Report 2016-131 Recommendation 16 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 #16 To: Corrections and Rehabilitation, Department of

To ensure that prisons comply with its policies related to suicide prevention and response, Corrections should continue to develop its audit process and implement it at all prisons by February 2018. The process should include, but not be limited to, audits of the quality of prisons' risk evaluations and treatment plans.

Annual Follow-Up Agency Response From October 2023

The Continuous Quality Improvement Tool (CQIT) and the indicators and measures continue to undergo data validation with CDCR, the plaintiffs, and the Office of the Special Master as part of an ongoing effort to resume CQIT audits. In the interim, the current iteration of the Suicide Prevention CQI Onsite Audit is being utilized by the Statewide Suicide Prevention Coordinators to conduct regular site reviews of prisons with mental health programs. These reviews produce recommendations and formal corrective actions for all deficiencies noted. This guidebook is updated regularly as key indicators complete the Court-mandated data remediation process.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Annual Follow-Up Agency Response From October 2022

The Quality Management program worked with the Office of the Special Master in refining the CQIT and associated reports. The Chart Audit Tool, which evaluates SRASHE and treatment plans, is in use and will continue to be utilized.

Per direction from the Office of the Special Master, CDCR will implement CQIT in 10 institutions beginning July 2018.

Update: The CQIT and the indicators and measures continue to undergo data validation with CDCR, the plaintiffs, and the Office of the Special Master as part of an ongoing effort to resume CQIT audits.

Occurring in a parallel process is the review of the Suicide Prevention CQIT on-site guidebook. The measures have been established, and methodology and questions have been developed for all suicide prevention-related indicators. Work continues to finalize language and seek feedback from the parties, after which time CDCR will begin implementing the guidebook for on-site monitoring of institutional suicide prevention practices.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Annual Follow-Up Agency Response From October 2021

The ongoing use of the CQIT is a matter of active discussion amongst the Coleman parties, and the parties are working to determine when the CQIT audits will resume.

The Suicide Prevention CQIT is being designed to be separate from CQIT and will be able to run independently from the full CQIT. This tool is being tested at 4 institutions currently and will be refined based upon feedback from those using the tool. Target completion for this tool is early 2022.

Outside of the CQIT process, CDCR has hired a Senior Psychologist-Specialist for each region to participate in regular site visits to audit the suicide prevention practices of each institution. Any deficiencies identified during these site visits result in Corrective Action Plans. A sample of 4 Regional SPRFIT Reports are attached as proof of practice for auditing this item.

Supporting documentation will be provided as directed.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Annual Follow-Up Agency Response From October 2020

Chart Audit Tool Update:

All required revisions to the Chart Audit Tool audits have been completed and approved by the parties in the Coleman case. The audits of SRASHEs resumed on April 1, 2020, for SRASHEs completed in the first quarter of 2020.

Continuous Quality Improvement Tool:

All CQIT audits were completed in 2018 and 2019. Ongoing use of the CQIT is a matter of active discussion amongst the Coleman parties, and no additional audits are currently scheduled at any CDCR institutions.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

Annual Follow-Up Agency Response From November 2019

Due to the volume of the response, the updates will be submitted via email.

California State Auditor's Assessment of Annual Follow-Up Status: Pending

1-Year Agency Response

The Quality Management program worked with the Office of the Special Master in refining the CQIT and associated reports. The Chart Audit Tool, which evaluates SRASHE and treatment plans, is in use and will continue to be utilized.

Per direction from the Office of the Special Master, CDCR will implement CQIT in 10 institutions beginning July 2018. The CQIT Audit of California State Prison, Los Angeles County was completed the week of July 16, 2018. Audits of the remaining nine institutions will be completed through October 2018.

California State Auditor's Assessment of 1-Year Status: Pending

6-Month Agency Response

The Quality Management program continues to work with the Office of the Special Master in refining the CQIT and associated reports. The Chart Audit Tool, which evaluates SRASHE and treatment plans, is in use and will continue to be utilized.

Per direction from the Office of the Special Master, CDCR will implement CQIT in 10 institutions beginning March 2018.

California State Auditor's Assessment of 6-Month Status: Pending

60-Day Agency Response

The Quality Management program continues to work with the Office of the Special Master in refining the CQIT and associated reports. The Chart Audit Tool, which evaluates SRASHE and treatment plans, is in use and will continue to be utilized.

California State Auditor's Assessment of 60-Day Status: Pending

All Recommendations in 2016-131

Agency responses received are posted verbatim.