CCHCS MAT policy is 30 second monitoring. In practice, no monitoring occurs.
CCHCS policy states Suboxone diversion control is achieved by the nurse monitoring the inmate 30 seconds after administering the Suboxone film.
MAT Normalization is achieved by the omission of the observed monitoring period.
In practice, the 30 second monitoring is omitted.
- 03/2022 OIG Cycle 6 inspection at PBSP (p. 50) “a medication nurse did not follow the CCHCS care guide when administering Suboxone medication”
- 08/2022 OIG Cycle 6 inspection at HDSP
(p.19) “HDSP providers reported that they saw many critically ill patients in clinic and TTA due to Suboxone misuse. Due to the Suboxone misuse epidemic at the institution, patients who before had presented with benign symptoms, now required workups for conditions such as skin infections, spinal abscesses, heart infections, and bone infections. Upon diagnosis or hospital return, these patients were frequently housed in the TTA for long periods, requiring complicated care and treatment, which increased CTC and TTA provider workloads and reduced available beds.”
(p.83) “As discussed in the Access to Care indicator, providers were seeing many critically ill patients due to Suboxone diversion and misuse. Providers advised that intravenous injection of diverted Suboxone was so common that if a patient presented with a simple complaint such as routine back pain, providers might have been required to send the patient to the hospital or do a resource intensive infection workup. Providers could not quantify the number of Suboxone-related infections that occurred, because there was no official tracking, but we were told “many,” and given numbers of seven confirmed cases in the past few months to 20 total over the past year. Medical leadership and providers also expressed concern over CCHCS headquarters’ ISUDT plans to transfer ISUDT care to the already understaffed provider team.”
(p.94) “Staff advised that the implementation of the ISUDT program impacted the availability of clinic space, custody transport staff, and nursing staff. In addition, both medical leadership and staff advised the high number of patients on Suboxone, its diversion, and the high number of diversion-related serious medical complications had placed a significant burden on an already strained prison health care system.”
| The OIG provided commentary is in Italics: |
- 11/2022 OIG Cycle 6 inspection at PVSP (p.49) “medication nurses did not follow the CCHCS care guide when administering Suboxone medication”
- Cell front medication pass, medication nurse did not wait 30 seconds to observe patient, did not always check hands, and did not alway provide patient education when administering Suboxone medication.
- 07/2023 OIG Cycle 6 inspection at ISP (p.49) “medication nurses did not follow proper administration of Suboxone medication as required by CCHCS policy”
- Medication nurse did not complete the 30-sec observation when administering Suboxone medication.
- 11/2024 OIG Cycle 7 inspection at NKSP (p.60) “medication nurses did not follow CCHCS care guide when administering Suboxone medication”
- Medication nurse did not complete 30-sec observation when administering Suboxone medication.
- 04/2025 OIG Cycle 7 inspection at CCWF (p.57) “medication nurses did not follow the CCHCS care guide when administering Suboxone medication”
- Medication nurse did not complete 30-sec observation when administering Suboxone medication.
- 05/2025 OIG Cycle 7 inspection at CSP (p.48) “medication nurses did not follow CCHCS care guide when administering Suboxone medication”
- Medication nurse did not complete 30-sec observation when administering Suboxone medication.
- 05/2025 OIG Cycle 7 inspection at KVSP (p.50) “medication nurses did not follow the CCHCS care guide when administering Suboxone medication”
- Medication nurse did not complete 30-sec observation when administering Suboxone medication.
- 06/2025 OIG Cycle 7 inspection at CIW (p.54) “In two clinics, we observed a medication nurse who did not follow the CCHCS care guide when administering Suboxone medication”
- Medication nurse did not complete 30-sec observation when administering Suboxone medication.
- 07/2025 OIG Cycle 7 inspection at CMC (p.55) “a medication nurse did not follow the CCHCS care guide when administering Suboxone medication”
- Medication nurse did not complete 30-sec observation when administering Suboxone medication.
- 09/2025 OIG Cycle 7 inspection at CAL (p.51) “medication nurses did not follow the CCHCS care guide when administering Suboxone medication”
- Medication nurse did not complete 30-sec observation. Medication nurse did not instruct the patient to stop talking while taking the suboxone medication and the films are dissolving.
- 09/2025 OIG Cycle 7 inspection at PVSP (p.52) “medication nurses did not follow California Correctional Health Care Services’ care guide when administering Suboxone medication”
- Medication nurse did not complete 30-sec observation when administering Suboxone medication.
- 09/2025 OIG Cycle 7 inspection at SAC (p.55) “medication nurses did not follow the CCHCS care guide when administering Suboxone medication”
- Medication nurse did not complete 30-sec observation when administering Suboxone medication.
- 10/2025 OIG Cycle 7 inspection at MCSP (p.52) “medication nurses did not follow the CCHCS care guide when administering Suboxone medication”
- Medication nurse did not complete 30-sec observation when administering Suboxone medication.
