Report 2016-131 Recommendation 2 Responses
Report 2016-131: California Department of Corrections and Rehabilitation: It Must Increase Its Efforts to Prevent and Respond to Inmate Suicides (Release Date: August 2017)
Recommendation #2 To: Corrections and Rehabilitation, Department of
Corrections should immediately require mental health staff to score 100 percent on risk evaluation audits in order to pass. If a staff member does not pass, Corrections should require the prison to follow its current policies by reviewing additional risk evaluations to determine whether the staff member needs to undergo additional mentoring.
Annual Follow-Up Agency Response From October 2023
The Department's response remains the same. No further action will be taken, and the Department considers this matter closed.
California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement
Annual Follow-Up Agency Response From October 2022
The Department's response remains the same.
Previous Update
SRE Mentoring Update:
All institutional SPRFIT Coordinators maintain documentation and tracking related to the mentoring process for all clinical staff.
Chart Audit Revisions: SRE Mentoring:
Revised CAT audit questions have been completed and the field is now using the revisions as of April 1, 2020, which covers all documentation for 2020 Quarter 1 (1/1/2020-3/31/2020).
CDCR's position remains unchanged. We will not require 100 percent compliance for SRE mentoring. We are currently reviewing the SRE Mentoring policy and procedure to be more consistent with the current SRASHE form in EHRS. We will also be enhancing the oversight of the mentoring process to incorporate potential progressive discipline and/or referrals to the formal Peer Review Committee to consider action based upon clinical deficits of clinicians who repeatedly fail the mentoring process.
California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement
Annual Follow-Up Agency Response From October 2021
The Department's response remains the same.
Previous Update
SRE Mentoring Update:
All institutional SPRFIT Coordinators maintain documentation and tracking related to the mentoring process for all clinical staff.
Chart Audit Revisions: SRE Mentoring:
Revised CAT audit questions have been completed and the field is now using the revisions as of April 1, 2020, which covers all documentation for 2020 Quarter 1 (1/1/2020-3/31/2020).
CDCR's position remains unchanged. We will not require 100 percent compliance for SRE mentoring. We are currently reviewing the SRE Mentoring policy and procedure to be more consistent with the current SRASHE form in EHRS. We will also be enhancing the oversight of the mentoring process to incorporate potential progressive discipline and/or referrals to the formal Peer Review Committee to consider action based upon clinical deficits of clinicians who repeatedly fail the mentoring process.
California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement
Annual Follow-Up Agency Response From October 2020
SRE Mentoring Update:
All institutional SPRFIT Coordinators maintain documentation and tracking related to the mentoring process for all clinical staff.
Chart Audit Revisions: SRE Mentoring:
Revised CAT audit questions have been completed and the field is now using the revisions as of April 1, 2020, which covers all documentation for 2020 Quarter 1 (1/1/2020-3/31/2020).
Increase Passing Score on SRE chart audit tool:
CDCR's position remains unchanged. We will not require 100 percent compliance for SRE mentoring. We are currently reviewing the SRE Mentoring policy and procedure to be more consistent with the current SRASHE form in EHRS. We will also be enhancing the oversight of the mentoring process to incorporate potential progressive discipline and/or referrals to the formal Peer Review Committee to consider action based upon clinical deficits of clinicians who repeatedly fail the mentoring process.
Proof of Practice Item 2- Chart Updates Memorandum to be submitted via email.
- Completion Date: April 2020
California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement
Based on Corrections' response, they will not implement our recommendation as written.
- Auditee did not substantiate its claim of full implementation
Annual Follow-Up Agency Response From November 2019
Due to the volume of the response, the updates will be submitted through email, including proof of practice documentation.
- Estimated Completion Date: January 2020
California State Auditor's Assessment of Annual Follow-Up Status: Pending
1-Year Agency Response
The tracking and Suicide Risk Evaluation chart audit tool was completed in January 2018. The production of the electronic tool was completed in March 2018.
- Completion Date: March 2018
- Response Date: August 2018
California State Auditor's Assessment of 1-Year Status: Will Not Implement
Corrections maintains that it will allow clinicians to receive fail ratings in one of seven parts of a suicide risk evaluation and not receive re-mentoring. In our report on page 23 we stated that, because of the importance of each section of the risk evaluation, we believe requiring mental health staff to adequately complete all sections is essential for reducing the risk of inmate suicide.
- Auditee did not address all aspects of the recommendation
6-Month Agency Response
1. The California Correctional Health Care Services (CCHCS) Quality Management (QM) has developed an enterprise-wide tracking tool to track clinicians requiring Suicide Risk Evaluation (SRE) mentoring or re-mentoring.
2. CDCR revised the items on the SRE chart audit tool as the previous audit tool did not fully capture the scope of the risk assessment contained in the EHRS (now termed the Suicide Risk Assessment and Self Harm Evaluation or SRASHE). The change to the audit tool is in production.
3. CDCR has reviewed the recommendation to increase the passing score to 100 percent, and has determined the current criteria is sufficient and appropriate.
The tracking and SRE CAT audit items tool was completed in January 2018. The production of the electronic tool will be completed in March 2018.
- Estimated Completion Date: March 2018
- Response Date: February 2018
California State Auditor's Assessment of 6-Month Status: Pending
60-Day Agency Response
1. The California Correctional Health Care Services (CCHCS) Quality Management (QM) is developing an enterprise-wide tracking tool to track clinicians requiring Suicide Risk Evaluation (SRE) mentoring or re-mentoring to be beta tested the first week of September.
2. CDCR will be revising the SRE chart audit tool upon full implementation of the Electronic Health Record System (EHRS), as the current audit tool does not fully capture the scope of the risk assessment contained in the EHRS (now termed the Suicide Risk Assessment and Self Harm Evaluation or SRASHE). A workgroup will be established in late October 2017, with QM, the headquarters Suicide Prevention Unit, and selected institution Suicide Prevention and Response Focused Improvement Teams (SPRFIT), to develop the new audit criteria.
3. CDCR has reviewed the recommendation to increase the passing score to 100 percent, and has determined the current criteria is sufficient and appropriate.
- Estimated Completion Date: December 2017
- Response Date: October 2017
California State Auditor's Assessment of 60-Day Status: Pending
All Recommendations in 2016-131
Agency responses received are posted verbatim.