California City Correctional Facility Medical Inspection Report Cycle 4

Robert A. Barton Office of the Inspector General Inspector General California City Correctional Facility Medical Inspection Results Cycle 4 January 2017 Medical Inspection Unit Page 1 Office of the Inspector General State of California Office of the Inspector General CALIFORNIA CITY CORRECTIONAL FACILITY Medical Inspection Results Cycle 4 Robert A. Barton Inspector General Roy W. Wesley Chief Deputy Inspector General Shaun R. Spillane Public Information Officer January 2017 TABLE OF CONTENTS Executive Summary ............................................................................................................................. i Overall Assessment: Proficient ............................................................................................. iii Clinical Case Review and OIG Clinician Inspection Results ............................................... iii Compliance Testing Results.................................................................................................. iv Population-Based Metrics ..................................................................................................... ix Introduction ......................................................................................................................................... 1 About the Institution ........................................................................................................................... 1 Objectives, Scope, and Methodology.................................................................................................. 5 Case Reviews ................................................................................................................................... 6 Patient Selection for Retrospective Case Reviews .................................................................... 6 Benefits and Limitations of Targeted Subpopulation Review .................................................. 7 Case Reviews Sampled ............................................................................................................. 8 Compliance Testing ......................................................................................................................... 9 Sampling Methods for Conducting Compliance Testing .......................................................... 9 Scoring of Compliance Testing Results .................................................................................... 9 Dashboard Comparisons ......................................................................................................... 10 Overall Quality Indicator Rating for Case Reviews and Compliance Testing .............................. 10 Population-Based Metrics .............................................................................................................. 11 Medical Inspection Results ............................................................................................................... 12 Primary (Clinical) Quality Indicators of Health Care .................................................................... 12 Access to Care ......................................................................................................................... 13 Case Review Results ............................................................................................................ 13 Compliance Testing Results................................................................................................. 15 Recommendations ................................................................................................................ 16 Diagnostic Services ................................................................................................................. 17 Case Review Results ............................................................................................................ 17 Compliance Testing Results................................................................................................. 18 Recommendations ................................................................................................................ 18 Emergency Services................................................................................................................. 19 Case Review Results ............................................................................................................ 19 Recommendations ................................................................................................................ 21 Health Information Management (Medical Records) ............................................................. 22 Case Review Results ............................................................................................................ 22 Compliance Testing Results................................................................................................. 23 Recommendations ................................................................................................................ 24 Health Care Environment ....................................................................................................... 25 Compliance Testing Results................................................................................................. 25 Recommendation for CCHCS .............................................................................................. 27 Recommendations for CAC ................................................................................................. 27 California City Correctional Facility, Cycle 4 Medical Inspection Table of Contents Office of the Inspector General State of California Inter- and Intra-System Transfers ........................................................................................... 28 Case Review Results ............................................................................................................ 28 Compliance Testing Results................................................................................................. 30 Recommendation ................................................................................................................. 31 Pharmacy and Medication Management ................................................................................ 32 Case Review Results ............................................................................................................ 32 Compliance Testing Results................................................................................................. 34 Recommendations ................................................................................................................ 36 Preventive Services ................................................................................................................. 37 Compliance Testing Results................................................................................................. 37 Recommendations ................................................................................................................ 38 Quality of Nursing Performance ............................................................................................. 39 Case Review Results ............................................................................................................ 39 Recommendations ................................................................................................................ 42 Quality of Provider Performance ............................................................................................ 43 Case Review Results ............................................................................................................ 43 Recommendations ................................................................................................................ 45 Specialty Services .................................................................................................................... 46 Case Review Results ............................................................................................................ 46 Compliance Testing Results................................................................................................. 47 Recommendations ................................................................................................................ 47 Secondary (Administrative) Quality Indicators of Health Care..................................................... 48 Internal Monitoring, Quality Improvement, and Administrative Operations ......................... 49 Compliance Testing Results................................................................................................. 49 Recommendations ................................................................................................................ 51 Job Performance, Training, Licensing, and Certifications ..................................................... 52 Compliance Testing Results................................................................................................. 52 Recommendations ................................................................................................................ 53 Population-Based Metrics .............................................................................................................. 54 Appendix A — Compliance Test Results ......................................................................................... 57 Appendix B — Clinical Data ............................................................................................................ 70 Appendix C — Compliance Sampling Methodology ....................................................................... 73 California Correctional Health Care Services’ Response ................................................................. 80 California City Correctional Facility, Cycle 4 Medical Inspection Table of Contents Office of the Inspector General State of California LIST OF TABLES AND FIGURES Health Care Quality Indicators ........................................................................................................... ii CAC Executive Summary Table ..................................................................................................... viii CAC Health Care Staffing Resources as of May 2016 ........................................................................ 2 CAC Master Registry Data as of May 9, 2016 .................................................................................... 3 Commonly Used Abbreviations .......................................................................................................... 4 CAC Results Compared to State and National HEDIS Scores .......................................................... 56 California City Correctional Facility, Cycle 4 Medical Inspection List of Tables and Figures Office of the Inspector General State of California EXECUTIVE SUMMARY Pursuant to California Penal Code Section 6126, 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 court may find that an institution the OIG found to be providing adequate care still did not meet constitutional standards, depending on the analysis of the underlying data provided by the OIG. Likewise, an institution that has been rated inadequate by the OIG could still be found to pass constitutional muster with the implementation of remedial measures if the underlying data were to reveal easily mitigated deficiencies. 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. For this fourth cycle of inspections, the OIG added a clinical case review component and significantly enhanced the compliance portion of the inspection process from that used in prior cycles. In addition, the OIG added a population-based metric comparison of selected Healthcare Effectiveness Data Information Set (HEDIS) measures from other State and national health care organizations and compared that data to similar results for the California City Correctional Facility (CAC). The OIG performed its Cycle 4 medical inspection at CAC from May to July 2016. The inspection included in-depth reviews of 51 inmate-patient files conducted by clinicians, as well as reviews of documents from 318 inmate-patient files, covering 86 objectively scored tests of compliance with policies and procedures applicable to the delivery of medical care. The OIG assessed the case review and compliance results at CAC using 13 health care quality indicators applicable to the institution, made up of 11 primary clinical indicators and 2 secondary administrative indicators. To conduct clinical case reviews, the OIG employs a clinician team consisting of a physician and a registered nurse consultant, while compliance testing is done by a team of deputy inspectors general and registered nurses trained in monitoring medical policy compliance. Of the 11 primary indicators, 6 were rated by both case review clinicians and compliance inspectors, 3 were rated by case review clinicians only, and 2 were rated by compliance inspectors only; both secondary indicators were rated by compliance inspectors only. See the Health Care Quality Indicators table on page ii. Based on that analysis, OIG experts made a considered and measured overall opinion that the quality of health care at CAC was proficient. California City Correctional Facility, Cycle 4 Medical Inspection Page i Office of the Inspector General State of California Health Care Quality Indicators All Institutions– Fourteen Primary Indicators (Clinical) CAC Applicability Applicability Both case review 1–Access to Care All institutions and compliance Both case review 2–Diagnostic Services All institutions and compliance 3–Emergency Services All institutions Case review only 4–Health Information Management Both case review All institutions (Medical Records) and compliance 5–Health Care Environment All institutions Compliance only Both case review 6–Inter- and Intra-System Transfers All institutions and compliance Both case review 7–Pharmacy and Medication Management All institutions and compliance Female institutions 8–Prenatal and Post-Delivery Services Not Applicable only 9–Preventive Services All institutions Compliance only 10–Quality of Nursing Performance All institutions Case review only 11–Quality of Provider Performance All institutions Case review only Institutions with 12–Reception Center Arrivals Not Applicable reception centers All institutions with 13–Specialized Medical Housing an OHU, CTC, SNF, Not Applicable (OHU, CTC, SNF, Hospice) or Hospice Both case review 14–Specialty Services All institutions and compliance Two Secondary Indicators All Institutions– CAC Applicability (Administrative) Applicability 15–Internal Monitoring, Quality Improvement, and Administrative All institutions Compliance only Operations 16–Job Performance, Training, Licensing, All institutions Compliance only and Certifications California City Correctional Facility, Cycle 4 Medical Inspection Page ii Office of the Inspector General State of California Overall Assessment: Proficient Based on the clinical case reviews and compliance testing, the OIG’s overall assessment rating for CAC was proficient. Of the Overall Assessment 11 primary (clinical) quality indicators applicable to CAC, the Rating: OIG found 7 proficient, 4 adequate, and none inadequate. Of the two secondary (administrative) quality indicators, the OIG found Proficient both inadequate. To determine the overall assessment for CAC, the OIG considered individual clinical ratings and individual compliance question scores within each of the indicator categories, putting emphasis on the primary indicators. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed at CAC. Clinical Case Review and OIG Clinician Inspection Results The clinicians’ case reviews sampled patients with high medical needs and included a review of 860 patient care events.1 Of the 11 primary indicators applicable to CAC, 9 were evaluated by clinician case review; 2 were proficient, 7 were adequate, and none was inadequate. When determining the overall adequacy of care, the OIG 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 onsite may be adequate. The OIG clinicians identify inadequate medical care based on the risk of significant harm to the patient, not the actual outcome. Program Strengths — Clinical  CAC providers delivered good care, making appropriate assessments and sound medical plans for most patients. The chief medical executive (CME) and the chief physician & surgeon (CP&S) were committed to patient care and quality improvement.  CAC had an effective specialty services department, and staff had established an effective tracking process to ensure that patients received their appointments and diagnostic procedures timely.  CAC provided effective access to care. Each of the three clinics had an office technician who ensured that all provider and nursing appointments were completed.  CAC nursing staff and the interdisciplinary team had a valuable structured daily huddle. The teams worked cooperatively to provide integrated primary care to patients. Each clinic was 1 Each OIG clinician team includes a board-certified physician and registered nurse consultant with experience in correctional and community medical settings. California City Correctional Facility, Cycle 4 Medical Inspection Page iii Office of the Inspector General State of California adequately staffed with two registered nurses (RNs) and two licensed vocational nurse (LVN) care coordinators.  CAC nursing staff, custody, and office technicians maintained positive morale and felt they had a constructive working relationship with nursing leadership. All the providers expressed general job satisfaction with their positions. Program Weaknesses — Clinical  There were two areas, the triage and treatment area (TTA) and the receiving and release clinic (R&R), where the CAC nursing leadership team showed room for improvement in monitoring and evaluating staff and improving the process of patient education and training. This was evident with patients returning from outside hospitals, such as those who had undergone invasive procedures, such as a cardiac catheterization. Some of these patients did not receive any aftercare instructions. The TTA staff received and reviewed requests for health care services, and there were cases in which nursing staff failed to recognize the need to intervene emergently, resulting in delays of treatment. Compliance Testing Results Of the 13 health care indicators applicable to CAC, 10 were evaluated by compliance inspectors.2 There were 86 individual compliance questions within those 10 indicators, generating 981 data points, which tested CAC’s compliance with California Correctional Health Care Services (CCHCS) policies and procedures.3 Those 86 questions are detailed in Appendix A — Compliance Test Results. The institution’s inspection scores in the 10 applicable indicators ranged from 58.3 percent to 95.0 percent, with the secondary indicator Job Performance, Training, Licensing, and Certifications receiving the lowest score, and the primary indicator Preventive Services receiving the highest. Of the eight primary indicators applicable to compliance testing, the OIG rated seven proficient, one adequate, and none inadequate. Of the two secondary indicators, which involve administrative health care functions, both were rated inadequate. Program Strengths — Compliance As the CAC Executive Summary Table on page viii indicates, the institution’s compliance ratings were proficient, scoring above 85 percent, in the following seven primary indicators: Access to Care, Health Information Management (Medical Records), Health Care Environment, Inter- and Intra-System Transfers, Pharmacy and Medication Management, Preventive Services, and Specialty Services. The following are some of CAC’s strengths based on its compliance scores on individual questions in all the primary health care indicators: 2 The OIG’s compliance inspectors are trained deputy inspectors general and 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. California City Correctional Facility, Cycle 4 Medical Inspection Page iv Office of the Inspector General State of California  Patients had a standardized process to obtain and submit request forms for health care services; nursing staff timely reviewed patients’ requests and timely completed face-to-face visits with patients.  Providers conducted timely appointments with patients referred for a follow-up visit by a provider and with patients who were released from a community hospital and returned to the institution.  Health records staff timely scanned Initial Health Screening forms (CDCR Form 7277), health care services request forms, handwritten progress notes, specialty reports, hospital discharge reports, and medication administration records into patients’ electronic medical records.  Providers timely reviewed hospital discharge reports when patients returned to the institution.  All clinics were appropriately disinfected, cleaned, and sanitized, and each contained operable sinks and sufficient hand hygiene supplies. Clinical staff properly controlled exposure to blood-borne pathogens and contamination, and properly sterilized or disinfected medical equipment.  The institution followed adequate protocols for managing and storing bulk medical supplies in its clinical areas and warehouse.  For patients newly arriving at CAC from other CDCR institutions, nursing staff properly documented an assessment and disposition on the initial health screening forms, and signed and dated the form on the same day the patient arrived at the institution.  Nursing staff ensured that patients transferred from CAC to other institutions with complete transfer packets and all applicable medications, and that specialty service appointments were identified on the Health Care Transfer Information form (CDCR Form 7371).  Nursing staff timely delivered or administered prescribed medications without interruption for patients who suffered with chronic care conditions, patients with newly ordered medications, patients who returned to the institution from hospitals, and patients who transferred from one housing unit to another.  Nurses employed appropriate administrative controls and followed proper protocols while preparing patients’ medications.  In its main pharmacy, CAC followed general security, organization, and cleanliness management protocols; properly stored and monitored refrigerated, frozen, and California City Correctional Facility, Cycle 4 Medical Inspection Page v Office of the Inspector General State of California non-refrigerated medications; properly accounted for narcotic medications; and followed key medication error reporting protocols.  The institution timely offered or provided patients with required tuberculosis medications, immunizations, and colorectal cancer screenings.  Patients at the highest risk of contracting valley fever were timely transferred out of the institution.  When a specialty service was performed, providers timely reviewed the specialist’s report; when providers’ specialty services requests were denied, the denial occurred within the required time frame, and the provider timely communicated the denial to the patient. The following are some of the strengths identified within the two secondary administrative indicators:  CAC promptly processed patients’ initial medical appeals during the most recent 12 months and addressed all appealed issues when responding to patients’ second-level medical appeals.  All nursing staff who administered medications possessed current clinical competency validations. Program Weaknesses — Compliance The institution received no ratings of inadequate, scoring below 75 percent, in the primary indicators, but did receive inadequate ratings in both secondary indicators, Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications. The following are some of the weaknesses identified by CAC’s compliance scores for individual questions in all the primary health care indicators:  Providers did not always timely see newly arrived patients who were referred to them as a result of nurses’ initial health care assessments.  Most clinics were lacking some essential equipment and supplies in the common areas and exam rooms, and many clinics had exam rooms that did not have an environment conducive to providing adequate medical services.  Sampled patients who transferred into CAC from other institutions with previously approved or scheduled specialty service appointments often received their appointments late. California City Correctional Facility, Cycle 4 Medical Inspection Page vi Office of the Inspector General State of California The following are some of the weaknesses identified within the two secondary administrative indicators:  Emergency Medical Response Review Committee incident review packages and emergency response drill packages lacked required documentation.  Clinical supervisors did not complete structured performance appraisals of providers and appropriate periodic reviews of nursing staff.  Nursing staff did not receive new employee orientation training within 30 days of being hired. The CAC Executive Summary Table on the following page lists the quality indicators the OIG inspected and assessed during the clinical case reviews and objective compliance tests, and provides the institution’s rating in each area. The overall indicator ratings were based on a consensus decision by the OIG’s clinicians and non-clinical inspectors. California City Correctional Facility, Cycle 4 Medical Inspection Page vii Office of the Inspector General State of California CAC Executive Summary Table Case Compliance Overall Indicator Primary Indicators (Clinical) Review Rating Rating Rating Access to Care Proficient Proficient Proficient Diagnostic Services Adequate Adequate Adequate Emergency Services Adequate Not applicable Adequate Health Information Management Adequate Proficient Proficient (Medical Records) Health Care Environment Not applicable Proficient Proficient Inter- and Intra-System Transfers Adequate Proficient Proficient Pharmacy and Medication Management Adequate Proficient Proficient Preventive Services Not applicable Proficient Proficient Quality of Nursing Performance Adequate Not applicable Adequate Quality of Provider Performance Adequate Not applicable Adequate Specialty Services Proficient Proficient Proficient The Prenatal and Post-Delivery Services, Reception Center Arrivals, and Specialized Medical Housing (OHU, CTC, SNF, and Hospice) indicators did not apply to this institution. Case Compliance Overall Indicator Secondary Indicators (Administrative) Review Rating Rating Rating Internal Monitoring, Quality Improvement, Not applicable Inadequate Inadequate and Administrative Operations Job Performance, Training, Licensing, and Not applicable Inadequate Inadequate Certifications Compliance results for quality indicators are proficient (greater than 85.0 percent), adequate (75.0 percent to 85.0 percent), or inadequate (below 75.0 percent). California City Correctional Facility, Cycle 4 Medical Inspection Page viii Office of the Inspector General State of California Population-Based Metrics The institution performed adequately as measured by population-based metrics. Statewide, the institution outperformed Medi-Cal in all five comprehensive diabetic care measures, and outperformed Kaiser in four of the five measures; CAC scored lower than Kaiser did in blood pressure control for diabetic patients. Nationally, CAC outperformed Medicaid, Medicare, and commercial health plans in all five diabetic measures; the institution outperformed or matched the United States Department of Veterans Affairs (VA) in three of the four applicable measures, and scored only 1 percentage point lower than the VA in diabetic patient eye exams. With regard to influenza shots for younger adults, the institution performed more poorly than all statewide and national health care organizations. However, CAC offered the immunization to all patients sampled, but 55 percent of them refused it, which negatively affected the institution’s score. The institution outperformed or matched all statewide and national health care organizations for colorectal cancer screenings. Overall, CAC’s performance calculated by population-based metrics demonstrated a generally adequate chronic care and preventive services program. The institution could improve some scores by making interventions to lower patients’ refusal rates. California City Correctional Facility, Cycle 4 Medical Inspection Page ix Office of the Inspector General State of California INTRODUCTION Under the authority of California Penal Code Section 6126, 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. For this fourth cycle of inspections, the OIG augmented the breadth and quality of its inspection program used in prior cycles, adding a clinical case review component and significantly enhancing the compliance component of the program. The California City Correctional Facility (CAC) was the 30th Medical Inspection of Cycle 4. During the inspection process, the OIG assessed the delivery of medical care to patients in 11 primary clinical health care indicators and 2 secondary administrative health care indicators applicable to the institution. It is important to note that while the primary quality indicators represent the clinical care being provided by the institution at the time of the inspection, the secondary quality indicators are purely administrative and are not reflective of the actual clinical care provided. The OIG is committed to reporting on each institution’s delivery of medical care to assist in identifying areas for improvement, but the federal court will ultimately determine whether any institution’s medical care meets constitutional standards. ABOUT THE INSTITUTION The California City Correctional Facility was activated December 2013 and primarily houses low-level general population inmates. CAC is committed to protecting public safety, ensuring the safety of CDCR personnel, and providing proper care and supervision of all offenders under its jurisdiction while offering opportunities for successful reentry into society. The institution operates seven clinics in which staff members handle non-urgent requests for medical services, including six facility clinics and a specialty clinic. CAC also conducts screenings in its receiving and release clinical area (R&R) and treats patients needing urgent or emergency care in its triage and treatment area (TTA). Patients who require a higher level of inpatient care are transferred to other nearby institutions. California Correctional Health Care Services (CCHCS) has designated CAC a “basic” care institution. Basic institutions are located 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-patient population. At the time of this report, CAC had not yet received a review from the Commission on Accreditation for Corrections, a professional peer review process based on national standards set by the American Correctional Association. The institution’s first review was planned for late November 2016. California City Correctional Facility, Cycle 4 Medical Inspection Page 1 Office of the Inspector General State of California Based on staffing data the OIG obtained from the institution, CAC’s vacancy rate among medical managers, providers, nursing supervisors, and non-supervisory nurses was six percent in May 2016, with all the vacancies for non-supervisory nursing staff. As indicated below, CAC showed that two staff members were redirected to non-patient care areas as of May 2016. Those positions represented two staff members who were temporarily loaned to other institutions; both of them had returned to CAC by September 2016. CAC Health Care Staffing Resources as of May 2016 Primary Care Nursing Management Nursing Staff Totals Providers Supervisors Description Number % Number % Number % Number % Number % Authorized 5 8% 4.7 8% 8.3 13% 44.6 71% 62.6 100% Positions Filled Positions 5 100% 4.7 100% 8.3 100% 41 92% 59 94% Vacancies 0 0% 0 0% 0 0% 3.6 8% 3.6 6% Recent Hires (within 12 4 80% 1 21% 2 24% 9 22% 16 27% months) Staff Utilized 0 0% 0 0% 0 0% 0 0% 0 0% from Registry Redirected Staff (to Non-Patient 1 20% 0 0% 1 12% 0 0% 2 3% Care Areas) Staff on Long-term 1 20% 0 0% 0 0% 2 5% 3 5% Medical Leave Note: CAC Health Care Staffing Resources data was not validated by the OIG. California City Correctional Facility, Cycle 4 Medical Inspection Page 2 Office of the Inspector General State of California As of May 9, 2016, the Master Registry for CAC showed that the institution had a total population of 1,828. Within that total population, zero percent were designated as high medical risk, Priority 1 (High 1), and 0.2 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 labs 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 are 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. CAC Master Registry Data as of May 9, 2016 Medical Risk Level # of Inmate-Patients Percentage High 1 0 0.0% High 2 3 0.2% Medium 332 18.2% Low 1,493 81.6% Total 1,828 100.0% California City Correctional Facility, Cycle 4 Medical Inspection Page 3 Office of the Inspector General State of California Commonly Used Abbreviations ACLS Advanced Cardiovascular Life Support HIV Human Immunodeficiency Virus AHA American Heart Association HTN Hypertension ASU Administrative Segregation Unit INH Isoniazid (anti-tuberculosis medication) BLS Basic Life Support IV Intravenous CBC Complete Blood Count KOP Keep-on-Person (in taking medications) CC Chief Complaint LPT Licensed Psychiatric Technician CCHCS California Correctional Health Care Services LVN Licensed Vocational Nurse CCP Chronic Care Program MAR Medication Administration Record California Department of Corrections and CDCR MRI Magnetic Resonance Imaging Rehabilitation CEO Chief Executive Officer MD Medical Doctor CHF Congestive Heart Failure NA Nurse Administered (in taking medications) CME Chief Medical Executive N/A Not Applicable CMP Comprehensive Metabolic (Chemistry) Panel NP Nurse Practitioner CNA Certified Nursing Assistant OB Obstetrician CNE Chief Nurse Executive OHU Outpatient Housing Unit C/O Complains of OIG Office of the Inspector General COPD Chronic Obstructive Pulmonary Disease P&P Policies and Procedures (CCHCS) CP&S Chief Physician and Surgeon PA Physician Assistant CPR Cardio-Pulmonary Resuscitation PCP Primary Care Provider CSE Chief Support Executive POC Point of Contact CT Computerized Tomography PPD Purified Protein Derivative CTC Correctional Treatment Center PRN As Needed (in taking medications) DM Diabetes Mellitus RN Registered Nurse Directly Observed Therapy (in taking DOT Rx Prescription medications) Dx Diagnosis SNF Skilled Nursing Facility Subjective, Objective, Assessment, Plan, EKG Electrocardiogram SOAPE Education ENT Ear, Nose and Throat SOMS Strategic Offender Management System ER Emergency Room S/P Status Post eUHR electronic Unit Health Record TB Tuberculosis FTF Face-to-Face TTA Triage and Treatment Area History and Physical (reception center H&P UA Urinalysis examination) HIM Health Information Management UM Utilization Management California City Correctional Facility, Cycle 4 Medical Inspection Page 4 Office of the Inspector General State of California OBJECTIVES, SCOPE, AND METHODOLOGY 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 14 primary (clinical) and 2 secondary (administrative) quality indicators 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 indicators address the administrative functions that support a health care delivery system. The 14 primary quality indicators are Access to Care, Diagnostic Services, Emergency Services, Health Information Management (Medical Records), Health Care Environment, Inter- and Intra-System Transfers, Pharmacy and Medication Management, Prenatal and Post-Delivery Services, Preventive Services, Quality of Nursing Performance, Quality of Provider Performance, Reception Center Arrivals, Specialized Medical Housing (OHU, CTC, SNF, Hospice), and Specialty Services. The two secondary quality indicators are Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications. 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 deputy inspectors general and registered nurses. The ratings may be derived from the case review results alone, the compliance test results alone, or a combination of both these information sources. For example, the ratings for the primary quality indicators Quality of Nursing Performance and Quality of Provider Performance are derived entirely from the case review results, while the ratings for the primary quality indicators Health Care Environment and Preventive Services are derived entirely from compliance test results. As another example, primary quality indicators such as Diagnostic Services and Specialty Services receive ratings derived from both sources. At CAC, 13 of the quality indicators were applicable, consisting of 11 primary clinical indicators and 2 secondary administrative indicators. Of the 11 primary indicators, six were rated by both case review clinicians and compliance inspectors, three were rated by case review clinicians only, and two were rated by compliance inspectors only; both secondary indicators were rated by compliance inspectors only. California City Correctional Facility, Cycle 4 Medical Inspection Page 5 Office of the Inspector General State of California Consistent with the OIG’s agreement with the Receiver, this report only addresses the conditions found related to medical care criteria. The OIG does not review for efficiency and economy of operations. Moreover, if the OIG learns of an inmate-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, specific identifying details related to any such cases are not included in the OIG’s public report. 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 should not necessarily be interpreted as indicative of deficient medical care delivery. CASE REVIEWS The OIG has added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders. At the conclusion of Cycle 3, the federal Receiver and the Inspector General determined that the health care provided at the institutions was not fully evaluated by the compliance tool alone, and that the compliance tool was not designed to provide comprehensive qualitative assessments. Accordingly, the OIG added case reviews in which OIG physicians and nurses evaluate selected cases in detail to determine the overall quality of health care provided to the inmate-patients. The OIG’s clinicians perform a retrospective chart review of selected patient files to evaluate the care given by an institution’s primary care providers and nurses. Retrospective chart review is a well-established review process used by health care organizations that perform peer reviews and patient death reviews. Currently, CCHCS uses retrospective chart review as part of its death review process and in its pattern-of-practice reviews. CCHCS also uses a more limited form of retrospective chart review when performing appraisals of individual primary care providers. PATIENT SELECTION FOR RETROSPECTIVE CASE REVIEWS Because retrospective chart review is time consuming and requires qualified health care professionals to perform it, OIG clinicians must carefully sample patient records. Accordingly, the group of patients the OIG targeted for chart review carried the highest clinical risk and utilized the majority of medical services. As there were only three patients at PVSP classified by CCHCS as high-risk, the majority of the patients selected for retrospective chart review were patients with chronic care illnesses, including diabetes, that were classified as medium-risk. The reason the OIG targeted these patients for review is twofold: 1. The goal of retrospective chart 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 are considered high-risk and California City Correctional Facility, Cycle 4 Medical Inspection Page 6 Office of the Inspector General State of California account for more than half of the institution’s pharmaceutical, specialty, community hospital, and emergency costs. 2. Selecting this target group for chart 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 will be providing 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 charts generated during death reviews, sentinel events (unexpected occurrences involving death or serious injury, or risk thereof), and hospitalizations are mostly of high-risk patients. BENEFITS AND LIMITATIONS OF TARGETED SUBPOPULATION REVIEW Because the selected patients utilize the broadest range of services offered by the health care system, the OIG’s retrospective chart review provides adequate data for a qualitative assessment of the most vital system processes (referred to as “primary quality indicators”). Retrospective chart 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 ability of the institution to provide adequate 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 adequately care 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 conclusions from the retrospective chart reviews to the general population. For example, if the high-risk diabetic patients reviewed have poorly-controlled diabetes, one cannot conclude that the entire diabetic population is inadequately controlled. Similarly, if the high-risk diabetic patients under review have poor outcomes and require significant specialty interventions, one cannot conclude that the entire diabetic population is having similarly poor outcomes. California City Correctional Facility, Cycle 4 Medical Inspection Page 7 Office of the Inspector General State of California Nonetheless, the health care system’s response to this subpopulation can be accurately evaluated and yields valuable systems information. In the above example, if the health care system is providing appropriate diabetic monitoring, medication therapy, and specialty referrals for the high-risk patients reviewed, then it can be reasonably inferred that the health care system is also providing appropriate diabetic services to the entire diabetic subpopulation. However, if these same high-risk patients needing monitoring, medications, and referrals are generally not getting those services, it is likely that the health care system is not providing appropriate diabetic services to the greater diabetic subpopulation. CASE REVIEWS SAMPLED As indicated in Appendix B, Table B–1: CAC Sample Sets, the OIG clinicians evaluated medical charts for 51 unique inmate-patients. Appendix B, Table B–4: CAC Case Review Sample Summary, clarifies that both nurses and physicians reviewed charts for 22 of those patients, for 73 reviews in total. Physicians performed detailed reviews of 30 charts, and nurses performed detailed reviews of 17 charts, totaling 47 detailed reviews. For detailed case reviews, physicians or nurses looked at all encounters occurring in approximately six months of medical care. Nurses also performed a limited or focused review of medical records for an additional 25 inmate-patients. These generated 860 clinical events for review (Appendix B, Table B–3: CAC Event-Program). The inspection tool provides details on whether the encounter was adequate or had significant deficiencies, and identifies deficiencies by programs and processes to help the institution focus on improvement areas. While the sample method specifically pulled only 3 chronic care patient records, i.e., 3 diabetes patients (Appendix B, Table B–1: CAC Sample Sets), the 51 unique inmate-patients sampled included patients with 114 chronic care diagnoses, including 8 additional patients with diabetes, for a total of 11 (Appendix B, Table B–2: CAC 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 overall operation of the institution’s system and staff were assessed for adequacy. The OIG’s case review methodology and sample size matched other qualitative research. The empirical findings, supported by expert statistical consultants, showed adequate conclusions after 10 to 15 charts had undergone full clinician review. In qualitative statistics, this phenomenon is known as “saturation.” The OIG asserts that the physician sample size of 30 detailed reviews certainly far exceeds the saturation point necessary for an adequate qualitative review. With regard to reviewing charts from different providers, the case review is not intended to be a focused search for poorly performing providers; rather, it is focused on how the system cares for those patients who need care the most. Nonetheless, while not sampling cases by each provider at the institution, the OIG inspections adequately review most providers. Providers would only escape OIG case review if institutional management successfully mitigated patient risk by having the more poorly performing providers care for the less complicated, California City Correctional Facility, Cycle 4 Medical Inspection Page 8 Office of the Inspector General State of California low-utilizing, and lower-risk patients. The OIG’s clinicians concluded that the case review sample size was more than adequate to assess the quality of services provided. Based on the collective results of clinicians’ case reviews, the OIG rated each quality indicator as either proficient (excellent), adequate (passing), inadequate (failing), or not applicable. A separate confidential CAC Supplemental Medical Inspection Results: Individual Case Review Summaries report details the case reviews 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. COMPLIANCE TESTING SAMPLING METHODS FOR CONDUCTING COMPLIANCE TESTING From May to July 2016, deputy inspectors general and registered nurses 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 inmate-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 318 individual inmate-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 May 23, 2016, field inspectors conducted a detailed onsite inspection of CAC’s medical facilities and clinics; interviewed key institutional employees; and reviewed employee records, logs, medical appeals, death reports, and other documents. This generated 981 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 CAC’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 The OIG rated the institution in the following eight primary (clinical) and two secondary (administrative) quality indicators applicable to the institution for compliance testing:  Primary indicators: Access to Care, Diagnostic Services, Health Information Management (Medical Records), Health Care Environment, Inter- and Intra-System Transfers, Pharmacy California City Correctional Facility, Cycle 4 Medical Inspection Page 9 Office of the Inspector General State of California and Medication Management, Preventive Services, and Specialty Services (OHU, CTC, SNF, and Hospice).  Secondary indicators: Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications. After compiling the answers to the 86 questions, the OIG derived a score for each primary and secondary quality indicator identified above 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 percent), adequate (between 75 percent and 85 percent), or inadequate (less than 75 percent). DASHBOARD COMPARISONS In the first ten medical inspection reports of Cycle 4, the OIG identified where similar metrics for some of the individual compliance questions were available within the CCHCS Dashboard, which is a monthly report that consolidates key health care performance measures statewide and by institution. However, there was not complete parity between the metrics due to differing time frames for data collecting and differences in sampling methods, rendering the metrics unable to be compared. The OIG has removed the Dashboard comparisons to eliminate confusion. Dashboard data is available on CCHCS’s website, www.cphcs.ca.gov. 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 deputy inspectors general 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 inmate-patients. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed. California City Correctional Facility, Cycle 4 Medical Inspection Page 10 Office of the Inspector General State of California POPULATION-BASED METRICS The OIG identified a subset of Healthcare Effectiveness Data Information Set (HEDIS) measures applicable to the CDCR inmate-patient population. To identify outcomes for CAC, the OIG reviewed some of the compliance testing results, randomly sampled additional inmate-patients’ records, and obtained CAC data from the CCHCS Master Registry. The OIG compared those results to HEDIS metrics reported by other statewide and national health care organizations. California City Correctional Facility, Cycle 4 Medical Inspection Page 11 Office of the Inspector General State of California MEDICAL INSPECTION RESULTS PRIMARY (CLINICAL) QUALITY INDICATORS OF HEALTH CARE The primary quality indicators assess the clinical aspects of health care. As shown on the Health Care Quality Indicators table on page ii of this report, 11 of the OIG’s primary indicators were applicable to CAC. Of those 11 indicators, six were rated by both the case review and compliance components of the inspection, three were rated by the case review component alone, and two were rated by the compliance component alone. The CAC Executive Summary Table on page viii shows the case review and compliance ratings for each applicable indicator. Summary of Case Review Results: The clinical case review component assessed 9 of the 11 primary (clinical) indicators applicable to CAC. Of these nine indicators, OIG clinicians rated two proficient, seven adequate, and none inadequate. The OIG physicians rated the overall adequacy of care for each of the 30 detailed case reviews they conducted. Of these 30 cases, none was proficient, 29 were adequate, and one was inadequate. In the 860 events reviewed, there were 176 deficiencies, of which 20 were considered to be of such magnitude that, if left unaddressed, they would likely contribute to patient harm. Adverse Events Identified During Case Review: Medical care is a complex dynamic process with many moving parts, subject to human error even within the best health care organizations. Adverse events are typically identified and tracked by all major health care organizations for the purpose of quality improvement. They are not generally representative of medical care delivered by the organization. The OIG identified adverse events for the dual purposes of quality improvement and the illustration of problematic patterns of practice found during the inspection. Because of the anecdotal description of these events, the OIG cautions against drawing inappropriate conclusions regarding the institution based solely on adverse events.  There were no unsafe conditions or sentinel events identified in the case reviews at CAC. Summary of Compliance Results: The compliance component assessed 8 of the 11 primary (clinical) indicators applicable to CAC. Of these eight indicators, OIG inspectors rated seven proficient, one adequate, and none inadequate. The results of those assessments are summarized within this section of the report. The test questions used to assess compliance for each indicator are detailed in Appendix A. California City Correctional Facility, Cycle 4 Medical Inspection Page 12 Office of the Inspector General State of California ACCESS TO CARE This indicator evaluates the institution’s ability to provide Case Review Rating: inmate-patients with timely clinical appointments. Areas specific to Proficient inmate-patients’ access to care are reviewed, such as initial Compliance Score: assessments of newly arriving inmates, acute and chronic care Proficient follow-ups, face-to-face nurse appointments when an inmate-patient (87.9%) requests to be seen, provider referrals from nursing lines, and Overall Rating: follow-ups after hospitalization or specialty care. Compliance Proficient testing for this indicator also evaluates whether inmate-patients have Health Care Services Request forms (CDCR Form 7362) available in their housing units. Case Review Results The OIG clinicians reviewed 455 outpatient provider and nursing encounters and identified eight minor deficiencies. CAC performed well with regard to Access to Care, and the OIG clinicians rated this indicator proficient. Nurse-to-Provider Referrals Sick call nurses were required to refer the patient to a provider when the condition required a higher level of care. Within the 232 outpatient nursing encounters reviewed, there were two instances in which provider appointments did not occur timely and one in which the appointment did not occur.  In case 8, a nurse evaluated a patient for constipation and requested a provider appointment within 14 days. This appointment occurred more than two months later.  In case 9, a nurse evaluated a patient for arm pain and requested a provider appointment in three to five days. The appointment occurred ten days later.  In case 35, a nurse evaluated the patient for ear pain and requested a routine provider appointment. This appointment did not occur. Nursing Follow-up Appointments CAC performed well with nursing follow-up appointments, but there were two deficiencies:  In case 9, a nurse treated cuts on the patient’s feet. The requested follow-up in one week did not occur.  In case 16, a nurse treated earwax impaction and requested that the patient follow up in 48 hours. The appointment did not occur. California City Correctional Facility, Cycle 4 Medical Inspection Page 13 Office of the Inspector General State of California Provider-to-Provider Follow-up Appointments The institution performed well with provider-ordered follow-up appointments, which are among the most important aspects of the Access to Care indicator. Provider Follow-up After Specialty Service The providers generally evaluated their patients timely after specialty services appointments, but there was one delay:  In case 16, the patient had an esophagogastroduodenoscopy (imaging of the esophagus and stomach). The 14-day provider follow-up appointment did not occur until six weeks later. Specialty Service Appointments CAC performed well with specialty service appointments, but there were two deficiencies, one of which was significant (case 42):  In case 38, a provider requested a general surgery evaluation, but the patient was seen by an ear, nose, and throat (ENT) specialist.  In case 42, a provider requested to have the patient, with gastrointestinal bleeding, follow up with the gastroenterologist in four weeks. The appointment occurred 11 weeks later. Intra-System Transfer Nurses at CAC assessed patients transferring in and appropriately referred them to a provider, and providers evaluated the patients timely. Follow-up After Hospitalization Fifteen hospital or outside emergency department events were reviewed. The providers timely assessed all patients returning from higher levels of care. Clinician Onsite Inspection The OIG clinicians interviewed CAC staff regarding issues with access to care. Each of the three clinics had an office technician who attended the morning huddles and used a tracking process to ensure provider follow-up appointments were completed. The providers reported seeing 15 patients each day, and the clinic nurses saw about six patients each day on the nurse line. There were no backlogs in the three clinics. Conclusion CAC performed well with regard to Access to Care. The case review rating for CAC in this indicator was proficient. California City Correctional Facility, Cycle 4 Medical Inspection Page 14 Office of the Inspector General State of California Compliance Testing Results The institution performed in the proficient range in the Access to Care indicator, with a compliance score of 87.9 percent. CAC scored 100 percent on five of the six test areas, as described below:  Inmates had access to health care services request forms at all six housing units inspected (MIT 1.101).  Inspectors sampled 30 health care services request forms submitted by patients across all facility clinics. Nursing staff reviewed all forms on the same day they were received and completed a face-to-face encounter with all 30 patients within one business day of reviewing the request form (MIT 1.003, 1.004).  All six patients sampled who were referred to and seen by a provider, and for whom the provider ordered a sick call follow-up appointment, received a timely follow-up appointment (MIT 1.006).  CAC offered a follow-up appointment with a provider to patients within five days of discharge from a community hospital for all 12 patients sampled (MIT 1.007).  Among seven health care services request forms sampled on which nursing staff referred the patient for a provider appointment, six patients (86 percent) received a timely appointment. One patient’s form indicated a routine referral to a provider, but the related Nursing Assessment Protocol indicated no referral was needed. Inspectors did not find evidence that the patient was seen by a provider or that the patient refused the appointment (MIT 1.005). The institution performed adequately in the two areas below:  When the OIG reviewed recent appointments for 30 sampled patients with chronic care conditions, 25 patients (83 percent) received timely provider follow-up appointments. Four patients received chronic care appointments from 9 to 148 days late. For one patient, there was no evidence the appointment occurred at all (MIT 1.001).  Inspectors sampled 24 patients who received a high-priority or routine specialty service; 19 of them (79 percent) received a timely follow-up appointment with a provider. Five patients received follow-up appointments from 6 to 20 days late (MIT 1.008). The institution showed opportunity for improvement in the following test area:  Among seven patients sampled who had transferred into CAC from another institution and been referred to a provider based on nursing staff’s initial healthcare screening, only three (43 percent) received their follow-up appointments timely. Four patients received their follow-up appointments from 8 to 14 days late (MIT 1.002). California City Correctional Facility, Cycle 4 Medical Inspection Page 15 Office of the Inspector General State of California Recommendations No specific recommendations. California City Correctional Facility, Cycle 4 Medical Inspection Page 16 Office of the Inspector General State of California DIAGNOSTIC SERVICES This indicator addresses several types of diagnostic services. Case Review Rating: Specifically, it addresses whether radiology and laboratory services Adequate were timely provided to inmate-patients, whether the primary care Compliance Score: provider timely reviewed the results, and whether the results were Adequate communicated to the inmate-patient within the required time (77.3%) frames. In addition, for pathology services, the OIG determines Overall Rating: whether the institution received a final pathology report and Adequate whether the provider timely reviewed and communicated the pathology results to the patient. The case reviews also factor in the appropriateness, accuracy, and quality of the diagnostic test(s) ordered and the clinical response to the results. Case Review Results The OIG clinicians reviewed 105 events in diagnostic services and found 12 minor deficiencies. Most deficiencies were related to the health information management process, and one was related to scheduling. Most reviewed tests were performed as ordered, reviewed timely by providers, and relayed quickly to patients. The case review rating for Diagnostic Services was adequate.  Ten deficiencies occurred when x-ray reports were not retrieved or scanned into the eUHR. However, the providers were aware of the reports on follow-up visits, so this did not affect patient care.  One laboratory report was not retrieved or scanned into the eUHR.  One STAT lab (urgently done) was ordered but not done. Conclusion The OIG rated Diagnostic Services at CAC adequate, as the improperly processed diagnostic orders were infrequent. California City Correctional Facility, Cycle 4 Medical Inspection Page 17 Office of the Inspector General State of California Compliance Testing Results The institution received an adequate compliance score of 77.3 percent in the Diagnostic Services indicator, which encompasses radiology, laboratory, and pathology services. For clarity, each type of diagnostic service is discussed separately below: Radiology Services  All ten of the radiology services sampled were timely performed (MIT 2.001). Providers properly evidenced their review of the radiology results for eight of the ten patients (80 percent). For two patients, there was no evidence the provider reviewed the reports (MIT 2.002). Providers communicated the radiology results timely to nine of the ten patients (90 percent); the provider communicated the results eight days late to one patient (MIT 2.003). Laboratory Services  Laboratory services were completed within the time frame specified in the provider’s order for eight of ten patients sampled (80 percent). Two patients’ laboratory services were performed one and seven days late (MIT 2.004). Providers’ properly evidenced their review of laboratory test results for all ten patients sampled within two business days of receipt (MIT 2.005). Providers timely communicated laboratory test results to nine of the ten patients (90 percent); the provider communicated the results two days late to one patient (MIT 2.006). Pathology Services  CAC received the final pathology report timely for only five of nine inmate patients sampled (56 percent). Three reports were received from 15 to 158 days late, and one pathology report was not found in the eUHR for one patient (MIT 2.007). Providers timely reviewed the pathology test results for six of the seven applicable reports (86 percent). For one patient, the provider did not initial and date the report to evidence his timely of the results (MIT 2.008). Providers timely communicated the final pathology results to only one of the seven patients sampled (14 percent). Providers communicated the pathology results to four patients from 3 to 210 days late. For two patients, there was no evidence found in eUHR that the pathology results were communicated at all (MIT 2.009). Recommendations No specific recommendations. California City Correctional Facility, Cycle 4 Medical Inspection Page 18 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, Adequate treatment, and transportation 24 hours per day. Provision of Compliance Score: emergency care is based on a patient’s emergent situation, clinical Not Applicable condition, and need for a higher level of care. The OIG reviews emergency response services including first aid, basic life support Overall Rating: (BLS), and advanced cardiac life support (ACLS) consistent with Adequate 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 The OIG clinicians reviewed 20 urgent or emergent events and found 14 deficiencies, four significant (three in case 1 and one in case 32). The OIG rated Emergency Services at CAC adequate. Provider Performance The providers generally evaluated patients timely and made appropriate assessments and plans during urgent or emergent events. The OIG identified two minor deficiencies, which are also described in the Quality of Provider Performance indicator:  In case 32, there was no provider progress note documenting an emergent event of chest pain.  In case 41, there was no provider progress note documenting an emergent event when the patient presented at the TTA with fever, shortness of breath, and a productive cough. Nursing Performance The nursing care provided during emergency medical response incidents was generally adequate. There were 12 deficiencies in this area. While most nursing deficiencies were minor, some TTA encounters demonstrated inadequate assessment, response time delays, and insufficient interventions or monitoring. In several instances, assessment and monitoring by the first medical responder did not occur or was not documented. The following examples demonstrated these case review findings: California City Correctional Facility, Cycle 4 Medical Inspection Page 19 Office of the Inspector General State of California  In case 1, the TTA RN failed to refer the patient with testicular pain to a provider. Six days later, the patient was sent to a higher level of care.  During another encounter in case 1, there was a significant delay of 30 minutes in transferring the patient to the TTA after the initial evaluation by the RN of a patient with facial and eye injuries. After the evaluation, the RN released the patient back to custody and failed to obtain vital signs, to assess the neurological status, and to document the reason the patient was released back to custody. When the patient was brought to the TTA, the severity of the multiple facial injuries and lacerations, bruising, swelling, and active bleeding to his eye required a transfer to a higher level of care. The patient was sent to the hospital and was diagnosed with a sub-conjunctival hemorrhage (small blood vessel breaks in the eye).  In case 5, the RN did not assess the patient with severe abdominal pain and vomiting in the TTA. The RN called the provider and received telephone orders to administer medication and transfer the patient to a higher level of care. The RN should have included the assessment of the patient and specific roles and actions of medical and custody staff, and documented the time and the mode of transportation.  In case 19, on two separate occurrences, the first responders did not document the initial notification of time or assessment. In one occurrence, the patient arrived in the TTA with complaints of dizziness. In the other occurrence, the RN and supervisor were the first responders and did not document the time of their arrival or what actions they took for a patient found down in the shower, with head and facial injuries, and impaired vision. The patient required a higher level of care.  In case 27, the patient was transferred to the hospital with abdominal pain and vomiting. There was a delay of 35 minutes for TTA nursing staff to notify the physician on call.  In case 32, significant deficiencies occurred. The RN assessed the patient with a one-week history of chest pain, but did not administer aspirin, nitroglycerin, or start an intravenous fluid access line. Also, the RN contacted the physician on call, but failed to document any orders.  In case 43, the nurse failed to recheck the patient’s vital signs for 81 minutes. In addition, there was a 21-minute delay notifying the on-call physician upon the patient’s arrival to the TTA. California City Correctional Facility, Cycle 4 Medical Inspection Page 20 Office of the Inspector General State of California Emergency Medical Response Review Committee CAC conducted timely EMRRC meetings with good attendance by custody and health care team representatives. CAC staff performed and analyzed routine emergency drills and identified areas for improvement. There was one deficient case:  In case 1, the EMRRC failed to address the 30-minute delay of medical intervention, and did not request a rationale for the return back to his cell for a patient with significant injuries. Onsite Clinical Inspection The TTA was readily accessible from each yard. There were two nurses on each shift and one provider during business hours. The TTA had two beds and adequate space for patient evaluation, with working areas for both nurses and providers. The TTA also had ample lighting and was stocked well with medications and medical equipment, such as an automated external defibrillator (AED) and an emergency crash cart. The TTA staff duties included responding to medical emergencies in the clinics. First watch RNs were responsible for collecting requests for health care services out in the housing units and reviewing them for severity of the complaints. According to the chief nurse executive (CNE) and supervising RN (SRNIII), nurses new to CCHCS and hired within the most recent four months were assigned to the TTA. These nurses did not have emergency nursing experience, and one of the nurses informed the OIG staff that her nursing background was in a skilled nursing facility. In addition, the new employees’ education files lacked any specific TTA emergency training for these nurses. However, the CNE recognized the need to improve the emergency response at CAC. The CNE described quality improvement plans to provide trauma emergency training through the local ambulance company for all of the nursing staff. Conclusion Providers, nurses, and custody staff at CAC provided timely and appropriate urgent and emergent care in a coordinated process. The OIG clinicians rated Emergency Services at CAC adequate. Recommendations No specific recommendations. California City Correctional Facility, Cycle 4 Medical Inspection Page 21 Office of the Inspector General State of California HEALTH INFORMATION MANAGEMENT (MEDICAL RECORDS) Health information management is a crucial link in the delivery of Case Review Rating: medical care. Medical personnel require accurate information in Adequate order to make sound judgments and decisions. This indicator Compliance Score: examines whether the institution adequately manages its health care Proficient information. This includes determining whether the information is (87.2%) correctly labeled and organized and available in the electronic unit Overall Rating: health record (eUHR); whether the various medical records (internal Proficient and external, e.g., hospital and specialty reports and progress notes) are obtained and scanned timely into the inmate-patient’s eUHR; whether records routed to clinicians include legible signatures or stamps; and whether hospital discharge reports include key elements and are timely reviewed by providers. In this indicator, the OIG’s case review and compliance review processes yielded different results, with the case review giving an adequate rating and the compliance review resulting in a proficient score. The OIG’s internal review process considered those factors that led to both scores. The clinicians indicated some diagnostic reports were not retrieved or scanned into the eUHR; however, the providers were aware of the report results in most cases. As a result, the OIG’s medical inspection team concluded that the appropriate overall score for this indicator should be proficient. Case Review Results The OIG clinicians identified 34 deficiencies related to health information management. The OIG clinicians rated this indicator adequate. Hospital Records Fifteen hospital or outside emergency department events were reviewed, and the hospital records were timely retrieved, reviewed, and scanned into the eUHR. Missing Documents (Progress Notes and Forms) Most pertinent documents, nursing and provider progress notes were scanned into the eUHR. There was one missing document. In case 48, a provider prescribed an antibiotic, and there was no keep-on-person (KOP) medication administration record indicating that the patient received the medication. Scanning Performance There were 14 misfiled documents. In case 40, a hospital discharge summary of a different patient was scanned into the eUHR. This was the only significant deficiency in this indicator. California City Correctional Facility, Cycle 4 Medical Inspection Page 22 Office of the Inspector General State of California Specialty Services Reports Most specialty services reports were retrieved, reviewed, and scanned into the eUHR. However, there were five reports not retrieved or scanned into the eUHR. In case 43, a positron emission tomography (PET) scan and a computed tomography (CT) scan were not retrieved or scanned into the eUHR. Diagnostic Reports The OIG clinicians found 11 diagnostic reports were not retrieved or scanned into the eUHR. However, the providers documented reviewing the reports and addressed the findings on follow-up visits. There were ten x-ray reports not retrieved or scanned into the eUHR. This is also discussed in the Diagnostic Services indicator. Legibility Most provider and nursing progress notes were dictated or legible. Clinician Onsite Inspection CAC medical record staff were prompt in retrieving and scanning specialty reports and hospital discharge summaries. The reports were timely scanned into the eUHR after being reviewed by the providers. Conclusion CAC performed well with its retrieval of specialty reports and hospital discharge summaries. Although x-ray reports were not always retrieved or scanned into the eUHR, the providers were aware of the reports. The OIG clinicians rated this indicator adequate. Compliance Testing Results CAC scored in the proficient range in the Health Information Management (Medical Records) indicator, receiving a compliance score of 87.2 percent.  On the following four tests, CAC scored 100 percent and timely scanned documents into the patient’s eUHR file: all 20 sampled initial health screening forms, health care services request forms, and non-dictated progress notes (MIT 4.001); all 20 sampled MARs (MIT 4.005); all 20 sampled specialty service consultant reports (MIT 4.003); and all 11 sampled hospital discharge reports (MIT 4.004).  The eUHR files for 11 out of 12 patients sent or admitted to the hospital were complete and reviewed by providers within three calendar days of discharge (92 percent). For one patient, there was no evidence a final discharge summary report was received; instead, the provider reviewed and signed a hospital admission progress report, which did not include key California City Correctional Facility, Cycle 4 Medical Inspection Page 23 Office of the Inspector General State of California elements of a discharge report, including the date of admission, diagnosis, discharge date, or medications ordered upon discharge (MIT 4.008). The institution performed in the adequate range in the following area:  CAC scored 75 percent in its labeling and filing of documents scanned into patients’ eUHRs. For this test, the OIG bases its score on 12 mislabeled or misfiled documents; three documents were scanned under the wrong date (MIT 4.006). The institution showed room for improvement in the following area:  When the OIG reviewed various medical documents such as hospital discharge reports, initial health screening forms, certain medication records, and specialty services reports to ensure that clinical staff legibly documented their names on the forms, only 14 of 32 samples (44 percent) showed compliance. Eighteen of the samples did not include clinician name stamps, and the signatures were illegible (MIT 4.007). Recommendations No specific recommendations. California City Correctional Facility, Cycle 4 Medical Inspection Page 24 Office of the Inspector General State of California HEALTH CARE ENVIRONMENT This indicator addresses the general operational aspects of the Case Review Rating: institution’s clinics, including certain elements of infection control Not Applicable and sanitation, medical supplies and equipment management, the Compliance Score: Proficient availability of both auditory and visual privacy for inmate-patient (86.4%) visits, and the sufficiency of facility infrastructure to conduct comprehensive medical examinations. Rating of this component is Overall Rating: based entirely on the compliance testing results from the visual Proficient observations inspectors make at the institution during their onsite visit. Clinician Comments Although OIG clinicians did not rate the health care environment at CAC, they obtained the following information during their onsite visit:  The three medical clinics were centrally located, had ample lighting, and were stocked well with medications and medical equipment.  The TTA had two beds and adequate space for patient evaluation, with working areas for both nurses and providers. The TTA also had ample lighting and was sufficiently stocked with medications and medical equipment, such as an automated external defibrillator (AED) and an emergency crash cart. Compliance Testing Results The institution received a proficient compliance score of 86.4 percent in the Health Care Environment indicator. The institution performed at a proficient level in 8 of the indicator’s 11 test areas, as described below:  All nine clinics were appropriately disinfected, cleaned, and sanitized, and all had operable sinks and sufficient quantities of hygiene supplies in the clinical areas (MIT 5.101, 5.103).  CAC was compliant at all nine clinics regarding mitigation of exposure to blood-borne pathogens and contaminated waste (MIT 5.105).  The non-clinic medical storage area in CAC’s main medical storage warehouse generally met the supply management process and support needs of the medical health care program. CAC scored 100 percent on this test (MIT 5.106).  All nine clinics inspected followed adequate medical supply storage and management protocols in their clinical areas (MIT 5.107). California City Correctional Facility, Cycle 4 Medical Inspection Page 25 Office of the Inspector General State of California  Clinical health care staff at eight of the nine applicable clinics (89 percent) ensured that reusable invasive and non-invasive medical equipment was properly sterilized and disinfected. At one clinic, inspectors determined that various equipment items designated as sterilized and ready for use were not date stamped, included expired date stamps, or were stored in torn sealed packages, breaching the instruments’ sterility (MIT 5.102).  Clinicians adhered to universal hand hygiene protocols in eight of the nine clinics (89 percent). At one clinic, a nurse did not wash or sanitize her hands after patient contact (MIT 5.104).  Clinic common areas at eight of nine clinics had an environment conducive to providing medical services (89 percent); one clinic did not provide auditory privacy at the blood draw station (MIT 5.109). CAC received an adequate score in the following area:  Inspectors examined emergency response bags to determine if institution staff inspected the bags daily and inventoried them monthly, and whether the bags contained all essential items. Emergency response bags were compliant at five of the six applicable clinical locations (83 percent). At one location, the inspector found the bag compartments unsealed prior to the inspection (MIT 5.111). The institution showed room for improvement in the two areas below:  Only six of nine clinic exam rooms observed (67 percent) had appropriate space, configuration, supplies, and equipment to allow clinicians to perform a proper clinical examination. Three clinics lacked auditory privacy by allowing two patients to be examined in the same exam room at the same time (Figure 1). In addition, in one of those three clinics, the otoscope was not easily accessible for use Figure 1: No auditory privacy for two patients at the exam table (MIT 5.110). examined at the same time. California City Correctional Facility, Cycle 4 Medical Inspection Page 26 Office of the Inspector General State of California  Some clinics’ common areas and exam rooms were missing core equipment or other essential supplies necessary to conduct a comprehensive exam. As a result, only three of the nine clinic locations were compliant (33 percent). Equipment and supply deficiencies in six clinics’ common areas or exam rooms consisted of the following: three clinics did not have a nebulization unit; two clinics lacked tongue depressors; one clinic lacked an otoscope and tips, hemoccult cards and developer, and lubricating jelly, and the thermometer lacked a calibration sticker; and the receiving and release (R&R) clinical area lacked an exam table and Snellen chart (MIT 5.108). Other Information Obtained from Non-Scored Results The OIG gathered information to determine if the institution’s physical infrastructure was maintained in a manner that supported health care management’s ability to provide adequate health care. The OIG did not score this question. When OIG inspectors interviewed health care managers, they did not express concerns about the facility’s infrastructure or its effect on staff’s ability to provide adequate health care. Pending lease approval, the institution had three proposed infrastructure projects: additional medical administrative space, dental area improvements, and a pharmacy area fume hood. Upon the lease approval, the estimated completion for all three projects is March 2017 (MIT 5.999). Recommendation for CCHCS The OIG recommends that CCHCS develop a statewide policy to identify required core equipment and supplies for each type of clinical setting, including primary care clinics, specialty clinics, TTAs, and R&Rs. Recommendations for CAC The OIG recommends that CAC develop local operating procedures that ensure the following:  All clinical areas maintain a full complement of core medical equipment that includes nebulization units and a Snellen vision chart, and all exam rooms have an exam table in the immediate area, tongue depressors, an otoscope and tips, lubricating jelly, and hemoccult cards and developer.  Staff members regularly monitor medical equipment to ensure applicable equipment is currently calibrated and reusable invasive medical equipment is properly sterilized. California City Correctional Facility, Cycle 4 Medical Inspection Page 27 Office of the Inspector General State of California INTER- AND INTRA-SYSTEM TRANSFERS This indicator focuses on the management of inmate-patients’ Case Review Rating: medical needs and continuity of patient care during the inter- and Adequate intra-facility transfer process. The patients reviewed for Inter- and Compliance Score: Intra-System Transfers include inmates received from other CDCR Proficient facilities and inmates transferring out of CAC to another CDCR (94.8%) facility. The OIG review includes evaluation of the institution’s Overall Rating: ability to provide and document health screening assessments, Proficient 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 inmate-patients who transfer out of the facility, the OIG evaluates the ability of the institution to document transfer information that includes pre-existing health conditions, pending appointments, tests and requests for specialty services, medication transfer packages, and medication administration prior to transfer. The OIG clinicians also evaluate the care provided to patients returning to the institution from an outside hospital and check to ensure appropriate implementation of the hospital assessment and treatment plans. In this indicator, the OIG’s case review and compliance testing processes yielded different results, with the case review giving an adequate rating and the compliance review resulting in a proficient score. The OIG’s internal review process considered those factors that led to both scores. The clinicians found a low number of deficiencies related to the assessment and disposition section of the transfer forms and determined that the compliance score of proficient was a more appropriate overall rating for this indicator. Case Review Results The OIG clinicians reviewed 22 encounters for Inter- and Intra-System Transfers. The OIG reviewed three encounters for inmates transferring out of CAC to other institutions, and four for inmates transferring into CAC from other institutions. The OIG reviewed 15 encounters for patients returning to CAC from a community hospital or emergency department. There were 14 deficiencies, two of which were significant (cases 1 and 24). In general, the transfer processes at CAC were adequate. Transfers In The OIG clinicians found a few minor deficiencies for inmates transferring into CAC from other CDCR institutions, primarily related to incomplete documentation and inadequate assessments. California City Correctional Facility, Cycle 4 Medical Inspection Page 28 Office of the Inspector General State of California  In case 21, the nurse failed to obtain the history of the patient’s recent infection, the reason for the patient’s current antibiotic regimen, and the patient’s history of alcohol abuse. The nurse also failed to document the patient’s denture appliances.  In case 22, the nurse failed to assess the patient’s elevated risk criteria for coccidioidomycosis (valley fever).  In case 23, the nurse failed to document the patient had a positive tuberculosis (TB) skin test. The information was corrected two months later. Transfers Out Deficiencies found with patients transferring out of CAC were largely due to incomplete nursing documentation of significant medical information on the Health Care Transfer Information form (CDCR Form 7371). One significant deficiency occurred when there was a lapse in nursing assessment prior to transferring the patient, which placed the patient at a risk of harm (case 24).  In case 24, the nurse failed to assess the patient on the day of transfer. The receiving institution sent the patient to the TTA with possible TB, after discovery of a cough for six days and prior TB. In this same case, the nurse failed to document the date of the last chest x-ray and a significant food allergy to mustard on the health care transfer form.  In case 25, the nurse did not document the TB code, date of the last chest x-ray, and lab results on the health care transfer form.  In case 32, the nurse did not document the next provider visit date, the specialty service appointment, and the reason for twice-per-week nursing visits on the health care transfer form. Hospitalizations Patients returning from hospitalizations are some of the highest-risk encounters due to two factors. First, these patients are generally hospitalized for a severe illness or injury. Second, they are at risk due to potential lapses in care that can occur during any transfer. The R&R and TTA RNs processed patients who were discharged from the hospital upon their return to CAC. The majority of the patients were processed in the TTA. Most hospital reports were retrieved and scanned into the eUHR within acceptable time frames. However, some were not received timely or not received at all (further discussed in Health Information Management and Specialty Services). In the majority of cases, RNs appropriately reviewed the discharge medications and plans of care and obtained physician orders. California City Correctional Facility, Cycle 4 Medical Inspection Page 29 Office of the Inspector General State of California The quality of most nursing care was adequate. However, there were cases that illustrated how the lack of attention to detail can result in transfer errors or risk of harm for patients returning from the hospital.  In case 1, the patient returned from the hospital with facial injuries and required dressing changes to his eye. The RN failed to adequately assess the severity of the injuries, failed to educate the patient on wound care, and failed to obtain antibiotic orders from the provider.  In case 2, the RN failed to adequately assess the patient with an abnormal heart rhythm upon the patient’s return from an outside medical facility. The nurse failed to document medications or the discharge plan.  In case 4, the patient returned from the hospital with significant facial and eye swelling and a broken nose. The nurse in the TTA failed to follow hospital recommendations, which were to help the patient keep his head elevated and to apply ice to the swollen area. The next day his condition had worsened, he complained of a severe headache and dizziness, and his eye was swollen shut. This resulted in readmission to the hospital and an overnight stay. Onsite Visit There were two nurses assigned to the R&R, with one on second watch and one on third. These nurses were responsible for assessing intra-system transfers and patients returning from offsite medical specialty service appointments. The R&R nurses indirectly referred patients to the providers via the chronic care nurses in the clinic. The providers were notified of the new patient arrivals during the morning huddle. The OIG’s case reviews showed this process to work well, as patients were seen timely by providers. When patients transferred out, all medications were accounted for and verified prior to transferring. If a medication was not received, the nurse retrieved the medication from the Omnicell (electronic storage). All medication orders were processed timely. During the onsite visit, the R&R nurse could not describe the new CCHCS transfer policy for a medical hold. Compliance Testing Results The institution obtained a proficient compliance score of 94.8 percent in the Inter- and Intra-System Transfers indicator. The institution scored in the proficient range on all five tests, as follows:  CAC scored 100 percent when the OIG tested one patient who transferred out of CAC during the OIG’s onsite inspection to determine whether his transfer package included the required medications and related documentation. Although three inmates transferred out on the testing day, only one was prescribed medications (MIT 6.101). California City Correctional Facility, Cycle 4 Medical Inspection Page 30 Office of the Inspector General State of California  The OIG tested 30 patients who transferred into CAC from another CDCR institution; nursing staff completed an initial health screening assessment form on the same day of the patient’s arrival for 29 of the patients (97 percent). In one instance, nursing staff neglected to answer all applicable questions on the patient’s initial health screening form (MIT 6.001). Nursing staff timely completed the assessment and disposition sections of the screening form for 29 of 30 patients (97 percent). For one patient, nursing staff failed to answer if a provider referral was required (MIT 6.002).  Inspectors tested 20 patients who transferred out of CAC to another CDCR institution to determine whether their scheduled specialty service appointments were listed on the health care transfer form. CAC nursing staff identified the scheduled appointments on the transfer forms for 19 of the samples tested (95 percent). For one patient, nursing staff did not document a pending specialty service on the transfer form (MIT 6.004).  Of seven sampled patients who transferred into CAC with an existing medication order, six (86 percent) received their medications without interruption upon arriving at CAC. One patient did not receive his prescribed KOP medication, which did not arrive until the next day (MIT 6.003). Recommendation The OIG recommends that CAC provide training for all TTA, R&R, and utilization management staff on the CCHCS revision of the health care transfer medical hold policy. California City Correctional Facility, Cycle 4 Medical Inspection Page 31 Office of the Inspector General State of California PHARMACY AND MEDICATION MANAGEMENT This indicator is an evaluation of 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: administration of the medication. By combining both a quantitative Proficient (92.1%) 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, Proficient 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. In this indicator, the OIG’s case review and compliance review processes yielded different results, with the case review giving an adequate rating and the compliance review resulting in a proficient score. The OIG’s internal review process considered those factors that led to both scores. Case reviews focused on medication administration as secondary processes, while compliance reviewers considered medication administration as well as medication storage, pharmacy protocols, and other factors to arrive at a rating for this indicator. As a result, the compliance review rating of proficient was deemed a more appropriate reflection of the overall indicator rating. Case Review Results The OIG clinicians evaluated pharmacy and medication management as secondary processes as they related to the quality of clinical care provided. From a clinical perspective, pharmacy performance and medication administration were adequate. There were 49 medication and pharmacy events reviewed. There were 16 deficiencies, one of which was significant (case 39). Medication errors found during case reviews were rare. Medication administration During their onsite visit, the OIG clinicians met with medical and nursing representatives regarding case review findings. The majority of the patients received self-administered medications. Nurse-administered (NA) and direct observation therapy (DOT) medications were given at pill lines, where there were 40 to 50 patients in the morning and evening lines but just one or two patients in the noon lines. The medication staff stated that they received copies of orders timely. The nurse educators were able to provide staff education files that demonstrated competency testing in medication management for a random selection of nursing staff. However, the following deficiencies were found during case review: California City Correctional Facility, Cycle 4 Medical Inspection Page 32 Office of the Inspector General State of California Documentation  In case 13, the nurse failed to document the dosage of the vaccine and the method of its administration.  In case 21, the nurse documented that the patient received a meningitis vaccine, but the provider had ordered a pneumonia vaccine.  In case 42, the nurse illegibly documented the date the patient received the medication.  In case 37, the patient refused vaccination, but the vaccination form showed that the patient received the vaccination. Failure to Administer or Notify  In case 6, the licensed psychiatric technician failed to administer insulin on two different dates; on another occasion, another licensed psychiatric technician did not evaluate the patient for signs and symptoms of elevated blood glucose and failed to report it to or notify the registered nurse.  In case 15, a medication administration record for phenytoin (seizure medication) was incorrectly filed.  In case 22, there was a three-day delay in the patient receiving self-administered medications.  In case 26, the pharmacy failed to deliver a prescribed medication, and the nursing staff failed to verify the patient’s medications and identify that this medication had not been delivered.  In case 31, the provider discontinued a medication, but the nurse did not verify the patient’s new prescription order and continued to administer the medication.  In case 35, the nurse failed to inform the provider that the patient did not show up for the medication on multiple days.  In case 37, the nurse failed to address the patient’s request for a renewal of diabetic medication, causing a lapse in medication continuity.  In case 39, after returning from an offsite hospitalization for severe constipation, the patient did not receive his prescribed medication. This placed the patient at risk of requiring another hospitalization. California City Correctional Facility, Cycle 4 Medical Inspection Page 33 Office of the Inspector General State of California Conclusion The OIG clinicians rated the Pharmacy and Medication Management indicator adequate. Compliance Testing Results The institution received a proficient compliance score of 92.1 percent in the Pharmacy and Medication Management indicator. For discussion purposes below, this indicator is divided into three sub indicators: medication administration, observed medication practices and storage controls, and pharmacy protocols. Medication Administration This sub indicator consists of four applicable questions in which the institution received a proficient score of 97.0 percent and scored in the proficient range in each of the following areas:  CAC timely administered or delivered new medication orders to all 30 patients sampled (MIT 7.002).  The institution ensured that all 21 patients sampled received their medications without interruption when they transferred from one housing unit to another (MIT 7.005).  Nursing staff timely dispensed long-term chronic care medications to 28 of the 29 patients sampled (97 percent). One patient did not receive one month of his KOP medication during the OIG’s three-month testing period (MIT 7.001).  CAC timely provided new and previously prescribed medications to 11 of 12 sampled patients upon their return to the institution from a community hospital (92 percent). One patient received his medication one day late (MIT 7.003). Observed Medication Practices and Storage Controls In this sub-indicator, the institution received an adequate average score of 82 percent, but scored a proficient 100 percent in the following test:  Nursing staff at all four of the sampled medication preparation and administration locations employed appropriate administrative controls and protocols when preparing patients’ medication (MIT 7.105). CAC scored in the adequate range in the five tests below:  The OIG interviewed nursing staff and inspected narcotics storage areas at six applicable clinic and pill line locations to assess narcotic security controls. Nursing staff had strong medication security controls over narcotic medications at five locations (83 percent). For California City Correctional Facility, Cycle 4 Medical Inspection Page 34 Office of the Inspector General State of California one clinic, on the day of inspection, the narcotics logbook was not counter-signed by two nursing staff during the shift change (MIT 7.101).  CAC properly stored non-narcotic medications that did not require refrigeration at eight of the ten applicable clinics and medication line storage locations sampled (80 percent). Inspectors found the following deficiencies: the crash cart seal number did not correspond to the crash cart logbook at one location; at a second location, a bottle of hydrogen peroxide was not labeled with the date the bottle was opened (MIT 7.102).  Nursing staff followed appropriate administrative controls and protocols when distributing medications to patients at four of five applicable medication preparation and administrative locations (80 percent). At one location, nursing staff did not discontinue a patient’s medications per the provider’s order (MIT 7.106).  Non-narcotic refrigerated medications were properly stored in six of eight clinics and medication line storage locations (75 percent). Two locations stored batteries in the refrigeration unit against the battery manufacturer’s recommendation (MIT 7.103).  Nursing staff at only three of the four sampled medication preparation and administration locations (75 percent) followed proper hand hygiene contamination control protocols during the medication preparation and administrative processes. At one location, nursing staff did not have access to non-latex gloves during medication administration (MIT 7.104). Pharmacy Protocols For this sub-indicator, the institution scored 100 percent in each of the five test areas:  In its main pharmacy, CAC followed general security, organization, and cleanliness management protocols; properly stored and monitored non-narcotic medications that required refrigeration and those that did not; and maintained adequate controls and properly accounted for narcotic medications (MIT 7.107, 7.108, 7.109, 7.110).  CAC’s pharmacist in charge timely processed all 26 inspector-sampled medication error reports (MIT 7.111). Non-Scored Tests  In addition to testing reported medication errors, OIG inspectors follow up on any significant medication errors found during the case reviews or compliance testing to determine whether the errors were properly identified and reported. The OIG provides those results for information purposes only. At CAC, the OIG did not find any applicable medication errors subject to this test (MIT 7.998). California City Correctional Facility, Cycle 4 Medical Inspection Page 35 Office of the Inspector General State of California  The OIG tested patients housed in isolation units to determine if they had immediate access to their prescribed KOP rescue asthma inhalers and nitroglycerin medications. One applicable patient confirmed he had physical possession of his rescue medication (MIT 7.999). Recommendations No specific recommendations. California City Correctional Facility, Cycle 4 Medical Inspection Page 36 Office of the Inspector General State of California PREVENTIVE SERVICES This indicator assesses whether various preventive medical services Case Review Rating: are offered or provided to inmate-patients. These include cancer Not Applicable screenings, tuberculosis screenings, and influenza and chronic care Compliance Score: Proficient immunizations. This indicator also assesses whether certain (95.0%) institutions take preventive actions to relocate inmate-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 performed in the proficient range in the Preventive Services indicator, with a compliance score of 95.0 percent. Six test areas scored in the proficient range, including five scores of 100 percent, as described below:  CAC timely administered tuberculosis medications to all four sampled patients with tuberculosis (MIT 9.001).  The institution was compliant in offering annual influenza vaccinations to all 30 sampled patients (MIT 9.004).  CAC offered colorectal cancer screenings to all 30 sampled patients subject to the annual screening requirement (MIT 9.005).  The OIG tested whether CAC offered vaccinations for influenza, pneumonia, and hepatitis to patients who suffered from a chronic care condition; all eight sampled patients received recommended vaccinations at the required interval (MIT 9.008).  The OIG tested five patients at high risk for contracting coccidioidomycosis infection (valley fever), identified as medically restricted and ineligible to reside at CAC, to determine if they were transferred out of the institution within 60 days from the time they were deemed ineligible. Inspectors found that CAC timely transferred all five patients (MIT 9.009).  The institution scored 90 percent for conducting annual tuberculosis (TB) screenings. CAC timely screened all 30 sampled patients for tuberculosis within the prior year. All 15 of the patients classified as Code 22 (requiring a TB skin test in addition to signs and symptoms screenings) were properly tested. In addition to the sampled Code 22 patients, inspectors sampled 15 patients classified as Code 34 (those who had previously tested for TB and California City Correctional Facility, Cycle 4 Medical Inspection Page 37 Office of the Inspector General State of California subject only to an annual signs and symptoms screening). For three patients, nursing staff did not complete the history section of the Tuberculin Testing/Evaluation Report (CDCR Form 7331) (MIT 9.003). The institution scored in the adequate range in the following area:  Three of the four patients sampled (75 percent) were properly monitored while taking TB medications. One patient’s required TB monitoring evaluation form was completed but it was not timely scanned into their eUHR after the evaluation occurred (MIT 9.002). Recommendations No specific recommendations. California City Correctional Facility, Cycle 4 Medical Inspection Page 38 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 Compliance Score: review process, and, therefore, does not have a score under the Not Applicable compliance testing component. The OIG nurses conduct case reviews that include reviewing face-to-face encounters related to Overall Rating: nursing sick call requests identified on the Health Care Services Adequate Request form (CDCR Form 7362), 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 health care services request forms 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 triage and treatment area (TTA) or related to emergency medical responses are reported under Emergency Services. Case Review Results OIG nursing clinicians rated the Quality of Nursing Performance at CAC adequate. The OIG evaluated 860 events during case review. Of these, approximately 210 were outpatient encounters from sick call requests and primary care clinic nurse follow-up visits. In general, nursing performed well. In all, 72 deficiencies were found in outpatient nursing services, the majority of which were minor and unlikely to contribute to patient harm. Nevertheless, these deficient areas are clearly established in CCHCS policy as requirements for nursing care and practice and, therefore, require quality improvement strategies. Eight cases had significant deficiencies with the potential for adverse outcomes or unnecessary delays in needed health care services. Nursing Sick Call The majority of sick call RNs appropriately assessed complaints and symptoms, and provided necessary interventions for patients presenting with medical issues in the outpatient nurse clinics. There were 8 significant deficiencies (two in case 44 and one each in cases 18, 27, 30, 31, 36, and 41). The quality of nursing performance was affected by patterns of deficiencies in the form of lacking assessments or providing inadequate assessments. There was also improper implementation of or delays in interventions based on assessment. California City Correctional Facility, Cycle 4 Medical Inspection Page 39 Office of the Inspector General State of California The following examples demonstrated intervention delays and either no assessment or inadequate assessment:  In case 18, the patient had a painful, red eye and blurry vision. The nurse did not perform an adequate assessment, and instructed the patient to complete a sick call request to be seen by the clinic nurse. The nurse also failed to contact the provider emergently. When the patient was seen the following day, he was transferred by the provider to an offsite eye center for an eye infection.  In case 19, on several different encounters, the sick call nurse failed to assess the patient for symptoms such as dizziness or toothache. Nurses also failed to assess patients with medical symptoms in cases 13, 16, and 39. Incomplete nursing assessment also occurred in cases 10, 11, 15, 20, 22, 32, 37, 38, and 42.  In case 6, the licensed psychiatric technician failed to evaluate a patient with elevated blood sugar readings, and did not contact the RN.  In case 41, the patient submitted a sick call request for immediate help for lack of energy and feelings of passing out. The nurse reviewed the sick call request form and inappropriately deferred to the clinic nurse two days later. The next day, the patient was sent to the TTA with an elevated temperature, cough, and body aches. The patient was transferred to the hospital, where he underwent eight days of care for pneumonia.  In case 43, the nurse saw the patient for a rash, possibly related to an allergic reaction. The nurse failed to contact the provider for consultation. Five days later, the patient submitted another sick call request form, and the nurse failed to adequately assess the severity of the rash and integrity of the skin. One month later, the provider saw the patient for cellulitis (skin infection) and ordered wound checks by the nurse for seven days. The nurse failed to check the wound on two of the seven days, and on two other days, the nurse failed to adequately assess and describe the measurement of the wound.  In case 44, the nurse failed to notify the provider of abnormal vital signs and wheezing in a patient with a cough and uncontrolled diabetes. The patient was given the nursing protocol medications of acetaminophen and chlorpheniramine (allergy medication) for viral rhinitis (common cold), and sent back to his housing unit. The following case involved a patient death, which was not preventable:  In case 27, the nurse inadequately assessed the patient with severe abdominal pain and vomiting, sent him back to his housing unit, and made a routine referral to the provider. The nurse failed to intervene and immediately notify the provider at the time of the sick call visit. Twelve hours later, the patient was taken to the TTA and sent out to the hospital. The patient California City Correctional Facility, Cycle 4 Medical Inspection Page 40 Office of the Inspector General State of California had sepsis (infection in the blood system), acute pancreatitis, and kidney failure. The patient died at the hospital ten days later. The OIG review felt this deficiency did not affect the patient outcome, and the death was not preventable. The failure to refer or notify the provider of significant abnormal findings or vital signs was also found in cases 8, 23, and 40. At times, nurses failed to provide an adequate assessment upon a patient’s return from an offsite specialty service procedure, as illustrated in the following examples:  In case 16, the nurse failed to assess the patient after the patient returned from a specialty service, an endoscopic stomach biopsy, that was performed offsite.  In case 33, the nurse failed to assess the patient after return from another endoscopic biopsy.  In case 30, upon return from an offsite intravenous cardiac catheterization angiogram (procedure to view the heart’s arteries), the nurse did not examine the intravenous site and did not instruct the patient on post-procedure care.  In case 31, the patient had an MRI (magnetic resonance imaging) examination with contrast dye. The nurse failed to reinforce specific discharge instructions about drinking water every hour. Failure of nurses to ensure that all post-procedure instructions are reinforced and that supplies are available can place patients at risk of harm and complications. This patient also had two sick call encounters, and the nurse failed to notify the provider of severe leg pain. The nurse did not refer the patient urgently to the provider. Six days later, the patient transferred to the hospital for leg swelling from poor circulation of the leg veins. In addition, the nurse failed to contact the provider upon the patient’s return from the hospital to discuss the type of housing for the patient. Clinical Onsite Visit The OIG clinicians visited all yard clinics. The clinics were clean and organized. The main medical clinic, which was separate from the clinic yards, was in a central location. This clinic was staffed with physicians, LVNs, RNs, medication nurses, and supervisors. It was observed that the physicians and nursing staff had excellent medical equipment, with new Welch-Allen diagnostic wall units (instruments for eye and ear examinations) for the nurses and the providers. The OIG clinicians attended the morning huddle during their onsite visit. The entire medical and support staff attended and discussed specific patient panels as outlined in the huddle script. All huddles were brief and succinct. The clinics were well staffed. The two RNs in each clinic conducted the face-to-face sick call visits and routine primary care management visits for chronic care patients. The LVN care coordinators completed wound care, blood pressure checks, and care coordination reviews for preventive vaccinations and patient education needs; and obtained laboratory results, diagnostic reports, and California City Correctional Facility, Cycle 4 Medical Inspection Page 41 Office of the Inspector General State of California other information needed for the RN visits. At the time of the onsite inspection, in clinics A and B, one RN shared an office with two LVNs and did not have a private and confidential space to assess patients, and used a folding screen when necessary. The other RN had a private office down the hall. At CAC, the providers and clinical staff frequently communicated via e-mail. In some instances, this was ineffective and, as a result, wound care and medication orders did not always occur. In addition, blood pressure checks were not communicated to the provider as requested. When staff was asked about this communication gap, they could not explain or give a reason. The nurses onsite were asked to explain how referrals were tracked. On Yard B, the nurse stated that referrals were documented on the daily appointment sheet, and informed the patient to return to the clinic if he did not receive a ducat (appointment slip) for the appointment. On Yard C, appointments were confirmed through the Strategic Offender Management System database. The schedulers in the main medical clinic stated Med-SATS (scheduling and aging tracking system) was used to schedule and check referrals and appointments. Conclusion The outpatient nursing care at CAC was adequate. Although some cases lacked adequate nursing assessment, intervention, and documentation, strategies for ongoing quality improvement and monitoring of nursing services was evident. Recommendations The OIG recommends that CAC management implement the following:  Evaluate the processes currently in place for orienting, mentoring, and monitoring the performance of nursing staff at all levels.  Develop quality improvement projects that include ongoing education, monitoring, evaluation, and feedback methods to ensure that nurses at all levels are aware of and involved in improving nursing performance and services. California City Correctional Facility, Cycle 4 Medical Inspection Page 42 Office of the Inspector General State of California QUALITY OF PROVIDER PERFORMANCE In this indicator, the OIG physicians provide a qualitative Case Review Rating: evaluation of the adequacy of provider care at the institution. Adequate Appropriate evaluation, diagnosis, and management plans are Compliance Score: reviewed for programs including, but not limited to, nursing sick Not Applicable call, chronic care programs, TTA, and specialty services. The assessment of provider care is performed entirely by OIG Overall Rating: physicians. There is no compliance testing component associated Adequate with this quality indicator. Case Review Results OIG clinicians reviewed 224 medical provider encounters and identified 25 deficiencies related to provider performance. Of those 25 deficiencies, three were considered significant deficiencies (two in case 44 and one in case 46). As a whole, CAC provider performance was rated a strong adequate, bordering proficient. Assessment and Decision-Making In most cases, CAC providers made appropriate assessments and sound medical plans. There was one significant deficiency:  In case 46, the provider documented that the patient had a calculated 19.2 percent 10-year risk of heart disease or stroke but did not prescribe the recommended high intensity cholesterol lowering medication. The failure to prescribe a statin placed the patient at risk for cardiovascular events. Emergency Care Providers generally made appropriate triage decisions when patients presented emergently to the TTA. In addition, the providers generally were available for consultation with the TTA nursing staff. However, there were two minor deficiencies identified related to the quality of provider care in emergency services. The cases below are also discussed in the Emergency Services indicator:  In case 32, there was no provider progress note documenting the emergent event for a patient with chest pain.  In case 41, there was no provider progress note documenting the emergent event for a patient in the TTA with fever, shortness of breath, and productive cough. Hospital Return CAC providers properly signed hospital discharge summaries and timely addressed all the recommendations. California City Correctional Facility, Cycle 4 Medical Inspection Page 43 Office of the Inspector General State of California Chronic Care Chronic care performance was adequate as most providers demonstrated good care in regard to hypertension, asthma, hepatitis C infection, and cardiovascular disease. The providers’ thorough documentation showed sound assessments and plans. The OIG clinicians identified the following deficiencies in the chronic care program:  In case 34, the oversight committee had recommended hepatitis C virus treatment. The provider evaluating the patient more than a month later failed to review and address the recommendation.  In case 36, the provider ordered blood pressure checks for two weeks. On the follow-up visit, the provider did not address the elevated blood pressure readings. In addition, the provider documented that the patient’s previously ordered cholesterol lowering medication should be continued, but the medication had expired five days prior to the visit and was not renewed.  In case 52, the provider did not address two elevated blood pressure readings during a patient visit. The management of diabetes was adequate. Most providers demonstrated excellent diabetic management skills. However, the OIG clinicians identified the following two significant deficiencies in diabetic care:  In case 44, the patient had poorly controlled diabetes with average fasting blood glucose of 174 mg/dL. The provider failed to adjust the basal insulin, and the 90-day follow-up was too long for a diabetic patient not at goal.  Also in case 44, a nurse consulted a provider for a critical high blood glucose level of 479 mg/dL; the provider should have ordered a next-day follow-up appointment, requesting that a provider conduct a thorough evaluation and assessment of diabetic control. Specialty Services CAC providers generally referred appropriately and reviewed specialty reports timely. Not all the reports were properly signed by the providers; however, all specialist recommendations were timely addressed. There was one minor deficiency:  In case 30, after reviewing a normal cardiac catheterization, indicating that chest pain was not due to coronary artery disease, the provider inappropriately requested cardiology follow-up for chest pain. California City Correctional Facility, Cycle 4 Medical Inspection Page 44 Office of the Inspector General State of California Health Information Management The providers generally documented outpatient and TTA encounters on the same day. Most progress notes were dictated and generally legible. Clinician Onsite Inspection At the time of the OIG inspection, there was no provider vacancy. All CAC providers were enthusiastic about their work and expressed satisfactions with nursing, specialty, and diagnostic services. Each provider was mainly assigned to one clinic to ensure continuity of care. The three clinics were centrally located, and this enabled the providers to easily consult with each other. Morning huddles were productive, and led by providers, attended by nurses, care coordinators, custody staff, and office technicians. The chief medical executive (CME) and chief physician and surgeon were committed to patient care and quality improvement. All the providers expressed general job satisfaction with their positions, and morale was good overall. Conclusion The providers at CAC delivered good care in the majority of the physician-reviewed cases. Among the 30 cases, 29 were adequate, and one was inadequate. The OIG rates CAC provider performance as adequate. Recommendations No specific recommendations. California City Correctional Facility, Cycle 4 Medical Inspection Page 45 Office of the Inspector General State of California SPECIALTY SERVICES This indicator focuses on specialist care from the time a request for Case Review Rating: services or physician’s order for specialist care is completed to the Proficient time of receipt of related recommendations from specialists. This Compliance Score: indicator also evaluates the providers’ timely review of specialist Proficient records and documentation reflecting the patients’ care plans, (88.6%) including course of care when specialist recommendations were not Overall Rating: ordered, and whether the results of specialists’ reports are Proficient communicated to the patients. For specialty services denied by the institution, the OIG determines whether the denials are timely and appropriate, and whether the inmate-patient is updated on the plan of care. Case Review Results The OIG clinicians reviewed 90 events regarding Specialty Services. There were just eight deficiencies in this category, only one of which was significant (case 42). Most of the deficiencies were related to the health information management process. The case review rating for Specialty Services was proficient. Provider Performance Case review showed that patients were generally referred to specialists appropriately by the providers, except on one occasion; this episode is discussed further in the Quality of Provider Performance indicator. The providers also timely reviewed and addressed specialists’ recommendations. Specialty Access On one occasion, a specialty service did not occur within the requested time frame:  In case 42, a provider requested to have the patient follow-up with the gastroenterologist in four weeks for an evaluation of anemia (a low blood count), but the appointment occurred 11 weeks later. On one occasion, specialty services appointments did not occur:  In case 38, a provider requested for a general surgery evaluation, but the patient was actually seen by an ear, nose, and throat (ENT) specialist. Health Information Management The OIG identified five specialty reports that were not retrieved or scanned into the eUHR; however, providers were aware of the reports during follow-up visits. California City Correctional Facility, Cycle 4 Medical Inspection Page 46 Office of the Inspector General State of California Clinician Onsite Inspection At the time of the OIG inspection, the specialty services staff had established an effective tracking process to ensure that patients received their necessary specialty appointments and diagnostic procedures timely. CAC also had an effective process to ensure specialty reports were retrieved and scanned into the eUHR. Conclusion Missed or delayed specialty appointments were rare, and most specialty reports were retrieved and available for review. The OIG clinicians rated the Specialty Services indicator at CAC proficient. Compliance Testing Results The institution received a proficient compliance score of 88.6 percent in the Specialty Services indicator. CAC scored 100 percent for five of the six test areas, as described below:  Providers timely received and reviewed the specialists’ reports for all patients who received a routine and high-priority specialty service (MIT 14.002, 14.004).  For all 12 patients sampled, denials of providers’ specialty services requests occurred within the required time frame and the providers timely communicated the denial status for the requested services to the patients (MIT 14.006, 14.007).  All 15 patients sampled received their routine specialty services appointment within 90 calendar days of the provider’s order. For 13 of the 15 patients sampled (87 percent), the high-priority specialty services appointment occurred within 14 calendar days of the provider’s order. One patient received the service appointment two days late. While another patient refused the specialty appointment but it was scheduled 12 days late (MIT 14.003, 14.001). The institution scored within the inadequate range on the following test:  When patients are approved or scheduled for specialty services appointments at one institution and then transfer to another institution, policy requires that the receiving institution timely schedule and hold the patient’s appointment. Two of the six patients sampled who transferred to CAC with an approved specialty service appointment (33 percent) received it within the required time frame. Four patients received their specialty appointments from 2 to 39 days late (MIT 14.005). Recommendations No specific recommendations. California City Correctional Facility, Cycle 4 Medical Inspection Page 47 Office of the Inspector General State of California SECONDARY (ADMINISTRATIVE) QUALITY INDICATORS OF HEALTH CARE The last two quality indicators (Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications) involve health care administrative systems and processes. Testing in these areas applies only to the compliance component of the process. Therefore, there is no case review assessment associated with either of the two indicators. As part of the compliance component of the first of these two indicators, the OIG does not score several questions. Instead, the OIG presents the findings for informational purposes only. For example, the OIG describes certain local processes in place at CAC. To test both the scored and non-scored areas within these two secondary quality indicators, OIG inspectors interviewed key institutional employees and reviewed documents during their onsite visit to CAC in May 2016. They also reviewed documents obtained from the institution and from CCHCS prior to the start of the inspection. Of these two secondary indicators, OIG compliance inspectors rated both inadequate. The test questions used to assess compliance for each indicator are detailed in Appendix A. California City Correctional Facility, Cycle 4 Medical Inspection Page 48 Office of the Inspector General State of California INTERNAL MONITORING, QUALITY IMPROVEMENT, AND ADMINISTRATIVE OPERATIONS 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 inmate-patient medical appeals and addresses Compliance Score: all appealed issues. Inspectors also verify that the institution follows Inadequate reporting requirements for adverse/sentinel events and inmate (68.8%) deaths, and whether the institution is making progress toward its Overall Rating: Performance Improvement Work Plan initiatives. In addition, the Inadequate OIG verifies that the Emergency Medical Response Review Committee (EMRRC) performs required reviews and that staff 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. Compliance Testing Results The institution scored within the inadequate range in the Internal Monitoring, Quality Improvement, and Administrative Operations indicator, receiving a compliance score of 68.8 percent, showing need for improvement in the following three areas:  The OIG reviewed documentation for 12 emergency medical response incidents addressed by the institution’s Emergency Medical Response Review Committee (EMRRC) during the prior six-month period and found that the required EMRRC Event Checklist forms were either not fully completed or not available at all. Further, the committee minutes did not document discussion of all of the three required questions for the 12 incidents. As a result, CAC received a score of zero on this test (MIT 15.007).  Emergency response drill packages for three medical emergency response drills conducted in the prior quarter did not include required documentation; none of the three drill packages contained a Medical Report of Injury or Unusual Occurrence (CDCR Form 7219) and one of the drill packages did not list the CPR initiation time. As a result, CAC received a score of zero on this test (MIT 15.101).  Inspectors reviewed six recent months’ Quality Management Committee (QMC) meeting minutes and confirmed that the QMC evaluated program performance and took action when the committee identified improvement opportunities. Three of the six meeting were scheduled monthly (50 percent); due to scheduling conflicts, the other three meetings were each scheduled one week late (MIT 15.003). The institution scored in the proficient range with 100 percent scores on each of the following five tests: California City Correctional Facility, Cycle 4 Medical Inspection Page 49 Office of the Inspector General State of California  The institution promptly processed all inmate medical appeals in each of the most recent 12 months (MIT 15.001). In addition, based on a sample of ten second-level medical appeals, the institution’s responses addressed all of the patients’ appealed issues (MIT 15.102).  CAC took adequate steps to ensure the accuracy of its Dashboard data reporting (MIT 15.004).  CAC reached targeted performance objectives for all of the three quality improvement initiatives identified in its 2015 Performance Improvement Work Plan (MIT 15.005).  Medical staff promptly submitted the Initial Inmate Death Report (CDCR Form 7229A) to CCHCS’s Death Review Unit for the one applicable death that occurred at CAC in the prior 12-month period (MIT 15.103). Other Information Obtained from Non-Scored Areas  The OIG gathered non-scored data regarding the completion of death review reports. CCHCS’s Death Review Committee timely completed its death review summary for the one death that occurred during the testing period. For any inmate deaths that occurred prior to November 1, 2015, the CCHCS Death Review Committee (DRC) was required to complete a death review summary within 30 business days of the death and submit it to the institution’s chief executive officer (CEO) five business days later. The DRC timely completed both the death review summary and the subsequent CEO notification (MIT 15.996).  Inspectors met with the institution’s CEO and chief support executive (CSE) to inquire about CAC’s protocols for tracking appeals. The health care appeals coordinator provided monthly appeals summary reports to the appropriate management staff. The reports addressed statistics on appeal issues by subject area (medical, dental, mental health, medication, and staff complaints) and the area the appeals were assigned. Management discussed issues at the Quality Management Committee meetings, and evaluated trends and any hotspot areas. In the six months preceding the OIG’s inspection, management did not identify any critical problems through medical appeals (MIT 15.997).  Non-scored data regarding the institution’s practices for implementing local operating procedures (LOPs) indicated that the institution had an effective process in place for revising existing LOPs and developing new ones. When new or revised policies and procedures were received from CCHCS, the health program specialist (HPS) distributed them to appropriate subject matter experts (SME) assigned by management. The SME reviewed the new policy and returned to the HPS for review by the respective sub-committee and Quality Management committee. Once approved, training on the new or revised LOPs was provided to impacted staff within 30 days. At the time of the OIG’s inspection in May 2016, CAC had California City Correctional Facility, Cycle 4 Medical Inspection Page 50 Office of the Inspector General State of California implemented, or was developing, 25 of the 29 stakeholder-recommended LOPs (86 percent) (MIT 15.998).  The OIG discusses the institution’s health care staffing resources in the About the Institution section of this report (MIT 15.999). Recommendations No specific recommendations. California City Correctional Facility, Cycle 4 Medical Inspection Page 51 Office of the Inspector General State of California JOB PERFORMANCE, TRAINING, LICENSING, AND CERTIFICATIONS In this indicator, the OIG examines whether the institution Case Review Rating: adequately manages its health care staffing resources by evaluating Not Applicable whether job performance reviews are completed as required; Compliance Score: specified staff possess current, valid credentials and professional Inadequate licenses or certifications; nursing staff receive new employee (58.3%) orientation training and annual competency testing; and clinical and Overall Rating: custody staff have current medical emergency response Inadequate certifications. Compliance Testing Results The institution received an inadequate compliance score of 58.3 percent in the Job Performance, Training, Licensing, and Certifications indicator. The following four areas displayed opportunities for improvement:  The OIG inspected records from March 2016 for five nurses, to determine if their nursing supervisors properly completed monthly performance reviews. Inspectors identified the following deficiencies for the five nurses’ monthly nursing reviews (MIT 16.101): o The supervisor did not complete the required number of reviews for two nurses; o The supervisor’s review did not summarize aspects that were well done for four nurses; o The documentation did not confirm that the supervising nurse discussed the findings with two nurses.  None of the institution’s five providers who required a structured clinical performance appraisal appropriately received one. One provider had not received a performance evaluation since he was hired in 2013, and four received their last annual performance appraisal from six months to almost four years late. Also, all five providers’ most recent performance appraisal package lacked a Unit Health Record Clinical Appraisal, and four applicable providers lacked both a 360-Degree Evaluation and a Core Competency-Based Evaluation (MIT 16.103).  CAC hired seven nurses within the last 12 months, and not one of them received a timely new employee orientation training. Six nurses received their orientation six to eight weeks late and one nurse had still not received an orientation at the time of the inspection (over eight months late) (MIT 16.107). California City Correctional Facility, Cycle 4 Medical Inspection Page 52 Office of the Inspector General State of California  The OIG tested provider, nursing, and custody staff records to determine if the institution ensured that those staff members had current emergency response certifications. The institution’s provider and nursing staff were all compliant, but custody managers were not. While the California Penal Code exempts custody managers who primarily perform managerial duties from medical emergency response certification training, CCHCS policy does not allow for such an exemption. As a result, the institution received a score of 67 percent on this test (MIT 16.104). The institution received a proficient score of 100 percent in the following four test areas:  All providers were current with their professional licenses, and nursing staff and the pharmacist in charge were current with their professional licenses and certification requirements (MIT 16.001, 16.105).  All ten nurses sampled were current with their clinical competency validations (MIT 16.102).  The institution’s pharmacy and providers who prescribed controlled substances were current with their Drug Enforcement Agency registrations (MIT 16.106). Recommendations No specific recommendations. California City Correctional Facility, Cycle 4 Medical Inspection Page 53 Office of the Inspector General State of California POPULATION-BASED METRICS 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. It 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, the OIG used a subset of HEDIS measures applicable to the CDCR inmate-patient population. Selection of the measures was based on the availability, reliability, and feasibility of the data required for performing the measurement. The OIG collected data utilizing various information sources, including the eUHR, the Master Registry (maintained by CCHCS), as well as a random sample of patient records analyzed and abstracted by trained personnel. Data obtained from the CCHCS Master Registry and Diabetic Registry was not independently validated by the OIG and is presumed to be accurate. For some measures, the OIG used the entire population rather than statistically random samples. While the OIG is not a certified HEDIS compliance auditor, the OIG uses similar methods to ensure that measures are comparable to those published by other organizations. Comparison of Population-Based Metrics For the California City Correctional Facility, seven of the nine HEDIS measures were applicable for comparison and are listed in the following CAC Results Compared to State and National HEDIS Scores table. Multiple health plans publish their HEDIS performance measures at the State and national levels. The OIG has provided selected results for several health plans in both categories for comparative purposes. California City Correctional Facility, Cycle 4 Medical Inspection Page 54 Office of the Inspector General State of California Results of Population-Based Metric Comparison Comprehensive Diabetes Care For chronic care management, the OIG 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 in order to produce optimal results. CAC performed well with its management of diabetes. When compared statewide, CAC significantly outperformed Medi-Cal in all five diabetic measures. CAC also outperformed Kaiser Permanente in four of the five diabetic measures. However, CAC’s scores were lower than Kaiser’s, both the North and South regions, for diabetic patients’ blood pressure control by 6 and 7 percentage points, respectively. When compared nationally, CAC significantly outperformed Medicaid, Medicare, and commercial health plans (based on data obtained from health maintenance organizations) in all five of the diabetic measures listed. In addition, CAC performed better than the U.S. Department of Veterans Affairs (VA) in two of the four applicable measures, matched the VA for diabetic patients’ blood pressure control, and scored only one percentage point lower for eye exams. Immunizations For influenza shots for younger adults, CAC scored much lower than all other entities reporting data did in this measure (Kaiser, commercial plans, and the VA). However, the institution’s low score was largely due to patient refusals. CAC offered the immunization to all sampled patients, but 55 percent of them refused the offers, which adversely affected the institution’s score. CAC had no patients over the age of 65. Cancer Screening For colorectal cancer screenings, CAC scored the same as, or better than, all other entities that reported data (Kaiser, commercial plans, Medicare, and the VA). Similar to influenza immunization results, the institution offered cancer screenings to all patients sampled, but 18 percent of them refused the offers, negatively affecting CAC’s scores. Summary The population-based metrics performance for CAC reflects an adequate chronic care program, further corroborated by the institution’s adequate score in the Quality of Provider Performance and Quality of Nursing Performance indicators, and its proficient score in the Access to Care and Preventive Services indicators. For influenza immunizations, and cancer screening measures, CAC has an opportunity to improve its scores by placing an emphasis on educating patients regarding their refusal of these preventive services. California City Correctional Facility, Cycle 4 Medical Inspection Page 55 Office of the Inspector General State of California CAC Results Compared to State and National HEDIS Scores California National HEDIS Clinical Measures CAC Kaiser HEDIS HEDIS HEDIS (No. Kaiser HEDIS Com- HEDIS VA Cycle 4 Medi-Cal CA) (So.CA) Medicaid mercial Medicare Average Results1 20152 20153 20153 20154 20154 20154 20145 Comprehensive Diabetes Care HbA1c Testing (Monitoring) 100% 86% 95% 94% 86% 91% 93% 99% Poor HbA1c Control (>9.0%)6, 7 3% 39% 18% 24% 44% 31% 25% 19% HbA1c Control (<8.0%)6 92% 49% 70% 62% 47% 58% 65% - Blood Pressure Control (<140/90)6 78% 63% 84% 85% 62% 65% 65% 78% Eye Exams 89% 53% 69% 81% 54% 56% 69% 90% Immunizations Influenza Shots - Adults (18–64) 45% - 54% 55% - 50% - 58% Influenza Shots - Adults (65+)8 - - - - - - 72% 76% Immunizations: Pneumococcal8 - - - - - - 70% 93% Cancer Screening Colorectal Cancer Screening 82% - 80% 82% - 64% 67% 82% 1. Unless otherwise stated, data was collected in May 2016 by reviewing medical records from a sample of CAC’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 2015 HEDIS Aggregate Report for Medi-Cal Managed Care. 3. Data was obtained from Kaiser Permanente November 2015 reports for the Northern and Southern California regions. 4. National HEDIS data for Medicaid, commercial plans, and Medicare was obtained from the 2015 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 CAC 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. There were no patients over the age of 65 in the population at CAC; therefore, these measures were omitted from the comparative analysis. California City Correctional Facility, Cycle 4 Medical Inspection Page 56 Office of the Inspector General State of California APPENDIX A — COMPLIANCE TEST RESULTS California City Correctional Facility Range of Summary Scores: 58.33% - 95.00% Indicator Overall Score (Yes %) Access to Care 87.90% Diagnostic Services 77.28% Emergency Services Not Applicable Health Information Management (Medical Records) 87.20% Health Care Environment 86.36% Inter- and Intra-System Transfers 94.81% Pharmacy and Medication Management 92.10% Prenatal and Post-Delivery Services Not Applicable Preventive Services 95.00% Quality of Nursing Performance Not Applicable Quality of Provider Performance Not Applicable Reception Center Arrivals Not Applicable Specialized Medical Housing (OHU, CTC, SNF, Hospice) Not Applicable Specialty Services 88.57% Internal Monitoring, Quality Improvement, and Administrative Operations 68.75% Job Performance, Training, Licensing, and Certifications 58.33% California City Correctional Facility, Cycle 4 Medical Inspection Page 57 Office of the Inspector General State of California Scored Answers Yes Reference + Access to Care Number Yes No No Yes % N/A 1.001 Chronic care follow-up appointments: Was the inmate-patient’s most 25 5 30 83.33% 0 recent chronic care visit within the health care guideline’s maximum allowable interval or within the ordered time frame, whichever is shorter? 1.002 For endorsed inmate-patients received from another CDCR 3 4 7 42.86% 23 institution: If the nurse referred the inmate-patient to a provider during the initial health screening, was the inmate-patient seen within the required time frame? 1.003 Clinical appointments: Did a registered nurse review the 30 0 30 100.00% 0 inmate-patient’s request for service the same day it was received? 1.004 Clinical appointments: Did the registered nurse complete a 30 0 30 100.00% 0 face-to-face visit within one business day after the CDCR Form 7362 was reviewed? 1.005 Clinical appointments: If the registered nurse determined a referral to 6 1 7 85.71% 23 a primary care provider was necessary, was the inmate-patient seen within the maximum allowable time or the ordered time frame, whichever is the shorter? 1.006 Sick call follow-up appointments: If the primary care provider 6 0 6 100.00% 24 ordered a follow-up sick call appointment, did it take place within the time frame specified? 1.007 Upon the inmate-patient’s discharge from the community hospital: 12 0 12 100.00% 0 Did the inmate-patient receive a follow-up appointment within the required time frame? 1.008 Specialty service follow-up appointments: Do specialty service 19 5 24 79.17% 6 primary care physician follow-up visits occur within required time frames? 1.101 Clinical appointments: Do inmate-patients have a standardized 6 0 6 100.00% 0 process to obtain and submit health care services request forms? Overall Percentage: 87.90% California City Correctional Facility, Cycle 4 Medical Inspection Page 58 Office of the Inspector General State of California Scored Answers Yes Reference + Diagnostic Services Number Yes No No Yes % N/A 2.001 Radiology: Was the radiology service provided within the time frame 10 0 10 100.00% 0 specified in the provider’s order? 2.002 Radiology: Did the primary care provider review and initial the 8 2 10 80.00% 0 diagnostic report within specified time frames? 2.003 Radiology: Did the primary care provider communicate the results of 9 1 10 90.00% 0 the diagnostic study to the inmate-patient within specified time frames? 2.004 Laboratory: Was the laboratory service provided within the time 8 2 10 80.00% 0 frame specified in the provider’s order? 2.005 Laboratory: Did the primary care provider review and initial the 10 0 10 100.00% 0 diagnostic report within specified time frames? 2.006 Laboratory: Did the primary care provider communicate the results of 9 1 10 90.00% 0 the diagnostic study to the inmate-patient within specified time frames? 2.007 Pathology: Did the institution receive the final diagnostic report within 5 4 9 55.56% 0 the required time frames? 2.008 Pathology: Did the primary care provider review and initial the 6 1 7 85.71% 2 diagnostic report within specified time frames? 2.009 Pathology: Did the primary care provider communicate the results of 1 6 7 14.29% 2 the diagnostic study to the inmate-patient within specified time frames? Overall Percentage: 77.28% California City Correctional Facility, Cycle 4 Medical Inspection Page 59 Office of the Inspector General State of California Emergency Services Scored Answers Assesses reaction times and responses to emergency situations. The OIG RN clinicians will use detailed information obtained from the institution’s incident Not Applicable packages to perform focused case reviews. Scored Answers Health Information Management Yes Reference + (Medical Records) Number Yes No No Yes % N/A 4.001 Are non-dictated progress notes, initial health screening forms, and 20 0 20 100.00% 0 health care services request forms scanned into the eUHR within three calendar days of the inmate-patient encounter date? 4.002 Are dictated / transcribed documents scanned into the eUHR within Not Applicable five calendar days of the inmate-patient encounter date? 4.003 Are specialty documents scanned into the eUHR within the required 20 0 20 100.00% 0 time frame? 4.004 Are community hospital discharge documents scanned into the eUHR 11 0 11 100.00% 0 within three calendar days of the inmate-patient date of hospital discharge? 4.005 Are medication administration records (MARs) scanned into the eUHR 20 0 20 100.00% 0 within the required time frames? 4.006 During the eUHR review, did the OIG find that documents were 9 3 12 75.00% 0 correctly labeled and included in the correct inmate-patient’s file? 4.007 Did clinical staff legibly sign health care records, when required? 14 18 32 43.75% 0 4.008 For inmate-patients discharged from a community hospital: Did 11 1 12 91.67% 0 the preliminary hospital discharge report include key elements and did a PCP review the report within three calendar days of discharge? Overall Percentage: 87.20% California City Correctional Facility, Cycle 4 Medical Inspection Page 60 Office of the Inspector General State of California Scored Answers Yes Reference + Health Care Environment Number Yes No No Yes % N/A 5.101 Infection Control: Are clinical health care areas appropriately 9 0 9 100.00% 0 disinfected, cleaned and sanitary? 5.102 Infection control: Do clinical health care areas ensure that reusable 8 1 9 88.89% 0 invasive and non-invasive medical equipment is properly sterilized or disinfected as warranted? 5.103 Infection Control: Do clinical health care areas contain operable sinks 9 0 9 100.00% 0 and sufficient quantities of hygiene supplies? 5.104 Infection control: Does clinical health care staff adhere to universal 8 1 9 88.89% 0 hand hygiene precautions? 5.105 Infection control: Do clinical health care areas control exposure to 9 0 9 100.00% 0 blood-borne pathogens and contaminated waste? 5.106 Warehouse, Conex and other non-clinic storage areas: Does the 1 0 1 100.00% 0 medical supply management process adequately support the needs of the medical health care program? 5.107 Clinical areas: Does each clinic follow adequate protocols for 9 0 9 100.00% 0 managing and storing bulk medical supplies? 5.108 Clinical areas: Do clinic common areas and exam rooms have 3 6 9 33.33% 0 essential core medical equipment and supplies? 5.109 Clinical areas: Do clinic common areas have an adequate environment 8 1 9 88.89% 0 conducive to providing medical services? 5.110 Clinical areas: Do clinic exam rooms have an adequate environment 6 3 9 66.67% 0 conducive to providing medical services? 5.111 Emergency response bags: Are TTA and clinic emergency medical 5 1 6 83.33% 3 response bags inspected daily and inventoried monthly, and do they contain essential items? 5.999 For Information Purposes Only: Does the institution’s health care management believe that all clinical areas have physical plant Information Only infrastructures sufficient to provide adequate health care services? Overall Percentage: 86.36% California City Correctional Facility, Cycle 4 Medical Inspection Page 61 Office of the Inspector General State of California Scored Answers Yes Reference + Inter- and Intra-System Transfers Number Yes No No Yes % N/A 6.001 For endorsed inmate-patients received from another CDCR 29 1 30 96.67% 0 institution or COCF: Did nursing staff complete the initial health screening and answer all screening questions on the same day the inmate-patient arrived at the institution? 6.002 For endorsed inmate-patients received from another CDCR 29 1 30 96.67% 0 institution or COCF: When required, did the RN complete the assessment and disposition section of the health screening form; refer the inmate-patient 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? 6.003 For endorsed inmate-patients received from another CDCR 6 1 7 85.71% 23 institution or COCF: If the inmate-patient had an existing medication order upon arrival, were medications administered or delivered without interruption? 6.004 For inmate-patients transferred out of the facility: Were scheduled 19 1 20 95.00% 0 specialty service appointments identified on the Health Care Transfer Information Form 7371? 6.101 For inmate-patients transferred out of the facility: Do medication 1 0 1 100.00% 2 transfer packages include required medications along with the corresponding Medication Administration Record (MAR) and Medication Reconciliation? Overall Percentage: 94.81% California City Correctional Facility, Cycle 4 Medical Inspection Page 62 Office of the Inspector General State of California Scored Answers Yes Reference + Pharmacy and Medication Management Number Yes No No Yes % N/A 7.001 Did the inmate-patient receive all chronic care medications 28 1 29 96.55% 1 within the required time frames or did the institution follow departmental policy for refusals or no-shows? 7.002 Did health care staff administer or deliver new order prescription 30 0 30 100.00% 0 medications to the inmate-patient within the required time frames? 7.003 Upon the inmate-patient’s discharge from a community 11 1 12 91.67% 0 hospital: Were all medications ordered by the institution’s primary care provider administered or delivered to the inmate-patient within one calendar day of return? 7.004 For inmate-patients received from a county jail: Were all medications ordered by the institution’s reception center provider Not Applicable administered or delivered to the inmate-patient within the required time frames? 7.005 Upon the inmate-patient’s transfer from one housing unit to 21 0 21 100.00% 0 another: Were medications continued without interruption? 7.006 For inmate-patients en route who lay over at the institution: If the temporarily housed inmate-patient had an existing Not Applicable medication order, were medications administered or delivered without interruption? 7.101 All clinical and medication line storage areas for narcotic 5 1 6 83.33% 7 medications: Does the institution employ strong medication security controls over narcotic medications assigned to its clinical areas? 7.102 All clinical and medication line storage areas for non-narcotic 8 2 10 80.00% 3 medications: Does the institution properly store non-narcotic medications that do not require refrigeration in assigned clinical areas? 7.103 All clinical and medication line storage areas for non-narcotic 6 2 8 75.00% 5 medications: Does the institution properly store non-narcotic medications that require refrigeration in assigned clinical areas? 7.104 Medication preparation and administration areas: Do nursing 3 1 4 75.00% 9 staff employ and follow hand hygiene contamination control protocols during medication preparation and medication administration processes? 7.105 Medication preparation and administration areas: Does the 4 0 4 100.00% 9 institution employ appropriate administrative controls and protocols when preparing medications for inmate-patients? 7.106 Medication preparation and administration areas: Does the 4 1 5 80.00% 8 institution employ appropriate administrative controls and protocols when distributing medications to inmate-patients? California City Correctional Facility, Cycle 4 Medical Inspection Page 63 Office of the Inspector General State of California Scored Answers Yes Reference + Pharmacy and Medication Management Number Yes No No Yes % N/A 7.107 Pharmacy: Does the institution employ and follow general 1 0 1 100.00% 0 security, organization, and cleanliness management protocols in its main and satellite pharmacies? 7.108 Pharmacy: Does the institution’s pharmacy properly store 1 0 1 100.00% 0 non-refrigerated medications? 7.109 Pharmacy: Does the institution’s pharmacy properly store refrigerated 1 0 1 100.00% 0 or frozen medications? 7.110 Pharmacy: Does the institution’s pharmacy properly account for 1 0 1 100.00% 0 narcotic medications? 7.111 Pharmacy: Does the institution follow key medication error reporting 26 0 26 100.00% 4 protocols? 7.998 For Information Purposes Only: During eUHR compliance testing and case reviews, did the OIG find that medication errors were properly Information Only identified and reported by the institution? 7.999 For Information Purposes Only: Do inmate-patients in isolation housing units have immediate access to their KOP prescribed rescue Information Only inhalers and nitroglycerin medications? Overall Percentage: 92.10% California City Correctional Facility, Cycle 4 Medical Inspection Page 64 Office of the Inspector General State of California Prenatal and Post-Delivery Services Scored Answers This indicator is not applicable to this institution. Not Applicable Scored Answers Yes Reference + Preventive Services Number Yes No No Yes % N/A 9.001 Inmate-patients prescribed TB medications: Did the institution 4 0 4 100.00% 0 administer the medication to the inmate-patient as prescribed? 9.002 Inmate-patients prescribed TB medications: Did the institution 3 1 4 75.00% 0 monitor the inmate-patient monthly for the most recent three months he or she was on the medication? 9.003 Annual TB Screening: Was the inmate-patient screened for TB within 27 3 30 90.00% 0 the last year? 9.004 Were all inmate-patients offered an influenza vaccination for the most 30 0 30 100.00% 0 recent influenza season? 9.005 All inmate-patients from the age of 50 through the age of 75: Was 30 0 30 100.00% 0 the inmate-patient offered colorectal cancer screening? 9.006 Female inmate-patients from the age of 50 through the age of 74: Was the inmate-patient offered a mammogram in compliance with Not Applicable policy? 9.007 Female inmate-patients from the age of 21 through the age of 65: Not Applicable Was the inmate-patient offered a pap smear in compliance with policy? 9.008 Are required immunizations being offered for chronic care 8 0 8 100.00% 22 inmate-patients? 9.009 Are inmate-patients at the highest risk of coccidioidomycosis (valley 5 0 5 100.00% 0 fever) infection transferred out of the facility in a timely manner? Overall Percentage: 95.00% California City Correctional Facility, Cycle 4 Medical Inspection Page 65 Office of the Inspector General State of California Quality of Nursing Performance Scored Answers The quality of nursing performance will be assessed during case reviews, conducted by OIG clinicians, and is not applicable for the compliance portion of the medical inspection. The methodologies OIG clinicians use to evaluate the quality of nursing Not Applicable performance are presented in a separate inspection document entitled OIG MIU Retrospective Case Review Methodology. Quality of Provider Performance Scored Answers The quality of provider performance will be assessed during case reviews, conducted by OIG clinicians, and is not applicable for the compliance portion of the medical inspection. The methodologies OIG clinicians use to evaluate the quality of Not Applicable provider performance are presented in a separate inspection document entitled OIG MIU Retrospective Case Review Methodology. Reception Center Arrivals Scored Answers This indicator is not applicable to this institution. Not Applicable Specialized Medical Housing (OHU, CTC, SNF, Hospice) Scored Answers This indicator is not applicable to this institution. Not Applicable California City Correctional Facility, Cycle 4 Medical Inspection Page 66 Office of the Inspector General State of California Scored Answers Yes Reference + Specialty Services Number Yes No No Yes % N/A 14.001 Did the inmate-patient receive the high-priority specialty service within 13 2 15 86.67% 0 14 calendar days of the PCP order? 14.002 Did the PCP review the high priority specialty service consultant report 13 0 13 100.00% 2 within the required time frame? 14.003 Did the inmate-patient receive the routine specialty service within 90 15 0 15 100.00% 0 calendar days of the PCP order? 14.004 Did the PCP review the routine specialty service consultant report 15 0 15 100.00% 0 within the required time frame? 14.005 For endorsed inmate-patients received from another CDCR 2 4 6 33.33% 0 institution: If the inmate-patient was approved for a specialty services appointment at the sending institution, was the appointment scheduled at the receiving institution within the required time frames? 14.006 Did the institution deny the primary care provider request for specialty 12 0 12 100.00% 0 services within required time frames? 14.007 Following the denial of a request for specialty services, was the 12 0 12 100.00% 0 inmate-patient informed of the denial within the required time frame? Overall Percentage: 88.57% California City Correctional Facility, Cycle 4 Medical Inspection Page 67 Office of the Inspector General State of California Scored Answers Internal Monitoring, Quality Improvement, and Yes Reference + Administrative Operations Number Yes No No Yes % N/A 15.001 Did the institution promptly process inmate medical appeals during the 12 0 12 100.00% 0 most recent 12 months? 15.002 Does the institution follow adverse/sentinel event reporting Not Applicable requirements? 15.003 Did the institution Quality Management Committee (QMC) meet at 3 3 6 50.00% 0 least monthly to evaluate program performance, and did the QMC take action when improvement opportunities were identified? 15.004 Did the institution’s Quality Management Committee (QMC) or other 1 0 1 100.00% 0 forum take steps to ensure the accuracy of its Dashboard data reporting? 15.005 For each initiative in the Performance Improvement Work Plan 3 0 3 100.00% 1 (PIWP), has the institution performance improved or reached the targeted performance objective(s)? 15.006 For institutions with licensed care facilities: Does the Local Governing Body (LGB), or its equivalent, meet quarterly and exercise Not Applicable its overall responsibilities for the quality management of patient health care? 15.007 Does the Emergency Medical Response Review Committee perform 0 12 12 0.00% 0 timely incident package reviews that include the use of required review documents? 15.101 Did the institution complete a medical emergency response drill for 0 3 3 0.00% 0 each watch and include participation of health care and custody staff during the most recent full quarter? 15.102 Did the institution’s second level medical appeal response address all 10 0 10 100.00% 0 of the inmate-patient’s appealed issues? 15.103 Did the institution’s medical staff review and submit the initial inmate 1 0 1 100.00% 0 death report to the Death Review Unit in a timely manner? 15.996 For Information Purposes Only: Did the CCHCS Death Review Committee submit its inmate death review summary to the institution Information Only timely? 15.997 For Information Purposes Only: Identify the institution’s protocols Information Only for tracking medical appeals. 15.998 For Information Purposes Only: Identify the institution’s protocols Information Only for implementing health care local operating procedures. 15.999 For Information Purposes Only: Identify the institution’s health care Information Only staffing resources. Overall Percentage: 68.75% California City Correctional Facility, Cycle 4 Medical Inspection Page 68 Office of the Inspector General State of California Scored Answers Job Performance, Training, Licensing, and Yes Reference + Certifications Number Yes No No Yes % N/A 16.001 Do all providers maintain a current medical license? 7 0 7 100.00% 0 16.101 Does the institution’s Supervising Registered Nurse conduct periodic 0 5 5 0.00% 0 reviews of nursing staff? 16.102 Are nursing staff who administer medications current on their clinical 10 0 10 100.00% 0 competency validation? 16.103 Are structured clinical performance appraisals completed timely? 0 5 5 0.00% 2 16.104 Are staff current with required medical emergency response 2 1 3 66.67% 0 certifications? 16.105 Are nursing staff and the Pharmacist-in-Charge current with their 5 0 5 100.00% 1 professional licenses and certifications? 16.106 Do the institution’s pharmacy and authorized providers who prescribe 1 0 1 100.00% 0 controlled substances maintain current Drug Enforcement Agency (DEA) registrations? 16.107 Are nursing staff current with required new employee orientation? 0 1 1 0.00% 0 Overall Percentage: 58.33% California City Correctional Facility, Cycle 4 Medical Inspection Page 69 Office of the Inspector General State of California APPENDIX B — CLINICAL DATA Table B-1: CAC Sample Sets Sample Set Total Death Review/Sentinel Events 1 Diabetes 3 Emergency Services — Non-CPR 5 High Risk 11 Hospitalization 5 Intra-System Transfers In 3 Intra-System Transfers Out 3 RN Sick Call 15 Specialty Services 5 51 California City Correctional Facility, Cycle 4 Medical Inspection Page 70 Office of the Inspector General State of California Table B-2: CAC Chronic Care Diagnoses Diagnosis Total Anemia 2 Arthritis/Degenerative Joint Disease 5 Asthma 5 Cardiovascular Disease 3 Chronic Pain 10 Cirrhosis/End-Stage Liver Disease 1 Diabetes 11 Diagnosis 19 Gastroesophageal Reflux Disease 10 Gastrointestinal Bleed 1 Hepatitis C 14 Hyperlipidemia 11 Hypertension 20 Mental Health 1 Seizure Disorder 1 114 California City Correctional Facility, Cycle 4 Medical Inspection Page 71 Office of the Inspector General State of California Table B-3: CAC Event — Program Program Total Diagnostic Services 105 Emergency Care 28 Hospitalization 26 Intra-System Transfers In 12 Intra-System Transfers Out 11 Outpatient Care 567 Specialized Medical Housing 0 Specialty Services 111 860 Table B-4: CAC Case Review Sample Summary Total MD Reviews, Detailed 30 MD Reviews, Focused 1 RN Reviews, Detailed 17 RN Reviews, Focused 25 Total Reviews 73 Total Unique Cases 51 Overlapping Reviews (MD & RN) 22 California City Correctional Facility, Cycle 4 Medical Inspection Page 72 Office of the Inspector General State of California APPENDIX C — COMPLIANCE SAMPLING METHODOLOGY California City Correctional Facility 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 inmate-patient—any risk level) (30)  Randomize MIT 1.002 Nursing Referrals OIG Q: 6.001  See Intra-system Transfers (30) 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: 4.008  See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (12) 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) (9)  Randomize California City Correctional Facility, Cycle 4 Medical Inspection Page 73 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 (20) 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 (0)  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: 4.008  Community hospital discharge documents (11)  First 20 IPs selected MIT 4.005 OIG Q: 7.001  MARs (20)  First 20 IPs selected MIT 4.006 Documents for  Any misfiled or mislabeled document identified (12) any tested inmate during OIG compliance review (12 or more = No) MIT 4.007 Legible Signatures & OIG Qs: 4.008,  First 8 IPs sampled Review 6.001, 6.002,  One source document per IP 7.001, 12.001, (32) 12.002 & 14.002 MIT 4.008 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 inmate-patients from each of the 6 months (if not 5 in a month, supplement from another, as (12) needed) Health Care Environment MIT 5.101-105 Clinical Areas OIG inspector  Identify and inspect all onsite clinical areas. MIT 5.107–111 (9) 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 (30) MIT 6.004 Specialty Services MedSATS  Date of transfer (3–9 months) Send-Outs  Randomize (20) MIT 6.101 Transfers Out OIG inspector  R&R IP transfers with medication (3) onsite review California City Correctional Facility, Cycle 4 Medical Inspection Page 74 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 inmate-patient—any risk level (30)  Randomize MIT 7.002 New Medication Master Registry  Rx count Orders  Randomize (30)  Ensure no duplication of IPs tested in MIT 7.001 MIT 7.003 Returns from OIG Q: 4.008  See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (12) 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) (21)  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 (13) 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 (30) reports MIT 7.999 Isolation Unit KOP Onsite active  KOP rescue inhalers & nitroglycerin medications Medications medication for IPs housed in isolation units (1) listing Prenatal and Post-Delivery Services MIT 8.001-007 Recent Deliveries OB Roster  Delivery date (2–12 months) N/A at this institution  Most recent deliveries (within date range) Pregnant Arrivals OB Roster  Arrival date (2–12 months) N/A at this institution  Earliest arrivals (within date range) California City Correctional Facility, Cycle 4 Medical Inspection Page 75 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) (4)  Randomize MIT 9.003 TB Code 22, Annual SOMS  Arrival date (at least 1 year prior to inspection) TST  TB Code (22) (15)  Randomize TB Code 34, Annual SOMS  Arrival date (at least 1 year prior to inspection) Screening  TB Code (34) (15)  Randomize MIT 9.004 Influenza SOMS  Arrival date (at least 1 year prior to inspection) Vaccinations  Randomize (30)  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) (30)  Randomize MIT 9.006 Mammogram SOMS  Arrival date (at least 2 yrs prior to inspection)  Date of birth (age 52–74) N/A at this institution  Randomize MIT 9.007 Pap Smear SOMS  Arrival date (at least three yrs prior to inspection)  Date of birth (age 24–53) N/A at this 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 (30)  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) (5)  All California City Correctional Facility, Cycle 4 Medical Inspection Page 76 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)  Arrived from (county jail, return from parole, etc.) N/A at this institution  Randomize Specialized Medical Housing MITs 13.001–004 CTC CADDIS  Admit date (1–6 months)  Type of stay (no MH beds)  Length of stay (minimum of 5 days) N/A at this institution  Randomize MIT 13.101 Call Buttons OIG inspector  Review by location CTC onsite review N/A at this institution Specialty Services Access 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) (15)  Remove optometry, physical therapy or podiatry  Randomize MIT 14.005 Specialty Services MedSATS  Arrived from (other CDCR institution) Arrivals  Date of transfer (3–9 months) (6)  Randomize MIT 14.006-007 Denials InterQual  Review date (3–9 months) (2)  Randomize IUMC/MAR  Meeting date (9 months) Meeting Minutes  Denial upheld (10)  Randomize California City Correctional Facility, Cycle 4 Medical Inspection Page 77 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Internal Monitoring, Quality Improvement, & 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 Performance Institution PIWP  PIWP with updates (12 months) Improvement Work  Medical initiatives Plans (PIWP) (4) MIT 15.006 LGB LGB meeting  Quarterly meeting minutes (12 months) N/A at this minutes institution MIT 15.007 EMRRC EMRRC meeting  Monthly meeting minutes (6 months) (12) 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  Initial death reports (1) 12 months MIT 15.996 Death Review OIG summary  Between 35 business days & 12 months prior Committee log - deaths  CCHCS death reviews (1) MIT 15.998 Local Operating Institution LOPs  All LOPs Procedures (LOPs) (all) California City Correctional Facility, Cycle 4 Medical Inspection Page 78 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Job Performance, Training, Licensing, and Certifications MIT 16.001 Provider licenses Current provider  Review all listing (at start of (7) inspection) MIT 16.101 RN Review Onsite  RNs who worked in clinic or emergency setting Evaluations supervisor six or more days in sampled month periodic RN  Randomize (5) reviews MIT 16.102 Nursing Staff Onsite nursing  On duty one or more years Validations education files  Nurse administers medications (10)  Randomize MIT 16.103 Provider Annual OIG Q:16.001  All required performance evaluation documents Evaluation Packets (7) MIT 16.104 Medical Emergency Onsite  All staff Response certification o Providers (ACLS) Certifications tracking logs o Nursing (BLS/CPR) (all) o Custody (CPR/BLS) MIT 16.105 Nursing staff and Onsite tracking  All required licenses and certifications Pharmacist in system, logs, or Charge Professional employee files Licenses and Certifications (all) MIT 16.106 Pharmacy and Onsite listing of  All DEA registrations Providers’ Drug provider DEA Enforcement Agency registration #s & (DEA) Registrations pharmacy registration (all) document MIT 16.107 Nursing Staff New Nursing staff  New employees (hired within last 12 months) Employee training logs Orientations (all) California City Correctional Facility, Cycle 4 Medical Inspection Page 79 Office of the Inspector General State of California C C ALIFORNIA ORRECTIONAL H C S ’ EALTH ARE ERVICES R ESPONSE California City Correctional Facility, Cycle 4 Medical Inspection Page 80 Office of the Inspector General State of California