inmates with
diabetes.
Recommendation 2.7

We recommend that the Clinical Services Bureau create policies and procedures to effectively
manage nutrition and medical care for diabetic patients during disruptions or delays to the
normal schedule.

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Recommendation 2.8

We recommend that the Clinical Services Bureau develop policies, where appropriate, that help
the organization be more compliant with CDC standards regarding medical issues such as the
COVID-19 pandemic.
Recommendation 3.1

We recommend that the Clinical Services Bureau ensure that the use of emergency medical
technicians in the prison is consistent with state statutes and best practices, and that licensed
nurses (or other qualified medical professionals) are used in situations that require a level of skill
and knowledge beyond what an EMT is certified for.
Recommendation 3.2

We recommend that executive management at the Utah Department of Corrections ensure that
personnel in the Clinical Services Bureau fully comply with required NCCHC standards.
Recommendation 3.3

We recommend that the Clinical Services Bureau ensure compliance with statute regarding the
protection of personal health information.
Recommendation 3.4

We recommend that the Clinical Services Bureau follow the inmate handbook regarding copays
for mental health services.
Recommendation 4.1

We recommend that the Clinical Services Bureau follow Utah Administrative Rule when
implementing incentive programs.
Recommendation 4.2

We recommend that the Clinical Services Bureau be transparent with the Legislature in how
program funds are being used.
Recommendation 4.3

We recommend that the Clinical Services Bureau create meaningful performance metrics that
reflect program activity.
Recommendation 4.4

We recommend that the Clinical Services Bureau ensure that its formulary, procedures, policies,
and training materials are all up to date.

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A Performance Audit of Healthcare in State Prisons (December 2021)

Appendix B

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A Performance Audit of Healthcare in State Prisons (December 2021)

Medical Consultant Report for the Office of the Legislative Auditor General for Utah
Introduction: I am a board-certified family physician with over 45 years of clinical experience
in a variety of settings. I am familiar with quality standards of care and have performed many
reviews and audits of clinical care. My review was primarily focused on the review of the charts
of inmates that were selected by the audit team. I was also able to participate in a number of the
interviews with clinical staff.
Setting: This is a review of the quality of care being provided to inmates in the state’s prison
system. My focus was on the Draper facility but did include a small number of chart reviews for
inmates in the Gunnison facility. The Draper facility houses nearly 2,800 inmates. There is
clinical staff for mental health care which I did not review. On the medical care side, there are
three physicians and eight physician assistants who comprise the provider team. They are
supported by 38 registered nurses (12 are considered to be senior nurses), and 22 emergency
medical technicians who are referred to as the “med techs.” The medical director, a boardcertified family physician, is primarily located at the Gunnison facility, but usually comes to
Draper once a week.
Components of Quality of Care: There are many factors that influence the quality of care that a
patient receives, and I will focus on a few of the most important factors and discuss each factor
as it impacts the Draper prison facility.
• The adequacy of the clinical staff including the number of providers and the training and
experience of those providers.
• The adequacy of the support staff for the providers including the number of support staff
and the training/qualifications of that staff.
• The adequacy of funding to support adequate personnel and adequate treatments that are
indicated for the patients being served.
• The adequacy of the facilities in which patients are treated. For the Draper facility this
would include the clinic space and the infirmary space. Facility adequacy is a function of
the physical space, the equipment available, and the support staff available.
• The adequacy of the medical record system including the ability to quickly retrieve
patient information and have it displayed in a functional fashion.
• The adequacy and availability and utilization of treatment protocols for serious
conditions (can also include common conditions) that would assist all providers and
support staff in providing consistent, quality care.
• The presence of an active, internal quality review program that can identify and address
issues sooner than later and implement appropriate corrective actions.
• Finally, the adequacy of the overall functioning of the health care system, i.e. how well
all these parts are working together to provide quality care.
The Patient Population: As noted above, this facility houses nearly 2,800 inmates. Based upon
the review of 76 patient charts, it is clear that this is a very sick population as compared with an
“outside” population of patients. Most of the inmates had problem lists that documented between
6 and 20 medical problems which included 4–6 serious, chronic health care problems, including:
diabetes mellitus (types I and II), hypertension, hyperlipidemia, chronic obstructive pulmonary
disease, hepatitis (primarily type C), congestive heart failure, cancer, and serious infections

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(particularly COVID19 over the past 18 months). These medical issues are further complicated
by these inmates’ mental health concerns. From my review, it would appear that approximately
50% of the inmates suffered from significant mental illness.
Quality of Care Issues:
1. Provider Staffing
A. I believe that the number of medical providers is generally adequate to care for this
population as long as there are no extenuating clinical circumstances. Recognizing
that staffing must be adequate enough to cover provider absences during leave or sick
time off.
i. I was impressed by the commitment to provide quality care by the providers
that I interviewed. These are well trained clinicians who want to do their very
best in caring for this challenging population.
B. The increased workload imposed upon the clinical staff by the COVID19 pandemic
as it impacted the prison population, made the number of providers inadequate to
maintain a high quality of clinical care for all patients, but especially for the
COVID19 patients.
C. Provider recruitment, for all levels of health professionals, has always been a
challenge for this facility (and this is true of most prisons and jails in our nation), and
I will address this issue in my recommendations.
2. Support Staff
A. I am concerned with the use of emergency medical technicians (basic) as the frontline clinical staff who interact with the inmates on a daily basis.
i. Emergency Medical Technicians (EMTs) have very limited clinical training
which is focused on responding to medical emergencies. They do not have
patient assessment education and training beyond those emergency situations.
Since the vast majority of medical concerns from the inmates do not involve
the medical emergencies for which EMTs are trained, they are not
appropriately suited to correctly evaluate these inmates and their medical
concerns.
ii. According to state law, EMTs are only permitted to work in an emergency
health care setting, which is appropriate to their training, such as on an
ambulance or in an emergency room.
iii. While EMTs may administer medications on the order of a licensed health
care provider, the vast majority of the medications that they are charged with
administering would not have been included in their EMT training. Lack of
familiarity with a medication is concerning because the EMT would not know
what the medication is treating, and the expected outcome and they would not
be familiar with common side effects or adverse reactions. EMTs are assigned
to the “pill lines” where they distribute all the medications that have been
ordered for each inmate. This role is not really appropriate for the kind of
training that an EMT receives.
iv. In contrast, the Gunnison facility uses nurses for the “med tech” role. This
role is legally within the scope of practice of a registered nurse because they
have received education and training in overall patient assessment.

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A Performance Audit of Healthcare in State Prisons (December 2021)

v. There is not adequate supervision of the EMTs/Med techs by the nursing staff
in the Draper facility. Adequate supervision could partially (but not
completely) overcome the limited training of the EMTs/Med techs.
vi. Clinical leadership for the prison states that they cannot afford, nor can they
recruit, the number of nurses that would be needed to replace the EMTs. I
will also address this issue in my recommendations.
3. Funding
A. There are significant funding issues related to the recruitment and retention of
provider staff and nursing staff that I will address in my recommendations.
B. The COVID19 pandemic exposed additional funding concerns regarding adequate
staffing and adequate treatment of this disease.
4. Facilities
A. I did not inspect the Draper prison’s clinical facilities as part of this audit. I have
however, for a past audit, toured those clinical facilities. While this facility is old
and due for replacement, the facilities can be considered adequate even though the
spaces are limited in size and the infirmary is also small. From my prior visit, I
felt that the clinical facilities had adequate equipment and generally had adequate
support staff.
5. Medical Record System
A. The state prison uses an electronic health record (EHR) known as M-Track. This
is a very outdated, slow and complex system that does not have the ability to
display all of a patient’s information on a single screen (e.g., encounters, lab
results, consultation reports, treatments) so one has to close out one view (e.g.
encounters) in order to see another view (e.g. lab results). This system is
inefficient and therefore wastes provider time. Further, the limited availability of
information can easily lead to diagnostic and/or treatment errors.
B. When the prison moves into their new facility, I have been told that they will be
getting a new EHR, which is long overdue. I am not familiar with the brand of
EHR that has been selected so I can’t comment on its adequacy. However, I was
very disappointed to learn that the providers have had minimal input on the
selection of this new record system. Since providers are the key users of an
electronic health record, it would be highly appropriate for them to have been
consulted and allowed to “test drive” the EHRs under consideration prior to a
final purchase decision.
6. Treatment Protocols
A. My concern is for a protocol relating to the care of COVID19 positive patients.
The medical director stated that they have a protocol, and a copy was to be sent to
auditor staff. Based upon our interview with the medical director, I was concerned
that financial issues were preventing inmates from being treated to the community
standard of care. I have the following concerns:
i. Patients testing positive for COVID19 need to be isolated and
quarantined, and this was reportedly being done, but I was not able to

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document that. Patients who test positive and are high risk need to be
closely monitored, at a minimum, daily checking of their vital signs,
especially their temperature and their oxygen saturation. When there is
any evidence of a patient’s condition worsening, those checks should
occur more frequently, e.g. 2-4 times/day.
a. For several patients who were diagnosed with COVID19, the provider
would request “monitoring” or “increased monitoring” but those orders
did not contain any specificity such as requiring the checks noted above.
7. Quality Review Program
A. The prison’s clinical program does have an active quality review program. Audit
staff has received copies of agendas and minutes for some of their meetings. I
have not reviewed any of those documents and have not been able to attend one of
their meetings in order to comment on the adequacy of their process.
8. Systems Issues (in addition to all those issues already presented)
A. Inmates report medical concerns/requests by filling out an Inmate Care Request
(ICR) form and giving it to the Med Tech who is doing “pill line” in their housing
unit. Unfortunately, the med techs have neither the required skills nor the time to
carefully assess these concerns in order to determine their potential urgency. The
Draper facility averages 290 ICRs per day!
B. ICRs are to be triaged by a registered nurse who makes a decision on what action
needs to be taken: schedule an emergent clinic visit (could take from 1 day to 2
weeks), schedule a routine clinic visit (could take 1-2 months), or in some cases
just a medication refill is required. For the most part, this triage process works
adequately when we can assume that the written complaint adequately reflects the
problem since neither the patient, nor the med tech have the skills needed to
adequately assess many types of complaints. ICRs have to be “closed” by
someone. Ideally, this happens after an appropriate visit, or after the medication
was re-ordered, etc. However, there were occasions when an ICR was “closed”
without the patient ever being evaluated. I considered some of these closed but
not evaluated ICRs to be concerning because of a needed medication or the
complaint was medically concerning.
C. The next step occurs when the triage nurse sends the ICR to the clinic schedulers.
I did not personally explore this stage, but audit staff has done so. Once again,
there is a concern with how these appointments are prioritized.
9. Chart Reviews: I reviewed 76 charts as selected by the legislative auditors.
A. A number of charts were for COVID19 positive patients, including several who
died from that disease. In some of the charts, the care provided was appropriate
even when the ultimate outcome was death. This is true of patients in community
settings. However, there were some charts where the patient’s monitoring was not
performed as needed. One patient did not have a follow-up check for 4 days; at
which time he was much sicker. Another patient was found to have a below
normal oxygen saturation, but no action was taken until he was much sicker two
days later.

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A Performance Audit of Healthcare in State Prisons (December 2021)

B. I have concerns about the care of diabetic patients. There does not appear to be a
strong emphasis on controlling this disease in order to prevent the predictable
complications. Inmates are allowed to have abnormal blood sugar levels and
abnormal hemoglobin A1c levels without any special action being taken. In
addition, the administration of insulin (especially short acting types) is not
routinely tied to when the inmate has access to food. When using regular insulin,
a patient needs to eat within 30 minutes of administration. If the insulin is given
more than 30 minutes after the inmate has eaten, the blood sugar level will
already be abnormally high before the insulin can take effect.

10. Summary: My review of medical cases at the Utah Department of Corrections found
some significant concerns that need to be immediately addressed. The concerns I
identified are systemic in nature and resulted in some inmates receiving either insufficient
or inappropriate care. Thankfully, most inmates in my review did receive sufficient care,
but I am concerned that if systemic weaknesses are not corrected concerns in care could
multiply. Some of the concerns I identified included, but are not limited to, unreasonable
delays and inconsistencies in critical medications, failure to follow a pharmaceutical
regimen prescribed by a specialist, inmate care requests that had not been acted upon or
completed, unreasonable delays in appropriate exam and treatment plans, and failure to
follow standards in statute (e.g., using EMT’s in a manner outside of their training).
Finally, the degree of insufficient and/or inappropriate care that some inmates received
raises concerns about the overall operations and management of the prison medical
system.
11. Recommendations
A. I believe that the state legislature needs to fund a loan repayment program
specifically for the state prison system. This program should be open to health
care providers including physicians, physician assistants, nurse practitioners,
registered nurses, dentists, and pharmacists. I would recommend that such a
program be administered by the Utah Department of Health (UDOH) which has
experience with these types of programs. The loan repayment amounts and
duration of eligibility for this funding should be determined through discussions
between the prison’s clinical leadership team and the UDOH staff who will
administer the program and write the rules to implement such a program.
B. The legislature needs to fund salary schedules for health care providers in the
prison system at a competitive level.
C. The legislature needs to fully fund the pharmaceutical needs at the state prison.
This requires that leadership in the Department of Corrections carefully prepare a
justifiable budget to present to the Governor’s Office and state legislature that
reflects these costs.
D. The prison’s health care providers need to be given early access to and training on
the new electronic health record system. This needs to be done well in advance of
its actual implementation so that there is a smooth transition from the old system.
E. I support the development of treatment protocols for chronic conditions and other,
frequently encountered conditions. These protocols will serve as orientation
material for new providers and as the basis for quality review of the care being

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given for those conditions. However, treatment protocols should reflect the
current standard of care in the community at large. If there are reasons why this is
not possible, it should be explained within the protocol.
F. The current system in which ICRs go to EMTs, and then to triage nurses, and then
to schedulers, and finally result in some action or a visit with a provider, needs to
be thoroughly re-evaluated. As noted earlier, the Draper facility needs to begin a
process to phase out the use of EMTs as med techs and replace them with RNs.
By having competitive salaries and a loan repayment opportunity, this should be
feasible. There also needs to be ongoing review of the actions of the schedulers to
assure that patient needs are being met on a timely basis. This type of oversight
can be done by the senior registered nurses on staff.

Respectfully submitted on October 4, 2021.
Marc E. Babitz, M.D.

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CURRICULUM VITAE
MARC E. BABITZ, M.D.

EDUCATION
High School:

Hiram W. Johnson Senior High School
Sacramento, California
Fall 1962-Spring 1965
Undergraduate: University of California, Davis Campus
Davis, California
Fall 1965-Spring 1968
Medical School: University of California, San Francisco
School of Medicine
Fall 1968-Spring 1972
Degrees received: B.S. - Medical Sciences, Spring 1969
M.D. - Spring 1972
Internship:

Community Hospital of Sonoma County
Family Practice Residency Program
Santa Rosa, California
July 1, 1972-June 30, 1973

Residency:

Community Hospital of Sonoma County
Family Practice Residency Program
Santa Rosa, California
July 1, 1973-December 31, 1975
Note: the completion of my residency training requirements was
obtained in conjunction with my Public Health Service, as noted
below, on June 30, 1976)

Other:

Contemporary Executive Development Program
School of Government and Business Administration
George Washington University
Washington, D.C.
January 29 - March 8, 1985
(Awarded 9.0 CEUs for course)
Mass Casualty Care Services - 1984
Andrews Air Force Base, Maryland
June 24-29, 1984
Fort A.P. Hill, Virginia
September 10-15, 1984
Advanced Trauma Life Support Certification
Uniformed Services University of Health Sciences
Bethesda, Maryland
April 24-26, 1985

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Advanced Cardiac Life Support Certification
National Institute of Health
Bethesda, Maryland
May 1986
Advanced Life Support in Obstetrics
University of Utah
Salt Lake City, Utah
August 1995
BOARD CERTIFICATION
Diplomate of the American Board of Family Practice, 1976 to 2014. Passed the recertification examinations given in July 1982, July 1988, July 1994, July 2000, July 2007
and November 2014.
LICENSURE
State of California - Certificate No. G 025179, issued 1973.
(inactive status effective 1984)
District of Columbia - License No. 14955, issued 12-31-84.
(inactive status effective 1989)
State of Colorado - License No. 28886, issued 07-07-88.
DEA number BB1691434, non-practicing license, expires 05-31-99.
State of Utah - License No. 94-284584-1205, issued 12-28-94 (expires 1/31/2022).
Controlled Substance License No. 94-284584-9915.
DEA number - BB1691434, expires 07-31-21.
EMPLOYMENT HISTORY (since residency)
Clinic provider, Salt Lake Health Clinic of Utah (operated by the State of Utah, Dept. of
Health). Working as a family physician to maintain my continuity practice from my years as a
full-time employee, and to support the clinic as patient demands dictate. May 2021 – present.
Retired from full-time employment with the State of Utah on March 1, 2021.
Final Position before full-time retirement (under a new Director)
Director, Division of Family Health and Preparedness, Utah Department of Health, August
2020 – March 2021. Continued to serve as the Medical Director for the Health Clinics of Utah
and Family Dental Plan (the Ogden and Provo medical clinics were closed on August 15th and
the Ogden dental clinic closed on August 31st). The Salt Lake Dental clinic closed on October
31st. The dental clinics were successfully transferred to the University of Utah’s School of
Dentistry. The Salt Lake medical clinic remains open. Responsible for oversight of four Bureaus:
Bureau of Emergency Medical Services and Preparedness; Bureau of Licensing and
Certification; Bureau of Maternal and Child Health; and Children with Special Health Care
Needs. Provide oversight and consultation for the Department’s Center for Medical Cannabis
and the Background Criminal Screening program.

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A Performance Audit of Healthcare in State Prisons (December 2021)

Previous
Deputy Director, Utah Department of Health and Medical Director, Health Clinics of Utah;
October 2016 – August 2020. Primary responsibility is to support the Director in whatever areas
are needed (e.g., national accreditation, legislation, implementation of programs for pharmacist
dispensing of Naloxone and hormonal contraceptives, personnel, collaboration with local health
officers/departments). A major focus is on supporting the Public Health programs in the
Divisions of Disease Control and Prevention and Family Health and Preparedness. Also,
supervising the Office of American Indian/Alaska Native Health Affairs, the Office of Health
Disparities Reduction, and our newest program for Medical Cannabis. Oversight of our Center
for Medical Cannabis includes review and approval of CME programs; coordination of, and
support for, the Cannabinoid Product Board; serving as Chair of the Compassionate Use Board;
and ongoing consultation with Center staff, as needed. Health Clinics of Utah consists of 3
medical clinics (Ogden, Salt Lake and Provo), 2 fixed dental clinics (Ogden and Salt Lake) and a
mobile dental clinic. This department has over 1,000 employees and an annual budget of
approximately $3 billion (most of which is for the state Medicaid program whose director is a
co-deputy director for the department).
Director, Division of Family Health and Preparedness, Utah Department of Health,
September 2009 – October 2016. Also, serving as the Medical Director for the Health Clinics of
Utah, Salt Lake Clinic, May 2011 – present. Responsible for oversight of: the Bureau of Primary
Care; the Bureau of Emergency Medical Services and Preparedness; the Bureau of Child
Development; the Bureau of Health Facility Licensing, Certification and Resident Assessment;
the Bureau of Maternal and Child Health; and the Bureau for Children with Special Health Care
Needs. This Division has over 300 full-time employees and an annual budget of over
$130,000,000. Since July 1, 2011, serving as Medical Director for our Salt Lake Clinic,
including supervising 2 FT PAs, and providing patient care.
Director, Division of Health Systems Improvement, Utah Department of Health, May 1,
2005 – August 2009 (part-time through June 2008, full-time as of July 2008). Responsible for
oversight of: the Office of Primary Care and Rural Health; the Bureau of Emergency Medical
Services and Preparedness; the Bureau of Child Care Licensing; the Bureau of Health Facility
Licensing, Certification and Resident Assessment; the Bureau of Clinical Services (the state’s
medical and dental clinics for Medicaid patients); the American Indian/Alaska Native Health
Initiative; and, the state’s Patient Safety Initiative.
Professor (Clinical) and Director of Student Programs in Family Medicine, Department of
Family and Preventive Medicine, University of Utah School of Medicine, December 1994 – June
2008 (Associate Professor 12/’94 – 6/’04). Responsible for the administration and oversight of
the Department’s medical student programs (pre-doc director), including the maintenance and
expansion of the preceptor network, advisor to the Family Medicine Interest Group, director of
the senior Honors/Career Track program, and advisor/mentor for students interested in family
medicine careers. I served as the coursemaster for the “Social Medicine” course (1st and 2nd
years), Family Medicine Clerkship (3rd year) and the Pubic/Community Project course (4th year).
Also served as the Principal Investigator for the Utah Area Health Education Center’s federal
grant (formerly served as the Senior Associate Director), instructed in the Physician Assistant

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(PA) program and precepted FP residents. Other teaching responsibilities included the “Cultural
Competence Mutual Respect” courses established by the Vice-President’s office, having served
as a small group facilitator for the “Ethics” course taught annually to senior medical students. I
have also taught in the College of Nursing’s Advanced Practice Nursing (NP) program and
precepted NP students.
Uniformed Service
United States Public Health Service: On active duty from January 1, 1975 to December
31,1994. Assimilated into the Regular Corps on May 21, 1990 (permanent grade O-5, effective
July 1, 1991). Retirement Rank: Captain, O-6.
Duty Stations:

Region VIII, PHS - Regional Clinical Coordinator
Denver, Colorado
June 1, 1987 - November 18, 1994
Responsible for clinical oversight of federal programs assisting medically
underserved populations in six states (CO, UT, WY, MT, SD, ND), including the
National Health Service Corps, the community and migrant health center programs and
the health care for the homeless program. Duties included consultation, education and
training, and grant oversight.
NHSC Central Office - Chief Medical Officer
Rockville, Maryland
February 27, 1984 - June 1, 1987
Served as the lead physician representing over 3,000 NHSC physician assignees
plus other clinicians serving in Health Professions Shortage Areas throughout the
nation. Responsible for the development and implementation of national policy
regarding the recruitment, selection, placement, support, and retention of these providers.
NHSC Field Station - Russian River Health Center
Guerneville, California
January 1, 1975 - February 16, 1984
Served as a rural family physician providing a full range of primary care services,
including inpatient care and perinatal care in a medically underserved area. Also, served as the
center’s medical director for seven years and as the center’s administrator for five years.
Accomplishments included the recruitment of additional providers to the site, building of an
expanded, modern clinical facility, development of community linkages and establishment of
strong teaching linkages with health professions schools and residency programs.
HONORS / AWARDS
Recipient of the "Gold-Headed Cane" award upon graduation from medical school on June
10, 1972.
Recipient of the "Achievement Medal" for outstanding service to the United States Public
Health Service - 1980.

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Recipient of a Resolution of the Board of Supervisors of the County of Sonoma, State of
California which proclaims a tribute to Marc Babitz, M.D. for exemplary service to Sonoma
County - February 15, 1984.
Fellow of the American Academy of Family Physicians; awarded in Kansas City, Missouri;
October 1984.
Recipient of the "Public Health Service Citation" for successfully directing the funding and
construction of a new health center facility for the Russian River Health Center, Inc. December 3, 1984.
Recipient of the "Commendation Medal" of the United States Public Health Service for nine
years of excellent service at the Russian River Health Center and to the Guerneville, CA.
community - December 3, 1984.
Recipient of the "Unit Commendation" of the United States Public Health Service for full
participation in the Clearing-Staging Unit (Disaster Medical Assistance Team II) of the
Health Resources and Services Administration - December 4, 1984.
Recipient of the "Outstanding Service Medal" of the United States Public Health Service for
leadership in continuing medical education accreditation for professionals in the National
Health Service Corps - April 15, 1987.
Recipient of the "Commander's Award" of the National Disaster Medical System for
exceptional contributions to the Public Health Service - Rockville, Clearing-Staging Unit,
serving as Deputy Commander from January 1986 through May 1987.
Recipient of the "Unit Commendation" of the United States Public Health Service from
Surgeon General C. Everett Koop for participation on the Training, Awards and Recognition
Workgroup of the Surgeon General's Revitalization Task Force - March 10, 1988.
Recipient of the "Unit Commendation" of the United States Public Health Service from
Surgeon General C. Everett Koop for participation in the development of the prototype
National Disaster Medical System/ PHS Clearing Staging Unit - April 21, 1988.
Recipient of the "National Emergency Preparedness Service Ribbon" of the United States
Public Health Service from Captain Richard J. Bertin for contributions in establishing the
Rockville Disaster Medical Assistance Team - May 11, 1990.
Recipient of the "Unit Commendation" of the United States Public Health Service from
Assistant Surgeon General Robert Harmon for the development and implementation of a
series of multi-regional training programs - May 22, 1990.
Recipient of the "USPHS Director's Award" from Dr. Don Weaver, Director of the National
Health Service Corps, for exhibiting leadership, creativity, and ingenuity in the development
of recruitment materials - January 17, 1991.

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Recipient of a "U.S. Department of Health and Human Services Certificate of Appreciation"
from Jane Artist, Regional Director, HHS, Region VIII, for my efforts with the PHS Health
Promotion Program, "Live Life Litely" - January 17, 1991.
Recipient of a "U.S. Department of Health and Human Services Certificate" from Jane Artist,
Regional Director, HHS, Region VIII, and Schuyler J. Baab, Deputy Under Secretary for
Intergovernmental Affairs, DHHS, in recognition and appreciation of my outstanding
contribution to our National Breast Cancer Awareness Month Activities - January 17, 1991.
Recipient of the "Outstanding Service Medal" of the United States Public Health Service for
initiative and outstanding clinical leadership in PHS primary care programs during a period
which required creative approaches to physician recruitment and retention activities to assure
services to medically underserved populations - February 15, 1991.
Recipient of the “Recognition and Appreciation” Award of the U.S. Public Health Service
Recruitment Program - June 17, 1991.
Recipient of the National Health Service Corps' Director's Award for "continual dedication,
professional excellence and outstanding contributions to the mission of the National Health
Service Corps" - March 1993.
Recipient of the Recognition Award from the Administrator of the Health Resources and
Services Administration for "work as a part of the Hurricane Andrew relief effort" - January
1993.
Recipient of the President's Recognition Award of the Uniformed Services Academy of
Family Physicians for "outstanding contributions made to uniformed Family Practice" March 23, 1993.
Recipient of a Special Recognition Award from the National Migrant Resource Program, on
behalf of migrant health providers in the mid-western U.S., for outstanding contributions to
the improvement of Migrant Health. Presented at the Third Midwest Migrant Stream Forum
October 29, 1993.
Recipient of the Special Assignment Service Ribbon, dated December 1992, from Surgeon
General Antonia Novello in recognition of services provided in the aftermath of Hurricane
Andrew. Presented July 11, 1994.
Recipient of the Crisis Response Service Award, dated December 1992, from Surgeon
General Antonia Novello in recognition of services provided in the aftermath of Hurricane
Andrew. Presented July 11, 1994.
Recipient of the Unit Commendation, dated December 1992, from Surgeon General Antonia
Novello for exemplary performance of duty in the aftermath of Hurricane Andrew. Presented
July 11, 1994.

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Recipient of a Recognition Award from the Department of Family Medicine, University of
Colorado Health Sciences Center for significant contributions, dedication, and loyalty to
Family Medicine. Presented September 21, 1994.
Recipient of a Total Commitment Award from the Community Health Association of
Mountain/Plains States for my long-standing commitment to the clinicians in Region VIII.
Presented at the CHAMPS 9th Annual Primary Care Conference - October 7, 1994.
Recipient of an award from the Mountain/Plains Clinicians Network for “outstanding
contributions and invaluable service in the forging of new models of clinician involvement in
the delivery of primary care services to poor and underserved populations.” Presented at the
CHAMPS/MPCN Annual Primary Care Conference - October 7, 1994.
Recipient of the Meritorious Service Medal from the M. Joycelyn Elders, M.D., Surgeon
General of the Public Health Service for exemplary performance of duty over the course of
my career. Awarded on November 4, 1994.
Recipient of the National Health Service Corps’ Directors Award for outstanding
contributions to the mission of the National Health Service Corps, 1974 - 1994. Presented
upon retirement, on November 18, 1994.
Recipient of a recognition award from the Office of Migrant Health, Bureau of Primary
Health Care, Health Resources and Services Administration, for my “caring commitment to
improving the health of migrant farm workers and their families.” Presented upon retirement,
on November 18, 1994.
First holder of the Thomas Fincher Harry Morton, M.D., Endowed Chair in Family
Medicine, December 19, 1994 – Spring 2000.
Recipient of the Director’s Award from the Bureau of Primary Health Care, U.S. Public
Health Service, for outstanding contributions toward the Bureau’s future direction and
achieving its mission. Awarded on April 24, 1995.
Recipient of the Community Award for 1997 from the Junior League of Salt Lake City, in
recognition of multiple volunteer efforts to improve our community’s health, including
support for the 1996 CARE FAIR, May 13, 1997.
Recipient of the National Health Service Corps Director’s Award “for sustained, exemplary
service in support of clinicians in medically underserved communities, and creativity in
developing Community Oriented Primary Care programs.” Presented by Dr. Donald Weaver,
Assistant Surgeon General; Director, National Health Service Corps; on June 13, 1997.
Recipient of an award from the Junior League of Salt Lake City for my partnership with them
to provide screening physical examinations at their annual C.A.R.E. Fair for underserved
individuals and families, presented November 20, 1999.

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Appointed as a Fellow of the National Consortium on Community-Based Medical Education,
April 14, 2000.
Appointed as a Senior Fellow of the National Consortium on Community-Based Medical
Education, April 9, 2001.
Nominated as the University of Utah School of Medicine’s candidate for the “Humanism in
Medicine Award” from the Association of American Medical Colleges and the Pfizer
Humanities Initiative, November 2002. This award, as the University of Utah’s faculty
recipient, was presented on May 22, 2003.
Nominated for the University of Utah School of Medicine’s Jarcho Teaching Award, which
is the School of Medicine’s most prestigious teaching award, April 2003.
Recipient of the Heather Belsey Award, University of Utah School of Medicine, for
outstanding dedication to the homeless community and leadership to the students of the
University of Utah School of Medicine, 2002 – 2003, presented Fall 2003.
Nominated for the University of Utah School of Medicine’s Jarcho Teaching Award, which
is the School of Medicine’s most prestigious teaching award, April 2005.
Awarded the Thomas Fincher Harry Morton, M.D., Endowed Chair in Family Medicine,
Spring 2005 – Spring 2008.
Recipient of the Legacy of Excellence Award from the Junior League of Salt Lake City, in
recognition of 10 years of volunteer service and leadership for their C.A.R.E. Fair and to the
medically underserved populations in our community, September 17, 2005.
Recipient of the University of Utah School of Medicine’s Leonard W. Jarcho, M.D.
Distinguished Teaching Award, which is the School of Medicine’s most prestigious teaching
award, May 2006.
Recipient of the 2009 Governor’s Award for Excellence in Outstanding Public Service, in
recognition of your extraordinary commitment to excellence in serving the citizens of Utah,
June 4, 2009.
Recipient of a Distinguished Service Award from the Utah Medical Association “for
dedicated service as a member of the UMA Board and Speaker of the House.” September 15,
2017.
Nominated for UMA’s 2020 Doctor of the Year by the Salt Lake County Medical Society.
Was not chosen as the finalist. August 2020.
Recipient of the Utah Medical Association’s 2021 Doctor of the Year. Presented at the
annual House of Delegates meeting in Midway, UT, September 10, 2021.

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Recipient of the Utah Academy of Family Physicians 2021 Family Medicine Champion
Award. Presented at the annual business meeting in Salt Lake City, UT, September17, 2021.
EDUCATIONAL ACTIVITIES (Faculty Appointments)
Adjunct Professor of Pharmacy, College of Pharmacy, University of Utah, Salt Lake City,
UT, 2011 – present.
Adjunct Professor of Nursing, College of Nursing, University of Utah, Salt Lake City, UT,
March 22, 2010 – present.
Professor (Clinical Track) and Director of Student Programs in Family Medicine,
Department of Family and Preventive Medicine, School of Medicine, University of Utah,
Salt Lake City, UT, July 1, 2004 – June 30, 2008.
Associate Professor (Clinical Track) and Director of Student Programs in Family Medicine,
Department of Family and Preventive Medicine, School of Medicine, University of Utah,
Salt Lake City, UT, December 19, 1994 – June 30, 2004. Also, the first holder of the T.H.F.
Morton, MD Endowed Chair in Family Medicine, 1994 - 2000.
Associate Clinical Professor, Department of Family Medicine, School of Medicine,
University of Colorado Health Sciences Center, Denver, CO., December 1, 1992 - November
18, 1994.
Assistant Clinical Professor, Department of Preventive Medicine and Biometrics, School of
Medicine, University of Colorado Health Sciences Center, Denver, CO., March 1, 1992 November 18, 1994.
Assistant Clinical Professor, Department of Family Medicine, School of Medicine,
University of Colorado Health Sciences Center, Denver, CO., August 1, 1987 - November
30, 1992.
Clinical Assistant Professor, Department of Community and Family Medicine, School of
Medicine, Georgetown University, Washington, D.C., February 1, 1985 - April 15, 1987.
Clinical Instructor, Department of Family Practice, School of Medicine, University of
California, Davis, CA., January 1, 1980 - July 1, 1982.
Clinical Teaching Faculty Appointment, Division of Ambulatory and Community Medicine,
Department of Medicine, University of California School of Medicine, San Francisco, CA.,
1978 - 1982.
Assistant Clinical Professor, Division of Family and Community Medicine, School of
Medicine, University of California, San Francisco, CA., September 1, 1982 - February 10,
1984.

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Clinical Instructor in Family, Community, and Preventive Medicine, Stanford University
School of Medicine, Stanford, CA., April 1, 1979 - August 31, 1980.
Preceptor for clinical preceptorships in Family Practice at the Russian River Health Center,
Inc., for medical students and Family Practice residents.
Preceptor for the Family Nurse Practitioner training program, California State College at
Sonoma, Rohnert Park, CA., 1974 - 1982.
Clinical Instructor, Family Practice Residency Program, Community Hospital of Sonoma
County, Santa Rosa, CA., July 1976 - February 1984.
Preceptor for the Primary Care Associate Program, Stanford University, Palo Alto, CA.,
1979 - 1980.
Preceptor for the FNP - PA Training Program, University of California, Davis, CA., 1979 1981.
Supervising Physician for a Family Nurse Practitioner engaged in the Experimental Health
Manpower Prescribing Project (the A.B. 717 project in California). Project was completed on
July 1, 1983.
PROFESSIONAL ACTIVITIES
Summer Preceptee - Medical Student Preceptorship in General Practice, sponsored by the
California Academy of General Practice (now known as the California Academy of Family
Physicians), for two weeks, Summer - 1970.
Member of the Medical School Admissions Committee at the University of California School
of Medicine, San Francisco, Fall 1969 - Spring 1972.
Resident member of the Board of Directors of the California Academy of Family Physicians,
1973 - 1974.
Family Practice Resident representative on the California Health Manpower Policy
Commission, March 1974 - June 1977.
Member of the Board of Directors of the Sonoma County Branch of the American Heart
Association of the Redwood Empire, 1977.
Member of the Board of Directors of the Sonoma County Coordinated Home Health Care
Agency, 1977 - 1980.
Member of the Board of Directors of the Russian River Health Center, Inc., serving as the
Administrator from March 1977 to July 1982, and Medical Director from March 1977 to
August 1983.

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Member of the Board of Medical Quality Assurance, Division of Allied Health Professions,
February 1978 - June 1982. Offices held: Board Vice-President - 1980, Division
Vice-President - 1980, Division President - 1981, Board Vice-President - 1982.
Chairman of the Physician's Assistant Examining Committee of the State of California,
September 1978 - December 1980; and March 1981 - June 1982.
Member, National Health Service Corps, Coordination and Education Program Planning
Committee for the Statewide Area Health Education Center system, northern California,
1979 - 1980.
Member of the Task Force on Physician's Assistants and Nurse Practitioners of the California
Academy of Family Physicians, 1980 - 1981.
Member of the Commission on Health Manpower, California Medical Association, 1981 1984.
Member of the Resident Selection Committee, Family Practice Residency Training Program,
Community Hospital of Sonoma County, Santa Rosa, CA., 1977 - 1981, and 1983.
Member of the District III Medical Quality Review Committee, California Board of Medical
Quality Assurance, 1983 - 1984.
Chairman, Family Practice Department, Community Hospital of Sonoma County, Santa
Rosa, CA., 1983.
Member, Disaster Medical Assistance Team, HRSA Clearing-Staging Unit, Rockville, MD.,
Alternate Team Leader 1984 -'85, Team Leader 1985 -'86, Deputy Unit Commander January
1986 - May 1987.
Interviewer for the Admissions Committee of the Uniformed Services University of Health
Sciences School of Medicine, Bethesda, MD., 1984-1985, 1985-1986 and 1986-1987.
Member of the Membership and Member Services Committee of the Uniformed Services
Academy of Family Physicians, 1985 - 1994.
Member of the Training, Awards and Recognition Workgroup of the Surgeon General's
Revitalization Task Force for the Commissioned Corps of the U.S. Public Health Service,
1987.
Member of the Clinical Leadership Task Force of the State of Colorado, Department of
Health, established as part of the Cooperative Agreement between the PHS/HRSA and the
State of Colorado, 1987 - 1989.

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Delegate to the Commissioned Officers Association House of Delegates meeting
representing the Rocky Mountain Chapter of the U.S. Public Health Service Professional
Association, held in Scottsdale, AZ., 1988.
President of the Rocky Mountain Chapter of the U.S. Public Health Service Professional
Association, 1988/89.
Member of the Board of Directors of the Uniformed Services Academy of Family Physicians
(a chapter of the AAFP), 1988 – 1993. (First PHS officer to serve on the Board.)
Member of the Committee on Members' AAFP Insurance & Financial Services, of the
American Academy of Family Physicians, appointed for 1988, reappointed for 1989,
reappointed for 1990.
Part-time, temporary family practice physician with the Colorado Permanente Medical
Group, P.C., doing patient care for their Urgent Care Centers (in Lakewood and at the
Special Care Center in Denver), December 1988 to March 1990.
Member of the Committee on Community Health Services of the Bureau of Health Care
Delivery and Assistance, Health Resources and Services Administration, Public Health
Service; February 1989 - December 1990.
Member of the Board of Directors of the Uniformed Services Academy of Family Physicians
Foundation, 1991 - 1994 (first PHS officer to serve on the Board), elected as the first
President of the Foundation, February 1992 - 1994.
Temporary duty assignment to New Iberia, LA., to provide medical assistance in the
aftermath of Hurricane Andrew, November 1992.
Member of the Conference Series Program Committee for the Western and Rocky Mountain
STFM Annual Meetings, 1993 - 1995.
Faculty Advisor, Family Medicine Interest Group, School of Medicine, University of Utah,
Salt Lake City, UT, January 1995 – June 2008.
Member, LCME Accreditation Steering Committee, School of Medicine, University of Utah,
Salt Lake City, UT, June 1995 - October 1996.
Member of the Utah AHEC Advisory Board and Executive Committee, 1995 – 1999.
Associate Director for Education, June 1995 – July 2000. Senior Associate Director, July
2000 – June 2008.
Member, Third Year Curriculum Committee and Third Year Promotions Committee, School
of Medicine, University of Utah, Salt Lake City, UT, July 1995 – January 2008.
Faculty Advisor for the senior Honors program in Family Medicine, July 1995 – June 2008.

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Member of the Board of Directors of the Utah Academy of Family Physicians, representing
medical student programs at the University of Utah, January 1996 – present, President-Elect
for 2000, President for 2001, Past-President for 2002, Treasurer for 2004-10.
Member of the Physicians Licensing Board, Division of Occupational and Professional
Licensing, Department of Commerce, State of Utah, July 1, 1996 – June 2001.
Member of the Physician Assistant Licensing Board, Division of Occupational and
Professional Licensing, Department of Commerce, State of Utah, July 1, 1996 – June 2001
(Chairman for 1997 - 2001).
Faculty Advisor, Rural Medicine Interest Group, School of Medicine, University of Utah,
Salt Lake City, UT, July 1996 – June 2008.
Developed a curriculum (a four lecture series) on Health Care Delivery Systems for the Utah
Physician Assistant Program, presented during academic years 1996 – present.
Faculty Advisor, Health Care for the Homeless Clinic Students, School of Medicine,
University of Utah, Salt Lake City, UT, January 1997 – June 2008.
Member of the State Advisory Committee for the Provider Enrichment Program of the
Association for Utah Community Health, funded by a demonstration grant from the National
Health Service Corps, March 1997 - 2000.
Member (by gubernatorial appointment) of the Special Population Provider Financial
Assistance Committee, as the urban representative of the Association for Utah Community
Health, for a four year term ending October 1, 2001. Elected Chairman for 1997-1999.
Delegate to the Utah Medical Association, representing the Utah Academy of Family
Physicians, 1998 - 2000, 2002 – 2011; representing the Board of Trustees, 2012 – present.
Member of the Utah Department of Health’s Primary Care Needs Assessment Committee,
January 1999 – 2000. Committee provides oversight and guidance to Health Department staff
as they develop and perform a statewide needs assessment for primary health care services.
Member, Advisory Group for the “Promoting, Reinforcing, and Improving Medical
Education (PRIME) project, sponsored by the Division of Medicine,
BHPr/HRSA/PHS/DHHS, under contract to the American Medical Student Association,
January 1999 – 2003.
Member, Fourth Year Curriculum Committee and Fourth Year Promotions Committee,
School of Medicine, University of Utah, Salt Lake City, UT, July 2000 – January 2008.
Member, Service-Learning Advisory Board, Bennion Center, University of Utah,
representing the School of Medicine, Salt Lake City, UT, 2000 – 2008 (Chair, 2004 – 2008).
Member – Class Committee, 2000 – 2004.

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Member – Faculty Committee, 2004 – 2008 (Chair, 2004 - 2008).
Member, Clinical Faculty Review Committee, Department of Family and Preventive
Medicine, University of Utah SOM, 2002.
Member (by gubernatorial appointment) of the Utah Health Care Workforce Financial
Assistance Program Advisory Committee, from December 1, 2002 – May 1, 2005. Elected
Chairman for 2003-4.
Project Director, for “Achieving Diversity in Dentistry and Medicine,” a project funded by
the Health Resources and Services Administration through a contract with the American
Medical Student Association Foundation, from October 1, 2003 – July 2008.
Member of the Physicians Licensing Board, Division of Occupational and Professional
Licensing, Department of Commerce, State of Utah, July 1, 2004 – June 30, 2008,
reappointed for July 1, 2008 – September 21, 2012 (Chair from July 2008 – July 2009).
President-Elect, Salt Lake County Medical Association, December 2004 – November 2005.
Member of the Board of Directors of the Utah Academy of Family Physicians Foundation,
November 2005 - present, elected as President of the Foundation, November 2005 - present.
President, Salt Lake County Medical Society, December 2005 – November 2006.
Past-President, Salt Lake County Medical Society, December 2006 – November 2007.
Member, Board of Directors, Lowell Bennion Community Service Center, University of
Utah, Spring 2007 – June 2009.
Physician Reviewer for HRSA (Health Resources and Services Administration) of Federal
Tort Claims actions against covered primary care providers; 2010 – 2018.
Member, Board of Directors, Salt Lake Community Health Centers, Inc., Summer 2008 –
April 2010.
Member, Board of Directors, Midvale Family Health Center, February 2009 – April 2010.
Chair, Refugee Health Advisory Committee for Utah’s Refugee Advisory Board, February
2009 – 2011.
Speaker of the House of Delegates for the Utah Medical Association, elected at the 2012
session, re-elected at the 2014 session; September 2012 – 2016. In this role, also serve on the
Board of Trustees and the Executive Committee of the Utah Medical Association; September
2012 – 2016.

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Educational Consultant to Utah Medical Association for the production of an online, 3.5
hour, 6-module CME course titled “Controlled Substances, Education for the Prescriber.” I
reviewed and edited content and organization, developed patient case studies, and developed
the required exams at the conclusion of each module. Fall 2013.
Member, Utah’s Multi-Cultural Commission, July 2015 – 2020.
Contracted Consultant with the Office of the Legislative Auditor General for Utah to assist
with their audit of healthcare in the state prison system. August-September 2021.
PUBLICATIONS: Journals
"Family Practice Residency-Community Clinic Linkages for Physician Exchange," The
Journal of Family Practice, Vol. 12, No. 2: 361-363, 1981, Jonathan E. Rodnick and Marc
Babitz.
"Teaching Longitudinal Care Without Patients," Family Medicine, Vol. XVI, No. 6:
229-230, 1984; Marc E. Babitz, M.D.; Jonathan E. Rodnick, M.D.; and Rick Flinders, M.D.
"Clinical Performance In A Field Exercise For The National Disaster Medical System,"
Military Medicine, Vol. 154, No. 12: 587-589, 1989; CDR Thomas V. Holohan; CDR Marc
Babitz; and Capt Darrell N. Berry.
“Commentary: Service-Education Linkages for Community-Based Training of Family
Physicians,” Family Medicine, Vol. 28:No. 9: 616-617, 1996, Babitz, ME.
“Ambulatory Care Sensitive Hospitalization Rates in the Aged Medicare Population in Utah,
1990 to 1994: A Rural-Urban Comparison,” The Journal of Rural Health, Vol. 13, No. 4: 285
- 294, 1997; Michael P. Silver, MPH, Marc E. Babitz, MD, and Michael K. Magill, MD.
“Physicians’ Perceptions of Non-Medical Variables Influencing the Decision to Hospitalize
Elderly Patients with Ambulatory-Care Sensitive Conditions,” Utah’s Health, An Annual
Review, Vol. VI:19-28, 1999; M.J. Egger, Ph.D., M.E. Babitz, M.D., M. Bishop, M.B.A.
“Community Oriented Primary Care (COPC): An Effective Paradigm for Preventive Care,”
Utah’s Health, An Annual Review, Vol. VII:11-16, 2000-2001; M.E. Babitz, M.D., F.M.
Bishop, Ph.D., M.S.P.H.
“Integrating Public Health into Medical Education: Community Health Projects in a
Primary Care Preceptorship,” Academic Medicine, Vol. 76:No. 10: 1076-1079, 2001; M.K.
Magill, MD, R. Quinn, MPA, M. Babitz, MD, S. Saffel-Shrier, MS, RD, S. Shomaker, MD,
JD.
“Combining Medical Education and Service,” Physicians Practice Digest, Vol. 11:No. 6: A1A2, 2001; M. Babitz, MD.

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“An Assessment of the Health Background, Status, and Care Utilization of the Sudanese
Youth “Lost Boys” Population in Salt Lake City,” Utah’s Health: An Annual Review, Vol.
IX:46-51, 2003; R. Thompson, BA, M.E. Babitz, M.D.
“Mutual Respect in Healthcare: Assessing Cultural Competence for the University of Utah
Interdisciplinary Health Sciences,” Journal of Allied Health, Summer 2009, Vol. 38, No.
2:54-62; GM Musolino, PT, MSEd, EdD; M Babitz, MD; ST Burkhalter; C Thompson,
MStat; R Harris, MD, MBA; RS Ward, PT, PhD; S Chase-Cantarini, RN.
“Understanding and Eliminating Disparities in Health Care: Development and Assessment
of Cultural Competence for Interdisciplinary Health Professionals at the University of Utah –
a 3-year Investigation, “ Journal of Physical Therapy Education, Winter 2010, Vol. 24, No.
1:25-36; GM Musolino, PT, MSEd, EdD; ST Burkhalter; B Crookston, MPH; RS Ward, PT,
PhD; RM Harris, MD, MBA; S Chase-Canatarini, RN, MS; M Babitz, MD.
“Commentary: The PCP Perspective on Urine Drug Testing: An Underused Tool,” Pain
Management Today eNewsletter series, Vol. 1, Issue 7, February 2011, sponsored by the
Journal of Family Practice; M Babitz, MD.
“Commentary: The PCP Perspective on Risk Stratification and Evaluation of High-Risk
Behaviors for Chronic Opioid Therapy,” Pain Management Today eNewsletter series, Vol. 1,
Issue 3, December 2010, sponsored by the Journal of Family Practice; M Babitz, MD.
PUBLICATIONS: Abstracts
Babitz, M.E., Parham, D.L., and Schneider, D.A. A clinical support strategy for the National
Health Service Corps. USPHS Professional A. Ann. Meeting, Program Abstr., 20:50-1, April
9-12, 1985.
Haberberger, R. and Babitz, M.E. National Health Service Corps physician continuing
education survey. USPHS Professional A. Ann. Meeting, Program Abstr., 20:48, April 9-12,
1985.
Babitz, M., Wells, J., and Smith, D. Community Oriented Primary Care As Practiced In
Federally Funded Community Health Centers. USPHS Professional A. Ann. Meeting,
Program Abstr., 23:30-1, May 22-25, 1988.

Burnett, W.H. and Babitz, M.E. The Family Practice Movement and the United States Public
Health Service: Introducing Care to the Underserved at the Predoctoral Level. STFM 1990
Ann. Predoctoral Education Conference, Program Abstr., February 1 - 4, 1990.
Chung, C., LoGiudice, F., Levesque, R., and Babitz, M. Live Life Litely Program. USPHS
Professional A. Ann. Meeting, Program Abstr., 26:67, May 26-29, 1991.

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Clark, C. and Babitz, M., Embedding the Teaching of a Community-Based Research Model
Within a Service-Learning Course for Fourth Year Medical Students: How To Do It. Did
They Learn It? 3rd Annual International K-H Service-Learning Research Conference,
Program Abstract, November 6-8, 2003.
Babitz, M., Clark, C., Stewart, M. An Electronic, Virtual Community to Teach Community
Oriented Primary Care. Association of American Medical Colleges Annual Meeting, GEA
Session, Program Abstr., November 7 – 12, 2003.
Babitz, M., Clark, C., Stewart, M. An Electronic, Interactive, Virtual Community to Teach
Community Oriented Primary Care. STFM 2004 Ann. Predoctoral Education Conference,
Program Abstr., January 29 – February 1, 2004.
Dyer, J., Babitz, M. Nurse Practitioners, Nurse Midwives and Physicians – Effective Rural
Health Care Teams. NRHA 2004 Ann. Conf., Program Abstr., May 27 – 29, 2004.
Babitz, M; Clark, C; Stewart, M; An Electronic, Interactive, Virtual Community to Teach
Community Oriented Primary Care. NRHA 20054 Ann. Conf., Program Abstr., May 19 – 22,
2004.
Musolino, G.; Harris, R.; Babitz, M.; Ward, S.; Chase-Cantarini, S.; Smith, Y.; Mutual
Respect in Healthcare: Assessing Cultural Competence for the Interdisciplinary Health
Sciences at the University of Utah. APTA Combined Sections meeting, Abstr., 2006.
Babitz, ME; Clark, C; Stewart, M and Cochella, S, An Electronic, Interactive, Virtual, Urban
Community to Teach Community-Oriented Primary Care, STFM 33rd Ann. Predoctoral
Education Conference, Program Abstracts, 2007.
Babitz, ME; Clark, C; Quinn, R, Teaching Public Health and Community Health Using a
“COPC” Approach, STFM 34th Ann. Predoctoral Education Conference, Program Abstracts
and Family Medicine Digital Resource Library, 2008.
Babitz, ME; Ipsen, S, Utah’s Safety Net Initiative: Collaboration in the Care of the
Underserved, ASTHO – NACCHO 2008 Conference, Program Abstracts/Poster Showcase
Directory, September 2008.
PUBLICATIONS: Book Chapter
Babitz, M.E., "COPC: Doing Something Is Better Than Doing Nothing." In Nutting, PA (ed):
Community-Oriented Primary Care: From Principle to Practice. HRSA publication No.
HRS-A-PE 86-1, 1987. U.S. Government Printing Office, Washington, D.C.
PUBLICATIONS: Other
Babitz, M, Burnett, W, Berringer, B. A comprehensive manpower strategy for the Public
Health Service: a working document. In: Proposed Strategies for Fulfilling Primary Care
Manpower Needs. Rockville, MD: National Health Service Corps: 1990:appendix A.

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"Community Oriented Primary Care," a 56 minute, educational videotape presentation by
Marc E. Babitz, M.D., produced by JSI Research & Training Institute under contract with the
National Health Service Corps, September 1993.
"Continuous Quality Improvement in Health Care," Practice Management Guide, A
Supplement to Physician Assistant, 5-9, September 1993; Marc E. Babitz, M.D.
Magill, M.K., Babitz, M.E. and Silver, M.P., Letter to the Editor. Corresp. N Engl J Med
1996; 335:896.
“Continuous Quality Improvement,” a series of 6 educational videotapes (approximately 40
minutes each) by Marc E. Babitz, M.D. and Les Wallace, Ph.D., produced by the Community
Health Association of the Mountain/Plains States, under contract with the U.S. Public Health
Service, Region VIII, Winter 1996 - 1997.
“Practicing with a Physician Assistant: A Physician’s Perspective,” Utah Medical
Association’s bulletin, Vol. 47/No.1:January 1999, Marc Babitz, MD.
“Quality assurance: myth, reality or law?” Utah Medical Association’s bulletin, Vol. 47/No.
12:December 1999, Marc Babitz, MD.
“Coordination with the Community,” “Coordination with Colleagues,” and “Coordination of
Referral Arrangements,” a series of featured interviews in The Healthcare Collaborator
newsletter, November 2000, Marc Babitz, MD.
PUBLICATIONS: Educational Software
“Caring for a Community: Learning the Process of Community Oriented Primary Care,” an
interactive, educational, computer software program on a CD-ROM that utilizes a “virtual”
rural community in which the user can learn and practice community oriented primary care
from Needs Assessment, to Prioritization, to Intervention, through Summary and Evaluation.
Introduced in June 2004, authored by Marc Babitz, MD and Claire Clark, PhD.
“An Introduction to Public Health,” an educational, computer software program on a CDROM, that provides users with an introduction and overview of Public Health. Introduced in
August 2004, authored by Marc Babitz, MD.
“Caring for a Community: Learning the Process of Community Oriented Primary Care,” an
interactive, educational, computer software program on a CD-ROM that utilizes a “virtual”
urban, multi-cultural community in which the user can learn and practice community
oriented primary care from Needs Assessment, to Prioritization, to Intervention, through
Summary and Evaluation. Introduced in June 2008, authored by Marc Babitz, MD.

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POSTERS:
PHS Experience Prepares Faculty to Teach Cross-Cultural Health Care, a poster by Marc E.
Babitz, MD and Larry Li, MD, MSPH, for the National Health Service Corps’ 25th
Anniversary Conference, April 24 – 26, 1998, Washington, D.C. Also presented at the NHSC
Annual Conference series for 1999: Las Vegas, October 7 – 9, and Orlando, November 3 – 5;
and 2000: McClean, April 6 – 8, San Jose, November 16 – 18, and Orlando, December 7 - 9.
Social Factors in Rural Pneumonia Hospitalizations, a summer research project by Sean
Paulsen and Gregory Daynes (MS IIs), coordinated by Marlene Egger, Ph.D., Mike Magill,
M.D., and myself. Presented at the Annual Meeting of the Society of Teachers of Family
Medicine, April 1998.
The Virtual Community – An Innovative Approach to Teaching C.O.P.C., a poster by
Student Programs in Family Medicine, DFPM, for the 29th Annual Predoctoral Education
Conference of the Society of Teachers of Family Medicine, Austin, TX, January 2003.
An Electronic, Virtual Community to Teach Community-Oriented Primary Care, a poster by
Student Programs in Family Medicine, DFPM, for the Association of American Medical
Colleges Annual Meeting, Washington, D.C., November 2003.
An Electronic, Virtual Community to Teach Community-Oriented Primary Care, a poster by
Student Programs in Family Medicine, DFPM, for the 30th Annual Predoctoral Education
Conference of the Society of Teachers of Family Medicine, New Orleans, LA, January –
February 2004.
Utah’s Safety Net Initiative: Collaboration in the Care of the Underserved, a poster by the
Division of Health Systems Improvement, Utah Department of Health, for the 2008 ASTHO
-NACCHO meeting, Sacramento, CA, September 9 – 12, 2008.
INVITED,UNIVERSITY GUEST LECTURESHIPS
“Community Oriented Primary Care,” presented at the Robert Wood Johnson University of
Medicine and Dentistry of New Jersey, June 10, 1998, in New Brunswick, NJ. Audience
included medical students, family practice residents and faculty from the Department of
Family Medicine.
“Caring for the Patient Who’s Not in the Room, Community Oriented Primary Care,”
presented at the University of Nebraska School of Medicine, August 26, 1998, in Omaha,
NE. Presented to the second-year medical school class and selected faculty as the lead
presentation for their Integrated Clinical Experience curriculum.
“Caring for the Patient Who’s Not in the Room, Community Oriented Primary Care,”
presented at the Indiana University School of Medicine, December 7, 1998, in Indianapolis,
IN. Presented to the third-year medical school class as part of a series on Current Issues in
Medicine.

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“Caring for the Patient Who’s Not in the Room, Community Oriented Primary Care,”
presented at the University of Nebraska School of Medicine, August 26, 1999, in Omaha,
NE. Presented to the second-year medical school class as the lead presentation for their
Integrated Clinical Experience curriculum.
“Caring for the Patient Who’s Not in the Room, Community Oriented Primary Care,”
presented at the University of Nebraska School of Medicine, August 30, 2000, in Omaha,
NE. Presented to the second-year medical school class as the lead presentation for their
Integrated Clinical Experience curriculum.
“Caring for the Patient Who’s Not in the Room, Community Oriented Primary Care,”
presented at the University of Nebraska School of Medicine, August 30, 2001, in Omaha,
NE. Presented to the second-year medical school class as the lead presentation for their
Integrated Clinical Experience curriculum.
“Caring for the Patient Who’s Not in the Room, Community Oriented Primary Care,”
presented at the University of Nebraska School of Medicine, August 28, 2002, in Omaha,
NE. Presented to the second-year medical school class as the lead presentation for their
Integrated Clinical Experience curriculum.
“Caring for the Patient Who’s Not in the Room, Community Oriented Primary Care,”
presented at the University of Nebraska School of Medicine, August 28, 2003, in Omaha,
NE. Presented to the second-year medical school class as the lead presentation for their
Integrated Clinical Experience curriculum.
“Caring for the Patient Who’s Not in the Room, Community Oriented Primary Care,”
presented at the St. Louis University School of Medicine, March 8, 2004, in St. Louis, MO.
Presented to the first-year medical school class as part of their Physician, Patient and Society
course.
“Caring for the Patient Who’s Not in the Room, Community Oriented Primary Care,”
presented at the University of Nebraska School of Medicine, August 25, 2004, in Omaha,
NE. Presented to the second-year medical school class as the lead presentation for their
Integrated Clinical Experience curriculum.
OTHER INVITED PRESENTATIONS
“Is There Nothing More That I Can Do.” Keynote presentation for the Advanced Care
Planning Conference, held virtually, November 10, 2020. Conference sponsored by
Comagine and the Utah Commission on Aging.
GRANTS RECEIVED
Pre-Doctoral Training Grant, from the Division of Medicine, Bureau of Health Professions,
Health Resources and Services Administration, Public Health Service/DHHS; for $130,000
(+ 8% indirect) per year for three years, July 1, 1996 - June 30, 1999.

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1996-1997 Faculty Enhancement Award from the Society of Teachers of Family Medicine to
study curriculum reform at the Oregon Health Sciences University and its impact on their
Department of Family Medicine. Awarded $2,000 to offset travel and per diem expenses.
Health Research Center Semi-Annual Grant Award, Department of Family and Preventive
Medicine, University of Utah, with Marlene Egger, Ph.D., to study Physician Variables in the
Decision to Admit to the Hospital, Fall 1996 - Spring 1997.
Intermountain Health Care Student Programs Grant, to support family medicine clerkships
and preceptorships in rural sites (including funds for faculty, staff and student travel
stipends). Awarded $160,000 for 1997 and 1998. Awarded $120,000 for 1999. Awarded
$80,000 for 2000, 2001, 2002, 2003, 2004, 2005, 2006, 2007 and 2008. (This was an ongoing
grant to the Department since 1992).
Pre-Doctoral Training Grant, from the Division of Medicine, Bureau of Health Professions,
Health Resources and Services Administration, Public Health Service/DHHS; for three years,
July 1, 2001 - June 30, 2004, for $120,809 (+ 8% indirect) in year one, and $114,329 per year
in years two and three.
Pre-Doctoral Training Grant, from the Division of Medicine, Bureau of Health Professions,
Health Resources and Services Administration, Public Health Service/DHHS; for three years,
July 1, 2005 - June 30, 2008, for $111,100 (+ 8% indirect) in year one, $99,085 (+ 8%
indirect) in year two, (final year of funding dependent on level of congressional
appropriations).
PROFESSIONAL PRESENTATIONS
I have made several hundred public presentations to local, regional, and national
organizations during the course of my professional career. Many of these have been part of
accredited continuing medical education programs. The majority of these presentations were
made while I was an officer in the Public Health Service or as faculty of the University of Utah;
however, others have been made as a private individual. The following list notes the topics of
presentations made in recent years:
Community Oriented Primary Care/Caring for the Patient Who’s Not in the Room
(Presented as the Opening Keynote session for the American College of Nurse
Practitioners Annual Meeting; October 18, 2001; Atlanta, GA.).
Nurse Practitioners, Nurse Midwives and Physicians - Effective Rural Health Care
Teams
The Practical Application of Community-Oriented Primary Care (COPC) Theory by
FP Residency Programs
Continuous Quality Improvement
Cultural Competence in Health Care/Cultural Diversity in Health Care
The Male Genital Exam (designed for providers in STD clinics)
Clinical Prevention in Family Practice
Shared Leadership in Health Care
Practice Management for New Health Care Providers
The State of Health Care in America

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Quality Assurance in Ambulatory Care Settings
Rural Health Care
Clinical Leadership: Roles and Skills
Health Care Issues for Homeless and Migrant Families
Developing and Implementing Health Care Plans
Preventive Health Care Schedules
Health Needs Assessment
Improving Patient Compliance
Recruitment and Retention for Underserved Communities
Contracting Issues for Health Professionals
The Role of the Health Services (Clinical) Director
The Organization and Functions of the Public Health Service
The Meaning of Service in the Health Professions (to Pharmacy students)
Access to Health Care (to PH students)
Health Professions Workforce Issues (to PH students)
Patients I Have Known: And, What They Taught Me
PROFESSIONAL SOCIETY MEMBERSHIPS
American Academy of Family Physicians
Utah Academy of Family Physicians (President-elect for 2000, President for 2001, PastPresident for 2002, Treasurer 2004 - 2010), Foundation member and President 2005 –
2020.
Uniformed Services Academy of Family Physicians (adjunct member)
Utah Medical Association (Ex-Officio member Board of Trustees, representing UDOH, 2011
- 2012; elected as Speaker of the House of Delegates and official member of the Board of
Directors and the Executive Committee, 2012 – 2016; ex officio member of the Council of
Trustees representing the Utah Department of Health, 2016 - 2020).
Salt Lake County Medical Association (President-Elect 2004 - 2005, President 2005 – 2006,
Past-President 2006 - 2007).
Commissioned Officers Association of the U.S. Public Health Service, 1984-2014.
Gold-Headed Cane Society, University of California, San Francisco, 1972 – present.
HOSPITAL STAFF MEMBERSHIPS
Current
Salt Lake Regional Medical Center, Salt Lake City, UT, Active Staff, 1995 – 2004, Courtesy
Staff, 2005 - present.
Primary Children’s Medical Center, Salt Lake City, UT, Active Staff, 1996 – 2004, Active
Referral Staff, 2005 - present.
Past
LDS Hospital, Salt Lake City, UT, Courtesy Staff, Fall 1996 - 2010.
Intermountain Medical Center, Murray, UT, Courtesy Staff, Fall 2007 – 2010.
University Hospital, University of Utah Health Sciences Center, Salt Lake City, UT, Active
Staff, 1995 – 2008.
Community Hospital of Sonoma County, Santa Rosa, CA., Active Staff, 1976 - 1984.

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Palm Drive Hospital, Sebastopol, CA., Courtesy Staff, 1976 - 1984.
Healdsburg General Hospital, Healdsburg, CA., Courtesy Staff 1981 - 1984.
REFERENCES - Available on request.

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Agency Response

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CHAPTER II
Recommendation 2.1. We recommend that the executive director of the Department of
Corrections ensure that all recommendations in this audit are adequately implemented.
Department Response: The Department concurs.
What: The executive director will continually monitor and ensure the implementation of all
recommendations in this audit, many of which have already occurred or are in the process of
occurring.
How: The director of CSB will report through the deputy executive director over CSB, through
weekly meetings. The deputy executive director will update the executive director monthly.
When: The weekly updates have already begun. The monthly updates will begin on January 3,
2022.
Contact: Chyleen Richey, Deputy Executive Director, crichey@utah.gov, 385-695-0677

Recommendation 2.2. We also recommend that the executive director of the Department
of Corrections launch an internal review to determine if additional changes not
addressed in this report are needed regarding operations and/or staff.
Department Response: The Department concurs.
What: The Internal Audit Bureau (IAB) will include this in its development of the next year’s audit
plan.
How: IAB will conduct a risk-based audit after careful consideration of this legislative audit. IAB
will look at all areas of clinical services to determine if any additional changes may be beneficial
to the Department.
When: Completed by December 2022
Contact: Rachel Summers, Internal Audit Director, rlsummers@utah.gov, 385-529-6966

Recommendation 2.3. We recommend that the Clinical Services Bureau ensure providers
and other medical staff define the term “monitor” in patient charts with specific
parameters on a case-by-case basis.
Department Response: The Department concurs.

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What: The Department has purchased a new Electronic Health Record (EHR) System (Fusion).
How: The new system has additional capabilities which will allow a provider or other medical
staff to check boxes for more focused follow up and monitoring, thereby eliminating vague
follow-up recommendations. Each chronic care category will auto-populate templated follow-up
needs according to diagnosis.
When: Fully operational by March 2022 (proposed date)
Contact: Dr. Darrel Olsen, Clinical Director, darrelolsen@utah.gov, 801-380-7880

Recommendation 2.4. We recommend that the Clinical Services Bureau increase
oversight to ensure appropriate case-by-case patient follow up procedures are being
completed.
Department Response: The Department concurs.
What: Continuous Quality Improvement (CQI) system
How: The CQI committee will follow a random sample of inmate cases reviewed on a monthly
basis to ensure appropriate case-by-case patient follow up. Lack of appropriate follow-up and
corrective action will be addressed with the specific provider by the Clinical Director.
When: January 2022
Contact: Bobbi Brown, Senior RN (CQI Manager) bobbibrown@utah.gov, 435 528-6081

Recommendation 2.5. We recommend that the Clinical Services Bureau ensure that all
patients have access to:
● Appropriate and timely clinical judgements rendered by a qualified healthcare
professional.
● Correct treatments and medications for corresponding diagnoses.
Department Response: The Department concurs.
What: Continuous Quality Control (CQI) system
How: The CQI committee during the previously mentioned monthly reviews will determine if
clinical assessments are timely and appropriate. They will also review recommendations for
outside treatments and medications requested. Lack of appropriate and timely care or failure to
follow recommendations (or document otherwise) will be addressed with the specific provider by
the Clinical Director.

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When: January 2022
Contact: Bobbi Brown, Senior RN (CQI Manager) bobbibrown@utah.gov, 435 528-6081

Recommendation 2.6. We recommend that the Clinical Services Bureau follow internal
policies and professionally recognized standards regarding the administration of insulin
and oversight of inmates with diabetes.
Department Response: The Department concurs. However, we would like to clarify that all
diabetics in general population have access to a glucometer to monitor blood sugars at any
time. In high security areas, glucometers are available at pill lines for inmate testing, and in
some instances, additional pill line access is provided based on inmate need.
What: Monthly Chronic Care team (senior RNs) reviews
How: The Chronic Care team will conduct monthly meetings reviewing medical standards in
comparison to diabetes management protocols for a random sample of diabetic inmates, which
will be documented and maintained at the Bureau level for CQI review.
When: January 2022
Contact: Adam Archer, Senior RN, aarcher@utah.gov, 801 576-7290

Recommendation 2.7. We recommend that the Clinical Services Bureau create policies
and procedures to effectively manage nutrition and medical care for diabetic patients
during disruptions or delays to the normal schedule.
Department Response: The Department concurs.
What: Addition to CSB policy manual (formerly Technical Manual)
How: CSB will add a section to its internal policy addressing managing disruptions or delays for
chronic care health needs, as well as nutrition management.
When: February 2022
Contact: Jane Reed, Records Manager, janereed@utah.gov, 801 576-7124

Recommendation 2.8. We recommend that the Clinical Services Bureau develop policies
where appropriate that help the organization be more compliant with CDC standards
regarding medical issues such as the COVID-19 pandemic.

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Department Response: The Department concurs.
What: Addition to CSB policy manual (formerly Technical Manual)
How: CSB will add a section to its internal policy addressing infectious disease processes, by
adding guidance on handling pandemics based upon lessons learned.
When: February 2022
Contact: Jane Reed, Records Manager, janereed@utah.gov., 801 576-7124

CHAPTER III
Recommendation 3.1. We recommend that the Clinical Services Bureau ensure that the
use of emergency medical technicians in the prison is consistent with state statutes and
best practices, and that licensed nurses (or other qualified medical professionals) are
used in situations that require a level of skill and knowledge beyond what an EMT is
certified for.
Department Response: The Department concurs.
What: Legal review
How: The Department has requested that its legal counsel at the Utah Attorney General’s Office
review the Utah State Prison’s utilization of EMTs, including the prison’s use of EMTs to deliver
inmate medications, to ensure it is not inconsistent with state or federal law or NCCHC
standards. If the Department’s utilization of EMTs is found to be inconsistent with applicable
laws or standards, CSB will adjust its practices to come into compliance.
When: Immediately
Contact: Colleen Guymon, Deputy Director, colleenguymon@utah.gov, 801 576-7110

Recommendation 3.2. We recommend that executive management at the Department of
Corrections ensure that personnel in the Clinical Services Bureau fully comply with
NCCHC standards.
Department Response: The Department concurs.
What: 1) Tracking assessment data, 2) ICR face-to-face encounters with qualified health
professionals, and 3) medication disposal.

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1. The data used to reach the health, mental health, and dental assessment conclusions
has many nuances that cannot be adequately captured by the aggregate analysis.
a. Initial Health Assessment - All inmates receive an intake screening upon entry to
the prison. The data used in this section refers to a follow-up physical
examination which is to be completed within 7 days by NCCHC standard. To
provide perspective, this is a 98.4% success rate over the three year period.
Some explanation to account for some of the missing exam data includes:
i.
When an inmate received an initial health assessment in a county jail
prior to being transferred to prison.
ii.
During 2018 and 2019, when an inmate had returned to prison within 6
months, the former policy was to not complete a new physical exam
unless something was discovered during the intake health screenings.
b. Mental Health Intakes - All inmates receive a mental health screening upon entry
to prison. The data used in this section refers to follow-up mental health
evaluations required when a mental health issue is flagged during the intake
screening to be completed within a 30-day time frame. Of the 143 mental health
evaluations reported as not completed, during a brief spot check of a small
number of cases, we found 17 that were completed within the time frame. This
was due to variations in how the information was entered in Mtrack, which could
not be captured by the data aggregation method, i.e they were entered as a note
instead of in the exam data field.
i.
The average MH evaluation completion rate for males in the 3 year period
was 97%.
ii.
The average MH evaluation completion rate for females in the 2 year
period was 96%. (Data from 2018 was not requested)
iii.
In the mental health data there was no mention of how many days past
the standard were encompassed in the findings.
c. Dental Examinations - The vast majority of the missing dental examinations to be
completed within 30 days occurred in 2020 when there was an order in place
outlining that dental exams were routine and not a priority during the pandemic
outbreak and we were strongly advised to delay these examinations.
i.
Dental Examination completion within 30 days 2018 - 99.82%
ii.
Dental Examination completion within 30 days 2019 - 100%
iii.
Dental Examination completion within 30 days 2020 - 77%
iv.
In the dental data there was no mention of how many days past the
standard were encompassed in the findings.
How:
1. CSB will review how this data is collected and collated so that the Department can more
easily and accurately determine its compliance with required standards.
2. CSB is in the process of ensuring all ICRs submitted are accompanied by a face-to-face
encounter with a qualified health professional. All nursing staff will receive training on the
standard for reviewing, which may occur during pill lines as well. Face-to-face
encounters will occur within 24 hours.

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3. All EMTs and other staff associated with medication delivery will receive quarterly
training on proper medication disposal with the requirement being added to each staff’s
UPM.
When:
1. In the short term, before March of 2022, CSB management will review the data collection
and collation to determine improvements that can be made through existing technology.
In the long term, beginning March of 2022 and beyond, the Electronic Health Record
System (currently being developed) will resolve this difficulty of tracking compliance.
2. Face-to-face encounters regarding ICRs has already been initiated and will be fully
implemented by January 2022.
3. Medication disposal training has been implemented and is scheduled to occur on a
quarterly basis.
Contact: Chyleen Richey, Deputy Executive Director, crichey@utah.gov, 385-695-0677

Recommendation 3.3. We recommend that the Clinical Services Bureau ensure
compliance with statute regarding the protection of personal health information.
Department Response: The Department concurs.
What: Mandatory Quarterly Training for medication delivery staff
How: CSB will conduct and document mandatory quarterly training regarding protecting
personal health information. This training requirement will be added to the Utah Performance
Management System.
When: Quarterly training will begin in March 2022
Contact: Eric Difrancesco, RN, DON, edifranc@utah.gov, 385 224-3201

Recommendation 3.4. We recommend that the Clinical Services Bureau follow the
inmate handbook regarding copays for mental health services.
Department Response: The Department concurs.
What: While the Department has statutory authority to collect a $5 copay for medical services,
when an inmate has assets exceeding $200,000, the statute requires that inmate to pay up to
20% of the inmate’s total asset value. CSB made the decision to publish in the inmate handbook
that there would be no copay for mental health services in order to remove any real or perceived
barrier to accessing mental health services. However, CSB collected copays on several

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inmates. While it technically had the authority to do so, it was inconsistent with its messaging
and intent.
How: CSB immediately stopped charging mental health copays when this inconsistency was
brought to its attention by the auditors.
When: October 2021
Contact: Chyleen Richey, Deputy Executive Director, crichey@utah.gov, 385-695-0677

CHAPTER IV
Recommendation 4.1. We recommend that the Clinical Services Bureau follow Utah
Administrative Rule when implementing incentive programs.
Department Response: The Department concurs.
What: CSB and DHRM will develop a process to monitor incentive awards. It is important to note
that everyone received money that was appropriately intended by the Department. What is in
dispute is the administrative method.
How: Incentive awards for RN overtime have been modified to be accounted for through shift
differential. Bonus and Retention awards will be used sparingly and administered with DHRM
oversight.
When: Immediately
Contact: Brooke Baker, HR Manager, bbaker@utah.gov, 385 258-7827

Recommendation 4.2. We recommend that the Clinical Services Bureau be transparent
with the Legislature in how program funds are being used.
Department Response: The Department concurs.
What: The savings from unfilled FTE pins is used to fund medical services.
How: While this information is provided to the LFA, it is not specifically highlighted or expressly
pointed out.
When: The Department will begin expressly pointing this out to the LFA this 2022 General
Session and moving forward.

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Contact: Chyleen Richey, Deputy Executive Director, crichey@utah.gov, 385-695-0677

Recommendation 4.3. We recommend that the Clinical Services Bureau create
meaningful performance metrics that reflect program activity.
Department Response: The Department concurs. However, it is important to clarify that the 3day closure goal is not a medical standard, but rather an internal efficiency goal intended to
drive improvement over time. Healthcare is completed according to medical triage and need.
What: The 3-day closure performance measure reflects one aspect of the SUCCESS initiative,
created by Gov. Herbert’s GOMB. This measure was developed in close collaboration with that
office. The 4-1 data tracking formula was designed to capture those requests that were closed in
less than a day, as they can be entered at any time of day. When creating this performance
measure, GOMB had difficulty finding a measure that could be improved by 25%, as CSB was
already meeting their performance measures close to 100%. We have since been directed to
re-evaluate these measures with Gov. Cox’s new administration. The Department has been
working on re-evaluating all Department measures since the beginning of this year and is
committed to doing so in a way that collects and uses staff input.
How: CSB leadership began brainstorming and coordinating with the Department’s Executive
Office and Director of Operational Excellence prior to the beginning of this audit to generate
measurements that aim to track the quality of medical services provided to our incarcerated
population. These revisions, which began to take shape even prior to this audit, will align CSB
more closely with the Department’s goals and expectations, while also aligning with the
recommendations of this audit and the Governor’s office.
When: The development of these performance measures is in the final discussion stages, but it
is important to solicit feedback from medical providers and CSB staff so that we have quality
measures that are supported and understood by all staff. We intend to have the measure
finalized and operationalized in January 2022.
Contact: Steve Gehrke, Director of Operational Excellence, sgehrke@utah.gov, 385-237-8040

Recommendation 4.4. We recommend that the Clinical Services Bureau ensure that
formulary, procedures, policies, and training materials are all up to date.
Department Response: The Department concurs.
What: While the Department recognizes that some trainings and protocols are unlikely to
change from year-to-year, we will implement a process to review training materials and
protocols annually. In addition, we will continue quarterly Pharmacy and Therapeutics meetings
to review medications.

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How: CSB will compile all training material and develop an annual sign off, demonstrating that
all training has been reviewed annually (though some training content will not change). In
addition, formulary reviews that are conducted quarterly will be documented annually as
reviewed, even if no changes are formally made.
When: March 2022
Contact: Wes Shuman, Senior RN, Training Manager, wshuman@utah.gov, 801-507-6537

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