Prison Sterilization Audit

Sterilization of
Female Inmates
Some Inmates Were Sterilized Unlawfully,
and Safeguards Designed to Limit Occurrences
of the Procedure Failed
Report -
June
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Doug Cordiner Chief Deputy
Elaine M. Howle State Auditor
621 Capi t ol Mal l , Sui t e 1200 Sacr ament o, CA 95814 916. 445. 0255 916. 327. 0019 f ax www. audi t or. ca. gov
June,,ao ao-ao
TeGovernorofCalifornia
PresidentproTemporeoftheSenate
SpeakeroftheAssembly
StateCapitol
Sacramento,California,8
DearGovernorandLegislativeLeaders:
As requested by the Joint Legislative Audit Committee, the California State Auditor (state auditor)
presentsthisauditreportconcerningfemaleinmatesterilizationsoccurringbetweenscalyears aooo6
and aoa. Te California Department of Corrections and Rehabilitation (Corrections) oversees
theinmatepopulationoftheStatesadultprisons,fourofwhichhousedsubstantiallyallwomen.
However, for much of our audit period, Corrections role in providing inmates with medical care
was not signicant. California Correctional Health Care Services (Receivers Oce) played the
more substantial role under the direction of a federal court-appointed receiver who took control of
prisonmedicalcareinaoo6andwillretaincontroluntilthecourtndsCorrectionscanmaintaina
constitutionallyadequateprisonmedicalcaresystem.
Tis report concludes that during our eight-year audit period, female inmates were sterilized
byaprocedureknownasbilateraltuballigation,asurgerygenerallyperformedforthesolepurpose
of sterilization. State regulations impose informed consent requirements that must be met before a
womancanbesterilized,however,CorrectionsandtheReceiversOcesometimesfailedtoensure
that inmates consent for sterilization was lawfully obtained. Overall, we noted that , inmates
weresterilizedfollowingdecienciesintheinformedconsentprocess.Fora;ofthe,inmates,the
physician performing the procedure or an alternate physician failed to sign the inmates consent
form certifying that the inmate appeared mentally competent and understood the lasting eects
of the procedure. For 8 of the , inmates, we noted potential violations of the waiting period
between when the inmate consented to the procedure and when the sterilization surgery actually
tookplace.Finally,amongthese, inmatesweresixwhoweresterilizedfollowingviolationsofboth
these requirements. Although neither Corrections nor the Receivers Oces employees actually
performedthesterilizationprocedures,weconcludedthattheyhadaresponsibilitytoensurethatthe
informed consentrequirementswerefollowedinthoseinstancesinwhichtheiremployeesobtained
inmatesconsent, whichwasthecaseforatleast,ofthe,inmates.
Our audit also noted that prison medical sta infrequently requested approval to sterilize inmates,
and when they did so, it was not always clear that these requests were approved. However, since
January aoo,medicalclaimsdatafromtheReceiversOceshowthatthenumberoffemaleinmates
who have undergone bilateral tubal ligations and other medical procedures that may result in
sterilizationhasgreatlydecreased.
Respectfullysubmitted,
ELAINEM.HOWLE,CPA
StateAuditor
Blankpageinsertedforreproductionpurposesonly.
v California State Auditor Report 2013-120
June 2014
Contents
Summary 1
Introduction 7
Audit Results
California Correctional Health Care Services Failed to Ensure
That Its Staand Others Always Obtained an Inmates Informed
Consent Lawfully Prior to Sterilization 19
Protocols Designed to Ensure That Sterilization Is Medically
NecessaryFailed 26
The Receivers Oce Must Take Additional Steps to Rectify Failures
That Led to Inmates Being Sterilized by Bilateral Tubal Ligation 28
Recommendations 31
Appendix
Statistical and Demographic Information About Female Inmates
WhoReceived Medical Treatment Potentially Causing Sterilization
Between Fiscal Years 200506 Through 201213 35
Response to the Audit
California Correctional Health Care Services 39
California State Auditors Comment on the Response
FromCaliforniaCorrectional Health Care Services 43
vi California State Auditor Report 2013-120
June 2014
1 California State Auditor Report 2013-120
June 2014
Audit Highlights . . .
Our audit of female inmate sterilizations
occurring over an eight-year period
revealed the following:
144 female inmates were sterilized
through a surgery known as bilateral
tubal ligation.
39 inmates were sterilized following
deciencies in the informed
consent process.
We saw no evidence that the inmates
physician signed the required consent
form in 27 cases.
In 18 cases, we noted potential
violations of the required waiting
period between when the inmate
consented to the procedure and when
the sterilization procedure actually
took place.
Among these 39 inmates there were
six cases where we noted violations of
both consent form and waiting period.
Neither the California Department of
Corrections and Rehabilitation nor the
California Correctional Health Care
Services ensured that the informed
consent requirements were followed in
19 instances in which their employees
obtained inmates consent.
Summary
Results in Brief
TeCaliforniaDepartmentofCorrectionsandRelabilitation
(Corrections)overseestleinmatepopulationoftleStates
adultprisons.Duringoureiglt-yearauditperiodwliclwe
denedasscalyears:oo,o6tlrougl:o:fouroftlese
prisonslousedsubstantiallyalloftlefemaleinmates:California
InstitutionforWomen,CentralCaliforniaWomensFacility,Folsom
WomensFacility,andValleyStatePrisonforWomen(Valley).
Valleynolongerlouseswomensinceitsconversiontoamens
prisonin)anuary:o.Formuclofourauditperiod,Corrections
roleinprovidinginmateswitlmedicalcarewasnotsignicant,
tlemoresubstantialrolewasplayedbyCaliforniaCorrectional
HealtlCareServices(ReceiversOce)undertledirectionofa
federalcourt-appointedreceiver.Areceivertookcontrolofprison
medicalcarein:oo6andwillretaincontroluntiltlecourtnds
tlatCorrectionscanmaintainaconstitutionallyadequateprison
medicalcaresystem.
Fromscalyears:oo,o6tlrougl:o:,((femaleinmates
weresterilizedbyaprocedureknownasabilateraltuballigation.
Telastoftlesefemaleinmatesterilizationsoccurredin:o.
Altlouglvarioussurgicalproceduresmayresultinafemales
sterilization,bilateraltuballigationsaregenerallysurgical
procedurestlatareperformedfortlesolepurposeofsterilization,
andstateregulationsimposecertainrequirementstlatmustbe
metbeforesuclaprocedureisperformed.However,tlestate
entitiesresponsibleforprovidingmedicalcaretotleseinmates
Corrections
andtleReceiversOcesometimesfailedtoensure
tlatinmatesconsentforsterilizationwaslawfullyobtained.
Overall,wenotedtlat,inmates
a
weresterilizedfollowing
decienciesintleinformedconsentprocess.Wefoundtwotypes
ofdeciencies.First,wefoundnoevidencetlattleinmates
plysiciantleindividualwlowouldperformtleprocedurein
alospitaloranalternateplysiciansignedtleconsentformas
requiredbystateregulations.Second,wenotedpotentialviolations
oftlerequiredwaitingperiodbetweenwlentleinmateconsented
1
Corrections was responsible for inmate health care between July , , and the appointment
of the rst federal receiver, eective April . During this time period, inmates had tubal
ligation procedures, and based on available and potentially incomplete medical records,
documentation for at least four of these inmates demonstrated potential violations of informed
consent requirements.
2
The true number of inmates for whom Corrections or the Receivers Oce did not ensure that
lawful consent was obtained before sterilization may be higher. For example, one hospital
destroyed seven inmate medical records in accordance with its records retention policy. Five of
these seven inmates consented to the sterilization procedure while in prison, and it is unclear
based on available recordswhether physicians signed the sterilization consent forms just prior
to surgery.

California State Auditor Report 2013-120
June 2014
2
totleprocedureandwlentlesterilizationsurgeryactuallytook
place.Someinmatesweresterilizedfollowingviolationsofbotlof
tleserequirements.AltlouglneitlerCorrectionsnoremployees
oftleReceiversOceactuallyperformedtlesterilization
procedures,weconcludedtlattleyladaresponsibilitytoensure
tlattleinformedconsentrequirementswerefollowedintlose
instanceswlentleiremployeesobtainedinmatesconsent,wlicl
wastlecaseforatleast,oftle,inmates.Eitlertleremaining
:oinmatessignedtleirconsenttobesterilizedataplysical
locationotlertlanaprisonortleReceiversOceladdiculty
determiningwletlertleindividualwloobtainedconsentwas
an employee.
Lawfulconsentisrepresentedbykeystepsasdenedbytle
CaliforniaCodeofRegulations,Title::(Title::).Forexample,
tleplysicianoranalternateplysicianmustsigntleconsentform
justbeforeperformingtlesurgery,andawaitingperiodisrequired
aftertlepatientsignstleconsentform.Temissingplysicians
signaturesonsomeoftleinmatesconsentformsareespecially
concerningbecauseofwlattleplysiciansignaturecerties:tlat
tlerequiredwaitingperiodlasbeensatisedandtlattlepatient
appearsmentallycompetentandunderstandstlelastingeectsof
sterilization.Teplysicianistlelastcleckintleinformedconsent
processandprovidestlepatientwitltlenalopportunityto
clangelermind.
Alltlebilateraltuballigationswereviewedwereperformedat
generalacutecarelospitalsratlertlaninprisonmedicalfacilities.
AlawyerfortleReceiversOcestatedtlattlespecicprovisions
ofTitle::donotapplytoprisonemployees,becauseTitle::
appliesonlytogeneralacutecarelospitals.Nevertleless,because
employeesoftleReceiversOceplayedasignicantroleintlese
,inmatescareandinobtainingtleirconsenttobesterilized,
ourlegalcounseladvisedustlatacourtwouldlikelyndtlattle
ReceiversOceladaresponsibilitytoensuretlatconsentwas
lawfullyobtainedfromtleseinmatesinaccordancewitlTitle::.
Altlougltleconsentformswewereabletoreviewdemonstrated
tlateaclfemaleinmatesignedaconsentform,welaveconcerns
aboutwletlertlefemaleinmatesundergoingbilateraltubal
ligationsreceivedadequatecounselingabouttleirdecisiontobe
sterilized.DespiteaReceiversOcepolicytlatprisonmedical
stamustuseprogressnotesatermfordocumentinginformation
madeinaninmatesmedicalrecordtosummarizediscussions
witlinmates,innoinstancedidwendafemaleinmatewlose
progressnotesadequatelyreectedtlatsleladbeencounseled
aboutlerdecisiontobesterilized.Telackofnotesintleinmates
medicalrecordsregardinginformedconsentandsterilization
madeitimpossibleforustoreaclaconclusionastotlequality
June 2014
andcontentoftleconsultationsbetweenprisonmedicalsta and
inmates.Wewerealsounabletoconcludewletlerinmatesreceived
educationalmaterials,wletlerprisonmedicalstaanswered
inmatesquestions,orwletlertlesestaprovidedtleinmates
witlalloftlenecessaryinformationtomakesuclasensitiveand
life-clangingdecisionassterilization.
TeReceiversOcealsofailedtoensuretlattleprisonmedical
staunderitsdirectionfollowedstateregulationsrequiringspecic
approvalsforbilateraltuballigationprocedures,includingapprovals
bytwocommitteesmadeupofligl-rankingprisonmedicalsta
andmedicalexecutivesfromtleReceiversOce.Tefailure
toobtaintlenecessaryapprovalswassystemic,allbutone of
tle(( bilateraltuballigationprocedureslackedtlenecessary
approvals.Overall,ourlereviewdemonstratedtlatprisonmedical
stainfrequentlyrequestedapprovaltosterilizeinmates,andwlen
tleydid,itwasnotalwayscleartlattlese requestswereapproved.
Inmanycases,prisonmedicalstasimplyrequested approvalfor
otlermedicalproceduressuclascesareansectionsatlospitals
anddidnotindicatetlattleinmatewasalsotobesterilized.
Since)anuary:oo,wlentleReceiversOceassertsitbecame
awareoftlesterilizationproceduresfollowingallegationsby
alegaladvocacygroupitsmedicalclaimsdataslowtlattle
numberoffemaleinmateswlolaveundergonebilateraltubal
ligationsandotlermedicalprocedurestlatresultinsterilization
lasgreatlydecreased.Inaddition,sincetlattimewefound
tlattleReceiversOcelasbetteradleredtoitsprocessesfor
reviewingmedicalservicesfornecessityandforobtainingrequired
approvalsformedicalservices.Nevertleless,becausetlefunction
ofapprovingamedicalprocedurelasbeenandremainsseparate
fromtleprocessforscledulingtleprocedureatageneralacute
carelospitalorotlercommunitymedicalfacility,tleopportunity
stillexistsforinmatestoreceivemedicalservicestlatarenot
autlorized.UntiltleReceiversOceensurestlatmedical
scledulingisdrivenbyautlorizedrequestsforservice,itrisks
subjectinginmatestopotentiallyunnecessarymedicalprocedures
andcannotdemonstratetlatitisinfullcontroloftlemedicalcare
inmatesreceive.
Recommendations
Toensuretlattlenecessaryeducationanddisciplinaryaction
canbetaken,tleReceiversOceslouldreporttotleCalifornia
DepartmentofPublicHealtl,wlicllicensesgeneralacutecare
lospitals,andtleMedicalBoardofCalifornia,wlicllicenses
plysicians,tlenamesofalllospitalsandplysiciansassociated
witlinmatesbilateraltuballigationsduringscalyears:oo,o6
June 2014
4
tlrougl:o:forwliclconsentwasunlawfullyobtained.
TeReceiversOceslouldmaketlesereferralsassoonas
is practicable.
Toensuretlatitcanbettermonitorlowitsmedicalstaand
contractorsadleretotleinformedconsentrequirementsof
Title::,sections;o;o;.tlrougl;o;o;.;,tleReceiversOce
sloulddevelopaplanbyAugust:o(toimplementaprocessby
December:o(tlatwouldincludetlefollowing:
Providingadditionaltrainingtoprisonmedicalstaregarding
Title::requirementsforobtaininginformedconsentfor
sterilizationprocedures,includingtleapplicableformsand
mandatorywaitingperiodrequirements,toensuretlatconsent
islawfullyobtained.
Developingclecklistsorotlertoolstlatprisonmedicalsta
canusetoensuretlatmedicalproceduresarenotscleduled
untilaftertleapplicablewaitingperiodsforsterilizationlave
been satised.
Periodicallyreviewing,onaconsistentbasis,asampleofcases
inwliclinmatesreceivedtreatmentresultinginsterilizationat
generalacutecarelospitals,toensuretlatallinformedconsent
requirementsweresatised.
UntilsucltimeastleReceiversOceimplementsaprocess
forobtaininginmateconsentforsterilizationunderTitle::tlat
complieswitlallaspectsoftleregulations,itsloulddiscontinue
itspracticeoffacilitatinganinmatesconsentforsterilizationin
tleprisonandallowtlegeneralacutecarelospitaltoobtainan
inmatesconsent.
Toimprovetlequalityoftleinformationprisonmedicalsta
documentininmatemedicalrecords,tleReceiversOce
slould dotlefollowing:
Trainitsentireprisonmedicalstaonitspolicyintle inmate
medicalproceduresrelatedtoappropriatedocumentationin
inmatesmedicalrecords.Tistrainingslouldbecompletedby
December , :o(.
Eitlerdeveloporincorporateintoanexistingprocessameans
bywliclitevaluatesprisonmedicalstasdocumentationin
inmatemedicalrecordsandretrainsprisonmedicalstaas
necessary.TeReceiversOcesloulddevelopandimplement
tlisprocessby)uneo,:o,.
June 2014
Toensuretlatinmatesreceiveonlymedicalservicestlatare
autlorizedtlrouglitsutilizationmanagementprocess,tle
ReceiversOcesloulddotlefollowing:
DevelopprocessesbyAugust,:o(,sucltlataprocedure
tlatmayresultinsterilizationisnotscleduledunlesstle
procedureisapprovedattlenecessaryleveloftleutilization
management process.
ByOctober,:o(,trainitsscledulingstatoverifytlattle
appropriateutilizationmanagementapprovalsaredocumented
beforetleyscleduleaproceduretlatmayresultinsterilization.
Agency Comments
Initsresponsetotleaudit,tleReceiversOcegenerallyagreed
witltlereportsfactualndings,butnotedtlatitreacled
conclusionsaboutitsdutytoensurecompliancewitltle
sterilizationandconsentproceduressetfortlinTitle::tlatdier
fromtlereport.Nevertleless,tleReceiversOcepledgedto
implementalloftlerecommendations.
June 2014
June 2014
Introduction
Background
TeCaliforniaDepartmentofCorrectionsandRelabilitation
(Corrections)overseestleStatesprisonpopulation,wliclincludes
adultprisons.Oftlese,fourprisonslousedsubstantiallyallof
tlefemaleinmatesintleeigltyearsspanningscalyears:oo,o6
tlrougl:o:.Twooftleprisons,CaliforniaInstitutionfor
Women(CIW)andCentralCaliforniaWomensFacility(Central),
aredesignatedwomensprisonsandcontinuetolousefemale
inmates.In)anuary:oCorrectionsrealignedtlepopulationsof
twoprisons,convertingValleyStatePrisonforWomen(Valley)toa
mensprisonandestablislingFolsomWomensFacility(Folsom)at
FolsomStatePrison.Asof)une:otlefemaleinmatepopulations
attleCIW,Central,andFolsomprisonswere:,,,,:,,and
86 women,respectively.TablelistsCorrectionstotalfemale
inmatepopulationduringourauditperiod,andFigureontle
followingpageindicatestlelocationsoftleprisonsforwomenand
providesgeneralinformation.AccordingtoCorrectionsassociate
wardenofmissionforfemaleoenderprogramsandservicesand
speciallousing,tlefemaleinmatepopulationdecreasedin:o:
becauseoftle:oRealignmentlegislationaddressingpublicsafety.
Table 1
Female Inmate Population From 2006 Through 2013
2006 2007 2008 2009 2010 2011 2012 2013
Female inmate
population*
11,749 11,888 11,392 11,027 10,096 9,565 6,409 5,919
Sources: California Department of Corrections and Rehabilitations monthly population reports (as
of June 30
th
of each year).
* The female inmate population includes the number of female inmates incarcerated in prisons,
camps, community correctional centers, and state hospitals, but excludes females on parole.
Medical Care in Prisons
Multipleentitiesareinvolvedinprovidingmedicalcaretoinmates
oroverseeingtleirmedicalservices,includingCorrections,
CaliforniaCorrectionalHealtlCareServices(ReceiversOce)
undertledirectionofafederalcourt-appointedreceiver(receiver),
andcommunity-basedmedicalproviders.Altlouglmultiple
entitiesareinvolved,since:oo6tlereceiverlasbeenresponsible
forcontrollingprisonmedicalservicesasaresultoflitigation
concerningprisonlealtlcare.InApril:oonineinmatesleda
classactionlawsuitagainststateocialsinfederalcourt(court)
June 2014
8
allegingtlatCorrectionswasprovidingconstitutionallyinadequate
medicalcare.Tiscaseresultedina)une:oo:agreementrequiring
Correctionstoimprovemedicalcareforprisoners.However,in
)une:oo,,tlecourtdeterminedtlattleCaliforniaprisonmedical
caresystemwasbrokenbeyondrepairandruledtlatitwould
establislareceiversliptocontroltledeliveryofmedicalservicesto
allprisonersconnedbyCorrections.Tecourtappointedtlerst
receivereectiveApril:oo6,andtlecurrentreceiverlasserved
intlerolesince)anuary:oo8.Before:oo6Correctionscontrolled
medicalcaretoinmates,nowitisresponsibleformaintainingtle
custodyofinmatesastleyreceivetleirmedicalcare.
Figure 1
Prisons That Housed Primarily Women During Our Audit Period
Fiscal Years 200506 Through 201213
FOLSOM WOMENS FACILITY
(began housing women in January 2013)
Located in Folsom, Sacramento County
Total population 186 (June 30, 2013)
CENTRAL CALIFORNIA WOMENS FACILITY
(opened in 1990)
Located in Chowchilla, Madera County
Total population 3,525 (June 30, 2013)
VALLEY STATE PRISON FOR WOMEN
(converted to a mens facility in January 2013)
Located in Chowchilla, Madera County
CALIFORNIA INSTITUTION FOR WOMEN
(opened in 1952)
Located in Corona, Riverside County
Source: California Department of Corrections and Rehabilitation.
June 2014
Tecourtgavetlereceiverbroadautloritytoreformtleprison
medicalcaresystemuntilitndstlatstateocialsareable
tomaintainaconstitutionallyadequateprisonmedicalcare
system.Tereceiversautlorityincludesalloftlesecretaryof
Correctionspowersforadministering,controlling,managing,
operating,andnancingtleprisonmedicalcaresystem.Furtler,
tlereceiverisrequiredtorequesttlattlecourtwaivestatelaws,
regulations,and contractualrequirementsiftleyareimpediments
toreform andotleralternativesareinadequate.Inexecutingtle
autloritygivenbytlefederalcourt,tlereceiverleadsanddirects
tleactivitiesoftleReceiversOce.Prisonplysicians,nurses,and
otlermedicalstanowworkfortlereceiver.
Process for Approving Medical Procedures for Inmates
Ingeneral,tleReceiversOcemustensuretlattlecareinmates
receiveismedicallynecessary.Typically,tlisismedicalcaretlatis
necessarytoprotectlife,topreventsignicantillnessordisability,
ortoalleviateseverepainandtlatissupportedbylealtloutcome
dataasbeingeective.CaliforniaCodeofRegulations,Title,
(Title ,),speciesrequirementsrelatedtoprisonmedicalcareand
denescertainmedicalproceduresasexcluded,meaningtleyare
servicestlatcannotbeprovidedtoinmatesbecause tle services
treatconditionstlatimproveontleirown,suclastlecommon
cold,ortreatconditionstlatarecosmeticornotamenableto
treatment,suclastattooremovalormultiple-organtransplants.
Title,liststuballigationsandvasectomiestlatarenotmedically
necessaryasexcludedservices.Aninmatesplysicianmayprescribe
anexcludedserviceasclinicallynecessary,inwliclcasetle
excludedservicemustbeapprovedbytwo committees:onebased
intleprisonandtleotler attleReceiversOce leadquarters.
Title,establislestwocommittees,knownasutilization
managementcommittees,tlatconvenetoapproveordenyrequests
forexcludedservices.Tesecommitteesarerequiredtoconsider
availablelealtlcareoutcomedatasupportingtleeectiveness
oftleexcludedserviceandotlerfactors,suclastleseverityof
tleinmatescondition,tlelengtloftleinmatessentence,tle
availabilityoftleservice,andtlecost.Terstcommitteeis
establisledineaclprisonandiscalledtleInstitutionalUtilization
ManagementCommittee(institutionalcommittee).Aninstitutional
committeeconsistsofatleasttlreestaplysicianswlovoteto
approveordenyrequestsforexcludedmedicalservices.Tose
requeststlatreceivetleinstitutionalcommitteesapprovalmust
beforwardedtotleHeadquartersUtilizationManagement
Committee(leadquarterscommittee).Teleadquarters committee
meetstoreviewexcludedservicesrequestsapprovedbyeacl
institutional committee.Itisrequiredtoconsidertlesame
June 2014
10
factorsastleinstitutionalcommittees,andonlytlosecommittee
memberstlatarelicensedplysiciansmayvotetoapproveordeny
arequestforanexcludedservice.Teinstitutionalcommitteeand
leadquarterscommitteearedepictedaslevelsand(inFigure:.
Tegurealsodepictstlatadeniedrequestforanexcludedservice
maybe appealed.
TeReceiversOcemaintainsanddistributestleInmate Medical
Services Policies and Procedures(prisonmedicalprocedures),
wliclestablislestwopreliminarylevelsofreview(levelsand:
inFigure :)beforetleinstitutionalcommittee.Levelinvolvesa
prisonnursereviewingtlerequestfortleexcludedserviceand
forwardingtlerequest,alongwitlanycorrespondingstatewide
programguidelines,tolevel:fortlisreviewertoapproveordeny
tlerequest.Televel:reviewerarolelledbytleprisonsclief
medicalexecutiveordesigneeforwardstleapprovedrequestto
tleinstitutionalcommittee.
Teapprovalprocessfornonexcludedservicesissligltlydierent
fromtleapprovalprocessforexcludedservicesjustdiscussed.
Wlereasaninmatesplysicianseekingapprovalforanexcluded
servicemustultimatelysecureapprovalfrombotllevel(tle
institutionalcommittee)andlevel((tleleadquarterscommittee)
beforetreating tleinmate,tlereisnosuclrequirementfor
nonexcludedservices.Ratler,aplysiciantypicallyneedsonly
level :approvalfromtleprisonscliefmedicalexecutiveor
designee.Levelsand(considerrequestsfornonexcluded
servicesonlywlentlerequestlasbeendeniedatalowerlevel
ofreviewandistlenappealed.Tus,fornonexcludedservices,
Figure:slowstlatayesatlevel:oraboveresultsintleservice
being approved.
Process for Obtaining an Inmates Informed Consent forSterilization
Stateregulationsspecifytleinformedconsentrequirementsfor
sterilizationsatgeneralacutecarelospitals.Femaleinmatesmay
lavemedicalneedstlattleprison-basedmedicalstaarenot
trainedorequippedtoaddresssuclaslaboranddeliveryorotler
surgeriesinwliclcasetleReceiversOcearrangesformedical
careatgeneralacutecarelospitals.
June 2014
Figure 2
Process for Reviewing a Request for Service
SERVICE
DENIED
SERVICE
DENIED
SERVICE
DENIED
SERVICE
DENIED
SERVICE
DENIED
SERVICE
DENIED
Request for Service
that is, by state regulations,
EXCLUDED
*
Request for Service that is
NONEXCLUDED
If requesting physician
appeals the decision
Approved
Denied
L E V E L 3
Institutional Utilization Management Committee
Reviews the Request for Service
L E V E L 4
Headquarters Utilization Management Committee
L E V E L 1
Institutional Utilization Management Nurse
Forwards the Request for Service
and review criteria to Level 2
L E V E L 2
Institutional Chief Medical Executive
SERVICE
APPROVED
FORWARD FORWARD
Patient-Physician Encounter
Patient presents symptoms, physician diagnoses and recommends
treatment. Physician submits a Request for Service seeking
authorization to provide medical services.
Sources: California Correctional Health Care Services deputy medical executive of utilization management and California State Auditors analysis of
Inmate Medical Services Policies and Procedures.
* Excluded services are not to be provided to inmates unless approved by level 4. Services include surgery, such as tubal ligation.
Nonexcluded services are medical services not otherwise dened as excluded services in state regulations.
June 2014
Wlensterilizationprocedurestakeplacein
generalacutecarelospitals,aswastlecasewitl
tlebilateraltuballigationswereviewed,tle
CaliforniaCodeofRegulations,Title::(Title::),
specieslowinformedconsentmustbeobtained
anddocumented.Teserequirementsapplywlen
tlepurposeoftleprocedureistorendertle
patientincapableofreproduction.Title::outlines
keyrolesintleconsentprocessandmandatesa
waitingperioddenedastletimebetween
wlentleinmatesignedtleconsentform
and wlentleproceduremaybeperformed.
SelectedTitle::requirementsforinformed
consentaredescribedintletextbox.
Title::statestlattleformprovidedbytle
CaliforniaDepartmentofPublicHealtlmustbe
usedtodocumentapatientsinformedconsentfor
sterilization.Treeorfourindividualsmustsigntle
formcertifyingtleirroleintleinformedconsent
processfortlesterilizationprocedure.Wlentle
patientsignstleconsentform,sleiscertifyingtlat
sleunderstandstlattlesterilizationprocedure
mustbeconsideredpermanentandirreversible.
Tepatientisalsocertifyingtlatsleunderstands
tlereisawaitingperiodandtlatslecanclange
lermindatanytime.Teformdoesnotinclude
aplaceforawitnessssignature,altlouglTitle::
permitstlepatienttolaveawitnessoflercloice
presentwlenslesignstleconsentform.
Teindividualobtainingtlepatientsconsentalsosignstleform,
certifyingtlattlepatientappearsmentallycompetentandstill
desirespermanentsterilizationafterreceivingcounselingontle
procedureseectsandadiscussionofalternativeformsofbirtl
control.Ifneeded,aninterpreterwillsigntleformattestingtlatle
orslelastranslatedtotlepatienttleinformationandadvicetlat
tlepersonobtainingconsentpresentedorallytotleindividualto
besterilized.
Finally,tleplysicianperformingtleprocedureoranalternate
plysicianmustsigntleconsentformcertifyingtlat,justpriorto
surgery,tlepatientwasagaincounseledontleprocedureandtlat
consentcouldstillbewitldrawn.Teplysicianalsocertiestlat
tlepatientappearsmentallycompetentandtlatatleastodays
lavepassedsincetlepatientconsentedtotleprocedure,exceptin
instancesofanemergencyabdominalsurgery,prematuredelivery,
orwlentlepatientlaswaivedtlewaitingperiod.Regardlessof
tleseexceptionstotleo-daywaitingperiod,Title::prolibitstle
Selected California Code of Regulations, Title22,
Requirements Regarding Informed Consent
forSterilizations
The patient must be at least 18 years old or independent.
The patient must consent at least 30 days before the
sterilization, but not more than 180 days.
Exceptions: Sterilization may be performed at least 72 hours
after consent if the patient either:
Waives the 30-day waiting period in writing.
Undergoes emergency abdominal surgery or
premature delivery and consent was at least 30 days
before the expected date of surgery or delivery.
The patient must be given an opportunity to have a
witness of her choice present at the time of consent.
The patient must consent by signing the California
Department of Public Health form. The following
persons must also sign the form certifying that consent
wasinformed:
Interpreter, if one was provided.
Person who obtained consent.
Physician who performed the sterilization,
oranalternate physician.
Sources: California Code of Regulations, Title 22,
sections70707.1 through 70707.7.
June 2014
sterilizationofapatientlesstlan;:loursafterslelassignedtle
consentform.Teplysicianscounselingtotlepatientiseectively
tlelastopportunitytoensuretlatalllegalrequirementsfortle
patientsinformedconsentlavebeensatised.
Title,containsrequirementstlatapplytoprisonsanddenes
tle requirementsforaninmatesinformedconsentforallmedical
treatmentsnotjuststerilizations.Suclrequirementsgenerally
statetlattleinmatesinformedwrittenconsentmustbeobtained,
ascircumstancespermit,beforetreatmentisundertakenforserious
procedures.Title,alsostatestlataninmateiscapableofgiving
informedconsentifintleopinionoflealtlcarestatleinmate
isawaretlereisaplysiologicaldisorderforwlicltreatmentor
medicationisrecommended,abletounderstandtlenature,
purpose,andalternativesoftlerecommendedtreatment,and able
tounderstandandreasonablydiscusstlepossiblesideeectsand
anylazardsassociatedwitl tlerecommendedtreatment.
Asslownintletextbox,tleReceiversOce
lasspecicpoliciesforitsstatofollowtoensure
tlattlereisatlorougldiscussionbetweentle
inmateandtleplysicianbeforetleinmates
consenttosurgery.Asearlyas)anuary:oo:,botl
beforeandafterinmatemedicalcarewastaken
overbyareceiver,policiescontainedwitlintle
prisonmedicalproceduresrequiredtlatprison
medicalstarecordtleessenceoftleirinformed
consentdiscussionswitlinmatesaboutpotential
procedures.Furtler,tleprisonmedicalprocedures
explaintlatdocumentingtleinformedconsent
processprotectstlemedicalstafromclargesof
battery,negligence,andiorunprofessionalconduct.
Excluded and Nonexcluded Medical Procedures That
Result inSterilization
Abilateraltuballigationwliclisnotmedically
necessaryisanexcludedserviceasstated
previously.Tesolepurposeoftlisprocedureisto
sterilizeawoman.Incontrast,aproceduresuclas
alysterectomyintendedtotreatcanceroraddress
otlerlealtlproblemsalsoresultsinsterilization,
altlougltlatwasnottleprocedurespurpose.
Fromscalyear:oo,o6tlrougl:o:,claims
datafromtleReceiversOceslowtlat;,( female
inmatesladvariousprocedurestlatcouldlave
resultedinsterilization.Wedeterminedtlat((of
tleseinmatesunderwentabilateraltubal ligation
Prison Medical Policies and Procedures
Regarding Informed Consent
Policies
Medical sta shall document in the patients health
record that the patient has freely given informed consent
prior to treatment.
Informed consent shall be an educational process.
Documentation shall substantiate that medical sta has
provided sucient information to the patient in language
and terms the patient understands.
Medical sta shall explain the nature of the anticipated
treatment, the expected outcomes and risks, and
possiblealternatives.
Medical sta shall document an acknowledgment that
the patient can withdraw his or her consent at any time.
Procedures
The prison medical sta shall:
Use medical notes in the inmates le to record the
essence of the informed consent process.
Enter the times and dates of all discussions with
the patient pertinent to proposed treatment,
recording sucient information about the essence
ofthediscussion.
Sign the medical notes with his or her full name and title.
Source: Inmate Medical Services Policies and Procedures (in eect
since January 2002).
June 2014
14
or similarprocedurefortlesolepurposeofsterilization.
3
We
focusedourauditontlefemaleinmateswlounderwentabilateral
tuballigation,giventlisproceduresclassicationasanexcluded
serviceunderTitle,.Additionalinformationaboutfemaleinmates
isinTableA.onpage6intleAppendix,wlicldetailstlevarious
sterilizationproceduresinmatesunderwentbyproceduretype.For
femaleinmateswlounderwentabilateraltuballigation,TableA.:
onpage;summarizesotlerprocedurestleyladduringtlesame
lospitalstayforexample,acesareansectionandTableA.on
page;presentsselectedfemaleinmatedemograplics.
Scope and Methodology
Te)ointLegislativeAuditCommittee(auditcommittee)
directed tleCaliforniaStateAuditor(stateauditor)toreview
tleReceiversOceandotlerresponsibleentitiespoliciesand
proceduresrelatedtosterilizationsoffemaleinmates.Teaudit
committeeapprovedeigltobjectives.Table:beginningonpage ,
liststleobjectivestlattleauditcommitteeapprovedandtle
metlodsweusedtoaddresstlem.
3
Some of the inmates underwent a medical procedure known as salpingectomy, which is the
removal of all or a portion of the fallopian tubes. In this report we use the term bilateral tubal
ligation to describe a bilateral tubal ligation or salpingectomy performed when sterilization was
the intent of the surgery; we do not distinguish between these two procedures.
June 2014
Table 2
Audit Objectives and the Methods Used to Address Them
AUDIT OBJECTIVE METHOD
1 Review and evaluate the laws, rules and regulations
signicant to the audit objectives.
Reviewed relevant state laws, regulations, and other background materials.
2 Determine what entities are involved in providing
medical services to inmates and identify the roles
and responsibilities California Correctional Health
Care Services (Receivers Oce) and other entities,
such as the California Department of Corrections and
Rehabilitation (Corrections), may have in overseeing
medical services and sterilization procedures for
femaleinmates.
Reviewed pertinent state laws, regulations, and federal court documents.
Interviewed key ocials.
3 Review and assess policies and procedures used by the
Receivers Oce and other entities that may be involved
for handling sterilization procedures for female inmates,
including informed consent procedures, and determine
whether they are consistent with applicable laws
andregulations.
a. Identify any changes to the regulations or laws
relating to the sterilization of female inmates over
the past eight years and determine whether the
Receivers Oce or any other oversight entitys
policies and procedures reect such changes.
Reviewed laws, regulations, federal court documents, and the Receivers Oce
policies and procedures for utilization management and informed consent in
eect during our audit period, including any changes to these documents.
Compared the laws and regulations to the policies and procedures to determine
whether the policies and procedures were consistent with key requirements.
4 Determine how the Receivers Oce or any other
entity monitors to ensure compliance with policies and
procedures related to sterilization of female inmates.
Reviewed laws, regulations, policies and procedures, medical records, and
otherdocuments.
Assessed whether sterilization procedures were requested and approved in
accordance with pertinent requirements for the following inmates:
All females we identied that underwent a bilateral tubal ligation during
scal years 200506 through 201213.
Twenty females we haphazardly selected from those females we identied
who had a sterilization procedure other than a bilateral tubal ligation during
April2010 through June 2013.
5 Identify protocols and practices relating to obtaining
the informed consent authorizing the sterilization of
female inmates, including any recent changes in the
past eight years.
a. Identify any changes to protocols or practices over
the past eight years that clarify the circumstances
under which a sterilization procedure can be
suggested to a female inmate.
Reviewed policies and procedures, and documents communicating
procedurechanges.
continued on next page . . .
June 2014
AUDIT OBJECTIVE METHOD
6 For the most recent eight-year period, determine the
number of sterilization procedures performed each
year, and to the extent possible, for each sterilization
procedure perform the following:
Determine whether the inmate was pregnant,
why the procedure was performed, whether the
procedure was deemed medically necessary,
and whether the process for obtaining approval
complied with applicable policies and laws.
Identify the demographics of each inmate, including
economic status, ethnicity, race, number of prison
terms, number of pregnancies, and number of child
births. Determine whether there are any trends in
the data.
Determine whether the inmate consented to
authorize the procedure and whether such consent
was lawfully obtained. Determine when, where, and
how the consent was obtained.
Determine whether the sterilizations were
performed in conjunction with other medical
procedures and, if so, identify those procedures.
To the extent possible, determine whether the
inmate was informed about the procedure and
whether she led a complaint about the procedures.
Reviewed pertinent laws, regulations, policies and procedures, and
otherdocuments.
Utilized a certied medical coder to identify Current Procedural Terminology
(CPT) codes associated with medical procedures that result in female sterilization.
Using medical claims data that the Receivers Oce supplied and that included
CPT codes, we identied all female inmates that underwent a medical procedure
that could result in sterilization, including a bilateral tubal ligation, during scal
years200506 through 201213.
For inmates receiving bilateral tubal ligations, we reviewed inmate medical
records from the Receivers Oce, from the hospital where the sterilization
procedure was performed, and, in some instances, from the physician that
performed the sterilization procedure. However, our review was limited because
the Receivers Oce and one hospital could not provide us with all inmate health
records we requested. We used available records to determine, to the extent
possible, the following:
Whether the inmate was pregnant, why the physician performed
the sterilization procedure, and whether the procedure was deemed
medicallynecessary.
Whether the inmates sterilization consent complied with applicable laws.
When, where, and how the inmates consent to sterilization was obtained.
The number of pregnancies and child births for each inmate as well
as whether English was her primary language and other selected
demographicinformation.
We reviewed the CPT codes associated with the bilateral tubal ligations to
understand how often these procedures took place while at a hospital for
childbirth.
We reviewed the extent to which inmate medical records documented
discussions between the physician and the inmate about the sterilization
procedure. We also accessed databases of complaints Corrections and the
Receivers Oce each maintain and searched the records for inmates who
underwent a bilateral tubal ligation. For these inmates, we did not identify any
complaints regarding this procedure.
7 Determine funding sources for the sterilization
procedures and whether the expense for
suchprocedures was appropriate and allowable.
Ifnot,identify any consequences.
We identied one inmate for whom we determined that the Receivers Oce
received Medi-Cal federal reimbursement for the inmates pregnancy-related hospital
services, which included a bilateral tubal ligation. Both state and federal regulations
prohibit theuse of Medi-Cal funds for the sterilization of institutionalized individuals.
Althoughthe Receivers Oce did not seek reimbursement for the bilateral tubal
ligation procedure directly, we determined that it was performed in conjunction with a
cesarean section surgery. Medi-Cal reimbursed the Receivers Oce for a portion of the
inmates hospitalization costs including use of the surgical room; thereimbursement
included federal funds. We notied the Receivers Oce andthe California Department
of Health Care Serviceswhich administers Medi-Caland directed these entities to
evaluate the appropriateness of the Medi-Cal reimbursement for this inmate. In order
to identifythe Medi-Cal reimbursement, in addition to some of the methods noted
above,we performed the following steps:
Reviewed budget documents showing federal reimbursements for inmates
receiving medical care at o-site facilities.
For inmates receiving tubal ligation procedures during the time when the State
was receiving federal reimbursement, we researched whether the Receivers
Oce submitted reimbursement claims for these inmates.
8 Review and assess any other issues that are signicant
to the policies and procedures of the Receivers
Oce orother responsible entities related to the
sterilizationof female inmates.
Our review of medical claims data and inmate health les at times raised concerns
about the accuracy of the medical claims the Receivers Oce may have paid. We
provided the Receivers Oce with the information necessary for it to research
theseclaims.
Sources: The California State Auditors analysis of Joint Legislative Audit Committee audit request number 2013120, and information and
documentation identied in the table column titled Method.
June 2014
Assessment of Data Reliability
Inperformingtlisaudit,werelieduponelectronicdatales
extractedfromvariousinformationsystems.TeU.S.Covernment
AccountabilityOce(CAO),wlosestandardswearestatutorily
requiredtofollow,requiresustoassesstlesuciencyand
appropriatenessofcomputer-processedinformationtlatweuseto
supportndings,conclusions,orrecommendations.Tableslows
tleresultsoftlisanalysisfordataobtainedfromtleReceivers
OceandCorrections.
Table 3
Methods Used to Assess Data Reliability
INFORMATION SYSTEM PURPOSE METHODS AND RESULTS CONCLUSION
California Correctional Health
Care Services (Receivers Oce)
Contract Medical Database (CMD)
CMD Access Version
CMD Web Version
CMD Interface
Data as of November 2013
To determine the
number and type
of sterilization
procedures by scal
year performed
on female inmates
for the period of
July1,2005, through
June 30, 2013.
We performed data-set verication procedures and electronic
testing of key data elements and did not identify any issues.
We performed manual review of medical records for all 148inmates
electronically identied as having undergone a bilateral tubal
ligation procedure. As a result of this review, we identied
fourinmates whose CMD records showed that they had undergone
a bilateral tubal ligation, but review of the inmates hardcopy
medical les showed that the procedure was not performed.
We did not perform completeness testing due to a variety of factors
that make it dicult to determine denitively how often female
inmates received medical procedures resulting in sterilization when
sterilization was the sole purpose for the surgery, as we describe in
the Appendix.
Undetermined
reliability for
the purposes of
this audit.
California Department of
Corrections and Rehabilitation
(Corrections)
Strategic Oender Management
System (SOMS)
Data as of December 2013
To identify the
demographics of
each female inmate
who we identied as
having undergone
a bilateral tubal
ligation procedure
between July 1, 2005,
and June 30, 2013.
We performed data-set verication procedures and electronic
testing of key data elements and did not identify any issues.
In April 2012 we issued a condential management letter to
Corrections that detailed our review of selected information
systemcontrols, which included general and business process
application controls. During this review, we identied signicant
weaknesses in Corrections general controls over its information
systems. General controls support the functioning of business
process application controls; both are needed to ensure complete
and accurate information processing. If the general controls are
inadequate, the business process application controls are unlikely
to function properly and could be overridden. Due to pervasive
weaknesses in Corrections general controls, we did not perform
any testing of the business process application controls. Because
our audit period covers inmates who underwent a sterilization
procedure between July 1, 2005, and June 30, 2013, and we
performed our control review in April 2012, the majority of our
audit period occurred prior to the issuance of our control review.
Not suciently
reliable for the
purposes of
this audit.
Corrections
Tests of Adult Basic Education
(TABE) Master File Access
Database
Data as of January 2014
To identify the TABE
reading test score
closest to a female
inmates bilateral
tubal ligation
procedure date for
those inmates who
underwent the
procedure between
July 1, 2005, and
June 30, 2013.
Source: California State Auditors analysis of various documents, interviews, and data obtained from the entities listed in the table.
June 2014
June 2014
Audit Results
California Correctional Health Care Services Failed to Ensure That
Its Sta and Others Always Obtained an Inmates Informed Consent
Lawfully Prior to Sterilization
Betweenscalyears:oo,o6and:o:,((femaleinmates
underwentmedicalprocedurestlatwereintendedtoresultin
permanentsterilization.Tesemedicalprocedureswliclwere
bilateraltuballigationsorcomparableproceduresinwlicltle
fallopiantubesarecuttopreventconceptionweresometimes
performedwitloutsatisfyingtlelegalrequirementsforobtaining
inmatesinformedconsentforsterilization.Overall,wenoted
tlat,inmatesweresterilizedfollowingcertaindecienciesin
tleinformedconsentprocess.For:;consentforms,wesawno
evidencetlattleinmatesplysiciantleindividualwlowould
performtleprocedureinalospitaloranalternateplysician
signedtlerequiredconsentform.For8consentforms,wenoted
potentialviolationsoftlerequiredwaitingperiodbetweenwlen
tleinmateconsentedtotleprocedureandwlentlesterilization
surgeryactuallytookplace.
4
Someinmatesweresterilizedeven
tlougltleirconsentformreectedviolationsofbotloftlese
requirements.Ourlegalcounsellasadvisedustlat,basedon
tlesefacts,acourtwouldlikelyconcludetlattlese,inmates
consentwasnotlawfullyobtained.Moreover,altlouglneitler
tleCaliforniaDepartmentofCorrectionsandRelabilitation
(Corrections)noremployeesofCaliforniaCorrectionalHealtl
CareServices(ReceiversOce)actuallyperformedtle
sterilizationprocedurestlemselves,ourlegalcounseladvisedus
tlatCorrectionsandtleReceiversOcenevertlelesslavea
responsibilitytoensuretlattleinformedconsentrequirements
werefollowedintloseinstanceswlentleiremployeesobtained
inmatesconsent,wliclwastlecaseforatleast,oftle
, inmates.
Temissingplysicianssignaturesontleconsentformsare
particularlyconcerningbecauseeaclplysicianmustcertify,by
signingtleformslortlybeforetlesterilizationprocedure,tlat
tlerequiredwaitingperiodlasbeensatisedandtlattlepatient
appearsmentallycompetentandunderstandstlelastingeects
oftleprocedure.Teplysicianistlelastcleckintleinformed
consentprocessandprovidestlepatientwitltlenalopportunity
4
In early June , one hospital informed us that it had found one consent form that was
unavailable during our audit eldwork. The consent form lacked a physicians signature but was
signed by the inmate more than days before the sterilization procedure. We have not modied
the numbers in our report since the hospital recently made this information available to us and
since we characterize such instances in our report as potential violations of the waiting period.
We have shared our evidence with the Receivers Oce so that it may refer such cases to the
proper authorities for review.
June 2014
20
towitldrawlerconsenttolavingtleprocedure.Ourlegalcounsel
advisesustlatwitloutsuclacerticationfromtleplysicianoran
alternateplysician,tleinmatesconsentwasnotlawfullyobtained
understateregulations.Civentleimportanceoftleplysicians
roleintleinformedconsentprocess,welaveaskedtleReceivers
Oceundertledirectionoftlefederalreceivertorefertlese
questionablecasestotleMedicalBoardofCaliforniaandtle
CaliforniaDepartmentofPublicHealtl,wlicllavetleenforcement
autloritytoinvestigateplysicianandlospitalpractices, respectively.
TetruenumberofcasesinwliclCorrectionsortleReceivers
Ocedidnotensuretlatconsentwaslawfullyobtainedpriorto
sterilizationmaybeligler.Forexample,inaccordancewitlits
recordsretentionpolicy,onelospitaldestroyedseven inmates
medicalrecords,leavingitunclearbasedonotlerlealtl
recordsavailablefromtleReceiversOcewletlertle
plysiciansperformingtlesesevensterilizationprocedures
lad signed tle necessaryconsentforms.Inatleastveoftlese
seven cases,tleinmateconsentedtotleprocedurewlileinprison.
IfCorrectionsorReceiversOceemployeesobtainedconsentfrom
tleseinmates,CorrectionsortleReceiversOceisresponsiblefor
ensuringtlatconsentwaslawfullyobtainedpriorto surgery.
Sincetleappointmentoftlerstreceiver,eectiveinApril:oo6,
tleReceiversOcelasladultimateresponsibilityforensuring
adequatemedicalcarefortleStatesinmatepopulation.Duringour
review,itbecameapparenttlattleReceiversOcelacksaprocess
toensuretlatitsprison-basedmedicalstaandotlersfollow
tleinformedconsentrequirementsundertleCaliforniaCodeof
Regulations,Title::(Title::).TeReceiversOceconrmed
tlatitsownemployeesweretleindividualsobtainingtleinmates
consentin,oftle:;instancesinwliclplysiciansdidnotsign
tleconsentformsandin;oftle8instancesinwlicltlecriteria
fortlewaitingperiodwaspotentiallynotmet.
Weaskedtledeputydirectorofmedicalservicestoexplainwlytle
ReceiversOcedidnotensuretlataninmatesinformedconsent
forsterilizationwasobtainedlawfullyintlosecasesinwlicl
itsemployeesweretlepersonsobtainingconsent.A Receivers
Oceattorneyrespondedtoourinquiry,statingtlattlespecic
provisionsofTitle::donotapplytoprisonemployeesbecause
Title::appliestogeneralacutecarelospitals.Furtler,tleattorney
statedtlattleReceiversOceisnotinapositiontoensure
compliancebystaoutsideoftleprisonbecauseitdoesnotlave
prisonclinicalstapresentattlelospitaltoobservetlenal
signatureprocesseverytimeaninmateundergoesaprocedure.
Finally,tleattorneystatedtlattleReceiversOcedoesnot
believetlattleinmatesconsentwasunlawful,providingno
furtler explanationforsuclaconclusion.
The true number of cases in which
Corrections or the Receivers
Oce did not ensure that consent
was lawfully obtained prior to
sterilization may be higher.
June 2014
ContrarytotlebeliefexpressedbytleattorneyfortleReceivers
Oce,ourlegalcounseladvisedustlatacourtwouldlikely
concludeCorrections
andtleReceiversOceladaresponsibility
toensuretlatinformedconsentforsterilizationwaslawfully
obtainedfromfemaleinmateswlentleiremployeesweretle
personsobtainingtleinmatesconsent.Californiacourtslaveleld
tlataplysicianwlodidnotperformamedicalproceduremaybe
responsibleforobtaininginformedconsentfromtlepatientiftle
doctorperformingtleprocedurefailstodoso.Inreaclingtlese
decisions,tlecourtsfocusedontleligllevelofinvolvementby
tleplysicianinprovidingcaretotlepatientbeforetleprocedure
wasperformedbyadierentdoctor.Intlisregard,Corrections
andtleReceiversOcearelegallyresponsibleforproviding
medicaltreatmenttoinmatesandforobtainingtleinmateswritten
informedconsentforseriousmedicalprocedures.Moreover,
attimestleinmatesmedicalrecordsslowtlatemployeesof
CorrectionsortleReceiversOceprovidedprenatalcareto
tlesepatientsandarrangedfortlesterilizationprocedurestobe
performedoutsideoftleprisoninageneralacutecarelospital.
Inaddition,employeesforCorrectionsandtleReceiversOce
weretlepersonsobtainingtleinmatesconsenttosterilizationfor
atleast,oftle,inmatesforwlomwenotedproblems.Civen
tleselegalautloritiesandfacts,ourlegalcounseldeterminedtlat
acourtwouldlikelyconcludetlatprisonlealtlautloritieswere
responsibleforensuringtlattleseinmatesinformedconsentmet
legalrequirementsbecauseaplysicianatalospitalfailedtosign
tleconsentformorfailedtoensuretlattlerequirementsfora
waitingperiodladbeensatised.
Physicians Sometimes Sterilized Inmates When Available Health Records
Cast Doubt on Whether the Required Waiting Period Was Observed
IftleReceiversOceladaprocesstoreviewtleinformed
consentformssignedbyinmatespriortosterilization,itwould
lavenotednotjusttleabsenceoftleplysicianssignatureonsome
oftleconsentforms,butalsopotentialviolationsoftlerequired
waitingperiodbetweentledateoftleinmatesconsentandtle
dateofsterilization.Altlouglwecouldnotdenitivelyconclude
wletlertimingviolationsladoccurred,giventlatsomeinmates
medicalrecordswereincomplete,wenevertlelessidentied
8 casesinwliclwelaveconcernstlatinmatesmaylavebeen
sterilizedwitloutcomplyingwitltlenecessarywaitingperiod.
5
Corrections was responsible for inmate health care between July , , and the appointment
of the rst federal receiver, eective April . During this time period, inmates had tubal
ligation procedures. Documentation in the available and potentially incomplete medical records
demonstrated that for at least four of these inmates, potential violations of the informed consent
requirements occurred.
Employees for Corrections and
the Receivers Oce were the
persons obtaining the inmates
consent to sterilization for at least
of the inmates for whom we
notedproblems.
June 2014
22
Witlsomeexceptions,Title::requirestlatpatientswloareto
besterilizedinageneralacutecarelospitallaveatleastodays
(andnomoretlan8odays)betweentledateofconsentand
tledateofsterilization.In;oftle8casesforwliclwelave
concerns,inmatesweresterilizedlesstlanodaysaftersigninga
consentform,andintleremainingcasetleinmatewassterilized
moretlan8odaysafterconsentwasobtained.In:oftlese
8cases,tle inmatesprovidedconsenttosterilizationwlilein
prison,and tleReceiversOceconrmedtlatitsemployees
or Correctionsemployeesobtainedconsentinsevenoftle
: cases.Title::generallyprolibitssterilizingapatientunless
slelasladaspecicperiodoftimetoconsidertlispermanent
andlife-clangingdecision,andprolibitssterilizingapatientonce
tlistimelaselapsed,afterwliclconsentmustberenewedto
be eective.
UnderTitle::,sterilizationmayoccursoonertlanodayswlena
patientvoluntarilyrequestsinwritingtlatitbeperformedinless
timeorwlentleprocedureisperformedattletimeofemergency
abdominalsurgeryorprematuredelivery.
6
However,inallcases
;: loursmustlavepassedafterwritteninformedconsentisgiven.
Ourreviewofavailablemedicalrecordsfoundinstancesinwlicl
wequestiontleapplicationoftleseexceptionstotleo-day
waitingperiod.Forexample,tlelospitalplysicianforInmate A
fromValleyStatePrisonforWomen(Valley)citedemergency
abdominalsurgeryasajusticationforsterilizingtleinmate
beforetleendoftleo-daywaitingperiod.InmateAsignedler
consentforsterilizationonNovember:;,:oo;,atValleyprison.
Teinmatesexpecteddeliverydatewas)anuary , :oo8(more
tlano daysafterlerconsent).However,onDecember 8, :oo;,
tleprisonscleduledInmateAforacesarean sectionatypeof
abdominalsurgeryandabilateraltuballigationprocedure to
take placeonDecember:,:oo;.Wlenscledulingtleprocedures
to takeplace,prisonmedicalstanotedtlattlecesareansection
procedurewasroutineasopposedtourgentoremergent,
and wesawnoindicationintleinmatesmedicalrecordto
indicateanemergencymedicalcondition.InmateAwassterilized
onDecember:,:oo;,:(daysaftersleconsentedtotle
procedure anddaysbeforelerexpecteddeliverydate.
Inanotlerexample,weareskepticalastolowascleduled
cesareansectionprocedurewouldconstituteprematuredelivery
wlentleprocedurewasplannedtotakeplaceonadatebefore
tleinmatesexpecteddeliverydate.Specically,on)une:,:oo,,
InmateTfromtleCaliforniaInstitutionforWomen(CIW)
6
When a patient is sterilized prior to expiration of the -day waiting period due to premature
labor or emergency abdominal surgery, Title still requires the patient to consent at least
days before her expected delivery date or days before she intended to be sterilized.
In of the cases for which
we have concerns, inmates were
sterilized less than days after
signing a consent form even
though the law requires patients
to have at least days between
the date of consent and the date
ofsterilization.
June 2014
signedlerconsentforsterilization,witltlesigningoccurringat
tleprisonandtlepersonobtainingconsentbeinganemployee
oftleReceiversOce.InmateTsexpecteddeliverydatewas
)uly o, :oo,,ormoretlanodaysafterlerconsent.However,
on )uly:,:oo,,tleprisonscleduledInmateTforacesarean
sectionprocedureontlefollowingday,)uly,:oo,,;daysbefore
lerexpecteddeliverydateandonly:odaysaftersleladconsented
tosterilization.Areviewoflermedicalrecorddidnotindicateany
emergencyconditionstlatnecessitatedanearlierdelivery.
Inotlercases,plysicianssignedconsentformsindicatingtlat
o daysladpassedwlentlisclearlywasnottlecase.Forexample,
InmateKfromValleysignedlerconsentforabilateraltuballigation
on)anuary:,:oo,andwassterilizedonFebruary, :oo,only
::dayslater.ForanotlerinmateatValley,tleplysiciancorrectly
claimedtlatodaysladpassedbutfailedtorealizetlatmoretlan
8odaysladelapsed.Specically,InmateDfromValleysigned
lerconsentforsterilizationinprisonon)une:o,:oo6,andwas
sterilizedon)anuary:,:oo;,orrouglly,6daysafterconsent.
Oneoftlereasonsforwaitingatleastodaysbeforesterilization
is toprovidetlepatientwitlenougltimetoreectonlercloice
andtomakesuresledesiressterilization.Duringourreviewwe
cameacrossoneinmatewlomaynotlavedesiredtobesterilized
and,inouropinion,forwlomtlerewasnovalidconsentform.
InmateXfromValleyinitiallyconsentedtosterilizationviabilateral
tuballigationon)une:o,:oo8,tlepersonobtainingconsentwas
anemployeeoftleReceiversOce.However,abouttlree weeks
later,on)ulyo,:oo8,InmateXclangedlermind.Medicalnotes
intleinmatesmedicalrecordconrmtlatsleclangedlermind
andindicatetlattlesignedconsentformwasreturnedtotle
inmate.TenonAugust:,:oo8,prisonmedicalstascleduled
tleinmateforacesareansectionatageneralacutecarelospital
onSeptember;,:oo8.Teinmatesprisonmedicalrecordsdo
notindicatetlatslewasalsobeingscleduledforasterilization
procedure,andtlerearenootlermedicalnotesreectingtlattle
inmateagainclosetobesterilized.Nevertleless,wlentleinmate
arrivedattlelospitalonSeptember;,:oo8,slesignedastandard
lospital-developedconsentformforsurgery,documenting
lerconsenttoacesareansectionandbilateraltuballigation.
However,tlelospitalconsentformdidnotrecognizetleo-day
requirementforsterilization.Wealsonotedtlattleplysician
performingtlesurgerysomelowobtainedtlesterilizationconsent
formtlat ladbeenreturnedtotleinmatein)ulyandsignedit.
CiventlatInmate Xladpreviouslywitldrawnlerconsenttobe
sterilizedwliclwaslerrigltwequestiontlelawfulnessof
InmateXsconsenttosterilization,becausetlenecessarywaiting
periodwasnotobserved.Inouropinion,prisonmedicalstaand
Physicians signed consent forms
indicating that days had passed
when this clearly was not the case.
June 2014
24
tlelospitalplysicianwereobligatedtoensuretlatInmateXlad
signedanotlersterilizationconsentformtlatallowedforalawful
waiting period.
Inmates Who Consented to Sterilization While in Prison Likely Did So
Without a Witness of Their Choice
Teproblemsassociatedwitltlelackofplysiciansignatures
ontleconsentformsandpotentialwaitingperiodviolationsare
compoundedbytlefacttlatinmateslavelittleornoopportunity
tolaveawitnessoftleircloicepresentwlentleysigntle
sterilizationconsentforminprison.Inmatesfrequentlysigned
tleseformsinprison,accountingforatleastooftle(( inmates
wloserecordswereviewed.AnattorneyfromtleReceivers
Oceexplainedtlatallowinginmatestolaveawitnessoftleir
cloosingduringtleconsentprocessispracticallyunworkablein
aprisonsetting.Ifaninmatewantedanyonefromanywlereasa
witness,accordingtotlestacounsel,tleReceiversOcecould
notaccommodatesuclarequestforlogisticalreasonsandfor
institutionalsafetyandsecurityconcerns.
Nevertleless,Title::isveryclearinstatingtlatanindividual
lasgiveninformedconsenttosterilizationonlyif certain
requirementsaremet.Oneoftleserequirementsisbeing
permittedtolaveawitnessoftlepatientscloicepresentwlen
consentisobtained.Altlougltlewitnessisnotrequiredto
signtle consentform,andnoplaceontleformisprovidedfor
awitnessssignature,lavingawitnessoftlepatientscloice
presentwlopresumablyknowstlepatientwellservesasa
safeguardtolelpensuretlattlepatientunderstandstleprocedure
andtrulydesirestobepermanentlysterilized.Awitnessoftle
inmatescloicecanalsolelpprotecttleStatefromallegations
tlattleinmatewascoercedintolerdecisiontobesterilized.Te
unwillingnessorinabilityoftleReceiversOcetoprovideinmates
witltleopportunitytolaveawitnessoftleircloiceasrequired
byTitle ::servestoreinforceandliglliglttleproblematic
processtlatprisonmedicalstafollowedwlenobtaining
inmates consentforsterilization.
Prison Medical Sta Did Not Document Their Discussions With Inmates
Regarding Sterilization Procedures
Finally,ourreviewofconsentpracticesoftleReceiversOce
relatedtosterilizationuncoveredanotlersystemicdeciency
inlowprisonmedicalstaadleretoinformedconsent
requirements.AsdiscussedintleIntroduction,tleInmate Medical
Services Policies and Procedures(prisonmedicalprocedures)
The unwillingness or inability of the
Receivers Oce to provide inmates
with the opportunity to have a
witness of their choice highlights
the problematic process that prison
sta followed when obtaining
inmates consent for sterilization.
June 2014
establislesexpectationsforlowinmatesaretobecounseled
andlowinformedconsentistobeobtainedinaprisonsetting.
Since)anuary:oo:prisonmedicalprocedureslaverequired
tlat informedconsentbeaprocesstoeducatetleinmateandtlat
prisonmedicalstadocumentintleinmateslealtlletledate,
time,andessenceoftlediscussionaboutapotentialprocedure
anditsrisksandalternatives.Fortle((inmateswereviewed,
welookedfordocumentationineaclinmatesmedicalrecord
tlatwouldallowustoevaluatelowinmateswerecounseledon
tleproposedsterilizationprocedureandwlatinformationtley
wereprovidedabouttleprocedurebeforeland.However,forall
((caseswereviewed,prisonmedicalstafailedtodocument
wlatwasdiscussedwitltleinmate,asrequiredbyprison
medicalprocedures.Sometimes,prisonmedicalstasimply
notedtlattleinmatesignedtleconsentformortlattleinmate
desires sterilization.
Telackofnotesineaclinmatesmedicalrecordregarding
informedconsentandsterilizationmadeitimpossibleforusto
concludeontlequalityandtlecontentoftleconsultationbetween
prisonmedicalstaandeaclinmate.Wewerealsounabletoreacl
aconclusionastowletlerinmatesreceivedinformationabout
tleprocedureandwletlerprisonmedicalstaansweredinmates
questionspriortotleirmakingtlissensitiveandlife-clanging
decision.Weslaredourobservationsabouttlelackofnotesintle
inmatemedicalrecordswitltledeputydirectorofmedicalservices
attleReceiversOce,askingforlisperspectiveonwlywesaw
sucllimitedinformationintleinmatesmedicalrecordsregarding
tleinformedconsentdiscussion.Inresponse,tleReceiversOce
statedtlrouglanattorneytlatitisatadisadvantageinreplying
toourquestionbecauseCorrectionsinitiatedtlepoliciesand
trainingdescribinglowinformedconsentwastobedocumented
inaninmateslealtlrecord.TeattorneyfortleReceiversOce
statedtlataltlougllisexplanationwasprobablycorrect,itwas
speculative.Teattorneystatedtlattleprocedurelasastatutory
formtlatcoversalltleelementsofconsent,andincaseswlere
tleReceiversOceplysiciansstartedtleconsentprocess,
tleylikelyassumedtlat tleformwouldserveastlerequired
documentation,obviatingtleneedtoprepareaseparate,duplicate
progressnote.Teattorneynotedtlatsterilizationrepresentsa
rareinstancewlereaprocedurecarrieswitlitamandatedconsent
form.Altlouglmucltimelaspassed,tleReceiversOcelas
noteliminatedtlepolicygoverningdocumentationofinformed
consent,andif,infact,tleconsentformwasaproxyforaprogress
note,wearesurprisedbytlefacttlatwedidnotndconsent
formsinalltleinmatelealtlrecordswereviewed.
For all cases we reviewed,
prison medical sta failed to
document what was discussed with
the inmate, as required by prison
medical procedures.
June 2014
26
Protocols Designed to Ensure That Sterilization Is Medically
NecessaryFailed
AsdescribedintleIntroduction,Title,oftleCaliforniaCodeof
Regulations(Title,)requiresareviewandapprovalprocessfor
certainmedicalprocedures,referredtoasexcludedservices,tlat
generallycannotbeprovidedtoinmates.Teregulationsinclude
sterilizationprocedures,suclastuballigations,asanexample
ofexcludedservicestlat,ifprovided,mustbeapprovedbytle
HeadquartersUtilizationManagementCommittee(leadquarters
committee)beforeland.However,CorrectionsandtleReceivers
Ocefailedtoensuretlattleprisonmedicalstaundertleir
directionfollowedstateregulationsrequiringtleproperapproval
ofsterilizationprocedures.
Prisonmedicalstamaylavebeenconfusedormisinformed
abouttleneedtoobtainleadquarterscommitteeapprovalprior
toaninmatessterilization.AnOctober,,,memotoprison
medicalstafromCorrectionswliclwastlestateagencyin
controlofinmatelealtlcareattlattimestatedtlatpostpartum
tuballigationprocedureswouldbeoeredtoinmatesaspartof
obstetricalcare.Inouropinion,tle,,,memoappearstomove
bilateraltuballigationsfromexcludedservicestononexcluded
serviceswlenperformedaspartofobstetricalcare,witlout
acknowledgingtlerequiredapprovalprocessmandatedin
regulations.OcialsatCorrectionscouldnotfurtlerexplain tle
purposeoftle,,,memoandlowitwasintendedtoaect
tle approvalprocess,ifatall,forsterilizationprocedures.
AsslowninFigure:intleIntroduction,prisonmedical
proceduresallowtleReceiversOcetoprovideexcludedservices
toinmatesifutilizationmanagementcommitteesattleprison
(level)andatleadquarters(level()approvetlerequestedservice.
Tesecommitteesaremadeupofplysiciansandotlercorrectional
ocialswloevaluatetlemeritsofamedicalproceduretle
inmatesplysicianlasproposed.Teinmatesplysicianmakes
lisorlerrequestbycompletingapaperformcalledaRequestfor
Service,wliclincludesspacestolistbotltlerequestedprocedure
andtlereasonwlyitismedicallynecessary.TeRequestfor
Serviceformalsolasalocationtonotewletlertleservicelas
beenapprovedordenied.Iftleprocedureisapproved,tleformis
forwardedtootlerprisonmedicalstatoscleduletlepatientfor
treatment.Intlecaseofabilateraltuballigation,tleprocedure
wouldbescleduledatalospitalwitlalocalplysicianwloworks
onbelalfoftleReceiversOce.
Duringourreviewwesawnoevidencetlattlebilateraltubal
ligationprocedures,witloneexceptionin:o,receivedall
tlerequiredlevelsofapproval.Tismaypartiallyexplainwly
During our review we saw no
evidence that the bilateral
tubal ligation procedures, with
oneexception in , received all
the required levels of approval.
June 2014
tleReceiversOceassertedtlatitwasnotawaretlattlese
sterilizationproceduresweretakingplaceuntil)anuary :oo,
wlen alegaladvocacygroupcalled)usticeNowbeganallegingtlat
medicallyunnecessarysterilizationproceduresladbeenperformed.
Overall,ourlereviewdemonstratedtlatprisonmedicalsta
infrequentlyrequestedapprovaltosterilizeinmates,andwlen
tleydid,itwasnotalwayscleartlattlese requestswereapproved.
Inmanycases,prisonmedicalstasimplyrequested approvalfor
otlermedicalproceduressuclascesareansectionsatlospitals
and didnotalsoindicatetlattleinmatewastobesterilized.Oftle
(( inmateswloserecordswereviewed,wefoundonly,6Request
forServiceformstlatgavesomeindicationtlatinmateswereto
besterilized.In:;oftlese,6cases,wedidnotseeanyevidenceof
priorrevieworapprovaloftlesterilizations.Wealsodidnotnda
consentformintleinmatesleforoneoftlese:;inmates,tlus,
foroneinmatetlemedicalrecordsfromtleReceiversOcedid
notcontainasterilizationconsentorarequiredmedicalrequest
and approval.
Sleddingfurtlerligltonlowprisonmedicalstafailedtoadlere
totleutilizationmanagementprocess,wesawtlatinsome
instancestletimeelapsingbetweenwlentleprisonplysician
requestedapprovalforinmatesterilizationandwlentleprocedure
wasperformedwassoslorttlatwequestionlowfeasibleitwould
lavebeenforutilizationmanagementreviewcommitteesbotl
attleprisonandatleadquarterstoreviewandconsidertle
sterilizationprocedurebeforetleinmatessurgery.Specically,
wenotedtlatlesstlanaweekelapsedbetweentledateoftle
requestandtledateoftlesurgeryin:instancesinwliclmedical
stasougltapprovalforsterilizationprocedures.Forexample,we
reviewedtlemedicalrecordforInmateC,wloladbeenaninmate
atCIW.InmateCsplysiciansubmittedaRequestforService
form askingforL+D,meaninglaboranddelivery,clarifyingon
tleformtlattleinmatealsodesiredatuballigation.TeRequest
forServiceformdatedAugusto,:oo,lackedanyevidence
ofreviewandapproval.Followingacesareansectionintle
lospital,InmateCladasterilizationproceduretwodayslateron
August :, :oo,.Itisunlikelytlattletwodaysbetweentlesigning
oftleformandtlesurgeryweresucientforbotlaleveland
level(reviewoftlerequestedsterilizationprocedure.
Ourauditalsonoted8casesinwliclprisonmedicalsta
requestedapprovalformedicalprocedureswitlnomention
ofsterilization,andyettleinmatewassterilizedwitlinoneto
tlree daysoftlerequest.Inaparticularlyegregiouscase,tle
plysicianforInmateTatCIWsubmittedaRequestforService
formdated)uly:,:oo,,requestingapprovalforpregnant
evaluationitreatmentservices,witlnoadditionalinformationon
tleformtoindicatetlattleplysicianwasrequestingasterilization
Our le review demonstrated that
prison medical sta infrequently
requested approval to sterilize
inmates,and when they did, it was
notalways clear that these requests
wereapproved.
June 2014
28
procedureforwlicltleinmateladsignedaconsentform.After
lavinganormaldeliveryoflerclildinalocallospital,InmateT
wassterilizedtlefollowingday,on)uly,:oo,.
Overall,ourreviewofavailableinmatemedicalrecordsindicates
tlattleReceiversOcedidnotadequatelymonitorandcontrol
tlesterilizationproceduresbeingperformedoninmates,and
prisonmedicalstadidnotalwaysrequestapprovalbeforeinmates
weresterilized.Inligltoftle,,,memotlatappearedtomake
certainsterilizationproceduresanacceptableformoftreatment,
itisunclearwletlerprisonmedicalstatlougltapprovalfrom
leadquarterswasunnecessarybeforearrangingfortlesterilization
ofinmatesundertleircare.
WeaskedtledeputymedicalexecutiveattleReceiversOce
(deputymedicalexecutive)wlolasbeeninclargeoftleutilization
managementprocesssince)uly:oo8toexplainlowbilateral
tuballigationscouldlavebeenperformedwitlouttlenecessary
approvalsfromleadquarters.Inresponse,sleexplainedtlatfemale
prisonsrequiredextensiveone-on-one,verbal,teleplonic,andotler
educationbetween:oo8and:ootodevelopbotltleinstitutional
utilizationmanagementcommitteesandtleprocessesforreferring
casestoleadquartersforreview.Tedeputymedicalexecutive
alsostatedtlattleautlorizationsystemiscurrentlypaperbased,
explainingtlatifanelectronicautlorizationsystemexistedtoblock
tlelocalapprovalofexcludedservices,forcingtleroutingofrequests
toleadquartersforreview,inadvertentscledulingofexcludedservices
byinstitutionscould,lypotletically,bedecreased.According totle
deputymedicalexecutive,anelectronicautlorizationsystemcould
allowleadquartersstatoreview,inrealtime,wliclprocedures
lavebeenautlorizedintleprisonsandgenerateanalertwlen
proposedmedicalservicesrequireleadquartersreview.However,
tledeputy medicalexecutiveacknowledgedtlattleReceiversOce
lackssuclanelectronicautlorizationsystem.WitltleReceivers
Ocerelyingonprisonstoconsistentlyforwardpaper-basedrequests
forsterilizationstoleadquartersforapproval,coupledwitlits
inabilitytoblockprisonsfromscledulingsterilizationprocedures
witloutitsapproval,tleReceiversOcewasnotwellpositionedto
monitorandcontrollowofteninmatesweresterilizedandwletler
suclsterilizationswere appropriate.
The Receivers Oce Must Take Additional Steps to Rectify Failures
That Led to Inmates Being Sterilized by Bilateral Tubal Ligation
In:oo,afteritbecameawaretlattlesterilizationprocedures
weretakingplace,tleReceiversOceconductedareviewtlat
identiedweaknessesintlewaytlattlemedicalstaintlefemale
prisonsprocessedandconsideredsterilizationrequests.According
The Receivers Oce did not
adequately monitor and control
the sterilization procedures being
performed on inmates, and prison
medical sta did not always
request approval before inmates
weresterilized.
June 2014
toaninternalreporttledeputymedicalexecutiveissuedtoan
executiveattleReceiversOcefollowingareviewofValleyand
otlerfemaleprisons,sleconcluded,DespitelanguageinTitle ,
andtleDepartmentOperationsManualrestrictingtleuseof
sterilizations,[bilateral]tuballigations,andlysterectomiestlatare
intendedtoprovidesterilization,tleleaderslipteamsat[certain
femaleprisons]couldnotdocumenttlatanoversigltprogramlad
beendevelopedtoconsistentlyreviewrequestsforsterilization,or
lysterectomytlatwouldresultinsterilization,todetermineiftley
weremedicallynecessary,andtlatallotlerconservativemeasures
commonlyattemptedintlecommunityladfailed.Intleinternal
report,tledeputymedicalexecutivealsocommentedspecically
aboutproblemsatValley,statingtlatbotltle[prison]based
OB-CYNplysicianatValleyand[community-basedplysicians]do
not,tome,appearcapableofobjectiveoversigltoftleirutilization,
andcommunity-institutionalpersonalandprofessionalfamiliarity
issoliglandcomplex,tlat[leadquarters]oversigltoftlesecases
willbenecessarytoensurecompliance.
Tedeputymedicalexecutivescommentswerewellfounded
regardingtleneedforoversigltfromleadquarters,asler
observationswereconrmedbyourown.However,wenotetlat
tleReceiversOcelassincetakensomestepstofurtlerlimit
lowoftensterilizationprocedurestakeplace,includingtraining
medicalstaandclangingitsmedicalclaimssystem.Ouranalysis
of medicalclaimsdatasince:oofromtleReceiversOceslows
tlattlenumberoffemaleinmatesundergoingbilateraltuballigations
andotlermedicalprocedurestlatresultinsterilizationlasgreatly
decreased.Fortleeiglt-yearauditperiodwereviewed,TableA.
intleAppendixsummarizestlemedicalprocedurestlatladtle
potentialtosterilizetlefemaleinmate.Altlouglitisstillpossible
foraninmatetobescleduledforandundergomedicalprocedures
resultinginsterilizationwitloutmedicalstaobtainingalloftle
necessaryapprovals,ourreviewofproceduresinmatesunderwent
in :ooandlatertlatresultedinsterilizationfoundtlatadlerenceto
tleutilizationmanagementreviewprocessimproved.
The Receivers Oce Still Must Prevent Sta From Scheduling
UnauthorizedProcedures
Asdiscussedearlierintlisreport,justoneoftle((inmateswe
reviewedladabilateraltuballigationtlatwasscleduledand
performedwitldocumentedutilizationmanagementapproval.
Becausetlefunctionsofapprovingamedicalprocedureand
scledulingitareseparate,prisonmedicalstaareabletoscledule
procedureswitloutnecessaryutilizationmanagementreview,
meaningtlatinmatescouldstillreceivemedicalservicestlatare
notautlorized.Wlenweaskedtledeputymedicalexecutive
Our analysis of medical claims
data since from the Receivers
Oce shows that the number
of female inmates undergoing
bilateral tubal ligations and other
medical procedures that result in
sterilization has greatly decreased.
June 2014
30
overutilizationmanagementwlytlisweaknesslasnotbeen
addressed,slerespondedtlatutilizationmanagementlasdone
itsbesttocommunicatetoscledulingstatlatanautlorized
procedurerequestisneeded,buttlatutilizationmanagementlas
noautlorityovertlescledulingunit.Wlenweinquiredwletler
tledirectoroflealtlcareoperations,wloisresponsiblefor
utilizationmanagementandtlenursingunit,couldgivetlenursing
unitdirectiontostopscledulingunapprovedmedicalservices,
tledeputymedicalexecutiveagreedtlattliswouldbeafeasible
alternativetoutilizationmanagementneedingtoacquirescleduling
autlority.Furtler,tledeputymedicalexecutivenotedtlatametlod
toelectronicallyblocktlescledulingofmedicalservicesuntiltley
receiveutilizationmanagementapprovalcurrentlydoesnotexist.
However,tledeputymedicalexecutivestatedtlattleReceivers
Oceisprocuringanewcomputersystemtlatwillrequireprior
autlorizationbeforescleduling,wliclslouldbeavailablein
fall:o,.UntiltleReceiversOcecanlinkmedicalscleduling
witlutilizationmanagementautlorization,itrisksinmatesbeing
scleduledforandreceivingmedicalprocedurestlatarenot
autlorizedasmedicallynecessary,suclasbilateraltuballigations.
The Receivers Oce Has Taken Steps to Improve Adherence to Its
Utilization Management Process
TelevelofadlerencetotleReceiversOceutilization management
processmaycorrelatetotlelevelofstaandmanagementtraining
abouttleprocess.Webelievetlatitisessentialtotrainprison-based
medicalstabecausetleyareresponsibleforensuringtlattleir
institutionsprovidenecessarycare.AsFigure:onpagedepicts,
eaclinstitutionsutilizationmanagementnurseandmedicalexecutives
playimportantrolesinimplementingtleutilizationmanagement
process.TeReceiversOcetrainsmedicalstaontleutilization
managementprocessinformalandinformalways,including
classroom-basedcoursework,teclnicalassistance,andutilization
processmonitoring.Wefoundtlattle:otrainingcontentwas
sucientlycomprelensivetoensuretlatprison-basedmedicalsta
understoodtleutilizationmanagementprocess.Coursesforutilization
managementnursesandprison-basedmedicalexecutivescovered
tlreekeycomponents:tleutilizationmanagementreviewprocess,tle
applicationofmedicaldecisionsupportcriteria,andTitle,service
exclusionsandcommitteereviews.
Accordingtotledeputymedicalexecutive,tlenursestraining
lasoccurredeaclyearfrom:ootlrougl:o,buttle
trainings before:ofocusedontlemedicaldecisionsupport
criteriaanddidnotincludeutilizationmanagement.Slealsostated
tlattlemedicalexecutivestrainingispartofapilotprogramtlat
beganin:o:.Te:o(utilizationmanagementworkplanwlicl
Until the Receivers Oce can link
medical scheduling with utilization
management authorization, it
risks inmates being scheduled for
and receiving medical procedures
that are not authorized as
medicallynecessary.
June 2014
outlinesquantitativeperformanceobjectivesfortledeliveryof
lealtlcareunderstatelawindicatestlattlenursesandmedical
executivestrainingisscleduledtoruntlrougltleendof:o(.
Ourreviewofmedicallesalsorevealedbetteradlerenceto
utilizationmanagementrequirementssince:oo.Specically,we
reviewedmedicalrecordsfor:ofemaleinmateswlounderwent
nonexcludedmedicalprocedures,suclaslysterectomies,
betweenApril,:oo,and)uneo,:o.For,oftleseinmates
or,, percentoftlecasesreviewedtleRequestforService
reected utilizationmanagementreviewsandapprovals.In
contrast,utilizationmanagementreviewsandapprovalswere
foundinlesstlanpercentofallbilateraltuballigationcaseswe
reviewedfor tleeigltscalyearsbeginningin:oo,o6tlrougl
:o:. Forexample,InmateNfromCIWladalysterectomy
in:o:totreatwlatlermedicalprogressnotesciteasuterine
broidsandleavybleeding.TeRequestforServicefortleinmates
procedurereectedutilizationmanagementreviewatlevels,:,
and(refertoFigure :onpageforinformationontlelevelsof
review).Altlouglanonexcludedprocedurecanbeapprovedat
level:, tleRequestforServicereectedtlattlelevel:reviewer
deferredtle decisionandtlerequestwenttolevel(tleinstitutions
utilizationmanagementcommittee),wlereitwasapproved.For
oneinmatewefoundnoRequestforService,andtluswecouldnot
determinewletlertlelysterectomysleunderwentwasreviewed
andapprovedasrequired.Despitetlislapse,since:ootle
ReceiversOceisbetterabletoensuretlattletreatmentinmates
areprescribedisscrutinizedanddeemedmedicallynecessary.
Finally,tleReceiversOcealsomadeclangestoitsmedical
billingsystemintlefallof:ootoagmedicalclaimsforcertain
sterilizationproceduresanddelaytlepaymentoftleseclaimsuntil
leadquarterscouldreviewandapprovetleprocedure.Altlougl
tleclangetoitsbillingsystemwouldnotpreventsterilizations
fromtakingplace,sinceitfocusesonstoppingpaymentfortle
procedureratlertlanstoppingtleprocedureitself,tlisstepand
tleincreasedtrainingsappeartolavebeeneective.
Recommendations
Toensuretlattlenecessaryeducationanddisciplinaryaction
canbetaken,tleReceiversOceslouldreporttotleCalifornia
DepartmentofPublicHealtl,wlicllicensesgeneralacutecare
lospitals,andtleMedicalBoardofCalifornia,wlicllicenses
plysicians,tlenamesofalllospitalsandplysiciansassociatedwitl
inmatesbilateraltuballigationsduringscalyears:oo,o6tlrougl
:o:forwliclconsentwasunlawfullyobtained.TeReceivers
Oceslouldmaketlesereferralsassoonasispracticable.
June 2014
32
Toensuretlatitcanbettermonitorlowitsmedicalstaand
contractorsadleretotleinformedconsentrequirementsof
Title::,sections;o;o;.tlrougl;o;o;.;,tleReceiversOce
sloulddevelopaplanbyAugust:o(toimplementaprocessby
December:o(tlatwouldincludetlefollowing:
Providingadditionaltrainingtoprisonmedicalstaregarding
Title::requirementsforobtaininginformedconsentfor
sterilizationprocedures,includingtleapplicableformsand
mandatorywaitingperiodrequirementstoensuretlatconsent
is lawfullyobtained.
Developingclecklistsorotlertoolstlatprisonmedicalsta
canusetoensuretlatmedicalproceduresarenotscleduled
untilaftertleapplicablewaitingperiodsforsterilizationlave
been satised.
Periodicallyreviewing,onaconsistentbasis,asampleofcases
inwliclinmatesreceivedtreatmentresultinginsterilizationat
generalacutecarelospitals,toensuretlatallinformedconsent
requirementsweresatised.
WorkingwitlCorrectionstoestablislaprocesswlerebyinmates
canlavewitnessesoftleircloicewlenconsentingtosterilization,
asrequiredbyTitle::,orworkingtorevisesuclrequirementsso
tlattlereisanappropriatebalancebetweentleneedforsecure
custodyandtleinmatesabilitytolaveawitnessoflercloice.
UntilsucltimeastleReceiversOceimplementsaprocess
forobtaininginmateconsentforsterilizationunderTitle::tlat
complieswitlallaspectsoftleregulations,itsloulddiscontinue
itspracticeoffacilitatinganinmatesconsentforsterilizationin
tleprisonandallowtlegeneralacutecarelospitaltoobtainan
inmatesconsent.
Toimprovetlequalityoftleinformationprisonmedicalsta
documentininmatemedicalrecords,tleReceiversOce
slould dotlefollowing:
Trainitsentiremedicalstaonitspolicyintleinmate
medicalproceduresrelatedtoappropriatedocumentationin
inmatesmedicalrecords.Tistrainingslouldbecompletedby
December ,:o(.
Eitlerdeveloporincorporateintoanexistingprocessameans
bywliclitevaluatesprisonmedicalstasdocumentationin
inmatesmedicalrecordsandretrainsmedicalstaasnecessary.
TeReceiversOcesloulddevelopandimplementtlisprocess
by)uneo,:o,.
June 2014
Toensuretlatinmatesreceiveonlymedicalservicestlatare
autlorizedtlrouglitsutilizationmanagementprocess,tleReceivers
Ocesloulddotlefollowing:
DevelopprocessesbyAugust,:o(,sucltlataproceduretlat
mayresultinsterilizationisnotscleduledunlesstleprocedureis
approvedattlenecessaryleveloftleutilizationmanagement process.
ByOctober,:o(,trainitsscledulingstatoverifytlattle
appropriateutilizationmanagementapprovalsaredocumented
beforetleyscleduleaproceduretlatmayresultinsterilization.
Ensuretlattlecomputersystemitprocuresincludesfunctionality
toelectronicallylinkmedicalscledulingwitlautlorizationtlrougl
tleutilizationmanagementprocesstopreventallunautlorized
procedures,regardlessofwletlertleymayresultinsterilization,
frombeingscleduled.
WeconductedtlisauditundertleautlorityvestedintleCaliforniaStateAuditorbySection 8,(
etseq.oftleCaliforniaCovernmentCodeandaccordingtogenerallyacceptedgovernmentauditing
standards.Tosestandardsrequiretlatweplanandperformtleaudittoobtainsucient,appropriate
evidencetoprovideareasonablebasisforourndingsandconclusionsbasedonourauditobjectives
speciedintlescopesectionoftlereport.Webelievetlattleevidenceobtainedprovidesa
reasonablebasisforourndingsandconclusionsbasedonourauditobjectives.
Respectfullysubmitted,
ELAINEM.HOWLE,CPA
StateAuditor
Date: )une,,:o(
Sta: CrantParks,AuditPrincipal
SlaronL.Fuller,CPA
MyriamK.Arce,MPA,CIA
KatlrynCardenas,MPPA
OswinClan,MPP
DanaDouglty,RN,MPP
ITAuditSupport: Miclelle).Baur,CISA,AuditPrincipal
LindsayM.Harris,MBA
CrantVolk,MA,CFE
LegalCounsel: ScottA.Baxter,)D
)oseplL.Porcle,)D
Forquestionsregardingtlecontentsoftlisreport,pleasecontact
MargaritaFernndez,CliefofPublicAairs,at,6.((,.o:,,.
June 2014
June 2014
Appendix
STATISTICAL AND DEMOGRAPHIC INFORMATION ABOUT
FEMALE INMATES WHO RECEIVED MEDICAL TREATMENT
POTENTIALLY CAUSING STERILIZATION BETWEEN
FISCAL YEARS 200506 THROUGH 201213
Te)ointLegislativeAuditCommittee(auditcommittee)
directed tleCaliforniaStateAuditor(stateauditor)todetermine
tlenumberofsterilizationproceduresperformedonfemale
inmatesovertlemostrecenteiglt-yearperiod.Teaudit
committeealsoaskedtlestateauditortodeterminewlatotler
procedures,ifany,wereperformedalongwitltlesesterilizations
andtoprovidedemograplicinformationfortleinmatesaected.
Avarietyoffactorsmakeitdiculttodeterminedenitively
lowoftenfemaleinmatesreceivedmedicalproceduresforwlicl
sterilizationwastlesolepurposefortlesurgery.Forexample,
awomanbeingtreatedforuterinecancermayneedtolavea
lysterectomy,resultinginsterilization,eventlougltlatwasnot
tlestatedpurposefortleprocedure.Complicatingmatterseven
furtler,itispossibletlatcertaininmatesweresterilizedbefore
ourauditperiodandtlensubsequentlyreceivedalysterectomy
orotlerproceduretlatcommonlyresultsinsterilization.Insucl
circumstances,tlelysterectomyorotlerprocedurewouldappear
inourdataset,andyettlosesurgeriesdidnotactuallycausetle
inmatessterilization.
Witltleseclallengesinmind,weaddressedtleauditcommittees
requestbyanalyzingCaliforniaCorrectionalHealtlCareServices
(ReceiversOce)inmatemedicalclaimsdata.TableA.ontle
followingpageprovidescountsofmedicalprocedurestlatlad
tle potentialtocausetlesterilizationoffemaleinmatesbetween
scalyears:oo,o6and:o:.Tetablealsoslowstlatmedical
providerssubmittedclaimspertainingto;,(uniqueinmatesfor
medicalprocedurestlatcouldlavecausedtleirsterilization.
TeproceduregroupingsinTableA.slowtlenumberand
frequencyinwliclbilateraltuballigationsoccurred.According
toourmedicalconsultant,tleReceiversOce,andourownle
reviewforeaclinmateaected,tleseprocedureswereperformed
solely fortlepurposeofsterilization.Wealsoselectedatotalof
:6lesfromtleotlertwocategoriesslowninTableA.and
concludedtlattleseprocedureswereperformedinresponse
tospecicmedicalconditionsandtlatsterilizationwasnot
mentionedasanexplanationfortlesurgery.
June 2014
Table A.1
Inmate Medical Procedures Potentially Resulting in Sterilization
FISCAL YEAR
200506 200607 200708 200809 200910 201011 201112 201213
TOTAL NUMBER OF
INDIVIDUAL INMATES
Number of inmates per year 101 154 218 153 100 50 27 18 794*
GENERAL PROCEDURE NUMBER OF PROCEDURES PERFORMED PER YEAR
TOTAL NUMBER OF
PROCEDURES PERFORMED
Bilateral tubal ligation 26 28 37 29 19 4 1 0 144
Hysterectomy 67 104 147 97 70 28 13 13 539
Other 12 27 43 36 13 19 13 6 169
Totals 105 159 227 162 102 51 27 19 852
Sources: California State Auditors analysis of data obtained from California Correctional Health Care Services (Receivers Oce) Contract Medical
Database (CMD), CMD Access Version, CMD Web Version, and CMD Interface Version.
Notes: The data presented in this table are of undetermined reliability for the purpose of reporting medical procedures that could result in
sterilization; however, it was the most accessible information. Further, our audit noted four instances in which tubal ligation procedures recorded
inCMD did not take place, based on our review of documentation obtained from hospitals, physicians, and the Receivers Oce. As a result, we have
adjusted the total number of tubal ligation procedures shown in the table to 144; however, similar errors may exist in other procedure categories.
* 794 is a count of unique inmates that received at least one medical procedure that could have resulted in sterilization. This amount is not a sum of
the other data in this row, since some inmates received multiple procedures over the scal years shown.
Furtler,tleprocedurescountedintletablemaynot
always lave causedaninmatessterilization,becausetleinmate
maylaveundergoneasterilizationprocedurebeforeouraudit
period.Wegroupedinmatemedicalproceduresasrecordedin
tleContractMedicalDatabasebasedontleirCurrentProcedural
Terminology codes.
Becausetleauditrequestseemedmostfocusedoninmates
wloladproceduresforwliclsterilizationwastleintentoftle
procedure,weobtainedadditionaldataonmedicalprocedurestlat
wereperformedduringtlesamelospitalstayastlebilateraltubal
ligation.AsslowninTableA.:,tle((inmatesmostfrequently
ladbilateraltuballigationswlenalsolavingacesareansection.
June 2014
Table A.2
Number of Inmates Sterilized at Hospitals During Their Stay for Child Birth
POSTPARTUM
STERILIZATION
PROCEDURE OCCURRED AS
PART OF A CESAREAN SECTION
TOTAL FEMALE
INMATES
Total 22 122 144
Sources: California State Auditors analysis of data obtained from the California Correctional Health
Care Services Contract Medical Database (CMD), CMD Access Version, CMD Web Version, and CMD
Interface Version.
Note: For the 144 inmates who were sterilized by bilateral tubal ligation during our audit period,
we reviewed the Current Procedural Terminology (CPT) codes physicians used to bill the Receivers
Oce for these services. CMD billing records revealed that 22 inmates had CPT Code 58605
(postpartum tubal ligation), while 122 inmates had CPT Code 58611 (tubal ligation at time of
cesarean section).
TableA.slowsselecteddemograplicsbyscalyearfortle
(( inmateswloladabilateraltuballigation.Tefemaleinmates
weretypicallyyoungwlentleyladtleirbilateraltuballigation,
mostlybetween:6and(oyearsofage,andladbeenpregnant
ve ormoretimeswitlatleasttlreeclildbirtls,notcounting
tleclilddeliveredattletimeoftlesterilizationprocedure.Te
inmatesgenerallytestedatlesstlanaliglscloollevelofreading
prociencyandwerepredominatelyoftlewlite,Hispanic,and
blackraces.Inaddition,Englislwastleprimarylanguagefor
tlemajorityoftleinmatesandmostwereincarceratedfortle
rst time.
Table A.3
Demographics for Female Inmates Having Bilateral Tubal Ligation Surgery
FISCAL YEAR
DEMOGRAPHIC CATEGORY 200506 200607 200708 200809 200910 201011 201112 201213 TOTAL
Age at sterilization
2125 5 1 5 1 2 0 0 0 14
2630 4 8 12 11 8 1 0 0 44
3135 9 10 9 7 8 1 0 0 44
3640 7 9 9 7 1 1 1 0 35
4145 1 0 2 3 0 1 0 0 7
Number of pregnancies
04 6 8 6 6 5 0 0 0 31
56 12 7 12 10 6 1 0 0 48
78 5 7 10 11 7 1 0 0 41
921 3 6 9 2 1 2 1 0 24
continued on next page . . .
June 2014
FISCAL YEAR
DEMOGRAPHIC CATEGORY 200506 200607 200708 200809 200910 201011 201112 201213 TOTAL
Number of live children
02 4 8 8 4 4 1 0 0 29
34 13 11 12 15 7 1 0 0 59
56 7 4 14 7 6 2 0 0 40
711 2 5 3 3 2 0 1 0 16
Education* (reading grade level)
Beginning literacy (03.9) 4 3 1 3 3 1 0 0 15
Intermediate literacy (46.9) 5 9 7 8 5 0 0 0 34
Advanced literacy (78.9) 4 2 8 6 3 0 0 0 23
High school level literacy (912.9) 12 11 15 12 6 3 1 0 60
No scores available 1 3 6 0 2 0 0 0 12
Ethnicity / race
Black 8 9 6 8 3 1 0 0 35
Hispanic 10 9 10 7 10 0 1 0 47
Mexican 1 0 3 1 1 0 0 0 6
White 6 10 16 12 3 3 0 0 50
Other 1 0 2 1 2 0 0 0 6
Primary language
English 18 8 16 21 14 4 1 0 82
Spanish 1 3 1 0 0 0 0 0 5
Unknown 7 17 20 8 5 0 0 0 57
Number of incarceration periods
1 period 15 23 27 21 13 2 0 0 101
2 periods 9 2 6 5 5 2 1 0 30
3 periods 2 3 4 3 1 0 0 0 13
Sources: California State Auditors analysis of inmate health records and data obtained from California Correctional Health Care Services Contract
Medical Database (CMD), CMD Access Version, CMD Web Version, and CMD Interface Version; California Department of Corrections and Rehabilitations
(Corrections) Strategic Oender Management System; and Corrections Tests of Adult Basic Education Master File Access database.
* The groupings are from Corrections categorization of the inmates reading ability score on the Tests of Adult Basic Education. The data in this table
arethe test scores that the inmates received closest to the tubal ligation procedure date, regardless of whether the inmate took the test before
orafter the procedure.
Race and ethnicity are reported based on Corrections categories for inmates.
June 2014
* California State Auditors comment appears on page 43.
*
1
June 2014
June 2014
June 2014
June 2014
Comment
CALIFORNIA STATE AUDITORS COMMENT ON THE
RESPONSE FROM CALIFORNIA CORRECTIONAL HEALTH
CARE SERVICES
Toprovideclarityandperspective,wearecommentingon
tleCaliforniaCorrectionalHealtlCareServices(Receivers
Oce)responsetoouraudit.Tenumberbelowcorresponds
totlenumberwelaveplacedintlemarginoftleReceivers
Oce response.
WequestiontleassertionmadebytleReceiversOcetlatit
receivednoMedi-Calreimbursementrelatedtosterilizations.
As we stateinTable:,objective;,onpage6,weidentied
one inmateforwlomwedeterminedtlattleReceiversOce
receivedMedi-Calfederalreimbursementforpregnancy-related
lospitalservices.We describetlecircumstancesoftlat
reimbursement,wliclincludetlefacttlatitcoveredlospital
costsincludingtleuseoftle surgicalroomfortleinmates
sterilizationprocedure.WedirectedtleReceiversOceto
workwitl tle CaliforniaDepartmentofHealtlCareServices
to ascertain tleappropriatenessoftleMedi-Calreimbursementfor
tlisinmate.UntiltleReceiversOcelasdoneso,tleconclusion
tle ReceiversOcelasdrawnis premature.
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