California City Correctional Facility Medical Inspection Report Cycle 5

Roy W. Wesley Office of the Inspector General Inspector General California City Correctional Facility Medical Inspection Results Cycle 5 June 2018 Fairness Integrity Respect Medical Inspection Unit Page 1 Office of the Inspe ct or GSeneeral rvice TransparencStatye of California Office of the Inspector General CALIFORNIA CITY CORRECTIONAL FACILITY Medical Inspection Results Cycle 5 Roy W. Wesley Inspector General Bryan B. Beyer Chief Deputy Inspector General Shaun R. Spillane Public Information Officer June 2018 T C ABLE OF ONTENTS Foreword ........................................................................................................................................ i Executive Summary ...................................................................................................................... iii Overall Rating: Proficient .......................................................................................................... iii Clinical Case Review and OIG Clinician Inspection Results ................................................. v Compliance Testing Results ................................................................................................. vi Recommendations .............................................................................................................. vii Population-Based Metrics ................................................................................................... vii Introduction ................................................................................................................................... 1 About the Institution ................................................................................................................... 1 Objectives, Scope, and Methodology .............................................................................................. 4 Case Reviews ............................................................................................................................. 5 Patient Selection for Retrospective Case Reviews ................................................................. 6 Benefits and Limitations of Targeted Subpopulation Review ................................................ 7 Case Review Sampling Methodology.................................................................................... 7 Breadth of Case Reviews ...................................................................................................... 8 Case Review Testing Methodology ....................................................................................... 9 Compliance Testing .................................................................................................................. 12 Sampling Methods for Conducting Compliance Testing ...................................................... 12 Scoring of Compliance Testing Results ............................................................................... 12 Overall Quality Indicator Rating for Case Reviews and Compliance Testing ............................. 13 Population-Based Metrics ......................................................................................................... 13 Medical Inspection Results........................................................................................................... 14 Access to Care ............................................................................................................ 16 Case Review Results .......................................................................................................... 16 Compliance Testing Results ................................................................................................ 18 Diagnostic Services..................................................................................................... 20 Case Review Results .......................................................................................................... 20 Compliance Testing Results ................................................................................................ 21 Emergency Services .................................................................................................... 22 Case Review Results .......................................................................................................... 22 Health Information Management ................................................................................ 25 Case Review Results .......................................................................................................... 25 Compliance Testing Results ................................................................................................ 27 Health Care Environment ........................................................................................... 28 Compliance Testing Results ................................................................................................ 28 Inter- and Intra-System Transfers................................................................................ 30 Case Review Results .......................................................................................................... 30 Compliance Testing Results ................................................................................................ 32 Pharmacy and Medication Management ..................................................................... 33 Case Review Results .......................................................................................................... 33 Compliance Testing Results ................................................................................................ 34 California City Correctional Facility, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California Prenatal and Post-Delivery Services ........................................................................... 37 Preventive Services ..................................................................................................... 38 Compliance Testing Results ................................................................................................ 38 Quality of Nursing Performance ................................................................................ 40 Case Review Results .......................................................................................................... 40 Quality of Provider Performance .............................................................................. 43 Case Review Results .......................................................................................................... 43 Reception Center Arrivals ......................................................................................... 46 Specialized Medical Housing .................................................................................... 47 Specialty Services...................................................................................................... 48 Case Review Results .......................................................................................................... 48 Compliance Testing Results ................................................................................................ 49 Administrative Operations (Secondary) ..................................................................... 51 Compliance Testing Results ................................................................................................ 51 Recommendations ........................................................................................................................ 54 Population-Based Metrics ............................................................................................................ 55 Appendix A — Compliance Test Results ..................................................................................... 58 Appendix B — Clinical Data........................................................................................................ 71 Appendix C — Compliance Sampling Methodology .................................................................... 75 California Correctional Health Care Services’ Response............................................................... 82 California City Correctional Facility, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California L T F IST OF ABLES AND IGURES CAC Executive Summary Table .................................................................................................... iv CAC Health Care Staffing Resources as of October 2017 ............................................................... 2 CAC Master Registry Data as of October 2, 2017 ........................................................................... 3 Exhibit 1. Case Review Definitions ................................................................................................ 5 Chart 1. Case Review Sample Selection .......................................................................................... 8 Chart 2. Case Review Testing and Deficiencies ............................................................................ 10 Chart 3. Inspection Indicator Review Distribution ......................................................................... 14 CAC Results Compared to State and National HEDIS Scores ....................................................... 57 Table B-1: CAC Sample Sets ........................................................................................................ 71 Table B-2: CAC Chronic Care Diagnoses ..................................................................................... 72 Table B-3: CAC Event – Program................................................................................................. 73 Table B-4: CAC Review Sample Summary................................................................................... 74 California City Correctional Facility, Cycle 5 Medical Inspection List of Tables and Figures Office of the Inspector General State of California This page intentionally left blank. California City Correctional Facility, Cycle 5 Medical Inspection Office of the Inspector General State of California F OREWORD Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), the OIG conducts a comprehensive inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG explicitly makes no determination regarding the constitutionality of care in the prison setting. That determination is left to the Receiver and the federal court. The assessment of care by the OIG is just one factor in the court’s determination whether care in the prisons meets constitutional standards. The OIG’s inspections are mandated by the Penal Code and not aimed at specifically resolving the court’s questions on constitutional care. To the degree that they provide another factor for the court to consider, the OIG is pleased to provide added value to the taxpayers of California. In Cycle 5, for the first time, the OIG will be inspecting institutions delegated back to CDCR from the Receivership. There is no difference in the standards used for assessment of a delegated institution versus an institution not yet delegated. The Receiver delegated California City Correctional Facility back to CDCR in May 2017. This fifth cycle of inspections will continue evaluating the areas addressed in Cycle 4, which included clinical case review, compliance testing, and a population-based metric comparison of selected Healthcare Effectiveness Data Information Set (HEDIS) measures. In agreement with stakeholders, the OIG made changes to both the case review and compliance components. The OIG found that in every inspection in Cycle 4, larger samples were taken than were needed to assess the adequacy of medical care provided. As a result, the OIG reduced the number of case reviews and sample sizes for compliance testing. Also, in Cycle 4, compliance testing included two secondary (administrative) indicators (Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications). For Cycle 5, these have been combined into one secondary indicator, Administrative Operations. California City Correctional Facility, Cycle 5 Medical Inspection Page i Office of the Inspector General State of California This page intentionally left blank. California City Correctional Facility, Cycle 5 Medical Inspection Page ii Office of the Inspector General State of California E S XECUTIVE UMMARY The OIG performed its Cycle 5 medical inspection at California City Correctional Facility (CAC) from October to December of 2017. The OVERALL RATING: inspection included in-depth reviews of 42 patient files conducted by clinicians, as well as reviews of documents from 964 patient files, Proficient covering 83 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 12 health care quality indicators applicable to the institution. To conduct clinical case reviews, the OIG employs a clinician team consisting of a physician and a registered nurse consultant, while a team of registered nurses trained in monitoring medical policy compliance conducts compliance testing. Both case review clinicians and compliance inspectors rated six of the indicators; only case review clinicians rated three of the indicators; and only compliance inspectors scored three of the indicators. The CAC Executive Summary Table on the following page identifies the applicable individual indicators and scores for this institution. The OIG experts made a considered and measured overall opinion that the quality of health care at CAC was proficient. California City Correctional Facility, Cycle 5 Medical Inspection Page iii Office of the Inspector General State of California CAC Executive Summary Table Cycle 5 Cycle 4 Case Review Compliance Inspection Indicators Overall Overall Rating Rating Rating Rating 1—Access to Care Proficient Proficient Proficient Proficient 2—Diagnostic Services Proficient Adequate Adequate Adequate 3—Emergency Services Adequate Not Applicable Adequate Adequate 4—Health Information Proficient Proficient Proficient Proficient Management 5—Health Care Environment Not Applicable Proficient Proficient Proficient 6—Inter- and Intra-System Adequate Proficient Adequate Proficient Transfers 7—Pharmacy and Medication I Proficient Proficient Proficient n Proficient Management a 8—Prenatal and Post-Delivery Not Applicable Not Applicable Not Applicable Not Applicable Services 9—Preventive Services Not Applicable Proficient Proficient Proficient 10—Quality of Nursing Proficient Not Applicable Proficient Adequate Performance 11—Quality of Provider Adequate Not Applicable Adequate Adequate Performance 12—Reception Center Arrivals Not Applicable Not Applicable Not Applicable Not Applicable 13—Specialized Medical Housing Not Applicable Not Applicable Not Applicable Not Applicable 14—Specialty Services Proficient Proficient Proficient Proficient 15—Administrative Operations Not Applicable Adequate Adequate Inadequate* (Secondary) *In Cycle 4, there were two secondary (administrative) indicators. This score reflects the average of those two scores. California City Correctional Facility, Cycle 5 Medical Inspection Page iv Office of the Inspector General State of California Clinical Case Review and OIG Clinician Inspection Results The clinicians’ case reviews sampled patients with high medical needs and included a review of 664 patient care events.1 As depicted on the summary table on page iv, of the 12 indicators applicable to CAC, 9 were evaluated by clinician case review; 6 were proficient, and 3 were adequate. 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’s chief medical executive (CME) and chief physician and surgeon (CP&S) provided diligent appointment and scheduling oversight, including providing direct patient care when needed. Their active intervention helped CAC achieve a proficient rating for the Access to Care indicator. • CAC performed well in the Diagnostic Services and Health Information Management indicators. CAC successfully implemented the new electronic health record system (EHRS) and used the system’s new features to improve process shortcomings previously noted by the OIG in Cycle 4. • CAC implemented a well-functioning sick call process. The institution’s nurses reviewed all sick call requests the same day they received them, and triaged and assessed patients timely. The nurses’ accurate assessments and appropriate interventions contributed to the proficient rating for the Quality of Nursing Performance indicator. • CAC performed exceptionally well with the Pharmacy and Medication Management indicator. CAC’s unique processes ensured all prescriptions were tracked and patients received their medications promptly and reliably. Program Weaknesses — Clinical • Nurses in the Triage and Treatment Area (TTA) did not record the exact times they performed assessments and interventions. During emergency medical responses, the nurses often recorded conflicting information, resulting in timeline discrepancies. 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 5 Medical Inspection Page v Office of the Inspector General State of California • CAC can improve in the continuity of medications for patients transferring into CAC and in the recording of vital information on the transfer form for patients transferring out of CAC. • CAC’s providers did not consistently address all their patients’ problems and occasionally failed to review their patients’ medical records appropriately. Compliance Testing Results Of the 12 health care indicators applicable to CAC, 9 were evaluated by compliance inspectors.2 Of these, seven were proficient and two were adequate. There were 83 individual compliance questions within those nine indicators, generating 964 data points that tested CAC’s compliance with California Correctional Health Care Services (CCHCS) policies and procedures.3 Those 83 questions are detailed in Appendix A — Compliance Test Results. Program Strengths — Compliance The following are some of CAC’s strengths based on its compliance scores on individual questions in the health care indicators: • Nursing staff at CAC reviewed patients’ health care service requests and completed face-to-face visits within the required time frames. Patients also received timely follow-up appointments after a specialty care service or upon discharge from community hospital. • CAC’s staff performed well with retrieving and scanning high-priority reports, routine specialty reports, and community hospital discharge documents timely. • Nursing staff at medication line locations followed proper administrative controls and appropriate protocols during medication preparation and administration. • The institution did an excellent job with offering and providing preventive medical services to patients including health screenings, administering immunizations, and monitoring patients on tuberculosis (TB) medications. • Patients received high-priority and routine specialty service appointments timely. 2 The OIG’s compliance inspectors are trained registered nurses with expertise in CDCR policies regarding medical staff and processes. 3 The OIG used its own clinicians to provide clinical expert guidance for testing compliance in certain areas where CCHCS policies and procedures did not specifically address an issue. California City Correctional Facility, Cycle 5 Medical Inspection Page vi Office of the Inspector General State of California Program Weaknesses — Compliance The following are some of the weaknesses identified by CAC’s compliance scores on individual questions in the health care indicators: • The institution’s providers performed poorly with reviewing pathology reports and communicating results to patients. • Supervising nurses at CAC did not properly perform nursing reviews of subordinate staff. Recommendations The OIG recommends the following: • CCHCS should examine CAC’s excellent medication processes and consider replicating those processes statewide. Population-Based Metrics In general, the institution performed well as measured by population-based metrics. In comprehensive diabetes care, CAC outperformed most state and national health care plans in the five diabetic measures. However, CAC scored lower than two health care plans in monitoring diabetic blood pressure and lower than one in diabetic eye exams. With regard to immunization measures, CAC scored higher than two health care plans in providing influenza immunizations to younger adults. Colorectal cancer screening scores were excellent; CAC outperformed all reporting health care entities. Overall, CAC’s population-based metrics performance reflected a well-functioning chronic care program, compared to the other state and national health care plans reviewed. The institution may improve its scores for influenza vaccinations to younger adults by educating patients on the benefits of these preventive services. California City Correctional Facility, Cycle 5 Medical Inspection Page vii Office of the Inspector General State of California This page intentionally left blank. California City Correctional Facility, Cycle 5 Medical Inspection Page viii Office of the Inspector General State of California I NTRODUCTION Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), and at the request of the federal Receiver, the OIG developed a comprehensive medical inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG conducted a clinical case review and a compliance inspection, ensuring a thorough, end-to-end assessment of medical care within CDCR. California City Correctional Facility (CAC) was the 28th medical inspection of Cycle 5. During the inspection process, the OIG assessed the delivery of medical care to patients using the primary clinical health care indicators applicable to the institution. The Administrative Operations indicator is secondary because it does not reflect the actual clinical care provided. ABOUT THE INSTITUTION Located in California City, in Kern County, the California City Correctional Facility (CAC) opened in 2013. CAC primarily houses medium-security Level II and general population inmates. The institution operates multiple medical clinics where medical staff members handle non-urgent requests for medical services. In addition, CAC operates a triage and treatment area (TTA) for urgent or emergent patient care, a receiving and release (R&R) clinic for assessment of arriving and departing patients, and a specialty clinic. CCHCS has designated CAC as a “basic” health care institution. Basic care 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. On August 21, 2017, the institution received national accreditation from the Commission on Accreditation for Corrections. This accreditation program is a professional peer review process based on national standards set by the American Correctional Association. Based on staffing data the OIG obtained from the institution as identified in the CAC Health Care Staffing Resources as of October 2017 table on the following page, CAC’s vacancy rate was 8 percent among medical managers, primary care providers, supervisors, and rank-and-file nurses in October 2017, with the highest vacancy percentages among management at 20 percent. California City Correctional Facility, Cycle 5 Medical Inspection Page 1 Office of the Inspector General State of California CAC Health Care Staffing Resources as of October 2017 Primary Care Nursing Management Nursing Staff Totals Providers Supervisors Description Number % Number % Number % Number % Number % Authorized 5 7% 4.7 7% 9.5 14% 50.8 73% 70 100% Positions Filled Positions 4 80% 4.7 100% 9 95% 47 93% 64.7 92% Vacancies 1 20% 0 0% 0.5 5% 3.8 7% 5.3 8% Recent Hires (within 12 3 75% 1 21% 3 33% 12 26% 19 29% months) Staff Utilized 0 0% 0 0% 0 0% 0 0% 0 0% from Registry Redirected Staff (to Non-Patient 0 0% 0 0% 1 11% 0 0% 1 2% Care Areas) Staff on 0 0% 0 0% 0 0% 1 2% 1 2% Extended Leave Note: CAC Health Care Staffing Resources data was not validated by the OIG. As of October 2, 2017, the Master Registry for CAC showed that the institution had a total population of 2,501. Within that total population, none were designated as high medical risk, Priority 1 (High 1), and 0.2 percent was designated as high medical risk, Priority 2 (High 2). Patients’ assigned risk levels are based on the complexity of their required medical care related to their specific diagnoses, frequency of higher levels of care, age, and abnormal laboratory results and procedures. High 1 has at least two high-risk conditions; High 2 has only one. Patients at high medical risk are more susceptible to poor health outcomes than those at medium or low medical risk. Patients at high medical risk also typically require more health care services than do patients with lower assigned risk levels. The table on the following page illustrates the breakdown of the institution’s medical risk levels at the start of the OIG medical inspection. California City Correctional Facility, Cycle 5 Medical Inspection Page 2 Office of the Inspector General State of California CAC Master Registry Data as of October 2, 2017 Medical Risk Level # of Patients Percentage High 1 0 0.0% High 2 4 0.2% Medium 365 14.6% Low 2,132 85.2% Total 2,501 100.0% California City Correctional Facility, Cycle 5 Medical Inspection Page 3 Office of the Inspector General State of California O , S , M BJECTIVES COPE AND ETHODOLOGY In designing the medical inspection program, the OIG reviewed CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. The OIG also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the Receiver’s office, CDCR, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of the OIG’s inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates medical care delivery by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population-based metrics. To maintain a metric-oriented inspection program that evaluates medical care delivery consistently at each state prison, the OIG identified 15 indicators (14 primary (clinical) indicators and one secondary (administrative) indicator) of health care to measure. The primary quality indicators cover clinical categories directly relating to the health care provided to patients, whereas the secondary quality indicator addresses the administrative functions that support a health care delivery system. The CAC Executive Summary Table on page iv of this report identifies these 15 indicators. The OIG rates each of the quality indicators applicable to the institution under inspection based on case reviews conducted by OIG clinicians and compliance tests conducted by OIG registered nurses. The case review results alone, the compliance test results alone, or a combination of both these information sources may influence an indicator’s overall rating. For example, the OIG derives the ratings for the primary quality indicators Quality of Nursing Performance and Quality of Provider Performance entirely from the case review done by clinicians, while the ratings for the primary quality indicators Health Care Environment and Preventive Services are derived entirely from compliance testing done by registered nurse inspectors. As another example, primary quality indicators such as Diagnostic Services and Specialty Services receive ratings derived from both sources. The OIG does not inspect for efficiency or cost-effectiveness of medical operations. Consistent with the OIG’s agreement with the Receiver, this report only addresses the quality of CDCR’s medical operations and its compliance with quality-related policies. Moreover, if the OIG learns of a patient needing immediate care, the OIG notifies the chief executive officer of health care services and requests a status report. Additionally, if the OIG learns of significant departures from community standards, it may report such departures to the institution’s chief executive officer or to CCHCS. Because these matters involve confidential medical information protected by state and federal privacy laws, the OIG does not include specific identifying details related to any such cases in the public report. California City Correctional Facility, Cycle 5 Medical Inspection Page 4 Office of the Inspector General State of California In all areas, the OIG is alert for opportunities to make appropriate recommendations for improvement. Such opportunities may be present regardless of the score awarded to any particular quality indicator; therefore, recommendations for improvement are not necessarily indicative of deficient medical care delivery. CASE REVIEWS The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders, which continues in the Cycle 5 medical inspections. The following exhibit provides definitions that describe this process. Exhibit 1. Case Review Definitions Case = Sample = Patient An appraisal of the medical care provided to one patient over a specific period, which can comprise detailed or focused case reviews. Detailed Case Review A review that includes all aspects of one patient’s medical care assessed over a six-month period. This review allows the OIG clinicians to examine many areas of health care delivery, such as access to care, diagnostic services, health information management, and specialty services. Focused Case Review A review that focuses on one specific aspect of medical care. This review tends to concentrate on a singular facet of patient care, such as the sick call process or the institution’s emergency medical response. Case Review Event A direct or indirect interaction between the patient and the health care system. Examples of direct interactions include provider encounters and nurse encounters. An example of an indirect interaction includes a provider reviewing a diagnostic test and placing additional orders. Case Review Deficiency A medical error in procedure or in clinical judgment. Both procedural and clinical judgment errors can result in policy non-compliance, elevated risk of patient harm, or both. Adverse Deficiency A medical error that increases the risk of, or results in, serious patient harm. Most health care organizations refer to these errors as adverse events. California City Correctional Facility, Cycle 5 Medical Inspection Page 5 Office of the Inspector General State of California The OIG’s clinicians perform a retrospective case review of selected patient files to evaluate the care given by an institution’s primary care providers and nurses. Retrospective case review is a well-established review process used by health care organizations that perform peer reviews and patient death reviews. Currently, CCHCS uses retrospective case review as part of its death review process and in its pattern-of-practice reviews. CCHCS also uses a more limited form of retrospective case review when performing appraisals of individual primary care providers. Patient Selection for Retrospective Case Reviews Because retrospective case review is time-consuming and requires qualified health care professionals to perform it, the OIG must carefully select a sample of patient records for clinician review. Accordingly, the group of patients the OIG targeted for case review carried the highest clinical risk and utilized the majority of medical services. The majority of patients selected for retrospective case review were high-utilizing patients with chronic care illnesses who were classified as high or medium risk. The reason the OIG targeted these patients for review is twofold: 1. The goal of retrospective case review is to evaluate all aspects of the health care system. Statewide, high-risk and high-utilization patients consume medical services at a disproportionate rate; 11 percent of the total patient population is high-risk and accounts for more than half of the institution’s pharmaceutical, specialty, community hospital, and emergency costs. 2. Selecting this target group for case review provides a significantly greater opportunity to evaluate all the various aspects of the health care delivery system at an institution. Underlying the choice of high-risk patients for detailed case review, the OIG clinical experts made the following three assumptions: 1. If the institution is able to provide adequate clinical care to the most challenging patients with multiple complex and interdependent medical problems, it is more likely to provide adequate care to patients with less complicated health care issues. Because clinical expertise is required to determine whether the institution has provided adequate clinical care, the OIG utilizes experienced correctional physicians and registered nurses to perform this analysis. 2. The health of less complex patients is more likely to be affected by processes such as timely appointment scheduling, medication management, routine health screening, and immunizations. To review these processes, the OIG simultaneously performs a broad compliance review. 3. Patient cases generated during death reviews, sentinel events (unexpected occurrences involving death or serious injury, or risk thereof), and hospitalizations are more likely to comprise high-risk patients. California City Correctional Facility, Cycle 5 Medical Inspection Page 6 Office of the Inspector General State of California Benefits and Limitations of Targeted Subpopulation Review Because the patients selected utilize the broadest range of services offered by the health care system, the OIG’s retrospective case review provides adequate data for a qualitative assessment of the most vital system processes (referred to as “primary quality indicators”). Retrospective case review provides an accurate qualitative assessment of the relevant primary quality indicators as applied to the targeted subpopulation of high-risk and high-utilization patients. While this targeted subpopulation does not represent the prison population as a whole, the institution’s ability to respond with adequate medical care to this subpopulation is a crucial and vital indicator of how the institution provides health care to its whole patient population. Simply put, if the institution’s medical system does not respond adequately for those patients needing the most care, then it is not fulfilling its obligations, even if it takes good care of patients with less complex medical needs. Since the targeted subpopulation does not represent the institution’s general prison population, the OIG cautions against inappropriate extrapolation of medical conditions or outcomes from the retrospective case reviews to the general population. For example, if the high-risk diabetic patients reviewed have poorly controlled diabetes, one cannot conclude that all the diabetics’ conditions are poorly controlled. Similarly, if the high-risk diabetic patients under review have poor outcomes, one cannot conclude that the entire diabetic population is having similarly poor outcomes. The OIG does not extrapolate conditions or outcomes, but instead extrapolates the institution’s response for those patients needing the most care because the response yields valuable system information. In the above example, if the institution responds by providing appropriate diabetic monitoring, medication therapy, and specialty referrals for the high-risk patients reviewed, then it is reasonable to infer that the institution is also responding appropriately to all the diabetics in the prison. However, if these same high-risk patients needing monitoring, medications, and referrals are not getting those needed services, it is likely that the institution is not providing appropriate diabetic services. Case Review Sampling Methodology Using a predefined case review sampling algorithm, OIG analysts apply various filters to each institution’s patient population. The various filters include medical risk status, number of prescriptions, number of specialty appointments, number of clinic appointments, and other health-related data. The OIG uses these filters to narrow down the population to those patients with the highest utilization of medical resources (see Chart 1, next page). To prevent selection bias, the OIG ensures that the same clinicians who perform the case reviews do not participate in the sample selection process. California City Correctional Facility, Cycle 5 Medical Inspection Page 7 Office of the Inspector General State of California Chart 1. Case Review Sample Selection Sample Selection Analysts apply filters to the population to obtain samples (S) with high utilization. Six permutations, Population or arrangements, of case review types are possible for each sample. S S MD RN MD RN MD RN S S S S D F D D F D Case = Sample = Patient MD RN RN D D F MD = Provider RN = Registered Nurse D = Detailed Review F = Focused Review The OIG’s case sample size matched those of other qualitative research. The empirical findings, supported by expert statistical consultants, showed adequate conclusions after 10 to 15 cases had undergone comprehensive, or detailed, clinician review. In qualitative statistics, this phenomenon is known as “saturation.” The OIG found the Cycle 4 medical inspection sample size of 30 for detailed physician reviews far exceeded the saturation point necessary for an adequate qualitative review. At the end of Cycle 4 inspections, the OIG re-analyzed the case review results using half the number of cases; there were no significant differences in the ratings. To improve inspection efficiency while preserving the quality of the inspection, the OIG reduced the number of the samples for Cycle 5 medical inspections to the current levels. For most basic institutions, the OIG samples 20 cases for detailed physician review. For intermediate institutions and several basic institutions with larger high-risk populations, the OIG samples 25 cases. For California Health Care Facility, the OIG samples 30 cases for detailed physician review. Breadth of Case Reviews As indicated in Appendix B, Table B–1: CAC Sample Sets, the OIG clinicians evaluated medical records for 42 unique cases. Appendix B, Table B–4: CAC Case Review Sample Summary clarifies that both nurses and physicians reviewed records for 12 of those cases, for 54 reviews in total. Physicians performed detailed reviews of 20 cases, and nurses performed detailed reviews of 13 cases, totaling 33 detailed case reviews. Nurses also performed focused reviews for an California City Correctional Facility, Cycle 5 Medical Inspection Page 8 Office of the Inspector General State of California additional 21 cases. These generated 664 clinical events for review (Appendix B, Table B–3: CAC Event—Program). While the sample method specifically pulled only 4 chronic care patient records, i.e., 4 diabetes cases (Appendix B, Table B–1: CAC Sample Sets), the 42 unique cases sampled included patients with 110 chronic care diagnoses, including 11 additional cases with diabetes (for a total of 15), (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 OIG did assess for adequacy the overall operation of the institution’s system and staff. Case Review Testing Methodology A physician, a nurse consultant, or both clinician inspectors review each case. The OIG clinician inspector can perform one of two different types of case review: detailed or focused (see Exhibit 1, p. 5, and Chart 1, p. 8). As the OIG clinician inspector reviews the medical record for each sample, the inspector records pertinent interactions between the patient and the health care system. These interactions are also known as case review events. When an OIG clinician inspector identifies a medical error, the inspector also records these errors as case review deficiencies. If a deficiency is of such magnitude that it caused, or had the potential to cause, serious patient harm, then the OIG clinician records it as an adverse deficiency (see Chart 2, next page). California City Correctional Facility, Cycle 5 Medical Inspection Page 9 Office of the Inspector General State of California Chart 2. Case Review Testing and Deficiencies Case Review Testing The OIG clinicians examine the chosen samples, performing a detailed case review or a focused case review, to determine the events that occurred. Sample = Patient = Case No Deficiency Sample Events Deficiency A sample leading to events Deficiencies Not all events lead to deficiencies (medical errors); however, if there are errors, then the OIG clinicians determine whether any are adverse. Sample Events Deficiency* A sample leading to events with deficiencies observed Adverse * If a deficiency is serious Deficiency enough, the OIG clinician labels it adverse. When the OIG clinician inspectors have reviewed all cases, they analyze the deficiencies. OIG inspectors search for similar types of deficiencies to determine if a repeating pattern of errors existed. When the same type of error occurs multiple times, the OIG inspectors identify those errors as findings. When the error is frequent, the likelihood is high that the error is regularly recurring at the institution. The OIG categorizes and summarizes these deficiencies in one or more health care quality indicators in this report to help the institution focus on areas for improvement. Additionally, the OIG physicians also rate each of the detailed physician cases for adequacy based on whether the institution met the patient’s medical needs and if it placed the patient at California City Correctional Facility, Cycle 5 Medical Inspection Page 10 Office of the Inspector General State of California significant risk of harm. The cumulative analysis of these cases gives the OIG clinicians additional perspective to help determine whether the institution is providing adequate medical services or not.4 Based on the collective results of clinicians’ case reviews, the OIG clinicians rated each quality indicator proficient (excellent), adequate (passing), or inadequate (failing). A separate confidential CAC Supplemental Medical Inspection Results: Individual Case Review Summaries report details the case reviews the OIG clinicians conducted and is available to specific stakeholders. For further details regarding the sampling methodologies and counts, see Appendix B — Clinical Data, Table B-1; Table B-2; Table B-3; and Table B-4. 4 Regarding individual provider performance, the OIG did not design the medical inspection to be a focused search for poorly performing providers; rather, the inspection assesses each institution’s systemic health care processes. Nonetheless, while the OIG does not purposefully sample cases to review each provider at the institution, the cases usually involve most of the institutions’ providers. Providers should only escape OIG case review if institutional managers assigned poorly performing providers the care of low-utilizing and low-risk patients, or if the institution had a relatively high number of providers. California City Correctional Facility, Cycle 5 Medical Inspection Page 11 Office of the Inspector General State of California COMPLIANCE TESTING Sampling Methods for Conducting Compliance Testing From October to December 2017, registered nurse inspectors obtained answers to 83 objective medical inspection test (MIT) questions designed to assess the institution’s compliance with critical policies and procedures applicable to the delivery of medical care. To conduct most tests, inspectors randomly selected samples of patients for whom the testing objectives were applicable and reviewed their electronic medical records. In some cases, inspectors used the same samples to conduct more than one test. In total, inspectors reviewed health records for 338 individual patients and analyzed specific transactions within their records for evidence that critical events occurred. Inspectors also reviewed management reports and meeting minutes to assess certain administrative operations. In addition, during the week of October 16, 2017, registered nurse 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 964 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 After compiling the answers to the 83 questions for the nine applicable indicators for which compliance testing was applicable, the OIG compliance team derived a score for each quality indicator by calculating the percentage score of all Yes answers for each of the questions applicable to a particular indicator, then averaging those scores. Based on those results, the OIG assigned a rating to each quality indicator of proficient (greater than 85 percent), adequate (between 75 percent and 85 percent), or inadequate (less than 75 percent). California City Correctional Facility, Cycle 5 Medical Inspection Page 12 Office of the Inspector General State of California OVERALL QUALITY INDICATOR RATING FOR CASE REVIEWS AND COMPLIANCE TESTING The OIG derived the final rating for each quality indicator by combining the ratings from the case reviews and from the compliance testing, as applicable. When combining these ratings, the case review evaluations and the compliance testing results usually agreed, but there were instances for this inspection when the rating differed for a particular quality indicator. In those instances, the inspection team assessed the quality indicator based on the collective ratings from both components. Specifically, the OIG clinicians and registered nurse inspectors discussed the nature of individual exceptions found within that indicator category and considered the overall effect on the ability of patients to receive adequate medical care. To derive an overall assessment rating of the institution’s medical inspection, the OIG evaluated the various rating categories assigned to each of the quality indicators applicable to the institution, giving more weight to the rating results of the primary quality indicators, which directly relate to the health care provided to patients. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed. POPULATION-BASED METRICS The OIG identified a subset of Healthcare Effectiveness Data Information Set (HEDIS) measures applicable to the CDCR patient population. To identify outcomes for CAC, the OIG reviewed some of the compliance testing results, randomly sampled additional 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 5 Medical Inspection Page 13 Office of the Inspector General State of California M I R EDICAL NSPECTION ESULTS The OIG’s case review and clinician teams use quality indicators to assess the clinical aspects of health care. The CAC Executive Summary Table on page iv of this report identifies the 12 indicators applicable to this institution. The following chart depicts their union and intersection: Chart 3. Inspection Indicator Review Distribution The Administrative Operations indicator is a secondary indicator; therefore, the OIG did not rely upon this indicator when determining the institution’s overall score. Based on the analysis and results in all the primary indicators, the OIG experts made a considered and measured opinion that the quality of health care at CAC was proficient. Summary of Case Review Results: The clinical case review component assessed nine primary (clinical) indicators applicable to CAC. Of these nine indicators, OIG clinicians rated six proficient and three adequate. The OIG physicians rated the overall adequacy of care for each of the 20 detailed case reviews they conducted. Of these 20 cases, 5 were proficient, 14 were adequate, and one was inadequate. In the 664 events reviewed, there were 67 deficiencies, 11 of which were considered to be of such magnitude that, if left unaddressed, they would likely contribute to patient harm. California City Correctional Facility, Cycle 5 Medical Inspection Page 14 Office of the Inspector General State of California Adverse Deficiencies Identified During Case Review: Adverse deficiencies are medical errors that markedly increased the risk of, or resulted in, serious patient harm. Medical care is a complex and dynamic process with many moving parts, subject to human error even within the best health care organizations. All major health care organizations typically identify and track adverse deficiencies for the purpose of quality improvement. Adverse deficiencies are not typically representative of medical care delivered by the organization. The OIG normally identifies adverse deficiencies for the dual purposes of quality improvement and the illustration of problematic patterns of practice found during the inspection. Because of the anecdotal nature of these deficiencies, the OIG cautions against drawing inappropriate conclusions regarding the institution based solely on adverse deficiencies. The OIG identified no adverse deficiencies in the case reviews at CAC. Summary of Compliance Results: The compliance component assessed 9 of the 12 indicators applicable to CAC. Of these nine indicators, OIG inspectors rated seven proficient and two adequate. 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 5 Medical Inspection Page 15 Office of the Inspector General State of California ACCESS TO CARE This indicator evaluates the institution’s ability to provide patients Case Review Rating: with timely clinical appointments. Compliance and case review Proficient teams review areas specific to patients’ access to care, such as initial Compliance Score: assessments of newly arriving patients, acute and chronic care Proficient follow-ups, face-to-face nurse appointments when patients request to (94.6%) be seen, provider referrals from nursing lines, and follow-ups after Overall Rating: hospitalization or specialty care. Compliance testing for this Proficient indicator also evaluates whether patients have Health Care Services Request forms (CDCR Form 7362) available in their housing units. Case Review Results The OIG clinicians reviewed 300 outpatient encounters with providers and nurses and identified six deficiencies, only four of which were significant. The OIG clinicians rated this indicator proficient. RN Sick Call Access The institution performed well with access to sick call. CAC scheduled sick call appointments timely, and nurses assessed the patients within one business day of the request’s initial review. The OIG clinicians reviewed 35 sick call events and identified no nurse deficiencies. Nurse-to-Provider Referrals CCHCS policy requires sick call nurses to refer patients to a provider when their condition requires a higher level of care. CAC did well with this requirement. Nurse-to-provider appointments occurred timely and as scheduled. There were 136 outpatient-nursing encounters with no deficiencies identified. Nursing Follow-up Appointments Follow-up nursing appointments generated by providers and nurses took place as ordered, with one minor exception: • In case 20, one of the five follow-up appointments ordered for wound care did not take place. Provider to Provider Follow-up Appointments Provider-to-provider follow-up appointments are important to access to care. The OIG reviewed 149 provider encounters. Provider-ordered follow-up appointments took place as ordered, with one significant deficiency: California City Correctional Facility, Cycle 5 Medical Inspection Page 16 Office of the Inspector General State of California • In case 20, a patient with several chronic care diagnoses refused his one-month new patient appointment, but CAC did not reschedule it. Several months later, the CP&S ordered a follow-up appointment, but it did not take place. During his entire stay at CAC, a provider did not see the patient. Fortunately, when he transferred to another facility, the patient appeared to have suffered no harm. Provider Follow-up after Specialty Service Providers evaluated patients timely after specialty services appointments. Specialty Service Appointments CAC performed sufficiently with specialty service appointments; however, in the OIG’s review of 77 of these appointments, there were three deficiencies: • In case 13, the patient with retinal damage had an urgent referral to see an eye doctor. Urgent specialty referrals must be seen within two weeks of the request. The patient’s urgent referral took place two days late. • In case 16, the institution canceled and failed to reschedule the patient’s physical therapy appointment for back pain after the patient was sent to a community hospital for appendicitis. • In case 17, the institution canceled and failed to reschedule a podiatry appointment for the patient because the podiatrist was unavailable. Intra-System Transfer OIG clinicians reviewed seven cases in which patients transferred into CAC from other institutions. For six of the seven patients, CAC nurses assessed the patients and appropriately referred them to providers who evaluated the patients timely. There was one significant deficiency in which the nurse did not do this: • In case 20, the patient transferred from another institution back to CAC after admission for antibiotics to treat a serious leg infection. The patient’s required one-week follow-up appointment with a provider did not occur. Instead, CAC scheduled the appointment one month after his return. Follow-up After Hospitalization OIG clinicians reviewed 24 hospital and outside emergency department events. Providers assessed all 24 returning patients timely and adequately. Diagnostic Results The OIG reviewed 84 diagnostic events. Providers followed up on all results without deficiency. California City Correctional Facility, Cycle 5 Medical Inspection Page 17 Office of the Inspector General State of California Clinician Onsite Inspection OIG clinicians interviewed staff at CAC regarding 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 three clinics had no backlog. When asked about scheduling deficiencies, CAC staff pointed to a process in the new electronic health record system (EHRS) where scheduled appointments are canceled when a patient is sent out of the institution. The process requires the primary care provider to review and reorder any necessary appointments upon the patient’s return to the institution. This process likely contributed to the missed appointments for three of the significant deficiencies in cases 16, 17, and 20. Case Review Conclusion CAC’s access to care was excellent but its performance had declined slightly from the Cycle 4 medical inspection. In this inspection period, there were occasional occurrences of missed specialty appointments. Nonetheless, overall access to medical services was outstanding. The OIG clinicians rated the Access to Care indicator proficient. Compliance Testing Results The institution performed in the proficient range, with a score of 94.6 percent in the Access to Care indicator. The following tests earned scores in the proficient range: • Inspectors sampled 30 health care services request forms submitted by patients across all facility clinics. Nursing staff reviewed all request forms on the same day they were received and completed timely face-to-face triage encounters for all 30 patients (MIT 1.003, 1.004). • Of the eight sampled patients nursing staff referred to a provider, and for whom the provider subsequently ordered a follow-up appointment, all received their follow-up appointments timely (MIT 1.006). • All 19 sampled patients received a follow-up appointment with a provider within five days of discharge from a community hospital (MIT 1.007). • Among 25 patients sampled who transferred into CAC from other institutions and whom nurses referred to a provider based on their initial health care screening, 24 (96.0 percent) were seen within the required time frame. One patient’s provider appointment occurred six days late (MIT 1.002). • Among 16 health care services request forms sampled on which nursing staff referred the patient for a provider appointment, 15 patients (93.8 percent) received timely appointments. One patient received a routine appointment, but the patient’s complaint was not addressed (MIT 1.005). California City Correctional Facility, Cycle 5 Medical Inspection Page 18 Office of the Inspector General State of California • Of the 30 sampled patients who received a high-priority or routine specialty service, 27 (90.0 percent) received a timely follow-up appointment with a provider. Two patients received their high-priority specialty service follow-up appointments three and eight days late. One patient’s routine specialty service follow-up appointment was 77 days late (MIT 1.008). • When the OIG reviewed recent appointments for 25 sampled patients with chronic care conditions, 22 patients (88.0 percent) received timely routine appointments. Three other patients received their chronic care appointments from 19 to 61 days late (MIT 1.001). The institution received an adequate score on one test: • Patients had access to health care services request forms at five of the six housing units inspected (83.3 percent). One housing unit did not have a supply of the forms available for patients (MIT 1.101). California City Correctional Facility, Cycle 5 Medical Inspection Page 19 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 Proficient were timely provided to patients, whether primary care providers Compliance Score: timely reviewed results, and whether providers communicated results Adequate (75.6%) to the patient within required time frames. In addition, for pathology services, the OIG determines whether the institution received a final Overall Rating: pathology report and whether the provider timely reviewed and Adequate 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. In this indicator, the OIG case review and compliance review processes yielded different results, with the case review giving a proficient rating and the compliance review resulting in an adequate score. Compliance testing sampled significantly more pathology tests than case reviewers did in this medical inspection. Compliance testing identified problems with the communication of laboratory and pathology results to the patient. Most of these errors occurred because the providers neglected to specify the name of laboratory tests on their patient letter and sent pathology test notifications late. Because of the clinical importance of processing pathology reports, the OIG determined the overall rating of adequate was appropriate for this indicator. Case Review Results The OIG clinicians reviewed 84 diagnostic events and identified no deficiencies. The case review rating for this indicator was proficient. Test Completion CAC performed diagnostic tests flawlessly. CAC used the EHRS to track and complete diagnostic orders reliably within the ordered time frames. CAC completed all 84 events timely. Health Information Management CAC performed well with diagnostic tests. Providers timely reviewed and signed results for all reports and timely communicated the results to their patients. Clinician Onsite Inspection Staff explained that CAC provided time for training with the EHRS. The institution temporarily scheduled providers with fewer patient encounters to allow them to adjust to the new process. The EHRS notifies providers via electronic message when new laboratory results or other reports are available to review. CAC providers diligently reviewed their messages and test results and received a perfect record review score. California City Correctional Facility, Cycle 5 Medical Inspection Page 20 Office of the Inspector General State of California Case Review Conclusion The OIG clinicians rated the Diagnostic Services indicator proficient with no deficiencies. Compliance Testing Results The institution received an adequate compliance score of 75.6 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 • The institution timely performed radiology services for all ten patients sampled (MIT 2.001). CAC providers timely reviewed and initialed the corresponding radiology reports for eight of the ten patients (80.0 percent); providers did not review radiology reports for two patients (MIT 2.002). Providers timely communicated test results to all ten patients sampled (MIT 2.003). Laboratory Services • All ten sampled patients received their provider-ordered laboratory services timely (MIT 2.004). The institution’s providers also reviewed eight of the ten resulting laboratory services reports within the required time frame (80.0 percent); two reports were reviewed two days late (MIT 2.005). Providers timely communicated the results to only two of the ten patients sampled (20.0 percent). Seven patients received their tests results in a letter, but the letter did not indicate what specific tests were performed. For one other patient, the provider did not communicate the results (MIT 2.006). Pathology Services • Clinicians at CAC timely received the final pathology reports for eight of ten sampled patients (80.0 percent), but two patients’ pathology reports were received four and five days late (MIT 2.007). Providers properly evidenced their review of pathology results for seven of ten sampled reports (70.0 percent). Providers reviewed two reports between 9 and 20 days late; and there was no evidence found that the provider reviewed the pathology result for one patient (MIT 2.008). Finally, providers timely communicated the final pathology results to five of the ten patients sampled (50.0 percent). Providers communicated the results for five other reports between 4 to 41 days late (MIT 2.009). California City Correctional Facility, Cycle 5 Medical Inspection Page 21 Office of the Inspector General State of California EMERGENCY SERVICES An emergency medical response system is essential to providing Case Review Rating: effective and timely emergency medical response, assessment, Adequate treatment, and transportation 24 hours per day. Provision of Compliance Score: urgent/emergent care is based on a patient’s emergency situation, Not Applicable clinical condition, and need for a higher level of care. The OIG Overall Rating: reviews emergency response services including first aid, basic life Adequate support (BLS), and advanced cardiac life support (ACLS) consistent with the American Heart Association guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care, and the provision of services by knowledgeable staff appropriate to each individual’s training, certification, and authorized scope of practice. The OIG evaluates this quality indicator entirely through clinicians’ reviews of case files and conducts no separate compliance testing element. Case Review Results OIG clinicians reviewed 22 urgent or emergent events and identified nine deficiencies in the various aspects of emergency care. OIG clinicians considered two of the nine deficiencies significant, identified in cases 1 and 6. The case review rating for this indicator was adequate. CPR Response Custody staff initiated CPR and promptly notified health care staff. Nursing staff responded timely and provided appropriate care. The OIG found no delays in medical response times. Provider Performance Providers made appropriate triage decisions when patients presented emergently to the TTA and were available for consultation with the TTA nursing staff, with few exceptions. There were two minor deficiencies related to provider quality of emergency care: • In case 2, the patient was acutely ill with unstable low blood pressure. The provider correctly ordered the patient be transferred to an outside emergency department but did not order intravenous fluids to stabilize the patient’s blood pressure. Also, the provider’s progress note did not adequately describe the acutely ill patient. • In case 13, the provider on call ordered ibuprofen for the patient’s rib pain. Although the community emergency department recommended this medication, ibuprofen could have aggravated the patient’s recent gastritis (stomach inflammation and bleeding) and further impaired the patient’s chronic kidney disease. The provider should have recognized these risks and should not have prescribed ibuprofen. California City Correctional Facility, Cycle 5 Medical Inspection Page 22 Office of the Inspector General State of California Nursing Performance CAC nurses generally provided appropriate nursing assessments and interventions and contacted providers timely for urgent or emergent events. Of the 16 cases reviewed there were two deficiencies in the nursing performance, one of which was significant: • In case 6, the patient was unresponsive, and the nurse did not assess the patient’s mental status or response to interventions such as suctioning or the administration of oxygen and naloxone. Subsequent clinicians responsible for the care, as well as inspectors who subsequently reviewed the chart, could not determine if the interventions were effective. The patient was transferred from CAC to the community hospital where the patient was diagnosed with respiratory failure. Nursing Documentation Without proper documentation, health care staff often overlook changes in patient health, resulting in lapses in care. Also, the improper documentation makes it difficult for health care staff to assess the status of a patient’s ongoing condition. Nursing documentation was problematic for CAC’s emergency services. Nurses often struggled with the sequence of events and did not record the proper time of their assessments and interventions. OIG clinicians identified numerous documentation and timeline discrepancies in emergency medical response cases: • In case 5, the nurse recorded numerous timeline entry discrepancies, such as the administration times of medications and oxygen. • In case 6, the nurse caring for an unresponsive patient did not adequately record the assessment times. • In case 7, the nurse recorded identical vital signs at various times throughout a medical emergency, which the OIG clinicians believe is extremely unlikely. Emergency Medical Response Review Committee The emergency medical response review committee (EMRRC) met regularly and discussed emergency events. The EMRRC determined that the first medical responders needed documentation training and planned to provide the training to nursing staff. EMRRC discussed stock levels for nasal naloxone and how to better encourage the nurses to use established nursing protocols when assessing their patients. California City Correctional Facility, Cycle 5 Medical Inspection Page 23 Office of the Inspector General State of California Clinician Onsite Inspection During the onsite visit, OIG inspectors found CAC’s two-bed TTA patient care area sufficient to provide emergent medical care. The TTA was staffed with two nurses but did not have a designated provider. Nurses notified the patient’s primary care provider for all emergent events during clinic hours and the physician on call for all medical concerns after hours. CAC’s TTA was adequately staffed and stocked with medical supplies and equipment. According to nursing staff, there was a good rapport and a collaborative working relationship with custody. Case Review Conclusion OIG clinicians rated the Emergency Services indicator adequate. There were deficiencies in nursing documentation that CAC should target with quality improvement strategies. California City Correctional Facility, Cycle 5 Medical Inspection Page 24 Office of the Inspector General State of California HEALTH INFORMATION MANAGEMENT Health information management is a crucial link in the delivery of Case Review Rating: medical care. Medical personnel require accurate information in Proficient order to make sound judgments and decisions. This indicator Compliance Score: examines whether the institution adequately manages its health care Proficient (92.0%) information. This includes determining whether the information is correctly labeled and organized and available in the electronic Overall Rating: medical record; whether the various medical records (internal and Proficient external, e.g., hospital and specialty reports and progress notes) are obtained and scanned timely into the patient’s electronic medical record; whether records routed to clinicians include legible signatures or stamps; and whether hospital discharge reports include key elements and are timely reviewed by providers. During the OIG’s testing period, CAC had converted to the new electronic health record system (EHRS) in October 2016; therefore, all testing was completed in the EHRS. Case Review Results OIG clinicians reviewed 664 events and found five deficiencies related to health information management, one of which was significant, in case 13. These deficiencies were isolated and without a pattern. The case review rating for this indicator was proficient. Inter-Departmental Transmission CAC communicated well between departments. With the implementation of the EHRS, providers were able to complete review of important documents, such as hospital records. According to staff in health information management, after they scan records requiring provider review, they send a message through the EHRS to notify the appropriate provider the record is ready for review. This process corrected a frequent deficiency identified during the Cycle 4 inspection. Hospital Records OIG clinicians reviewed 18 hospital or emergency department transfers. CAC timely retrieved, scanned, and reviewed hospital records. The OIG identified only one minor deficiency: • In case 15, CAC did not scan a complete hospital record into the patient’s electronic medical record; the second and fourth pages of the hospital gastroenterologist consultation report were missing. California City Correctional Facility, Cycle 5 Medical Inspection Page 25 Office of the Inspector General State of California Specialty Services CAC retrieved, reviewed, and scanned most specialty services reports into the medical record. There was one significant deficiency: • In case 13, CAC scanned the offsite gastroenterology consultation report into an incorrect EHRS location. This type of error makes retrieval and review difficult, if possible at all. Diagnostic Reports CAC showed improvement in this area compared to the Cycle 4 inspection. For the Cycle 5 inspection, OIG clinicians reviewed 84 events and identified no deficiencies. The EHRS messages prompting providers to review laboratory reports likely corrected many of the minor deficiencies noted in the Cycle 4 inspection. The Diagnostic Services indicator also evaluates this area. Urgent/Emergent Records The OIG reviewed 36 events and identified only one minor deficiency: • In case 27, the nurse evaluated a patient transferred from another institution to CAC. The nurse transferred the patient to the TTA for further management of back and leg pain. The patient’s electronic medical record in the TTA was incomplete regarding nurse or provider management. Scanning Performance Of the five deficiencies identified in the Health Information Management indicator, four related to incomplete scanning or scanning into an incorrect medical record. The three cases 13, 15, and 27 have already been described in this section. The fourth case is described below: • In case 16, CAC incorrectly labeled the patient’s refusal as an authorization. Legibility Most provider and nursing notes were legible or typed. There was one minor deficiency: • In case 18, the nurse’s signature on a patient’s refusal form was illegible. Clinician Onsite Inspection The OIG clinicians noted improved health information performance at CAC compared to Cycle 4. According to staff in medical records, the message center in the EHRS notifies providers when a report requires provider review. This process led to an improvement over Cycle 4, when OIG clinicians determined that providers were not timely reviewing hospital and laboratory reports. California City Correctional Facility, Cycle 5 Medical Inspection Page 26 Office of the Inspector General State of California Case Review Conclusion CAC’s medical staff retrieved and scanned reports well. There were a few incomplete or incorrectly scanned documents. The institution showed clear improvement from the Cycle 4 medical inspection in the Health Information Management indicator. The OIG clinicians rated this indicator proficient. Compliance Testing Results The institution scored in the proficient range with a score of 92.0 percent in the Health Information Management indicator. The following tests received proficient scores: • Institution staff timely scanned all five sampled documents, such as non-dictated provider progress notes, nursing initial health screening forms, and patient health care service request forms into the patient’s electronic medical record within three days of the patient’s encounter (MIT 4.001). • Institution staff timely scanned all 20 specialty service consultant reports sampled into the patient’s health record file within five calendar days (MIT 4.003). • CAC’s records management staff timely scanned all 19 sampled hospital discharge reports or treatment records into patients’ health records (MIT 4.004). • The institution scored 91.7 percent in its labeling and filing of documents scanned into patients’ electronic medical records. For this test, the OIG bases its score on an allowable maximum of 24 mislabeled or misfiled documents. For the CAC medical inspection, inspectors identified two mislabeled documents (MIT 4.006). The following test received an inadequate score: • Among 19 applicable patients sampled who were admitted to a community hospital and then returned to the institution, CAC providers timely reviewed 13 patients’ corresponding hospital discharge reports within three calendar days of their discharge (68.4 percent). For six other sampled patients, five discharge reports were reviewed from one to 15 days late, and one final report was missing key information regarding a patient’s discharge date (MIT 4.007). California City Correctional Facility, Cycle 5 Medical Inspection Page 27 Office of the Inspector General State of California HEALTH CARE ENVIRONMENT This indicator addresses the general operational aspects of the Case Review Rating: institution’s clinics, including certain elements of infection control Not Applicable and sanitation, medical supplies and equipment management, the Compliance Score: availability of both auditory and visual privacy for patient visits, and Proficient (87.0%) the sufficiency of facility infrastructure to conduct comprehensive medical examinations. The OIG rates this component entirely on the Overall Rating: compliance testing results from the visual observations inspectors Proficient make at the institution during their onsite visit. This indicator is evaluated entirely by compliance testing. There is no case review portion. Compliance Testing Results The institution received a proficient score of 87.0 percent in the Health Care Environment indicator, with scores in the proficient range on the following tests: • CAC’s staff appropriately cleaned, disinfected, and sanitized all seven sampled clinics (MIT 5.101). • Health care staff at all seven clinics followed proper protocols to mitigate exposure to blood-borne pathogens and contaminated waste (MIT 5.105). • The bulk medical supply storage areas (outside of the clinics) met the supply management process and supported the needs of the medical health care program, earning CAC a score of 100 percent on this test (MIT 5.106). • All seven clinic exam rooms the OIG inspected had appropriate space, configuration, supplies, and equipment to allow clinicians to perform a proper clinical examination (MIT 5.110). • OIG inspectors examined emergency medical response bags (EMRBs) and the crash cart to determine whether institution staff inspected them daily, inventoried them monthly, and if they contained all essential items. EMRBs and the crash cart were compliant in all four applicable clinical locations (MIT 5.111). • Clinical health care staff in six of the seven applicable clinics (85.7 percent) properly sterilized or disinfected reusable invasive and noninvasive medical equipment. At one clinic, clinical staff did not properly process medical equipment pending sterilization or store previously sterilized instruments (MIT 5.102). California City Correctional Facility, Cycle 5 Medical Inspection Page 28 Office of the Inspector General State of California • Six of the seven clinic locations inspected (85.7 percent) had operable sinks and sufficient quantities of hand hygiene supplies in the examination areas. One clinic’s patient restroom did not have sufficient quantities of antiseptic soap and disposable hand towels (MIT 5.103). • Six of the seven clinics (85.7 percent) the OIG inspected followed adequate medical supply storage and management protocols. In one clinic, the system to replenish medical supplies was inadequate, and the OIG found medical supplies stored beyond manufacturers’ guidelines (MIT 5.107). • Six of seven clinics (85.7 percent) maintained clinic common areas that were conducive to providing medical services. In one clinic, the location of the vital sign station compromised patients’ auditory privacy (MIT 5.109). Two tests received scores in the inadequate range: • OIG inspectors observed clinician encounters with patients in seven clinics. Clinicians followed good hand hygiene practices in only three clinics (42.9 percent). At four clinics, however, clinicians failed to wash their hands before or after patient contact, or before applying gloves (MIT 5.104). • Five of seven clinic locations (71.4 percent) met compliance requirements for essential core medical equipment and supplies. The remaining two clinics were missing one or more functional pieces of properly calibrated core equipment or other medical supplies necessary to conduct a comprehensive exam. One clinic was missing an oto-ophthalmoscope, and in the other clinic, the oto-ophthalmoscope was not operational at the time of the inspection (MIT 5.108). 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 timely or adequate health care. The OIG does not score this question. • At the time of the OIG’s medical inspection, CAC did not have any infrastructure improvement projects in progress, and there were no plans of beginning any infrastructure improvement changes in the near future (MIT 5.999). California City Correctional Facility, Cycle 5 Medical Inspection Page 29 Office of the Inspector General State of California INTER- AND INTRA-SYSTEM TRANSFERS This indicator focuses on the management of patients’ medical needs Case Review Rating: and continuity of patient care during the inter- and intra-system Adequate transfer process. The patients reviewed for this indicator include Compliance Score: those received from, as well as those transferring out to, other CDCR Proficient (85.2%) institutions. The OIG review includes evaluation of the institution’s ability to provide and document health screening assessments, Overall Rating: initiation of relevant referrals based on patient needs, and the Adequate continuity of medication delivery to patients arriving from another institution. For those patients, the OIG clinicians also review the timely completion of pending health appointments, tests, and requests for specialty services. For patients who transfer out of the institution, 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 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. OIG expert analysis of both results showed clinically significant areas for improvement: medication continuity for patients transferring into the institution and the notation of pending specialty appointments for patients transferring to other CDCR institutions. Because of the clinical significance of these areas, the OIG determined the overall rating of adequate was appropriate for this indicator. Case Review Results The OIG clinicians reviewed 69 inter- and intra-system events that related to the transfer processes. These included 18 hospitalizations and outside emergency room events, each of which resulted in a transfer back to the institution. There were 12 deficiencies, one of which was significant. The case review rating for this indicator was adequate. Transfers In CAC performed acceptably with the transfer-in process at the institution. CAC staff ensured medication continuity, and the nurses assessed the patients and appropriately referred them to the provider most of the time. Of the seven transfer-in cases reviewed, the OIG identified one significant deficiency: • In case 20, the patient transferred from another CDCR institution back to CAC after receiving antibiotics for a serious leg infection. The patient’s provider follow-up California City Correctional Facility, Cycle 5 Medical Inspection Page 30 Office of the Inspector General State of California appointment that should have occurred within seven days after arrival did not occur. Instead, medical staff did not schedule the patient for a provider follow-up appointment until one month after he arrived. Transfers Out The transfer-out process for CAC was satisfactory. In all six cases reviewed, nurses performed face-to-face evaluations before patients transferred out of the institution. CAC generally sent health care transfer information, medications, and health care equipment with the patient to the receiving institution. However, there was a pattern of minor deficiencies of incomplete transfer information noted in four of the six cases reviewed: • In cases 3, 13, 18, and 29, the receiving and release (R&R) nurse did not indicate the institution to which the patient was transferring. Hospitalizations Patients returning from hospitalizations are some of the highest-risk encounters due to two factors. First, these patients usually require hospitalization for a severe illness or injury, and second, they are at risk due to potential lapses in care that can occur during any transfer. CAC also performed well in all 18 cases reviewed where the patient returned from a hospital or emergency department. There was no lapse in care or medications. The nurses provided good nursing assessments, interventions, and education for patients upon their return. The utilization management (UM) nurse updated the plan of care in the EHRS daily while patients were at the hospital. Additionally, the UM nurse followed up with a face-to-face evaluation after patients returned. Medical staff scheduled a provider follow-up appointment for patients within five days, and retrieved, reviewed, and signed the hospital discharge summaries in most cases reviewed. Clinician Onsite Inspection The R&R nurses were knowledgeable about their job duties and the transfer process. These nurses also processed patients returning from specialty appointments or the hospital. They completed patient assessments and consistently reviewed hospital discharge recommendations with the provider. Case Review Conclusion Overall, the institution performed acceptably for patients transferring into the institution and for patients returning from hospitals. However, for patients transferring to other institutions, the R&R nurses often did not indicate the facility to which the patient was transferring. This is an area for CAC to target for quality improvement. The Inter- and Intra-System Transfers indicator was adequate. California City Correctional Facility, Cycle 5 Medical Inspection Page 31 Office of the Inspector General State of California Compliance Testing Results The institution earned a proficient rating for this indicator, with a score of 85.2 percent. CAC received proficient scores on the following tests: • For all 25 sampled patients who transferred into CAC from another CDCR institution, nursing staff completed initial health screening assessments on the day the patient arrived (MIT 6.001). • The OIG inspected the transfer packages of four applicable patients who transferred out of CAC to determine whether their transfer packages included required medications and related documentation. All four transfer packages were compliant (MIT 6.101). • Nursing staff timely completed the assessment and disposition sections of the initial health screening forms for 24 of the 25 sampled patients who transferred into CAC from another CDCR institution (96.0 percent). For one patient, however, nursing staff did not complete the assessment and disposition sections of the form (MIT 6.002). One test received a score in the adequate range: • OIG inspectors tested five patients who transferred out of CAC to another CDCR institution to determine whether their previously scheduled specialty service appointments were listed on the health care transfer form. CAC nursing staff identified these scheduled appointments on the transfer forms for four of five samples tested (80.0 percent). For one patient, nursing staff did not list their pending specialty services (MIT 6.004). One test received an inadequate score: • OIG inspectors examined health records for six patients who transferred into CAC from another CDCR institution that had medications requiring administration or delivery at the next dosing interval after arrival. Three of the six patients sampled (50.0 percent) received their medications timely. Three other patients received their medications between one and three days late (MIT 6.003). California City Correctional Facility, Cycle 5 Medical Inspection Page 32 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, Proficient encompassing the process from the written prescription to the Compliance Score: administration of the medication. By combining both a quantitative Proficient (87.2%) 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 numerous entities across various departments affect medication management, this assessment considers internal review and approval processes, pharmacy, nursing, health information systems, custody processes, and actions taken by the prescriber, staff, and patient. Case Review Results The OIG clinicians evaluated 52 events related to medications and found no deficiencies. The case review rating for this indicator was proficient. Medication Continuity CAC performed well ensuring medication continuity for patients who transferred into CAC from other CDCR institutions and for patients who returned from community hospitals. Patients received their medications timely as scheduled without any lapses. There were no deficiencies identified. Medication Administration The pharmacist dispensed antibiotics on the same day that providers prescribed them and dispensed all other routine medications within three days. The nurses administered medications accurately, timely, and as prescribed to patients. Additionally, patients received their KOP (keep-on-person) medications timely. The OIG identified no deficiencies. Medication Reconciliation Medication reconciliation is a process of creating the most accurate list possible of all medications a patient is taking including drug name, dosage, frequency, time, and route. Medication reconciliation is required when a patient transfers between medical facilities. CAC nurses compared this list against physicians’ orders to provide the correct medications. CAC nurses performed well with this process. Pharmacy Errors The OIG identified no deficiencies in this area. California City Correctional Facility, Cycle 5 Medical Inspection Page 33 Office of the Inspector General State of California Clinician Onsite Inspection The OIG clinicians met with the pharmacy and nursing staff and inquired about their medication management process and systems. There was a designated medication nurse assigned to issue KOP medications to patients twice a day. Once the pharmacy delivered the medications to the medication nurse, that nurse would then scan the medications into the EHRS to record the receipt of the medications. This process ensured none of the pharmacy-dispensed medications were missing. The pharmacist informed the OIG clinicians that pharmacy staff reconciled orders daily to ensure that staff filled and dispensed all medications timely. Pharmacy and nursing staff both reported that implementation of the EHRS decreased their medication errors once they became familiar with the system. The medication nurses were knowledgeable regarding the medication preparation and administration process. Case Review Conclusion CAC did an outstanding job ensuring medication continuity and with administering and reconciling medications. Overall, the institution performed well in the Pharmacy and Medication Management indicator. The OIG rated this indicator proficient. Compliance Testing Results The institution received a proficient score of 87.2 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 For this sub-indicator, the institution received a proficient score of 95.4 percent, scoring in the proficient range on the following tests: • CAC provided ordered medications without interruption to all 25 patients sampled who transferred from one housing unit to another (MIT 7.005). • CAC staff timely provided chronic care medications for 18 of the 19 sampled patients (94.7 percent). One patient, who refused his chronic care medications on several occasions, did not receive the required counseling for missed doses (MIT 7.001). • Clinical staff timely provided new and previously prescribed medications to 18 of 19 patients sampled who had been discharged from a community hospital and returned to the institution (94.7 percent). One patient received his nurse-administered medication five days late (MIT 7.003). California City Correctional Facility, Cycle 5 Medical Inspection Page 34 Office of the Inspector General State of California • CAC timely administered or delivered new medication orders to 23 of 25 patients sampled (92.0 percent). Two patients received their medication one day late (MIT 7.002). Observed Medication Practices and Storage Controls The institution received a proficient score of 87.8 percent in this sub-indicator. The following tests scored 100 percent in the proficient range: • The OIG interviewed nursing staff and inspected areas where narcotics were stored at seven applicable locations to assess whether strong security controls existed. All seven areas were adequately controlled (MIT 7.101). • The institution properly stored non-narcotic refrigerated medications at all six applicable clinics and medication line locations (MIT 7.103). • Nursing staff at all six inspected medication line locations employed appropriate administrative controls and followed appropriate protocols during medication preparation (MIT 7.105). Two tests received adequate scores: • The OIG inspectors observed the medication preparation and administration processes at six applicable medication line locations. Nursing staff were compliant regarding proper hand hygiene and contamination control protocols at five of the six locations sampled (83.3 percent). At one location, not all nursing staff washed or sanitized their hands when required, such as before medication preparation, putting on gloves, or before each subsequent re-gloving (MIT 7.104). • Five of six inspected medication preparation and administration areas demonstrated appropriate administrative controls and protocols (83.3 percent). At one location, the following deficiencies were identified: the medication nurse was not able to verbalize the appropriate medication incident error reporting process; the medication nurse did not always ensure that patients swallowed direct observation therapy medications, and the medication nurse did not verify blood glucose reading prior to administering insulin medication to patients (MIT 7.106). One test received an inadequate score: • CAC properly stored non-narcotic medications that did not require refrigeration in three of the five applicable clinics and medication line storage locations (60.0 percent). In two locations, one or more of the following deficiencies were identified: there was no established system to return expired medication prescriptions to the pharmacy, and multi-use medication was not labeled with the date it was opened (MIT 7.102). California City Correctional Facility, Cycle 5 Medical Inspection Page 35 Office of the Inspector General State of California Pharmacy Protocols In this sub-indicator, CAC received an adequate score of 80.0 percent, composed of scores received at the institution’s main pharmacy, with proficient scores of 100 percent on the following tests: • CAC’s main pharmacy followed general security, organization, and cleanliness management protocols. In addition, the institution, properly stored non-refrigerated and refrigerated medications in the main pharmacy (MIT 7.107, 7.108, 7.109). • The OIG inspectors examined 25 medication error reports and five of the monthly statistical reports generated by the institution’s pharmacist in charge (PIC). All 25 reports were timely and correctly processed (MIT 7.111). The following test received an inadequate score: • The institution’s PIC did not properly account for narcotic medications stored in CAC’s pharmacy or review monthly inventories of controlled substances in the institution’s clinical and medication line storage locations. As a result, the institution received a score of zero on this test. Also, the monthly physical inventory of all controlled substances in the pharmacy were not routinely logged, and staff responsible for completing the medication area inspection checklist did not document the results on the form (MIT 7.110). Non-Scored Tests • In addition to the OIG’s testing of reported medication errors, inspectors follow up on any significant medication errors that were found during the 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 (MIT 7.998). • The OIG interviewed patients in isolation units to determine if they had immediate access to their prescribed KOP rescue inhalers. All four of the sampled patients had access to their asthmatic inhalers (MIT 7.999). California City Correctional Facility, Cycle 5 Medical Inspection Page 36 Office of the Inspector General State of California PRENATAL AND POST-DELIVERY SERVICES This indicator evaluates the institution’s capacity to provide timely Case Review Rating: and appropriate prenatal, delivery, and postnatal services to pregnant Not Applicable patients. This includes the ordering and monitoring of indicated Compliance Score: screening tests, follow-up visits, referrals to higher levels of care, Not Applicable e.g., high-risk obstetrics clinic, when necessary, and postnatal Overall Rating: follow-up. Not Applicable As CAC does not have female patients, this indicator did not apply. California City Correctional Facility, Cycle 5 Medical Inspection Page 37 Office of the Inspector General State of California PREVENTIVE SERVICES This indicator assesses whether the institution offered or provided Case Review Rating: various preventive medical services to patients. These include cancer Not Applicable screenings, tuberculosis screenings, and influenza and chronic care Compliance Score: immunizations. This indicator also assesses whether certain Proficient (92.7%) institutions take preventive actions to relocate patients identified as being at higher risk for contracting coccidioidomycosis Overall Rating: (valley fever). Proficient The OIG rates this indicator entirely through the compliance testing component; the case review process does not include a separate qualitative analysis for this indicator. Compliance Testing Results The institution scored in the proficient range for this indicator at 92.7 percent. The following five tests were in the proficient range: • All 30 sampled patients received annual tuberculosis screenings (MIT 9.003). • All 25 patients sampled timely received or were offered influenza vaccinations during the most recent influenza season (MIT 9.004). • All six patients at high risk for contracting coccidioidomycosis infection (valley fever) who were identified as medically restricted and ineligible to reside at CAC were transferred out of the institution within 60 days from the time they were deemed ineligible (MIT 9.009). • CAC offered colorectal cancer screenings to 24 of 25 sampled patients subject to the annual screening requirement (96.0 percent). For one patient, however, his medical record showed no evidence he had received results of a normal colonoscopy within the past ten years or that the institution offered him a colorectal cancer screening within the past 12-month period (MIT 9.005). • The OIG tested whether CAC offered required influenza, pneumonia, and hepatitis vaccinations to patients who suffered from a chronic condition; 13 of the 14 applicable sampled patients (92.9 percent) were offered the vaccinations timely. For one patient, OIG inspectors found no evidence that the patient had received or refused the pneumococcal immunization within the last five years (MIT 9.008). Two tests received adequate scores on the following two tests: • CAC scored 85.0 percent for the timely administration of tuberculosis (TB) medications to its patients. Of 20 sampled patients, 17 received their medication timely. For three patients, California City Correctional Facility, Cycle 5 Medical Inspection Page 38 Office of the Inspector General State of California nursing staff did not document if the patients received or refused TB medications (MIT 9.001). • The OIG reviewed CAC’s monitoring of 20 sampled patients who received TB medications and found the institution properly monitored 15 patients (75.0 percent). Two patients did not receive their required weekly monitoring. Two other patients did not have their weight documented. One final patient did not receive his required monthly monitoring (MIT 9.002). California City Correctional Facility, Cycle 5 Medical Inspection Page 39 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 Proficient completed entirely by OIG nursing clinicians within the case review Compliance Score: process and does not have a score under the OIG compliance testing Not Applicable component. Case reviews include face-to-face encounters and Overall Rating: indirect activities performed by nursing staff on behalf of the patient. Proficient Review of nursing performance includes all nursing services performed onsite, such as outpatient, inpatient, urgent/emergent, patient transfers, care coordination, and medication management. The key focus areas for evaluation of 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, and accurate, thorough, and legible documentation. Although the OIG reports nursing services provided in specialized medical housing units in the Specialized Medical Housing indicator, and those provided in the TTA or related to emergency medical responses in the Emergency Services indicator, this Quality of Nursing Performance indicator summarizes all areas of nursing services. Case Review Results The OIG clinicians reviewed 238 nursing encounters, of which 136 were in the outpatient setting. Most outpatient nursing encounters were for sick call requests, walk-in visits, and RN follow-up visits. In all, there were 37 deficiencies identified related to nursing care performance, only one of which was significant. The case review rating for this indicator was proficient. Nursing Assessment and Intervention A major component of high-quality nursing care is the nursing assessment, which includes both subjective and objective evaluations. Most CAC nurses included both of these elements in their nursing assessments. In progress notes, nurses properly reflected the patient’s condition and the care provided. Nurses demonstrated familiarity and competency with their patients. Although CAC nurses provided good care, the OIG identified a pattern of deficiencies in 7 of 22 applicable cases in which outpatient nurses recorded incomplete assessments and interventions. These deficiencies usually occurred when nurses omitted vital signs, but the OIG clinicians considered these deficiencies minor and unlikely to contribute to patient harm. Nursing Documentation Complete and accurate nursing documentation is another essential component of patient care. Without proper documentation, health care staff often overlook changes in patient health resulting in lapses in care. Also, the improper documentation makes it difficult for health care staff to assess the status of a patient’s ongoing condition. Overall, the nursing documentation in California City Correctional Facility, Cycle 5 Medical Inspection Page 40 Office of the Inspector General State of California all areas of nursing services was good, except documentation in emergency services and for transfer-out patients. Four of the six emergency medical response cases reviewed contained documentation deficiencies (cases 5, 6, 7, and 8). Additionally, four of the six transfer-out cases reviewed contained incomplete documentation (cases 3, 13, 18, and 20). The R&R nurse did not document the facilities to which the patients were transferring. These errors are discussed further in the Emergency Services and Inter- and-Intra-System Transfers indicators. Nursing Sick Call The OIG clinicians reviewed 35 sick call requests. The nurses facilitated an organized sick call process. CAC’s nurses reviewed all sick call requests on the same day they received them. The nurses triaged the patients timely, performed face-to-face assessments within one business day for patients with symptoms, and provided suitable nursing assessments and interventions. Urgent/Emergent Care The institution’s nurses provided acceptable emergency nursing care. This performance is further discussed in the Emergency Services indicator. Post-Hospital Returns Nurses at CAC provided good assessments, interventions, and education to patients returning from the hospital. The utilization management (UM) nurse recorded daily updates for patients that were in the hospital. Additionally, the UM nurse performed face-to-face evaluations with every patient after they returned to CAC. There was no pattern of deficiencies identified. Intra-System Transfers The nurses provided effective nursing care for patients arriving at CAC. Most nurses appropriately referred patients to providers; however, there was one significant deficiency. Nursing transfer performance is further discussed in the Inter- and-Intra-System Transfers indicator. Offsite Specialty Services and Telemedicine Most nurses made suitable nursing assessments for patients returning from offsite specialty appointments. Nursing staff properly reviewed the specialists’ recommendations and communicated pertinent information to the providers. Of the 11 cases in which nurses assessed a patient who returned from a specialty appointment, 2 contained minor deficiencies for incomplete nursing assessments: • In case 4, the nurse did not assess the patient’s pain when the patient returned from a prostate biopsy. • In case 13, the nurse did not reassess the patient who had moderately high blood pressure. California City Correctional Facility, Cycle 5 Medical Inspection Page 41 Office of the Inspector General State of California Clinician Onsite Inspection The OIG clinicians visited several clinical areas, including R&R, outpatient clinics, specialty services, utilization management, medication lines, and the TTA. CAC’s huddles which were very organized and included various members of the multi-disciplinary team who actively participated in the discussion. The institution’s sick call nurses averaged seven patients per day, and at the time of the onsite medical inspection, there was no backlog. Most nurses reported good morale, felt appreciated, and enjoyed working at the institution. Nursing managers were organized and prepared for the onsite questions. They reported using the OIG inspection as a tool for auditing and monitoring purposes. Case Review Conclusion The areas for CAC to target for quality improvement are emergency services and transfer documentation, and outpatient nursing assessments and interventions. Overall, CAC nurses provided very good quality nursing care. The OIG rated this indicator proficient. California City Correctional Facility, Cycle 5 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 evaluation Case Review Rating: of the adequacy of provider care at the institution. The case review Adequate clinicians review the provider care regarding appropriate evaluation, Compliance Score: diagnosis, and management plans for programs including, but not Not Applicable limited to, nursing sick call, chronic care programs, TTA, specialized Overall Rating: medical housing, and specialty services. OIG physicians alone assess Adequate provider care. There is no compliance testing component associated with this quality indicator. Case Review Results OIG clinicians reviewed 149 medical provider encounters and identified 17 deficiencies related to provider performance, 4 of which were significant. Of the 20 detailed cases reviewed, OIG clinicians rated 5 proficient, 14 adequate, and the care of one patient inadequate. Overall, the OIG clinicians rated the Quality of Provider Performance indicator adequate. Assessment and Decision-Making CAC providers made appropriate assessments and sound medical plans in most cases. In four of the 20 cases reviewed, OIG clinicians identified nine deficiencies related to assessment and decision-making (cases 2, 10, 13, and 16). Most deficiencies occurred with patients who were seen for multiple problems, in which one of the problems was not adequately managed: • In case 2, the patient described new symptoms of a headache, neck stiffness, and chills. The provider failed to examine or make a diagnosis of the patient’s symptoms. • In case 13, the patient was seen at an outside hospital for bleeding from his stomach. A computed tomography (CT) scan of the abdomen showed the patient had a markedly enlarged bladder, which was a finding unrelated to his bleeding. When the patient returned to CAC, the provider noted the finding of the patient’s enlarged bladder, but he failed to include the finding on the patient’s problem list and did not check the patient to see if the problem was still present. The degree of bladder enlargement seen on the CT scan was significant and alone should have prompted additional testing or intervention. • On another visit in case 13, the patient continued to have abdominal pain. The provider failed to consider the distended bladder as a cause of the patient’s abdominal pain. Fortunately, testing showed the bladder distention had resolved several months later. California City Correctional Facility, Cycle 5 Medical Inspection Page 43 Office of the Inspector General State of California Emergency Care Generally, providers made appropriate triage decisions in the TTA and were available for consultation with the TTA nursing staff. Two minor deficiencies with provider performance in emergency care were identified and are detailed in the Emergency Services indicator. Review of Records With few exceptions, CAC providers managed medical records sufficiently and performed flawlessly in signing diagnostic reports. However, providers did not always review their patient’s medical records appropriately; they either failed to proofread reports or did not carefully review the medical record when they saw the patient. These deficiencies occurred in 4 of the 20 cases reviewed (cases 4, 13, 16, and 38). One of these deficiencies was significant: • In case 4, the provider saw the patient for intestinal bleeding, but the provider failed to review the record of the patient’s prior colonoscopy (viewing the large intestine). As a result, the provider incorrectly recorded that the patient had a benign mass removed by a specialist, when the actual findings were the patient had simple hemorrhoids. Hospital Return CAC providers electronically signed hospital discharge summaries and timely addressed all the recommendations. No deficiencies were identified. Chronic Care Chronic care performance was appropriate, and continuity of provider care was good. Most providers managed patients with hypertension, hepatitis C infections, and cardiovascular disease very well. However, some providers failed to timely manage patients with deteriorating conditions. Four deficiencies were identified in the chronic care program, one of which was significant: • In case 16, the provider failed to note or respond to a patient whose asthma status had worsened. At the patient’s next six-month follow-up visit, the same provider managed an ingrown toenail for the patient but failed to address the patient’s asthma. Specialty Services Providers timely referred their patients to specialists when needed. There were no deficiencies. Health Information Management Providers at CAC generally documented outpatient and TTA encounters the same day they occurred. With a few exceptions, handwritten progress notes were legible. There were four minor deficiencies, three of which attributed to the provider failing to proofread the note to correct typos or charting errors. California City Correctional Facility, Cycle 5 Medical Inspection Page 44 Office of the Inspector General State of California Clinician Onsite Inspection CAC is classified as a basic institution by CCHCS and has only two high-risk or medically complex patients. At the time of the OIG inspection, there were no provider vacancies, compared to the one provider vacancy CAC experienced during the previous year. CAC managed that vacancy by having one provider work double coverage, as well as having the chief medical executive (CME) and the chief physician and surgeon (CP&S) see patients in clinics. The additional coverage during the vacancy provided good access to care for patients. However, leadership noted the provider with the additional patient population, at times, had suboptimal documentation and the notes lacked detail or diagnostic assessments of some complaints. CAC leadership also identified a few deficiencies in provider care, such as not addressing mildly abnormal vital signs or laboratory results. CAC’s annual review of providers addressed these problems and noted CAC provided focused training for these problems. The deficiencies CAC identified matched most of the deficiencies that OIG clinicians identified. Before the OIG onsite visit, CAC leadership reported the corrective actions that had already been implemented for the identified deficiencies. All CAC providers were enthusiastic about their work and expressed satisfaction with specialty services, nursing, and diagnostic services. To ensure continuity of care, CAC assigned each provider primarily to only one clinic. Three clinics were centrally located which allowed providers to consult with each other easily. The OIG noted one potential barrier to care; nurses performed face-to-face triage care at a location remote from the central clinic, distant from the providers. Morning huddles were productive, led by providers, and attended by nurses, the care coordinator, custody staff, leadership, and office technicians. While the huddles were thorough, the primary focus was ensuring patients were seen timely. The CME and CP&S were committed to patient care and quality improvement. A unique finding for CAC was the frequency of direct patient care performed by both the CME and the CP&S with the few complex medical patients, for patients assigned to the mid-level provider, or for patients nearing compliance deadlines for appointments and their primary provider had an unplanned absence from the institution. Case Review Conclusion CAC providers delivered good care for the majority of the physician cases reviewed by OIG clinicians. The institution’s CME and CP&S provided strong leadership in guiding providers, as well as direct patient care when needed. For the detailed physician case reviews, 5 were proficient, 14 were adequate, and one was inadequate. The areas CAC can improve include the need for providers to address all their patients’ problems and to review their patients’ medical records thoroughly. Despite these problems, the OIG rated the Quality of Provider Performance indicator adequate. California City Correctional Facility, Cycle 5 Medical Inspection Page 45 Office of the Inspector General State of California RECEPTION CENTER ARRIVALS This indicator focuses on the management of medical needs and Case Review Rating: continuity of care for patients arriving from outside the CDCR Not Applicable system. The OIG review includes evaluation of the ability of the Compliance Score: institution to provide and document initial health screenings, initial Not Applicable health assessments, continuity of medications, and completion of Overall Rating: required screening tests; address and provide significant Not Applicable accommodations for disabilities and health care appliance needs; and identify health care conditions needing treatment and monitoring. The patients reviewed for reception center cases are those received from non-CDCR facilities, such as county jails. CAC does not have a reception center; therefore, this indicator does not apply. California City Correctional Facility, Cycle 5 Medical Inspection Page 46 Office of the Inspector General State of California SPECIALIZED MEDICAL HOUSING This indicator addresses whether the institution follows appropriate Case Review Rating: policies and procedures when admitting patients to onsite inpatient Not Applicable facilities, including completion of timely nursing and provider Compliance Score: assessments. The case review assesses all aspects of medical care Not Applicable related to these housing units, including quality of provider and Overall Rating: nursing care. Not Applicable CAC does not have a specialized medical housing unit; therefore, this indicator does not apply. California City Correctional Facility, Cycle 5 Medical Inspection Page 47 Office of the Inspector General State of California SPECIALTY SERVICES This indicator focuses on specialist care from the time a physician Case Review Rating: completes a request for services or a physician’s order for specialist Proficient care to the time of receipt of related recommendations from Compliance Score: specialists. This indicator also evaluates the providers’ timely review Proficient (96.9%) of specialist records and documentation reflecting the patients’ care plans, including the course of care when specialist recommendations Overall Rating: were not 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 provider updates the patient on the plan of care. Case Review Results OIG clinicians reviewed 110 events related to specialty services, which included specialty consultations and procedures. CAC health care staff provided excellent specialty care in four challenging cases despite frequent offsite specialty consultations and procedures (cases 21, 22, 23, and 24). Specialty services deficiencies were rare, and the case review rating for this indicator was proficient. Access to Specialty Services CAC performed well with appointments and scheduling. The OIG identified three deficiencies, two of which were significant: • In case 16, the provider referred the patient to physical therapy for back pain. CAC canceled and did not reschedule this appointment after they sent the patient to the hospital for appendicitis. • In case 17, the provider referred the patient to a podiatrist (foot specialist) for a wound. The appointment was canceled because the podiatrist was not available that day. The appointment was not rescheduled. Nursing Performance Most nurses provided good assessments, interventions, and documentation for patients returning from offsite specialty and telemedicine appointments. Additionally, the nurses informed the provider of the specialist findings and recommendations, obtained orders, and scheduled provider follow-up appointments. The OIG identified two minor nursing deficiencies: • In case 4, the nurse evaluated the patient who returned from a prostate biopsy but did not evaluate the patient for pain following this surgical procedure. California City Correctional Facility, Cycle 5 Medical Inspection Page 48 Office of the Inspector General State of California • In case 13, the nurse did not evaluate the patient who had moderately high blood pressure. Provider Performance CAC’s providers performed well, and appropriately referred and managed patients requiring specialty health care services. No deficiencies were identified. Health Information Management In the previous year, CAC had successfully implemented the EHRS. There was only one significant deficiency, also discussed in the Health Information Management indicator: • In case 13, CAC staff scanned the patient’s offsite gastroenterology consultation report into an incorrect area of the EHRS. This scanning error made it difficult, if not impossible, to find the report. Clinician Onsite Inspection According to CAC’s leadership and providers, they were supported well by specialty services. The OIG agreed; the case reviews showed no occurrences in which CAC patients had problems obtaining timely onsite or offsite consultations. Case Review Conclusion Nearly all specialty appointments occurred timely, with very few deficiencies. Nurses usually assessed patients and arranged appropriate follow-up. Providers referred their patients to specialists when needed and reviewed the consultants’ reports. Significant deficiencies were infrequent and usually related to the scheduling of specialty appointments. The OIG rated the Specialty Services indicator proficient, despite the rare lapses in care. Compliance Testing Results The institution received a proficient score of 96.9 percent in this indicator, with the following six tests scoring in the proficient range: • For 15 sampled patients, all had high-priority specialty services appointments occur within 14 calendar days of the provider’s order (MIT 14.001). • Providers timely received and reviewed the high-priority specialists’ reports for all 15 patients sampled (MIT 14.002). • For 15 sampled patients, all had routine specialty services appointments occur within the required time frame (MIT 14.003). California City Correctional Facility, Cycle 5 Medical Inspection Page 49 Office of the Inspector General State of California • CAC scored 100 percent when tested for timeliness of denials of provider specialty services requests. For four sampled patients, denials of their specialty services requests occurred timely. Providers also timely informed patients of the denials so the patients could consider alternate treatment options (MIT 14.006, 14.007). • Providers timely received and reviewed 14 of the 15 sampled routine specialists’ reports (93.3 percent); one report was not reviewed timely (MIT 14.004). One test received a score in the adequate range: • When patients are approved or scheduled for specialty services at one institution and then transfer to another, CCHCS policy requires that the receiving institution reschedule and provide the patient’s appointment within the required time frame. Of 20 patients sampled, 17 (85.0 percent) received their appointments timely. Three patients received their appointments between 16 and 211 days late (MIT 14.005). California City Correctional Facility, Cycle 5 Medical Inspection Page 50 Office of the Inspector General State of California ADMINISTRATIVE OPERATIONS (SECONDARY) This indicator focuses on the institution’s administrative health care Case Review Rating: oversight functions. The OIG evaluates whether the institution Not Applicable promptly processes patient medical appeals and addresses all Compliance Score: appealed issues. Inspectors also verify that the institution follows Adequate (85.0%) reporting requirements for adverse/sentinel events and patient deaths. The OIG verifies that the Emergency Medical Response Review Overall Rating: Committee (EMRRC) performs required reviews and that staff Adequate perform required emergency response drills. Inspectors also assess whether the Quality Management Committee (QMC) meets regularly and adequately addresses program performance. For those institutions with licensed facilities, inspectors also verify that required committee meetings are held. In addition, the OIG examines whether the institution adequately manages its health care staffing resources by evaluating whether job performance reviews are completed as required; specified staff possess current, valid credentials and professional licenses or certifications; nursing staff receive new employee orientation training and annual competency testing; and clinical and custody staff have current emergency medical response certifications. The Administrative Operations indicator is a secondary indicator; therefore, it was not relied on for the institution’s overall score. Compliance Testing Results The institution received an adequate score of 85.0 percent in this indicator, with 11 tests scoring in the proficient range: • The institution’s Quality Management Committee (QMC) met monthly, evaluated program performance, and took action when management identified areas for improvement opportunities (MIT 15.003). • CAC took appropriate steps to ensure the accuracy of its Dashboard data reporting (MIT 15.004). • The OIG inspectors reviewed three emergency medical response drill packages conducted during the prior quarter. All three of the drill packages contained the required summary reports and related documentation. Additionally, the drills included participation by both health care and custody staff (MIT 15.101). • Based on a sample of 10 second-level medical appeals, the institution’s responses addressed all of the patients’ appealed issues (MIT 15.102). • Medical staff promptly submitted the initial Inmate Death Report (CDCR Form 7229A) to CCHCS’s Death Review Unit for the two applicable deaths that occurred at CAC in the prior 12-month period (MIT 15.103). California City Correctional Facility, Cycle 5 Medical Inspection Page 51 Office of the Inspector General State of California • All ten nurses sampled were current with their clinical competency validations (MIT 15.105). • All providers at CAC were current with their professional licenses. Similarly, all nursing staff and the PIC were current with their professional licenses and certification requirements (MIT 15.107, 15.109). • All active duty providers and nurses were current with their emergency response certifications (MIT 15.108). • All pharmacy staff and providers who prescribed controlled substances had current Drug Enforcement Agency registrations (MIT 15.110). • All nursing staff hired within the last year had timely received new employee orientation training (MIT 15.111). Two tests earned adequate scores: • The OIG inspectors reviewed data received from the institution to determine whether CAC timely processed at least 95 percent of its monthly patient medical appeals during the most recent 12-month period. CAC timely processed 10 of the 12 months of patient appeals reviewed (83.3 percent). Two months had between 5 to 7 percent of patient medical appeals in overdue status (MIT 15.001). • Five of the six providers at CAC had a proper clinical performance appraisal completed by their supervisor (83.3 percent). For one provider, a clinical appraisal was completed, but the results were not discussed with the provider (15.106). Two tests earned scores in the inadequate range: • The OIG inspected records from August 2017 for five nurses to determine if supervisors properly completed monthly performance reviews. Inspectors identified the following deficiencies for the monthly nursing reviews (MIT 15.104): o The supervisor did not complete the required number of reviews for one nurse; o The supervisor’s review did not summarize aspects that were well done, or for any needed improvements, for all five nurses. • The OIG reviewed 12 of the institution’s Emergency Medical Response Review Committee (EMRRC) incident packages for emergency medical responses during the prior six-month period. Only one of the 12 sampled incident packages complied with policy. The EMRRC minutes did not document discussion of all three required questions for 11 of the incidents. As a result, CAC received a score of 8.3 percent on this test (MIT 15.005). California City Correctional Facility, Cycle 5 Medical Inspection Page 52 Office of the Inspector General State of California Non-Scored Results • The OIG gathered non-scored data regarding the completion of death review reports by CCHCS’s Death Review Committee (DRC). Two deaths occurred at CAC during the OIG’s review period, both were unexpected (Level 1) deaths. CCHCS policy requires the DRC to complete its death review summary report within 60 days from the date of death and submit the report to the institution’s chief executive officer (CEO) within seven calendar days thereafter. For one patient, the DRC was completed timely, and the institution’s CEO was notified of the death review summary within the required time frames. For the other patient, the DRC was completed 119 days late, and no evidence was found that the CEO was notified of the death review summary (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). California City Correctional Facility, Cycle 5 Medical Inspection Page 53 Office of the Inspector General State of California R ECOMMENDATIONS The OIG recommends the following: • CCHCS should examine CAC’s excellent medication processes and consider replicating those processes statewide. California City Correctional Facility, Cycle 5 Medical Inspection Page 54 Office of the Inspector General State of California P -B M OPULATION ASED ETRICS The compliance testing and the case reviews give an accurate assessment of how the institution’s health care systems are functioning with regard to the patients with the highest risk and utilization. This information is vital to assess the capacity of the institution to provide sustainable, adequate care. However, one significant limitation of the case review methodology is that it does not give a clear assessment of how the institution performs for the entire population. For better insight into this performance, the OIG has turned to population-based metrics. For comparative purposes, the OIG has selected several Healthcare Effectiveness Data and Information Set (HEDIS) measures for disease management to gauge the institution’s effectiveness in outpatient health care, especially chronic disease management. The Healthcare Effectiveness Data and Information Set is a set of standardized performance measures developed by the National Committee for Quality Assurance with input from over 300 organizations representing every sector of the nation’s health care industry. It is used by over 90 percent of the nation’s health plans as well as many leading employers and regulators. HEDIS was designed to ensure that the public (including employers, the Centers for Medicare and Medicaid Services, and researchers) has the information it needs to accurately compare the performance of health care plans. Healthcare Effectiveness Data and Information Set data is often used to produce health plan report cards, analyze quality improvement activities, and create performance benchmarks. Methodology For population-based metrics, the OIG used a subset of HEDIS measures applicable to the CDCR patient population. Selection of the measures was based on the availability, reliability, and feasibility of the data required for performing the measurement. The OIG collected data utilizing various information sources, including the electronic medical record, the Master Registry (maintained by CCHCS), as well as a random sample of patient records analyzed and abstracted by trained personnel. 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 California City Correctional Facility (CAC), seven HEDIS measures were selected 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 5 Medical Inspection Page 55 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 to produce optimal results. CAC performed very well with its management of diabetes. When compared statewide, CAC outperformed most other reporting entities in all five diabetic measures. However, the institution scored one percentage point lower than Kaiser, North and South regions, for diabetic blood pressure control. When compared nationally, CAC outperformed Medicaid, Medi-Cal, Medicare, and commercial health care plans in all five diabetic measures. CAC outperformed the United State Department of Veterans Affairs (VA), and both Kaiser plans in four applicable measures. Immunizations Comparative data for immunizations was only fully available for the VA and partially available for Kaiser, commercial plans, Medicaid, and Medicare. Concerning administering influenza vaccinations to younger adults, CAC scored higher than Medicaid and commercial plans but scored lower than Kaiser and the VA. The patient refusal rate for younger adults was 45 percent, which negatively affected the institution’s score. CAC only had one patient over the age of 65; therefore, the sample was omitted from the comparative analysis. Cancer Screening Concerning colorectal cancer screening, CAC greatly outperformed all reporting health care entities. Relative to the HEDIS in Cycle 4, CAC was able to reduce patient refusals within Cycle 5 greatly. Summary CAC’s population-based metrics performance reflected a well-functioning chronic care program, compared to the other state and national health care entities reviewed. The institution may improve its scores for immunizations by reducing patient refusals through patient education. California City Correctional Facility, Cycle 5 Medical Inspection Page 56 Office of the Inspector General State of California CAC Results Compared to State and National HEDIS Scores California National HEDIS HEDIS CAC HEDIS HEDIS Kaiser Kaiser HEDIS HEDIS VA Clinical Measures Com- Medi-Cal (No. (So. Medicaid Medicare Average Cycle 5 mercial 20162 CA) CA) 20164 20164 20155 Results1 20164 20163 20163 Comprehensive Diabetes Care HbA1c Testing (Monitoring) 100% 86% 94% 94% 86% 90% 93% 98% Poor HbA1c Control (>9.0%)6, 7 7% 39% 20% 23% 45% 34% 27% 19% HbA1c Control (<8.0%)6 90% 49% 70% 63% 46% 55% 63% - Blood Pressure Control 82% 63% 83% 83% 59% 60% 62% 74% (<140/90)6 Eye Exams 87% 53% 68% 81% 53% 54% 69% 89% Immunizations Influenza Shots - Adults (18–64) 52% - 56% 57% 39% 48% - 55% Influenza Shots - Adults (65+)8 N/A - - - - - 72% 76% Immunizations: Pneumococcal8 N/A - - - - - 71% 93% Cancer Screening Colorectal Cancer Screening 95% - 79% 82% - 63% 67% 82% 1. Unless otherwise stated, data was collected in October 2017 by reviewing medical records from a sample of CAC’s population of applicable 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 2016 HEDIS Aggregate Report for Medi-Cal Managed Care. 3. Data was obtained from Kaiser Permanente November 2016 reports for the Northern and Southern California regions. 4. National HEDIS data for Medicaid, commercial plans, and Medicare was obtained from the 2016 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. Population limited to only one patient over the age of 65; therefore, sample omitted from the comparative analysis. California City Correctional Facility, Cycle 5 Medical Inspection Page 57 Office of the Inspector General State of California A A—C T R PPENDIX OMPLIANCE EST ESULTS California City Correctional Facility Range of Summary Scores: 75.6% - 96.9% Indicator Compliance Score (Yes %) 1–Access to Care 94.6% 2–Diagnostic Services 75.6% 3–Emergency Services Not Applicable 4–Health Information Management (Medical Records) 92.0% 5–Health Care Environment 87.0% 6–Inter- and Intra-System Transfers 85.2% 7–Pharmacy and Medication Management 87.2% 8–Prenatal and Post-Delivery Services Not Applicable 9–Preventive Services 92.7% 10–Quality of Nursing Performance Not Applicable 11–Quality of Provider Performance Not Applicable 12–Reception Center Arrivals Not Applicable 13–Specialized Medical Housing (OHU, CTC, SNF, Hospice) Not Applicable 14–Specialty Services 96.9% 15–Administrative Operations 85.0% California City Correctional Facility, Cycle 5 Medical Inspection Page 58 Office of the Inspector General State of California Scored Answers Yes Reference + 1–Access to Care Number Yes No No Yes % N/A Chronic care follow-up appointments: Was the patient’s most recent chronic care visit within the health care guideline’s 1.001 22 3 25 88.0% 0 maximum allowable interval or within the ordered time frame, whichever is shorter? For endorsed patients received from another CDCR institution: If 1.002 the nurse referred the patient to a provider during the initial health 24 1 25 96.0% 0 screening, was the patient seen within the required time frame? Clinical appointments: Did a registered nurse review the patient’s 1.003 30 0 30 100.0% 0 request for service the same day it was received? Clinical appointments: Did the registered nurse complete a 1.004 face-to-face visit within one business day after the CDCR Form 30 0 30 100.0% 0 7362 was reviewed? Clinical appointments: If the registered nurse determined a referral to a primary care provider was necessary, was the patient 1.005 15 1 16 93.8% 14 seen within the maximum allowable time or the ordered time frame, whichever is the shorter? Sick call follow-up appointments: If the primary care provider 1.006 ordered a follow-up sick call appointment, did it take place within 8 0 8 100.0% 22 the time frame specified? Upon the patient’s discharge from the community hospital: Did 1.007 the patient receive a follow-up appointment within the required 19 0 19 100.0% 0 time frame? Specialty service follow-up appointments: Do specialty service 1.008 primary care physician follow-up visits occur within required time 27 3 30 90.0% 0 frames? Clinical appointments: Do patients have a standardized process to 1.101 5 1 6 83.3% 0 obtain and submit health care services request forms? Overall percentage: 94.6% California City Correctional Facility, Cycle 5 Medical Inspection Page 59 Office of the Inspector General State of California Scored Answers Yes Reference + 2–Diagnostic Services Number Yes No No Yes % N/A Radiology: Was the radiology service provided within the time 2.001 10 0 10 100.0% 0 frame specified in the provider’s order? Radiology: Did the primary care provider review and initial the 2.002 8 2 10 80.0% 0 diagnostic report within specified time frames? Radiology: Did the primary care provider communicate the results 2.003 10 0 10 100.0% 0 of the diagnostic study to the patient within specified time frames? Laboratory: Was the laboratory service provided within the time 2.004 10 0 10 100.0% 0 frame specified in the provider’s order? Laboratory: Did the primary care provider review and initial the 2.005 8 2 10 80.0% 0 diagnostic report within specified time frames? Laboratory: Did the primary care provider communicate the 2.006 results of the diagnostic study to the patient within specified time 2 8 10 20.0% 0 frames? Pathology: Did the institution receive the final diagnostic report 2.007 8 2 10 80.0% 0 within the required time frames? Pathology: Did the primary care provider review and initial the 2.008 7 3 10 70.0% 0 diagnostic report within specified time frames? Pathology: Did the primary care provider communicate the results 2.009 5 5 10 50.0% 0 of the diagnostic study to the patient within specified time frames? Overall percentage: 75.6% 3–Emergency Services This indicator is evaluated only by case review clinicians. There is no compliance testing component. California City Correctional Facility, Cycle 5 Medical Inspection Page 60 Office of the Inspector General State of California Scored Answers Yes Reference + 4–Health Information Management Number Yes No No Yes % N/A Are non-dictated healthcare documents (provider progress notes) 4.001 5 0 5 100.0% 0 scanned within 3 calendar days of the patient encounter date? Are dictated/transcribed documents scanned into the patient’s 4.002 electronic health record within five calendar days of the encounter 0 0 0 NA 25 date? Are High-Priority specialty notes (either a Form 7243 or other 4.003 scanned consulting report) scanned within the required time 20 0 20 100.0% 0 frame? Are community hospital discharge documents scanned into the 4.004 patient’s electronic health record within three calendar days of 19 0 19 100.0% 0 hospital discharge? Are medication administration records (MARs) scanned into the 4.005 0 0 0 NA 25 patient’s electronic health record within the required time frames? During the inspection, were medical records properly scanned, 4.006 22 2 24 91.7% 0 labeled, and included in the correct patients’ files? For patients discharged from a community hospital: Did the preliminary hospital discharge report include key elements and 4.007 13 6 19 68.4% 0 did a primary care provider review the report within three calendar days of discharge? Overall percentage: 92.0% California City Correctional Facility, Cycle 5 Medical Inspection Page 61 Office of the Inspector General State of California Scored Answers Yes Reference + 5–Health Care Environment Number Yes No No Yes % N/A Are clinical health care areas appropriately disinfected, cleaned 5.101 7 0 7 100.0% 0 and sanitary? Do clinical health care areas ensure that reusable invasive and 5.102 non-invasive medical equipment is properly sterilized or 6 1 7 85.7% 0 disinfected as warranted? Do clinical health care areas contain operable sinks and sufficient 5.103 6 1 7 85.7% 0 quantities of hygiene supplies? Does clinical health care staff adhere to universal hand hygiene 5.104 3 4 7 42.9% 0 precautions? Do clinical health care areas control exposure to blood-borne 5.105 7 0 7 100.0% 0 pathogens and contaminated waste? Warehouse, Conex and other non-clinic storage areas: Does the 5.106 medical supply management process adequately support the needs 1 0 1 100.0% 0 of the medical health care program? Does each clinic follow adequate protocols for managing and 5.107 6 1 7 85.7% 0 storing bulk medical supplies? Do clinic common areas and exam rooms have essential core 5.108 5 2 7 71.4% 0 medical equipment and supplies? Do clinic common areas have an adequate environment conducive 5.109 6 1 7 85.7% 0 to providing medical services? Do clinic exam rooms have an adequate environment conducive 5.110 7 0 7 100.0% 0 to providing medical services? Emergency response bags: Are TTA and clinic emergency 5.111 medical response bags inspected daily and inventoried monthly, 4 0 4 100.0% 3 and do they contain essential items? Overall percentage: 87.0% California City Correctional Facility, Cycle 5 Medical Inspection Page 62 Office of the Inspector General State of California Scored Answers Yes Reference + 6–Inter- and Intra-System Transfers Number Yes No No Yes % N/A For endorsed patients received from another CDCR institution or COCF: Did nursing staff complete the initial health screening and 6.001 25 0 25 100.0% 0 answer all screening questions on the same day the patient arrived at the institution? For endorsed patients received from another CDCR institution or COCF: When required, did the RN complete the assessment and disposition section of the health screening form; refer the patient 6.002 24 1 25 96.0% 0 to the TTA, if TB signs and symptoms were present; and sign and date the form on the same day staff completed the health screening? For endorsed patients received from another CDCR institution or COCF: If the patient had an existing medication order upon 6.003 3 3 6 50.0% 19 arrival, were medications administered or delivered without interruption? For patients transferred out of the facility: Were scheduled 6.004 specialty service appointments identified on the patient’s health 4 1 5 80.0% 0 care transfer information form? For patients transferred out of the facility: Do medication transfer 6.101 packages include required medications along with the 4 0 4 100.0% 0 corresponding transfer packet required documents? Overall percentage: 85.2% California City Correctional Facility, Cycle 5 Medical Inspection Page 63 Office of the Inspector General State of California Scored Answers 7–Pharmacy and Medication Yes Reference + Management Number Yes No No Yes % N/A Did the patient receive all chronic care medications within the 7.001 required time frames or did the institution follow departmental 18 1 19 94.7% 6 policy for refusals or no-shows? Did health care staff administer, make available, or deliver new 7.002 order prescription medications to the patient within the required 23 2 25 92.0% 0 time frames? Upon the patient’s discharge from a community hospital: Were all 7.003 ordered medications administered, made available, or delivered to 18 1 19 94.7% 0 the patient within required time frames? For patients received from a county jail: Were all medications ordered by the institution’s reception center provider 7.004 Not Applicable administered, made available, or delivered to the patient within the required time frames? Upon the patient’s transfer from one housing unit to another: 7.005 25 0 25 100.0% 0 Were medications continued without interruption? For patients en route who lay over at the institution: If the 7.006 temporarily housed patient had an existing medication order, were Not Applicable medications administered or delivered without interruption? All clinical and medication line storage areas for narcotic 7.101 medications: Does the Institution employ strong medication 7 0 7 100.0% 2 security over narcotic medications assigned to its clinical areas? All clinical and medication line storage areas for non-narcotic medications: Does the Institution properly store non-narcotic 7.102 3 2 5 60.0% 4 medications that do not require refrigeration in assigned clinical areas? All clinical and medication line storage areas for non-narcotic 7.103 medications: Does the institution properly store non-narcotic 6 0 6 100.0% 3 medications that require refrigeration in assigned clinical areas? Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols 7.104 5 1 6 83.3% 3 during medication preparation and medication administration processes? Medication preparation and administration areas: Does the 7.105 institution employ appropriate administrative controls and 6 0 6 100.0% 3 protocols when preparing medications for patients? Medication preparation and administration areas: Does the 7.106 Institution employ appropriate administrative controls and 5 1 6 83.3% 3 protocols when distributing medications to patients? Pharmacy: Does the institution employ and follow general 7.107 security, organization, and cleanliness management protocols in 1 0 1 100.0% 0 its main and satellite pharmacies? California City Correctional Facility, Cycle 5 Medical Inspection Page 64 Office of the Inspector General State of California Scored Answers 7–Pharmacy and Medication Yes Reference + Management Number Yes No No Yes % N/A Pharmacy: Does the institution’s pharmacy properly store 7.108 1 0 1 100.0% 0 non-refrigerated medications? Pharmacy: Does the institution’s pharmacy properly store 7.109 1 0 1 100.0% 0 refrigerated or frozen medications? Pharmacy: Does the institution’s pharmacy properly account for 7.110 0 1 1 0.0% 0 narcotic medications? Does the institution follow key medication error reporting 7.111 25 0 25 100.0% 0 protocols? Overall percentage: 87.2% 8–Prenatal and Post-Delivery Services The institution has no female patients, so this indicator is not applicable. California City Correctional Facility, Cycle 5 Medical Inspection Page 65 Office of the Inspector General State of California Scored Answers Yes Reference + 9–Preventive Services Number Yes No No Yes % N/A Patients prescribed TB medication: Did the institution administer 9.001 17 3 20 85.0% 0 the medication to the patient as prescribed? Patients prescribed TB medication: Did the institution monitor the 9.002 patient monthly for the most recent three months he or she was on 15 5 20 75.0% 0 the medication? Annual TB Screening: Was the patient screened for TB within the 9.003 30 0 30 100.0% 0 last year? Were all patients offered an influenza vaccination for the most 9.004 25 0 25 100.0% 0 recent influenza season? All patients from the age of 50 - 75: Was the patient offered 9.005 24 1 25 96.0% 0 colorectal cancer screening? Female patients from the age of 50 through the age of 74: Was the 9.006 Not Applicable patient offered a mammogram in compliance with policy? Female patients from the age of 21 through the age of 65: Was 9.007 Not Applicable patient offered a pap smear in compliance with policy? Are required immunizations being offered for chronic care 9.008 13 1 14 92.9% 11 patients? Are patients at the highest risk of coccidioidomycosis (valley 9.009 6 0 6 100.0% 0 fever) infection transferred out of the facility in a timely manner? Overall percentage: 92.7% 10–Quality of Nursing Performance This indicator is evaluated only by case review clinicians. There is no compliance testing component. 11–Quality of Provider Performance This indicator is evaluated only by case review clinicians. There is no compliance testing component. California City Correctional Facility, Cycle 5 Medical Inspection Page 66 Office of the Inspector General State of California 12–Reception Center Arrivals The institution has no reception center, so this indicator is not applicable. 13–Specialized Medical Housing The institution has no specialized medical housing, so this indicator is not applicable. California City Correctional Facility, Cycle 5 Medical Inspection Page 67 Office of the Inspector General State of California Scored Answers Yes Reference + 14–Specialty Services Number Yes No No Yes % N/A Did the patient receive the high priority specialty service within 14.001 14 calendar days of the primary care provider order or the 15 0 15 100.0% 0 Physician Request for Service? Did the primary care provider review the high priority specialty 14.002 15 0 15 100.0% 0 service consultant report within the required time frame? Did the patient receive the routine specialty service within 90 14.003 calendar days of the primary care provider order or Physician 15 0 15 100.0% 0 Request for Service? Did the primary care provider review the routine specialty service 14.004 14 1 15 93.3% 0 consultant report within the required time frame? For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at 14.005 17 3 20 85.0% 0 the sending institution, was the appointment scheduled at the receiving institution within the required time frames? Did the institution deny the primary care provider request for 14.006 4 0 4 100.0% 0 specialty services within required time frames? Following the denial of a request for specialty services, was the 14.007 4 0 4 100.0% 0 patient informed of the denial within the required time frame? Overall percentage: 96.9% California City Correctional Facility, Cycle 5 Medical Inspection Page 68 Office of the Inspector General State of California Scored Answers Yes Reference 15–Administrative Operations + Number Yes No No Yes % N/A Did the institution promptly process inmate medical appeals 15.001 10 2 12 83.3% 0 during the most recent 12 months? Does the institution follow adverse / sentinel event reporting 15.002 Not Applicable requirements? Did the institution Quality Management Committee (QMC) meet at least monthly to evaluate program performance, and did the 15.003 6 0 6 100.0% 0 QMC take action when improvement opportunities were identified? Did the institution’s Quality Management Committee (QMC) or 15.004 other forum take steps to ensure the accuracy of its Dashboard 1 0 1 100.0% 0 data reporting? Does the Emergency Medical Response Review Committee 15.005 perform timely incident package reviews that include the use of 1 11 12 8.3% 0 required review documents? For institutions with licensed care facilities: Does the Local Governing Body (LGB), or its equivalent, meet quarterly and 15.006 Not Applicable exercise its overall responsibilities for the quality management of patient health care? Did the institution complete a medical emergency response drill 15.101 for each watch and include participation of health care and 3 0 3 100.0% 0 custody staff during the most recent full quarter? Did the institution’s second level medical appeal response address 15.102 10 0 10 100.0% 0 all of the patient’s appealed issues? Did the institution’s medical staff review and submit the initial 15.103 2 0 2 100.0% 0 inmate death report to the Death Review Unit in a timely manner? Does the institution’s Supervising Registered Nurse conduct 15.104 0 5 5 0.0% 0 periodic reviews of nursing staff? Are nursing staff who administer medications current on their 15.105 10 0 10 100.0% 0 clinical competency validation? 15.106 Are structured clinical performance appraisals completed timely? 5 1 6 83.3% 0 15.107 Do all providers maintain a current medical license? 7 0 7 100.0% 0 Are staff current with required medical emergency response 15.108 2 0 2 100.0% 1 certifications? Are nursing staff and the Pharmacist-in-Charge current with their professional licenses and certifications, and is the pharmacy 15.109 6 0 6 100.0% 1 licensed as a correctional pharmacy by the California State Board of Pharmacy? California City Correctional Facility, Cycle 5 Medical Inspection Page 69 Office of the Inspector General State of California Scored Answers Yes Reference 15–Administrative Operations + Number Yes No No Yes % N/A Do the institution’s pharmacy and authorized providers who 15.110 prescribe controlled substances maintain current Drug 1 0 1 100.0% 0 Enforcement Agency (DEA) registrations? 15.111 Are nursing staff current with required new employee orientation? 1 0 1 100.0% 0 Overall percentage: 85.0% California City Correctional Facility, Cycle 5 Medical Inspection Page 70 Office of the Inspector General State of California A B — C D PPENDIX LINICAL ATA Table B-1: CAC Sample Sets Total Death Review/Sentinel Events 2 Diabetes 4 Emergency Services – CPR 4 Emergency Services – Non-CPR 2 High Risk 2 Hospitalization 6 Intra-System Transfers in 3 Intra-System Transfers out 3 RN Sick Call 12 Specialty Services 4 42 California City Correctional Facility, Cycle 5 Medical Inspection Page 71 Office of the Inspector General State of California Table B-2: CAC Chronic Care Diagnoses Total Anemia 3 Arthritis/Degenerative Joint Disease 6 Asthma 6 COPD 2 Cancer 1 Cardiovascular Disease 2 Chronic Kidney Disease 3 Chronic Pain 9 Diabetes 15 Gastroesophageal Reflux Disease 9 Hepatitis C 15 Hyperlipidemia 14 Hypertension 21 Seizure Disorder 2 Thyroid Disease 2 110 California City Correctional Facility, Cycle 5 Medical Inspection Page 72 Office of the Inspector General State of California Table B-3: CAC Event – Program Total 84 Diagnostic Services 35 Emergency Care 48 Hospitalization 20 Intra-System Transfers in 8 Intra-System Transfers out 359 Outpatient Care 110 Specialty Services 664 California City Correctional Facility, Cycle 5 Medical Inspection Page 73 Office of the Inspector General State of California Table B-4: CAC Review Sample Summary Total MD Reviews Detailed 20 MD Reviews Focused 0 RN Reviews Detailed 13 RN Reviews Focused 21 Total Reviews 54 Total Unique Cases 42 Overlapping Reviews (MD & RN) 12 California City Correctional Facility, Cycle 5 Medical Inspection Page 74 Office of the Inspector General State of California A C — C S M PPENDIX OMPLIANCE AMPLING ETHODOLOGY California City Correctional Facility (CAC) Sample Category Quality (number of Indicator samples) Data Source Filters Access to Care MIT 1.001 Chronic Care Patients Master Registry • Chronic care conditions (at least one condition per patient—any risk level) (25) • Randomize MIT 1.002 Nursing Referrals OIG Q: 6.001 • See Intra-system Transfers (25) MITs 1.003-006 Nursing Sick Call MedSATS • Clinic (each clinic tested) (10 per clinic) • Appointment date (2–9 months) (30) • Randomize MIT 1.007 Returns from OIG Q: 4.007 • See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (19) MIT 1.008 Specialty Services OIG Q: 14.001 & • See Specialty Services Follow-up 14.003 (30) MIT 1.101 Availability of Health OIG onsite • Randomly select one housing unit from each yard Care Services review Request Forms (6) Diagnostic Services MITs 2.001–003 Radiology Radiology Logs • Appointment date (90 days–9 months) • Randomize (10) • Abnormal MITs 2.004–006 Laboratory Quest • Appt. date (90 days–9 months) • Order name (CBC or CMPs only) • Randomize (10) • Abnormal MITs 2.007–009 Pathology InterQual • Appt. date (90 days–9 months) • Service (pathology related) (10) • Randomize California City Correctional Facility, Cycle 5 Medical Inspection Page 75 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 (5) 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: 4.007 • Community hospital discharge documents (19) • First 20 IPs selected MIT 4.005 OIG Q: 7.001 • MARs (0) • First 20 IPs selected MIT 4.006 Documents for • Any misfiled or mislabeled document identified (2) any tested inmate during OIG compliance review (24 or more = No) MIT 4.007 Returns From Inpatient claims • Date (2–8 months) Community Hospital data • Most recent 6 months provided (within date range) • Rx count • Discharge date • Randomize (each month individually) • First 5 patients from each of the 6 months (if not 5 in a month, supplement from another, as needed) (19) Health Care Environment MIT 5.101-105 Clinical Areas OIG inspector • Identify and inspect all onsite clinical areas. MIT 5.107–111 (7) onsite review Inter- and Intra-System Transfers MIT 6.001-003 Intra-System SOMS • Arrival date (3–9 months) Transfers • Arrived from (another CDCR facility) • Rx count • Randomize (25) MIT 6.004 Specialty Services MedSATS • Date of transfer (3–9 months) Send-Outs • Randomize (5) MIT 6.101 Transfers Out OIG inspector • R&R IP transfers with medication (10) onsite review California City Correctional Facility, Cycle 5 Medical Inspection Page 76 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Pharmacy and Medication Management MIT 7.001 Chronic Care OIG Q: 1.001 See Access to Care Medication • At least one condition per patient—any risk level • Randomize (25) MIT 7.002 New Medication Master Registry • Rx count Orders • Randomize (25) • Ensure no duplication of IPs tested in MIT 7.001 MIT 7.003 Returns from OIG Q: 4.007 • See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (19) MIT 7.004 RC Arrivals – OIG Q: 12.001 • See Reception Center Arrivals Medication Orders (N/A at this institution) or MIT 7.005 Intra-Facility Moves MAPIP transfer • Date of transfer (2–8 months) data • To location/from location (yard to yard and to/from ASU) • Remove any to/from MHCB • NA/DOT meds (and risk level) (25) • Randomize MIT 7.006 En Route SOMS • Date of transfer (2–8 months) • Sending institution (another CDCR facility) • Randomize (0) • NA/DOT meds MITs 7.101-103 Medication Storage OIG inspector • Identify and inspect clinical & med line areas that Areas onsite review store medications (varies by test) MITs 7.104–106 Medication OIG inspector • Identify and inspect onsite clinical areas that Preparation and onsite review prepare and administer medications Administration Areas (varies by test) MITs 7.107-110 Pharmacy OIG inspector • Identify & inspect all onsite pharmacies (1) onsite review MIT 7.111 Medication Error Monthly • All monthly statistic reports with Level 4 or higher Reporting medication error • Select a total of 5 months (25) reports MIT 7.999 Isolation Unit KOP Onsite active • KOP rescue inhalers & nitroglycerin medications Medications medication for IPs housed in isolation units (4) listing Prenatal and Post-Delivery Services MIT 8.001-007 Recent Deliveries OB Roster • Delivery date (2–12 months) (N/A at this • Most recent deliveries (within date range) institution) Pregnant Arrivals OB Roster • Arrival date (2–12 months) (N/A at this • Earliest arrivals (within date range) institution) California City Correctional Facility, Cycle 5 Medical Inspection Page 77 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) (20) • Randomize MIT 9.003 TB Evaluation, SOMS • Arrival date (at least 1 year prior to inspection) Annual Screening • Birth Month (30) • Randomize MIT 9.004 Influenza SOMS • Arrival date (at least 1 year prior to inspection) Vaccinations • Randomize (25) • Filter out IPs tested in MIT 9.008 MIT 9.005 Colorectal Cancer SOMS • Arrival date (at least 1 year prior to inspection) Screening • Date of birth (51 or older) (25) • Randomize MIT 9.006 Mammogram SOMS • Arrival date (at least 2 yrs prior to inspection) (N/A at this • Date of birth (age 52–74) institution) • Randomize MIT 9.007 Pap Smear SOMS • Arrival date (at least three yrs prior to inspection) (N/A at this • Date of birth (age 24–53) institution) • Randomize MIT 9.008 Chronic Care OIG Q: 1.001 • Chronic care conditions (at least 1 condition per Vaccinations IP—any risk level) • Randomize (25) • Condition must require vaccination(s) MIT 9.009 Valley Fever Cocci transfer • Reports from past 2–8 months (number will vary) status report • Institution (6) • Ineligibility date (60 days prior to inspection date) • All California City Correctional Facility, Cycle 5 Medical Inspection Page 78 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Reception Center Arrivals MITs 12.001–008 RC SOMS • Arrival date (2–8 months) (N/A at this • Arrived from (county jail, return from parole, etc.) institution) • Randomize Specialized Medical Housing MITs 13.001–004 CTC CADDIS • Admit date (1–6 months) • Type of stay (no MH beds) • Length of stay (minimum of 5 days) (N/A at this • Randomize institution) MIT 13.101 Call Buttons OIG inspector • Review by location CTC onsite review (N/A at this institution) Specialty Services MITs 14.001–002 High-Priority MedSATS • Approval date (3–9 months) (15) • Randomize MITs 14.003–004 Routine MedSATS • Approval date (3–9 months) • Remove optometry, physical therapy or podiatry (15) • Randomize MIT 14.005 Specialty Services MedSATS • Arrived from (other CDCR institution) Arrivals • Date of transfer (3–9 months) (20) • Randomize MIT 14.006-007 Denials InterQual • Review date (3–9 months) (1) • Randomize IUMC/MAR • Meeting date (9 months) Meeting Minutes • Denial upheld (3) • Randomize California City Correctional Facility, Cycle 5 Medical Inspection Page 79 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.001 Medical Appeals Monthly medical • Medical appeals (12 months) (all) appeals reports MIT 15.002 Adverse/Sentinel Adverse/sentinel • Adverse/sentinel events (2–8 months) Events events report (0) MITs 15.003–004 QMC Meetings Quality • Meeting minutes (12 months) Management Committee (6) meeting minutes MIT 15.005 EMRRC EMRRC meeting • Monthly meeting minutes (6 months) (12) minutes MIT 15.006 LGB LGB meeting • Quarterly meeting minutes (12 months) (0) minutes MIT 15.101 Medical Emergency Onsite summary • Most recent full quarter Response Drills reports & • Each watch documentation (3) for ER drills MIT 15.102 2nd Level Medical Onsite list of • Medical appeals denied (6 months) Appeals appeals/closed (10) appeals files MIT 15.103 Death Reports Institution-list of • Most recent 10 deaths deaths in prior 12 • Initial death reports (2) months MIT 15.104 RN Review Onsite supervisor • RNs who worked in clinic or emergency setting Evaluations periodic RN six or more days in sampled month reviews • Randomize (5) MIT 15.105 Nursing Staff Onsite nursing • On duty one or more years Validations education files • Nurse administers medications (10) • Randomize MIT 15.106 Provider Annual Onsite • All required performance evaluation documents Evaluation Packets provider (6) evaluation files MIT 15.107 Provider licenses Current provider • Review all listing (at start of (7) inspection) MIT 15.108 Medical Emergency Onsite • All staff Response certification o Providers (ACLS) Certifications tracking logs o Nursing (BLS/CPR) (all) • Custody (CPR/BLS) MIT 15.109 Nursing staff and Onsite tracking • All required licenses and certifications Pharmacist in system, logs, or Charge Professional employee files Licenses and Certifications (all) California City Correctional Facility, Cycle 5 Medical Inspection Page 80 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.110 Pharmacy and Onsite listing of • All DEA registrations Providers’ Drug provider DEA Enforcement Agency registration #s & (DEA) Registrations pharmacy registration (all) document MIT 15.111 Nursing Staff New Nursing staff • New employees (hired within last 12 months) Employee training logs • Orientations (all) MIT 15.998 Death Review OIG summary • Between 35 business days & 12 months prior Committee log - deaths • CCHCS death reviews (2) California City Correctional Facility, Cycle 5 Medical Inspection Page 81 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 5 Medical Inspection Page 82 Office of the Inspector General State of California