Sterilization of

Female Inmates
Some Inmates Were Sterilized Unlawfully,
and Safeguards Designed to Limit Occurrences
of the Procedure Failed
Report -
June 
COMMITMENT
INTEGRITY
LEADERSHIP
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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
Te Governor of California 
President pro Tempore of the Senate 
Speaker of the Assembly 
State Capitol 
Sacramento, California ,¸8¡¡
Dear Governor and Legislative Leaders:
As  requested  by  the  Joint  Legislative  Audit  Committee,  the  California  State  Auditor  (state  auditor) 
presents this audit report concerning female inmate sterilizations occurring between fiscal years aoo¸–o6 
and  ao¡a–¡¡.  Te  California  Department  of  Corrections  and  Rehabilitation  (Corrections)  oversees 
the inmate population of the State’s ¡¡ adult prisons, four of which housed substantially all women. 
However,  for  much  of  our  audit  period,  Corrections’  role  in  providing  inmates  with  medical  care 
was  not  significant.  California  Correctional  Health  Care  Services  (Receiver’s  Office)  played  the 
more  substantial  role  under  the  direction  of  a  federal  court-appointed  receiver  who  took  control  of 
prison medical care in aoo6 and will retain control until the court finds Corrections can maintain a 
constitutionally adequate prison medical care system. 
Tis  report  concludes  that  during  our  eight-year  audit  period,  ¡¡¡  female  inmates  were  sterilized 
by a procedure known as bilateral tubal ligation, a surgery generally performed for the sole purpose 
of  sterilization.  State  regulations  impose  informed  consent  requirements  that  must  be  met  before  a 
woman can be sterilized, however, Corrections and the Receiver’s Office sometimes failed to ensure 
that  inmates’  consent  for  sterilization  was  lawfully  obtained.  Overall,  we  noted  that  ¡,  inmates 
were sterilized following deficiencies in the informed consent process. For a; of the ¡, inmates, the 
physician  performing  the  procedure  or  an  alternate  physician  failed  to  sign  the  inmate’s  consent 
form  certifying  that  the  inmate  appeared  mentally  competent  and  understood  the  lasting  effects 
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 
took place. Finally, among these ¡, inmates were six who were sterilized following violations of both 
these  requirements.  Although  neither  Corrections  nor  the  Receiver’s  Office’s  employees  actually 
performed the sterilization procedures, we concluded that they had a responsibility to ensure that the 
informed consent requirements were followed in those instances in which their employees obtained 
inmates’ consent, which was the case for at least ¡, of the ¡, inmates. 
Our  audit  also  noted  that  prison  medical  staff  infrequently  requested  approval  to  sterilize  inmates, 
and  when  they  did  so,  it  was  not  always  clear  that  these  requests  were  approved.  However,  since 
January ao¡o, medical claims data from the Receiver’s Office show that the number of female inmates 
who  have  undergone  bilateral  tubal  ligations  and  other  medical  procedures  that  may  result  in 
sterilization has greatly decreased. 
Respectfully submitted,
ELAINE M. HOWLE, CPA 
State Auditor
Blank page inserted for reproduction purposes only.
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 Staff and Others Always Obtained an Inmate’s Informed
Consent Lawfully Prior to Sterilization 19
Protocols Designed to Ensure That Sterilization Is Medically
Necessary Failed 26
The Receiver’s Office 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
Who Received Medical Treatment Potentially Causing Sterilization
Between Fiscal Years 2005–06 Through 2012–13 35
Response to the Audit
California Correctional Health Care Services 39
California State Auditor’s Comment on the Response
From California Correctional Health Care Services 43
vi California State Auditor Report 2013-120
June 2014
Blank page inserted for reproduction purposes only.
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
deficiencies in the informed
consent process.
• We saw no evidence that the inmate’s
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
Te California Department of Corrections and Relabilitation 
(Corrections) oversees tle inmate population of tle State’s 
¸¸ adult prisons. During our eiglt-year audit period—wlicl we 
defined as fiscal years :oo,–o6 tlrougl :o¡:–¡¸—four of tlese 
prisons loused substantially all of tle female inmates: California 
Institution for Women, Central California Women’s Facility, Folsom 
Women’s Facility, and Valley State Prison for Women (Valley). 
Valley no longer louses women since its conversion to a men’s 
prison in )anuary :o¡¸. For mucl of our audit period, Corrections’ 
role in providing inmates witl medical care was not significant, 
tle more substantial role was played by California Correctional 
Healtl Care Services (Receiver’s Office) under tle direction of a 
federal court-appointed receiver. A receiver took control of prison 
medical care in :oo6 and will retain control until tle court finds 
tlat Corrections can maintain a constitutionally adequate prison 
medical care system. 
From fiscal years :oo,–o6 tlrougl :o¡:–¡¸, ¡(( female inmates 
were sterilized by a procedure known as a bilateral tubal ligation. 
Te last of tlese female inmate sterilizations occurred in :o¡¡. 
Altlougl various surgical procedures may result in a female’s 
sterilization, bilateral tubal ligations are generally surgical 
procedures tlat are performed for tle sole purpose of sterilization, 
and state regulations impose certain requirements tlat must be 
met before sucl a procedure is performed. However, tle state 
entities responsible for providing medical care to tlese inmates—
Corrections
¡
 and tle Receiver’s Office—sometimes failed to ensure 
tlat inmates’ consent for sterilization was lawfully obtained. 
Overall, we noted tlat ¸, inmates
a
 were sterilized following 
deficiencies in tle informed consent process. We found two types 
of deficiencies. First, we found no evidence tlat tle inmate’s 
plysician—tle individual wlo would perform tle procedure in 
a lospital or an alternate plysician—signed tle consent form as 
required by state regulations. Second, we noted potential violations 
of tle required waiting period between wlen tle inmate consented 
1
Corrections was responsible for inmate health care between July , , and the appointment
of the first federal receiver, effective 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 Receiver’s Office 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 records—whether physicians signed the sterilization consent forms just prior
to surgery.

California State Auditor Report 2013-120
June 2014
2
to tle procedure and wlen tle sterilization surgery actually took 
place. Some inmates were sterilized following violations of botl of 
tlese requirements. Altlougl neitler Corrections nor employees 
of tle Receiver’s Office actually performed tle sterilization 
procedures, we concluded tlat tley lad a responsibility to ensure 
tlat tle informed consent requirements were followed in tlose 
instances wlen tleir employees obtained inmates’ consent, wlicl 
was tle case for at least ¡, of tle ¸, inmates. Eitler tle remaining 
:o inmates signed tleir consent to be sterilized at a plysical 
location otler tlan a prison or tle Receiver’s Office lad difficulty 
determining wletler tle individual wlo obtained consent was 
an employee. 
Lawful consent is represented by key steps as defined by tle 
California Code of Regulations, Title :: (Title ::). For example, 
tle plysician or an alternate plysician must sign tle consent form 
just before performing tle surgery, and a waiting period is required 
after tle patient signs tle consent form. Te missing plysicians’ 
signatures on some of tle inmates’ consent forms are especially 
concerning because of wlat tle plysician signature certifies: tlat 
tle required waiting period las been satisfied and tlat tle patient 
appears mentally competent and understands tle lasting effects of 
sterilization. Te plysician is tle last cleck in tle informed consent 
process and provides tle patient witl tle final opportunity to 
clange ler mind.
All tle bilateral tubal ligations we reviewed were performed at 
general acute care lospitals ratler tlan in prison medical facilities. 
A lawyer for tle Receiver’s Office stated tlat tle specific provisions 
of Title :: do not apply to prison employees, because Title :: 
applies only to general acute care lospitals. Nevertleless, because 
employees of tle Receiver’s Office played a significant role in tlese 
¡, inmates’ care and in obtaining tleir consent to be sterilized, 
our legal counsel advised us tlat a court would likely find tlat tle 
Receiver’s Office lad a responsibility to ensure tlat consent was 
lawfully obtained from tlese inmates in accordance witl Title ::. 
Altlougl tle consent forms we were able to review demonstrated 
tlat eacl female inmate signed a consent form, we lave concerns 
about wletler tle female inmates undergoing bilateral tubal 
ligations received adequate counseling about tleir decision to be 
sterilized. Despite a Receiver’s Office policy tlat prison medical 
staff must use progress notes—a term for documenting information 
made in an inmate’s medical record—to summarize discussions 
witl inmates, in no instance did we find a female inmate wlose 
progress notes adequately reflected tlat sle lad been counseled 
about ler decision to be sterilized. Te lack of notes in tle inmates’ 
medical records regarding informed consent and sterilization 
made it impossible for us to reacl a conclusion as to tle quality 
3 California State Auditor Report 2013-120
June 2014
and content of tle consultations between prison medical staff and 
inmates. We were also unable to conclude wletler inmates received 
educational materials, wletler prison medical staff answered 
inmates’ questions, or wletler tlese staff provided tle inmates 
witl all of tle necessary information to make sucl a sensitive and 
life-clanging decision as sterilization. 
Te Receiver’s Office also failed to ensure tlat tle prison medical 
staff under its direction followed state regulations requiring specific 
approvals for bilateral tubal ligation procedures, including approvals 
by two committees made up of ligl-ranking prison medical staff 
and medical executives from tle Receiver’s Office. Te failure 
to obtain tle necessary approvals was systemic, all but one of 
tle ¡(( bilateral tubal ligation procedures lacked tle necessary 
approvals. Overall, our file review demonstrated tlat prison medical 
staff infrequently requested approval to sterilize inmates, and wlen 
tley did, it was not always clear tlat tlese requests were approved. 
In many cases, prison medical staff simply requested approval for 
otler medical procedures—sucl as cesarean sections at lospitals—
and did not indicate tlat tle inmate was also to be sterilized. 
Since )anuary :o¡o, wlen tle Receiver’s Office asserts it became 
aware of tle sterilization procedures—following allegations by 
a legal advocacy group—its medical claims data slow tlat tle 
number of female inmates wlo lave undergone bilateral tubal 
ligations and otler medical procedures tlat result in sterilization 
las greatly decreased. In addition, since tlat time we found 
tlat tle Receiver’s Office las better adlered to its processes for 
reviewing medical services for necessity and for obtaining required 
approvals for medical services. Nevertleless, because tle function 
of approving a medical procedure las been and remains separate 
from tle process for scleduling tle procedure at a general acute 
care lospital or otler community medical facility, tle opportunity 
still exists for inmates to receive medical services tlat are not 
autlorized. Until tle Receiver’s Office ensures tlat medical 
scleduling is driven by autlorized requests for service, it risks 
subjecting inmates to potentially unnecessary medical procedures 
and cannot demonstrate tlat it is in full control of tle medical care 
inmates receive. 
Recommendations
To ensure tlat tle necessary education and disciplinary action 
can be taken, tle Receiver’s Office slould report to tle California 
Department of Public Healtl, wlicl licenses general acute care 
lospitals, and tle Medical Board of California, wlicl licenses 
plysicians, tle names of all lospitals and plysicians associated 
witl inmates’ bilateral tubal ligations during fiscal years :oo,–o6 
California State Auditor Report 2013-120
June 2014
4
tlrougl :o¡:–¡¸ for wlicl consent was unlawfully obtained. 
Te Receiver’s Office slould make tlese referrals as soon as 
is practicable.
To ensure tlat it can better monitor low its medical staff and 
contractors adlere to tle informed consent requirements of 
Title ::, sections ;o;o;.¡ tlrougl ;o;o;.;, tle Receiver’s Office 
slould develop a plan by August :o¡( to implement a process by 
December :o¡( tlat would include tle following: 
•  Providing additional training to prison medical staff regarding 
Title :: requirements for obtaining informed consent for 
sterilization procedures, including tle applicable forms and 
mandatory waiting period requirements, to ensure tlat consent 
is lawfully obtained.
•  Developing clecklists or otler tools tlat prison medical staff 
can use to ensure tlat medical procedures are not scleduled 
until after tle applicable waiting periods for sterilization lave 
been satisfied.
•  Periodically reviewing, on a consistent basis, a sample of cases 
in wlicl inmates received treatment resulting in sterilization at 
general acute care lospitals, to ensure tlat all informed consent 
requirements were satisfied.
•  Until sucl time as tle Receiver’s Office implements a process 
for obtaining inmate consent for sterilization under Title :: tlat 
complies witl all aspects of tle regulations, it slould discontinue 
its practice of facilitating an inmate’s consent for sterilization in 
tle prison and allow tle general acute care lospital to obtain an 
inmate’s consent.
To improve tle quality of tle information prison medical staff 
document in inmate medical records, tle Receiver’s Office 
slould do tle following:
•  Train its entire prison medical staff on its policy in tle inmate 
medical procedures related to appropriate documentation in 
inmates’ medical records. Tis training slould be completed by 
December ¸¡, :o¡(.
•  Eitler develop or incorporate into an existing process a means 
by wlicl it evaluates prison medical staffs’ documentation in 
inmate medical records and retrains prison medical staff as 
necessary. Te Receiver’s Office slould develop and implement 
tlis process by )une ¸o, :o¡,.
5 California State Auditor Report 2013-120
June 2014
To ensure tlat inmates receive only medical services tlat are 
autlorized tlrougl its utilization management process, tle 
Receiver’s Office slould do tle following:
•  Develop processes by August ¸¡, :o¡(, sucl tlat a procedure 
tlat may result in sterilization is not scleduled unless tle 
procedure is approved at tle necessary level of tle utilization 
management process.
•  By October ¸¡, :o¡(, train its scleduling staff to verify tlat tle 
appropriate utilization management approvals are documented 
before tley scledule a procedure tlat may result in sterilization.
Agency Comments
In its response to tle audit, tle Receiver’s Office generally agreed 
witl tle report’s factual findings, but noted tlat it reacled 
conclusions about its duty to ensure compliance witl tle 
sterilization and consent procedures set fortl in Title :: tlat differ 
from tle report. Nevertleless, tle Receiver’s Office pledged to 
implement all of tle recommendations. 
6 California State Auditor Report 2013-120
June 2014
Blank page inserted for reproduction purposes only.
7 California State Auditor Report 2013-120
June 2014
Introduction
Background
Te California Department of Corrections and Relabilitation 
(Corrections) oversees tle State’s prison population, wlicl includes 
¸¸ adult prisons. Of tlese, four prisons loused substantially all of 
tle female inmates in tle eiglt years spanning fiscal years :oo,–o6 
tlrougl :o¡:–¡¸. Two of tle prisons, California Institution for 
Women (CIW) and Central California Women’s Facility (Central), 
are designated womens’ prisons and continue to louse female 
inmates. In )anuary :o¡¸ Corrections realigned tle populations of 
two prisons, converting Valley State Prison for Women (Valley) to a 
men’s prison and establisling Folsom Women’s Facility (Folsom) at 
Folsom State Prison. As of )une :o¡¸ tle female inmate populations 
at tle CIW, Central, and Folsom prisons were :,¡¸¡, ¸,,:,, and 
¡86 women, respectively. Table ¡ lists Corrections’ total female 
inmate population during our audit period, and Figure ¡ on tle 
following page indicates tle locations of tle prisons for women and 
provides general information. According to Corrections’ associate 
warden of mission for female offender programs and services and 
special lousing, tle female inmate population decreased in :o¡: 
because of tle :o¡¡ Realignment legislation addressing public safety.
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 Rehabilitation’s 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
Multiple entities are involved in providing medical care to inmates 
or overseeing tleir medical services, including Corrections, 
California Correctional Healtl Care Services (Receiver’s Office) 
under tle direction of a federal court-appointed receiver (receiver), 
and community-based medical providers. Altlougl multiple 
entities are involved, since :oo6 tle receiver las been responsible 
for controlling prison medical services as a result of litigation 
concerning prison lealtl care. In April :oo¡ nine inmates filed a 
class action lawsuit against state officials in federal court (court) 
California State Auditor Report 2013-120
June 2014
8
alleging tlat Corrections was providing constitutionally inadequate 
medical care. Tis case resulted in a )une :oo: agreement requiring 
Corrections to improve medical care for prisoners. However, in 
)une :oo,, tle court determined tlat tle California prison medical 
care system was broken beyond repair and ruled tlat it would 
establisl a receiverslip to control tle delivery of medical services to 
all prisoners confined by Corrections. Te court appointed tle first 
receiver effective April :oo6, and tle current receiver las served 
in tle role since )anuary :oo8. Before :oo6 Corrections controlled 
medical care to inmates, now it is responsible for maintaining tle 
custody of inmates as tley receive tleir medical care.
Figure 1
Prisons That Housed Primarily Women During Our Audit Period
Fiscal Years 2005–06 Through 2012–13
FOLSOM WOMEN’S FACILITY
(began housing women in January 2013)
• Located in Folsom, Sacramento County
• Total population 186 (June 30, 2013)
CENTRAL CALIFORNIA WOMEN’S FACILITY
(opened in 1990)
• Located in Chowchilla, Madera County
• Total population 3,525 (June 30, 2013)
VALLEY STATE PRISON FOR WOMEN
(converted to a men’s facility in January 2013)
• Located in Chowchilla, Madera County
• Total population 2,142 (June 30, 2012)
CALIFORNIA INSTITUTION FOR WOMEN
(opened in 1952)
• Located in Corona, Riverside County
• Total population 2,131 (June 30, 2013)
Source: California Department of Corrections and Rehabilitation.
9 California State Auditor Report 2013-120
June 2014
Te court gave tle receiver broad autlority to reform tle prison 
medical care system until it finds tlat state officials are able 
to maintain a constitutionally adequate prison medical care 
system. Te receiver’s autlority includes all of tle secretary of 
Corrections’ powers for administering, controlling, managing, 
operating, and financing tle prison medical care system. Furtler, 
tle receiver is required to request tlat tle court waive state laws, 
regulations, and contractual requirements if tley are impediments 
to reform and otler alternatives are inadequate. In executing tle 
autlority given by tle federal court, tle receiver leads and directs 
tle activities of tle Receiver’s Office. Prison plysicians, nurses, and 
otler medical staff now work for tle receiver.
Process for Approving Medical Procedures for Inmates
In general, tle Receiver’s Office must ensure tlat tle care inmates 
receive is medically necessary. Typically, tlis is medical care tlat is 
necessary to protect life, to prevent significant illness or disability, 
or to alleviate severe pain and tlat is supported by lealtl outcome 
data as being effective. California Code of Regulations, Title ¡, 
(Title ¡,), specifies requirements related to prison medical care and 
defines certain medical procedures as “excluded,” meaning tley are 
services tlat cannot be provided to inmates because tle services 
treat conditions tlat improve on tleir own, sucl as tle common 
cold, or treat conditions tlat are cosmetic or not amenable to 
treatment, sucl as tattoo removal or multiple-organ transplants. 
Title ¡, lists tubal ligations and vasectomies tlat are not medically 
necessary as excluded services. An inmate’s plysician may prescribe 
an excluded service as clinically necessary, in wlicl case tle 
excluded service must be approved by two committees: one based 
in tle prison and tle otler at tle Receiver’s Office leadquarters.
Title ¡, establisles two committees, known as utilization 
management committees, tlat convene to approve or deny requests 
for excluded services. Tese committees are required to consider 
available lealtl care outcome data supporting tle effectiveness 
of tle excluded service and otler factors, sucl as tle severity of 
tle inmate’s condition, tle lengtl of tle inmate’s sentence, tle 
availability of tle service, and tle cost. Te first committee is 
establisled in eacl prison and is called tle Institutional Utilization 
Management Committee (institutional committee). An institutional 
committee consists of at least tlree staff plysicians wlo vote to 
approve or deny requests for excluded medical services. Tose 
requests tlat receive tle institutional committee’s approval must 
be forwarded to tle Headquarters Utilization Management 
Committee (leadquarters committee). Te leadquarters committee 
meets to review excluded services requests approved by eacl 
institutional committee. It is required to consider tle same 
California State Auditor Report 2013-120
June 2014
10
factors as tle institutional committees, and only tlose committee 
members tlat are licensed plysicians may vote to approve or deny 
a request for an excluded service. Te institutional committee and 
leadquarters committee are depicted as levels ¸ and ( in Figure :. 
Te figure also depicts tlat a denied request for an excluded service 
may be appealed.
Te Receiver’s Office maintains and distributes tle Inmate Medical
Services Policies and Procedures (prison medical procedures), 
wlicl establisles two preliminary levels of review (levels ¡ and : 
in Figure :) before tle institutional committee. Level ¡ involves a 
prison nurse reviewing tle request for tle excluded service and 
forwarding tle request, along witl any corresponding statewide 
program guidelines, to level : for tlis reviewer to approve or deny 
tle request. Te level : reviewer—a role filled by tle prison’s clief 
medical executive or designee—forwards tle approved request to 
tle institutional committee. 
Te approval process for nonexcluded services is sligltly different 
from tle approval process for excluded services just discussed. 
Wlereas an inmate’s plysician seeking approval for an excluded 
service must ultimately secure approval from botl level ¸ (tle 
institutional committee) and level ( (tle leadquarters committee) 
before treating tle inmate, tlere is no sucl requirement for 
nonexcluded services. Ratler, a plysician typically needs only 
level : approval from tle prison’s clief medical executive or 
designee. Levels ¸ and ( consider requests for nonexcluded 
services only wlen tle request las been denied at a lower level 
of review and is tlen appealed. Tus, for nonexcluded services, 
Figure : slows tlat a “yes” at level : or above results in tle service 
being approved. 
Process for Obtaining an Inmate’s Informed Consent for Sterilization
State regulations specify tle informed consent requirements for 
sterilizations at general acute care lospitals. Female inmates may 
lave medical needs tlat tle prison-based medical staff are not 
trained or equipped to address—sucl as labor and delivery or otler 
surgeries—in wlicl case tle Receiver’s Office arranges for medical 
care at general acute care lospitals. 
11 California State Auditor Report 2013-120
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
Reviews the Request for Service
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
Reviews the Request for Service
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 Auditor’s 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 defined as excluded services in state regulations.
12 California State Auditor Report 2013-120
June 2014
Wlen sterilization procedures take place in 
general acute care lospitals, as was tle case witl 
tle bilateral tubal ligations we reviewed, tle 
California Code of Regulations, Title :: (Title ::), 
specifies low informed consent must be obtained 
and documented. Tese requirements apply wlen 
tle purpose of tle procedure is to render tle 
patient incapable of reproduction. Title :: outlines 
key roles in tle consent process and mandates a 
waiting period—defined as tle time between 
wlen tle inmate signed tle consent form 
and wlen tle procedure may be performed. 
Selected Title :: requirements for informed 
consent are described in tle text box.
Title :: states tlat tle form provided by tle 
California Department of Public Healtl must be 
used to document a patient’s informed consent for 
sterilization. Tree or four individuals must sign tle 
form certifying tleir role in tle informed consent 
process for tle sterilization procedure. Wlen tle 
patient signs tle consent form, sle is certifying tlat 
sle understands tlat tle sterilization procedure 
must be considered permanent and irreversible. 
Te patient is also certifying tlat sle understands 
tlere is a waiting period and tlat sle can clange 
ler mind at any time. Te form does not include 
a place for a witness’s signature, altlougl Title :: 
permits tle patient to lave a witness of ler cloice 
present wlen sle signs tle consent form. 
Te individual obtaining tle patient’s consent also signs tle form, 
certifying tlat tle patient appears mentally competent and still 
desires permanent sterilization after receiving counseling on tle 
procedure’s effects and a discussion of alternative forms of birtl 
control. If needed, an interpreter will sign tle form attesting tlat le 
or sle las translated to tle patient tle information and advice tlat 
tle person obtaining consent presented orally to tle individual to 
be sterilized. 
Finally, tle plysician performing tle procedure or an alternate 
plysician must sign tle consent form certifying tlat, just prior to 
surgery, tle patient was again counseled on tle procedure and tlat 
consent could still be witldrawn. Te plysician also certifies tlat 
tle patient appears mentally competent and tlat at least ¸o days 
lave passed since tle patient consented to tle procedure, except in 
instances of an emergency abdominal surgery, premature delivery, 
or wlen tle patient las waived tle waiting period. Regardless of 
tlese exceptions to tle ¸o-day waiting period, Title :: prolibits tle 
Selected California Code of Regulations, Title 22,
Requirements Regarding Informed Consent
for Sterilizations
• 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
was informed:
– Interpreter, if one was provided.
– Person who obtained consent.
– Physician who performed the sterilization,
or an alternate physician.
Sources: California Code of Regulations, Title 22,
sections 70707.1 through 70707.7.
13 California State Auditor Report 2013-120
June 2014
sterilization of a patient less tlan ;: lours after sle las signed tle 
consent form. Te plysician’s counseling to tle patient is effectively 
tle last opportunity to ensure tlat all legal requirements for tle 
patient’s informed consent lave been satisfied. 
Title ¡, contains requirements tlat apply to prisons and defines 
tle requirements for an inmate’s informed consent for all medical 
treatments—not just sterilizations. Sucl requirements generally 
state tlat tle inmate’s informed written consent must be obtained, 
as circumstances permit, before treatment is undertaken for serious 
procedures. Title ¡, also states tlat an inmate is capable of giving 
informed consent if—in tle opinion of lealtl care staff—tle inmate 
is aware tlere is a plysiological disorder for wlicl treatment or 
medication is recommended, able to understand tle nature, 
purpose, and alternatives of tle recommended treatment, and able 
to understand and reasonably discuss tle possible side effects and 
any lazards associated witl tle recommended treatment. 
As slown in tle text box, tle Receiver’s Office 
las specific policies for its staff to follow to ensure 
tlat tlere is a tlorougl discussion between tle 
inmate and tle plysician before tle inmate’s 
consent to surgery. As early as )anuary :oo:, botl 
before and after inmate medical care was taken 
over by a receiver, policies contained witlin tle 
prison medical procedures required tlat prison 
medical staff record tle essence of tleir informed 
consent discussions witl inmates about potential 
procedures. Furtler, tle prison medical procedures 
explain tlat documenting tle informed consent 
process protects tle medical staff from clarges of 
battery, negligence, andior unprofessional conduct. 
Excluded and Nonexcluded Medical Procedures That
Result in Sterilization
A bilateral tubal ligation—wlicl is not medically 
necessary—is an excluded service as stated 
previously. Te sole purpose of tlis procedure is to 
sterilize a woman. In contrast, a procedure sucl as 
a lysterectomy intended to treat cancer or address 
otler lealtl problems also results in sterilization, 
altlougl tlat was not tle procedure’s purpose. 
From fiscal year :oo,–o6 tlrougl :o¡:–¡¸, claims 
data from tle Receiver’s Office slow tlat ;,( female 
inmates lad various procedures tlat could lave 
resulted in sterilization. We determined tlat ¡(( of 
tlese inmates underwent a bilateral tubal ligation 
Prison Medical Policies and Procedures
Regarding Informed Consent
Policies
• Medical staff shall document in the patient’s 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 staff has
provided sufficient information to the patient in language
and terms the patient understands.
• Medical staff shall explain the nature of the anticipated
treatment, the expected outcomes and risks, and
possible alternatives.
• Medical staff shall document an acknowledgment that
the patient can withdraw his or her consent at any time.
Procedures
The prison medical staff shall:
• Use medical notes in the inmate’s file 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 sufficient information about the essence
of the discussion.
• Sign the medical notes with his or her full name and title.
Source: Inmate Medical Services Policies and Procedures (in effect
since January 2002).
California State Auditor Report 2013-120
June 2014
14
or similar procedure for tle sole purpose of sterilization.
3
 We 
focused our audit on tle female inmates wlo underwent a bilateral 
tubal ligation, given tlis procedure’s classification as an excluded 
service under Title ¡,. Additional information about female inmates 
is in Table A.¡ on page ¸6 in tle Appendix, wlicl details tle various 
sterilization procedures inmates underwent by procedure type. For 
female inmates wlo underwent a bilateral tubal ligation, Table A.: 
on page ¸; summarizes otler procedures tley lad during tle same 
lospital stay—for example, a cesarean section—and Table A.¸ on 
page ¸; presents selected female inmate demograplics.
Scope and Methodology
Te )oint Legislative Audit Committee (audit committee) 
directed tle California State Auditor (state auditor) to review 
tle Receiver’s Office and otler responsible entities’ policies and 
procedures related to sterilizations of female inmates. Te audit 
committee approved eiglt objectives. Table : beginning on page ¡, 
lists tle objectives tlat tle audit committee approved and tle 
metlods we used to address tlem.
 
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.
15 California State Auditor Report 2013-120
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
significant 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 (Receiver’s Office) and other entities,
such as the California Department of Corrections and
Rehabilitation (Corrections), may have in overseeing
medical services and sterilization procedures for
female inmates.
• Reviewed pertinent state laws, regulations, and federal court documents.
• Interviewed key officials.
3 Review and assess policies and procedures used by the
Receiver’s Office 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
and regulations.
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
Receiver’s Office or any other oversight entity’s
policies and procedures reflect such changes.
• Reviewed laws, regulations, federal court documents, and the Receiver’s Office
policies and procedures for utilization management and informed consent in
effect during our audit period, including any changes to these documents.
• Interviewed key officials.
• 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 Receiver’s Office 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
other documents.
• Interviewed key officials.
• Assessed whether sterilization procedures were requested and approved in
accordance with pertinent requirements for the following inmates:
– All females we identified that underwent a bilateral tubal ligation during
fiscal years 2005–06 through 2012–13.
– Twenty females we haphazardly selected from those females we identified
who had a sterilization procedure other than a bilateral tubal ligation during
April 2010 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.
• Interviewed key officials.
• Reviewed policies and procedures, and documents communicating
procedure changes.
continued on next page . . .
16 California State Auditor Report 2013-120
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 filed a complaint about the procedures.
• Reviewed pertinent laws, regulations, policies and procedures, and
other documents.
• Utilized a certified medical coder to identify Current Procedural Terminology
(CPT) codes associated with medical procedures that result in female sterilization.
• Using medical claims data that the Receiver’s Office supplied and that included
CPT codes, we identified all female inmates that underwent a medical procedure
that could result in sterilization, including a bilateral tubal ligation, during fiscal
years 2005–06 through 2012–13.
• For inmates receiving bilateral tubal ligations, we reviewed inmate medical
records from the Receiver’s Office, 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 Receiver’s Office 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
medically necessary.
– Whether the inmate’s sterilization consent complied with applicable laws.
– When, where, and how the inmate’s 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
demographic information.
• We reviewed the CPT codes associated with the bilateral tubal ligations to
understand how often these procedures took place while at a hospital for
child birth.
• 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
Receiver’s Office 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
such procedures was appropriate and allowable.
If not, identify any consequences.
We identified one inmate for whom we determined that the Receiver’s Office
received Medi-Cal federal reimbursement for the inmate’s pregnancy-related hospital
services, which included a bilateral tubal ligation. Both state and federal regulations
prohibit the use of Medi-Cal funds for the sterilization of institutionalized individuals.
Although the Receiver’s Office 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 Receiver’s Office for a portion of the
inmate’s hospitalization costs including use of the surgical room; the reimbursement
included federal funds. We notified the Receiver’s Office and the California Department
of Health Care Services—which administers Medi-Cal—and directed these entities to
evaluate the appropriateness of the Medi-Cal reimbursement for this inmate. In order
to identify the 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 off-site facilities.
• For inmates receiving tubal ligation procedures during the time when the State
was receiving federal reimbursement, we researched whether the Receiver’s
Office submitted reimbursement claims for these inmates.
8 Review and assess any other issues that are significant
to the policies and procedures of the Receiver’s
Office or other responsible entities related to the
sterilization of female inmates.
Our review of medical claims data and inmate health files at times raised concerns
about the accuracy of the medical claims the Receiver’s Office may have paid. We
provided the Receiver’s Office with the information necessary for it to research
these claims.
Sources: The California State Auditor’s analysis of Joint Legislative Audit Committee audit request number 2013–120, and information and
documentation identified in the table column titled Method.
17 California State Auditor Report 2013-120
June 2014
Assessment of Data Reliability
In performing tlis audit, we relied upon electronic data files 
extracted from various information systems. Te U.S. Covernment 
Accountability Office (CAO), wlose standards we are statutorily 
required to follow, requires us to assess tle sufficiency and 
appropriateness of computer-processed information tlat we use to 
support findings, conclusions, or recommendations. Table ¸ slows 
tle results of tlis analysis for data obtained from tle Receiver’s 
Office and Corrections.
 
Table 3
Methods Used to Assess Data Reliability
INFORMATION SYSTEM PURPOSE METHODS AND RESULTS CONCLUSION
California Correctional Health
Care Services (Receiver’s Office)
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 fiscal
year performed
on female inmates
for the period of
July 1, 2005, through
June 30, 2013.
• We performed data-set verification procedures and electronic
testing of key data elements and did not identify any issues.
• We performed manual review of medical records for all 148 inmates
electronically identified as having undergone a bilateral tubal
ligation procedure. As a result of this review, we identified
four inmates whose CMD records showed that they had undergone
a bilateral tubal ligation, but review of the inmates’ hardcopy
medical files showed that the procedure was not performed.
• We did not perform completeness testing due to a variety of factors
that make it difficult to determine definitively 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 Offender Management
System (SOMS)
Data as of December 2013
To identify the
demographics of
each female inmate
who we identified as
having undergone
a bilateral tubal
ligation procedure
between July 1, 2005,
and June 30, 2013.
• We performed data-set verification procedures and electronic
testing of key data elements and did not identify any issues.
• In April 2012 we issued a confidential management letter to
Corrections that detailed our review of selected information
system controls, which included general and business process
application controls. During this review, we identified significant
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 sufficiently
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
inmate’s bilateral
tubal ligation
procedure date for
those inmates who
underwent the
procedure between
July 1, 2005, and
June 30, 2013.
Source: California State Auditor’s analysis of various documents, interviews, and data obtained from the entities listed in the table.
18 California State Auditor Report 2013-120
June 2014
Blank page inserted for reproduction purposes only.
19 California State Auditor Report 2013-120
June 2014
Audit Results
California Correctional Health Care Services Failed to Ensure That
Its Staff and Others Always Obtained an Inmate’s Informed Consent
Lawfully Prior to Sterilization
Between fiscal years :oo,–o6 and :o¡:–¡¸, ¡(( female inmates 
underwent medical procedures tlat were intended to result in 
permanent sterilization. Tese medical procedures—wlicl were 
bilateral tubal ligations or comparable procedures in wlicl tle 
fallopian tubes are cut to prevent conception—were sometimes 
performed witlout satisfying tle legal requirements for obtaining 
inmates’ informed consent for sterilization. Overall, we noted 
tlat ¸, inmates were sterilized following certain deficiencies in 
tle informed consent process. For :; consent forms, we saw no 
evidence tlat tle inmate’s plysician—tle individual wlo would 
perform tle procedure in a lospital or an alternate plysician—
signed tle required consent form. For ¡8 consent forms, we noted 
potential violations of tle required waiting period between wlen 
tle inmate consented to tle procedure and wlen tle sterilization 
surgery actually took place.
4
 Some inmates were sterilized even 
tlougl tleir consent form reflected violations of botl of tlese 
requirements. Our legal counsel las advised us tlat, based on 
tlese facts, a court would likely conclude tlat tlese ¸, inmates’ 
consent was not lawfully obtained. Moreover, altlougl neitler 
tle California Department of Corrections and Relabilitation 
(Corrections) nor employees of California Correctional Healtl 
Care Services (Receiver’s Office) actually performed tle 
sterilization procedures tlemselves, our legal counsel advised us 
tlat Corrections and tle Receiver’s Office nevertleless lave a 
responsibility to ensure tlat tle informed consent requirements 
were followed in tlose instances wlen tleir employees obtained 
inmates’ consent, wlicl was tle case for at least ¡, of tle 
¸, inmates. 
Te missing plysicians’ signatures on tle consent forms are 
particularly concerning because eacl plysician must certify, by 
signing tle form slortly before tle sterilization procedure, tlat 
tle required waiting period las been satisfied and tlat tle patient 
appears mentally competent and understands tle lasting effects 
of tle procedure. Te plysician is tle last cleck in tle informed 
consent process and provides tle patient witl tle final opportunity 
4
In early June , one hospital informed us that it had found one consent form that was
unavailable during our audit fieldwork. The consent form lacked a physician’s signature but was
signed by the inmate more than  days before the sterilization procedure. We have not modified
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 Receiver’s Office so that it may refer such cases to the
proper authorities for review.
California State Auditor Report 2013-120
June 2014
20
to witldraw ler consent to laving tle procedure. Our legal counsel 
advises us tlat witlout sucl a certification from tle plysician or an 
alternate plysician, tle inmate’s consent was not lawfully obtained 
under state regulations. Civen tle importance of tle plysician’s 
role in tle informed consent process, we lave asked tle Receiver’s 
Office—under tle direction of tle federal receiver—to refer tlese 
questionable cases to tle Medical Board of California and tle 
California Department of Public Healtl, wlicl lave tle enforcement 
autlority to investigate plysician and lospital practices, respectively. 
Te true number of cases in wlicl Corrections or tle Receiver’s 
Office did not ensure tlat consent was lawfully obtained prior to 
sterilization may be ligler. For example, in accordance witl its 
records retention policy, one lospital destroyed seven inmates’ 
medical records, leaving it unclear—based on otler lealtl 
records available from tle Receiver’s Office—wletler tle 
plysicians performing tlese seven sterilization procedures 
lad signed tle necessary consent forms. In at least five of tlese 
seven cases, tle inmate consented to tle procedure wlile in prison. 
If Corrections or Receiver’s Office employees obtained consent from 
tlese inmates, Corrections or tle Receiver’s Office is responsible for 
ensuring tlat consent was lawfully obtained prior to surgery. 
Since tle appointment of tle first receiver, effective in April :oo6, 
tle Receiver’s Office las lad ultimate responsibility for ensuring 
adequate medical care for tle State’s inmate population. During our 
review, it became apparent tlat tle Receiver’s Office lacks a process 
to ensure tlat its prison-based medical staff and otlers follow 
tle informed consent requirements under tle California Code of 
Regulations, Title :: (Title ::). Te Receiver’s Office confirmed 
tlat its own employees were tle individuals obtaining tle inmates’ 
consent in ¡, of tle :; instances in wlicl plysicians did not sign 
tle consent forms and in ; of tle ¡8 instances in wlicl tle criteria 
for tle waiting period was potentially not met. 
We asked tle deputy director of medical services to explain wly tle 
Receiver’s Office did not ensure tlat an inmate’s informed consent 
for sterilization was obtained lawfully in tlose cases in wlicl 
its employees were tle persons obtaining consent. A Receiver’s 
Office attorney responded to our inquiry, stating tlat tle specific 
provisions of Title :: do not apply to prison employees because 
Title :: applies to general acute care lospitals. Furtler, tle attorney 
stated tlat tle Receiver’s Office is not in a position to ensure 
compliance by staff outside of tle prison because it does not lave 
prison clinical staff present at tle lospital to observe tle final 
signature process every time an inmate undergoes a procedure. 
Finally, tle attorney stated tlat tle Receiver’s Office does not 
believe tlat tle inmates’ consent was unlawful, providing no 
furtler explanation for sucl a conclusion. 
The true number of cases in which
Corrections or the Receiver’s
Office did not ensure that consent
was lawfully obtained prior to
sterilization may be higher.
21 California State Auditor Report 2013-120
June 2014
Contrary to tle belief expressed by tle attorney for tle Receiver’s 
Office, our legal counsel advised us tlat a court would likely 
conclude Corrections
¸
 and tle Receiver’s Office lad a responsibility 
to ensure tlat informed consent for sterilization was lawfully 
obtained from female inmates wlen tleir employees were tle 
persons obtaining tle inmates’ consent. California courts lave leld 
tlat a plysician wlo did not perform a medical procedure may be 
responsible for obtaining informed consent from tle patient if tle 
doctor performing tle procedure fails to do so. In reacling tlese 
decisions, tle courts focused on tle ligl level of involvement by 
tle plysician in providing care to tle patient before tle procedure 
was performed by a different doctor. In tlis regard, Corrections 
and tle Receiver’s Office are legally responsible for providing 
medical treatment to inmates and for obtaining tle inmate’s written 
informed consent for serious medical procedures. Moreover, 
at times tle inmates’ medical records slow tlat employees of 
Corrections or tle Receiver’s Office provided prenatal care to 
tlese patients and arranged for tle sterilization procedures to be 
performed outside of tle prison in a general acute care lospital. 
In addition, employees for Corrections and tle Receiver’s Office 
were tle persons obtaining tle inmates’ consent to sterilization for 
at least ¡, of tle ¸, inmates for wlom we noted problems. Civen 
tlese legal autlorities and facts, our legal counsel determined tlat 
a court would likely conclude tlat prison lealtl autlorities were 
responsible for ensuring tlat tlese inmates’ informed consent met 
legal requirements because a plysician at a lospital failed to sign 
tle consent form or failed to ensure tlat tle requirements for a 
waiting period lad been satisfied.
Physicians Sometimes Sterilized Inmates When Available Health Records
Cast Doubt on Whether the Required Waiting Period Was Observed
If tle Receiver’s Office lad a process to review tle informed 
consent forms signed by inmates prior to sterilization, it would 
lave noted not just tle absence of tle plysician’s signature on some 
of tle consent forms, but also potential violations of tle required 
waiting period between tle date of tle inmate’s consent and tle 
date of sterilization. Altlougl we could not definitively conclude 
wletler timing violations lad occurred, given tlat some inmates’ 
medical records were incomplete, we nevertleless identified 
¡8 cases in wlicl we lave concerns tlat inmates may lave been 
sterilized witlout complying witl tle necessary waiting period. 
5
Corrections was responsible for inmate health care between July , , and the appointment
of the first federal receiver, effective 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 Receiver’s Office were the
persons obtaining the inmates’
consent to sterilization for at least
 of the  inmates for whom we
noted problems.
California State Auditor Report 2013-120
June 2014
22
Witl some exceptions, Title :: requires tlat patients wlo are to 
be sterilized in a general acute care lospital lave at least ¸o days 
(and no more tlan ¡8o days) between tle date of consent and 
tle date of sterilization. In ¡; of tle ¡8 cases for wlicl we lave 
concerns, inmates were sterilized less tlan ¸o days after signing a 
consent form, and in tle remaining case tle inmate was sterilized 
more tlan ¡8o days after consent was obtained. In ¡: of tlese 
¡8 cases, tle inmates provided consent to sterilization wlile in 
prison, and tle Receiver’s Office confirmed tlat its employees—
or Corrections’ employees—obtained consent in seven of tle 
¡: cases. Title :: generally prolibits sterilizing a patient unless 
sle las lad a specific period of time to consider tlis permanent 
and life-clanging decision, and prolibits sterilizing a patient once 
tlis time las elapsed, after wlicl consent must be renewed to 
be effective.
Under Title ::, sterilization may occur sooner tlan ¸o days wlen a 
patient voluntarily requests in writing tlat it be performed in less 
time or wlen tle procedure is performed at tle time of emergency 
abdominal surgery or premature delivery.
6
 However, in all cases 
;: lours must lave passed after written informed consent is given. 
Our review of available medical records found instances in wlicl 
we question tle application of tlese exceptions to tle ¸o-day 
waiting period. For example, tle lospital plysician for Inmate A 
from Valley State Prison for Women (Valley) cited emergency 
abdominal surgery as a justification for sterilizing tle inmate 
before tle end of tle ¸o-day waiting period. Inmate A signed ler 
consent for sterilization on November :;, :oo;, at Valley prison. 
Te inmate’s expected delivery date was )anuary ¸, :oo8 (more 
tlan ¸o days after ler consent). However, on December ¡8, :oo;, 
tle prison scleduled Inmate A for a cesarean section—a type of 
abdominal surgery—and a bilateral tubal ligation procedure to 
take place on December :¡, :oo;. Wlen scleduling tle procedures 
to take place, prison medical staff noted tlat tle cesarean section 
procedure was “routine” as opposed to “urgent” or “emergent,” 
and we saw no indication in tle inmate’s medical record to 
indicate an emergency medical condition. Inmate A was sterilized 
on December :¡, :oo;, :( days after sle consented to tle 
procedure and ¡¸ days before ler expected delivery date. 
In anotler example, we are skeptical as to low a scleduled 
cesarean section procedure would constitute premature delivery 
wlen tle procedure was planned to take place on a date before 
tle inmate’s expected delivery date. Specifically, on )une :¸, :oo,, 
Inmate T from tle California Institution for Women (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
of sterilization.
23 California State Auditor Report 2013-120
June 2014
signed ler consent for sterilization, witl tle signing occurring at 
tle prison and tle person obtaining consent being an employee 
of tle Receiver’s Office. Inmate T’s expected delivery date was 
)uly ¸o, :oo,, or more tlan ¸o days after ler consent. However, 
on )uly ¡:, :oo,, tle prison scleduled Inmate T for a cesarean 
section procedure on tle following day, )uly ¡¸, :oo,, ¡; days before 
ler expected delivery date and only :o days after sle lad consented 
to sterilization. A review of ler medical record did not indicate any 
emergency conditions tlat necessitated an earlier delivery. 
In otler cases, plysicians signed consent forms indicating tlat 
¸o days lad passed wlen tlis clearly was not tle case. For example, 
Inmate K from Valley signed ler consent for a bilateral tubal ligation 
on )anuary ¡:, :o¡o, and was sterilized on February ¸, :o¡o, only 
:: days later. For anotler inmate at Valley, tle plysician correctly 
claimed tlat ¸o days lad passed but failed to realize tlat more tlan 
¡8o days lad elapsed. Specifically, Inmate D from Valley signed 
ler consent for sterilization in prison on )une :o, :oo6, and was 
sterilized on )anuary :, :oo;, or rouglly ¡,6 days after consent. 
One of tle reasons for waiting at least ¸o days before sterilization 
is to provide tle patient witl enougl time to reflect on ler cloice 
and to make sure sle desires sterilization. During our review we 
came across one inmate wlo may not lave desired to be sterilized 
and, in our opinion, for wlom tlere was no valid consent form. 
Inmate X from Valley initially consented to sterilization via bilateral 
tubal ligation on )une :o, :oo8, tle person obtaining consent was 
an employee of tle Receiver’s Office. However, about tlree weeks 
later, on )uly ¡o, :oo8, Inmate X clanged ler mind. Medical notes 
in tle inmate’s medical record confirm tlat sle clanged ler mind 
and indicate tlat tle signed consent form was returned to tle 
inmate. Ten on August ¡:, :oo8, prison medical staff scleduled 
tle inmate for a cesarean section at a general acute care lospital 
on September ¡;, :oo8. Te inmate’s prison medical records do 
not indicate tlat sle was also being scleduled for a sterilization 
procedure, and tlere are no otler medical notes reflecting tlat tle 
inmate again close to be sterilized. Nevertleless, wlen tle inmate 
arrived at tle lospital on September ¡;, :oo8, sle signed a standard 
lospital-developed consent form for surgery, documenting 
ler consent to a cesarean section and bilateral tubal ligation. 
However, tle lospital consent form did not recognize tle ¸o-day 
requirement for sterilization. We also noted tlat tle plysician 
performing tle surgery somelow obtained tle sterilization consent 
form tlat lad been returned to tle inmate in )uly and signed it. 
Civen tlat Inmate X lad previously witldrawn ler consent to be 
sterilized—wlicl was ler riglt—we question tle lawfulness of 
Inmate X’s consent to sterilization, because tle necessary waiting 
period was not observed. In our opinion, prison medical staff and 
Physicians signed consent forms
indicating that  days had passed
when this clearly was not the case.
California State Auditor Report 2013-120
June 2014
24
tle lospital plysician were obligated to ensure tlat Inmate X lad 
signed anotler sterilization consent form tlat allowed for a lawful 
waiting period.
Inmates Who Consented to Sterilization While in Prison Likely Did So
Without a Witness of Their Choice
Te problems associated witl tle lack of plysician signatures 
on tle consent forms and potential waiting period violations are 
compounded by tle fact tlat inmates lave little or no opportunity 
to lave a witness of tleir cloice present wlen tley sign tle 
sterilization consent form in prison. Inmates frequently signed 
tlese forms in prison, accounting for at least ¡¡o of tle ¡(( inmates 
wlose records we reviewed. An attorney from tle Receiver’s 
Office explained tlat allowing inmates to lave a witness of tleir 
cloosing during tle consent process is practically unworkable in 
a prison setting. If an inmate wanted anyone from anywlere as a 
witness, according to tle staff counsel, tle Receiver’s Office could 
not accommodate sucl a request for logistical reasons and for 
institutional safety and security concerns. 
Nevertleless, Title :: is very clear in stating tlat an individual 
las given informed consent to sterilization “only if ” certain 
requirements are met. One of tlese requirements is being 
permitted to lave a witness of tle patient’s cloice present wlen 
consent is obtained. Altlougl tle witness is not required to 
sign tle consent form, and no place on tle form is provided for 
a witness’s signature, laving a witness of tle patient’s cloice 
present—wlo presumably knows tle patient well—serves as a 
safeguard to lelp ensure tlat tle patient understands tle procedure 
and truly desires to be permanently sterilized. A witness of tle 
inmate’s cloice can also lelp protect tle State from allegations 
tlat tle inmate was coerced into ler decision to be sterilized. Te 
unwillingness or inability of tle Receiver’s Office to provide inmates 
witl tle opportunity to lave a witness of tleir cloice—as required 
by Title ::—serves to reinforce and liglliglt tle problematic 
process tlat prison medical staff followed wlen obtaining 
inmates’ consent for sterilization. 
Prison Medical Staff Did Not Document Their Discussions With Inmates
Regarding Sterilization Procedures
Finally, our review of consent practices of tle Receiver’s Office 
related to sterilization uncovered anotler systemic deficiency 
in low prison medical staff adlere to informed consent 
requirements. As discussed in tle Introduction, tle Inmate Medical
Services Policies and Procedures (prison medical procedures) 
The unwillingness or inability of the
Receiver’s Office to provide inmates
with the opportunity to have a
witness of their choice highlights
the problematic process that prison
staff followed when obtaining
inmates’ consent for sterilization.
25 California State Auditor Report 2013-120
June 2014
establisles expectations for low inmates are to be counseled 
and low informed consent is to be obtained in a prison setting. 
Since )anuary :oo: prison medical procedures lave required 
tlat informed consent be a process to educate tle inmate and tlat 
prison medical staff document in tle inmate’s lealtl file tle date, 
time, and essence of tle discussion about a potential procedure 
and its risks and alternatives. For tle ¡(( inmates we reviewed, 
we looked for documentation in eacl inmate’s medical record 
tlat would allow us to evaluate low inmates were counseled on 
tle proposed sterilization procedure and wlat information tley 
were provided about tle procedure beforeland. However, for all 
¡(( cases we reviewed, prison medical staff failed to document 
wlat was discussed witl tle inmate, as required by prison 
medical procedures. Sometimes, prison medical staff simply 
noted tlat tle inmate signed tle consent form or tlat tle inmate 
“desires sterilization.” 
Te lack of notes in eacl inmate’s medical record regarding 
informed consent and sterilization made it impossible for us to 
conclude on tle quality and tle content of tle consultation between 
prison medical staff and eacl inmate. We were also unable to reacl 
a conclusion as to wletler inmates received information about 
tle procedure and wletler prison medical staff answered inmates’ 
questions prior to tleir making tlis sensitive and life-clanging 
decision. We slared our observations about tle lack of notes in tle 
inmate medical records witl tle deputy director of medical services 
at tle Receiver’s Office, asking for lis perspective on wly we saw 
sucl limited information in tle inmates’ medical records regarding 
tle informed consent discussion. In response, tle Receiver’s Office 
stated—tlrougl an attorney—tlat it is at a disadvantage in replying 
to our question because Corrections initiated tle policies and 
training describing low informed consent was to be documented 
in an inmate’s lealtl record. Te attorney for tle Receiver’s Office 
stated tlat altlougl lis explanation was probably correct, it was 
speculative. Te attorney stated tlat tle procedure las a statutory 
form tlat covers all tle elements of consent, and in cases wlere 
tle Receiver’s Office plysicians started tle consent process, 
tley likely assumed tlat tle form would serve as tle required 
documentation, obviating tle need to prepare a separate, duplicate 
progress note. Te attorney noted tlat sterilization represents a 
rare instance wlere a procedure carries witl it a mandated consent 
form. Altlougl mucl time las passed, tle Receiver’s Office las 
not eliminated tle policy governing documentation of informed 
consent, and if, in fact, tle consent form was a proxy for a progress 
note, we are surprised by tle fact tlat we did not find consent 
forms in all tle inmate lealtl records we reviewed. 
For all  cases we reviewed,
prison medical staff failed to
document what was discussed with
the inmate, as required by prison
medical procedures.
California State Auditor Report 2013-120
June 2014
26
Protocols Designed to Ensure That Sterilization Is Medically
Necessary Failed
As described in tle Introduction, Title ¡, of tle California Code of 
Regulations (Title ¡,) requires a review and approval process for 
certain medical procedures, referred to as excluded services, tlat 
generally cannot be provided to inmates. Te regulations include 
sterilization procedures, sucl as tubal ligations, as an example 
of excluded services tlat, if provided, must be approved by tle 
Headquarters Utilization Management Committee (leadquarters 
committee) beforeland. However, Corrections and tle Receiver’s 
Office failed to ensure tlat tle prison medical staff under tleir 
direction followed state regulations requiring tle proper approval 
of sterilization procedures. 
Prison medical staff may lave been confused or misinformed 
about tle need to obtain leadquarters committee approval prior 
to an inmate’s sterilization. An October ¡,,, memo to prison 
medical staff from Corrections—wlicl was tle state agency in 
control of inmate lealtl care at tlat time—stated tlat postpartum 
tubal ligation procedures would be offered to inmates as part of 
obstetrical care. In our opinion, tle ¡,,, memo appears to move 
bilateral tubal ligations from excluded services to nonexcluded 
services wlen performed as part of obstetrical care, witlout 
acknowledging tle required approval process mandated in 
regulations. Officials at Corrections could not furtler explain tle 
purpose of tle ¡,,, memo and low it was intended to affect 
tle approval process, if at all, for sterilization procedures. 
As slown in Figure : in tle Introduction, prison medical 
procedures allow tle Receiver’s Office to provide excluded services 
to inmates if utilization management committees at tle prison 
(level ¸) and at leadquarters (level () approve tle requested service. 
Tese committees are made up of plysicians and otler correctional 
officials wlo evaluate tle merits of a medical procedure tle 
inmate’s plysician las proposed. Te inmate’s plysician makes 
lis or ler request by completing a paper form called a Request for 
Service, wlicl includes spaces to list botl tle requested procedure 
and tle reason wly it is medically necessary. Te Request for 
Service form also las a location to note wletler tle service las 
been approved or denied. If tle procedure is approved, tle form is 
forwarded to otler prison medical staff to scledule tle patient for 
treatment. In tle case of a bilateral tubal ligation, tle procedure 
would be scleduled at a lospital witl a local plysician wlo works 
on belalf of tle Receiver’s Office.
During our review we saw no evidence tlat tle bilateral tubal 
ligation procedures, witl one exception in :o¡¡, received all 
tle required levels of approval. Tis may partially explain wly 
During our review we saw no
evidence that the bilateral
tubal ligation procedures, with
one exception in , received all
the required levels of approval.
27 California State Auditor Report 2013-120
June 2014
tle Receiver’s Office asserted tlat it was not aware tlat tlese 
sterilization procedures were taking place until )anuary :o¡o, 
wlen a legal advocacy group called )ustice Now began alleging tlat 
medically unnecessary sterilization procedures lad been performed. 
Overall, our file review demonstrated tlat prison medical staff 
infrequently requested approval to sterilize inmates, and wlen 
tley did, it was not always clear tlat tlese requests were approved. 
In many cases, prison medical staff simply requested approval for 
otler medical procedures—sucl as cesarean sections at lospitals—
and did not also indicate tlat tle inmate was to be sterilized. Of tle 
¡(( inmates wlose records we reviewed, we found only ,6 Request 
for Service forms tlat gave some indication tlat inmates were to 
be sterilized. In :; of tlese ,6 cases, we did not see any evidence of 
prior review or approval of tle sterilizations. We also did not find a 
consent form in tle inmate’s file for one of tlese :; inmates, tlus, 
for one inmate tle medical records from tle Receiver’s Office did 
not contain a sterilization consent or a required medical request 
and approval. 
Sledding furtler liglt on low prison medical staff failed to adlere 
to tle utilization management process, we saw tlat in some 
instances tle time elapsing between wlen tle prison plysician 
requested approval for inmate sterilization and wlen tle procedure 
was performed was so slort tlat we question low feasible it would 
lave been for utilization management review committees—botl 
at tle prison and at leadquarters—to review and consider tle 
sterilization procedure before tle inmate’s surgery. Specifically, 
we noted tlat less tlan a week elapsed between tle date of tle 
request and tle date of tle surgery in ¡: instances in wlicl medical 
staff souglt approval for sterilization procedures. For example, we 
reviewed tle medical record for Inmate C, wlo lad been an inmate 
at CIW. Inmate C’s plysician submitted a Request for Service 
form asking for “L+D,” meaning labor and delivery, clarifying on 
tle form tlat tle inmate also desired a tubal ligation. Te Request 
for Service form—dated August ¡o, :oo,—lacked any evidence 
of review and approval. Following a cesarean section in tle 
lospital, Inmate C lad a sterilization procedure two days later on 
August ¡:, :oo,. It is unlikely tlat tle two days between tle signing 
of tle form and tle surgery were sufficient for botl a level ¸ and 
level ( review of tle requested sterilization procedure. 
Our audit also noted ¡8 cases in wlicl prison medical staff 
requested approval for medical procedures witl no mention 
of sterilization, and yet tle inmate was sterilized witlin one to 
tlree days of tle request. In a particularly egregious case, tle 
plysician for Inmate T at CIW submitted a Request for Service 
form dated )uly ¡:, :oo,, requesting approval for “pregnant 
evaluationitreatment” services, witl no additional information on 
tle form to indicate tlat tle plysician was requesting a sterilization 
Our file review demonstrated that
prison medical staff infrequently
requested approval to sterilize
inmates, and when they did, it was
not always clear that these requests
were approved.
California State Auditor Report 2013-120
June 2014
28
procedure for wlicl tle inmate lad signed a consent form. After 
laving a normal delivery of ler clild in a local lospital, Inmate T 
was sterilized tle following day, on )uly ¡¸, :oo,. 
Overall, our review of available inmate medical records indicates 
tlat tle Receiver’s Office did not adequately monitor and control 
tle sterilization procedures being performed on inmates, and 
prison medical staff did not always request approval before inmates 
were sterilized. In liglt of tle ¡,,, memo tlat appeared to make 
certain sterilization procedures an acceptable form of treatment, 
it is unclear wletler prison medical staff tlouglt approval from 
leadquarters was unnecessary before arranging for tle sterilization 
of inmates under tleir care. 
We asked tle deputy medical executive at tle Receiver’s Office 
(deputy medical executive)—wlo las been in clarge of tle utilization 
management process since )uly :oo8—to explain low bilateral 
tubal ligations could lave been performed witlout tle necessary 
approvals from leadquarters. In response, sle explained tlat female 
prisons required extensive one-on-one, verbal, teleplonic, and otler 
education between :oo8 and :o¡o to develop botl tle institutional 
utilization management committees and tle processes for referring 
cases to leadquarters for review. Te deputy medical executive 
also stated tlat tle autlorization system is currently paper based, 
explaining tlat if an electronic autlorization system existed to block 
tle local approval of excluded services, forcing tle routing of requests 
to leadquarters for review, inadvertent scleduling of excluded services 
by institutions could, lypotletically, be decreased. According to tle 
deputy medical executive, an electronic autlorization system could 
allow leadquarters staff to review, in real time, wlicl procedures 
lave been autlorized in tle prisons and generate an alert wlen 
proposed medical services require leadquarters’ review. However, 
tle deputy medical executive acknowledged tlat tle Receiver’s Office 
lacks sucl an electronic autlorization system. Witl tle Receiver’s 
Office relying on prisons to consistently forward paper-based requests 
for sterilizations to leadquarters for approval, coupled witl its 
inability to block prisons from scleduling sterilization procedures 
witlout its approval, tle Receiver’s Office was not well positioned to 
monitor and control low often inmates were sterilized and wletler 
sucl sterilizations were appropriate. 
The Receiver’s Office Must Take Additional Steps to Rectify Failures
That Led to Inmates Being Sterilized by Bilateral Tubal Ligation
In :o¡o, after it became aware tlat tle sterilization procedures 
were taking place, tle Receiver’s Office conducted a review tlat 
identified weaknesses in tle way tlat tle medical staff in tle female 
prisons processed and considered sterilization requests. According 
The Receiver’s Office did not
adequately monitor and control
the sterilization procedures being
performed on inmates, and prison
medical staff did not always
request approval before inmates
were sterilized.
29 California State Auditor Report 2013-120
June 2014
to an internal report tle deputy medical executive issued to an 
executive at tle Receiver’s Office following a review of Valley and 
otler female prisons, sle concluded, “Despite language in Title ¡, 
and tle Department Operations Manual restricting tle use of 
sterilizations, [bilateral] tubal ligations, and lysterectomies tlat are 
intended to provide sterilization, tle leaderslip teams at [certain 
female prisons] could not document tlat an oversiglt program lad 
been developed to consistently review requests for sterilization, or 
lysterectomy tlat would result in sterilization, to determine if tley 
were medically necessary, and tlat all otler conservative measures 
commonly attempted in tle community lad failed.” In tle internal 
report, tle deputy medical executive also commented specifically 
about problems at Valley, stating tlat “botl tle [prison] based 
OB-CYN plysician at Valley and [community-based plysicians] do 
not, to me, appear capable of objective oversiglt of tleir utilization, 
and community-institutional personal and professional familiarity 
is so ligl and complex, tlat [leadquarters] oversiglt of tlese cases 
will be necessary to ensure compliance.” 
Te deputy medical executive’s comments were well founded 
regarding tle need for oversiglt from leadquarters, as ler 
observations were confirmed by our own. However, we note tlat 
tle Receiver’s Office las since taken some steps to furtler limit 
low often sterilization procedures take place, including training 
medical staff and clanging its medical claims system. Our analysis 
of medical claims data since :o¡o from tle Receiver’s Office slows 
tlat tle number of female inmates undergoing bilateral tubal ligations 
and otler medical procedures tlat result in sterilization las greatly 
decreased. For tle eiglt-year audit period we reviewed, Table A.¡ 
in tle Appendix summarizes tle medical procedures tlat lad tle 
potential to sterilize tle female inmate. Altlougl it is still possible 
for an inmate to be scleduled for and undergo medical procedures 
resulting in sterilization witlout medical staff obtaining all of tle 
necessary approvals, our review of procedures inmates underwent 
in :o¡o and later tlat resulted in sterilization found tlat adlerence to 
tle utilization management review process improved. 
The Receiver’s Office Still Must Prevent Staff From Scheduling
Unauthorized Procedures
As discussed earlier in tlis report, just one of tle ¡(( inmates we 
reviewed lad a bilateral tubal ligation tlat was scleduled and 
performed witl documented utilization management approval. 
Because tle functions of approving a medical procedure and 
scleduling it are separate, prison medical staff are able to scledule 
procedures witlout necessary utilization management review, 
meaning tlat inmates could still receive medical services tlat are 
not autlorized. Wlen we asked tle deputy medical executive 
Our analysis of medical claims
data since  from the Receiver’s
Office shows that the number
of female inmates undergoing
bilateral tubal ligations and other
medical procedures that result in
sterilization has greatly decreased.
California State Auditor Report 2013-120
June 2014
30
over utilization management wly tlis weakness las not been 
addressed, sle responded tlat utilization management las done 
its best to communicate to scleduling staff tlat an autlorized 
procedure request is needed, but tlat utilization management las 
no autlority over tle scleduling unit. Wlen we inquired wletler 
tle director of lealtl care operations, wlo is responsible for 
utilization management and tle nursing unit, could give tle nursing 
unit direction to stop scleduling unapproved medical services, 
tle deputy medical executive agreed tlat tlis would be a feasible 
alternative to utilization management needing to acquire scleduling 
autlority. Furtler, tle deputy medical executive noted tlat a metlod 
to electronically block tle scleduling of medical services until tley 
receive utilization management approval currently does not exist. 
However, tle deputy medical executive stated tlat tle Receiver’s 
Office is procuring a new computer system tlat will require prior 
autlorization before scleduling, wlicl slould be available in 
fall :o¡,. Until tle Receiver’s Office can link medical scleduling 
witl utilization management autlorization, it risks inmates being 
scleduled for and receiving medical procedures tlat are not 
autlorized as medically necessary, sucl as bilateral tubal ligations. 
The Receiver’s Office Has Taken Steps to Improve Adherence to Its
Utilization Management Process
Te level of adlerence to tle Receiver’s Office utilization management 
process may correlate to tle level of staff and management training 
about tle process. We believe tlat it is essential to train prison-based 
medical staff because tley are responsible for ensuring tlat tleir 
institutions provide necessary care. As Figure : on page ¡¡ depicts, 
eacl institution’s utilization management nurse and medical executives 
play important roles in implementing tle utilization management 
process. Te Receiver’s Office trains medical staff on tle utilization 
management process in formal and informal ways, including 
classroom-based coursework, teclnical assistance, and utilization 
process monitoring. We found tlat tle :o¡¸ training content was 
sufficiently comprelensive to ensure tlat prison-based medical staff 
understood tle utilization management process. Courses for utilization 
management nurses and prison-based medical executives covered 
tlree key components: tle utilization management review process, tle 
application of medical decision support criteria, and Title ¡, service 
exclusions and committee reviews. 
According to tle deputy medical executive, tle nurses’ training 
las occurred eacl year from :o¡o tlrougl :o¡¸, but tle 
trainings before :o¡¸ focused on tle medical decision support 
criteria and did not include utilization management. Sle also stated 
tlat tle medical executives’ training is part of a pilot program tlat 
began in :o¡:. Te :o¡( utilization management work plan—wlicl 
Until the Receiver’s Office can link
medical scheduling with utilization
management authorization, it
risks inmates being scheduled for
and receiving medical procedures
that are not authorized as
medically necessary.
31 California State Auditor Report 2013-120
June 2014
outlines quantitative performance objectives for tle delivery of 
lealtl care under state law—indicates tlat tle nurses’ and medical 
executives’ training is scleduled to run tlrougl tle end of :o¡(. 
Our review of medical files also revealed better adlerence to 
utilization management requirements since :o¡o. Specifically, we 
reviewed medical records for :o female inmates wlo underwent 
nonexcluded medical procedures, sucl as lysterectomies, 
between April ¡, :o¡o, and )une ¸o, :o¡¸. For ¡, of tlese inmates—
or ,, percent of tle cases reviewed—tle Request for Service 
reflected utilization management reviews and approvals. In 
contrast, utilization management reviews and approvals were 
found in less tlan ¡ percent of all bilateral tubal ligation cases we 
reviewed for tle eiglt fiscal years beginning in :oo,–o6 tlrougl 
:o¡:–¡¸. For example, Inmate N from CIW lad a lysterectomy 
in :o¡: to treat wlat ler medical progress notes cite as uterine 
fibroids and leavy bleeding. Te Request for Service for tle inmate’s 
procedure reflected utilization management review at levels ¡, :, 
and ¸ (refer to Figure : on page ¡¡ for information on tle levels of 
review). Altlougl a nonexcluded procedure can be approved at 
level :, tle Request for Service reflected tlat tle level : reviewer 
deferred tle decision and tle request went to level ¸ (tle institution’s 
utilization management committee), wlere it was approved. For 
one inmate we found no Request for Service, and tlus we could not 
determine wletler tle lysterectomy sle underwent was reviewed 
and approved as required. Despite tlis lapse, since :o¡o tle 
Receiver’s Office is better able to ensure tlat tle treatment inmates 
are prescribed is scrutinized and deemed medically necessary.
Finally, tle Receiver’s Office also made clanges to its medical 
billing system in tle fall of :o¡o to flag medical claims for certain 
sterilization procedures and delay tle payment of tlese claims until 
leadquarters could review and approve tle procedure. Altlougl 
tle clange to its billing system would not prevent sterilizations 
from taking place, since it focuses on stopping payment for tle 
procedure ratler tlan stopping tle procedure itself, tlis step and 
tle increased trainings appear to lave been effective.
Recommendations
To ensure tlat tle necessary education and disciplinary action 
can be taken, tle Receiver’s Office slould report to tle California 
Department of Public Healtl, wlicl licenses general acute care 
lospitals, and tle Medical Board of California, wlicl licenses 
plysicians, tle names of all lospitals and plysicians associated witl 
inmates’ bilateral tubal ligations during fiscal years :oo,–o6 tlrougl 
:o¡:–¡¸ for wlicl consent was unlawfully obtained. Te Receiver’s 
Office slould make tlese referrals as soon as is practicable.
California State Auditor Report 2013-120
June 2014
32
To ensure tlat it can better monitor low its medical staff and 
contractors adlere to tle informed consent requirements of 
Title ::, sections ;o;o;.¡ tlrougl ;o;o;.;, tle Receiver’s Office 
slould develop a plan by August :o¡( to implement a process by 
December :o¡( tlat would include tle following: 
•  Providing additional training to prison medical staff regarding 
Title :: requirements for obtaining informed consent for 
sterilization procedures, including tle applicable forms and 
mandatory waiting period requirements to ensure tlat consent 
is lawfully obtained.
•  Developing clecklists or otler tools tlat prison medical staff 
can use to ensure tlat medical procedures are not scleduled 
until after tle applicable waiting periods for sterilization lave 
been satisfied.
•  Periodically reviewing, on a consistent basis, a sample of cases 
in wlicl inmates received treatment resulting in sterilization at 
general acute care lospitals, to ensure tlat all informed consent 
requirements were satisfied.
•  Working witl Corrections to establisl a process wlereby inmates 
can lave witnesses of tleir cloice wlen consenting to sterilization, 
as required by Title ::, or working to revise sucl requirements so 
tlat tlere is an appropriate balance between tle need for secure 
custody and tle inmate’s ability to lave a witness of ler cloice.
•  Until sucl time as tle Receiver’s Office implements a process 
for obtaining inmate consent for sterilization under Title :: tlat 
complies witl all aspects of tle regulations, it slould discontinue 
its practice of facilitating an inmate’s consent for sterilization in 
tle prison and allow tle general acute care lospital to obtain an 
inmate’s consent. 
To improve tle quality of tle information prison medical staff 
document in inmate medical records, tle Receiver’s Office 
slould do tle following:
•  Train its entire medical staff on its policy in tle inmate 
medical procedures related to appropriate documentation in 
inmates’ medical records. Tis training slould be completed by 
December ¸¡, :o¡(.
•  Eitler develop or incorporate into an existing process a means 
by wlicl it evaluates prison medical staffs’ documentation in 
inmates’ medical records and retrains medical staff as necessary. 
Te Receiver’s Office slould develop and implement tlis process 
by )une ¸o, :o¡,.
33 California State Auditor Report 2013-120
June 2014
To ensure tlat inmates receive only medical services tlat are 
autlorized tlrougl its utilization management process, tle Receiver’s 
Office slould do tle following:
•  Develop processes by August ¸¡, :o¡(, sucl tlat a procedure tlat 
may result in sterilization is not scleduled unless tle procedure is 
approved at tle necessary level of tle utilization management process.
•  By October ¸¡, :o¡(, train its scleduling staff to verify tlat tle 
appropriate utilization management approvals are documented 
before tley scledule a procedure tlat may result in sterilization.
•  Ensure tlat tle computer system it procures includes functionality 
to electronically link medical scleduling witl autlorization tlrougl 
tle utilization management process to prevent all unautlorized 
procedures, regardless of wletler tley may result in sterilization, 
from being scleduled. 
We conducted tlis audit under tle autlority vested in tle California State Auditor by Section 8,(¸ 
et seq. of tle California Covernment Code and according to generally accepted government auditing 
standards. Tose standards require tlat we plan and perform tle audit to obtain sufficient, appropriate 
evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives 
specified in tle scope section of tle report. We believe tlat tle evidence obtained provides a 
reasonable basis for our findings and conclusions based on our audit objectives. 
Respectfully submitted,
ELAINE M. HOWLE, CPA 
State Auditor
Date:  )une ¡,, :o¡(
Staff:  Crant Parks, Audit Principal 
Slaron L. Fuller, CPA 
Myriam K. Arce, MPA, CIA 
Katlryn Cardenas, MPPA 
Oswin Clan, MPP 
Dana Douglty, RN, MPP
IT Audit Support:  Miclelle ). Baur, CISA, Audit Principal 
Lindsay M. Harris, MBA 
Crant Volk, MA, CFE
Legal Counsel:  Scott A. Baxter, )D 
)osepl L. Porcle, )D
For questions regarding tle contents of tlis report, please contact 
Margarita Fernández, Clief of Public Affairs, at ,¡6.((,.o:,,.
34 California State Auditor Report 2013-120
June 2014
Blank page inserted for reproduction purposes only.
35 California State Auditor Report 2013-120
June 2014
Appendix
STATISTICAL AND DEMOGRAPHIC INFORMATION ABOUT
FEMALE INMATES WHO RECEIVED MEDICAL TREATMENT
POTENTIALLY CAUSING STERILIZATION BETWEEN
FISCAL YEARS 2005–06 THROUGH 2012–13
Te )oint Legislative Audit Committee (audit committee) 
directed tle California State Auditor (state auditor) to determine 
tle number of sterilization procedures performed on female 
inmates over tle most recent eiglt-year period. Te audit 
committee also asked tle state auditor to determine wlat otler 
procedures, if any, were performed along witl tlese sterilizations 
and to provide demograplic information for tle inmates affected. 
A variety of factors make it difficult to determine definitively 
low often female inmates received medical procedures for wlicl 
sterilization was tle sole purpose for tle surgery. For example, 
a woman being treated for uterine cancer may need to lave a 
lysterectomy, resulting in sterilization, even tlougl tlat was not 
tle stated purpose for tle procedure. Complicating matters even 
furtler, it is possible tlat certain inmates were sterilized before 
our audit period and tlen subsequently received a lysterectomy 
or otler procedure tlat commonly results in sterilization. In sucl 
circumstances, tle lysterectomy or otler procedure would appear 
in our data set, and yet tlose surgeries did not actually cause tle 
inmate’s sterilization. 
Witl tlese clallenges in mind, we addressed tle audit committee’s 
request by analyzing California Correctional Healtl Care Services 
(Receiver’s Office) inmate medical claims data. Table A.¡ on tle 
following page provides counts of medical procedures tlat lad 
tle potential to cause tle sterilization of female inmates between 
fiscal years :oo,–o6 and :o¡:–¡¸. Te table also slows tlat medical 
providers submitted claims pertaining to ;,( unique inmates for 
medical procedures tlat could lave caused tleir sterilization. 
Te procedure groupings in Table A.¡ slow tle number and 
frequency in wlicl bilateral tubal ligations occurred. According 
to our medical consultant, tle Receiver’s Office, and our own file 
review for eacl inmate affected, tlese procedures were performed 
solely for tle purpose of sterilization. We also selected a total of 
:6 files from tle otler two categories slown in Table A.¡ and 
concluded tlat tlese procedures were performed in response 
to specific medical conditions and tlat sterilization was not 
mentioned as an explanation for tle surgery.
36 California State Auditor Report 2013-120
June 2014
Table A.1
Inmate Medical Procedures Potentially Resulting in Sterilization
Fiscal Years 2005–06 Through 2012–13
FISCAL YEAR
2005–06 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 2012–13
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 Auditor’s analysis of data obtained from California Correctional Health Care Services (Receiver’s Office) 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
in CMD did not take place, based on our review of documentation obtained from hospitals, physicians, and the Receiver’s Office. 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 fiscal years shown.
Furtler, tle procedures counted in tle table may not 
always lave caused an inmate’s sterilization, because tle inmate 
may lave undergone a sterilization procedure before our audit 
period. We grouped inmate medical procedures—as recorded in 
tle Contract Medical Database—based on tleir Current Procedural 
Terminology codes. 
Because tle audit request seemed most focused on inmates 
wlo lad procedures for wlicl sterilization was tle intent of tle 
procedure, we obtained additional data on medical procedures tlat 
were performed during tle same lospital stay as tle bilateral tubal 
ligation. As slown in Table A.:, tle ¡(( inmates most frequently 
lad bilateral tubal ligations wlen also laving a cesarean section.
37 California State Auditor Report 2013-120
June 2014
Table A.2
Number of Inmates Sterilized at Hospitals During Their Stay for Child Birth
Fiscal Years 2005–06 Through 2012–13
POSTPARTUM
STERILIZATION
PROCEDURE OCCURRED AS
PART OF A CESAREAN SECTION
TOTAL FEMALE
INMATES
Total 22 122 144
Sources: California State Auditor’s 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 Receiver’s
Office 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).
Table A.¸ slows selected demograplics by fiscal year for tle 
¡(( inmates wlo lad a bilateral tubal ligation. Te female inmates 
were typically young wlen tley lad tleir bilateral tubal ligation, 
mostly between :6 and (o years of age, and lad been pregnant 
five or more times witl at least tlree clildbirtls, not counting 
tle clild delivered at tle time of tle sterilization procedure. Te 
inmates generally tested at less tlan a ligl sclool level of reading 
proficiency and were predominately of tle wlite, Hispanic, and 
black races. In addition, Englisl was tle primary language for 
tle majority of tle inmates and most were incarcerated for tle 
first time.
Table A.3
Demographics for Female Inmates Having Bilateral Tubal Ligation Surgery
Fiscal Years 2005–06 Through 2012–13
FISCAL YEAR
DEMOGRAPHIC CATEGORY 2005–06 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 2012–13 TOTAL
Age at sterilization
21–25 5 1 5 1 2 0 0 0 14
26–30 4 8 12 11 8 1 0 0 44
31–35 9 10 9 7 8 1 0 0 44
36–40 7 9 9 7 1 1 1 0 35
41–45 1 0 2 3 0 1 0 0 7
Number of pregnancies
0–4 6 8 6 6 5 0 0 0 31
5–6 12 7 12 10 6 1 0 0 48
7–8 5 7 10 11 7 1 0 0 41
9–21 3 6 9 2 1 2 1 0 24
continued on next page . . .
38 California State Auditor Report 2013-120
June 2014
FISCAL YEAR
DEMOGRAPHIC CATEGORY 2005–06 2006–07 2007–08 2008–09 2009–10 2010–11 2011–12 2012–13 TOTAL
Number of live children
0–2 4 8 8 4 4 1 0 0 29
3–4 13 11 12 15 7 1 0 0 59
5–6 7 4 14 7 6 2 0 0 40
7–11 2 5 3 3 2 0 1 0 16
Education* (reading grade level)
Beginning literacy (0–3.9) 4 3 1 3 3 1 0 0 15
Intermediate literacy (4–6.9) 5 9 7 8 5 0 0 0 34
Advanced literacy (7–8.9) 4 2 8 6 3 0 0 0 23
High school level literacy (9–12.9) 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 Auditor’s 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 Rehabilitation’s
(Corrections) Strategic Offender Management System; and Corrections’ Tests of Adult Basic Education Master File Access database.
* The groupings are from Corrections’ categorization of the inmate’s reading ability score on the Tests of Adult Basic Education. The data in this table
are the test scores that the inmates received closest to the tubal ligation procedure date, regardless of whether the inmate took the test before
or after the procedure.

Race and ethnicity are reported based on Corrections’ categories for inmates.
39 California State Auditor Report 2013-120
June 2014
* California State Auditor’s comment appears on page 43.
*
1
40 California State Auditor Report 2013-120
June 2014
41 California State Auditor Report 2013-120
June 2014
42 California State Auditor Report 2013-120
June 2014
Blank page inserted for reproduction purposes only.
43 California State Auditor Report 2013-120
June 2014
Comment
CALIFORNIA STATE AUDITOR’S COMMENT ON THE
RESPONSE FROM CALIFORNIA CORRECTIONAL HEALTH
CARE SERVICES
To provide clarity and perspective, we are commenting on 
tle California Correctional Healtl Care Services’ (Receiver’s 
Office) response to our audit. Te number below corresponds 
to tle number we lave placed in tle margin of tle Receiver’s 
Office response.
We question tle assertion made by tle Receiver’s Office tlat it 
received no Medi-Cal reimbursement related to sterilizations. 
As we state in Table :, objective ;, on page ¡6, we identified 
one inmate for wlom we determined tlat tle Receiver’s Office 
received Medi-Cal federal reimbursement for pregnancy-related 
lospital services. We describe tle circumstances of tlat 
reimbursement, wlicl include tle fact tlat it covered lospital 
costs including tle use of tle surgical room for tle inmate’s 
sterilization procedure. We directed tle Receiver’s Office to 
work witl tle California Department of Healtl Care Services 
to ascertain tle appropriateness of tle Medi-Cal reimbursement for 
tlis inmate. Until tle Receiver’s Office las done so, tle conclusion 
tle Receiver’s Office las drawn is premature.
1

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