OIG
Avenal State Prison Medical Inspection Report Cycle 5
Roy W. Wesley Office of the Inspector General
Inspector General
Avenal State Prison
Medical Inspection Report
Cycle 5
August 2018
Office of the Inspector General
AVENAL STATE PRISON
Medical Inspection Report
Cycle 5
Roy W. Wesley
Inspector General
Bryan B. Beyer
Chief Deputy Inspector General
Shaun R. Spillane
Public Information Officer
August 2018
T C
ABLE OF ONTENTS
Foreword ............................................................................................................................................... i
Overall Rating: Adequate ................................................................................................................ iii
Executive Summary ............................................................................................................................ iii
Expert Clinician Case Review Results ................................................................................... v
Compliance Testing Results .................................................................................................. vi
Recommendation .................................................................................................................. vii
Population-Based Metrics ..................................................................................................... vii
Introduction .......................................................................................................................................... 1
About the Institution ......................................................................................................................... 1
Objectives, Scope, and Methodology .................................................................................................. 4
Case Reviews .................................................................................................................................... 5
Patient Selection for Retrospective Case Reviews ................................................................. 6
Benefits and Limitations of Targeted Subpopulation Review ................................................ 7
Case Review Sampling Methodology .................................................................................... 7
Breadth of Case Reviews ........................................................................................................ 8
Case Review Testing Methodology ........................................................................................ 9
Compliance Testing ........................................................................................................................ 12
Sampling Methods for Conducting Compliance Testing ..................................................... 12
Scoring of Compliance Testing Results ............................................................................... 12
Overall Quality Indicator Rating for Case Reviews and Compliance Testing ............................... 13
Population-Based Metrics............................................................................................................... 13
Medical Inspection Results ................................................................................................................ 14
Access to Care ................................................................................................................. 16
Case Review Results............................................................................................................. 16
Compliance Testing Results ................................................................................................. 18
Diagnostic Services.......................................................................................................... 20
Case Review Results............................................................................................................. 20
Compliance Testing Results ................................................................................................. 21
Emergency Services ......................................................................................................... 22
Case Review Results............................................................................................................. 22
Health Information Management..................................................................................... 25
Case Review Results............................................................................................................. 25
Compliance Testing Results ................................................................................................. 26
Health Care Environment ................................................................................................ 28
Compliance Testing Results ................................................................................................. 28
Inter- and Intra-System Transfers.................................................................................... 31
Case Review Results............................................................................................................. 31
Compliance Testing Results ................................................................................................. 33
Pharmacy and Medication Management ......................................................................... 35
Case Review Results............................................................................................................. 35
Compliance Testing Results ................................................................................................. 36
Avenal State Prison, Cycle 5 Medical Inspection Table of Contents
Office of the Inspector General State of California
Prenatal and Post-Delivery Services ............................................................................... 39
Preventive Services .......................................................................................................... 40
Compliance Testing Results ................................................................................................. 40
Quality of Nursing Performance .................................................................................. 42
Case Review Results............................................................................................................. 42
Quality of Provider Performance ................................................................................. 46
Case Review Results............................................................................................................. 46
Reception Center Arrivals ............................................................................................ 49
Specialized Medical Housing ....................................................................................... 50
Case Review Results............................................................................................................. 50
Compliance Testing Results ................................................................................................. 51
Specialty Services ......................................................................................................... 53
Case Review Results............................................................................................................. 53
Compliance Testing Results ................................................................................................. 54
Administrative Operations (Secondary) ....................................................................... 56
Compliance Testing Results ................................................................................................. 56
Recommendation ............................................................................................................................... 58
Population-Based Metrics .................................................................................................................. 59
Appendix A — Compliance Test Results ............................................................................................ 62
Appendix B — Clinical Data ............................................................................................................. 75
Appendix C — Compliance Sampling Methodology ........................................................................ 79
California Correctional Health Care Services’ Response .................................................................. 86
Avenal State Prison, Cycle 5 Medical Inspection Table of Contents
Office of the Inspector General State of California
L T F
IST OF ABLES AND IGURES
ASP Executive Summary Table ......................................................................................................... iv
ASP Health Care Staffing Resources as of August, 2017 ................................................................... 2
ASP Master Registry Data as of August 28, 2017 .............................................................................. 3
Exhibit 1. Case Review Definitions .................................................................................................... 5
Chart 1. Case Review Sample Selection ............................................................................................. 8
Chart 2. Case Review Testing and Deficiencies ............................................................................... 10
Chart 3. Inspection Indicator Review Distribution............................................................................ 14
Avenal State Prison Results Compared to State and National HEDIS Score ................................... 61
Table B-1: ASP Sample Sets ............................................................................................................. 75
Table B-2: ASP Chronic Care Diagnoses ......................................................................................... 76
Table B-3: ASP Event – Program ..................................................................................................... 77
Table B-4: ASP Review Sample Summary ....................................................................................... 78
Avenal State Prison, Cycle 5 Medical Inspection List of Tables and Figures
Office of the Inspector General State of California
This page intentionally left blank.
Avenal State Prison, Cycle 5 Medical Inspection
Office of the Inspector General State of California
F
OREWORD
Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector
General (OIG) responsibility for oversight of the California Department of Corrections and
Rehabilitation (CDCR), the OIG conducts a comprehensive inspection program to evaluate the
delivery of medical care at each of CDCR’s 35 adult prisons. The OIG explicitly makes no
determination regarding the constitutionality of care in the prison setting. That determination is left
to the Receiver and the federal court. The assessment of care by the OIG is just one factor in the
court’s determination whether care in the prisons meets constitutional standards.
The OIG’s inspections are mandated by the Penal Code and not aimed at specifically resolving the
court’s questions on constitutional care. To the degree that they provide another factor for the court
to consider, the OIG is pleased to provide added value to the taxpayers of California.
In Cycle 5, for the first time, the OIG will be inspecting institutions delegated back to CDCR from
the Receivership. There is no difference in the standards used for assessment of a delegated
institution versus an institution not yet delegated. The Receiver delegated Avenal State Prison back
to CDCR in October 2016.
This fifth cycle of inspections will continue evaluating the areas addressed in Cycle 4, which
included clinical case review, compliance testing, and a population-based metric comparison of
selected Healthcare Effectiveness Data Information Set (HEDIS) measures. In agreement with
stakeholders, the OIG made changes to both the case review and compliance components. The OIG
found that in every inspection in Cycle 4, larger samples were taken than were needed to assess the
adequacy of medical care provided. As a result, the OIG reduced the number of case reviews and
sample sizes for compliance testing. Also, in Cycle 4, compliance testing included two secondary
(administrative) indicators (Internal Monitoring, Quality Improvement, and Administrative
Operations; and Job Performance, Training, Licensing, and Certifications). For Cycle 5, these have
been combined into one secondary indicator, Administrative Operations.
Avenal State Prison, Cycle 5 Medical Inspection Page i
Office of the Inspector General State of California
This page intentionally left blank.
Avenal State Prison, Cycle 5 Medical Inspection Page ii
Office of the Inspector General State of California
E S
XECUTIVE UMMARY
The OIG completed the Cycle 5 medical inspection of Avenal State
Prison (ASP) in August 2018. The vast majority of our inspection
findings were based on ASP’s health care delivery between
OVERALL RATING:
December 2016 and October 2017. Our policy compliance
inspectors performed an onsite inspection in August 2017. After
Adequate
reviewing the institution’s health care delivery, our case review
clinicians performed an onsite inspection in January 2018.
Our clinician team, consisting of expert physicians and nurse consultants, reviewed cases (patient
medical records) and interpreted our policy compliance results to determine the quality of health
care the institution provided. Our compliance team, consisting of registered nurses, monitored the
institution’s compliance with its medical policies by answering a predetermined set of policy
compliance questions.
Our clinician team reviewed 50 cases that contained 580 patient-related events. Our compliance
team tested 86 policy questions by observing ASP’s processes and examining 386 patient records
and 1,042 data points. We distilled the results from both the case review and compliance testing
into 13 health care indicators, and have listed the individual indicators and ratings applicable for
this institution in the ASP Executive Summary Table on the following page. Our experts made a
considered and measured opinion that the overall quality of health care at ASP was adequate.
Avenal State Prison, Cycle 5 Medical Inspection Page iii
Office of the Inspector General State of California
ASP Executive Summary Table
Case Review Compliance Cycle 5 Cycle 4
Inspection Indicators
Rating Rating Overall Rating Rating
1—Access to Care Proficient Proficient Proficient Adequate
2—Diagnostic Services Proficient Adequate Proficient Adequate
3—Emergency Services Proficient Not Applicable Proficient Adequate
4—Health Information
Proficient Inadequate Adequate Adequate
Management
5—Health Care Environment Not Applicable Inadequate Inadequate Proficient
6—Inter- and Intra-System
Adequate Proficient Adequate Adequate
Transfers
7—Pharmacy and Medication
Adequate Inadequate Inadequate Inadequate
Management
8—Prenatal and Post-Delivery
Not Applicable Not Applicable Not Applicable Not Applicable
Services
9—Preventive Services Not Applicable Proficient Proficient Inadequate
10—Quality of Nursing
Adequate Not Applicable Adequate Adequate
Performance
11—Quality of Provider
Adequate Not Applicable Adequate Adequate
Performance
12—Reception Center Arrivals Not Applicable Not Applicable Not Applicable Not Applicable
13—Specialized Medical
Adequate Proficient Adequate Adequate
Housing
14—Specialty Services Proficient Adequate Proficient Adequate
15—Administrative Operations
Not Applicable Proficient Proficient Inadequate*
(Secondary)
*In Cycle 4, there were two secondary (administrative) indicators. This score reflects the average of those two
scores.
Avenal State Prison, Cycle 5 Medical Inspection Page iv
Office of the Inspector General State of California
Expert Clinician Case Review Results
Our clinicians reviewed the care of patients with high medical needs and included a review of more
than 580 patient care events.1 The vast majority of our case review covered the period between
February 2017 and October 2017. Of the 13 indicators applicable to ASP, our clinicians rated 10; 5
were proficient, and 5 were adequate. When determining the overall adequacy of care, we paid
particular attention to the clinical nursing and provider quality indicators, as adequate health care
staff can sometimes overcome suboptimal processes and programs. However, the opposite is not
true; inadequate health care staff cannot provide adequate care, even though the established
processes and programs may be adequate. We identify inadequate medical care based on the risk of
significant harm to the patient, not the actual outcome.
Program Strengths — Clinical
• ASP performed well with Access to Care. During the daily clinic huddles, the medical staff
collaborated to ensure they scheduled all the follow-up appointments the patients needed.
• ASP completed virtually all laboratory and diagnostic tests appropriately. The staff retrieved
and scanned the diagnostic reports into the medical records timely.
• Treatment and Triage Area (TTA) providers made appropriate assessments, interventions,
and decisions during urgent or emergent medical situations.
• ASP providers and nurses provided excellent care for their OHU patients.
• ASP did well providing specialty appointments to patients. The staff retrieved and scanned
the specialty reports into the medical records timely.
Program Weaknesses — Clinical
• The pharmacy and nursing staff did not always ensure that patients received critical
medications. This problem was evident in the Inter- and Intra-System Transfers, Pharmacy
and Medication Management, and Specialized Medical Housing indicators.
1 Each OIG clinician team includes a board-certified physician and registered nurse consultant with experience in
correctional and community medical settings.
Avenal State Prison, Cycle 5 Medical Inspection Page v
Office of the Inspector General State of California
Compliance Testing Results
Of the 13 health care indicators applicable to ASP, our compliance inspectors2 evaluated ten. Of
these, five were proficient, two were adequate, and three were inadequate. The vast majority of our
compliance testing was of medical care that occurred between December 2016 and August 2017.
There were 86 individual compliance questions within those ten indicators, generating 1,042 data
points that tested ASP’s compliance with California Correctional Health Care Services (CCHCS)
policies and procedures.3 Appendix A — Compliance Test Results provides details for the 86
questions.
Program Strengths — Compliance
The following are some of ASP’s strengths based on its compliance scores on individual questions
in all the health care indicators:
• ASP medical staff did an excellent job of following appropriate policies and procedures
when they admitted patients to the outpatient housing unit (OHU); this performance
included the completion of timely nursing and provider assessments.
• The institution performed well offering and providing preventive medical services to its
patients, including health screening and immunizations.
• ASP did well with some of the inter- and intra-facility transfer processes, including
providing initial health screenings for newly arrived patients and listing pending specialty
appointments for those patients transferring out of the institution.
• Nurses received and reviewed patients' Health Care Services Request forms timely. In
addition, nurses conducted face-to-face triage encounters for all patients sampled within the
required time frames.
• Patients at ASP received their chronic care appointments and hospital discharge follow-up
appointments within the required time frames.
Program Weaknesses — Compliance
The following are some of the weaknesses identified by ASP’s compliance scores on individual
questions in all the health care indicators:
• Clinical staff at ASP did not maintain proper hand hygiene practices during patient
encounters.
2 The OIG’s compliance inspectors are trained registered nurses with expertise in CDCR policies regarding medical
staff and processes.
3 The OIG used its own clinicians to provide clinical expert guidance for testing compliance in certain areas where
CCHCS policies and procedures did not specifically address an issue.
Avenal State Prison, Cycle 5 Medical Inspection Page vi
Office of the Inspector General State of California
• The institution’s medical warehouse did not follow its supply management processes
sufficiently and stored medical supplies beyond the manufacturers’ guidelines.
• Medical clinics at ASP lacked properly calibrated medical equipment and medical supplies
needed to provide standard medical care.
• ASP stored medications beyond the manufacturers’ guidelines in its main pharmacy and
medication line storage locations.
Recommendation
• ASP’s pharmacist in charge (PIC) and chief nurse executive (CNE) should implement
quality improvement measures to adjust their pharmacy and nursing administration
processes and ensure medications are available when patients need them. In this
inspection, the institution did not reliably give needed medications to patients who
transferred from other institutions, returned from the hospital, or needed intravenous
antibiotics.
Population-Based Metrics
In general, ASP performed well as measured by population-based metrics. In comprehensive
diabetes care, ASP outperformed all state and national health care plans in the four of five diabetic
measures; however, ASP scored lower than one health care plan for diabetic eye exams.
Regarding immunization measures, only partial data was available for Pneumococcal
immunizations, and immunizations for the older adult population. ASP scored higher than all other
health care plans for influenza immunizations for younger adults. ASP had the lowest score for all
other health care plans for colorectal cancer screening.
Compared to other health care plans with reported population-based metrics, ASP performed well
in most clinical measures reviewed. The institution may improve its scores for colorectal cancer
screenings by reducing patient refusals through educating patients on the benefits of these
preventive services.
Avenal State Prison, Cycle 5 Medical Inspection Page vii
Office of the Inspector General State of California
This page intentionally left blank.
Avenal State Prison, Cycle 5 Medical Inspection Page viii
Office of the Inspector General State of California
I
NTRODUCTION
Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector
General (OIG) responsibility for oversight of the California Department of Corrections and
Rehabilitation (CDCR), and at the request of the federal Receiver, the OIG developed a
comprehensive medical inspection program to evaluate the delivery of medical care at each of
CDCR’s 35 adult prisons. The OIG conducted a clinical case review and a compliance inspection,
ensuring a thorough, end-to-end assessment of medical care within CDCR.
Avenal State Prison (ASP) was the 24th medical inspection of Cycle 5. During the inspection
process, the OIG assessed the delivery of medical care to patients using the primary clinical health
care indicators applicable to the institution. The Administrative Operations indicator is secondary
because it does not reflect the actual clinical care provided.
ABOUT THE INSTITUTION
Avenal State Prison, located in the city of Avenal in Kings County, opened in 1987. ASP is
designated as a low-medium security institution and currently provides housing for both general
population and sensitive needs yard (SNY) custody inmates; it is comprised of six separate,
semi-autonomous facilities. The institution operates seven clinics where staff members handle
non-urgent requests for medical services, including six facility clinics and one specialty clinic. ASP
also conducts screenings in its receiving and release clinical area; treats patients needing urgent or
emergency care in its triage and treatment area (TTA); and treats patients who require assistance
with the activities of daily living, but who do not require inpatient care, in its outpatient housing
unit (OHU). California Correctional Health Care Services (CCHCS) has designated ASP as a
“basic” care institution. Basic institutions are in rural areas away from tertiary care centers and
specialty care providers whose services would likely be used frequently by higher-risk patients.
Basic institutions have the capability to provide limited specialty medical services and consultation
for a generally healthy inmate population.
On August 17, 2015, the institution received national accreditation from the Commission on
Accreditation for Corrections. This accreditation program is a professional peer review process
based on national standards set by the American Correctional Association.
Based on staffing data the OIG obtained from the institution, ASP’s vacancy rate among medical
managers, primary care providers, supervisors, and rank-and-file nurses was 8 percent in August
2017, with the highest vacancy percentages among primary care providers.
Avenal State Prison, Cycle 5 Medical Inspection Page 1
Office of the Inspector General State of California
ASP Health Care Staffing Resources as of August, 2017
Primary Care Nursing
Management Nursing Staff Totals
Providers Supervisors
Description Number % Number % Number % Number % Number %
Authorized
5 6% 7.5 8% 9.5 10% 68.9 76% 90.9 100%
Positions
Filled
5 100% 6.5 87% 9.5 100% 63 91% 84 92%
Positions
Vacancies 0 0% 1 13% 0 0% 5.9 9% 6.9 8%
Recent
Hires
0 0% 1 15% 3 32% 4 6% 8 10%
(within 12
months)
Staff
Utilized
0 0% 0 0% 0 0% 0 0% 0 0%
from
Registry
Redirected
Staff
(to 0 0% 0 0% 0 0% 0 0% 0 0%
Non-Patient
Care Areas)
Staff on
Extended 0 0% 0 0% 0 0% 1 2% 1 1%
Leave
Note: ASP Health Care Staffing Resources data was not validated by the OIG.
As of August 28, 2017, the Master Registry for ASP showed that the institution had a total
population of 3,784. Within that total population, 0.1 percent were designated as high medical risk,
Priority 1 (High 1), and 0.6 percent were designated as high medical risk, Priority 2 (High 2).
Patients’ assigned risk levels are based on the complexity of their required medical care related to
their specific diagnoses, frequency of higher levels of care, age, and abnormal laboratory tests and
procedures. High 1 has at least two high-risk conditions; High 2 has only one. Patients at high
medical risk are more susceptible to poor health outcomes than those at medium or low medical
risk. Patients at high medical risk also typically require more health care services than do patients
with lower assigned risk levels. The chart below illustrates the breakdown of the institution’s
medical risk levels at the start of the OIG medical inspection.
Avenal State Prison, Cycle 5 Medical Inspection Page 2
Office of the Inspector General State of California
ASP Master Registry Data as of August 28, 2017
Medical Risk Level # of Patients Percentage
High 1 2 0.1%
High 2 22 0.6%
Medium 1,558 41.2%
Low 2,202 58.2%
Total 3,784 100.0%
Avenal State Prison, Cycle 5 Medical Inspection Page 3
Office of the Inspector General State of California
O , S , M
BJECTIVES COPE AND ETHODOLOGY
In designing the medical inspection program, the OIG reviewed CCHCS policies and procedures,
relevant court orders, and guidance developed by the American Correctional Association. The OIG
also reviewed professional literature on correctional medical care; reviewed standardized
performance measures used by the health care industry; consulted with clinical experts; and met
with stakeholders from the court, the Receiver’s office, CDCR, the Office of the Attorney General,
and the Prison Law Office to discuss the nature and scope of the OIG’s inspection program. With
input from these stakeholders, the OIG developed a medical inspection program that evaluates
medical care delivery by combining clinical case reviews of patient files, objective tests of
compliance with policies and procedures, and an analysis of outcomes for certain population-based
metrics.
To maintain a metric-oriented inspection program that evaluates medical care delivery consistently
at each state prison, the OIG identified 15 indicators (14 primary (clinical) indicators and one
secondary (administrative) indicator) of health care to measure. The primary quality indicators
cover clinical categories directly relating to the health care provided to patients, whereas the
secondary quality indicator addresses the administrative functions that support a health care
delivery system. The ASP Executive Summary Table on page iv of this report identifies these
15 indicators.
The OIG rates each of the quality indicators applicable to the institution under inspection based on
case reviews conducted by OIG clinicians and compliance tests conducted by OIG registered
nurses. The case review results alone, the compliance test results alone, or a combination of both
these information sources may influence an indicator’s overall rating. For example, the OIG derives
the ratings for the primary quality indicators Quality of Nursing Performance and Quality of
Provider Performance entirely from the case review done by clinicians, while the ratings for the
primary quality indicators Health Care Environment and Preventive Services are derived entirely
from compliance testing done by registered nurse inspectors. As another example, primary quality
indicators such as Diagnostic Services and Specialty Services receive ratings derived from both
sources.
The OIG does not inspect for efficiency or cost-effectiveness of medical operations. Consistent with
the OIG’s agreement with the Receiver, this report only addresses the quality of CDCR’s medical
operations and its compliance with quality-related policies. Moreover, if the OIG learns of a patient
needing immediate care, the OIG notifies the chief executive officer of health care services and
requests a status report. Additionally, if the OIG learns of significant departures from community
standards, it may report such departures to the institution’s chief executive officer or to CCHCS.
Because these matters involve confidential medical information protected by state and federal
privacy laws, the OIG does not include specific identifying details related to any such cases in the
public report.
Avenal State Prison, Cycle 5 Medical Inspection Page 4
Office of the Inspector General State of California
In all areas, the OIG is alert for opportunities to make appropriate recommendations for
improvement. Such opportunities may be present regardless of the score awarded to any particular
quality indicator; therefore, recommendations for improvement are not necessarily indicative of
deficient medical care delivery.
CASE REVIEWS
The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its
stakeholders, which continues in the Cycle 5 medical inspections. The following exhibit provides
definitions that describe this process.
Exhibit 1. Case Review Definitions
Case = Sample = Patient
An appraisal of the medical care provided to one patient over a specific
period, which can comprise detailed or focused case reviews.
Detailed Case Review
A review that includes all aspects of one patient’s medical care assessed over
a six-month period. This review allows the OIG clinicians to examine many
areas of health care delivery, such as access to care, diagnostic services,
health information management, and specialty services.
Focused Case Review
A review that focuses on one specific aspect of medical care. This review
tends to concentrate on a singular facet of patient care, such as the sick call
process or the institution’s emergency medical response.
Case Review Event
A direct or indirect interaction between the patient and the health care system.
Examples of direct interactions include provider encounters and nurse
encounters. An example of an indirect interaction includes a provider
reviewing a diagnostic test and placing additional orders.
Case Review Deficiency
A medical error in procedure or in clinical judgment. Both procedural and
clinical judgment errors can result in policy non-compliance, elevated risk of
patient harm, or both.
Adverse Deficiency
A medical error that increases the risk of, or results in, serious patient harm.
Most health care organizations refer to these errors as adverse events.
Avenal State Prison, Cycle 5 Medical Inspection Page 5
Office of the Inspector General State of California
The OIG’s clinicians perform a retrospective case review of selected patient files to evaluate the
care given by an institution’s primary care providers and nurses. Retrospective case review is a
well-established review process used by health care organizations that perform peer reviews and
patient death reviews. Currently, CCHCS uses retrospective case review as part of its death review
process and in its pattern-of-practice reviews. CCHCS also uses a more limited form of
retrospective case review when performing appraisals of individual primary care providers.
Patient Selection for Retrospective Case Reviews
Because retrospective case review is time consuming and requires qualified health care
professionals to perform it, the OIG must carefully select a sample of patient records for clinician
review. Accordingly, the group of patients the OIG targeted for case review carried the highest
clinical risk and utilized the majority of medical services. The majority of patients selected for
retrospective case review were high-utilizing patients with chronic care illnesses who were
classified as high or medium risk. The reason the OIG targeted these patients for review is twofold:
1. The goal of retrospective case review is to evaluate all aspects of the health care system.
Statewide, high-risk and high-utilization patients consume medical services at a
disproportionate rate; 11 percent of the total patient population is high-risk and accounts for
more than half of the institution’s pharmaceutical, specialty, community hospital, and
emergency costs.
2. Selecting this target group for case review provides a significantly greater opportunity to
evaluate all the various aspects of the health care delivery system at an institution.
Underlying the choice of high-risk patients for detailed case review, the OIG clinical experts made
the following three assumptions:
1. If the institution is able to provide adequate clinical care to the most challenging patients
with multiple complex and interdependent medical problems, it is more likely to provide
adequate care to patients with less complicated health care issues. Because clinical expertise
is required to determine whether the institution has provided adequate clinical care, the OIG
utilizes experienced correctional physicians and registered nurses to perform this analysis.
2. The health of less complex patients is more likely to be affected by processes such as timely
appointment scheduling, medication management, routine health screening, and
immunizations. To review these processes, the OIG simultaneously performs a broad
compliance review.
3. Patient cases generated during death reviews, sentinel events (unexpected occurrences
involving death or serious injury, or risk thereof), and hospitalizations are more likely to
comprise high-risk patients.
Avenal State Prison, Cycle 5 Medical Inspection Page 6
Office of the Inspector General State of California
Benefits and Limitations of Targeted Subpopulation Review
Because the patients selected utilize the broadest range of services offered by the health care
system, the OIG’s retrospective case review provides adequate data for a qualitative assessment of
the most vital system processes (referred to as “primary quality indicators”). Retrospective case
review provides an accurate qualitative assessment of the relevant primary quality indicators as
applied to the targeted subpopulation of high-risk and high-utilization patients. While this targeted
subpopulation does not represent the prison population as a whole, the institution’s ability
to respond with adequate medical care to this subpopulation is a crucial and vital indicator of how
the institution provides health care to its whole patient population. Simply put, if the institution’s
medical system does not respond adequately for those patients needing the most care, then it is not
fulfilling its obligations, even if it takes good care of patients with less complex medical needs.
Since the targeted subpopulation does not represent the institution’s general prison population, the
OIG cautions against inappropriate extrapolation of medical conditions or outcomes from the
retrospective case reviews to the general population. For example, if the high-risk diabetic patients
reviewed have poorly controlled diabetes, one cannot conclude that all the diabetics’ conditions are
poorly controlled. Similarly, if the high-risk diabetic patients under review have poor outcomes, one
cannot conclude that the entire diabetic population is having similarly poor outcomes. The OIG
does not extrapolate conditions or outcomes, but instead extrapolates the institution’s response for
those patients needing the most care because the response yields valuable system information.
In the above example, if the institution responds by providing appropriate diabetic monitoring,
medication therapy, and specialty referrals for the high-risk patients reviewed, then it is reasonable
to infer that the institution is also responding appropriately to all the diabetics in the prison.
However, if these same high-risk patients needing monitoring, medications, and referrals are not
getting those needed services, it is likely that the institution is not providing appropriate diabetic
services.
Case Review Sampling Methodology
Using a pre-defined case review sampling algorithm, OIG analysts apply various filters to each
institution’s patient population. The various filters include medical risk status, number of
prescriptions, number of specialty appointments, number of clinic appointments, and other
health-related data. The OIG uses these filters to narrow down the population to those patients with
the highest utilization of medical resources (see Chart 1, next page). To prevent selection bias, the
OIG ensures that the same clinicians who perform the case reviews do not participate in the sample
selection process.
Avenal State Prison, Cycle 5 Medical Inspection Page 7
Office of the Inspector General State of California
Chart 1. Case Review Sample Selection
The OIG’s case sample sizes matched those of other qualitative research. The empirical findings,
supported by expert statistical consultants, showed adequate conclusions after 10 to 15 cases had
undergone comprehensive, or detailed, clinician review. In qualitative statistics, this phenomenon is
known as “saturation.” The OIG found the Cycle 4 medical inspection sample size of 30 for
detailed physician reviews far exceeded the saturation point necessary for an adequate qualitative
review. At the end of Cycle 4 inspections, the OIG re-analyzed the case review results using half
the number of cases; there were no significant differences in the ratings. To improve inspection
efficiency while preserving the quality of the inspection, the OIG reduced the number of the
samples for Cycle 5 medical inspections to the current levels. For most basic institutions, the OIG
samples 20 cases for detailed physician review. For intermediate institutions and several basic
institutions with larger high-risk populations, the OIG samples 25 cases. For California Health Care
Facility, the OIG samples 30 cases for detailed physician review.
Breadth of Case Reviews
As indicated in Appendix B, Table B–1: ASP Sample Sets, the OIG clinicians evaluated medical
records for 50 unique patients. Appendix B, Table B–4: ASP Case Review Sample Summary clarifies
that both nurses and physicians reviewed 11 of those cases, for 61 case reviews in total. Physicians
performed detailed reviews of 20 cases, and nurses performed detailed reviews of 13 cases, totaling
Avenal State Prison, Cycle 5 Medical Inspection Page 8
Office of the Inspector General State of California
33 detailed case reviews. For detailed case reviews, physicians or nurses looked at all encounters
occurring in approximately six months of medical care. Nurses and physicians also performed
focused reviews of an additional 28 cases. These reviews generated 580 clinical events for review
(Appendix B, Table B–3: ASP Event—Program).
While the sample method specifically pulled only 4 chronic care patient records, i.e., 4 diabetes
patients (Appendix B, Table B–1: ASP Sample Sets), the 50 unique patients sampled included
patients with 121 chronic care diagnoses, including 2 additional patients with diabetes (for a total of
5) (Appendix B, Table B–2: ASP Chronic Care Diagnoses). The OIG’s sample selection tool
allowed evaluation of many chronic care programs because the complex and high-risk patients
selected from the different categories often had multiple medical problems. While the OIG did not
evaluate every chronic disease or health care staff member, the OIG did assess for adequacy the
overall operation of the institution’s system and staff.
Case Review Testing Methodology
A physician, a nurse consultant, or both clinician inspectors review each case. The OIG clinician
inspector can perform one of two different types of case review: detailed or focused (see Exhibit 1,
page 5, and Chart 1, page 8). As the OIG clinician inspector reviews the medical record for each
sample, the inspector records pertinent interactions between the patient and the health care system.
These interactions are also known as case review events. When an OIG clinician inspector identifies
a medical error, the inspector also records these errors as case review deficiencies. If a deficiency is
of such magnitude that it caused, or had the potential to cause, serious patient harm, then the OIG
clinician records it as an adverse deficiency (see Chart 2, next page).
Avenal State Prison, Cycle 5 Medical Inspection Page 9
Office of the Inspector General State of California
Chart 2. Case Review Testing and Deficiencies
When the OIG clinician inspectors have reviewed all cases, they analyze the deficiencies. OIG
inspectors search for similar types of deficiencies to determine if a repeating pattern of errors
existed. When the same type of error occurs multiple times, the OIG inspectors identify those errors
as findings. When the error is frequent, the likelihood is high that the error is regularly recurring at
the institution. The OIG categorizes and summarizes these deficiencies in one or more health care
quality indicators in this report to help the institution focus on areas for improvement.
Avenal State Prison, Cycle 5 Medical Inspection Page 10
Office of the Inspector General State of California
Additionally, the OIG physicians also rate each of the detailed physician cases for adequacy based
on whether the institution met the patient’s medical needs and if it placed the patient at significant
risk of harm. The cumulative analysis of these cases gives the OIG clinicians additional perspective
to help determine whether the institution is providing adequate medical services or not.4
Based on the collective results of clinicians’ case reviews, the OIG clinicians rated each quality
indicator proficient (excellent), adequate (passing), or inadequate (failing). A separate confidential
ASP Supplemental Medical Inspection Results: Individual Case Review Summaries report details
the case reviews the OIG clinicians conducted and is available to specific stakeholders. For further
details regarding the sampling methodologies and counts, see Appendix B — Clinical Data, Table
B-1; Table B-2; Table B-3; and Table B-4.
4 Regarding individual provider performance, the OIG did not design the medical inspection to be a focused search for
poorly performing providers; rather, the inspection assesses each institution’s systemic health care processes.
Nonetheless, while the OIG does not purposefully sample cases to review each provider at the institution, the cases
usually involve most of the institutions’ providers. Providers should only escape OIG case review if institutional
managers assigned poorly performing providers the care of low-utilizing and low-risk patients, or if the institution had a
relatively high number of providers.
Avenal State Prison, Cycle 5 Medical Inspection Page 11
Office of the Inspector General State of California
COMPLIANCE TESTING
Sampling Methods for Conducting Compliance Testing
Our nurse inspectors attained answers to 86 objective medical inspection test (MIT) questions
designed to assess the institution’s compliance with critical policies and procedures applicable to
the delivery of medical care. To conduct most tests, inspectors randomly selected samples of
patients for whom the testing objectives were applicable and reviewed their electronic unit health
records. In some cases, inspectors used the same samples to conduct more than one test. In total,
inspectors reviewed health records for 381 individual patients and analyzed specific transactions
within their records for evidence that critical events occurred. Inspectors also reviewed management
reports and meeting minutes to assess certain administrative operations. In addition, during the
week of August 28, 2017, field registered nurse inspectors conducted a detailed onsite inspection of
ASP’s medical facilities and clinics; interviewed key institutional employees; and reviewed
employee records, logs, medical appeals, death reports, and other documents. This generated 1,042
scored data points to assess care.
In addition to the scored questions, the OIG obtained information from the institution that it did not
score. This included, for example, information about ASP’s plant infrastructure, protocols for
tracking medical appeals and local operating procedures, and staffing resources.
For details of the compliance results, see Appendix A — Compliance Test Results. For details of the
OIG’s compliance sampling methodology, see Appendix C — Compliance Sampling Methodology.
Scoring of Compliance Testing Results
After compiling the answers to the 86 questions for the ten applicable indicators, the OIG derived a
score for each quality indicator by calculating the percentage score of all Yes answers for each of
the questions applicable to a particular indicator, then averaging those scores. Based on those
results, the OIG assigned a rating to each quality indicator of proficient (greater than 85.0 percent),
adequate (between 75.0 percent and 85.0 percent), or inadequate (less than 75.0 percent).
Avenal State Prison, Cycle 5 Medical Inspection Page 12
Office of the Inspector General State of California
OVERALL QUALITY INDICATOR RATING FOR CASE REVIEWS AND COMPLIANCE
TESTING
The OIG derived the final rating for each quality indicator by combining the ratings from the case
reviews and from the compliance testing, as applicable. When combining these ratings, the case
review evaluations and the compliance testing results usually agreed, but there were instances when
the rating differed for a particular quality indicator. In those instances, the inspection team assessed
the quality indicator based on the collective ratings from both components. Specifically, the OIG
clinicians and registered nurse inspectors discussed the nature of individual exceptions found within
that indicator category and considered the overall effect on the ability of patients to receive
adequate medical care.
To derive an overall assessment rating of the institution’s medical inspection, the OIG evaluated the
various rating categories assigned to each of the quality indicators applicable to the institution,
giving more weight to the rating results of the primary quality indicators, which directly relate to
the health care provided to patients. Based on that analysis, OIG experts made a considered and
measured overall opinion about the quality of health care observed.
POPULATION-BASED METRICS
The OIG identified a subset of Healthcare Effectiveness Data Information Set (HEDIS) measures
applicable to the CDCR patient population. To identify outcomes for ASP, the OIG reviewed some
of the compliance testing results, randomly sampled additional patients’ records, and obtained ASP
data from the CCHCS Master Registry. The OIG compared those results to HEDIS metrics reported
by other statewide and national health care organizations.
Avenal State Prison, Cycle 5 Medical Inspection Page 13
Office of the Inspector General State of California
M I R
EDICAL NSPECTION ESULTS
The OIG’s case review and clinician teams use quality indicators to assess the clinical aspects of
health care. The ASP Executive Summary Table on page iv of this report identifies the 13 indicators
applicable to this institution. The following chart depicts their union and intersection:
Chart 3. Inspection Indicator Review Distribution
The Administrative Operations indicator is a secondary indicator; therefore, the OIG did not rely
upon this indicator when determining the institution’s overall score. Based on the analysis and
results in all the primary indicators, the OIG experts made a considered and measured opinion that
the quality of health care at ASP was adequate.
Summary of Case Review Results: The clinical case review component assessed 10 of the 12
primary (clinical) indicators applicable to ASP. Of these 10 indicators, OIG clinicians rated 5
proficient and 5 adequate.
The OIG physicians rated the overall adequacy of care for each of the 20 detailed case reviews they
conducted. Of these 20 cases, 2 were proficient, 14 were adequate, and 4 were inadequate. In the
580 events reviewed, there were 69 deficiencies, of which 17 were considered to be of such
magnitude that, if left unaddressed, they would likely contribute to patient harm.
Adverse Deficiencies Identified During Case Review: Adverse deficiencies are medical errors
that markedly increased the risk of, or resulted in, serious patient harm. Medical care is a complex
and dynamic process with many moving parts, subject to human error even within the best health
Avenal State Prison, Cycle 5 Medical Inspection Page 14
Office of the Inspector General State of California
care organizations. All major health care organizations typically identify and track adverse
deficiencies for the purpose of quality improvement. Adverse deficiencies are not typically
representative of medical care delivered by the organization. The OIG normally identifies adverse
deficiencies for the dual purposes of quality improvement and the illustration of problematic
patterns of practice found during the inspection. Because of the anecdotal nature of these
deficiencies, the OIG cautions against drawing inappropriate conclusions regarding the institution
based solely on adverse deficiencies.
There were two adverse deficiencies in the case reviews at ASP.
• In case 2, the patient returned from the hospital, but the provider did not address a 19mm
lung nodule, which could have been cancer. By overlooking the findings, the provider
placed the patient at risk of delayed diagnosis and treatment of possible cancer. Fortunately,
ASP addressed the problem after the OIG informed the institution of the situation, and the
nodule was benign. We also discuss this case in the Quality of Provider Performance
indicator.
• In case 22, a provider reviewed several laboratory tests showing high potassium levels and
an electrocardiogram (EKG, a test to measure the heart’s electrical activity) which showed
that the patient was at risk for a dangerous heart rhythm disturbance. When the potassium
rose to a critically high level, the provider did not treat the dangerous potassium levels or
obtain a repeat EKG to determine if the patient needed emergent treatment. These errors
placed the patient at risk of serious complications such as arrhythmia and death. Fortunately,
ASP addressed the problem after the OIG informed the institution of the situation. We also
discuss this case in the Quality of Provider Performance indicator.
Summary of Compliance Results: The compliance component assessed 10 of the 13 indicators
applicable to ASP. Of these ten indicators, OIG inspectors rated five proficient, two adequate, and
three inadequate. We detail the test questions used to assess compliance for each indicator in
Appendix A.
Avenal State Prison, Cycle 5 Medical Inspection Page 15
Office of the Inspector General State of California
ACCESS TO CARE
This indicator evaluates the institution’s ability to provide patients
Case Review Rating:
with timely clinical appointments. OIG inspectors review areas Proficient
specific to patients’ access to care such as initial assessments of Compliance Score:
newly arriving inmates, acute and chronic care follow ups, Proficient
(90.4%)
face-to-face nurse appointments when a patient requests to be seen,
provider referrals from nursing lines, and follow up after Overall Rating:
hospitalization or specialty care. Compliance testing for this indicator Proficient
also evaluates whether patients have Health Care Services Request
forms (CDCR Form 7362) available in their housing units.
Case Review Results
We reviewed 419 provider, nurse, specialty, and hospital events that required a follow-up
appointment and identified 12 deficiencies relating to Access to Care, of which 5 were significant.
The case review rating for Access to Care was proficient.
Provider-to-Provider Follow-up Appointments
Provider-ordered follow-up appointments are important elements of access to care. ASP performed
well with these appointments. We identified only one minor deficiency, and most appointments
occurred timely.
RN Sick Call Access
ASP performed well with sick call access. ASP scheduled most sick call appointments timely.
Nursing sick call appointments had no backlog. We reviewed 52 sick call events and identified only
one minor scheduling delay.
RN-to-Provider Referrals
Sick call nurses assess patients and make referrals to a provider when needed. ASP had difficulty
with scheduling timely RN-to-provider appointments. Of the seven occurrences in which an RN
referred the patient to a provider, we found three deficiencies, two of which were significant:
• In case 15, the RN requested a provider appointment within 14 days to evaluate the patient's
chronic back pain. This appointment did not occur.
• In case 34, the RN requested a provider appointment within 14 days to evaluate the patient’s
arthritic pain. The appointment occurred six weeks later.
Avenal State Prison, Cycle 5 Medical Inspection Page 16
Office of the Inspector General State of California
RN Follow-up Appointments
ASP performed well with scheduling and completing RN appointments generated by providers or
other nurses. Most RN appointments occurred within the time frames specified, and there were only
two minor delays.
Intra-System Transfers
ASP performed well with ensuring timely provider and RN appointments for patients who
transferred in from other CDCR facilities. Of the six patients reviewed who transferred into ASP,
five patients received provider and RN appointments within 30 days. One patient’s appointment
occurred three days late. All pending specialty appointments occurred timely.
Follow-up After Hospitalization
Providers should see patients returning from hospitalization within a time frame that ensures patient
safety and optimal clinical outcomes, but in no case later than five days from the discharge date.
ASP performed well with these appointments. We reviewed 17 hospital returns, and all follow-up
appointments occurred timely.
Specialized Medical Housing
ASP providers completed history and physical examinations timely for all newly admitted
Outpatient Housing Unit (OHU) patients and saw the patients regularly. There were no deficiencies
in this area.
Access to Specialty Services
We found that most specialty appointments took place within the requested time frame. There were
only two deficiencies in this area, one of which was a significant delay:
• In case 48, a provider ordered a follow-up with a lung specialist within two weeks. The
appointment did not occur until one month later.
Provider Follow-up After Specialty Service Visits
Providers should evaluate all patients within 14 days after a routine specialty service visit, or earlier
if indicated. ASP performed well with these appointments, but we identified two significant
deficiencies:
• In case 22, an orthopedic surgeon saw the patient, but the patient did not receive a follow-up
with the primary provider until six weeks later.
• In case 31, after an ophthalmologist saw the patient, there was no follow-up appointment
with the primary provider.
Avenal State Prison, Cycle 5 Medical Inspection Page 17
Office of the Inspector General State of California
Follow-up After Urgent/Emergent Care
ASP performed well scheduling provider follow-ups after TTA events. All appointments occurred
within the specified time frame.
Clinician Onsite Inspection
During the onsite visit, clinic nurses reported seeing about 10 patients each day in the RN clinics,
and providers reported seeing about 14 patients each day. Each of the six clinics had a designated
office technician who attended daily clinic huddles and coordinated with the providers to ensure
that they scheduled important follow-up appointments. Staff reported that there were no provider or
nursing appointment backlogs.
Case Review Conclusion
ASP performed well in the Access to Care indicator. Most provider, nursing, and specialty
appointments occurred timely. We rated ASP proficient in this area.
Compliance Testing Results
The institution earned a proficient compliance score of 90.4 percent in the Access to Care indicator.
The following tests earned scores in the proficient range:
• We reviewed recent appointments for 25 patients with chronic care conditions and found
that 22 (88.0 percent) received timely routine appointments. One patient’s appointment was
five days late, one patient’s appointment was 117 days late, and one patient did not receive a
chronic care appointment at all (MIT 1.001).
• We sampled 30 Health Care Services Request forms (CDCR Form 7362) submitted by
patients across all facility clinics. Nursing staff reviewed all service request forms the same
day they collected them (MIT 1.003). Nursing staff also completed timely face-to-face
triage encounters for all 30 patients (MIT 1.004).
• We sampled 12 health care services request forms on which the nurse referred the patient for
a provider appointment. Eleven (11) patients (91.7 percent) received a timely appointment.
The one exception was a patient for whom there was no evidence that an appointment
occurred at all (MIT 1.005).
• Of the three sampled patients who a nurse referred to and was seen by a provider, and for
whom that provider subsequently ordered a follow-up appointment, all three patients
received their follow-up appointments timely (MIT 1.006).
• Patients had access to health care services request forms at all six housing units we
inspected (MIT 1.101).
Avenal State Prison, Cycle 5 Medical Inspection Page 18
Office of the Inspector General State of California
Three tests earned adequate scores:
• Primary care provider visits timely occurred for 19 of 25 sampled patients who either
transferred into ASP with a pre-existing chronic care condition requiring provider follow-up
or received a new provider referral during intake screening (76.0 percent). For three
patients, appointments occurred 2, 10, and 11 days late. For four patients, appointments
occurred 2 to 46 days late. For the remaining two patients, a provider’s follow up
appointment did not occur at all (MIT 1.002).
• Fourteen of 17 sampled patients who returned from a community hospital (82.4 percent)
received a timely provider follow-up appointment upon their return to ASP. Two patients
received their follow-up appointments one and two days late. For the remaining patient,
there was no evidence that the provider addressed his hospital return (MIT 1.007).
• We sampled 29 patients who received provider-ordered specialty services; 22 of them
(75.9 percent) received a timely follow-up appointment with the provider. Six patients
received follow-up appointments from 2 to 21 days late. One patient’s follow-up
appointment was 72 days late (MIT 1.008).
Avenal State Prison, Cycle 5 Medical Inspection Page 19
Office of the Inspector General State of California
DIAGNOSTIC SERVICES
This indicator addresses whether ASP provided timely radiology and
Case Review Rating:
laboratory services to patients, whether primary care providers Proficient
timely reviewed the results, and whether providers communicated
Compliance Score:
the results to patients within the required time frame. For pathology
Adequate
services, the OIG determines whether the institution received a final
(75.4%)
pathology report and whether the provider timely reviewed and
Overall Rating:
communicated the pathology results to the patient. Case reviews in
Proficient
addition evaluate the appropriateness of the diagnostic test(s) and of
the clinical response to the results.
For this indicator, the case review and compliance review processes yielded different results, with
the case reviewers assigning a proficient rating and the compliance testing resulting in an adequate
score. The main reason for the lower compliance score was that providers did not properly
communicate laboratory and pathology results to their patients. However, the case reviews showed
that while providers did not consistently send result notifications to their patients, they discussed
the results with their patients during their appointments. Because the deficient notification process
did not increase the risk of harm, we determined that the overall rating for this indicator was
proficient.
Case Review Results
We reviewed 56 events in diagnostic services and found only one minor deficiency. The case
review rating of the Diagnostic Services indicator at ASP was proficient.
Test Completion
ASP had an effective laboratory process, completing most laboratory tests timely. ASP also had an
effective diagnostic procedure process, completing most x-rays, ultrasounds, CT scans, and MRI
scans timely. We found no deficiencies.
Health Information Management
Health Information Management timely retrieved and scanned most laboratory reports, diagnostic
procedure reports, and pathology reports into the medical records. We found only one minor
deficiency, a mislabeled diagnostic report.
Clinician Onsite Inspection
Each of the main clinics had an assigned phlebotomist to ensure timely laboratory draws. ASP also
had an effective tracking process to ensure timely diagnostic procedures.
Avenal State Prison, Cycle 5 Medical Inspection Page 20
Office of the Inspector General State of California
Case Review Conclusion
We rated the Diagnostic Services indicator at ASP proficient, finding only one minor deficiency, a
mislabeled diagnostic report. ASP completed laboratory and other diagnostic tests as requested,
retrieving and scanning them timely into the medical record.
Compliance Testing Results
The institution earned an adequate compliance score of 75.4 percent in the Diagnostic Services
indicator, which encompasses radiology, laboratory, and pathology services. For clarity, we discuss
each type of diagnostic service separately below.
Radiology Services
• ASP performed ordered radiology services for all ten patients sampled timely (MIT 2.001).
Providers then timely reviewed the corresponding diagnostic services reports for six of the
ten patients (60.0 percent); providers reviewed one patient’s report three days late. For the
remaining three patients, we found no evidence the providers reviewed their reports
(MIT 2.002). Among the original ten patients sampled, one transferred out of the institution
before the primary care provider could communicate the radiology results. Providers timely
communicated test results to eight of the remaining nine patients (88.9 percent); a provider
communicated one patient’s test result 73 days late (MIT 2.003).
Laboratory Services
• ASP timely performed all ten sampled laboratory services, and providers also reviewed the
resulting reports timely (MIT 2.004, 2.005). Providers communicated the corresponding
laboratory reports timely to only one of the ten patients (10.0 percent). For the remaining
nine patients, the written communications they received from their provider failed to
identify the laboratory tests referenced (MIT 2.006).
Pathology Services
• The institution retrieved the final pathology report timely for nine of ten patients sampled
(90.0 percent). For one patient, the institution received the pathology report 22 days late
(MIT 2.007). Providers then timely reviewed the pathology reports for nine of the ten
patients sampled (90.0 percent). A provider did not review one patient’s final pathology
report (MIT 2.008). Lastly, providers communicated final pathology results timely to only
four of the ten patients sampled (40.0 percent). For three patients, providers communicated
their pathology results one, 25, and 84 days late. For the remaining three patients, providers
did not identify the type of test reported in their written communications (MIT 2.009).
Avenal State Prison, Cycle 5 Medical Inspection Page 21
Office of the Inspector General State of California
EMERGENCY SERVICES
An emergency medical response system is essential to providing
Case Review Rating:
effective and timely emergency medical response, assessment, Proficient
treatment, and transportation 24 hours per day. Provision of
Compliance Score:
urgent/emergent care is based on a patient’s emergency situation,
Not Applicable
clinical condition, and need for a higher level of care. The OIG
Overall Rating:
reviews emergency response services including first aid, basic life
Proficient
support (BLS), and advanced cardiac life support (ACLS) consistent
with the American Heart Association guidelines for cardiopulmonary
resuscitation (CPR) and emergency cardiovascular care, and the provision of services by
knowledgeable staff appropriate to each individual’s training, certification, and authorized scope of
practice.
The OIG evaluates this quality indicator entirely through clinicians’ reviews of case files and
conducts no separate compliance testing element.
Case Review Results
We reviewed 14 cases that yielded 21 urgent/emergent events. There were 11 deficiencies, the
majority of which were nurse documentation deficiencies. Only one of these deficiencies were
significant. The case review rating of the Emergency Services indicator at ASP was proficient.
CPR Response
The CPR response was appropriate in the three cases reviewed. We identified minor documentation
deficiencies related to a late medication entry (case 4) and incomplete documentation of CPR (case
5). These minor deficiencies did not affect patient care.
Provider Performance
ASP providers performed well in emergency services. Providers were readily available and made
appropriate decisions. There were no provider deficiencies. ASP providers effectively utilized
outside diagnostic services before sending patients to community emergency departments.
• In case 20, medical staff sent a patient with abdominal pain to an offsite radiology service,
where a CT scan revealed appendicitis. The patient went from the offsite radiology service
directly to a community hospital for surgical intervention. If the CT scan had been normal,
the patient might have been returned to the institution safely, thus potentially avoiding an
unnecessary emergency room visit. This thoughtfully planned intervention was a good
practice.
Avenal State Prison, Cycle 5 Medical Inspection Page 22
Office of the Inspector General State of California
Nursing Performance
ASP nurses performed well in emergency care. Nursing performance during emergency responses
was suitable and proper. Nurses made timely and accurate patient assessments, interventions, and
reassessments. ASP nurses normally collaborated with the providers to provide good emergency
care. However, there were three nursing assessment deficiencies in the 14 applicable cases
reviewed:
• In case 6, the patient complained of stomach pain, but the nurse did not listen for bowel
sounds or examine the abdomen.
• In case 18, the patient was in the TTA for symptoms of dizziness, nausea, cough, and chills.
Before releasing the patient back to his regular housing unit, the TTA RN did not check to
see if the patient’s symptoms had improved.
• In case 19, the patient re-injured his hand while playing softball. The initial nurse did not
record which hand or fingers were involved and did not record the extent of the laceration.
Nursing Documentation
Nursing documentation was not always complete or appropriate. There were nine deficiencies in
which nurses did not record the full details of the interventions they provided during emergency
response events. These deficiencies included poor documentation of intravenous fluid
administration, full details of CPR, the location of the emergency event, the effectiveness of
medication or treatments, the patient’s condition on TTA discharge, and the description of wounds.
Most of these documentation deficiencies were not significant, except the following:
• In case 5, the TTA nurse did not record important details of the emergency response,
including when staff performed CPR, when the patient began to breathe on his own, whether
there was a pulse, when or how much the nurse gave of a second dose of naloxone
(medication to reverse opioid overdose), or when the paramedics arrived or left with the
patient.
• In case 18, the TTA nurse did not record when the patient arrived in the TTA, whether
breathing treatments were effective, or how much intravenous fluid the nurse gave the
patient.
Emergency Medical Response Review Committee
The Emergency Medical Response Review Committee (EMRRC) was an active working committee
at ASP. Medical and nursing administrative staff reviewed emergency response “codes” daily. The
EMRRC discussed significant clinical issues, environmental issues (such as parking exemptions for
emergency transport vehicles), policy changes and policy reinforcement (such as a policy that
prohibited the use of verbal orders). Clinical managers conducted surprise monthly training drills at
Avenal State Prison, Cycle 5 Medical Inspection Page 23
Office of the Inspector General State of California
different areas throughout the institution. The nursing instructor completed training drill report
summaries that included participants’ comments and suggestions for improvements.
Clinician Onsite Inspection
ASP staffed the TTA appropriately with two nurses assigned during each shift for 24-hour
coverage. The TTA nursing staff was knowledgeable and experienced in emergency procedures.
ASP assigned a provider to the TTA during daytime hours, and on-call providers were available
after hours. The TTA had two beds with sufficient medical supplies and equipment to handle
emergency medical responses. The housing unit custody staff and TTA nursing staff communicated
effectively via radios during emergent events.
Case Review Conclusion
Clinical and custody staff provided effective and timely emergency responses, assessments, and
treatments. Clinical staff made sound decisions based on patients’ clinical conditions, including
chest pain, racing heart rate, loss of consciousness, drug overdose, and physical injury. In most of
the cases, TTA staff provided appropriate assessments, interventions, and monitoring during
emergency medical responses. While ASP nurses could improve with their consistency in making
good assessments and recording accurate documentation, the ASP providers consistently made
good decisions and they were able to mitigate the errors successfully. We rated the Emergency
Services indicator at ASP proficient.
Avenal State Prison, Cycle 5 Medical Inspection Page 24
Office of the Inspector General State of California
HEALTH INFORMATION MANAGEMENT
Health information management is a crucial link in delivering
Case Review Rating:
medical care. Medical personnel require accurate information in Proficient
order to make sound judgments and decisions. This indicator Compliance Score:
examines whether the institution adequately manages its health care Inadequate
(72.9%)
information. This includes determining whether the information is
correctly labeled, organized, and available in the electronic health Overall Rating:
record system (EHRS); whether the various medical records (internal Adequate
and external, e.g., hospital and specialty reports and progress notes)
are obtained and scanned timely into the EHRS; whether records routed to clinicians include legible
signatures or stamps; and whether hospital discharge reports include key elements and are timely
reviewed by providers.
For this indicator, the case review and compliance review processes yielded different results, with
the case reviewers assigning a proficient rating and the compliance testing resulting in an
inadequate score. The main reason for the inadequate score was that ASP had problems with
mislabeled and misfiled documents as well as difficulty with retrieving outside hospital discharge
summaries and ensuring prompt provider review. The processing of hospital discharge summaries
is a key component of good patient care, and ASP can improve substantially in that area. We
determined that the most appropriate rating for this indicator was adequate.
Case Review Results
During the Cycle 5 case review, we reviewed 580 clinical events and identified three health
information management deficiencies, only one of which was significant. The case review rating of
the Health Information Management indicator was proficient.
Interdepartmental Transmission
We did not identify any problems when staff transmitted health information between departments
within the institution.
Hospital Records
We reviewed 17 offsite emergency department and hospital visits. ASP timely retrieved, reviewed,
and scanned hospital records into the medical record. There was one significant deficiency:
• In case 4, after the patient returned from an emergency department visit, ASP did not scan
the hospital report into the medical record until 11 months later.
Avenal State Prison, Cycle 5 Medical Inspection Page 25
Office of the Inspector General State of California
Missing Documents (Progress Notes and Forms)
ASP scanned most nursing and provider progress notes into the medical record. We identified only
two minor deficiencies related to missing provider orders.
Laboratory, Diagnostic, and Pathology Reports
ASP retrieved and scanned laboratory results, diagnostic procedure reports, and pathology reports
into the medical records. There were no deficiencies.
Specialty Services Reports
ASP timely retrieved and scanned specialty services reports into the medical record. We identified
no deficiencies.
Legibility
Providers and nurses dictated most progress notes, which increases legibility.
Scanning Performance
ASP timely scanned and correctly labeled most documents. We identified one minor deficiency
related to a mislabeled diagnostic report.
Clinician Onsite Inspection
ASP medical record staff retrieved and scanned medical records as soon as they received them.
ASP staff filed X-ray, ultrasound, CT scan, MRI scan, and bone scan reports in a separate database;
nevertheless, providers reviewed the reports and acknowledged them in their progress notes.
Case Review Conclusion
We identified only rare health information deficiencies in the case reviews and rated the Health
Information Management indicator proficient.
Compliance Testing Results
The institution received an inadequate compliance score of 72.9 percent in this indicator, with the
following two tests showing room for improvement:
• ASP scored 33.3 percent in its labeling and filing of documents scanned into patients’
electronic medical records. For this test, once we identify 24 mislabeled or misfiled
documents, we deduct the maximum points, and the resulting score is zero. During this
inspection, ASP mislabeled 16 documents (MIT 4.006).
• Among 17 sampled patients admitted to a community hospital and then returned to the
institution, ASP’s providers timely reviewed only nine corresponding hospital discharge
Avenal State Prison, Cycle 5 Medical Inspection Page 26
Office of the Inspector General State of California
reports within three calendar days of the discharge date (52.9 percent). Providers reviewed
four reports either one or two days late and reviewed one other report 23 days late. A
provider did not review another report at all. For yet another report, the provider initialed
and dated the first page of the hospital packet but did not evidence review by initialing and
dating the actual hospital discharge report. For the final patient, we found no evidence of the
hospital discharge documents in the electronic medical record (MIT 4.007).
Two tests received adequate scores:
• Staff scanned 16 of 20 specialty service consultant reports into the patients’ electronic
medical records within five calendar days (80.0 percent). However, four documents were
scanned two to four days late (MIT 4.003).
• ASP timely scanned 13 of the 16 sampled community hospital discharge reports or
treatment records into patients’ electronic medical records (81.3 percent); three reports were
scanned 2 to 22 days late (MIT 4.004).
Two tests received proficient scores:
• The institution timely scanned nine of ten sampled non-dictated health care documents (90.0
percent) into patients’ electronic medical records. One non-dictated health care document
was scanned one day late (MIT 4.001).
• ASP scored 100 percent for scanning the one applicable dictated or transcribed provider
progress note into the Electronic Unit Health Record (eUHR) timely (MIT 4.002).
Avenal State Prison, Cycle 5 Medical Inspection Page 27
Office of the Inspector General State of California
HEALTH CARE ENVIRONMENT
This indicator addresses the general operational aspects of the
Case Review Rating:
prison’s clinics, including certain elements of infection control and Not Applicable
sanitation, medical supplies and equipment management, availability Compliance Score:
of auditory and visual privacy for inmate-patient visits, and the Inadequate
(52.3%)
adequacy of facility infrastructure for conducting comprehensive
medical examinations. For most institutions, the rating for this Overall Rating:
component relies entirely on compliance testing results from the Inadequate
visual observations that inspectors make during on-site visits.
Compliance Testing Results
The institution received an inadequate compliance score of 52.3 percent in the Health Care
Environment indicator, showing room for improvement in the following areas:
• We observed clinician encounters with patients in nine clinics. Clinicians followed good
hand hygiene practices in only two clinic locations (22.2 percent). At seven clinic locations,
clinicians failed to wash their hands before or after patient contact or before applying gloves
(MIT 5.104).
• The non-clinic bulk medical supply
storage areas did not follow the
supply management process and
did not support the needs of the
health care program, resulting in a
score of zero for this test. We
noted the following deficiencies:
managers expressed concern that
crash cart medical supplies were
still pending receipt after ordering
them several months prior, and we
Figure 1: Expired medical supplies (these electrodes
found medical supplies that were
expired more than a year before the inspection)
kept beyond manufacturers’
guidelines (Figure 1) and stored directly on the floor (MIT 5.106).
• Only two of the ten clinics inspected followed adequate medical supply storage and
management protocols (20.0 percent). We found eight clinics had one or more of the
following deficiencies: staff reported that there was no system in place to replenish medical
supplies on a regular basis; clinics stored medical supplies beyond manufacturers’
guidelines; and medical supplies were not clearly identifiable (MIT 5.107).
Avenal State Prison, Cycle 5 Medical Inspection Page 28
Office of the Inspector General State of California
• Only four of the ten clinic locations (40.0 percent) met compliance requirements for
essential core medical equipment and supplies. The remaining six clinics were missing one
or more functional pieces of properly calibrated core equipment or other medical supplies
necessary to conduct a comprehensive exam. The missing items included an exam table, an
oto-ophthalmoscope, a sharps container, lubricating jelly, and tongue depressors. In
addition, several digital thermometers did not have calibration stickers or had expired
calibration stickers (MIT 5.108).
• Only two of nine clinic exam rooms we observed (22.2 percent) had appropriate space,
configuration, supplies, and equipment to allow clinicians to perform a proper clinical
examination. The remaining seven clinics had one or more of the following deficiencies:
exam rooms did not have a portable screen available for visual privacy; clinicians have
impeded access to an examination table; and staff stored personal belongings in the same
area with exam room supplies (MIT 5.110).
• We examined emergency response bags
(EMRBs) to determine if staff inspected
the bags daily and inventoried them
monthly, and whether they contained all
essential items. EMRBs were compliant in
only one of the eight applicable clinical
locations (12.5 percent). We found one or
more of the following deficiencies at
seven locations: staff had failed to
inventory the EMRB within the last 30
days; staff failed to verify that the bag’s
compartments were sealed and intact;
several EMRBs were missing oxygen tank
Figure 2: EMRB missing oxygen
wrenches (Figure 2) needed for the operation tank wrenches needed for operation
of the oxygen tanks; and the crash cart was
missing minimum levels of the medical supplies (MIT 5.111).
One test scored in the adequate range:
• Clinic staff appropriately disinfected, cleaned, and sanitized eight of the ten clinics
examined (80.0 percent). Clinic staff did not properly maintain the remaining two clinics;
we found filled trash bins that staff had not emptied the day prior (MIT 5.101).
Four tests earned proficient scores:
• Clinical health care staff at eight of the nine applicable clinics (88.9 percent) ensured that
they properly sterilized or disinfected reusable invasive and non-invasive medical
Avenal State Prison, Cycle 5 Medical Inspection Page 29
Office of the Inspector General State of California
equipment. Clinical staff in one clinic failed to mention disinfecting the examination table
before the start of shift as part of their daily start-up protocol (MIT 5.102).
• We examined ASP’s ten clinics to verify that adequate hygiene supplies were present and
sinks were operable; all clinics were compliant (MIT 5.103).
• When inspecting for proper protocols to mitigate exposure to blood-borne pathogens and
contaminated waste, we found nine of the ten clinics (90.0 percent) compliant. In one clinic,
we found the sharps container inaccessible at the time of inspection (MIT 5.105).
• All ten clinics had an environment conducive to providing medical services (MIT 5.109).
Non-Scored Results
We gathered information to determine if the staff maintained the institution’s physical infrastructure
in a manner that supported health care management’s ability to provide timely or adequate health
care. We did not score this question. When we interviewed health care managers, they did not have
concerns about the facility’s infrastructure or its effect on the staff’s ability to provide adequate
health care. At the time of inspection, ASP did not have any infrastructure projects (MIT 5.999).
Avenal State Prison, Cycle 5 Medical Inspection Page 30
Office of the Inspector General State of California
INTER- AND INTRA-SYSTEM TRANSFERS
This indicator focuses on the management of patients’ medical needs
Case Review Rating:
and continuity of patient care during the inter- and intra-facility Adequate
transfer process. The patients reviewed for Inter- and Intra-System Compliance Score:
Transfers include inmates received from other CDCR facilities and Proficient
(91.4%)
inmates transferring out of Avenal State Prison to another CDCR
facility. The OIG review includes evaluation of the institution’s Overall Rating:
ability to provide and document health screening assessments, Adequate
initiation of relevant referrals based on patient needs, and the
continuity of medication delivery to patients arriving from another institution. For those patients,
the OIG clinicians also review the timely completion of pending health appointments, tests, and
requests for specialty services. For patients who transfer out of the facility, the OIG evaluates the
institution’s documentation of transfer information that should include preexisting health
conditions, pending appointments, tests and requests for specialty services, medication transfer
packages, and medication administration prior to transfer. OIG clinicians also evaluate the care
provided to patients returning to the institution from an outside hospital and assess whether the
implementation of the hospital assessment and treatment plans was appropriate.
For this indicator, the case review and compliance review processes yielded different results, with
the case reviewers assigning an adequate rating and the compliance testing resulting in a proficient
score. After in-depth analysis of the compliance data across various indicators, we determined that
the proficient score was not representative of ASP’s transfer performance. Although our
compliance testing methodology resulted in a proficient score, pertinent compliance tests found in
other indicators revealed that ASP had room for improvement in several critical areas: ensuring
timely provider follow-ups after hospitalization, retrieving and reviewing hospital discharge
summaries, and maintaining medication continuity for patients returning from the hospital or
transferring from another CDCR institution. Considering all the relevant case review and
compliance factors, we determined the rating for this indicator was adequate.
Case Review Results
We reviewed 15 cases requiring outside hospitalization and emergency room events, 6 cases in
which patients arrived from other CDCR institutions, and 9 cases in which patients transferred out
to other institutions. These reviews resulted in 52 events related to the inter and intra-system
transfer processes. There were eight deficiencies, three of which were significant. Computer system
issues caused breaks in medication continuity in two of these cases. The case review rating of the
Inter- and Intra-System Transfers indicator at ASP was adequate.
Transfers In
The nurses at ASP performed thorough screening examinations for the six newly-arrived patients
we reviewed. Nurses asked their patients if they had any current medical complaints and explained
Avenal State Prison, Cycle 5 Medical Inspection Page 31
Office of the Inspector General State of California
how to request health services. LVNs evaluated new chronic care patients timely and provided
written information relevant to their medications and diagnoses. While nurses usually performed
appropriate screening, there was one case in which the nurse did not:
• In case 24, the R&R nurse did not assess the diabetic patient’s vital signs and blood glucose
level upon the patient’s arrival at ASP. The nurse noted the patient was high-priority for
medical provider assessment but scheduled the patient for a 30-day follow-up appointment
instead of the policy-required 7-day appointment.
Medication administration records revealed that patients normally received their medications
without lapses, but two cases demonstrated significant exceptions. In cases 2 and 25, computer
problems caused significant lapses in the administration of essential medications. These patients did
not receive medications timely for blood pressure, depression, anxiety, and valley fever. In both
cases, the R&R nurses did not use the established procedures to reconcile and ensure continuity of
medications for transferring patients when the electronic medical records system was “down,” or
not working.
• In case 2, the patient received his prescribed medications three days late.
• In case 25, the patient did not receive his antihypertensive and antifungal medications for
two weeks.
Transfers Out
Case reviewers evaluated nine cases in which ASP transferred patients to other institutions. ASP
performed very well in this area; there were no deficiencies. Nurses diligently recorded necessary
medical equipment, such as canes, walkers, and hearing-impaired vests in their documentation.
Nurses also noted that their patients’ medical conditions were stable before transfer out. Nurses
conscientiously recorded all current medications and gave their patients a five-day supply of
medications before transfers.
Nurses ensured communication of pending specialty appointments to receiving institutions. For
example, a nurse sent an email to the receiving institution concerning a pending general surgery
appointment for evaluating a scalp lesion. Nurses also informed the receiving institution of pending
vaccinations.
Hospitalizations
Patients returning from hospitalizations are some of the highest-risk encounters due to two factors.
First, these patients usually require hospitalization for a severe illness or injury, and second, they
are at risk due to potential lapses in care that can occur during any transfer.
ASP performed well in this area. Nurses in the TTA scheduled timely follow-up appointments for
patients returning from hospitalizations or emergency room visits and consulted with the providers
after reviewing hospital discharge recommendations. ASP timely retrieved, reviewed, and scanned
Avenal State Prison, Cycle 5 Medical Inspection Page 32
Office of the Inspector General State of California
hospital records into the medical record. However, there was one significant deficiency related to
delayed scanning of a hospital record:
• In case 4, the patient returned from an emergency department visit because of loss of
consciousness. ASP did not scan the hospital report into the medical record until 11 months
later.
Clinician Onsite Inspection
TTA nurses assessed all patients who returned from hospitalizations. They provided appropriate
verbal instructions and written materials to educate patients and gave patients the opportunity to
discuss and ask questions. The receiving and release nurses were knowledgeable about their job
duties and the transfer process.
Case Review Conclusion
ASP performed sufficiently regarding the Inter- and Intra-System Transfers indicator, but the
institution had some difficulty maintaining medication continuity for patients transferring in from
other CDCR institutions. The case review rating of this indicator was adequate.
Compliance Testing Results
The institution earned a proficient compliance score of 91.4 percent in the Inter- and Intra-System
Transfers indicator, with the following tests scoring in the proficient range:
• For 22 of 25 sampled patients who transferred into ASP from other CDCR institutions
(88.0 percent), nursing staff completed an Initial Health Screening (CDCR Form 7277) on
the same day the patient arrived. For one patient, nursing staff neglected to record an answer
for one of the screening questions. For another patient, nursing staff did not explain an
affirmative answer to one of the screening questions. For one final patient, nursing staff did
not document a complete set of vital signs (MIT 6.001).
• Nursing staff timely completed the assessment and disposition section of the screening form
for all 25 patients sampled (MIT 6.002).
• We inspected the transfer packet of one patient who was transferred out of the facility and
determined that the packet included required medications and support documentation
(MIT 6.101).
• We sampled seven patients who transferred from ASP to other CDCR institutions to
determine whether staff at ASP listed their scheduled specialty service appointments on the
Health Care Transfer Information form (CDCR Form 7371). Nursing staff documented
previously approved and pending specialty service appointments for six patients but failed
to do so for one other (85.7 percent) (MIT 6.004).
Avenal State Prison, Cycle 5 Medical Inspection Page 33
Office of the Inspector General State of California
The institution received an adequate score on one test:
• Among 12 applicable patients sampled who transferred into ASP from other CDCR
institutions with an existing medication order, 10 patients received their medications
without interruption (83.3 percent). One patient missed one dose of a directly observed
therapy (DOT) medication; the other patient incurred a one-week interruption of a keep-on-
person (KOP) medication (MIT 6.003).
Avenal State Prison, Cycle 5 Medical Inspection Page 34
Office of the Inspector General State of California
PHARMACY AND MEDICATION MANAGEMENT
This indicator evaluates the institution’s ability to provide
Case Review Rating:
appropriate pharmaceutical administration and security management, Adequate
encompassing the process from the written prescription to the Compliance Score:
medication administration. By combining both a quantitative Inadequate
(65.5%)
compliance test with case review analysis, this assessment identifies
issues in various stages of the medication management process, Overall Rating:
including ordering and prescribing, transcribing and verifying, Inadequate
dispensing and delivering, administering, and documenting and
reporting. Because effective medication management is affected by numerous entities across
various departments, this assessment considers internal review and approval processes, pharmacy,
nursing, health information systems, custody processes, and actions taken by the prescriber, staff,
and patient.
For this indicator, the case review and compliance review processes yielded different results, with
the case reviewers assigning an adequate rating and the compliance testing resulting in an
inadequate score. The main reason for the inadequate score was that ASP had severe problems with
two compliance sub-indicators: Observed Medication Practices and Storage Controls; and
Pharmacy Protocols, both of which received inadequate scores. We determined that the most
appropriate rating for this indicator was inadequate.
Case Review Results
We evaluated 26 events related to medications and found 6 deficiencies, 4 of which were
significant. The case review rating for this indicator was adequate.
Medication Continuity
There were two significant deficiencies related to lapses in medication continuity for newly arrived
patients. The Inter- and Intra-System Transfers indicator discusses those deficiencies.
Medication Administration
Nursing staff accurately and timely administered prescribed KOP and nurse-administered
medications.
Pharmacy Availability of Medications
ASP pharmacy staff did not always ensure that essential medications such as antibiotics, seizure
medications, and blood pressure medications were available. There was one significant deficiency:
• In case 50, the provider ordered an important blood thinner to prevent blood clots after the
patient sustained a leg fracture. The institution did not provide the blood thinner for two
days.
Avenal State Prison, Cycle 5 Medical Inspection Page 35
Office of the Inspector General State of California
• In case 52, medical staff prescribed the patient intravenous antibiotics for a jaw infection.
The patient did not receive the medication for one day because the antibiotic was not
available, placing the patient at risk for undertreated infection.
Clinician Onsite Inspection
During the onsite visit, the patient care teams discussed medication issues in the morning huddles.
Staff discussed patients that refused their medications while the pharmacist advised providers of
expiring medications that needed to be renewed.
Case Review Conclusion
ASP performed acceptably regarding Pharmacy and Medication Management, though there was
room for improvement with medication continuity for newly-arrived patients and the availability of
essential medications. The case review rating for this indicator was adequate.
Compliance Testing Results
The institution received an inadequate compliance score of 65.5 percent in the Pharmacy and
Medication Management indicator. For discussion purposes below, we divide this indicator into
three sub-indicators: medication administration, observed medication practices and storage controls,
and pharmacy protocols.
Medication Administration
In this sub-indicator, the institution received a proficient score of 87.7 percent. The following two
tests earned scores in the proficient range:
• ASP ensured that all 25 patients sampled who transferred from one housing unit to another
received their ordered medications without interruption (MIT 7.005).
• We found that 23 of 25 patients sampled (92.0 percent) timely received their newly ordered
medication. For one patient, nursing staff administered his medication one day late, and for
the other, nursing staff did not document a reason for the patient’s refusal of his medication
(MIT 7.002).
The following two tests earned scores in the adequate range:
• Clinical staff timely provided new and previously prescribed medications to 13 of 17
patients who returned from a community hospital (76.5 percent). Three patients received
their ordered medications one to two days late. One other patient never received his ordered
nurse-administered medication (MIT 7.003).
Avenal State Prison, Cycle 5 Medical Inspection Page 36
Office of the Inspector General State of California
• Among 17 sampled patients, 14 (82.4 percent) timely received their ordered chronic care
medications. Three patients received multiple supplies of their chronic care medications
within a shorter than normal replenishment period (MIT 7.001).
Observed Medication Practices and Storage Controls
In this sub-indicator, the institution received an inadequate score of 65.8 percent. Three of the six
tests in the sub-indicator received inadequate scores, as follows:
• ASP safely stored non-refrigerated, non-narcotic medications in two of the ten applicable
clinic and medication line storage locations (20.0 percent). In eight locations, we identified
one or more of the following deficiencies: the medication area lacked a designated area for
return-to-pharmacy medications; external and internal medications were not properly
separated when stored; medication storage areas were unlocked; multi-use medication was
not labeled with the date it was opened; and a personal food item was stored in the same
area as medications (MIT 7.102).
• ASP safely stored refrigerated, non-narcotic medications in two of eight applicable clinics
and medication line storage locations (25.0 percent). In six locations, we identified one or
more of the following deficiencies: the medication area lacked a designated area for return-
to-pharmacy refrigerated medications; staff did not complete temperature logbooks; staff did
not label previously opened multi-dose medications with the date they were first opened;
and clinics stored medications beyond manufacturers’ guidelines (MIT 7.103).
• We interviewed nursing staff and inspected narcotics storage areas at applicable clinic and
pill line locations to assess narcotics security controls. Nursing staff implemented strong
medication security controls over narcotic medications in six of nine locations
(66.7 percent). In two clinics, two licensed nursing staff did not perform a controlled
substance inventory on multiple dates. In another clinic, a licensed nurse did not counter-
sign the narcotics log for the disposal of a controlled substance (MIT 7.101).
One test in this sub-indicator earned an adequate score:
• We observed the medication preparation and administration processes at six applicable
medication line locations. The nursing staff was compliant regarding proper hand hygiene
and contamination control protocols at five locations (83.3 percent). At one location, the
medication nurse did not wash or sanitize hands before administering medications
(MIT 7.104).
Two tests earned proficient scores:
• Nursing staff at all six of the applicable inspected medication line locations employed
appropriate administrative controls and followed appropriate protocols during medication
preparation (MIT 7.105).
Avenal State Prison, Cycle 5 Medical Inspection Page 37
Office of the Inspector General State of California
• In all six medication areas, ASP employed appropriate administrative controls and protocols
when their staff distributed medications to their patients (MIT 7.106).
Pharmacy Protocols
In this sub-indicator, the institution received an inadequate score of 47.2 percent. All three tests in
this sub-indicator received inadequate scores, as follows:
• In its main pharmacy, ASP did not safely store non-refrigerated medications. The main
pharmacy stored these medications beyond the manufacturers’ guidelines (MIT 7.108).
• The institution’s pharmacist in charge (PIC) did not properly account for narcotic
medications stored in ASP’s pharmacy or review monthly inventories of controlled
substances in the institution’s clinical and medication line storage locations, resulting in a
score of zero on this test. We identified the following deficiencies: staff did not inventory all
controlled substances in the pharmacy monthly; staff responsible for completing the
medication area inspection checklist (CDCR Form 7477) did not document the results on the
form; and the PIC did not properly complete several Form 7477s and had missed names,
signatures, or dates on each inventory record (MIT 7.110).
• We examined 25 medication error follow-up reports. Only 9 of the PIC’s 25 reports were
timely or correctly processed (36.0 percent). The medication error statistical reports for
September 2016, October 2016, and June 2017 were submitted to the chief of pharmacy
services two to three business days late, accounting for 15 of the untimely reports. For the
last report, the packet was missing the medication error follow-up review form (CDCR Form
7541) (MIT 7.111).
Two tests in this sub-indicator warned proficient scores:
• In its main pharmacy, the institution followed general security, organization, and cleanliness
management protocols and safely stored and monitored medications that required
refrigeration (MIT 7.107, 7.109).
Non-Scored Tests
In addition to our testing of reported medication errors, we follow up on any significant medication
errors that were found during compliance testing to determine whether the institution properly
identified and reported the errors. We provide these results for information purposes only. At ASP,
we did not find any applicable medication errors, and ASP did not have any patients in
administrative segregation (MIT 7.998, 7.999).
Avenal State Prison, Cycle 5 Medical Inspection Page 38
Office of the Inspector General State of California
PRENATAL AND POST-DELIVERY SERVICES
This indicator evaluates the institution’s capacity to provide timely
Case Review Rating:
and appropriate prenatal, delivery, and postnatal services to pregnant
Not Applicable
patients. This includes the ordering and monitoring of indicated
Compliance Score:
screening tests, follow-up visits, referrals to higher levels of care,
Not Applicable
e.g., high-risk obstetrics clinic, when necessary, and postnatal
Overall Rating:
follow-up.
Not Applicable
As ASP does not have female patients, this indicator does not apply.
Avenal State Prison, Cycle 5 Medical Inspection Page 39
Office of the Inspector General State of California
PREVENTIVE SERVICES
This indicator assesses whether the institution offered or provided
Case Review Rating:
various preventive medical services to patients. These include cancer Not Applicable
screenings, tuberculosis screenings, and influenza and chronic care Compliance Score:
immunizations. This indicator also assesses whether certain Proficient
(93.8%)
institutions take preventive actions to relocate patients identified as
being at higher risk for contracting coccidioidomycosis Overall Rating:
(valley fever). Proficient
The OIG rates this indicator entirely through the compliance testing component; the case review
process does not include a separate qualitative analysis for this indicator.
Compliance Testing Results
The institution scored in the proficient range in this indicator with a compliance score of
93.8 percent. Six of the seven applicable tests scored in the proficient range:
• All 12 patients sampled received their ordered doses of tuberculosis (TB) medications in the
most recent three-month period reviewed (MIT 9.001).
• All 12 patients sampled taking TB medications received required monthly or weekly
monitoring timely (MIT 9.002).
• ASP timely administered or offered influenza vaccinations during the most recent influenza
season to all 25 patients sampled (MIT 9.004).
• ASP offered colorectal cancer screenings to all 25 sampled patients subject to the annual
screening requirement (MIT 9.005).
• We tested whether ASP offered patients who suffered from a chronic care condition the
required vaccinations for influenza, pneumonia, and hepatitis. The institution timely offered
vaccinations to all ten applicable sampled patients (MIT 9.008).
• We tested 20 patients identified as medically restricted and ineligible to reside at ASP due to
their elevated risk for contracting valley fever to determine if they transferred out of the
institution within 60 days of their ineligibility. We found that ASP timely transferred 18 of
those 20 patients (90.0 percent). ASP transferred one patient three days late; one other
patient remained housed at ASP for over 124 days by the time of OIG’s inspection
(MIT 9.009).
Avenal State Prison, Cycle 5 Medical Inspection Page 40
Office of the Inspector General State of California
One test received an inadequate score:
• We sampled 30 patients to determine whether those patients received TB screenings within
the last year and during their birth month as CCHCS policy requires. Of the 30 patients
sampled, 20 received their TB screening as required (66.7 percent). While the remaining ten
patients did receive TB screening within the last year, their screenings did not occur during
their birth month (MIT 9.003).
Avenal State Prison, Cycle 5 Medical Inspection Page 41
Office of the Inspector General State of California
QUALITY OF NURSING PERFORMANCE
The Quality of Nursing Performance indicator is a qualitative
Case Review Rating:
evaluation of the institution’s nursing services. The evaluation is
Adequate
completed entirely by OIG nursing clinicians within the case review
Compliance Score:
process, and, therefore, does not have a score under the compliance
Not Applicable
testing component. OIG nurses conduct case reviews that include
Overall Rating:
reviewing face-to-face encounters related to nursing sick call
Adequate
requests identified on the Health Care Services Request form, urgent
walk-in visits, referrals for medical services by custody staff, RN
case management, RN utilization management, clinical encounters by licensed vocational nurses
(LVNs) and licensed psychiatric technicians (LPTs), and any other nursing service performed on an
outpatient basis. The OIG case review also includes activities and processes performed by nursing
staff that are not considered direct patient encounters, such as the initial receipt and review of sick
call requests and follow-up with primary care providers and other staff on behalf of the patient. Key
focus areas for evaluation of outpatient nursing care include appropriateness and timeliness of
patient triage and assessment, identification and prioritization of health care needs, use of the
nursing process to implement interventions including patient education and referrals, and
documentation that is accurate, thorough, and legible. Nursing services provided in the outpatient
housing unit (OHU), correctional treatment center (CTC), or other inpatient units are reported under
the Specialized Medical Housing indicator. Nursing services provided in the triage and treatment
area (TTA) or related to emergency medical responses are reported under the Emergency Services
indicator.
Case Review Results
We reviewed 238 nursing encounters, 115 of which were in the outpatient setting. Most outpatient
nursing encounters were for sick call requests, walk-in visits, and RN follow-up visits. In all, there
were 32 deficiencies identified in nursing care performance, 2 of which were significant. The
Quality of Nursing Performance indicator at ASP was adequate.
Nursing Assessment
Although nurses at ASP usually evaluated patients appropriately by including both subjective
(patient interview) and objective (physical findings) assessments, some nurses often did not
perform focused assessments of patients’ complaints or reassess abnormal findings. We identified
examples of these findings in cases 6, 13, 17, 18, 20, 24, 42, and the following:
• In case 15, the patient reported “issues with walking” and numbness. The sick call nurse did
not evaluate the patient’s gait.
Avenal State Prison, Cycle 5 Medical Inspection Page 42
Office of the Inspector General State of California
• In case 19, the patient underwent surgery two weeks previously, and he reported constant
shoulder pain and numbness in three fingers since the surgery. The sick call nurse did not
evaluate the range of motion in the patient’s shoulder.
• In case 47, the patient reported difficulty swallowing. The sick call nurse did not ask the
patient about throat pain or the ability to swallow food and fluids and did not examine the
patient’s tongue, throat, or lymph nodes.
Nursing Intervention
When a nurse assesses a patient appropriately, the nurse should implement appropriate
interventions for the patient. There were some occasions in which nurses did not inform or consult
with a provider when needed or did not carry out providers’ orders. These errors occurred in cases
2, 35, 51, and the following:
• In case 35, the patient began to have joint pain and was worried that his valley fever illness
was returning. The nurse gave the patient ibuprofen but failed to notify or refer the patient to
a provider.
• In case 44, the TTA nurse evaluated the patient for a painful and swollen calf. The patient
reported pain for about a month, and his right calf was slightly larger in diameter than the
left calf. A doppler scan revealed good blood flow, but the patient needed additional
evaluation to rule out the possibility of a dangerous blood clot. The TTA nurse referred the
patient for follow-up with the clinic sick call nurse within three days, but should have
referred the patient to the TTA provider the same day or the clinic provider the following
day.
• In case 45, the patient had a toe wound, and the provider ordered daily wound checks and
dressing changes for two weeks. Nurses completed wound checks and dressing changes only
twice during that two-week period.
Nursing Documentation
Most nursing documentation in reviewed cases was sufficiently accurate and complete. For
example, OHU nursing documentation generally included thorough physical assessments,
descriptive characteristics of wounds, changes in patient status, medication compliance, provider
contacts, and subjective information directly from the patient. Nonetheless, ASP nurses often did
not record their medical care correctly. Documentation deficiencies occurred in cases 1, 5, 18, 29,
30, 34, 45, 51, and the following:
• In case 6, the first medical responder did not document the location of the emergency
medical response.
Avenal State Prison, Cycle 5 Medical Inspection Page 43
Office of the Inspector General State of California
• In case 19, the LVN saw the patient in the clinic with a laceration on his hand. The LVN did
not identify which hand had the laceration, the size or appearance of the laceration, or
mention that the LVN sent the patient to the TTA. Medical staff subsequently sent the
patient to the community hospital emergency department for laceration repair.
• In case 34, the patient requested a steroid injection for hand pain. The sick call nurse did not
contact the patient or record the intended treatment plan, the referral plan, or any other
acknowledgment of the patient’s request. Although the nurse recorded no documentation,
the patient received the steroid injection three days later.
Nursing Sick Call
ASP nurses usually performed well with sick call. ASP’s sick call process was timely and met the
needs of most patients regarding access to health care services. Although sick call nurses generally
provided appropriate nursing evaluation and intervention, there were several cases in which the
nurse did not properly evaluate or address the patient’s complaints or health issues.
• In case 13, the sick call nurse assessed the patient’s temperature, pulse, and respiratory rates
during the clinic visit but did not check the blood pressure of this patient with hypertension.
• In case 18, the patient requested information about his medication. The sick call nurse did
not evaluate the patient, record the referral to follow up with the provider, or record the final
disposition of the patient’s sick call request.
Urgent/Emergent Care
ASP nurses usually provided effective and timely emergency responses. The TTA nursing staff
were knowledgeable about emergency procedures. However, those nurses did not consistently make
appropriate assessments and had some difficulty recording their care accurately. We discuss this
performance further in the Emergency Services indicator.
Specialized Medical Housing
Nursing care and documentation were exceptional in the OHU. We reviewed 47 nursing encounters
and identified only three minor nursing documentation deficiencies. Nurses conducted pertinent
daily patient assessments and observations specific to the patient’s diagnosis and treatment plans.
We discuss this performance further in the Specialized Medical Housing indicator.
Post-Hospital Returns
Nurses in the TTA usually scheduled timely follow-up appointments for patients returning from an
outside hospital or emergency room. They consulted with the providers after reviewing hospital
discharge recommendations for follow-up care. ASP retrieved, reviewed, and scanned the hospital
records into the ASP medical record timely. The Health Information Management indicator
includes additional details.
Avenal State Prison, Cycle 5 Medical Inspection Page 44
Office of the Inspector General State of California
Inter- and Intra-System Transfers
For most patients, ASP nurses coordinated care appropriately during the transfer process. We also
discuss nursing performance in this area in the Inter- and Intra-System Transfers indicator.
Offsite Specialty Services Returns
ASP nurses also provided appropriate care to patients returning from community specialty
appointments. We further discuss this performance in the Specialty Services indicator.
Clinician Onsite Inspection
We met with ASP nurse managers during the onsite visit. The nurse managers researched the cases
we presented and were well prepared to address them. The primary care clinic huddle process was
well established and demonstrated a multidisciplinary team approach.
Case Review Conclusion
ASP nurses usually provided care that was timely and appropriate. However, there was room for
improvement in their assessment, intervention, documentation, emergency care, and in ensuring
medication continuity for patients transferring in from other CDCR institutions. Though ASP
nurses demonstrated several error patterns, most of the deficiencies did not severely increase the
risk of patient harm. The overall Quality of Nursing Performance indicator at ASP was adequate.
Avenal State Prison, Cycle 5 Medical Inspection Page 45
Office of the Inspector General State of California
QUALITY OF PROVIDER PERFORMANCE
In this indicator, the OIG physicians provide a qualitative evaluation
Case Review Rating:
of the adequacy of provider care at the institution. OIG physicians
Adequate
evaluated the appropriateness of evaluations, diagnoses, and
Compliance Score:
management plans for programs including, but not limited to,
Not Applicable
nursing sick call, chronic care programs, TTA, specialized medical
Overall Rating:
housing, and specialty services. Only OIG physicians perform
Adequate
assessments of provider care. There is no compliance testing
component for the Provide Performance Quality indicator.
Case Review Results
We reviewed 133 medical provider encounters and identified 15 deficiencies related to provider
performance. Of those 15 deficiencies, five were significant. We rated the Quality of Provider
Performance indicator adequate.
Assessment and Decision-Making
ASP providers usually made appropriate assessments and documented sound medical plans.
However, providers frequently made minor mistakes in this area. These deficiencies occurred in
cases 8, 13, 14, 22, 27, 49, and 53. Despite a strong pattern of errors, most of these deficiencies
were not significant and did not place the patient at increased risk of harm. There was one
exception:
• In case 22, a provider reviewed several laboratory tests showing high potassium levels and
an electrocardiogram (EKG, a test to measure the heart’s electrical activity) that showed that
the patient was at risk for a dangerous heart rhythm disturbance. When the potassium rose to
a critically high level, the provider did not treat the dangerous potassium levels or obtain a
repeat EKG to determine if the patient needed emergent treatment. These errors placed the
patient at risk of serious complications such as arrhythmia and death. Fortunately, ASP
addressed the problem after we informed the institution of the situation.
Review of Records
In most cases, providers reviewed their patients’ records properly, especially when the patients
returned from a hospital or specialist. Insufficient record review occurred in only three cases (2, 5,
and 48). A significant review error occurred in the following case:
• In case 2, the patient returned from the hospital, but the provider did not address a 19 mm
lung nodule, which could have been cancer. By overlooking the findings, the provider
placed the patient at risk of delayed diagnosis and treatment of cancer. Fortunately, ASP
addressed the problem after we informed the institution of the situation, and the nodule was
benign.
Avenal State Prison, Cycle 5 Medical Inspection Page 46
Office of the Inspector General State of California
Emergency Care
ASP providers were readily available for consultation with the TTA nursing staff when patients
presented emergently to the TTA. ASP providers made excellent decisions during emergent events.
We did not identify any provider emergency care deficiencies.
Chronic Care
ASP providers performed well in managing chronic medical conditions such as hypertension,
hyperlipidemia, asthma, hepatitis C infection, and seizure disorder. ASP providers could improve
with their diabetic care, as there were two significant deficiencies:
• In case 8, the patient had diabetes requiring long-acting insulin. Patients taking long-acting
insulin require monitoring of fasting (morning) blood glucose levels. In this case, the
provider monitored blood glucose levels only once daily in the afternoon, which was
insufficient. The provider should have monitored fasting blood glucose levels to adjust the
long-acting insulin dose properly. Also, the provider should not have prescribed a
long-acting oral medication because of the increased risk of low blood sugar when the
patient was taking other insulins at the same time.
• In case 53, the patient’s blood tests showed poor diabetic control that had deteriorated over
the six-month review period. The patient required close monitoring and timely insulin
adjustment. The long-acting insulin is typically titrated every three to seven days until
average fasting blood glucose is in the target range. However, the provider evaluated the
patient only two times in the review period and did not adjust the patient’s insulin. The
provider’s lack of intervention placed the patient at risk for complications of uncontrolled
diabetes such as cardiovascular disease, stroke, and blindness. The provider also set an
inappropriately high blood sugar target range for the patient.
Specialty Services
ASP providers performed extremely well in this area. When their patients required specialty care,
ASP providers referred appropriately and with the correct priority. The providers also reviewed
specialty reports timely. There was only one significant deficiency, which we discuss further in the
Specialty Services indicator.
Specialized Medical Housing
Providers visited OHU patients timely and made appropriate assessments and sound medical plans.
We did not identify any provider deficiencies in specialized medical housing.
Avenal State Prison, Cycle 5 Medical Inspection Page 47
Office of the Inspector General State of California
Health Information Management
ASP providers recorded their outpatient, TTA, and specialty housing encounters timely. Providers
dictated most progress notes, and handwritten records were usually legible.
Clinician Onsite Inspection
At the time of our inspection, there were no provider vacancies. The providers were enthusiastic
about their work and satisfied with the institution’s nursing, diagnostic, and specialty services. ASP
assigned each provider to only one clinic to enhance the continuity of care. On average, providers
saw 15 patients per day. Providers led productive morning huddles, which nurses, care
coordinators, custody staff, and office technicians attended. The care teams discussed significant
TTA encounters and hospital returns that occurred the previous day.
After the morning huddles, the medical staff attended a population health management meeting and
analyzed patient health metric data. By analyzing the data, the staff hoped to improve the clinical
outcomes of patients with chronic conditions such as diabetes and hypertension.
Case Review Conclusion
ASP providers performed well in multiple aspects of patient care, including emergency care,
chronic care, hospital returns, and specialized medical housing. The providers could improve with
their assessment and decision-making, review of records, and diabetic care. We rated the Quality of
Provider Performance indicator adequate.
Avenal State Prison, Cycle 5 Medical Inspection Page 48
Office of the Inspector General State of California
RECEPTION CENTER ARRIVALS
This indicator focuses on the management of medical needs and
Case Review Rating:
continuity of care for patients arriving from outside the CDCR
Not Applicable
system. The OIG review includes evaluation of the ability of the
Compliance Score:
institution to provide and document initial health screenings, initial
Not Applicable
health assessments, continuity of medications, and completion of
Overall Rating:
required screening tests; address and provide significant
Not Applicable
accommodations for disabilities and health care appliance needs; and
identify health care conditions needing treatment and monitoring.
The patients reviewed for reception center cases are those received from non-CDCR facilities, such
as county jails.
ASP does not have a reception center; therefore, this indicator does not apply.
Avenal State Prison, Cycle 5 Medical Inspection Page 49
Office of the Inspector General State of California
SPECIALIZED MEDICAL HOUSING
This indicator addresses whether the institution follows appropriate
Case Review Rating:
policies and procedures when admitting inmate-patients to onsite Adequate
inpatient facilities, including completion of timely nursing and Compliance Score:
provider assessments. The chart review assesses all aspects of Proficient
(100%)
medical care related to these housing units, including quality of
provider and nursing care. Avenal’s only specialized medical Overall Rating:
housing unit is an outpatient housing unit (OHU). Adequate
For this indicator, the case review and compliance review processes yielded different results, with
the case reviewers assigning an adequate rating and the compliance testing resulting in a proficient
score. The main reason for the adequate score: Despite excellent provider and nurse OHU
performance, ASP did not consistently make critical medications available to patients when they
needed them. Because this resulted in an increased risk of harm, we determined that the most
suitable rating for this indicator was adequate.
Case Review Results
The specialized medical housing unit at ASP was a 28-bed OHU, and ASP used all beds for
medical patients. There were no negative pressure rooms. We reviewed 7 OHU cases, which
yielded 64 events. The events reviewed included 9 provider and 47 nursing encounters. We
identified five deficiencies, one of which was a significant pharmacy deficiency in case 52. The
case review rating of the Specialized Medical Housing indicator was adequate.
Provider Performance
The providers visited OHU patients timely and made appropriate assessments and sound medical
plans. The providers did very well, as there were no deficiencies related to provider performance.
Nursing Performance
We reviewed 47 nursing encounters and found nursing care and documentation exceptional
despite rare deficiencies.
We reviewed patients admitted to the OHU for abdominal and back surgical wounds with
staples/sutures, leg fractures (two long bones), jaw bone infection, drug overdoses, and complaints
of weakness. Nurses conducted pertinent daily patient assessments and observations specific to
each patient’s diagnosis and treatment plan. Nurse documentation was thorough and included
general physical assessments, wound characteristics, the appearance of intravenous (IV) catheter
insertions sites, progress with ambulation, and patients’ abilities to perform self-care tasks.
Nursing documentation also included subjective information from the patient, changes in patient
status, medication compliance, and provider contacts. Nurses made regular patient rounds to assess
Avenal State Prison, Cycle 5 Medical Inspection Page 50
Office of the Inspector General State of California
patients and to ascertain patient needs. There were three minor nursing documentation deficiencies,
in cases 29 (twice) and 51.
Pharmacy and Medication Management
The OHU pharmacy and nursing staff sometimes had difficulty ensuring that essential
medications, such as antibiotics, and seizure and blood pressure medications were available and
given as prescribed. There were two deficiencies, both of which were significant:
• In case 50, a provider prescribed an important blood thinner to prevent blood clots after the
patient sustained a leg fracture. The blood thinner was not available for two days.
• In case 52, the patient had a jaw infection and was receiving intravenous antibiotics. The
patient did not receive the intravenous antibiotic for one day because it was not available,
placing the patient at risk for undertreated infection.
Clinical Onsite Inspection
In the OHU, registered nurses (RNs) were on duty during the day shifts. ASP staffed the evening
and night shifts with licensed vocational nurses (LVNs). Certified nursing assistants assisted the RN
on the day shift and the LVN on the afternoon shift. RN supervisors were available for all shifts 24
hours per day.
ASP staffed the OHU with experienced nurses and sufficient custody staff to support patient care.
Administrative staff reported that patient names and diagnoses were available in the EHRS.
Medical staff admitted patients who were scheduled for offsite procedures that required no food or
drink after midnight to the OHU, where the nurses monitored and educated the patients the day
before their procedures.
Case Review Conclusion
ASP providers appropriately admitted patients needing a higher level of care to the OHU and
provided appropriate care to those patients after admission. Provider and nursing care in the OHU
were excellent. However, critical medications were not consistently available when needed. We
therefore rated ASP’s Specialized Medical Housing indicator adequate.
Compliance Testing Results
The institution earned a proficient compliance score of 100.0 percent. All three tests in this
indicator were proficient:
• For all ten patients sampled, nursing staff timely completed an initial assessment on the day
of their admission to the OHU (MIT 13.001).
Avenal State Prison, Cycle 5 Medical Inspection Page 51
Office of the Inspector General State of California
• ASP’s providers timely completed subjective, objective, assessment, plan, and education
(SOAPE) notes at required intervals for all ten applicable OHU patients sampled
(MIT 13.003).
• When we observed the working order of sampled call buttons in OHU patient rooms, they
found all working properly. In addition, according to staff members interviewed, custody
officers and clinicians were able to expeditiously access patients’ locked rooms when
emergent events occurred (MIT 13.101).
Avenal State Prison, Cycle 5 Medical Inspection Page 52
Office of the Inspector General State of California
SPECIALTY SERVICES
This indicator focuses on specialist care from the time a provider
Case Review Rating:
requests or orders a specialty service until that care is completed and Proficient
that provider reviews and implements the specialist’s Compliance Score:
recommendations. If the ASP provider chooses not to implement the Adequate
(82.4%)
specialist’s recommendations then OIG clinicians evaluate
documentation of the reason. OIG clinicians also review whether Overall Rating:
ASP providers communicate specialist’s findings and Proficient
recommendations to the patients. For specialty services denied by the
institution, the OIG determines whether the denials are timely and appropriate, and whether
providers update the patient on the consequent plan of care.
For this indicator, the case review and compliance review processes yielded different results, with
the case reviewers assigning a proficient rating and the compliance testing resulting in an adequate
score. The main reason the compliance score was not proficient was that ASP had intermittent
difficulty providing specialty services to patients who had transferred into ASP with pre-approved
specialty referrals. Also, when ASP denied a specialty service, the staff did not timely communicate
the denial to the patient. However, these errors did not significantly result in a risk of patient harm
and we determined the rating for this indicator was proficient.
Case Review Results
We reviewed 69 events related to the Specialty Services indicator, which included 49 specialty
consultations and procedures and 20 nursing encounters. There were four deficiencies, two of
which were significant. The case review rating for this indicator was proficient.
Access to Specialty Services
Specialty appointments are integral to specialty services, and we found that most specialty
appointments occurred within the requested time frame. Delays in specialty access occurred in only
2 of the 23 applicable cases. One of those delays was significant:
• In case 48, a provider requested a lung specialist follow-up within two weeks; however, the
appointment did not occur until one month later.
Nursing Performance
We reviewed 20 nursing encounters when patients returned from their specialty appointments. The
nurses performed good patient assessments, obtained the specialist’s initial findings and
recommendations, and communicated them to the provider. Nurses provided education to the
patients as needed. We did not find any nursing performance deficiencies in specialty services.
Avenal State Prison, Cycle 5 Medical Inspection Page 53
Office of the Inspector General State of California
Provider Performance
We found that providers referred patients to specialists appropriately and addressed specialists’
recommendations after specialty appointments. There was one significant exception:
• In case 48, the patient had severe chronic lung disease. The pulmonologist recommended
pulmonary function testing and a follow-up in six to eight weeks. The provider reviewed the
consultation report but did not address the recommendations. This error resulted in a lapse
in care.
Health Information Management
ASP performed well in this area. The institution retrieved and scanned all specialty reports into the
medical record timely.
Case Review Conclusion
The Specialty Services indicator was proficient because ASP staff completed most specialty
appointments timely, retrieved and scanned specialty reports, properly reviewed the
recommendations, and acted on them appropriately.
Compliance Testing Results
The institution received an adequate compliance score of 82.4 percent in the Specialty Services
indicator. Five tests earned proficient scores, as follows:
• For all 15 patients sampled, high-priority specialty services appointments occurred within
14 calendar days of the provider’s order (MIT 14.001).
• Providers timely received and reviewed high-priority specialists’ reports for 14 of 15
patients sampled (93.3 percent). For one patient, ASP did not scan the report into the
patient’s electronic medical record (MIT 14.002).
• For all 15 patients sampled, routine priority specialty service appointments occurred within
90 calendar days of the provider’s order (MIT 14.003).
• Providers timely received and reviewed routine priority specialists’ reports for 14 of 15
patients sampled (93.3 percent). For one patient, the provider reviewed the report seven days
late (MIT 14.004).
• ASP’s health care management timely denied providers’ specialty services requests for 19
of 20 sampled patients (95.0 percent). Management denied one specialty services request
three days late (MIT 14.006).
Avenal State Prison, Cycle 5 Medical Inspection Page 54
Office of the Inspector General State of California
Two tests resulted in inadequate scores at the institution:
• Only 9 of 20 patients who transferred into ASP with an approved specialty service
(45.0 percent) received it within the required time frame. The remaining 11 patients sampled
received their services late or did not receive them at all: one patient received his service
one day late; three patients received their services from 12 to 20 days late; six patients never
received their services; for one final patient, the provider cancelled his service, but the
cancellation was out of compliance by four days (MIT 14.005).
• For 10 of 20 patients sampled (50.0 percent), providers timely communicated the denial
status of specialty services. For three patients, providers did not communicate the denial
status at all. For six other patients, the provider communicated the denial status from 2 to 17
days late. For one remaining patient, the provider communicated the denial status 40 days
late (MIT 14.007).
Avenal State Prison, Cycle 5 Medical Inspection Page 55
Office of the Inspector General State of California
ADMINISTRATIVE OPERATIONS (SECONDARY)
This indicator focuses on the institution’s administrative health care
Case Review Rating:
oversight functions. The OIG evaluates whether the institution Not Applicable
promptly processes patient medical appeals and addresses all Compliance Score:
appealed issues. Inspectors also verify that the institution follows Proficient
(94.4%)
reporting requirements for adverse/sentinel events and patient deaths.
The OIG verifies that the Emergency Medical Response Review Overall Rating:
Committee (EMRRC) performs required reviews and that staff Proficient
perform required emergency response drills. Inspectors also assess
whether the Quality Management Committee (QMC) meets regularly and adequately addresses
program performance. For those institutions with licensed facilities, inspectors also verify that
required committee meetings are held. In addition, the OIG examines whether the institution
adequately manages its health care staffing resources by evaluating whether job performance
reviews are completed as required; specified staff possess current, valid credentials and professional
licenses or certifications; nursing staff receive new employee orientation training and annual
competency testing; and clinical and custody staff have current emergency medical response
certifications. The Administrative Operations indicator is a secondary indicator; therefore, it was
not relied on for the institution’s overall score.
Compliance Testing Results
The institution received a proficient score of 94.4 percent in this indicator with several tests scoring
100.0 percent:
• We reviewed data received from the institution to determine if ASP timely processed at least
95 percent of its monthly patient medical appeals during the most recent 12-month period.
ASP timely processed all 12 months’ appeals reviewed (MIT 15.001).
• ASP’s Quality Management Committee (QMC) met monthly, evaluated program
performance, and acted when management identified areas for improvement opportunities
(MIT 15.003).
• ASP took adequate steps to ensure the accuracy of its Dashboard data reporting
(MIT 15.004).
• We reviewed drill packages for three medical emergency response drills conducted in the
prior quarter; each drill package contained all required summary reports and related
documentation. In addition, the drills included participation by both health care and custody
staff (MIT 15.101).
• Based on a sample of ten second-level medical appeals, the institution’s responses addressed
all the patients’ appealed issues (MIT 15.102).
Avenal State Prison, Cycle 5 Medical Inspection Page 56
Office of the Inspector General State of California
• All ten nurses sampled were current with their clinical competency validations
(MIT 15.105).
• We reviewed performance evaluation packets for ASP’s nine providers; ASP met all
performance review requirements for its providers (MIT 15.106).
• All providers at the institution were current with their professional licenses. Similarly, all
nursing staff and the pharmacist in charge were current with their professional licenses and
certification requirements (MIT 15.107, 15.109).
• All active-duty providers and nurses were current with their emergency response
certifications (MIT 15.108).
• All pharmacy staff and providers who prescribed controlled substances had current Drug
Enforcement Agency registrations (MIT 15.110).
• Nursing staff hired within the last year timely received new employee orientation training
(MIT 15.111).
One test earned an adequate score:
• When we examined records to determine if nursing supervisors were completing the
required number of monthly case reviews for subordinate nurses as well as discussing the
results of those reviews, four of five sampled nurse supervisors properly completed their
reviews (80.0 percent). One of the reviewing nurses did not discuss the review results with
the subordinate nurse (MIT 15.104).
One test earned an inadequate score:
• Of the 12 sampled incident packages for emergency medical responses reviewed by the
institution’s Emergency Medical Response Review Committee (EMRRC) during the prior
12-month period, 5 (41.7 percent) complied with policy. Seven incident packages did not
include the required EMRRC checklist (MIT 15.005).
Non-Scored Results
• We gathered non-scored data regarding the CCHCS Death Review Committee (DRC)
completing its death review reports. There were no applicable deaths that occurred at ASP
in the prior 12-month period (MIT 15.998).
• We discuss the institution’s health care staffing resources in the About the Institution section
of this report (MIT 15.999).
Avenal State Prison, Cycle 5 Medical Inspection Page 57
Office of the Inspector General State of California
R
ECOMMENDATION
• ASP’s pharmacist in charge (PIC) and chief nurse executive (CNE) should implement
quality improvement measures to adjust pharmacy and nursing administration
processes and ensure medications are available when patients need them. In this
inspection, the institution did not reliably give needed medications to patients who
transferred from other institutions, returned from the hospital, or needed intravenous
antibiotics.
Avenal State Prison, Cycle 5 Medical Inspection Page 58
Office of the Inspector General State of California
P -B M
OPULATION ASED ETRICS
The compliance testing and the case reviews give an accurate assessment of how the institution’s
health care systems are functioning with regard to the patients with the highest risk and utilization.
This information is vital to assess the capacity of the institution to provide sustainable, adequate
care. However, one significant limitation of the case review methodology is that it does not give a
clear assessment of how the institution performs for the entire population. For better insight into
this performance, the OIG has turned to population-based metrics. For comparative purposes, the
OIG has selected several Healthcare Effectiveness Data and Information Set (HEDIS) measures for
disease management to gauge the institution’s effectiveness in outpatient health care, especially
chronic disease management.
The Healthcare Effectiveness Data and Information Set is a set of standardized performance
measures developed by the National Committee for Quality Assurance with input from over
300 organizations representing every sector of the nation’s health care industry. It is used by over
90 percent of the nation’s health plans as well as many leading employers and regulators. HEDIS
was designed to ensure that the public (including employers, the Centers for Medicare and
Medicaid Services, and researchers) has the information it needs to accurately compare the
performance of health care plans. Healthcare Effectiveness Data and Information Set data is often
used to produce health plan report cards, analyze quality improvement activities, and create
performance benchmarks.
Methodology
For population-based metrics, we used a subset of HEDIS measures applicable to the CDCR patient
population. Selection of the measures was based on the availability, reliability, and feasibility of the
data required for performing the measurement. We collected data utilizing various information
sources, including the electronic medical record, the Master Registry (maintained by CCHCS), as
well as a random sample of patient records analyzed and abstracted by trained personnel. We did
not independently validate the data obtained from the CCHCS Master Registry and Diabetic
Registry and we presume it to be accurate. For some measures, we used the entire population rather
than statistically random samples. While the OIG is not a certified HEDIS compliance auditor, we
use similar methods to ensure that measures are comparable to those published by other
organizations.
Comparison of Population-Based Metrics
For the Avenal State Prison, we selected seven HEDIS measures and listed them in the following
ASP Results Compared to State and National HEDIS Scores table. Multiple health plans publish
their HEDIS performance measures at the State and national levels. We provide selected results for
several health plans in both categories for comparative purposes.
Avenal State Prison, Cycle 5 Medical Inspection Page 59
Office of the Inspector General State of California
Results of Population-Based Metric Comparison
For chronic care management, we chose measures related to the management of diabetes. Diabetes
is the most complex common chronic disease requiring a high level of intervention on the part of
the health care system to produce optimal results.
When compared statewide, ASP outperformed all plans by scoring higher in all five diabetic
measures tested. When compared nationally, ASP outperformed Medicaid, Medicare, and
commercial plans in all five diabetic measures. ASP outperformed the United States Department of
Veterans Affairs (VA) in three of the four applicable measures but scored one percentage point
lower for eye exams.
Comparative data for immunizations was only fully available for the VA and partially available for
Kaiser, commercial plans, Medicaid and Medicare. Additionally, ASP’s population did not contain
inmate-patients over the age of 65; therefore, we omitted influenza shots for patients 65 and older
and pneumococcal immunizations from the comparative analysis. With respect to administering
influenza vaccinations to younger adults, ASP scored higher than all State and national health
plans.
With respect to colorectal cancer screening, ASP scored much lower than all State and national
health plans. However, over half of the sampled patients refused the cancer screening, which
negatively affected the institution’s score.
Summary
ASP performed favorably with regard to population-based metrics in comparison to the other
health care plans reviewed. The institution may improve its scores for cancer screenings by
reducing patient refusals through patient education.
Avenal State Prison, Cycle 5 Medical Inspection Page 60
Office of the Inspector General State of California
Avenal State Prison Results Compared to State and National HEDIS Score
California National
HEDIS
Clinical Measures ASP Kaiser HEDIS HEDIS
HEDIS (No. Kaiser HEDIS Com- HEDIS VA
Cycle 5 Medi-Cal CA) (So.CA) Medicaid mercial Medicare Average
Results1 20172 20163 20163 20174 20174 20174 20165
Comprehensive
Diabetes Care
HbA1c Testing
100% 87% 94% 94% 87% 91% 94% 99%
(Monitoring)
Poor HbA1c Control
2% 38% 20% 23% 43% 33% 26% 18%
(>9.0%)6, 7
HbA1c Control
95% 52% 70% 63% 47% 56% 63% -
(<8.0%)6
Blood Pressure
92% 63% 83% 83% 60% 62% 64% 76%
Control (<140/90)6
Eye Exams 88% 57% 68% 81% 55% 54% 70% 89%
Immunizations
Influenza
70% - 56% 57% 39% 48% - 52%
Shots - Adults (18–64)
Influenza
N/a - - - - - 71% 72%
Shots - Adults (65+)8
Immunizations:
N/a - - - - - 74% 93%
Pneumococcal8
Cancer Screening
Colorectal Cancer
44% - 79% 82% - 62% 67% 82%
Screening
1. Unless otherwise stated, data was collected in August 2017 by reviewing medical records from a sample of ASP's
population of applicable inmate-patients. These random statistical sample sizes were based on a 95 percent confidence
level with a 15 percent maximum margin of error.
2. HEDIS Medi-Cal data was obtained from the California Department of Health Care Services Medi-Cal Managed Care
External Quality Review Technical Report (July 1, 2016 - June 30, 2017).
3. Data was obtained from Kaiser Permanente November 2016 reports for the Northern and Southern California regions.
4. National HEDIS data for Medicaid, commercial plans, and Medicare was obtained from the 2017 State of Health Care
Quality Report, available on the NCQA website: www.ncqa.org. The results for commercial plans were based on data
received from various health maintenance organizations.
5. The Department of Veterans Affairs (VA) data was obtained from the VA's website, www.va.gov.
For the Immunizations: Pneumococcal measure only, the data was obtained from the VHA Facility Quality and Safety
Report - Fiscal Year 2012 Data.
6. For this indicator, the entire applicable ASP population was tested.
7. For this measure only, a lower score is better. For Kaiser, the OIG derived the Poor HbA1c Control indicator using the
reported data for the <9.0% HbA1c control indicator.
8. Population did not contain inmate-patients over the age of 65; therefore, sample omitted from the comparative analysis.
Avenal State Prison, Cycle 5 Medical Inspection Page 61
Office of the Inspector General State of California
A A—C T R
PPENDIX OMPLIANCE EST ESULTS
Avenal State Prison
Range of Summary Scores: 52.3% - 100.0%
Indicator Compliance Score (Yes %)
1–Access to Care 90.4%
2–Diagnostic Services 75.4%
3–Emergency Services Not Applicable
4–Health Information Management (Medical Records) 72.9%
5–Health Care Environment 52.3%
6–Inter- and Intra-System Transfers 91.4%
7–Pharmacy and Medication Management 65.5%
8–Prenatal and Post-Delivery Services Not Applicable
9–Preventive Services 93.8%
10–Quality of Nursing Performance Not Applicable
11–Quality of Provider Performance Not Applicable
12–Reception Center Arrivals Not Applicable
13–Specialized Medical Housing (OHU, CTC, SNF, Hospice) 100.0%
14–Specialty Services 82.4%
15–Administrative Operations 94.4%
Avenal State Prison, Cycle 5 Medical Inspection Page 62
Office of the Inspector General State of California
Scored Answers
Yes
Reference +
1–Access to Care
Number Yes No No Yes % N/A
Chronic care follow-up appointments: Was the patient’s most
recent chronic care visit within the health care guideline’s
1.001 22 3 25 88.0% 0
maximum allowable interval or within the ordered time frame,
whichever is shorter?
For endorsed patients received from another CDCR institution: If
1.002 the nurse referred the patient to a provider during the initial health 19 6 25 76.0% 0
screening, was the patient seen within the required time frame?
Clinical appointments: Did a registered nurse review the patient’s
1.003 30 0 30 100.0% 0
request for service the same day it was received?
Clinical appointments: Did the registered nurse complete a
1.004 face-to-face visit within one business day after the CDCR Form 30 0 30 100.0% 0
7362 was reviewed?
Clinical appointments: If the registered nurse determined a
referral to a primary care provider was necessary, was the patient
1.005 11 1 12 91.7% 18
seen within the maximum allowable time or the ordered time
frame, whichever is the shorter?
Sick call follow-up appointments: If the primary care provider
1.006 ordered a follow-up sick call appointment, did it take place within 3 0 3 100.0% 27
the time frame specified?
Upon the patient's discharge from the community hospital: Did
1.007 the patient receive a follow-up appointment within the required 14 3 17 82.4% 0
time frame?
Specialty service follow-up appointments: Do specialty service
1.008 primary care physician follow-up visits occur within required time 22 7 29 75.9% 1
frames?
Clinical appointments: Do patients have a standardized process to
1.101 6 0 6 100.0% 0
obtain and submit health care services request forms?
Overall percentage: 90.4%
Avenal State Prison, Cycle 5 Medical Inspection Page 63
Office of the Inspector General State of California
Scored Answers
Yes
Reference +
2–Diagnostic Services
Number Yes No No Yes % N/A
Radiology: Was the radiology service provided within the time
2.001 10 0 10 100.0% 0
frame specified in the provider's order?
Radiology: Did the primary care provider review and initial the
2.002 6 4 10 60.0% 0
diagnostic report within specified time frames?
Radiology: Did the primary care provider communicate the results
2.003 8 1 9 88.9% 1
of the diagnostic study to the patient within specified time frames?
Laboratory: Was the laboratory service provided within the time
2.004 10 0 10 100.0% 0
frame specified in the provider's order?
Laboratory: Did the primary care provider review and initial the
2.005 10 0 10 100.0% 0
diagnostic report within specified time frames?
Laboratory: Did the primary care provider communicate the
2.006 results of the diagnostic study to the patient within specified time 1 9 10 10.0% 0
frames?
Pathology: Did the institution receive the final diagnostic report
2.007 9 1 10 90.0% 0
within the required time frames?
Pathology: Did the primary care provider review and initial the
2.008 9 1 10 90.0% 0
diagnostic report within specified time frames?
Pathology: Did the primary care provider communicate the results
2.009 4 6 10 40.0% 0
of the diagnostic study to the patient within specified time frames?
Overall percentage: 75.4%
3–Emergency Services
This indicator is evaluated only by case review clinicians. There is no compliance testing component.
Avenal State Prison, Cycle 5 Medical Inspection Page 64
Office of the Inspector General State of California
Scored Answers
Yes
Reference +
4–Health Information Management
Number Yes No No Yes % N/A
Are non-dictated health care documents (provider progress notes)
4.001 9 1 10 90.0% 0
scanned within 3 calendar days of the patient encounter date?
Are dictated/transcribed documents scanned into the patient’s
4.002 electronic health record within five calendar days of the encounter 1 0 1 100.0% 0
date?
Are High-Priority specialty notes (either a Form 7243 or other
4.003 scanned consulting report) scanned within the required time 16 4 20 80.0% 0
frame?
Are community hospital discharge documents scanned into the
4.004 patient’s electronic health record within three calendar days of 13 3 16 81.3% 0
hospital discharge?
Are medication administration records (MARs) scanned into the
4.005 0 0 0 NA 0
patient’s electronic health record within the required time frames?
During the inspection, were medical records properly scanned,
4.006 8 16 24 33.3% 0
labeled, and included in the correct patients’ files?
For patients discharged from a community hospital: Did the
preliminary hospital discharge report include key elements and
4.007 9 8 17 52.9% 0
did a primary care provider review the report within three
calendar days of discharge?
Overall percentage: 72.9%
Avenal State Prison, Cycle 5 Medical Inspection Page 65
Office of the Inspector General State of California
Scored Answers
Yes
Reference +
5–Health Care Environment
Number Yes No No Yes % N/A
Are clinical health care areas appropriately disinfected, cleaned
5.101 8 2 10 80.0% 0
and sanitary?
Do clinical health care areas ensure that reusable invasive and
5.102 non-invasive medical equipment is properly sterilized or 8 1 9 88.9% 1
disinfected as warranted?
Do clinical health care areas contain operable sinks and sufficient
5.103 10 0 10 100.0% 0
quantities of hygiene supplies?
Does clinical health care staff adhere to universal hand hygiene
5.104 2 7 9 22.2% 1
precautions?
Do clinical health care areas control exposure to blood-borne
5.105 9 1 10 90.0% 0
pathogens and contaminated waste?
Warehouse, Conex and other non-clinic storage areas: Does the
5.106 medical supply management process adequately support the needs 0 1 1 0.0% 0
of the medical health care program?
Does each clinic follow adequate protocols for managing and
5.107 2 8 10 20.0% 0
storing bulk medical supplies?
Do clinic common areas and exam rooms have essential core
5.108 4 6 10 40.0% 0
medical equipment and supplies?
Do clinic common areas have an adequate environment conducive
5.109 10 0 10 100.0% 0
to providing medical services?
Do clinic exam rooms have an adequate environment conducive
5.110 2 7 9 22.2% 1
to providing medical services?
Emergency response bags: Are TTA and clinic emergency
5.111 medical response bags inspected daily and inventoried monthly, 1 7 8 12.5% 2
and do they contain essential items?
Overall percentage: 52.3%
Avenal State Prison, Cycle 5 Medical Inspection Page 66
Office of the Inspector General State of California
Scored Answers
Yes
Reference +
6–Inter- and Intra-System Transfers
Number Yes No No Yes % N/A
For endorsed patients received from another CDCR institution or
COCF: Did nursing staff complete the initial health screening and
6.001 22 3 25 88.0% 0
answer all screening questions on the same day the patient arrived
at the institution?
For endorsed patients received from another CDCR institution or
COCF: When required, did the RN complete the assessment and
disposition section of the health screening form; refer the patient
6.002 25 0 25 100.0% 0
to the TTA, if TB signs and symptoms were present; and sign and
date the form on the same day staff completed the health
screening?
For endorsed patients received from another CDCR institution or
COCF: If the patient had an existing medication order upon
6.003 10 2 12 83.3% 13
arrival, were medications administered or delivered without
interruption?
For patients transferred out of the facility: Were scheduled
6.004 specialty service appointments identified on the patient’s health 6 1 7 85.7% 0
care transfer information form?
For patients transferred out of the facility: Do medication transfer
6.101 packages include required medications along with the 1 0 1 100.0% 5
corresponding transfer packet required documents?
Overall percentage: 91.4%
Avenal State Prison, Cycle 5 Medical Inspection Page 67
Office of the Inspector General State of California
Scored Answers
7–Pharmacy and Medication Yes
Reference +
Management
Number Yes No No Yes % N/A
Did the patient receive all chronic care medications within the
7.001 required time frames or did the institution follow departmental 14 3 17 82.4% 8
policy for refusals or no-shows?
Did health care staff administer, make available, or deliver new
7.002 order prescription medications to the patient within the required 23 2 25 92.0% 0
time frames?
Upon the patient’s discharge from a community hospital: Were all
7.003 ordered medications administered, made available, or delivered to 13 4 17 76.5% 0
the patient within required time frames?
For patients received from a county jail: Were all medications
ordered by the institution’s reception center provider
7.004 0 0 0 NA 0
administered, made available, or delivered to the patient within
the required time frames?
Upon the patient’s transfer from one housing unit to another:
7.005 25 0 25 100.0% 0
Were medications continued without interruption?
For patients en route who lay over at the institution: If the
7.006 temporarily housed patient had an existing medication order, were 0 0 0 NA 0
medications administered or delivered without interruption?
All clinical and medication line storage areas for narcotic
7.101 medications: Does the Institution employ strong medication 6 3 9 66.7% 1
security over narcotic medications assigned to its clinical areas?
All clinical and medication line storage areas for non-narcotic
medications: Does the Institution properly store non-narcotic
7.102 2 8 10 20.0% 0
medications that do not require refrigeration in assigned clinical
areas?
All clinical and medication line storage areas for non-narcotic
7.103 medications: Does the institution properly store non-narcotic 2 6 8 25.0% 2
medications that require refrigeration in assigned clinical areas?
Medication preparation and administration areas: Do nursing staff
employ and follow hand hygiene contamination control protocols
7.104 5 1 6 83.3% 4
during medication preparation and medication administration
processes?
Medication preparation and administration areas: Does the
7.105 institution employ appropriate administrative controls and 6 0 6 100.0% 4
protocols when preparing medications for patients?
Medication preparation and administration areas: Does the
7.106 Institution employ appropriate administrative controls and 6 0 6 100.0% 4
protocols when distributing medications to patients?
Pharmacy: Does the institution employ and follow general
7.107 security, organization, and cleanliness management protocols in 1 0 1 100.0% 0
its main and satellite pharmacies?
Avenal State Prison, Cycle 5 Medical Inspection Page 68
Office of the Inspector General State of California
Scored Answers
7–Pharmacy and Medication Yes
Reference +
Management
Number Yes No No Yes % N/A
Pharmacy: Does the institution’s pharmacy properly store
7.108 0 1 1 0.0% 0
non-refrigerated medications?
Pharmacy: Does the institution’s pharmacy properly store
7.109 1 0 1 100.0% 0
refrigerated or frozen medications?
Pharmacy: Does the institution’s pharmacy properly account for
7.110 0 1 1 0.0% 0
narcotic medications?
Does the institution follow key medication error reporting
7.111 9 16 25 36.0% 0
protocols?
Overall percentage: 65.5%
8–Prenatal and Post-Delivery Services
The institution has no female patients, so this indicator is not applicable.
Avenal State Prison, Cycle 5 Medical Inspection Page 69
Office of the Inspector General State of California
Scored Answers
Yes
Reference +
9–Preventive Services
Number Yes No No Yes % N/A
Patients prescribed TB medication: Did the institution administer
9.001 12 0 12 100.0% 0
the medication to the patient as prescribed?
Patients prescribed TB medication: Did the institution monitor the
9.002 patient monthly for the most recent three months he or she was on 12 0 12 100.0% 0
the medication?
Annual TB Screening: Was the patient screened for TB within the
9.003 20 10 30 66.7% 0
last year?
Were all patients offered an influenza vaccination for the most
9.004 25 0 25 100.0% 0
recent influenza season?
All patients from the age of 50 - 75: Was the patient offered
9.005 25 0 25 100.0% 0
colorectal cancer screening?
Female patients from the age of 50 through the age of 74: Was the
9.006 0 0 0 NA 0
patient offered a mammogram in compliance with policy?
Female patients from the age of 21 through the age of 65: Was
9.007 0 0 0 NA 0
patient offered a pap smear in compliance with policy?
Are required immunizations being offered for chronic care
9.008 10 0 10 100.0% 15
patients?
Are patients at the highest risk of coccidioidomycosis (valley
9.009 18 2 20 90.0% 0
fever) infection transferred out of the facility in a timely manner?
Overall percentage: 93.8%
10–Quality of Nursing Performance
This indicator is evaluated only by case review clinicians. There is no compliance testing component.
11–Quality of Provider Performance
This indicator is evaluated only by case review clinicians. There is no compliance testing component.
Avenal State Prison, Cycle 5 Medical Inspection Page 70
Office of the Inspector General State of California
12–Reception Center Arrivals
The institution has no reception center, so this indicator is not applicable.
Scored Answers
Yes
Reference +
13–Specialized Medical Housing
Number Yes No No Yes % N/A
For OHU, CTC, and SNF: Did the registered nurse complete an
13.001 initial assessment of the patient on the day of admission, or within 10 0 10 100.0% 0
eight hours of admission to CMF’s Hospice?
For CTC and SNF only: Was a written history and physical
13.002 0 0 0 NA 0
examination completed within the required time frame?
For OHU, CTC, SNF, and Hospice: Did the primary care provider
complete the Subjective, Objective, Assessment, Plan, and
13.003 10 0 10 100.0% 0
Education (SOAPE) notes on the patient at the minimum intervals
required for the type of facility where the patient was treated?
For OHU and CTC Only: Do inpatient areas either have properly
working call systems in its OHU & CTC or are 30-minute patient
13.101 1 0 1 100.0% 0
welfare checks performed; and do medical staff have reasonably
unimpeded access to enter patient’s cells?
Overall percentage: 100.0%
Avenal State Prison, Cycle 5 Medical Inspection Page 71
Office of the Inspector General State of California
Scored Answers
Yes
Reference +
14–Specialty Services
Number Yes No No Yes % N/A
Did the patient receive the high priority specialty service within
14.001 14 calendar days of the primary care provider order or the 15 0 15 100.0% 0
Physician Request for Service?
Did the primary care provider review the high priority specialty
14.002 14 1 15 93.3% 0
service consultant report within the required time frame?
Did the patient receive the routine specialty service within 90
14.003 calendar days of the primary care provider order or Physician 15 0 15 100.0% 0
Request for Service?
Did the primary care provider review the routine specialty service
14.004 14 1 15 93.3% 0
consultant report within the required time frame?
For endorsed patients received from another CDCR institution: If
the patient was approved for a specialty services appointment at
14.005 9 11 20 45.0% 0
the sending institution, was the appointment scheduled at the
receiving institution within the required time frames?
Did the institution deny the primary care provider request for
14.006 19 1 20 95.0% 0
specialty services within required time frames?
Following the denial of a request for specialty services, was the
14.007 10 10 20 50.0% 0
patient informed of the denial within the required time frame?
Overall percentage: 82.4%
Avenal State Prison, Cycle 5 Medical Inspection Page 72
Office of the Inspector General State of California
Scored Answers
Reference Yes
15–Administrative Operations +
Number Yes No No Yes % N/A
Did the institution promptly process inmate medical appeals
15.001 12 0 12 100.0% 0
during the most recent 12 months?
Does the institution follow adverse / sentinel event reporting
15.002 0 0 0 NA 0
requirements?
Did the institution Quality Management Committee (QMC) meet
at least monthly to evaluate program performance, and did the
15.003 6 0 6 100.0% 0
QMC take action when improvement opportunities were
identified?
Did the institution’s Quality Management Committee (QMC) or
15.004 other forum take steps to ensure the accuracy of its Dashboard 1 0 1 100.0% 0
data reporting?
Does the Emergency Medical Response Review Committee
15.005 perform timely incident package reviews that include the use of 5 7 12 41.7% 0
required review documents?
For institutions with licensed care facilities: Does the Local
Governing Body (LGB), or its equivalent, meet quarterly and
15.006 0 0 0 NA 0
exercise its overall responsibilities for the quality management of
patient health care?
Did the institution complete a medical emergency response drill
15.101 for each watch and include participation of health care and 3 0 3 100.0% 0
custody staff during the most recent full quarter?
Did the institution’s second level medical appeal response address
15.102 10 0 10 100.0% 0
all of the patient's appealed issues?
Did the institution's medical staff review and submit the initial
15.103 0 0 0 NA 0
inmate death report to the Death Review Unit in a timely manner?
Does the institution's Supervising Registered Nurse conduct
15.104 4 1 5 80.0% 0
periodic reviews of nursing staff?
Are nursing staff who administer medications current on their
15.105 10 0 10 100.0% 10
clinical competency validation?
15.106 Are structured clinical performance appraisals completed timely? 9 0 9 100.0% 0
15.107 Do all providers maintain a current medical license? 12 0 12 100.0% 0
Are staff current with required medical emergency response
15.108 2 0 2 100.0% 0
certifications?
Are nursing staff and the Pharmacist-in-Charge current with their
professional licenses and certifications, and is the pharmacy
15.109 licensed as a correctional pharmacy by the California State Board 5 0 5 100.0% 0
of Pharmacy?
Avenal State Prison, Cycle 5 Medical Inspection Page 73
Office of the Inspector General State of California
Scored Answers
Reference Yes
15–Administrative Operations +
Number Yes No No Yes % N/A
Do the institution’s pharmacy and authorized providers who
15.110 prescribe controlled substances maintain current Drug 1 0 1 100.0% 0
Enforcement Agency (DEA) registrations?
15.111 Are nursing staff current with required new employee orientation? 1 0 1 100.0% 0
Overall percentage: 94.4%
Avenal State Prison, Cycle 5 Medical Inspection Page 74
Office of the Inspector General State of California
A B — C D
PPENDIX LINICAL ATA
Table B-1: ASP Sample Sets
Sample Set Total
CTC/OHU 3
Death Review/Sentinel Events 1
Diabetes 4
Emergency Services - CPR 3
Emergency Services - Non-CPR 2
High Risk 5
Hospitalization 5
Intra-system Transfers-In 3
Intra-system Transfers-Out 3
RN Sick Call 18
Specialty Services 3
50
Avenal State Prison, Cycle 5 Medical Inspection Page 75
Office of the Inspector General State of California
Table B-2: ASP Chronic Care Diagnoses
Diagnosis Total
Anemia 1
Arthritis/Degenerative Joint Disease 5
Asthma 5
COPD 2
Cancer 6
Cardiovascular Disease 3
Chronic Pain 14
Cirrhosis/End Stage Liver Disease 1
Coccidioidomycosis 5
Diabetes 5
Gastroesophageal Reflux Disease 8
Hepatitis C 11
Hyperlipidemia 15
Hypertension 18
Mental Health 15
Migraine Headaches 2
Seizure Disorder 3
Sleep Apnea 1
Thyroid Disease 1
121
Avenal State Prison, Cycle 5 Medical Inspection Page 76
Office of the Inspector General State of California
Table B-3: ASP Event – Program
Diagnosis Total
Diagnostic Services 60
Emergency Care 26
Hospitalization 33
Intra-system Transfers-In 9
Intra-system Transfers-Out 10
Outpatient Care 295
Specialized Medical Housing 64
Specialty Services 83
580
Avenal State Prison, Cycle 5 Medical Inspection Page 77
Office of the Inspector General State of California
Table B-4: ASP Review Sample Summary
Total
MD Reviews Detailed 20
MD Reviews Focused 1
RN Reviews Detailed 13
RN Reviews Focused 27
Total Reviews 61
Total Unique Cases 50
Overlapping Reviews (MD & RN) 11
Avenal State Prison, Cycle 5 Medical Inspection Page 78
Office of the Inspector General State of California
A C — C S M
PPENDIX OMPLIANCE AMPLING ETHODOLOGY
Avenal State Prison (ASP)
Sample Category
Quality (number of
Indicator samples) Data Source Filters
Access to Care
MIT 1.001 Chronic Care Patients Master Registry • Chronic care conditions (at least one condition per
patient—any risk level)
(25) • Randomize
MIT 1.002 Nursing Referrals OIG Q: 6.001 • See Intra-system Transfers
(25)
MITs 1.003-006 Nursing Sick Call MedSATS • Clinic (each clinic tested)
(5 per clinic) • Appointment date (2–9 months)
(30) • Randomize
MIT 1.007 Returns from OIG Q: 4.007 • See Health Information Management (Medical
Community Hospital Records) (returns from community hospital)
(17)
MIT 1.008 Specialty Services OIG Q: 14.001 & • See Specialty Services
Follow-up 14.003
(30)
MIT 1.101 Availability of Health OIG onsite • Randomly select one housing unit from each yard
Care Services review
Request Forms
(6)
Diagnostic Services
MITs 2.001–003 Radiology Radiology Logs • Appointment date (90 days–9 months)
• Randomize
(10) • Abnormal
MITs 2.004–006 Laboratory Quest • Appt. date (90 days–9 months)
• Order name (CBC or CMPs only)
• Randomize
(10) • Abnormal
MITs 2.007–009 Pathology InterQual • Appt. date (90 days–9 months)
• Service (pathology related)
(10) • Randomize
Avenal State Prison, Cycle 5 Medical Inspection Page 79
Office of the Inspector General State of California
Sample Category
Quality (number of
Indicator samples) Data Source Filters
Health Information Management (Medical Records)
MIT 4.001 Timely Scanning OIG Qs: 1.001, • Non-dictated documents
(10) 1.002, & 1.004 • 1st 10 IPs MIT 1.001, 1st 5 IPs MITs 1.002, 1.004
MIT 4.002 OIG Q: 1.001 • Dictated documents
(1) • First 20 IPs selected
MIT 4.003 OIG Qs: 14.002 • Specialty documents
(20) & 14.004 • First 10 IPs for each question
MIT 4.004 OIG Q: 4.007 • Community hospital discharge documents
(16) • First 20 IPs selected
MIT 4.005 OIG Q: 7.001 • MARs
(0) • First 20 IPs selected
MIT 4.006 Documents for • Any misfiled or mislabeled document identified
(16) any tested inmate during OIG compliance review (24 or more = No)
MIT 4.007 Returns From Inpatient claims • Date (2–8 months)
Community Hospital data • Most recent 6 months provided (within date range)
• Rx count
• Discharge date
• Randomize (each month individually)
• First 5 patients from each of the 6 months (if not 5
in a month, supplement from another, as needed)
(17)
Health Care Environment
MIT 5.101-105 Clinical Areas OIG inspector • Identify and inspect all onsite clinical areas.
MIT 5.107–111 (10) onsite review
Inter- and Intra-System Transfers
MIT 6.001-003 Intra-System SOMS • Arrival date (3–9 months)
Transfers • Arrived from (another CDCR facility)
• Rx count
• Randomize
(25)
MIT 6.004 Specialty Services MedSATS • Date of transfer (3–9 months)
Send-Outs • Randomize
(7)
MIT 6.101 Transfers Out OIG inspector • R&R IP transfers with medication
(6) onsite review
Avenal State Prison, Cycle 5 Medical Inspection Page 80
Office of the Inspector General State of California
Sample Category
Quality (number of
Indicator samples) Data Source Filters
Pharmacy and Medication Management
MIT 7.001 Chronic Care OIG Q: 1.001 See Access to Care
Medication • At least one condition per patient—any risk level
• Randomize
(25)
MIT 7.002 New Medication Master Registry • Rx count
Orders • Randomize
(25) • Ensure no duplication of IPs tested in MIT 7.001
MIT 7.003 Returns from OIG Q: 4.007 • See Health Information Management (Medical
Community Hospital Records) (returns from community hospital)
(17)
MIT 7.004 RC Arrivals – OIG Q: 12.001 • See Reception Center Arrivals
Medication Orders
(N/A at this
institution)
MIT 7.005 Intra-Facility Moves MAPIP transfer • Date of transfer (2–8 months)
data • To location/from location (yard to yard and
to/from ASU)
• Remove any to/from MHCB
• NA/DOT meds (and risk level)
(25)
• Randomize
MIT 7.006 En Route SOMS • Date of transfer (2–8 months)
• Sending institution (another CDCR facility)
• Randomize
(0) • NA/DOT meds
MITs 7.101-103 Medication Storage OIG inspector • Identify and inspect clinical & med line areas that
Areas onsite review store medications
(varies by test)
MITs 7.104–106 Medication OIG inspector • Identify and inspect onsite clinical areas that
Preparation and onsite review prepare and administer medications
Administration Areas
(varies by test)
MITs 7.107-110 Pharmacy OIG inspector • Identify & inspect all onsite pharmacies
(1) onsite review
MIT 7.111 Medication Error Monthly • All monthly statistic reports with Level 4 or higher
Reporting medication error • Select a total of 5 months
(25) reports
MIT 7.999 Isolation Unit KOP Onsite active • KOP rescue inhalers & nitroglycerin medications
Medications medication for IPs housed in isolation units
(0) listing
Prenatal and Post-Delivery Services
MIT 8.001-007 Recent Deliveries OB Roster • Delivery date (2–12 months)
(N/A at this • Most recent deliveries (within date range)
institution)
Pregnant Arrivals OB Roster • Arrival date (2–12 months)
• Earliest arrivals (within date range)
(N/A at this
institution)
Avenal State Prison, Cycle 5 Medical Inspection Page 81
Office of the Inspector General State of California
Sample Category
Quality (number of
Indicator samples) Data Source Filters
Preventive Services
MITs 9.001–002 TB Medications Maxor • Dispense date (past 9 months)
• Time period on TB meds (3 months or 12 weeks)
(12) • Randomize
MIT 9.003 TB Evaluation, SOMS • Arrival date (at least 1 year prior to inspection)
Annual Screening • Birth Month
(30) • Randomize
MIT 9.004 Influenza SOMS • Arrival date (at least 1 year prior to inspection)
Vaccinations • Randomize
(25) • Filter out IPs tested in MIT 9.008
MIT 9.005 Colorectal Cancer SOMS • Arrival date (at least 1 year prior to inspection)
Screening • Date of birth (51 or older)
(25) • Randomize
MIT 9.006 Mammogram SOMS • Arrival date (at least 2 yrs prior to inspection)
(N/A at this • Date of birth (age 52–74)
institution) • Randomize
MIT 9.007 Pap Smear SOMS • Arrival date (at least three yrs prior to inspection)
(N/A at this • Date of birth (age 24–53)
institution) • Randomize
MIT 9.008 Chronic Care OIG Q: 1.001 • Chronic care conditions (at least 1 condition per
Vaccinations IP—any risk level)
• Randomize
(25) • Condition must require vaccination(s)
MIT 9.009 Valley Fever Cocci transfer • Reports from past 2–8 months
(number will vary) status report • Institution
• Ineligibility date (60 days prior to inspection date)
(20) • All
Avenal State Prison, Cycle 5 Medical Inspection Page 82
Office of the Inspector General State of California
Sample Category
Quality (number of
Indicator samples) Data Source Filters
Reception Center Arrivals
MITs 12.001–008 RC SOMS • Arrival date (2–8 months)
(N/A at this • Arrived from (county jail, return from parole, etc.)
institution) • Randomize
Specialized Medical Housing
MITs 13.001–003 OHU CADDIS • Admit date (1–6 months)
• Type of stay (no MH beds)
• Length of stay (minimum of 5 days)
(10) • Randomize
MIT 13.101 Call Buttons OIG inspector • Review by location
OHU onsite review
(all)
Specialty Services
MITs 14.001–002 High-Priority MedSATS • Approval date (3–9 months)
(15) • Randomize
MITs 14.003–004 Routine MedSATS • Approval date (3–9 months)
• Remove optometry, physical therapy or podiatry
(15) • Randomize
MIT 14.005 Specialty Services MedSATS • Arrived from (other CDCR institution)
Arrivals • Date of transfer (3–9 months)
(20) • Randomize
MIT 14.006-007 Denials InterQual • Review date (3–9 months)
(7) • Randomize
IUMC/MAR • Meeting date (9 months)
Meeting Minutes • Denial upheld
(13) • Randomize
Avenal State Prison, Cycle 5 Medical Inspection Page 83
Office of the Inspector General State of California
Sample Category
Quality (number of
Indicator samples) Data Source Filters
Administrative Operations
MIT 15.001 Medical Appeals Monthly medical • Medical appeals (12 months)
(all) appeals reports
MIT 15.002 Adverse/Sentinel Adverse/sentinel • Adverse/sentinel events (2–8 months)
Events events report
(0)
MITs 15.003–004 QMC Meetings Quality • Meeting minutes (12 months)
Management
Committee
(6) meeting minutes
MIT 15.005 EMRRC EMRRC meeting • Monthly meeting minutes (6 months)
(12) minutes
MIT 15.006 LGB LGB meeting • Quarterly meeting minutes (12 months)
(0) minutes
MIT 15.101 Medical Emergency Onsite summary • Most recent full quarter
Response Drills reports & • Each watch
documentation
(3) for ER drills
MIT 15.102 2nd Level Medical Onsite list of • Medical appeals denied (6 months)
Appeals appeals/closed
(10) appeals files
MIT 15.103 Death Reports Institution-list of • Most recent 10 deaths
deaths in prior 12 • Initial death reports
(0) months
MIT 15.104 RN Review Onsite supervisor • RNs who worked in clinic or emergency setting
Evaluations periodic RN six or more days in sampled month
reviews • Randomize
(5)
MIT 15.105 Nursing Staff Onsite nursing • On duty one or more years
Validations education files • Nurse administers medications
(10) • Randomize
MIT 15.106 Provider Annual Onsite • All required performance evaluation documents
Evaluation Packets provider
(9) evaluation files
MIT 15.107 Provider licenses Current provider • Review all
listing (at start of
(12) inspection)
MIT 15.108 Medical Emergency Onsite • All staff
Response certification o Providers (ACLS)
Certifications tracking logs o Nursing (BLS/CPR)
(all) • Custody (CPR/BLS)
MIT 15.109 Nursing staff and Onsite tracking • All required licenses and certifications
Pharmacist in system, logs, or
Charge Professional employee files
Licenses and
Certifications
(all)
Avenal State Prison, Cycle 5 Medical Inspection Page 84
Office of the Inspector General State of California
Sample Category
Quality (number of
Indicator samples) Data Source Filters
Administrative Operations
MIT 15.110 Pharmacy and Onsite listing of • All DEA registrations
Providers’ Drug provider DEA
Enforcement Agency registration #s &
(DEA) Registrations pharmacy
registration
(all) document
MIT 15.111 Nursing Staff New Nursing staff • New employees (hired within last 12 months)
Employee training logs •
Orientations
(all)
MIT 15.998 Death Review OIG summary • Between 35 business days & 12 months prior
Committee log - deaths • CCHCS death reviews
(0)
Avenal State Prison, Cycle 5 Medical Inspection Page 85
Office of the Inspector General State of California
C C
ALIFORNIA ORRECTIONAL
H C S ’
EALTH ARE ERVICES
R
ESPONSE
Avenal State Prison, Cycle 5 Medical Inspection Page 86
Office of the Inspector General State of California