Report 2016-131 Recommendation 2 Responses

Report 2016-131: California Department of Corrections and Rehabilitation: It Must Increase Its Efforts to Prevent and Respond to Inmate Suicides (Release Date: August 2017)

Recommendation #2 To: Corrections and Rehabilitation, Department of

Corrections should immediately require mental health staff to score 100 percent on risk evaluation audits in order to pass. If a staff member does not pass, Corrections should require the prison to follow its current policies by reviewing additional risk evaluations to determine whether the staff member needs to undergo additional mentoring.

6-Month Agency Response

1. The California Correctional Health Care Services (CCHCS) Quality Management (QM) has developed an enterprise-wide tracking tool to track clinicians requiring Suicide Risk Evaluation (SRE) mentoring or re-mentoring.

2. CDCR revised the items on the SRE chart audit tool as the previous audit tool did not fully capture the scope of the risk assessment contained in the EHRS (now termed the Suicide Risk Assessment and Self Harm Evaluation or SRASHE). The change to the audit tool is in production.

3. CDCR has reviewed the recommendation to increase the passing score to 100 percent, and has determined the current criteria is sufficient and appropriate.

The tracking and SRE CAT audit items tool was completed in January 2018. The production of the electronic tool will be completed in March 2018.

  • Estimated Completion Date: March 2018
  • Response Date: February 2018

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


60-Day Agency Response

1. The California Correctional Health Care Services (CCHCS) Quality Management (QM) is developing an enterprise-wide tracking tool to track clinicians requiring Suicide Risk Evaluation (SRE) mentoring or re-mentoring to be beta tested the first week of September.

2. CDCR will be revising the SRE chart audit tool upon full implementation of the Electronic Health Record System (EHRS), as the current audit tool does not fully capture the scope of the risk assessment contained in the EHRS (now termed the Suicide Risk Assessment and Self Harm Evaluation or SRASHE). A workgroup will be established in late October 2017, with QM, the headquarters Suicide Prevention Unit, and selected institution Suicide Prevention and Response Focused Improvement Teams (SPRFIT), to develop the new audit criteria.

3. CDCR has reviewed the recommendation to increase the passing score to 100 percent, and has determined the current criteria is sufficient and appropriate.

  • Estimated Completion Date: December 2017
  • Response Date: October 2017

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


All Recommendations in 2016-131

Agency responses received are posted verbatim.