June 2014

Sterilization of
Female Inmates
Some Inmates Were Sterilized Unlawfully,
and Safeguards Designed to Limit Occurrencesof the Procedure Failed
Report 2013-120

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Elaine M. Howle State Auditor
Doug Cordiner Chief Deputy

June 19, 20142013-120

The Governor of California
President pro Tempore of the Senate
Speaker of the AssemblyState Capitol
Sacramento, California 95814
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 2005–06
and 2012–13. The California Department of Corrections and Rehabilitation (Corrections) oversees
the inmate population of the State’s 33 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 themore substantial role under the direction of a federal court-appointed receiver who took control ofprison medical care in 2006 and will retain control until the court finds Corrections can maintain aconstitutionally adequate prison medical care system.
This report concludes that during our eight-year audit period, 144 female inmates were sterilized
by a procedure known as bilateral tubal ligation, a surgery generally performed for the sole purposeof sterilization. State regulations impose informed consent requirements that must be met before awoman can be sterilized; however, Corrections and the Receiver’s Office sometimes failed to ensurethat inmates’ consent for sterilization was lawfully obtained. Overall, we noted that 39 inmates
were sterilized following deficiencies in the informed consent process. For 27 of the 39 inmates, thephysician 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 effectsof the procedure. For 18 of the 39 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 39 inmates were six who were sterilized following violations of boththese 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 19 of the 39 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 2010, 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 insterilization has greatly decreased.
Respectfully submitted,

ELAINE M. HOWLE, CPA
State Auditor
621 Capitol Mall, Suite 1200

S a c r a m e n t o, C A 9 5 8 1 4

916.445.0255

916.327.0019 fax

w w w. a u d i t o r. c a . g o v

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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

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Summary
Results in Brief
The California Department of Corrections and Rehabilitation(Corrections) oversees the inmate population of the State’s
33 adult prisons. During our eight-year audit period—which we
defined as fiscal years 2005–06 through 2012–13—four of theseprisons housed substantially all of the 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 houses women since its conversion to a men’sprison in January 2013. For much of our audit period, Corrections’role in providing inmates with medical care was not significant;the more substantial role was played by California Correctional
Health Care Services (Receiver’s Office) under the direction of afederal court‑appointed receiver. A receiver took control of prison
medical care in 2006 and will retain control until the court findsthat Corrections can maintain a constitutionally adequate prison
medical care system.
From fiscal years 2005–06 through 2012–13, 144 female inmates
were sterilized by a procedure known as a bilateral tubal ligation.
The last of these female inmate sterilizations occurred in 2011.
Although various surgical procedures may result in a female’s
sterilization, bilateral tubal ligations are generally surgicalprocedures that are performed for the sole purpose of sterilization,and state regulations impose certain requirements that must be
met before such a procedure is performed. However, the state
entities responsible for providing medical care to these inmates—
Corrections1 and the Receiver’s Office—sometimes failed to ensurethat inmates’ consent for sterilization was lawfully obtained.
Overall, we noted that 39 inmates2 were sterilized following
deficiencies in the informed consent process. We found two typesof deficiencies. First, we found no evidence that the inmate’s
physician—the individual who would perform the procedure ina hospital or an alternate physician—signed the consent form as
required by state regulations. Second, we noted potential violationsof the required waiting period between when the inmate consented
1

2

Corrections was responsible for inmate health care between July 1, 2005, and the appointmentof the first federal receiver, effective April 2006. During this time period, 15 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.
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.

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 ofboth consent form and waiting period.
»» Neither the California Department ofCorrections 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.

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to the procedure and when the sterilization surgery actually took
place. Some inmates were sterilized following violations of both ofthese requirements. Although neither Corrections nor employeesof the Receiver’s Office actually performed the sterilization
procedures, we concluded that they had a responsibility to ensurethat the informed consent requirements were followed in thoseinstances when their employees obtained inmates’ consent, which
was the case for at least 19 of the 39 inmates. Either the remaining
20 inmates signed their consent to be sterilized at a physicallocation other than a prison or the Receiver’s Office had difficulty
determining whether the individual who obtained consent wasan employee.
Lawful consent is represented by key steps as defined by the
California Code of Regulations, Title 22 (Title 22). For example,
the physician or an alternate physician must sign the consent form
just before performing the surgery, and a waiting period is required
after the patient signs the consent form. The missing physicians’
signatures on some of the inmates’ consent forms are especiallyconcerning because of what the physician signature certifies: thatthe required waiting period has been satisfied and that the patient
appears mentally competent and understands the lasting effects ofsterilization. The physician is the last check in the informed consent
process and provides the patient with the final opportunity tochange her mind.
All the bilateral tubal ligations we reviewed were performed at
general acute care hospitals rather than in prison medical facilities.
A lawyer for the Receiver’s Office stated that the specific provisionsof Title 22 do not apply to prison employees, because Title 22
applies only to general acute care hospitals. Nevertheless, because
employees of the Receiver’s Office played a significant role in these
19 inmates’ care and in obtaining their consent to be sterilized,
our legal counsel advised us that a court would likely find that theReceiver’s Office had a responsibility to ensure that consent was
lawfully obtained from these inmates in accordance with Title 22.
Although the consent forms we were able to review demonstrated
that each female inmate signed a consent form, we have concerns
about whether the female inmates undergoing bilateral tubal
ligations received adequate counseling about their decision to besterilized. Despite a Receiver’s Office policy that prison medical
staff must use progress notes—a term for documenting information
made in an inmate’s medical record—to summarize discussions
with inmates, in no instance did we find a female inmate whose
progress notes adequately reflected that she had been counseled
about her decision to be sterilized. The lack of notes in the inmates’
medical records regarding informed consent and sterilization
made it impossible for us to reach a conclusion as to the quality

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and content of the consultations between prison medical staff andinmates. We were also unable to conclude whether inmates received
educational materials, whether prison medical staff answered
inmates’ questions, or whether these staff provided the inmateswith all of the necessary information to make such a sensitive andlife-changing decision as sterilization.
The Receiver’s Office also failed to ensure that the prison medical
staff under its direction followed state regulations requiring specificapprovals for bilateral tubal ligation procedures, including approvalsby two committees made up of high-ranking prison medical staff
and medical executives from the Receiver’s Office. The failure
to obtain the necessary approvals was systemic; all but one of
the 144 bilateral tubal ligation procedures lacked the necessary
approvals. Overall, 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.
In many cases, prison medical staff simply requested approval forother medical procedures—such as cesarean sections at hospitals—
and did not indicate that the inmate was also to be sterilized.
Since January 2010, when the Receiver’s Office asserts it becameaware of the sterilization procedures—following allegations bya legal advocacy group—its medical claims data show that the
number of female inmates who have undergone bilateral tubal
ligations and other medical procedures that result in sterilization
has greatly decreased. In addition, since that time we foundthat the Receiver’s Office has better adhered to its processes forreviewing medical services for necessity and for obtaining required
approvals for medical services. Nevertheless, because the functionof approving a medical procedure has been and remains separate
from the process for scheduling the procedure at a general acutecare hospital or other community medical facility, the opportunity
still exists for inmates to receive medical services that are notauthorized. Until the Receiver’s Office ensures that medicalscheduling is driven by authorized requests for service, it risks
subjecting inmates to potentially unnecessary medical procedures
and cannot demonstrate that it is in full control of the medical careinmates receive.
Recommendations
To ensure that the necessary education and disciplinary action
can be taken, the Receiver’s Office should report to the California
Department of Public Health, which licenses general acute care
hospitals, and the Medical Board of California, which licenses
physicians, the names of all hospitals and physicians associatedwith inmates’ bilateral tubal ligations during fiscal years 2005–06

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through 2012–13 for which consent was unlawfully obtained.
The Receiver’s Office should make these referrals as soon as
is practicable.
To ensure that it can better monitor how its medical staff andcontractors adhere to the informed consent requirements ofTitle 22, sections 70707.1 through 70707.7, the Receiver’s Officeshould develop a plan by August 2014 to implement a process by
December 2014 that would include the following:• Providing additional training to prison medical staff regarding
Title 22 requirements for obtaining informed consent forsterilization procedures, including the applicable forms andmandatory waiting period requirements, to ensure that consent
is lawfully obtained.
• Developing checklists or other tools that prison medical staff
can use to ensure that medical procedures are not scheduled
until after the applicable waiting periods for sterilization havebeen satisfied.
• Periodically reviewing, on a consistent basis, a sample of cases
in which inmates received treatment resulting in sterilization at
general acute care hospitals, to ensure that all informed consent
requirements were satisfied.
• Until such time as the Receiver’s Office implements a process
for obtaining inmate consent for sterilization under Title 22 thatcomplies with all aspects of the regulations, it should discontinue
its practice of facilitating an inmate’s consent for sterilization in
the prison and allow the general acute care hospital to obtain an
inmate’s consent.
To improve the quality of the information prison medical staff
document in inmate medical records, the Receiver’s Officeshould do the following:• Train its entire prison medical staff on its policy in the inmate
medical procedures related to appropriate documentation ininmates’ medical records. This training should be completed by
December 31, 2014.
• Either develop or incorporate into an existing process a meansby which it evaluates prison medical staffs’ documentation ininmate medical records and retrains prison medical staff asnecessary. The Receiver’s Office should develop and implement
this process by June 30, 2015.

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To ensure that inmates receive only medical services that are
authorized through its utilization management process, theReceiver’s Office should do the following:• Develop processes by August 31, 2014, such that a procedurethat may result in sterilization is not scheduled unless theprocedure is approved at the necessary level of the utilization
management process.
• By October 31, 2014, train its scheduling staff to verify that theappropriate utilization management approvals are documented
before they schedule a procedure that may result in sterilization.
Agency Comments
In its response to the audit, the Receiver’s Office generally agreed
with the report’s factual findings, but noted that it reachedconclusions about its duty to ensure compliance with thesterilization and consent procedures set forth in Title 22 that differ
from the report. Nevertheless, the Receiver’s Office pledged to
implement all of the recommendations.

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Introduction
Background
The California Department of Corrections and Rehabilitation(Corrections) oversees the State’s prison population, which includes
33 adult prisons. Of these, four prisons housed substantially all of
the female inmates in the eight years spanning fiscal years 2005–06
through 2012–13. Two of the prisons, California Institution for
Women (CIW) and Central California Women’s Facility (Central),are designated womens’ prisons and continue to house female
inmates. In January 2013 Corrections realigned the populations of
two prisons, converting Valley State Prison for Women (Valley) to amen’s prison and establishing Folsom Women’s Facility (Folsom) at
Folsom State Prison. As of June 2013 the female inmate populations
at the CIW, Central, and Folsom prisons were 2,131; 3,525; and186 women, respectively. Table 1 lists Corrections’ total female
inmate population during our audit period, and Figure 1 on thefollowing page indicates the locations of the prisons for women andprovides general information. According to Corrections’ associate
warden of mission for female offender programs and services andspecial housing, the female inmate population decreased in 2012
because of the 2011 Realignment legislation addressing public safety.
Table 1
Female Inmate Population From 2006 Through 2013

Female inmate
population*

2006

2007

2008

2009

2010

2011

2012

2013

11,74911,888

11,392

11,027

10,096

9,565

6,409

5,919

Sources: California Department of Corrections and Rehabilitation’s monthly population reports (asof June 30th 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 PrisonsMultiple entities are involved in providing medical care to inmatesor overseeing their medical services, including Corrections,
California Correctional Health Care Services (Receiver’s Office)under the direction of a federal court-appointed receiver (receiver),and community-based medical providers. Although multiple
entities are involved, since 2006 the receiver has been responsible
for controlling prison medical services as a result of litigation
concerning prison health care. In April 2001 nine inmates filed aclass action lawsuit against state officials in federal court (court)7

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alleging that Corrections was providing constitutionally inadequate
medical care. This case resulted in a June 2002 agreement requiring
Corrections to improve medical care for prisoners. However, inJune 2005, the court determined that the California prison medicalcare system was broken beyond repair and ruled that it would
establish a receivership to control the delivery of medical services toall prisoners confined by Corrections. The court appointed the firstreceiver effective April 2006, and the current receiver has servedin the role since January 2008. Before 2006 Corrections controlled
medical care to inmates; now it is responsible for maintaining thecustody of inmates as they receive their 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.

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The court gave the receiver broad authority to reform the prison
medical care system until it finds that state officials are able
to maintain a constitutionally adequate prison medical caresystem. The receiver’s authority includes all of the secretary of
Corrections’ powers for administering, controlling, managing,
operating, and financing the prison medical care system. Further,
the receiver is required to request that the court waive state laws,
regulations, and contractual requirements if they are impediments
to reform and other alternatives are inadequate. In executing theauthority given by the federal court, the receiver leads and directs
the activities of the Receiver’s Office. Prison physicians, nurses, andother medical staff now work for the receiver.
Process for Approving Medical Procedures for Inmates
In general, the Receiver’s Office must ensure that the care inmates
receive is medically necessary. Typically, this is medical care that isnecessary to protect life, to prevent significant illness or disability,
or to alleviate severe pain and that is supported by health outcome
data as being effective. California Code of Regulations, Title 15(Title 15), specifies requirements related to prison medical care anddefines certain medical procedures as “excluded,” meaning they areservices that cannot be provided to inmates because the services
treat conditions that improve on their own, such as the common
cold, or treat conditions that are cosmetic or not amenable totreatment, such as tattoo removal or multiple‑organ transplants.
Title 15 lists tubal ligations and vasectomies that are not medicallynecessary as excluded services. An inmate’s physician may prescribe
an excluded service as clinically necessary, in which case theexcluded service must be approved by two committees: one basedin the prison and the other at the Receiver’s Office headquarters.
Title 15 establishes two committees, known as utilization
management committees, that convene to approve or deny requests
for excluded services. These committees are required to consider
available health care outcome data supporting the effectivenessof the excluded service and other factors, such as the severity of
the inmate’s condition, the length of the inmate’s sentence, theavailability of the service, and the cost. The first committee isestablished in each prison and is called the Institutional Utilization
Management Committee (institutional committee). An institutional
committee consists of at least three staff physicians who vote toapprove or deny requests for excluded medical services. Thoserequests that receive the institutional committee’s approval mustbe forwarded to the Headquarters Utilization Management
Committee (headquarters committee). The headquarters committee
meets to review excluded services requests approved by each
institutional committee. It is required to consider the same9

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factors as the institutional committees, and only those committee
members that are licensed physicians may vote to approve or denya request for an excluded service. The institutional committee andheadquarters committee are depicted as levels 3 and 4 in Figure 2.
The figure also depicts that a denied request for an excluded service
may be appealed.
The Receiver’s Office maintains and distributes the Inmate Medical
Services Policies and Procedures (prison medical procedures),which establishes two preliminary levels of review (levels 1 and 2
in Figure 2) before the institutional committee. Level 1 involves a
prison nurse reviewing the request for the excluded service andforwarding the request, along with any corresponding statewide
program guidelines, to level 2 for this reviewer to approve or deny
the request. The level 2 reviewer—a role filled by the prison’s chief
medical executive or designee—forwards the approved request to
the institutional committee.
The approval process for nonexcluded services is slightly different
from the approval process for excluded services just discussed.
Whereas an inmate’s physician seeking approval for an excluded
service must ultimately secure approval from both level 3 (theinstitutional committee) and level 4 (the headquarters committee)
before treating the inmate, there is no such requirement fornonexcluded services. Rather, a physician typically needs only
level 2 approval from the prison’s chief medical executive ordesignee. Levels 3 and 4 consider requests for nonexcluded
services only when the request has been denied at a lower levelof review and is then appealed. Thus, for nonexcluded services,
Figure 2 shows that a “yes” at level 2 or above results in the service
being approved.
Process for Obtaining an Inmate’s Informed Consent for Sterilization
State regulations specify the informed consent requirements forsterilizations at general acute care hospitals. Female inmates may
have medical needs that the prison-based medical staff are nottrained or equipped to address—such as labor and delivery or othersurgeries—in which case the Receiver’s Office arranges for medicalcare at general acute care hospitals.

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Figure 2
Process for Reviewing a Request for Service
If requesting physician
appeals the decision
Approved
DeniedPatient-Physician Encounter
Patient presents symptoms, physician diagnoses and recommends
treatment. Physician submits a Request for Service seeking
authorization to provide medical services.

Request for Service
that is, by state regulations,

EXCLUDED*L E VE L 1
Institutional Utilization Management Nurse

Forwards the Request for Service
and review criteria to Level 2
FORWARD

Request for Service that is

NONEXCLUDED†FORWARDL E VE L 2
Institutional Chief Medical Executive

Reviews the Request for Service

SERVICEDENIEDSERVICEDENIEDL E VE L 3
Institutional Utilization Management Committee

Reviews the Request for Service

SERVICEDENIEDSERVICEDENIEDL E VE L 4
Headquarters Utilization Management Committee

Reviews the Request for Service

SERVICEDENIEDSERVICEDENIEDSERVICEAPPROVED
Sources: California Correctional Health Care Services’ deputy medical executive of utilization management and California State Auditor’s analysis ofInmate 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.

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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 thesterilization, 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 awitness 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.

When sterilization procedures take place ingeneral acute care hospitals, as was the case withthe bilateral tubal ligations we reviewed, theCalifornia Code of Regulations, Title 22 (Title 22),
specifies how informed consent must be obtainedand documented. These requirements apply when
the purpose of the procedure is to render thepatient incapable of reproduction. Title 22 outlines
key roles in the consent process and mandates a
waiting period—defined as the time between
when the inmate signed the consent form
and when the procedure may be performed.
Selected Title 22 requirements for informed
consent are described in the text box.
Title 22 states that the form provided by the
California Department of Public Health must be
used to document a patient’s informed consent forsterilization. Three or four individuals must sign theform certifying their role in the informed consent
process for the sterilization procedure. When thepatient signs the consent form, she is certifying that
she understands that the sterilization proceduremust be considered permanent and irreversible.
The patient is also certifying that she understands
there is a waiting period and that she can change
her mind at any time. The form does not include
a place for a witness’s signature, although Title 22
permits the patient to have a witness of her choicepresent when she signs the consent form.

The individual obtaining the patient’s consent also signs the form,
certifying that the patient appears mentally competent and still
desires permanent sterilization after receiving counseling on theprocedure’s effects and a discussion of alternative forms of birthcontrol. If needed, an interpreter will sign the form attesting that heor she has translated to the patient the information and advice thatthe person obtaining consent presented orally to the individual to
be sterilized.
Finally, the physician performing the procedure or an alternate
physician must sign the consent form certifying that, just prior tosurgery, the patient was again counseled on the procedure and thatconsent could still be withdrawn. The physician also certifies thatthe patient appears mentally competent and that at least 30 days
have passed since the patient consented to the procedure, except ininstances of an emergency abdominal surgery, premature delivery,or when the patient has waived the waiting period. Regardless ofthese exceptions to the 30-day waiting period, Title 22 prohibits theCalifornia State Auditor Report 2013-120

June 2014sterilization of a patient less than 72 hours after she has signed theconsent form. The physician’s counseling to the patient is effectively
the last opportunity to ensure that all legal requirements for thepatient’s informed consent have been satisfied.
Title 15 contains requirements that apply to prisons and defines
the requirements for an inmate’s informed consent for all medical
treatments—not just sterilizations. Such requirements generally
state that the inmate’s informed written consent must be obtained,as circumstances permit, before treatment is undertaken for serious
procedures. Title 15 also states that an inmate is capable of giving
informed consent if—in the opinion of health care staff—the inmate
is aware there is a physiological disorder for which treatment or
medication is recommended; able to understand the nature,
purpose, and alternatives of the recommended treatment; and able
to understand and reasonably discuss the possible side effects andany hazards associated with the recommended treatment.
As shown in the text box, the Receiver’s Officehas specific policies for its staff to follow to ensurethat there is a thorough discussion between theinmate and the physician before the inmate’s
consent to surgery. As early as January 2002, both
before and after inmate medical care was takenover by a receiver, policies contained within theprison medical procedures required that prison
medical staff record the essence of their informed
consent discussions with inmates about potential
procedures. Further, the prison medical procedures
explain that documenting the informed consent
process protects the medical staff from charges ofbattery, negligence, and/or unprofessional conduct.
Excluded and Nonexcluded Medical Procedures That
Result in Sterilization
A bilateral tubal ligation—which is not medicallynecessary—is an excluded service as statedpreviously. The sole purpose of this procedure is tosterilize a woman. In contrast, a procedure such asa hysterectomy intended to treat cancer or address
other health problems also results in sterilization,although that was not the procedure’s purpose.
From fiscal year 2005–06 through 2012–13, claims
data from the Receiver’s Office show that 794 female
inmates had various procedures that could haveresulted in sterilization. We determined that 144 ofthese inmates underwent a bilateral tubal ligation

Prison Medical Policies and Procedures
Regarding Informed Consent
Policies• Medical staff shall document in the patient’s healthrecord 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 anticipatedtreatment, the expected outcomes and risks, andpossible alternatives.
• Medical staff shall document an acknowledgment thatthe 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 theessence of the informed consent process.
• Enter the times and dates of all discussions withthe patient pertinent to proposed treatment,
recording sufficient information about the essenceof the discussion.
• Sign the medical notes with his or her full name and title.
Source: Inmate Medical Services Policies and Procedures (in effectsince January 2002).

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or similar procedure for the sole purpose of sterilization.3 We
focused our audit on the female inmates who underwent a bilateral
tubal ligation, given this procedure’s classification as an excluded
service under Title 15. Additional information about female inmatesis in Table A.1 on page 36 in the Appendix, which details the various
sterilization procedures inmates underwent by procedure type. For
female inmates who underwent a bilateral tubal ligation, Table A.2
on page 37 summarizes other procedures they had during the same
hospital stay—for example, a cesarean section—and Table A.3 on
page 37 presents selected female inmate demographics.
Scope and Methodology
The Joint Legislative Audit Committee (audit committee)
directed the California State Auditor (state auditor) to review
the Receiver’s Office and other responsible entities’ policies andprocedures related to sterilizations of female inmates. The audit
committee approved eight objectives. Table 2 beginning on page 15
lists the objectives that the audit committee approved and themethods we used to address them.

3

Some of the 144 inmates underwent a medical procedure known as salpingectomy, which is theremoval 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.

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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 HealthCare Services (Receiver’s Office) and other entities,
such as the California Department of Corrections andRehabilitation (Corrections), may have in overseeing
medical services and sterilization procedures forfemale inmates.

• Reviewed pertinent state laws, regulations, and federal court documents.

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.

• Reviewed laws, regulations, federal court documents, and the Receiver’s Officepolicies and procedures for utilization management and informed consent in
effect during our audit period, including any changes to these documents.

3

a. Identify any changes to the regulations or laws
relating to the sterilization of female inmates overthe past eight years and determine whether the
Receiver’s Office or any other oversight entity’s
policies and procedures reflect such changes.
4

Determine how the Receiver’s Office or any otherentity monitors to ensure compliance with policies andprocedures related to sterilization of female inmates.

• Interviewed key officials.

• 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.

• Reviewed laws, regulations, policies and procedures, medical records, andother documents.
• Interviewed key officials.
• Assessed whether sterilization procedures were requested and approved inaccordance 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 thepast eight years.

• Interviewed key officials.
• Reviewed policies and procedures, and documents communicatingprocedure changes.

a. Identify any changes to protocols or practices overthe past eight years that clarify the circumstances
under which a sterilization procedure can besuggested to a female inmate.

continued on next page . . .

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AUDIT OBJECTIVE

6

METHODFor the most recent eight-year period, determine thenumber of sterilization procedures performed eachyear, and to the extent possible, for each sterilization
procedure perform the following:• Reviewed pertinent laws, regulations, policies and procedures, andother documents.

•

Determine whether the inmate was pregnant,
why the procedure was performed, whether theprocedure was deemed medically necessary,and whether the process for obtaining approvalcomplied with applicable policies and laws.

• Using medical claims data that the Receiver’s Office supplied and that included
CPT codes, we identified all female inmates that underwent a medical procedurethat could result in sterilization, including a bilateral tubal ligation, during fiscal
years 2005–06 through 2012–13.

•

Identify the demographics of each inmate, including
economic status, ethnicity, race, number of prison
terms, number of pregnancies, and number of childbirths. Determine whether there are any trends inthe data.

•

Determine whether the inmate consented toauthorize the procedure and whether such consent
was lawfully obtained. Determine when, where, andhow 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 theinmate was informed about the procedure andwhether she filed a complaint about the procedures.

• Utilized a certified medical coder to identify Current Procedural Terminology(CPT) codes associated with medical procedures that result in female sterilization.

• 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 healthrecords 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 wellas whether English was her primary language and other selected
demographic information.
• We reviewed the CPT codes associated with the bilateral tubal ligations tounderstand how often these procedures took place while at a hospital forchild 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 theReceiver’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 forsuch procedures was appropriate and allowable.
If not, identify any consequences.

We identified one inmate for whom we determined that the Receiver’s Officereceived 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 acesarean section surgery. Medi-Cal reimbursed the Receiver’s Office for a portion of theinmate’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 toevaluate 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 Statewas 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 thesterilization 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 researchthese claims.

Sources: The California State Auditor’s analysis of Joint Legislative Audit Committee audit request number 2013–120, and information anddocumentation identified in the table column titled Method.

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Assessment of Data Reliability
In performing this audit, we relied upon electronic data files
extracted from various information systems. The U.S. Government
Accountability Office (GAO), whose standards we are statutorily
required to follow, requires us to assess the sufficiency andappropriateness of computer-processed information that we use tosupport findings, conclusions, or recommendations. Table 3 shows
the results of this analysis for data obtained from the Receiver’s
Office and Corrections.
Table 3
Methods Used to Assess Data Reliability
INFORMATION SYSTEMPURPOSE

California Correctional HealthCare Services (Receiver’s Office)

To determine thenumber and typeof sterilization
procedures by fiscal
year performedon female inmates
for the period ofJuly 1, 2005, throughJune 30, 2013.

• We performed data-set verification procedures and electronic
testing of key data elements and did not identify any issues.

To identify the
demographics ofeach female inmate
who we identified ashaving 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.

Contract Medical Database (CMD)
CMD Access Version
CMD Web Version
CMD Interface
Data as of November 2013

California Department ofCorrections and Rehabilitation(Corrections)
Strategic Offender Management
System (SOMS)
Data as of December 2013
Corrections
Tests of Adult Basic Education(TABE) Master File Access
Database
Data as of January 2014

To identify the TABE
reading test scoreclosest to a female
inmate’s bilateral
tubal ligation
procedure date forthose inmates who
underwent theprocedure between
July 1, 2005, andJune 30, 2013.

METHODS AND RESULTS• We performed manual review of medical records for all 148 inmateselectronically 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.

CONCLUSION

Undeterminedreliability forthe purposes ofthis audit.

• We did not perform completeness testing due to a variety of factorsthat make it difficult to determine definitively how often female
inmates received medical procedures resulting in sterilization whensterilization was the sole purpose for the surgery, as we describe in
the Appendix.

• In April 2012 we issued a confidential management letter toCorrections that detailed our review of selected information
system controls, which included general and business processapplication controls. During this review, we identified significant
weaknesses in Corrections’ general controls over its information
systems. General controls support the functioning of businessprocess 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 ouraudit period occurred prior to the issuance of our control review.

Source: California State Auditor’s analysis of various documents, interviews, and data obtained from the entities listed in the table.

Not sufficiently
reliable for the
purposes ofthis audit.

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Blank page inserted for reproduction purposes only.

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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 2005–06 and 2012–13, 144 female inmates
underwent medical procedures that were intended to result inpermanent sterilization. These medical procedures—which werebilateral tubal ligations or comparable procedures in which thefallopian tubes are cut to prevent conception—were sometimes
performed without satisfying the legal requirements for obtaining
inmates’ informed consent for sterilization. Overall, we notedthat 39 inmates were sterilized following certain deficiencies in
the informed consent process. For 27 consent forms, we saw noevidence that the inmate’s physician—the individual who would
perform the procedure in a hospital or an alternate physician—signed the required consent form. For 18 consent forms, we noted
potential violations of the required waiting period between when
the inmate consented to the procedure and when the sterilization
surgery actually took place.4 Some inmates were sterilized eventhough their consent form reflected violations of both of theserequirements. Our legal counsel has advised us that, based onthese facts, a court would likely conclude that these 39 inmates’
consent was not lawfully obtained. Moreover, although neither
the California Department of Corrections and Rehabilitation(Corrections) nor employees of California Correctional HealthCare Services (Receiver’s Office) actually performed thesterilization procedures themselves, our legal counsel advised usthat Corrections and the Receiver’s Office nevertheless have a
responsibility to ensure that the informed consent requirements
were followed in those instances when their employees obtained
inmates’ consent, which was the case for at least 19 of the
39 inmates.
The missing physicians’ signatures on the consent forms are
particularly concerning because each physician must certify, by
signing the form shortly before the sterilization procedure, thatthe required waiting period has been satisfied and that the patient
appears mentally competent and understands the lasting effectsof the procedure. The physician is the last check in the informed
consent process and provides the patient with the final opportunity
4

In early June 2014, 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 30 days before the sterilization procedure. We have not modified
the numbers in our report since the hospital recently made this information available to us andsince 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 theproper authorities for review.

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to withdraw her consent to having the procedure. Our legal counsel
advises us that without such a certification from the physician or analternate physician, the inmate’s consent was not lawfully obtained
under state regulations. Given the importance of the physician’srole in the informed consent process, we have asked the Receiver’s
Office—under the direction of the federal receiver—to refer thesequestionable cases to the Medical Board of California and theCalifornia Department of Public Health, which have the enforcement
authority to investigate physician and hospital practices, respectively.
The true number of cases in which
Corrections or the Receiver’s
Office did not ensure that consent
was lawfully obtained prior tosterilization may be higher.

The true number of cases in which Corrections or the Receiver’s
Office did not ensure that consent was lawfully obtained prior tosterilization may be higher. For example, in accordance with its
records retention policy, one hospital destroyed seven inmates’
medical records, leaving it unclear—based on other healthrecords available from the Receiver’s Office—whether thephysicians performing these seven sterilization procedures
had signed the necessary consent forms. In at least five of theseseven cases, the inmate consented to the procedure while in prison.
If Corrections or Receiver’s Office employees obtained consent fromthese inmates, Corrections or the Receiver’s Office is responsible for
ensuring that consent was lawfully obtained prior to surgery.
Since the appointment of the first receiver, effective in April 2006,
the Receiver’s Office has had ultimate responsibility for ensuring
adequate medical care for the State’s inmate population. During ourreview, it became apparent that the Receiver’s Office lacks a process
to ensure that its prison-based medical staff and others follow
the informed consent requirements under the California Code ofRegulations, Title 22 (Title 22). The Receiver’s Office confirmedthat its own employees were the individuals obtaining the inmates’
consent in 15 of the 27 instances in which physicians did not sign
the consent forms and in 7 of the 18 instances in which the criteria
for the waiting period was potentially not met.
We asked the deputy director of medical services to explain why the
Receiver’s Office did not ensure that an inmate’s informed consent
for sterilization was obtained lawfully in those cases in which
its employees were the persons obtaining consent. A Receiver’s
Office attorney responded to our inquiry, stating that the specificprovisions of Title 22 do not apply to prison employees because
Title 22 applies to general acute care hospitals. Further, the attorneystated that the Receiver’s Office is not in a position to ensurecompliance by staff outside of the prison because it does not haveprison clinical staff present at the hospital to observe the final
signature process every time an inmate undergoes a procedure.
Finally, the attorney stated that the Receiver’s Office does notbelieve that the inmates’ consent was unlawful, providing nofurther explanation for such a conclusion.

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Contrary to the belief expressed by the attorney for the Receiver’s
Office, our legal counsel advised us that a court would likely
conclude Corrections5 and the Receiver’s Office had a responsibility
to ensure that informed consent for sterilization was lawfully
obtained from female inmates when their employees were thepersons obtaining the inmates’ consent. California courts have heldthat a physician who did not perform a medical procedure may be
responsible for obtaining informed consent from the patient if thedoctor performing the procedure fails to do so. In reaching thesedecisions, the courts focused on the high level of involvement by
the physician in providing care to the patient before the procedure
was performed by a different doctor. In this regard, Corrections
and the Receiver’s Office are legally responsible for providing
medical treatment to inmates and for obtaining the inmate’s written
informed consent for serious medical procedures. Moreover,at times the inmates’ medical records show that employees ofCorrections or the Receiver’s Office provided prenatal care tothese patients and arranged for the sterilization procedures to be
performed outside of the prison in a general acute care hospital.
In addition, employees for Corrections and the Receiver’s Office
were the persons obtaining the inmates’ consent to sterilization for
at least 19 of the 39 inmates for whom we noted problems. Given
these legal authorities and facts, our legal counsel determined thata court would likely conclude that prison health authorities were
responsible for ensuring that these inmates’ informed consent met
legal requirements because a physician at a hospital failed to sign
the consent form or failed to ensure that the requirements for a
waiting period had been satisfied.
Physicians Sometimes Sterilized Inmates When Available Health Records
Cast Doubt on Whether the Required Waiting Period Was Observed
If the Receiver’s Office had a process to review the informed
consent forms signed by inmates prior to sterilization, it would
have noted not just the absence of the physician’s signature on someof the consent forms, but also potential violations of the required
waiting period between the date of the inmate’s consent and thedate of sterilization. Although we could not definitively conclude
whether timing violations had occurred, given that some inmates’
medical records were incomplete, we nevertheless identified
18 cases in which we have concerns that inmates may have beensterilized without complying with the necessary waiting period.

5

Corrections was responsible for inmate health care between July 1, 2005, and the appointmentof the first federal receiver, effective April 2006. During this time period, 15 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 andthe Receiver’s Office were thepersons obtaining the inmates’
consent to sterilization for at least
19 of the 39 inmates for whom wenoted problems.

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In 17 of the 18 cases for which
we have concerns, inmates weresterilized less than 30 days after
signing a consent form eventhough the law requires patientsto have at least 30 days between
the date of consent and the dateof sterilization.

With some exceptions, Title 22 requires that patients who are to
be sterilized in a general acute care hospital have at least 30 days
(and no more than 180 days) between the date of consent andthe date of sterilization. In 17 of the 18 cases for which we haveconcerns, inmates were sterilized less than 30 days after signing a
consent form, and in the remaining case the inmate was sterilized
more than 180 days after consent was obtained. In 12 of these18 cases, the inmates provided consent to sterilization while inprison, and the Receiver’s Office confirmed that its employees—
or Corrections’ employees—obtained consent in seven of the
12 cases. Title 22 generally prohibits sterilizing a patient unless
she has had a specific period of time to consider this permanentand life-changing decision, and prohibits sterilizing a patient once
this time has elapsed, after which consent must be renewed tobe effective.
Under Title 22, sterilization may occur sooner than 30 days when apatient voluntarily requests in writing that it be performed in lesstime or when the procedure is performed at the time of emergency
abdominal surgery or premature delivery.6 However, in all cases
72 hours must have passed after written informed consent is given.
Our review of available medical records found instances in which
we question the application of these exceptions to the 30-day
waiting period. For example, the hospital physician for Inmate A
from Valley State Prison for Women (Valley) cited emergency
abdominal surgery as a justification for sterilizing the inmate
before the end of the 30-day waiting period. Inmate A signed her
consent for sterilization on November 27, 2007, at Valley prison.
The inmate’s expected delivery date was January 3, 2008 (morethan 30 days after her consent). However, on December 18, 2007,
the prison scheduled Inmate A for a cesarean section—a type ofabdominal surgery—and a bilateral tubal ligation procedure to
take place on December 21, 2007. When scheduling the procedures
to take place, prison medical staff noted that the cesarean section
procedure was “routine” as opposed to “urgent” or “emergent,”
and we saw no indication in the inmate’s medical record toindicate an emergency medical condition. Inmate A was sterilized
on December 21, 2007, 24 days after she consented to theprocedure and 13 days before her expected delivery date.
In another example, we are skeptical as to how a scheduledcesarean section procedure would constitute premature delivery
when the procedure was planned to take place on a date before
the inmate’s expected delivery date. Specifically, on June 23, 2009,
Inmate T from the California Institution for Women (CIW)
6

When a patient is sterilized prior to expiration of the 30-day waiting period due to prematurelabor or emergency abdominal surgery, Title 22 still requires the patient to consent at least
30 days before her expected delivery date or 30 days before she intended to be sterilized.

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signed her consent for sterilization, with the signing occurring at
the prison and the person obtaining consent being an employeeof the Receiver’s Office. Inmate T’s expected delivery date was
July 30, 2009, or more than 30 days after her consent. However,on July 12, 2009, the prison scheduled Inmate T for a cesarean
section procedure on the following day, July 13, 2009, 17 days before
her expected delivery date and only 20 days after she had consented
to sterilization. A review of her medical record did not indicate any
emergency conditions that necessitated an earlier delivery.
In other cases, physicians signed consent forms indicating that
30 days had passed when this clearly was not the case. For example,
Inmate K from Valley signed her consent for a bilateral tubal ligation
on January 12, 2010, and was sterilized on February 3, 2010, only
22 days later. For another inmate at Valley, the physician correctly
claimed that 30 days had passed but failed to realize that more than
180 days had elapsed. Specifically, Inmate D from Valley signed
her consent for sterilization in prison on June 20, 2006, and wassterilized on January 2, 2007, or roughly 196 days after consent.
One of the reasons for waiting at least 30 days before sterilization
is to provide the patient with enough time to reflect on her choice
and to make sure she desires sterilization. During our review wecame across one inmate who may not have desired to be sterilized
and, in our opinion, for whom there was no valid consent form.
Inmate X from Valley initially consented to sterilization via bilateral
tubal ligation on June 20, 2008; the person obtaining consent wasan employee of the Receiver’s Office. However, about three weeks
later, on July 10, 2008, Inmate X changed her mind. Medical notesin the inmate’s medical record confirm that she changed her mind
and indicate that the signed consent form was returned to theinmate. Then on August 12, 2008, prison medical staff scheduled
the inmate for a cesarean section at a general acute care hospitalon September 17, 2008. The inmate’s prison medical records do
not indicate that she was also being scheduled for a sterilization
procedure, and there are no other medical notes reflecting that theinmate again chose to be sterilized. Nevertheless, when the inmate
arrived at the hospital on September 17, 2008, she signed a standard
hospital-developed consent form for surgery, documenting
her consent to a cesarean section and bilateral tubal ligation.
However, the hospital consent form did not recognize the 30-day
requirement for sterilization. We also noted that the physician
performing the surgery somehow obtained the sterilization consent
form that had been returned to the inmate in July and signed it.
Given that Inmate X had previously withdrawn her consent to besterilized—which was her right—we question the lawfulness ofInmate X’s consent to sterilization, because the necessary waiting
period was not observed. In our opinion, prison medical staff andPhysicians signed consent forms
indicating that 30 days had passed
when this clearly was not the case.

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the hospital physician were obligated to ensure that Inmate X had
signed another sterilization consent form that allowed for a lawful
waiting period.
Inmates Who Consented to Sterilization While in Prison Likely Did So
Without a Witness of Their Choice
The problems associated with the lack of physician signatureson the consent forms and potential waiting period violations arecompounded by the fact that inmates have little or no opportunity
to have a witness of their choice present when they sign thesterilization consent form in prison. Inmates frequently signed
these forms in prison, accounting for at least 110 of the 144 inmates
whose records we reviewed. An attorney from the Receiver’s
Office explained that allowing inmates to have a witness of theirchoosing during the consent process is practically unworkable ina prison setting. If an inmate wanted anyone from anywhere as awitness, according to the staff counsel, the Receiver’s Office could
not accommodate such a request for logistical reasons and forinstitutional safety and security concerns.

The unwillingness or inability of theReceiver’s Office to provide inmateswith the opportunity to have awitness of their choice highlights
the problematic process that prison
staff followed when obtaining
inmates’ consent for sterilization.

Nevertheless, Title 22 is very clear in stating that an individual
has given informed consent to sterilization “only if ” certain
requirements are met. One of these requirements is being
permitted to have a witness of the patient’s choice present whenconsent is obtained. Although the witness is not required tosign the consent form, and no place on the form is provided fora witness’s signature, having a witness of the patient’s choicepresent—who presumably knows the patient well—serves as asafeguard to help ensure that the patient understands the procedureand truly desires to be permanently sterilized. A witness of theinmate’s choice can also help protect the State from allegations
that the inmate was coerced into her decision to be sterilized. The
unwillingness or inability of the Receiver’s Office to provide inmateswith the opportunity to have a witness of their choice—as required
by Title 22—serves to reinforce and highlight the problematic
process that prison medical staff followed when 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 the Receiver’s Office
related to sterilization uncovered another systemic deficiency
in how prison medical staff adhere to informed consent
requirements. As discussed in the Introduction, the Inmate Medical
Services Policies and Procedures (prison medical procedures)

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establishes expectations for how inmates are to be counseled
and how informed consent is to be obtained in a prison setting.
Since January 2002 prison medical procedures have requiredthat informed consent be a process to educate the inmate and that
prison medical staff document in the inmate’s health file the date,time, and essence of the discussion about a potential procedureand its risks and alternatives. For the 144 inmates we reviewed,
we looked for documentation in each inmate’s medical recordthat would allow us to evaluate how inmates were counseled on
the proposed sterilization procedure and what information they
were provided about the procedure beforehand. However, for all
144 cases we reviewed, prison medical staff failed to document
what was discussed with the inmate, as required by prison
medical procedures. Sometimes, prison medical staff simply
noted that the inmate signed the consent form or that the inmate“desires sterilization.”
The lack of notes in each inmate’s medical record regarding
informed consent and sterilization made it impossible for us toconclude on the quality and the content of the consultation between
prison medical staff and each inmate. We were also unable to reacha conclusion as to whether inmates received information about
the procedure and whether prison medical staff answered inmates’
questions prior to their making this sensitive and life-changing
decision. We shared our observations about the lack of notes in theinmate medical records with the deputy director of medical services
at the Receiver’s Office, asking for his perspective on why we sawsuch limited information in the inmates’ medical records regarding
the informed consent discussion. In response, the Receiver’s Officestated—through an attorney—that it is at a disadvantage in replying
to our question because Corrections initiated the policies andtraining describing how informed consent was to be documented
in an inmate’s health record. The attorney for the Receiver’s Officestated that although his explanation was probably correct, it was
speculative. The attorney stated that the procedure has a statutory
form that covers all the elements of consent, and in cases where
the Receiver’s Office physicians started the consent process,they likely assumed that the form would serve as the required
documentation, obviating the need to prepare a separate, duplicate
progress note. The attorney noted that sterilization represents arare instance where a procedure carries with it a mandated consent
form. Although much time has passed, the Receiver’s Office has
not eliminated the policy governing documentation of informed
consent, and if, in fact, the consent form was a proxy for a progressnote, we are surprised by the fact that we did not find consent
forms in all the inmate health records we reviewed.

For all 144 cases we reviewed,
prison medical staff failed to
document what was discussed with
the inmate, as required by prison
medical procedures.

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Protocols Designed to Ensure That Sterilization Is Medically
Necessary Failed
As described in the Introduction, Title 15 of the California Code ofRegulations (Title 15) requires a review and approval process forcertain medical procedures, referred to as excluded services, thatgenerally cannot be provided to inmates. The regulations include
sterilization procedures, such as tubal ligations, as an example
of excluded services that, if provided, must be approved by the
Headquarters Utilization Management Committee (headquarters
committee) beforehand. However, Corrections and the Receiver’s
Office failed to ensure that the prison medical staff under theirdirection followed state regulations requiring the proper approvalof sterilization procedures.
Prison medical staff may have been confused or misinformed
about the need to obtain headquarters committee approval prior
to an inmate’s sterilization. An October 1999 memo to prison
medical staff from Corrections—which was the state agency incontrol of inmate health care at that time—stated that postpartum
tubal ligation procedures would be offered to inmates as part ofobstetrical care. In our opinion, the 1999 memo appears to movebilateral tubal ligations from excluded services to nonexcluded
services when performed as part of obstetrical care, without
acknowledging the required approval process mandated inregulations. Officials at Corrections could not further explain the
purpose of the 1999 memo and how it was intended to affectthe approval process, if at all, for sterilization procedures.

During our review we saw noevidence that the bilateral
tubal ligation procedures, with
one exception in 2011, received all
the required levels of approval.

As shown in Figure 2 in the Introduction, prison medical
procedures allow the Receiver’s Office to provide excluded services
to inmates if utilization management committees at the prison(level 3) and at headquarters (level 4) approve the requested service.
These committees are made up of physicians and other correctional
officials who evaluate the merits of a medical procedure theinmate’s physician has proposed. The inmate’s physician makes
his or her request by completing a paper form called a Request for
Service, which includes spaces to list both the requested procedureand the reason why it is medically necessary. The Request for
Service form also has a location to note whether the service has
been approved or denied. If the procedure is approved, the form is
forwarded to other prison medical staff to schedule the patient fortreatment. In the case of a bilateral tubal ligation, the procedure
would be scheduled at a hospital with a local physician who works
on behalf of the Receiver’s Office.
During our review we saw no evidence that the bilateral tubal
ligation procedures, with one exception in 2011, received all
the required levels of approval. This may partially explain why

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the Receiver’s Office asserted that it was not aware that thesesterilization procedures were taking place until January 2010,
when a legal advocacy group called Justice Now began alleging that
medically unnecessary sterilization procedures had been performed.
Overall, 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.
In many cases, prison medical staff simply requested approval forother medical procedures—such as cesarean sections at hospitals—
and did not also indicate that the inmate was to be sterilized. Of the
144 inmates whose records we reviewed, we found only 56 Request
for Service forms that gave some indication that inmates were to
be sterilized. In 27 of these 56 cases, we did not see any evidence ofprior review or approval of the sterilizations. We also did not find aconsent form in the inmate’s file for one of these 27 inmates; thus,
for one inmate the medical records from the Receiver’s Office did
not contain a sterilization consent or a required medical request
and approval.
Shedding further light on how prison medical staff failed to adhere
to the utilization management process, we saw that in someinstances the time elapsing between when the prison physician
requested approval for inmate sterilization and when the procedure
was performed was so short that we question how feasible it would
have been for utilization management review committees—bothat the prison and at headquarters—to review and consider thesterilization procedure before the inmate’s surgery. Specifically,
we noted that less than a week elapsed between the date of therequest and the date of the surgery in 12 instances in which medical
staff sought approval for sterilization procedures. For example, we
reviewed the medical record for Inmate G, who had been an inmate
at CIW. Inmate G’s physician submitted a Request for Service
form asking for “L+D,” meaning labor and delivery, clarifying on
the form that the inmate also desired a tubal ligation. The Request
for Service form—dated August 10, 2009—lacked any evidenceof review and approval. Following a cesarean section in thehospital, Inmate G had a sterilization procedure two days later on
August 12, 2009. It is unlikely that the two days between the signingof the form and the surgery were sufficient for both a level 3 andlevel 4 review of the requested sterilization procedure.
Our audit also noted 18 cases in which prison medical staff
requested approval for medical procedures with no mentionof sterilization, and yet the inmate was sterilized within one tothree days of the request. In a particularly egregious case, thephysician for Inmate T at CIW submitted a Request for Service
form dated July 12, 2009, requesting approval for “pregnant
evaluation/treatment” services, with no additional information on
the form to indicate that the physician 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.

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procedure for which the inmate had signed a consent form. After
having a normal delivery of her child in a local hospital, Inmate T
was sterilized the following day, on July 13, 2009.
The Receiver’s Office did notadequately monitor and control
the sterilization procedures being
performed on inmates, and prison
medical staff did not always
request approval before inmates
were sterilized.

Overall, our review of available inmate medical records indicatesthat the Receiver’s Office did not adequately monitor and control
the sterilization procedures being performed on inmates, andprison medical staff did not always request approval before inmates
were sterilized. In light of the 1999 memo that appeared to makecertain sterilization procedures an acceptable form of treatment,
it is unclear whether prison medical staff thought approval fromheadquarters was unnecessary before arranging for the sterilizationof inmates under their care.
We asked the deputy medical executive at the Receiver’s Office(deputy medical executive)—who has been in charge of the utilization
management process since July 2008—to explain how bilateral
tubal ligations could have been performed without the necessary
approvals from headquarters. In response, she explained that female
prisons required extensive one-on-one, verbal, telephonic, and othereducation between 2008 and 2010 to develop both the institutional
utilization management committees and the processes for referringcases to headquarters for review. The deputy medical executive
also stated that the authorization system is currently paper based,
explaining that if an electronic authorization system existed to block
the local approval of excluded services, forcing the routing of requests
to headquarters for review, inadvertent scheduling of excluded services
by institutions could, hypothetically, be decreased. According to thedeputy medical executive, an electronic authorization system could
allow headquarters staff to review, in real time, which procedures
have been authorized in the prisons and generate an alert when
proposed medical services require headquarters’ review. However,the deputy medical executive acknowledged that the Receiver’s Officelacks such an electronic authorization system. With the Receiver’s
Office relying on prisons to consistently forward paper‑based requests
for sterilizations to headquarters for approval, coupled with its
inability to block prisons from scheduling sterilization procedures
without its approval, the Receiver’s Office was not well positioned tomonitor and control how often inmates were sterilized and whether
such 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 2010, after it became aware that the sterilization procedures
were taking place, the Receiver’s Office conducted a review that
identified weaknesses in the way that the medical staff in the female
prisons processed and considered sterilization requests. According

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to an internal report the deputy medical executive issued to an
executive at the Receiver’s Office following a review of Valley andother female prisons, she concluded, “Despite language in Title 15
and the Department Operations Manual restricting the use ofsterilizations, [bilateral] tubal ligations, and hysterectomies that are
intended to provide sterilization, the leadership teams at [certain
female prisons] could not document that an oversight program had
been developed to consistently review requests for sterilization, or
hysterectomy that would result in sterilization, to determine if they
were medically necessary, and that all other conservative measurescommonly attempted in the community had failed.” In the internalreport, the deputy medical executive also commented specifically
about problems at Valley, stating that “both the [prison] based
OB‑GYN physician at Valley and [community-based physicians] donot, to me, appear capable of objective oversight of their utilization,and community-institutional personal and professional familiarity
is so high and complex, that [headquarters] oversight of these cases
will be necessary to ensure compliance.”
The deputy medical executive’s comments were well founded
regarding the need for oversight from headquarters, as her
observations were confirmed by our own. However, we note that
the Receiver’s Office has since taken some steps to further limit
how often sterilization procedures take place, including training
medical staff and changing its medical claims system. Our analysisof medical claims data since 2010 from the Receiver’s Office showsthat the number of female inmates undergoing bilateral tubal ligations
and other medical procedures that result in sterilization has greatly
decreased. For the eight-year audit period we reviewed, Table A.1
in the Appendix summarizes the medical procedures that had thepotential to sterilize the female inmate. Although it is still possible
for an inmate to be scheduled for and undergo medical procedures
resulting in sterilization without medical staff obtaining all of thenecessary approvals, our review of procedures inmates underwent
in 2010 and later that resulted in sterilization found that adherence tothe utilization management review process improved.
The Receiver’s Office Still Must Prevent Staff From Scheduling
Unauthorized Procedures
As discussed earlier in this report, just one of the 144 inmates wereviewed had a bilateral tubal ligation that was scheduled andperformed with documented utilization management approval.
Because the functions of approving a medical procedure andscheduling it are separate, prison medical staff are able to schedule
procedures without necessary utilization management review,
meaning that inmates could still receive medical services that are
not authorized. When we asked the deputy medical executive

Our analysis of medical claims
data since 2010 from the Receiver’s
Office shows that the numberof female inmates undergoingbilateral tubal ligations and othermedical procedures that result insterilization has greatly decreased.

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Until the Receiver’s Office can link
medical scheduling with utilization
management authorization, itrisks inmates being scheduled forand receiving medical proceduresthat are not authorized as
medically necessary.

over utilization management why this weakness has not beenaddressed, she responded that utilization management has done
its best to communicate to scheduling staff that an authorizedprocedure request is needed, but that utilization management has
no authority over the scheduling unit. When we inquired whether
the director of health care operations, who is responsible for
utilization management and the nursing unit, could give the nursing
unit direction to stop scheduling unapproved medical services,the deputy medical executive agreed that this would be a feasible
alternative to utilization management needing to acquire schedulingauthority. Further, the deputy medical executive noted that a method
to electronically block the scheduling of medical services until theyreceive utilization management approval currently does not exist.
However, the deputy medical executive stated that the Receiver’s
Office is procuring a new computer system that will require priorauthorization before scheduling, which should be available infall 2015. Until the Receiver’s Office can link medical schedulingwith utilization management authorization, it risks inmates beingscheduled for and receiving medical procedures that are notauthorized as medically necessary, such as bilateral tubal ligations.
The Receiver’s Office Has Taken Steps to Improve Adherence to Its
Utilization Management Process
The level of adherence to the Receiver’s Office utilization management
process may correlate to the level of staff and management training
about the process. We believe that it is essential to train prison-based
medical staff because they are responsible for ensuring that their
institutions provide necessary care. As Figure 2 on page 11 depicts,
each institution’s utilization management nurse and medical executives
play important roles in implementing the utilization management
process. The Receiver’s Office trains medical staff on the utilization
management process in formal and informal ways, includingclassroom-based coursework, technical assistance, and utilization
process monitoring. We found that the 2013 training content was
sufficiently comprehensive to ensure that prison-based medical staff
understood the utilization management process. Courses for utilization
management nurses and prison-based medical executives covered
three key components: the utilization management review process, theapplication of medical decision support criteria, and Title 15 service
exclusions and committee reviews.
According to the deputy medical executive, the nurses’ training
has occurred each year from 2010 through 2013, but thetrainings before 2013 focused on the medical decision support
criteria and did not include utilization management. She also statedthat the medical executives’ training is part of a pilot program thatbegan in 2012. The 2014 utilization management work plan—which

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outlines quantitative performance objectives for the delivery ofhealth care under state law—indicates that the nurses’ and medical
executives’ training is scheduled to run through the end of 2014.
Our review of medical files also revealed better adherence toutilization management requirements since 2010. Specifically, we
reviewed medical records for 20 female inmates who underwent
nonexcluded medical procedures, such as hysterectomies,
between April 1, 2010, and June 30, 2013. For 19 of these inmates—or 95 percent of the cases reviewed—the Request for Service
reflected utilization management reviews and approvals. In
contrast, utilization management reviews and approvals were
found in less than 1 percent of all bilateral tubal ligation cases wereviewed for the eight fiscal years beginning in 2005–06 through2012–13. For example, Inmate N from CIW had a hysterectomyin 2012 to treat what her medical progress notes cite as uterine
fibroids and heavy bleeding. The Request for Service for the inmate’s
procedure reflected utilization management review at levels 1, 2,
and 3 (refer to Figure 2 on page 11 for information on the levels ofreview). Although a nonexcluded procedure can be approved at
level 2, the Request for Service reflected that the level 2 reviewer
deferred the decision and the request went to level 3 (the institution’s
utilization management committee), where it was approved. For
one inmate we found no Request for Service, and thus we could not
determine whether the hysterectomy she underwent was reviewed
and approved as required. Despite this lapse, since 2010 theReceiver’s Office is better able to ensure that the treatment inmates
are prescribed is scrutinized and deemed medically necessary.
Finally, the Receiver’s Office also made changes to its medicalbilling system in the fall of 2010 to flag medical claims for certain
sterilization procedures and delay the payment of these claims until
headquarters could review and approve the procedure. Although
the change to its billing system would not prevent sterilizations
from taking place, since it focuses on stopping payment for theprocedure rather than stopping the procedure itself, this step andthe increased trainings appear to have been effective.
Recommendations
To ensure that the necessary education and disciplinary action
can be taken, the Receiver’s Office should report to the California
Department of Public Health, which licenses general acute care
hospitals, and the Medical Board of California, which licenses
physicians, the names of all hospitals and physicians associated withinmates’ bilateral tubal ligations during fiscal years 2005–06 through2012–13 for which consent was unlawfully obtained. The Receiver’s
Office should make these referrals as soon as is practicable.

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To ensure that it can better monitor how its medical staff andcontractors adhere to the informed consent requirements ofTitle 22, sections 70707.1 through 70707.7, the Receiver’s Officeshould develop a plan by August 2014 to implement a process by
December 2014 that would include the following:• Providing additional training to prison medical staff regarding
Title 22 requirements for obtaining informed consent forsterilization procedures, including the applicable forms andmandatory waiting period requirements to ensure that consent
is lawfully obtained.
• Developing checklists or other tools that prison medical staff
can use to ensure that medical procedures are not scheduled
until after the applicable waiting periods for sterilization havebeen satisfied.
• Periodically reviewing, on a consistent basis, a sample of cases
in which inmates received treatment resulting in sterilization at
general acute care hospitals, to ensure that all informed consent
requirements were satisfied.
• Working with Corrections to establish a process whereby inmates
can have witnesses of their choice when consenting to sterilization,
as required by Title 22, or working to revise such requirements sothat there is an appropriate balance between the need for secure
custody and the inmate’s ability to have a witness of her choice.
• Until such time as the Receiver’s Office implements a process
for obtaining inmate consent for sterilization under Title 22 thatcomplies with all aspects of the regulations, it should discontinue
its practice of facilitating an inmate’s consent for sterilization in
the prison and allow the general acute care hospital to obtain an
inmate’s consent.
To improve the quality of the information prison medical staff
document in inmate medical records, the Receiver’s Officeshould do the following:• Train its entire medical staff on its policy in the inmate
medical procedures related to appropriate documentation ininmates’ medical records. This training should be completed by
December 31, 2014.
• Either develop or incorporate into an existing process a meansby which it evaluates prison medical staffs’ documentation ininmates’ medical records and retrains medical staff as necessary.
The Receiver’s Office should develop and implement this processby June 30, 2015.

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June 2014

To ensure that inmates receive only medical services that are
authorized through its utilization management process, the Receiver’s
Office should do the following:• Develop processes by August 31, 2014, such that a procedure that
may result in sterilization is not scheduled unless the procedure isapproved at the necessary level of the utilization management process.
• By October 31, 2014, train its scheduling staff to verify that theappropriate utilization management approvals are documented
before they schedule a procedure that may result in sterilization.
• Ensure that the computer system it procures includes functionality
to electronically link medical scheduling with authorization throughthe utilization management process to prevent all unauthorizedprocedures, regardless of whether they may result in sterilization,from being scheduled.
We conducted this audit under the authority vested in the California State Auditor by Section 8543
et seq. of the California Government Code and according to generally accepted government auditing
standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate
evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives
specified in the scope section of the report. We believe that the evidence obtained provides areasonable basis for our findings and conclusions based on our audit objectives.
Respectfully submitted,

ELAINE M. HOWLE, CPA
State Auditor
Date:June 19, 2014

Staff:

Grant Parks, Audit Principal
Sharon L. Fuller, CPA
Myriam K. Arce, MPA, CIA
Kathryn Cardenas, MPPA
Oswin Chan, MPP
Dana Doughty, RN, MPP

IT Audit Support: Michelle J. Baur, CISA, Audit Principal
Lindsay M. Harris, MBA
Grant Volk, MA, CFE
Legal Counsel:

Scott A. Baxter, JD
Joseph L. Porche, JD

For questions regarding the contents of this report, please contact
Margarita Fernández, Chief of Public Affairs, at 916.445.0255.

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Blank page inserted for reproduction purposes only.

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Appendix
STATISTICAL AND DEMOGRAPHIC INFORMATION ABOUTFEMALE INMATES WHO RECEIVED MEDICAL TREATMENTPOTENTIALLY CAUSING STERILIZATION BETWEENFISCAL YEARS 2005–06 THROUGH 2012–13
The Joint Legislative Audit Committee (audit committee)
directed the California State Auditor (state auditor) to determine
the number of sterilization procedures performed on female
inmates over the most recent eight-year period. The audit
committee also asked the state auditor to determine what otherprocedures, if any, were performed along with these sterilizations
and to provide demographic information for the inmates affected.
A variety of factors make it difficult to determine definitively
how often female inmates received medical procedures for which
sterilization was the sole purpose for the surgery. For example,
a woman being treated for uterine cancer may need to have ahysterectomy, resulting in sterilization, even though that was not
the stated purpose for the procedure. Complicating matters evenfurther, it is possible that certain inmates were sterilized before
our audit period and then subsequently received a hysterectomy
or other procedure that commonly results in sterilization. In suchcircumstances, the hysterectomy or other procedure would appear
in our data set, and yet those surgeries did not actually cause theinmate’s sterilization.
With these challenges in mind, we addressed the audit committee’srequest by analyzing California Correctional Health Care Services(Receiver’s Office) inmate medical claims data. Table A.1 on thefollowing page provides counts of medical procedures that had
the potential to cause the sterilization of female inmates between
fiscal years 2005–06 and 2012–13. The table also shows that medical
providers submitted claims pertaining to 794 unique inmates for
medical procedures that could have caused their sterilization.
The procedure groupings in Table A.1 show the number andfrequency in which bilateral tubal ligations occurred. According
to our medical consultant, the Receiver’s Office, and our own filereview for each inmate affected, these procedures were performed
solely for the purpose of sterilization. We also selected a total of
26 files from the other two categories shown in Table A.1 andconcluded that these procedures were performed in responseto specific medical conditions and that sterilization was not
mentioned as an explanation for the surgery.

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Table A.1
Inmate Medical Procedures Potentially Resulting in Sterilization
Fiscal Years 2005–06 Through 2012–13
FISCAL YEAR

Number of inmates per year

2005–06

2006–07

2007–08

2008–09

2009–10

2010–11

2011–122012–13TOTAL NUMBER OFINDIVIDUAL INMATES

101

154

218

153

100

50

27

18

794*

GENERAL PROCEDURETOTAL NUMBER OF
PROCEDURES PERFORMEDNUMBER OF PROCEDURES PERFORMED PER YEAR

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 insterilization; however, it was the most accessible information. Further, our audit noted four instances in which tubal ligation procedures recordedin CMD did not take place, based on our review of documentation obtained from hospitals, physicians, and the Receiver’s Office. As a result, we haveadjusted 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.

Further, the procedures counted in the table may notalways have caused an inmate’s sterilization, because the inmate
may have undergone a sterilization procedure before our audit
period. We grouped inmate medical procedures—as recorded in
the Contract Medical Database—based on their Current Procedural
Terminology codes.
Because the audit request seemed most focused on inmates
who had procedures for which sterilization was the intent of theprocedure, we obtained additional data on medical procedures thatwere performed during the same hospital stay as the bilateral tubal
ligation. As shown in Table A.2, the 144 inmates most frequently
had bilateral tubal ligations when also having a cesarean section.

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Table A.2
Number of Inmates Sterilized at Hospitals During Their Stay for Child BirthFiscal Years 2005–06 Through 2012–13

Total

POSTPARTUM
STERILIZATIONPROCEDURE OCCURRED AS
PART OF A CESAREAN SECTIONTOTAL FEMALE
INMATES

22

122

144

Sources: California State Auditor’s analysis of data obtained from the California Correctional HealthCare 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 ofcesarean section).

Table A.3 shows selected demographics by fiscal year for the
144 inmates who had a bilateral tubal ligation. The female inmates
were typically young when they had their bilateral tubal ligation,
mostly between 26 and 40 years of age, and had been pregnant
five or more times with at least three childbirths, not counting
the child delivered at the time of the sterilization procedure. The
inmates generally tested at less than a high school level of reading
proficiency and were predominately of the white, Hispanic, andblack races. In addition, English was the primary language forthe majority of the inmates and most were incarcerated for the
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

2011–122012–13

TOTAL

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

0–4

6

8

6

6

5

0

0

0

31

5–6

12

7

12

10

6

1

0

0

48

Age at sterilization

Number of pregnancies

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 . . .

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FISCAL YEAR
DEMOGRAPHIC CATEGORY

2005–06

2006–07

2007–08

2008–09

2009–10

2010–11

2011–122012–13

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

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

Ethnicity / race†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

15

23

27

21

13

2

0

0

101

Number of incarceration periods
1 period
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.

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California State Auditor’s comment appears on page 43.

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Comment
CALIFORNIA STATE AUDITOR’S COMMENT ON THE
RESPONSE FROM CALIFORNIA CORRECTIONAL HEALTH
CARE SERVICES
To provide clarity and perspective, we are commenting on
the California Correctional Health Care Services’ (Receiver’s
Office) response to our audit. The number below corresponds
to the number we have placed in the margin of the Receiver’s
Office response.
We question the assertion made by the Receiver’s Office that it
received no Medi-Cal reimbursement related to sterilizations.
As we state in Table 2, objective 7, on page 16, we identified
one inmate for whom we determined that the Receiver’s Officereceived Medi‑Cal federal reimbursement for pregnancy‑related
hospital services. We describe the circumstances of thatreimbursement, which include the fact that it covered hospitalcosts including the use of the surgical room for the inmate’s
sterilization procedure. We directed the Receiver’s Office towork with the California Department of Health Care Services
to ascertain the appropriateness of the Medi‑Cal reimbursement forthis inmate. Until the Receiver’s Office has done so, the conclusion
the Receiver’s Office has drawn is premature.

1

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