Calipatria State Prison Medical Inspection Report Cycle 5

Roy W. Wesley Office of the Inspector General Inspector General Calipatria State Prison Medical Inspection Results Cycle 5 October 2018 Fairness Integrity Respect Medical Inspection Unit Page 1 Office of the Inspe ct or GSeneeral rvice TransparenStatce ofy Cal ifornia Office of the Inspector General CALIPATRIA STATE PRISON Medical Inspection Results Cycle 5 Roy W. Wesley Inspector General Bryan B. Beyer Chief Deputy Inspector General Shaun R. Spillane Public Information Officer October 2018 T C ABLE OF ONTENTS Foreword ............................................................................................................................................... i Executive Summary ............................................................................................................................ iii Overall Rating: Adequate ................................................................................................................ iii Expert Clinician Case Review Results....................................................................................... v Compliance Testing Results...................................................................................................... vi Recommendations .................................................................................................................... vii Population-Based Metrics ....................................................................................................... viii Introduction .......................................................................................................................................... 1 About the Institution ......................................................................................................................... 1 Objectives, Scope, and Methodology .................................................................................................. 5 Case Reviews .................................................................................................................................... 6 Patient Selection for Retrospective Case Reviews .................................................................... 7 Benefits and Limitations of Targeted Subpopulation Review ................................................... 8 Case Review Sampling Methodology ........................................................................................ 9 Breadth of Case Reviews ........................................................................................................ 10 Case Review Testing Methodology ......................................................................................... 11 Compliance Testing ........................................................................................................................ 14 Sampling Methods for Conducting Compliance Testing ......................................................... 14 Scoring of Compliance Testing Results ................................................................................... 14 Overall Quality Indicator Rating for Case Reviews and Compliance Testing ............................... 14 Population-Based Metrics............................................................................................................... 15 Medical Inspection Results ................................................................................................................ 16 Access to Care ................................................................................................................. 18 Case Review Results............................................................................................................. 18 Compliance Testing Results ................................................................................................. 21 Diagnostic Services.......................................................................................................... 23 Case Review Results............................................................................................................. 23 Compliance Testing Results ................................................................................................. 24 Emergency Services ......................................................................................................... 25 Case Review Results............................................................................................................. 25 Health Information Management..................................................................................... 28 Case Review Results............................................................................................................. 28 Compliance Testing Results ................................................................................................. 29 Health Care Environment ................................................................................................ 31 Compliance Testing Results ................................................................................................. 31 Inter- and Intra-System Transfers.................................................................................... 34 Case Review Results............................................................................................................. 34 Compliance Testing Results ................................................................................................. 37 Pharmacy and Medication Management ......................................................................... 38 Case Review Results............................................................................................................. 38 Compliance Testing Results ................................................................................................. 39 Prenatal and Post-Delivery Services .............................................................................. 43 Calipatria State Prison, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California Preventive Services .......................................................................................................... 44 Compliance Testing Results ................................................................................................. 44 Quality of Nursing Performance .................................................................................... 46 Case Review Results............................................................................................................. 46 Quality of Provider Performance .................................................................................. 51 Case Review Results............................................................................................................. 51 Reception Center Arrivals .............................................................................................. 54 Specialized Medical Housing ......................................................................................... 55 Case Review Results............................................................................................................. 55 Compliance Testing Results ................................................................................................. 57 Specialty Services ........................................................................................................... 58 Case Review Results............................................................................................................. 58 Compliance Testing Results ................................................................................................. 59 Administrative Operations (Secondary)......................................................................... 61 Compliance Testing Results ................................................................................................. 61 Recommendations .............................................................................................................................. 64 Population-Based Metrics .................................................................................................................. 65 Appendix A — Compliance Test Results .......................................................................................... 68 Appendix B — Clinical Data ............................................................................................................. 81 Appendix C — Compliance Sampling Methodology ........................................................................ 85 California Correctional Health Care Services’ Response .................................................................. 92 Calipatria State Prison, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California L T F IST OF ABLES AND IGURES CAL Executive Summary Table ........................................................................................................ iv CAL Health Care Staffing Resources as of October 2017 .................................................................. 2 CAL Master Registry Data as of October 23, 2017 ............................................................................ 3 Exhibit 1. Case Review Definitions .................................................................................................... 6 Chart 1. Case Review Sample Selection ........................................................................................... 10 Chart 2. Case Review Testing and Deficiencies ............................................................................... 12 Chart 3. Inspection Indicator Review Distribution............................................................................ 16 CAL Results Compared to State and National HEDIS Scores.......................................................... 67 Table B-1: CAL Sample Sets ............................................................................................................ 81 Table B-2: CAL Chronic Care Diagnoses ......................................................................................... 82 Table B-3: CAL – Event Program .............. ...................................................................................... 83 Table B-4: CAL Review Sample Summary ...................................................................................... 84 Calipatria State Prison, Cycle 5 Medical Inspection List of Tables and Figures Office of the Inspector General State of California This page intentionally left blank. Calipatria State Prison, Cycle 5 Medical Inspection Office of the Inspector General State of California F OREWORD Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), the OIG conducts a comprehensive inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG explicitly makes no determination regarding the constitutionality of care in the prison setting. That determination is left to the Receiver and the federal court. The assessment of care by the OIG is just one factor in the court’s determination whether care in the prisons meets constitutional standards. The OIG’s inspections are mandated by the Penal Code and not aimed at specifically resolving the court’s questions on constitutional care. To the degree that they provide another factor for the court to consider, the OIG is pleased to provide added value to the taxpayers of California. In Cycle 5, for the first time, the OIG will be inspecting institutions delegated back to CDCR from the Receivership. There is no difference in the standards used for assessment of a delegated institution versus an institution not yet delegated. Calipatria State Prison was delegated back to CDCR by the Receiver in December 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. Calipatria State Prison, Cycle 5 Medical Inspection Page i Office of the Inspector General State of California This page intentionally left blank. Calipatria State Prison, Cycle 5 Medical Inspection Page ii Office of the Inspector General State of California E S XECUTIVE UMMARY The OIG completed the Cycle 5 medical inspection of Calipatria State Prison (CAL) in August 2018. The vast majority of our OVERALL RATING: inspection findings were based on CAL’s health care delivery between January 2017 and January 2018. Our policy compliance Adequate inspectors performed an onsite inspection in October 2017. After reviewing the institution’s health care delivery, our case review clinicians performed an onsite inspection in May 2018. Our clinician team, consisting of expert physicians and nurse consultants, reviewed cases (patient medical records) and interpreted our policy compliance results to determine the quality of health care the institution provided. Our compliance team, consisting of registered nurses, monitored the institution’s compliance with its medical policies by answering a predetermined set of policy compliance questions. Our clinician team reviewed 49 cases that contained 724 patient-related events. Our compliance team tested 86 policy questions by observing CAL’s processes and examining 382 patient records and 1,022 data points. We distilled the results from both the case review and compliance testing into 13 health care indicators, and have listed the individual indicators and ratings applicable for this institution in the CAL Executive Summary Table on the following page. Our experts made a considered and measured opinion that the overall quality of health care at CAL was adequate. Calipatria State Prison, Cycle 5 Medical Inspection Page iii Office of the Inspector General State of California CAL Executive Summary Table Cycle 5 Cycle 4 Case Review Compliance Inspection Indicators Overall Overall Rating Rating Rating Rating 1—Access to Care Adequate Inadequate Inadequate Adequate 2—Diagnostic Services Proficient Adequate Adequate Proficient 3—Emergency Services Adequate Not Applicable Adequate Inadequate 4—Health Information Proficient Proficient Proficient Adequate Management 5—Health Care Environment Not Applicable Inadequate Inadequate Adequate 6—Inter- and Intra-System Inadequate Inadequate Inadequate Adequate Transfers 7—Pharmacy and Medication I Adequate Inadequate Adequate n Inadequate Management a 8—Prenatal and Post-Delivery Not Applicable Not Applicable Not Applicable Not Applicable Services 9—Preventive Services Not Applicable Proficient Proficient Inadequate 10—Quality of Nursing Adequate Not Applicable Adequate Adequate Performance 11—Quality of Provider Proficient Not Applicable Proficient Adequate Performance 12—Reception Center Arrivals Not Applicable Not Applicable Not Applicable Not Applicable 13—Specialized Medical Housing Adequate Proficient Adequate Proficient 14—Specialty Services Proficient Proficient Proficient Adequate 15—Administrative Operations Not Applicable Adequate Adequate Adequate* (Secondary) *In Cycle 4, there were two secondary (administrative) indicators. This score reflects the average of those two scores. Calipatria State Prison, Cycle 5 Medical Inspection Page iv Office of the Inspector General State of California Expert Clinician Case Review Results Our expert clinicians reviewed cases of patients with many medical needs and included a review of 724 patient care events.1 The vast majority of our case review covered the period between July 2017 and January 2018. As depicted on the executive summary table on page iv, clinicians rated 10 of the 13 indicators applicable to CAL. Of those ten applicable indicators, we rated four proficient, five adequate, and one inadequate. When determining the overall adequacy of care, we paid particular attention to the clinical nursing and provider quality indicators, as adequate health care staff can sometimes overcome suboptimal compliance (i.e., performance with processes and programs). However, the opposite is not true; inadequate health care staff cannot provide adequate care, even though the established processes and programs may be adequate. We identified inadequate medical care based on the risk of significant harm to the patient, not the actual outcome. Program Strengths — Clinical • Laboratory and diagnostic tests were completed reliably, and the test reports were retrieved and scanned into the medical record timely. • CAL consistently processed health information correctly. We found that medical staff had reliable access to their patients’ health care information. • CAL providers performed well across multiple aspects of patient care, including emergency care, chronic care, hospital returns, and specialized medical housing. The providers’ good performance compensated for the questionable care the nurses gave when patients transferred into the institution and to those in the outpatient housing unit (OHU). • CAL’s Specialty Services indicator was rated proficient since the staff completed most specialty appointments timely, and retrieved, labeled, and scanned specialty reports properly. Providers timely reviewed and addressed the recommendations. Nurses provided good assessments, reviewed specialists’ findings and recommendations, and communicated those results to providers. Program Weaknesses — Clinical • CAL experienced significant difficulty when patients transferred into the institution. Medical staff’s errors resulted in both poor medication continuity, and delayed provider and specialty appointments. 1 Each OIG clinician team consists of a board-certified physician and a registered nurse consultant with experience in correctional and community medical settings. Calipatria State Prison, Cycle 5 Medical Inspection Page v Office of the Inspector General State of California • OHU nurses struggled with making good nursing assessments. We found a deficiency pattern in which the OHU nurses ignored their patients’ complaints. Compliance Testing Results Of the 13 health care indicators applicable to CAL, 10 were evaluated by compliance inspectors2; of these, 4 were proficient, 2 were adequate, and 4 were inadequate. The vast majority of our compliance testing concerned medical care that occurred between January 2017 and October 2017. There were 86 individual compliance questions within those ten indicators, generating 1,022 data points, that tested CAL’s compliance with California Correctional Health Care Services (CCHCS) policies and procedures.3 Those 86 questions are detailed in Appendix A — Compliance Test Results. Program Strengths — Compliance The following are some of CAL’s strengths based on its compliance scores on individual questions in all the health care indicators: • Nursing staff at CAL timely completed the initial patient assessments upon admission. Also, providers timely completed patients’ written history and physical examinations upon admission, and completed additional patient evaluations at required intervals. • CAL’s Health Information Management (HIM) staff timely scanned dictated and non- dictated provider progress notes, initial health screening forms, patient health care services request forms, and specialty service consultant reports. • The institution retrieved high-priority and routine specialty service reports timely, and providers reviewed high-priority specialists’ reports within required time frames. • CAL timely offered its patients preventive services such as colorectal cancer screenings and immunizations. CAL also performed extremely well with performing tuberculosis (TB) screenings during patients’ birth months. Program Weaknesses — Compliance The following are some of the weaknesses identified by CAL’s compliance scores on individual questions in all the health care indicators: 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 expert clinical guidance for testing compliance in certain areas where CCHCS policies and procedures did not specifically address an issue. Calipatria State Prison, Cycle 5 Medical Inspection Page vi Office of the Inspector General State of California • Patients did not always receive their chronic care follow-up appointments or their high-priority or routine specialty service follow-up appointments within required time frames. • Medical clinics at CAL did not meet requirements for essential core medical equipment and supplies. Almost all clinics that we tested were missing properly calibrated medical equipment and medical supplies required to provide standard medical care. • Several medication lines did not adequately employ security controls for narcotic medications. In addition, CAL did not store non-narcotic medications appropriately. • Medication nurses did not properly demonstrate appropriate administrative controls and protocols in medication line areas. In addition, medication nurses did not maintain proper hand hygiene while distributing medications to patients. Recommendations The OIG recommends the following: • The chief nurse executive (CNE) should implement training for the triage and treatment area (TTA) and first medical responder nurses regarding documentation, timeline accuracy, and proper nursing assessment due to problems the institution’s nurses demonstrated in the emergency services case reviews. Specifically, the CNE should choose the nursing assessments of patients’ gastrointestinal conditions as a target for improved care. • The CNE should implement a quality improvement program to evaluate and monitor the various transfer-in processes due to errors identified during our case reviews. The CNE should focus on improving the receiving nurses’ performance and ensuring prompt provider appointments. The CNE should audit and track newly arrived patients’ pending diagnostic tests and specialty referrals to ensure that CAL provides those needed services without incurring lapses in care. • The CNE should improve its methods for evaluating the quality of care provided by nurses who assess sick call patients and those who assess new patients transferring in from other facilities due to the various concerns we identified in these areas during our inspection. • The CNE should revamp the way the institution appraises the performance of the OHU nurses. Nursing care was substandard in the majority of OHU cases we reviewed. • CCHCS should examine CAL’s well-run morning huddle process and consider the feasibility of replicating it statewide. Calipatria State Prison, Cycle 5 Medical Inspection Page vii Office of the Inspector General State of California Population-Based Metrics In general, CAL performed comparably to other health plans as measured by population-based metrics. In comprehensive diabetes care, CAL outperformed state and national health care plans in three of five diabetic measures. However, CAL scored lower than three health care plans for diabetic eye examinations and two for blood pressure control. Comparative data for immunizations was only fully available for the VA and partially available for Kaiser, commercial plans, and Medicare. Regarding administering influenza vaccinations to younger adults, CAL scored lower than all health care plans except commercial plans and Medicaid. When administering influenza vaccinations to older adults, CAL scored 100 percent, outperforming Medicare and the VA, the two health care plans with reported data for this measure. Regarding administering pneumococcal vaccines to older adults, CAL also scored higher than all health care plans. CAL may improve its scores for administering influenza vaccinations to younger adults by reducing patient refusals through educating patients on the benefits of these preventive services. Calipatria State Prison, Cycle 5 Medical Inspection Page viii Office of the Inspector General State of California I NTRODUCTION Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), and at the request of the federal Receiver, the OIG developed a comprehensive medical inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG conducted a clinical case review and a compliance inspection, ensuring a thorough, end-to-end assessment of medical care within CDCR. Calipatria State Prison (CAL) was the 30th 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 Calipatria State Prison (CAL) is located in the city of Calipatria, in Imperial County. The institution opened in 1992. Its primary mission is to protect the public by providing safe custody, quality health care, and the appropriate supervision of sentenced offenders. The institution runs eight medical clinics and treats patients needing urgent or emergent care in its triage and treatment area (TTA). CAL also treats patients who require assistance with the activities of daily living, but who do not require a higher level of inpatient care, in the institution’s outpatient housing unit (OHU). CAL has been designated by CCHCS as a “basic” care institution. Basic institutions are located in rural areas, away from tertiary care centers and specialty care providers whose services would likely be used frequently by higher-risk patients. Basic institutions have the capability to provide only limited specialty medical services and consultations for a generally healthy patient population. On August 5, 2016, 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 reported by the institution, CAL had 6.9 vacancies among nursing staff, 3 vacancies for nursing supervisors, and 3 vacancies for primary care providers. Six medical staff members were on extended leave at CAL. The institution also employed ten registry clinicians: two providers and eight nurses. Calipatria State Prison, Cycle 5 Medical Inspection Page 1 Office of the Inspector General State of California CAL Health Care Staffing Resources as of October 2017 Primary Care Nursing Management Nursing Staff Providers Supervisors Description Number % Number % Number % Number % Filled Positions 5 100% 3.5 54% 6.5 68% 56.7 89% Vacancies 0 0% 3 46% 3 32% 6.9 11% Total Authorized 5 100% 6.5 100% 9.5 100% 63.6 100% Positions CAL Health Care Positions Primary Care Nursing Management Nursing Staff Providers Supervisors Recent Hires (within 12 4 80% 0 0% 0 0% 11 19% months) Staff Utilized from 0 0% 2 57% 0 0% 8 14% Registry Limited Redirected Productivity Staff (to 0 0% 0 0% 0 0% 0 0% Non-Patient Care Areas) Staff on Extended 0 0% 1 29% 2 31% 3 5% Leave Full Productivity 1 20% .5 14% 4.5 69% 34.7 61% Total Filled Positions 5 100% 3.5 100% 6.5 100% 56.7 100% Note: CAL Health Care Staffing Resources data was not validated by the OIG. As of October 23, 2017, the Master Registry for CAL showed that the institution had a total population of 3,738. Within that total population, 0.1 percent was designated as high medical risk, Priority 1 (High 1), and 0.7 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 next page illustrates the breakdown of the institution’s medical risk levels at the start of the OIG medical inspection. Calipatria State Prison, Cycle 5 Medical Inspection Page 2 Office of the Inspector General State of California CAL Master Registry Data as of October 23, 2017 Medical Risk Level Number of Patients Percentage High 1 5 0.1% High 2 26 0.7% Medium 586 15.7% Low 3,121 83.5% Total 3,738 100.0% Calipatria State Prison, Cycle 5 Medical Inspection Page 3 Office of the Inspector General State of California This page intentionally left blank. Calipatria State Prison, Cycle 5 Medical Inspection Page 4 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 CAL 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. Calipatria State Prison, Cycle 5 Medical Inspection Page 5 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. Calipatria State Prison, Cycle 5 Medical Inspection Page 6 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-utilization patients consume medical services at a disproportionate rate. Between October 2011 and March 2012, nine percent of the total statewide adult inmate population was classified as high-risk and accounted for more than half of CCHCS’s pharmaceutical, specialty, community hospital, and emergency costs.4 This disproportionate utilization of health care resources was consistent with that observed in the general U.S. population. Based on the 2010 Medical Expenditure Panel Survey data, 5 percent of the U.S. population accounted for 50 percent of health care costs.5 By May 2018, the proportion of high-risk patients increased to 13.6 percent of the statewide adult inmate population.6 2. Selecting high-utilizing patients 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- and medium-risk patients for detailed case review, the OIG clinical experts made the following three assumptions: 4 California Correctional Health Care Services (CCHCS) Quality Management Section, High-Risk Patient Performance Report – Appropriate Placement in the CCHCS Primary Care Environment, August 2012; https://cchcs.ca.gov/wp- content/uploads/sites/60/2017/08/T21_20120915_Appendix6.pdf (accessed 9-10-18). 5 S.B. Cohen, The Concentration and Persistence in the Level of Health Expenditures Over Time: Estimates for the U.S. Population, 2009–2010 (Rockville, MD: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, 2012); https://meps.ahrq.gov/data_files/publications/st392/stat392.shtml (accessed 9-10-18). 6 CCHCS Public Dashboard, Statewide, May 2018; https://cchcs.ca.gov/wp-content/uploads/sites/60/2018/08/ Public-Dashboard-2018-05.pdf (accessed 9-10-18). Calipatria State Prison, Cycle 5 Medical Inspection Page 7 Office of the Inspector General State of California 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, adverse events (unexpected occurrences involving death or serious injury, or risk thereof), and hospitalizations are more likely to comprise high-risk patients. 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 Calipatria State Prison, Cycle 5 Medical Inspection Page 8 Office of the Inspector General State of California prison. However, if these same high-risk patients needing monitoring, medications, and referrals are not getting those needed services, it is likely that the institution is not providing appropriate diabetic services. Case Review Sampling Methodology Using a pre-defined case review sampling algorithm, OIG analysts apply various filters to each institution’s patient population. The various filters include medical risk status, number of prescriptions, number of specialty appointments, number of clinic appointments, and other health-related data. The OIG uses these filters to narrow down the population to those patients with the highest utilization of medical resources (see Chart 1, next page). To prevent selection bias, the OIG ensures that the same clinicians who perform the case reviews do not participate in the sample selection process. Calipatria State Prison, Cycle 5 Medical Inspection Page 9 Office of the Inspector General State of California Chart 1. Case Review Sample Selection The OIG’s case sample sizes matched those of other qualitative research. The empirical findings, supported by expert statistical consultants, showed adequate conclusions after 10 to 15 cases had undergone comprehensive, or detailed, clinician review. In qualitative statistics, this phenomenon is known as “saturation.” The OIG found the Cycle 4 medical inspection sample size of 30 for detailed physician reviews far exceeded the saturation point necessary for an adequate qualitative review. At the end of Cycle 4 inspections, the OIG re-analyzed the case review results using half the number of cases; there were no significant differences in the ratings. To improve inspection efficiency while preserving the quality of the inspection, the OIG reduced the number of the samples for Cycle 5 medical inspections to the current levels. For most basic institutions, the OIG samples 20 cases for detailed physician review. For intermediate institutions and several basic institutions with larger high-risk populations, the OIG samples 25 cases. For California Health Care Facility, the OIG samples 30 cases for detailed physician review. Breadth of Case Reviews As indicated in Appendix B, Table B-1: CAL Sample Sets, the OIG clinicians evaluated medical records for 49 unique cases. Appendix B, Table B-4: CAL Case Review Sample Summary clarifies that both nurses and physicians reviewed 14 of those cases, for 63 case reviews in total. Calipatria State Prison, Cycle 5 Medical Inspection Page 10 Office of the Inspector General State of California Physicians performed detailed reviews of 20 cases, and nurses performed detailed reviews of 14 cases, totaling 34 detailed case reviews. Nurses also performed a focused review of an additional 29 cases. These reviews generated 724 case review events (Appendix B, Table B-3: CAL Event – Program). While the sample method specifically pulled only 3 chronic care cases, i.e., 3 diabetes cases (Appendix B, Table B-1: CAL Sample Sets), the 49 unique cases sampled included 11 chronic care diagnoses, including 3 additional cases with diabetes for a total of 6 cases (Appendix B, Table B-2: CAL Chronic Care Diagnoses). The OIG’s sample selection tool allowed evaluation of many chronic care programs because the complex and high-risk patients selected from the different categories often had multiple medical problems. While the OIG did not evaluate every chronic disease or health care staff member, the OIG did assess for adequacy the overall operation of the institution’s system and staff. Case Review Testing Methodology A physician, a nurse consultant, or both clinician inspectors review each case. The OIG clinician inspector can perform one of two different types of case review: detailed or focused (see Exhibit 1, page 5, and Chart 1, page 8). As the OIG clinician inspector reviews the medical record for each sample, the inspector records pertinent interactions between the patient and the health care system. These interactions are also known as case review events. When an OIG clinician inspector identifies a medical error, the inspector also records these errors as case review deficiencies. If a deficiency is of such magnitude that it caused, or had the potential to cause, serious patient harm, then the OIG clinician records it as an adverse deficiency (see Chart 2, next page). Calipatria State Prison, Cycle 5 Medical Inspection Page 11 Office of the Inspector General State of California Chart 2. Case Review Testing and Deficiencies When the OIG clinician inspectors have reviewed all cases, they analyze the deficiencies. OIG inspectors search for similar types of deficiencies to determine if a repeating pattern of errors exists. 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. Calipatria State Prison, Cycle 5 Medical Inspection Page 12 Office of the Inspector General State of California Additionally, the OIG physicians also rate each of the detailed physician cases for adequacy based on whether the institution met the patient’s medical needs and if it placed the patient at significant risk of harm. The cumulative analysis of these cases gives the OIG clinicians additional perspective to help determine whether the institution is providing adequate medical services or not.7 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 CAL 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. 7 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. Calipatria State Prison, Cycle 5 Medical Inspection Page 13 Office of the Inspector General State of California COMPLIANCE TESTING Sampling Methods for Conducting Compliance Testing From October 2017 to January 2018, registered nurse inspectors obtained answers to 86 objective medical inspection test (MIT) questions designed to assess the institution’s compliance with critical policies and procedures applicable to the delivery of medical care. To conduct most tests, inspectors randomly selected samples of patients for whom the testing objectives were applicable and reviewed their electronic unit health records. In some cases, inspectors used the same samples to conduct more than one test. In total, inspectors reviewed health records for 382 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 30, 2017, registered nurse field inspectors conducted a detailed onsite inspection of CAL’s medical facilities and clinics; interviewed key institutional employees; and reviewed employee records, logs, medical appeals, death reports, and other documents. This generated 1,022 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 CAL’s plant infrastructure, protocols for tracking medical appeals and local operating procedures, and staffing resources. For details of the compliance results, see Appendix A — Compliance Test Results. For details of the OIG’s compliance sampling methodology, see Appendix C — Compliance Sampling Methodology. Scoring of Compliance Testing Results After compiling the answers to the 86 questions for the 10 applicable indicators, the OIG derived a score for each quality indicator by calculating the percentage score of all Yes answers for each of the questions applicable to a particular indicator, then averaging those scores. Based on those results, the OIG assigned a rating to each quality indicator of proficient (greater than 85.0 percent), adequate (between 75.0 percent and 85.0 percent), or inadequate (less than 75.0 percent). 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 Calipatria State Prison, Cycle 5 Medical Inspection Page 14 Office of the Inspector General State of California 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 CAL, the OIG reviewed some of the compliance testing results, randomly sampled additional patients’ records, and obtained CAL data from the CCHCS Master Registry. The OIG compared those results to HEDIS metrics reported by other statewide and national health care organizations. Calipatria State Prison, Cycle 5 Medical Inspection Page 15 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 CAL Executive Summary Table on page iv of this report identifies the 13 indicators applicable to this institution. The following chart depicts their union and intersection: Chart 3. Inspection Indicator Review Distribution The Administrative Operations indicator is a secondary indicator; therefore, the OIG did not rely upon this indicator when determining the institution’s overall score. Based on the analysis and results in all the primary indicators, the OIG experts made a considered and measured opinion that the quality of health care at CAL was adequate. Summary of Case Review Results: The clinical case review component assessed 10 of the 12 primary (clinical) indicators applicable to CAL. Of these ten indicators, OIG clinicians rated four proficient, five adequate, and one inadequate. The OIG physicians rated the overall adequacy of care for each of the 20 detailed case reviews they conducted. Of these 20 cases, 19 were adequate, and 1 was inadequate. In the 724 events reviewed, there were 114 deficiencies, 25 of which were considered to be of such magnitude that, if left unaddressed, they would likely contribute to patient harm. Calipatria State Prison, Cycle 5 Medical Inspection Page 16 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 one adverse deficiency in the case reviews at CAL: • In case 9, the patient had seizures and high blood pressure. Before he transferred into CAL, the patient had low blood levels of seizure medication and significantly high blood pressure. The sending institution’s provider ordered a seizure medication-level laboratory test and ordered the nurses to obtain a blood pressure check in two weeks. When the patient transferred into CAL, the receiving nurse did not review the pending laboratory test or the orders for the blood pressure check. Six weeks later, medical staff found the patient unconscious in his cell and transferred him to a community hospital due to persistent seizures that did not respond to medications. We also discuss this case in the Inter- and Intra-System Transfers indicator. Summary of Compliance Results: The compliance component assessed 10 of the 13 indicators applicable to CAL. Of these ten indicators, OIG inspectors rated four proficient, two adequate, and four inadequate. The results of those assessments are summarized within this section of the report. The test questions used to assess compliance for each indicator are detailed in Appendix A. Calipatria State Prison, Cycle 5 Medical Inspection Page 17 Office of the Inspector General State of California ACCESS TO CARE This indicator evaluates the institution’s ability to provide patients Case Review Rating: with timely clinical appointments. OIG inspectors review areas Adequate specific to patients’ access to care such as initial assessments of Compliance Score: newly arriving patients, acute and chronic care follow-up Inadequate (73.6%) appointments, face-to-face nurse appointments when a patient requests to be seen, provider referrals from nursing lines, and Overall Rating: follow-ups after hospitalization or specialty care. Compliance testing Inadequate for this indicator also evaluates whether patients have Health Care Services Request forms (CDCR Form 7362) available in their housing units. For this indicator, the case review and compliance review processes yielded different results, with the case reviewers assigning an adequate rating and the compliance testing resulting in an inadequate score. CAL implemented the new, systemwide electronic health records system (EHRS) during our testing period, and the institution’s implementation process may have contributed to the low compliance scores. Our compliance testing showed that CAL had significant difficulty ensuring timely provider access for chronic care patients, newly arrived patients, and patients who were referred by the sick call nurse. Our clinical experts considered CAL’s performance with these essential appointments deficient and rated this indicator inadequate overall. Case Review Results We reviewed 462 provider, nurse, specialty, and hospital events that required a follow-up appointment and identified 11 deficiencies relating to Access to Care, 6 of which were significant. The case review rating for Access to Care was adequate. Provider-to-Provider Follow-up Appointments Provider-ordered follow-up appointments are key elements of a properly functioning health care system. CAL usually performed well with these appointments; however, we found a pattern of significant deficiencies suggesting that CAL did not reliably provide these appointments during the review period: • In case 10, a provider requested a follow-up appointment for 30 days, but the appointment occurred in 68 days (38 days late). • In case 18, a provider requested that the patient follow up in two to three weeks, but the appointment occurred in six weeks (three weeks late). • In case 21, a provider requested that the patient follow up in 30 days, but the appointment occurred in 61 days (31 days late). Calipatria State Prison, Cycle 5 Medical Inspection Page 18 Office of the Inspector General State of California RN Sick Call Access CAL performed well with sick call access. The institution scheduled most sick call appointments timely. We reviewed 53 sick call events and identified only one significant deficiency: • In case 19, the patient complained of increased pain and swelling of the right knee. The sick call nurse did not evaluate the patient within one business day. Instead, the nurse saw the patient four days later. RN-to-Provider Referrals CCHCS policy requires sick call nurses to refer patients to a provider when their condition requires a higher level of assessment. CAL performed well with this requirement. RN-to-provider appointments occurred timely and as scheduled. Of the 17 occurrences when a RN referred the patient to a provider, we found two deficiencies: • In case 19, the nurse contacted the provider who gave instructions to have the patient follow up with the provider in 30 days. The nurse failed to order the follow-up appointment. • In case 46, the RN requested a provider appointment in 14 days; however, the appointment occurred in 21 days (7 days late). RN Follow-up Appointments CAL performed well with scheduling and completing RN appointments generated by providers or other nurses. The majority occurred within the time frames specified; however, there was one significant deficiency: • In case 22, the provider requested the patient to follow up with an RN in 14 days to recheck his blood pressure, but the appointment did not occur. Intra-System Transfers CAL performed acceptably with ensuring timely provider appointments for patients who transferred in from another CDCR facility. Of the five patients reviewed who transferred into CAL, the OIG identified one significant deficiency: • In case 27, the patient arrived from another institution, and the RN requested a provider follow-up appointment in 7 days; however, the appointment occurred in 28 days (21 days late). Follow-up After Hospitalization CDCR providers should see patients returning from a hospitalization within a time frame that ensures patient safety and optimal clinical outcomes, but in no case, no later than five days from the discharge date. CAL performed well with these appointments. OIG clinicians reviewed Calipatria State Prison, Cycle 5 Medical Inspection Page 19 Office of the Inspector General State of California hospital returns, and the follow-up appointments occurred timely with the exception of a single minor delay in case 21. Specialized Medical Housing CAL providers completed history and physical examinations timely for all patients newly admitted to the OHU patients and saw them regularly. The OIG observed no deficiencies in this category. Access to Specialty Services OIG clinicians found that most specialty appointments took place within the requested time frames. Provider Follow-Up After Specialty Service Visits CCHCS policy requires that providers evaluate all patients within 14 days after a routine specialty service visit. CAL performed well with these appointments; there were only three minor delays. Follow-up After Urgent/Emergent Care CAL performed well in scheduling provider follow-ups after patients visited the TTA for urgent concerns. All reviewed appointments occurred within the required time frame. Clinician Onsite Inspection During the onsite visit, clinic nurses reported seeing approximately 10 patients each day in the RN clinics, and providers reported seeing 12 to 15 patients each day. Each of the four clinics had an office technician who attended the daily clinic huddle and coordinated with the providers to ensure that they scheduled important follow-up appointments reliably. The office technicians reported there were no provider or nursing appointment backlogs. CAL managers reported that the institution’s implementation of the new EHRS caused some of the delayed access we found in our testing. Case Review Conclusion CAL usually performed acceptably with Access to Care, as the office technicians ensured that a majority of the provider, nursing, and specialty appointments occurred timely. During the onsite inspection, we observed no appointment backlogs. Even so, we found evidence that the institution had experienced difficulty with provider access during our case review period. Taken altogether, however, the OIG clinicians rated this indicator adequate. Calipatria State Prison, Cycle 5 Medical Inspection Page 20 Office of the Inspector General State of California Compliance Testing Results The institution performed in the inadequate range, with a score of 73.6 percent in the Access to Care indicator. The following tests earned scores in the inadequate range: • We reviewed recent appointments for 25 patients with chronic care conditions and found that 17 of them (68.0 percent) received timely provider follow-up appointments. Eight patients received chronic care appointments between 1 and 103 days late (MIT 1.001). • Provider visits occurred for 10 of 23 patients who either transferred into CAL with a pre-existing chronic care condition requiring follow-up appointment or who received a referral upon arriving to the institution (43.5 percent). For five patients, provider appointments occurred from 8 to 218 days late. For the remaining eight patients, a provider’s follow-up appointment did not occur at all (MIT 1.002). • Among 11 health care services request forms sampled whereby nursing staff referred the patient for a provider appointment, eight patients (72.7 percent) received their appointments in a timely manner. Three patients received their appointments from 5 to 13 days late (MIT 1.005). • Of the six applicable sampled patients whom nurses referred to a provider and for whom the provider subsequently ordered follow-up appointments, three (50.0 percent) received their follow-up appointments timely. One patient received his follow-up appointment two days late; and for the remaining two patients, a provider’s follow-up never occurred (MIT 1.006). • Of 25 sampled patients, 18 (72.0 percent) who received a high-priority appointment or routine specialty services also received timely provider follow-up appointments. Of those seven patients who did not receive timely follow-up appointments, two patients’ high-priority specialty service follow-up appointments were 10 and 14 days late; and five patients’ routine specialty service follow-up appointments were 2 to 60 days late (MIT 1.008). Two tests received scores in the adequate range: • We tested 25 patients discharged from a community hospital to determine whether they received a provider follow-up appointment at CAL within five calendar days of their return to the institution. Of these 25 patients, 19 (76.0 percent) received their provider follow-up appointments in a timely manner. Six patients received their appointments from 1 to 42 days late (MIT 1.007). • Patients had access to health care services request forms at five of six housing units inspected (83.3 percent). One housing unit did not have any health care services request forms (CDCR Form 7362) available for patients’ use (MIT 1.101). Calipatria State Prison, Cycle 5 Medical Inspection Page 21 Office of the Inspector General State of California Two tests received scores in the proficient range: • Nurses reviewed all 30 patients’ health care services request forms on the same day they collected them (MIT 1.003). • Nurses completed timely face-to-face triage encounters for 29 of the 30 health care services request forms (96.7 percent). For one patient, the face-to-face triage was one day late (MIT 1.004). Calipatria State Prison, Cycle 5 Medical Inspection Page 22 Office of the Inspector General State of California DIAGNOSTIC SERVICES This indicator addresses whether CAL provided timely radiology and Case Review Rating: laboratory services to patients, whether primary care providers Proficient timely reviewed the results, and whether providers communicated Compliance Score: Adequate the results to patients within the required time frame. For pathology (78.1%) services, the OIG determines whether the institution received a final pathology report and whether the provider timely reviewed and Overall Rating: Adequate communicated the pathology results to the patient. In addition, case reviewers evaluate the appropriateness of the diagnostic test(s) and of the clinical response to the results. For this indicator, the case review and compliance review processes yielded different results, with the case review giving a proficient rating and the compliance testing resulting in an adequate score. The main reason for the lower compliance score was that staff did not consistently retrieve pathology reports, and providers did not timely communicate those results to their patients. Because CAL showed room for improvement with its pathology report retrieval processes and due to these reports’ clinical importance, we assigned an overall rating for this indicator of adequate. Case Review Results OIG clinicians reviewed 72 events in diagnostic services and found two deficiencies, only one of which was significant. The case review rating for Diagnostic Services was proficient. Test Completion CAL demonstrated it had an effective laboratory process, with staff completing their laboratory tests timely. CAL also had an effective diagnostic procedure process, completing most X-rays, ultrasounds, CT scans, and MRI scans timely. We found no deficiencies in this area. Health Information Management CAL staff timely retrieved and scanned most laboratory reports and diagnostic procedure reports into the medical record. We found one minor deficiency, a late provider endorsement of a diagnostic report, and one significant deficiency as described below: • In case 14, staff did not retrieve or scan a pathology report into the medical record. Clinician Onsite Inspection CAL assigned dedicated phlebotomists to the main clinics to ensure timely laboratory blood draws. CAL also demonstrated an effective tracking process to ensure timely completion and report retrieval for diagnostic tests. Calipatria State Prison, Cycle 5 Medical Inspection Page 23 Office of the Inspector General State of California Case Review Conclusion CAL completed its laboratory and other diagnostic tests timely, and retrieved and scanned the reports into the medical record promptly. The OIG clinicians rated Diagnostic Services at CAL proficient. Compliance Testing Results The institution received an adequate compliance score of 78.1 percent in the Diagnostic Services indicator, which encompasses radiology, laboratory, and pathology services. For clarity, we discuss each type of diagnostic service separately below: Radiology Services • CAL timely performed radiology services for all ten sampled patients (MIT 2.001). Providers timely reviewed the corresponding diagnostic services reports for eight of the ten patients (80.0 percent); for one patient, the provider reviewed the diagnostic report one day late; and for the other patient, the provider did not review the report at all (MIT 2.002). Providers timely communicated test results to all ten patients (MIT 2.003). Laboratory Services • Eight of ten sampled patients (80.0 percent) received their provider-ordered laboratory services timely. For two patients, the institution provided laboratory services 6 and 14 days late (MIT 2.004). Providers then timely reviewed eight of ten laboratory services reports (80.0 percent); for two reports, providers reviewed them between 4 and 15 days late (MIT 2.005). Finally, providers timely communicated the results to eight of the ten patients (80.0 percent); for the other two patients, providers communicated their results 4 and 15 days late (MIT 2.006). Pathology Services • The institution timely received the final pathology report for seven of ten sampled patients (70.0 percent). For one patient, the institution received the report 26 days late; and for two patients, the institution did not obtain the final pathology reports (MIT 2.007). Providers timely reviewed the pathology results for seven of eight patients (87.5 percent). In the one exception, the provider documented evidence of review one day late (MIT 2.008). Providers timely communicated the final pathology results to only two of the eight sampled patients (25.0 percent). For four patients, providers communicated the pathology results between two and eight days late; and for the remaining two patients, providers did not communicate the results at all (MIT 2.009). Calipatria State Prison, Cycle 5 Medical Inspection Page 24 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 We reviewed 18 applicable cases, which yielded 27 urgent/emergent events. We found 21 deficiencies, most of which were minor and did not affect patient care. However, there was one significant deficiency in case 5. We rated the Emergency Services indicator adequate. CPR Response In the emergency medical response cases we reviewed, custody staff promptly notified medical staff and began CPR. First medical responders (FMRs) arrived on the scene timely, after which custody officers and nurses worked cooperatively to continue to deliver effective CPR. Provider Performance CAL providers performed well during urgent and emergent situations. They made good assessments and triaged their patients appropriately. We found only one deficiency wherein a provider did not record a progress note describing a TTA patient encounter (case 11). Nursing Performance CAL nurses usually made appropriate assessments and interventions, and notified providers promptly. However, we observed a pattern of deficiencies that demonstrated room for improvement in these areas. These deficiencies occurred in cases 4, 15, 18, 19, 20, and 22. The following examples illustrate some of these concerns: • In case 4, the patient was unresponsive, not breathing, and did not have a pulse. Medical staff performed CPR. The FMR administered oxygen at a moderate flow rate instead of a Calipatria State Prison, Cycle 5 Medical Inspection Page 25 Office of the Inspector General State of California high flow rate, potentially limiting the amount of oxygen that was delivered to the patient’s brain. Fortunately, the patient started breathing on his own. • In case 20, the patient complained of nausea and vomiting. The provider ordered a medication to help control the patient’s symptoms. The nurse administered the medication, but did not reassess the patient’s response to the medication. • In case 22, the patient complained of severe abdominal pain. The nurse noted that the patient had abdominal tenderness, but did not specify which part of the abdomen was tender. Additionally, the nurse did not obtain the patient’s blood pressure reading or temperature. Nursing Documentation Without proper documentation, health care staff often miss changes in their patients’ conditions, resulting in lapses in care. Nursing documentation was problematic for CAL emergency services. The OIG clinicians identified numerous documentation and timeline discrepancies in the 18 cases we reviewed. Often, the nurses failed to record the data from the automated external defibrillator (the AED, a portable device that can automatically diagnose life-threatening cardiac arrhythmias and can deliver an electric shock as a treatment to regulate the heart rate) or note the time when the AED delivered electric shocks. Additionally, the nurses did not document the amount of oxygen administered to the patients. Furthermore, nurses recorded their intervention times inaccurately, creating timeline discrepancies in the sequence of events (e.g., the time at which a nurse administered medications). Documentation deficiencies occurred in cases 1, 3, 6, 7, 8, 9, 15, 18, 19, and 22. We also identified one significant deficiency related to a missing emergency document: • In case 5, staff started CPR. However, the CPR record was missing from the medical record. We also discuss this case in the Health Information Management indicator. Emergency Medical Response Review Committee The Emergency Medical Response Review Committee (EMRRC) met regularly and discussed emergency events. The EMRRC’s performance was acceptable, but the committee did not identify or discuss the minor deficiencies that we identified in cases 3 and 8 concerning the documentation and timeline discrepancies. Clinician Onsite Inspection During our onsite visit, we observed that the TTA patient care area had two medical beds. Both sufficient space and ample supplies were available to provide emergent medical care. A provider was available for immediate consultation in emergency situations. Two RNs worked in the TTA. The nurses reported having good rapport and a collaborative working relationship with custody staff. Calipatria State Prison, Cycle 5 Medical Inspection Page 26 Office of the Inspector General State of California Case Review Conclusion CAL usually provided acceptable urgent and emergent care. However, the nurses demonstrated room for improvement in their assessments and documentation. We rated the Emergency Services indicator adequate. Calipatria State Prison, Cycle 5 Medical Inspection Page 27 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 (89.6%) 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, CAL had converted to the new EHRS in June 2017; therefore, about half of testing occurred in the EHRS and the other half in the electronic unit health record (eUHR). Case Review Results During the Cycle 5 case review, OIG clinicians reviewed 724 clinical events and identified five health information management deficiencies, only two of which were significant. OIG clinicians rated the institution’s Health Information Management indicator proficient. Interdepartmental Transmission We did not find any problems when staff transmitted health information among the different medical departments within the institution. Hospital Records OIG clinicians reviewed 18 offsite emergency department and hospital visits. CAL timely retrieved, reviewed, and scanned the offsite records into the medical record. There were no deficiencies. Missing Documents (Progress Notes and Forms) CAL scanned nearly all of its nursing and provider progress notes into the medical record. After the institution transitioned to the EHRS, providers and nurses recorded their care directly into the electronic medical record. We identified only two missing documents, one of which was significant: • In case 5, the patient lost consciousness, and CAL staff started CPR and brought him to the TTA; however, the institution lost the CPR record and failed to scan it into the medical record. Calipatria State Prison, Cycle 5 Medical Inspection Page 28 Office of the Inspector General State of California Laboratory, Diagnostic, and Pathology Reports CAL usually retrieved and scanned laboratory results, diagnostic procedures, and pathology reports into the medical records. We discussed CAL’s performance in this area in the Diagnostic Services indicator. Specialty Services Reports CAL timely retrieved and scanned specialty services reports into the medical record. We found no deficiencies in this area. Legibility Providers and nurses dictated most progress notes, and legibility was good. Scanning Performance CAL performed well with scanning and correctly labeling documents. OIG clinicians identified only two minor deficiencies related to mislabeled dates for two documents. Clinician Onsite Inspection Medical records staff retrieved and scanned medical records as soon as they received them. X-ray, ultrasound, computed tomography (CT) scan, magnetic resonance imaging (MRI) scan, and bone scan reports were stored in a separate database and did not require scanning into the medical record; providers reviewed and acknowledged these reports in their progress notes. Case Review Conclusion We identified only rare health information deficiencies in the case reviews and rated the CAL Health Information Management indicator proficient. Compliance Testing Results The institution scored in the proficient range with a score of 89.6 percent in the Health Information Management indicator. The following tests were proficient: • The institution timely scanned all 12 sampled non-dictated health care documents into the patients’ electronic medical records (MIT 4.001). • CAL scored 100 percent for timely scanning the one applicable dictated or transcribed provider progress note into the patient’s electronic medical record (MIT 4.002). • Staff scanned 18 of 20 specialty service consultant reports into the patient’s electronic medical records within five calendar days (90.0 percent). Two documents were scanned 1 and 12 days late (MIT 4.003). Calipatria State Prison, Cycle 5 Medical Inspection Page 29 Office of the Inspector General State of California • Among 25 sampled patients admitted to a community hospital and who then returned to the institution, CAL providers timely reviewed 23 patients’ corresponding hospital discharge reports within three calendar days of each patient’s discharge (92.0 percent). For the other two patients, the provider reviewed the hospital discharge report one day late (MIT 4.007). One test received an adequate score: • CAL timely scanned 17 of 20 community hospital discharge reports or treatment records into patients’ electronic medical records (85.0 percent); three reports were scanned from one to six days late (MIT 4.004). One test received an inadequate score: • The institution scored 70.8 percent in labeling and filing documents scanned into patients’ electronic medical records. For this test, once the OIG identifies 24 mislabeled or misfiled documents, the maximum points are lost, and the resulting score is zero. For this inspection, we identified seven mislabeled documents (MIT 4.006). Calipatria State Prison, Cycle 5 Medical Inspection Page 30 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 Inadequate (57.7%) 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 Inadequate make at the institution during their onsite visit. There is no case review portion. Compliance Testing Results The institution received scores in the inadequate range in the following seven tests: • Only one of ten clinic locations (10.0 percent) met compliance requirements for essential core medical equipment and supplies. The remaining nine clinics were missing one or more functional pieces of properly calibrated core equipment or other medical supplies necessary to conduct a comprehensive examination. The missing items included an examination table and disposable paper, a standard Snellen eye examination chart, a biohazard receptacle or bag, lubricating jelly, tongue depressors, a peak flow meter and tips, and a nebulization unit. In addition, a weight scale did not have current calibration stickers (MIT 5.108). • Inspectors examined emergency medical response bags (EMRBs) to determine if they were inspected daily, inventoried monthly, and whether they contained all essential items. EMRBs were compliant in only two of the seven clinical locations where they were stored (28.6 percent). Our inspectors observed one or more deficiencies at five clinics: staff did not inventory the EMRB within the past 30 days; and the EMRB oxygen tank was empty, or the valve key to turn on the oxygen was missing (Figure 1) (MIT 5.111). Figure 1: Gauge showing the empty status of the EMRB oxygen tank Calipatria State Prison, Cycle 5 Medical Inspection Page 31 Office of the Inspector General State of California • Clinicians followed good hand hygiene practices in only three of ten clinics (30.0 percent). At seven clinic locations, clinicians failed to wash their hands before or after patient contact or before applying gloves (MIT 5.104). • Only three of ten clinic examination rooms observed (30.0 percent) had appropriate space, configuration, supplies, and equipment to allow clinicians to perform proper clinical examinations. In seven clinics, one or more deficiencies were identified: examination room furniture had cracks that could harbor an infectious agent; examination tables had torn vinyl covers (Figure 2); patients lacked visual privacy because they were examined directly Figure 2: Torn vinyl cover across from the triage station, and no on examination table privacy screen was available; examination rooms had insufficient space; and patients could not lie fully extended on the examination table due to physical obstructions present in the room (MIT 5.110). • Only four of the ten clinics inspected followed adequate medical supply storage and management protocols (40.0 percent). At six clinics, one or more of the following deficiencies were observed: medical supplies were stored with germicidal wipes or disinfectant agents; clinics stored expired medical supplies; clinic staff stored food items in the medical cabinet location; and medical supplies were not clearly identifiable (MIT 5.107). • When inspecting the institution’s protocols to mitigate exposure to blood-borne pathogens and contaminated waste, we found six of ten clinics (60.0 percent) compliant. Clinical staff in four clinics did not have nearby access to personal protective equipment (MIT 5.105). • Clinical health care staff at six of nine applicable clinics (66.7 percent) ensured that reusable invasive and non-invasive medical equipment was properly sterilized or disinfected. Three clinics did not properly process, package, or store previously sterilized instruments (MIT 5.102). One test received a score in the adequate range: • Clinic common areas in eight of ten clinics (80.0 percent) had environments conducive to providing medical services. The location of triage and blood draw stations in two clinics compromised patients’ auditory privacy (MIT 5.109). Calipatria State Prison, Cycle 5 Medical Inspection Page 32 Office of the Inspector General State of California Three tests received scores in the proficient range: • Staff appropriately cleaned, disinfected, and sanitized all ten sampled clinics (MIT 5.101). • Nine of ten clinic locations inspected (90.0 percent) had operable sinks and sufficient quantities of hand hygiene supplies in the examination areas. However, one clinic’s patient restroom did not have any antiseptic soap (MIT 5.103). • The non-clinic bulk medical supply storage areas met the supply management process and support needs of the medical health care program (MIT 5.106). Non-Scored Results The OIG gathered information to determine whether 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. • OIG inspectors interviewed health care managers, and they did not identify any significant concerns. At the time of the OIG’s medical inspection, CAL had several significant infrastructure projects underway, which included increasing clinic space at four yards, adding a new administrative segregation unit primary care clinic, creating additional space for central health services, and expanding the health care administration area. These projects were scheduled to start in the spring of 2018 with the exception of the health care administration area, which started in the fall of 2017. The institution estimated that these projects would be completed between early 2018 and early 2020 (MIT 5.999). Calipatria State Prison, Cycle 5 Medical Inspection Page 33 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 Inadequate transfer process. The patients reviewed for this indicator include Compliance Score: those received from, as well as those transferring out to, other CDCR Inadequate (72.8%) institutions. The OIG review includes an evaluation of the institution’s ability to provide and document health screening Overall Rating: assessments, initiation of relevant referrals based on patient needs, Inadequate and the continuity of medication delivery to patients arriving from another institution. For those patients, the OIG clinicians also review the timely completion of pending health appointments, tests, and requests for specialty services. For patients who transfer out of the 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. Case Review Results We reviewed 40 inter- and intra-system transfer events, including information from both the sending and receiving institutions. These included 18 hospitalizations and outside emergency room events, each of which resulted in a transfer back to the institution. There were ten deficiencies, four of which were significant. The significant deficiencies were related to the transfer-in process. Transfers In The OIG clinicians reviewed five transfer-in cases; one of which was a direct admission into the OHU. CAL’s transfer-in process was problematic as we found improper record reviews, incomplete nursing assessments (case 9), poor medication continuity (cases 26 and 27), and delays in provider and specialty appointments (case 27): • In case 9, the patient had seizures and high blood pressure. Before he transferred into CAL, the patient had low blood levels of seizure medication and significantly high blood pressure. The provider from the sending institution ordered a seizure medication-level laboratory test and ordered the nurses to obtain a blood pressure check in two weeks. When the patient transferred into CAL, the receiving nurse did not review the pending laboratory test or the orders for the blood pressure check. Six weeks later, medical staff found the patient unconscious in his cell and transferred him to a community hospital due to persistent seizures that were unresponsive to medications. Calipatria State Prison, Cycle 5 Medical Inspection Page 34 Office of the Inspector General State of California • In case 26, medical staff admitted the newly arrived patient directly to the OHU. The nurse noted that the patient arrived without his rescue inhaler, but the patient did not receive his inhaler until the following day. The patient should have received his inhaler on the same day he arrived. • In case 27, the patient with inflammatory bowel disease transferred into CAL without his medications, one of which he was taking four times a day. The provider mistakenly prescribed the medications to start the next day, but should have prescribed them to start on the day the patient arrived. The nurses should have temporarily administered the medications from the after-hours medication cabinet until the pharmacy dispensed the new prescription. The patient missed three doses, which was a lapse in medication continuity. • Also in case 27, the patient had an overdue gastroenterologist specialty follow-up appointment. The patient should have seen a provider within seven days of arrival at CAL. Instead, that appointment occurred in 28 days. During that appointment, the provider did not realize that the patient had an overdue specialty follow-up. This oversight resulted in a lapse in care, as the patient did not see the gastroenterologist until three months later. Transfers Out The transfer-out process was satisfactory. We reviewed five cases in which patients transferred out to other CDCR institutions. One of the cases reviewed was a direct transfer out of the OHU. Most of the nurses performed face-to-face evaluations and educated patients about the transfer process a few days before the transfer. The nurses instructed the patients not to pack their medications with their property, but instead, to bring their medications to R&R the day of the transfer. Despite this process, one deficiency occurred as described below: • In case 30, the OHU licensed vocational nurse (LVN) completed the transfer-out process. Even though the LVN saw the patient before transfer, the patient transferred without his rescue inhaler. Patients must keep their rescue inhalers with them at all times in case they have trouble breathing during the transfer. The LVN should have notified the RN to ensure that the institution properly implemented the transfer process. The RN, who is more qualified to assess these patients’ needs, should have completed the transfer instead of the LVN. Hospitalizations Patients returning from hospitalizations are some of the highest-risk encounters due to two factors. First, these patients are usually hospitalized for a severe illness or injury. Second, they are at risk due to potential lapses in care that can occur during any transfer. CAL performed acceptably in the 18 events reviewed wherein the patient returned from a hospital or emergency department. In each event, CAL scheduled a provider follow-up within five days, the staff retrieved the hospital discharge summaries, and the providers reviewed and Calipatria State Prison, Cycle 5 Medical Inspection Page 35 Office of the Inspector General State of California signed them. When the patients returned to CAL, the nurses usually performed appropriate assessments and interventions, and provided the right type of education to their patients. However, the nurses did not consistently perform well in this area. We observed a pattern of deficiencies in which nurses made incomplete and inaccurate nursing assessments; these deficiencies occurred in cases 15, 19, and 20: • In case 15, the patient returned from the hospital with a diagnosis of inflammatory bowel disease and complained of severe abdominal pain. The nurse noted that the patient had bowel sounds, but did not indicate if the patient’s abdomen was flat, distended, soft, or firm. Additionally, the nurse did not examine the abdomen for tenderness. The nurse should have established a baseline examination to help determine if the patient’s condition improved or worsened over time. • In case 19, the patient returned from the hospital after having brain surgery to remove a tumor. The nurse assessed the patient and recorded a normal head examination. However, this assessment could not have been reflective of the patient’s actual condition since the patient just had brain surgery, had a surgical site, and had wound dressings that precluded a normal examination. The patient also had a scalp dressing over the surgical site, and the nurse should have indicated if the dressing was dry, intact, and clean. • In case 20, the patient returned from the hospital with a diagnosis of a right knee infection; the nurse did not describe the appearance of the knee or evaluate the patient’s gait. Clinician Onsite Inspection We met with medical, nursing, and pharmacy managers to discuss some of the case review findings. CAL reported that some of the deficiencies were related to the roll-out of the new EHRS, which affected multiple operational processes such as scheduling and documentation. The institution reported that its staff’s timeliness in delivering medication for inter-system transfer patients had improved since the case review period. In addition, the nurses received additional training regarding the transfer process. Case Review Conclusion Although CAL performed acceptably for patients transferring out of the institution and for patients returning from the hospitals, the institution experienced significant difficulty with patients transferring into the institution. CAL staff did not carefully consider their patients’ medical needs when they arrived at the institution, resulting in lapses in care. This represents an area for CAL to target to improve its quality of health care. We rated the Inter- and Intra-System Transfers indicator inadequate. Calipatria State Prison, Cycle 5 Medical Inspection Page 36 Office of the Inspector General State of California Compliance Testing Results The institution scored in the inadequate range for this indicator, with a score of 72.8 percent. The following test received a score of inadequate: • CAL scored zero when the OIG tested two patients who transferred out of CAL during the onsite inspection to determine whether the patients’ transfer packages included required medications and related documentation. Both transfer packages were missing the medication administration records and the transfer checklist (MIT 6.101). Two tests received scores in the adequate range: • For 21 of 25 sampled patients who transferred into CAL from other institutions (84.0 percent), nurses completed an Initial Health Screening form (CDCR Form 7277) on the same day the patients arrived. For four patients, nurses neglected to answer all applicable questions and did not document a complete set of vital signs (MIT 6.001). • We tested 20 patients who transferred out of CAL to another CDCR institution to determine whether staff at CAL listed their scheduled specialty service appointments on the Health Care Transfer Information form (CDCR Form 7371). Nurses listed the scheduled appointments for 16 of 20 sampled patients (80.0 percent). For four patients, nurses failed to document the pending specialty service appointments on the CDCR Form 7371 (MIT 6.004). Two tests received proficient scores: • Nurses timely completed the assessment and disposition sections of the screening form for all 17 applicable patients (MIT 6.002). • The two patients who transferred to CAL from other CDCR institutions with existing medication orders requiring nurses to issue or administer medications to them upon their arrival received their medications timely (MIT 6.003). Calipatria State Prison, Cycle 5 Medical Inspection Page 37 Office of the Inspector General State of California PHARMACY AND MEDICATION MANAGEMENT This indicator is an evaluation of the institution’s ability to provide Case Review Rating: appropriate pharmaceutical administration and security management, Adequate encompassing the process from the written prescription to the Compliance Score: administration of the medication. By combining both a quantitative Inadequate (58.4%) 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, Adequate dispensing and delivering, administering, and documenting and reporting. Because effective medication management is affected by numerous entities across various departments, this assessment considers internal review and approval processes, pharmacy, nursing, health information systems, custody processes, and actions taken by the prescriber, staff, and patient. For this indicator, the case review and compliance review processes yielded different results, with the case review assigning an adequate rating and the compliance review resulting in an inadequate score. In both case review and compliance testing, we found the institution administered medications to its patients appropriately. However, our compliance testing revealed poor performance in the institution’s observed medication practices, storage controls, and pharmacy protocols. Nevertheless, because those deficiencies did not directly place patients at risk of harm, we rated this indicator adequate overall. Case Review Results We evaluated 83 events related to medication administration and found 11 deficiencies, 6 of which were significant. Significant deficiencies occurred in cases 13, 15, 17, 20, 26, and 27. The case review rating for this indicator was adequate. Medication Continuity CAL performed sufficiently with chronic care medication continuity. In the majority of the cases reviewed, the patients received their medications without delay, except in cases 13 and 17: • In case 13, the patient submitted a request for glaucoma eye drop medication refills. The medication nurse documented that the prescription for the medication had expired, and the patient needed to see the provider or an RN. However, the clinic failed to schedule the appointment and did not communicate the information to the provider or the RN. A week later, the patient submitted two additional requests for the same medication refill. The medication nurse sent a message to the pharmacy requesting a refill. Pharmacy staff replied that they would send out the medication the same day; however, the patient received the medication one month later. This lapse in medication continuity placed the patient at risk for eye complications. Calipatria State Prison, Cycle 5 Medical Inspection Page 38 Office of the Inspector General State of California • In case 17, the patient had a pituitary tumor and low pituitary hormone levels. When the patient’s hormonal medication prescription was about to expire, the provider renewed it; however, the patient did not receive the medication until three weeks later. This lapse in medication continuity placed the patient at risk for a hormonal imbalance. CAL also did not consistently ensure medication continuity for patients transferring from community hospitals or transferring from other institutions (cases 20, 26, and 27). These patients experienced a lapse in medication continuity, which increased their risk for medical complications. We discuss these cases further in the Inter- and Intra-System Transfers indicator. Medication Administration CAL performed satisfactorily with medication administration. Patients usually received their self-administered and nurse-administered medications timely and as prescribed. However, there was one significant deficiency in which the nurse administered the wrong medication: • In case 15, the patient had a history of nausea and vomiting. The provider requested the administration of intravenous (IV) normal saline solution; however, the nurse administered the wrong concentration of the IV solution. Fortunately, the error did not result in any harm. Pharmacy Errors We found no deficiencies in this area. Clinician Onsite Inspection We met with the pharmacist and nursing management to discuss our case review findings. CAL reported that some of the deficiencies were related to the institution implementing the new EHRS, and its staff being unfamiliar with how and where to document the record of their care. When we interviewed the medication nurses, however, they were knowledgeable regarding medication preparation, and administration processes and procedures. Case Review Conclusion CAL performed satisfactorily with chronic care medication continuity, but sometimes had problems with ensuring medication continuity for patients who transferred into the institution or returned from the hospital. We rated the Pharmacy and Medication Management indicator adequate. Compliance Testing Results The institution received a score of 58.4 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. Calipatria State Prison, Cycle 5 Medical Inspection Page 39 Office of the Inspector General State of California Medication Administration For this sub-indicator, the institution received a proficient score of 87.2 percent. The following tests received scores in the range of proficient: • CAL patients timely received chronic care medications for 14 of 15 samples the OIG reviewed (93.3 percent). One patient did not receive all ordered medications or receive required counseling for missed doses (MIT 7.001). • Clinical staff timely provided new and previously prescribed medications to 22 of 25 sampled patients who had been discharged from a community hospital and returned to the institution (88.0 percent). Two patients received their medications one and two days late, and for one patient, the provider did not order the medications within the required time frame (MIT 7.003). • CAL ensured that 22 of 23 sampled patients (95.7 percent) received their medications without interruption when they transferred from one housing unit to another. For one patient, nurses did not document a reason for the patient’s refusal of his medication (MIT 7.005). One test received a score in the inadequate range: • CAL timely administered or delivered new medication orders to 18 of the 25 sampled patients (72.0 percent). For four patients, nurses administered medications one to two days late, and for the other three patients, nurses failed to document whether patients received or refused the medications (MIT 7.002). Observed Medication Practices and Storage Controls The institution scored 44.4 percent in this sub-indicator, with the following tests scoring in the inadequate range: • The institution demonstrated proper security controls for narcotic medications in four of the eight applicable clinic and medication line locations where narcotics were stored (50.0 percent). In four clinics, we observed one or more of the following deficiencies: the narcotics logbook revealed, on multiple occasions, a controlled substance inventory was not performed by two licensed nurses; the medication area did not store narcotic medications under double-lock control; and the narcotics logbook revealed several occasions when disposal of controlled substances was not performed by two licensed nurses. In addition, we found a discrepant narcotic inventory when we counted narcotic medications in one medication room (MIT 7.101). • CAL safely stored non-refrigerated, non-narcotic medications in four of the ten applicable clinics and medication line storage locations (40.0 percent). In six locations, we observed one or more of the following deficiencies: the medication area lacked a designated area for Calipatria State Prison, Cycle 5 Medical Inspection Page 40 Office of the Inspector General State of California return-to-pharmacy medications; oral and topical medications were not properly separated when stored; medication rooms and cabinets were unlocked; and a crash cart log showed on several occasions that staff were not checking the security lock on a daily basis (MIT 7.102). • Refrigerated, non-narcotic medications were safely stored in only one of the ten clinics and medication line storage locations (10.0 percent). In nine locations, we observed one or more of the following deficiencies: the medication area lacked a designated area for return-to- pharmacy refrigerated medications; and medication refrigerators were unlocked (MIT 7.103). • We observed the medication preparation and administration processes at six applicable medication line locations. Nurses were compliant regarding proper hand hygiene and contamination control protocols at three locations (50.0 percent). At three locations, some nurses did not wash or sanitize their hands prior to putting on gloves or before re-gloving (MIT 7.104). • Only one of six inspected medication preparation and administration areas demonstrated appropriate administrative controls and protocols (16.7 percent). In five locations, we observed one or more of the following deficiencies: patients waiting to receive their medications did not have sufficient outdoor cover to protect them from heat or inclement weather; medication nurses did not distribute medications to patients within the required time frame; medication nurses did not always ensure patients swallowed direct observation therapy medications; we observed a medication nurse electronically signing the medication administration record (MAR) prior to preparing and administering medications; and medication nurses did not disinfect previously opened multi-use insulin vials before withdrawing and administering medication (MIT 7.106). One test received a proficient score: • Nurses at all six of the inspected medication line locations employed appropriate administrative controls and followed appropriate protocols during medication preparation (MIT 7.105). Pharmacy Protocols CAL scored 52 percent in this sub-indicator, with the following tests scoring in the inadequate range: • In its main pharmacy, the institution did not follow general security protocols. Specifically, the sliding door to the controlled substances storage area was left unlocked. As a result, the institution scored zero in this test (MIT 7.107). • The institution’s pharmacist-in-charge (PIC) did not properly account for narcotic medications stored in CAL’s pharmacy or review monthly inventories of controlled Calipatria State Prison, Cycle 5 Medical Inspection Page 41 Office of the Inspector General State of California substances in the institution’s clinical and medication line storage locations. As a result, the institution received a score of zero in this test. Also, the PIC did not review several medication area inspection checklists (MIT 7.110). • The institution’s PIC followed required protocols for 15 of the 25 medication error reports and monthly statistical reports reviewed (60.0 percent). For five medication error reports, the PIC reported the monthly error statistical report for November 2016 one business day late. In addition, the PIC completed two of the five medication follow-up reports three business days late. For five other reports, the PIC did not share the monthly medication error statistical report with the local pharmacy and therapeutics committee, and other applicable improvement committees for December 2016 (MIT 7.111). The following two tests received scores of proficient: • In its main pharmacy, the institution properly stored and monitored non-narcotic medications that required refrigeration and those that did not (MIT 7.108, 7.109). Non-Scored Tests • In addition to the OIG’s testing of reported medication errors, inspectors follow up on any significant medication errors found during compliance testing to determine whether the institution properly identified and reported errors. The OIG provides those results for information purposes only. At CAL, the OIG did not find any applicable medication errors (MIT 7.998). • The OIG tested patients in isolation units to determine whether they had immediate access to their prescribed keep-on-person (KOP) asthma rescue inhalers. All ten applicable patients interviewed indicated they had access to their asthma rescue inhalers (MIT 7.999). Calipatria State Prison, Cycle 5 Medical Inspection Page 42 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 CAL does not have female patients, this indicator does not apply. Calipatria State Prison, Cycle 5 Medical Inspection Page 43 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 (86.5%) 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 86.5 percent. The following three tests were in the proficient range: • We found that 29 of 30 (96.7 percent) sampled patients received annual TB screenings. For one patient, the nurse failed to provide the TB screening during his birth month (MIT 9.003). • CAL offered annual influenza vaccinations to 24 of 25 sampled patients, subject to the annual screening requirement (96.0 percent). For one patient, the nurse failed to document if the patient received or refused the influenza vaccine (MIT 9.004). • All 25 sampled patients either had a normal colonoscopy within the past ten years or were offered a colorectal cancer screening in the past year (MIT 9.005). Two tests received adequate scores: • CAL scored 83.3 percent for administering timely anti-TB medications to patients with the disease. Out of 12 sampled patients, 10 received their medications timely. One patient received an incomplete TB treatment; and we identified three compliance deviations for the other patient (MIT 9.001). • We tested whether patients who suffered from chronic care conditions were offered vaccinations for influenza, pneumonia, and hepatitis. At CAL, 11 of 13 sampled patients (84.6 percent) received all recommended vaccinations at required intervals. For two patients, the institution failed to document whether the patients had received or refused a pneumovax vaccination within the past five years or a hepatitis vaccination (MIT 9.008). Calipatria State Prison, Cycle 5 Medical Inspection Page 44 Office of the Inspector General State of California One test received a score of inadequate: • We reviewed CAL’s monitoring of 12 sampled patients who received TB medications and noted that the institution was in compliance for 7 of them (58.3 percent). For five patients, the institution either failed to complete monitoring at all required intervals or failed to document weight changes (MIT 9.002). Calipatria State Prison, Cycle 5 Medical Inspection Page 45 Office of the Inspector General State of California QUALITY OF NURSING PERFORMANCE The Quality of Nursing Performance indicator is a qualitative Case Review Rating: evaluation of the institution’s nursing services. The evaluation is Adequate completed entirely by OIG nursing clinicians within the case review Compliance Score: process and 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 nurses on behalf of the patient. Adequate 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 the 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 We reviewed 269 nursing encounters, 119 of which were in the outpatient setting. Most outpatient nursing encounters were for sick call requests, walk-in visits, and RN follow-up visits. In all, we identified 80 deficiencies related to nursing care performance, 9 of which were significant. The case review rating for this indicator was adequate. Nursing Assessment A major part of providing appropriate nursing care involves the quality of nursing assessment, which includes both subjective (patient interview) and objective (evaluation and observation) portions. Most of the nurses included both elements in their nursing assessments. Although the nurses usually provided appropriate care, we identified a pattern of deficiencies of incomplete or missing outpatient nursing assessments in 15 of 37 cases. Most of these deficiencies were minor and unlikely to contribute to patient harm, except for the following: • In case 19, the patient complained of increased right knee pain and swelling. The nurse did not palpate the patient’s pulse behind the knee or assess for numbness and tingling. Additionally, the nurse did not evaluate the patient’s leg strength or his gait. • In case 37, the patient complained that his hives had returned after the provider stopped his medication. Hives is a possible indication of an allergic reaction, which in severe cases, can affect a person’s breathing. The nurse did not listen to the patient’s lungs. Calipatria State Prison, Cycle 5 Medical Inspection Page 46 Office of the Inspector General State of California • In case 44, the patient complained that he had a painful lump on his chest. The nurse did not examine the patient, but instead deferred assessment until the patient saw the surgeon. Independent assessment is a key responsibility of every medical clinician to ensure that a patient is evaluated and treated appropriately when the patient’s condition changes. Failure to independently assess patients can lead to lapses in care. Nursing Interventions and Implementation Most of the nurses provided appropriate and timely interventions based on their assessments. The nurses followed the nursing protocols to implement appropriate interventions. Most nurses followed providers’ orders, but there were minor exceptions in cases 15 and 27. In both cases, the provider prescribed liquid nutritional supplements, but the nurses did not issue them. One significant deficiency occurred in the following case: • In case 36, the patient complained that he had suffered from an abdominal rash for two weeks. He reported applying cream to the rash, but it was not working. The nurse diagnosed a fungal infection on his abdomen and issued a medication that, according to the nursing protocol, was authorized only for fungal foot infections. The nurse should have referred the patient to the provider. Additionally, the nurse did not ask the patient which cream he had been using on the rash. Furthermore, the nurse did not obtain the patient’s temperature during the visit. Nursing Documentation Complete and accurate nursing documentation is another essential component of patient care. Without proper documentation, health care staff often miss changes in patients’ health conditions, resulting in lapses in care. Also, improper documentation makes it difficult for staff to determine their patients’ current health care status. Overall, nursing documentation was good in all areas except for emergency services. Of the 18 cases reviewed for emergency services, 10 had documentation deficiencies. We discussed these cases further in the Emergency Services indicator. For outpatient nursing, the minor documentation deficiencies occurred in cases 17, 19, 21, 36, and 40. Nursing Sick Call We reviewed 53 sick call requests. Most nurses triaged the patients timely, saw patients with symptoms within one business day, and made acceptable nursing assessments and interventions. The average clinic nurse saw ten patients per day, and there was no appointment backlog. However, we did observe a pattern of deficiencies in which the nurses did not order follow-up appointments: Calipatria State Prison, Cycle 5 Medical Inspection Page 47 Office of the Inspector General State of California • In case 36, the patient complained of an abdominal rash and received treatment. The nurse recorded a plan for an RN follow-up in 14 days. However, the appointment did not occur, because the nurse did not order the appointment. • In case 38, the patient complained of athlete’s foot and shoulder pain, and received treatment. The nurse documented that the plan was to follow up with the RN in seven days. However, the appointment did not occur, because the nurse did not order the appointment. • In case 41, the patient complained that his current treatment for bumps on his neck was not working. The nurse recorded a plan to follow up with the provider, but did not specify a time frame. However, the appointment did not occur because the nurse did not order the appointment. The patient paroled a month later. Urgent/Emergent Care Both the nurses in the TTA and the FMR provided appropriate assessment and interventions to patients during emergency medical responses. However, nursing documentation was problematic in 10 of the 18 cases reviewed. We also discussed nursing performance in this area in the Emergency Services indicator. Care Management LVN care coordinators provided suitable care. CAL assigned a care coordinator to each clinic. The care coordinators’ main responsibilities were to educate chronic care patients and to perform TB screenings, electrocardiograms (EKGs), immunizations, blood pressure checks, and wound care. The LVNs also issued medical supplies and health care equipment as ordered. Only two minor deficiencies occurred, neither of which were likely to contribute to patient harm. Post-Hospital Returns CAL nurses provided acceptable nursing assessments, interventions, and education for patients returning from the hospital. However, we discerned a pattern wherein nurses did not fully complete their assessments. We also discussed nursing performance in this area in the Inter- and Intra-System Transfers indicator. Specialized Medical Housing OHU nurses did not always complete their assessments. In four of the nine cases reviewed, the nurses made incomplete assessments or did not perform them at all. We discuss this performance further in the Specialized Medical Housing indicator. Intra-System Transfers The transfer-in process was problematic. Nurses did not reliably review the records or often made incomplete assessments. Our clinicians observed lapses in medication continuity, and the Calipatria State Prison, Cycle 5 Medical Inspection Page 48 Office of the Inspector General State of California provider and specialty appointments did not occur timely. We also discussed nursing performance in this area in the Inter- and Intra-System Transfer indicator. Offsite Specialty Services Returns and Telemedicine CAL’s nurses provided appropriate nursing care for patients returning from offsite specialty and telemedicine appointments. Most of the nurses made appropriate nursing assessments, reviewed specialists’ recommendations properly, and communicated pertinent information to providers. We identified only minor deficiencies that were unlikely to contribute to patient harm. Clinician Onsite Inspection We spoke with various nurses in several clinical areas, including the TTA, OHU, R&R, specialty, utilization management, and the outpatient clinics. During our onsite inspection, the prison was on lockdown due to a custody-related issue. Custody officers explained that the yard was still on a modified program from the previous day. They also reported that all patients would be escorted to their appointments and would still be seen as scheduled. There were no delays resulting from the modified program. One particularly well-run meeting was the morning huddle. The huddles were organized and facilitated by the RN. The team consisted of the provider, SRN, RN, primary care LVN, care coordinator LVN, medication LVN, psychiatric technician, office technician, and a custody officer. The RN followed a standardized huddle script and discussed the following items: new arrivals, TTA visits, hospital admissions and discharges, and patients whose prescriptions were expiring. CAL innovatively leveraged technology to improve the effectiveness of their morning huddles. The team reviewed the huddle report on a large-screen monitor, so every team member could follow along and participate. Also, three team members had access to computers to efficiently research patient-related questions and implement decisions in real time. Whenever the provider had a question about a patient’s medications, the nurse researched the information on the computer. If anyone asked questions about patient appointments, the office technician researched the patient’s appointment history and could schedule an appointment immediately. CAL’s organization of the morning huddles resulted in efficient discussion and swift resolution of any patient issues that arose. We also discuss CAL’s impressive huddle performance from a provider perspective in the Quality of Provider Performance indicator. Calipatria State Prison, Cycle 5 Medical Inspection Page 49 Office of the Inspector General State of California Case Review Conclusion Although CAL’s nurses usually provided acceptable nursing care, we observed several areas in which the institution could improve. We found the following issues: sick call nurses made incomplete assessments, sick call nurses did not reliably enter orders for provider follow-up appointments, R&R nurses did not carefully review records, R&R nurses made incomplete assessments, R&R nurses did not ensure medication continuity, and TTA nurses recorded poor quality documentation. Despite these concerns, because CAL’s nursing care was generally sufficient overall, the OIG clinicians rated the Quality of Nursing Performance indicator adequate. Calipatria State Prison, Cycle 5 Medical Inspection Page 50 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 Proficient 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. Proficient OIG physicians alone assess provider care. There is no compliance testing component associated with this quality indicator. Case Review Results We reviewed 121 medical provider encounters and identified five deficiencies related to provider performance. Of those five deficiencies, two were significant. OIG physicians performed 20 detailed case reviews. We rated 19 cases adequate and 1 case inadequate. The one inadequate case was not related to poor provider performance. Due to CAL providers’ strong overall performance, we rated the Quality of Provider Performance indicator proficient. Assessment and Decision-Making Providers usually made appropriate assessments and documented sound decisions. However, there were two deficiencies in assessment or decision-making in case 10; one of which was significant as described below: • In case 10, the patient’s laboratory tests showed poorly controlled diabetes. A provider reviewed the results, but did not schedule a follow-up appointment. Two months later, the patient asked for help because he felt disoriented. Medical staff found that he had a dangerously high blood glucose level. Review of Records In most cases, providers properly reviewed their patients’ records, especially when the patients returned from a hospital or specialist appointment. Insufficient record review errors occurred in only two cases (23 and 27), one of which was significant as described below: • In case 23, the specialist recommended that the provider prescribe eye drops for the patient’s glaucoma (elevated eye pressure); however, our clinicians found no indication that the provider prescribed the medication. Calipatria State Prison, Cycle 5 Medical Inspection Page 51 Office of the Inspector General State of California Emergency Care CAL providers were readily available for consultation with the TTA nurses when patients presented emergently to the TTA. CAL providers made excellent decisions during emergent events. We found only one minor deficiency in case 11. Chronic Care CAL providers performed well in managing chronic medical conditions such as hypertension, hyperlipidemia, asthma, hepatitis C infection, and seizure disorder. CAL providers might improve their practice of diabetic care, because we noted two deficiencies, one of which we considered significant. We discussed this concern on the previous page under the Assessment and Decision-Making heading of this indicator. Specialty Services CAL providers performed extremely well in this area. When their patients required specialty care, the providers made appropriate specialty referrals and requested them within the correct time frame. The providers also timely reviewed specialty reports. We observed only one significant deficiency, which we further discuss in the Specialty Services indicator. Specialized Medical Housing Providers completed their rounds for OHU patients timely, and made appropriate assessments and sound decisions. We did not identify any provider deficiencies for this area. Health Information Management CAL providers recorded their patient encounters timely. Providers dictated most progress notes, and the few handwritten notes were legible. We found only one minor deficiency in case 11. Clinician Onsite Inspection At the time of our second onsite inspection, there were no provider vacancies at the institution. The providers were enthusiastic about their work and satisfied with the institution’s nursing, diagnostic, and specialty services. CAL assigned each provider to one clinic to enhance the continuity of care. Providers saw approximately 12 to 15 patients per day. The morning huddles were innovative, efficient, and paperless. As we discussed in the Quality of Nursing Performance indicator, the lead nurse conducted the morning huddle and displayed the huddle agenda on a large-screen monitor. The care teams appropriately discussed patients who required care in the TTA, who had returned from the hospital, or who had recently arrived at CAL. Nurses accessed these patients’ electronic medical records immediately, so the provider could review them during the huddle and implement care plans straight away. When the medication nurse informed the provider of an expiring prescription, the provider immediately renewed it without any delay. Likewise, the clinic team collaboratively reviewed laboratory Calipatria State Prison, Cycle 5 Medical Inspection Page 52 Office of the Inspector General State of California results and patient appointments, and quickly resolved any patient care issues. We also discussed the institution’s huddle performance from a nursing perspective in the Quality of Nursing Performance indicator. Case Review Conclusion CAL providers performed well across multiple aspects of patient care, including emergency care, chronic care, hospital returns, and specialized medical housing. We rated the Quality of Provider Performance indicator proficient. Calipatria State Prison, Cycle 5 Medical Inspection Page 53 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. CAL does not have a reception center; therefore, this indicator does not apply. Calipatria State Prison, Cycle 5 Medical Inspection Page 54 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 Adequate facilities, including completion of timely nursing and provider Compliance Score: assessments. The case review assesses all aspects of medical care Proficient (93.3%) related to these housing units, including quality of provider and nursing care. The outpatient housing unit (OHU) is the only Overall Rating: specialized medical housing at CAL. Adequate For this indicator, the case review and compliance review processes yielded different results, with the case reviewers assigning an adequate rating and the compliance testing resulting in a proficient score. In the case reviews, nursing performance in the OHU was substandard. This poor nursing performance was offset by very good provider performance, resulting in appropriate overall care. In addition, only four compliance tests were available, and these only marginally represented the quality of patient care. Therefore, we heavily relied upon the case review rating for the overall rating of this indicator, which was adequate. Case Review Results The institution had 18 OHU beds, two of which were in negative pressure rooms capable of housing patients who needed respiratory isolation. We reviewed nine cases in which CAL staff cared for OHU patients. These cases yielded 31 provider and 58 nursing events. We found 25 deficiencies, 6 of which were significant, occurring in cases 1, 2, 15, 19, 23, and 28. The case review rating for this indicator was adequate. Provider Performance CAL’s OHU providers properly cared for their patients. They completed rounds for their patients promptly, and made proper assessments and sound decisions. We found only one significant provider deficiency: • In case 23, the specialist recommended eye drops for the patient’s glaucoma, but the provider did not prescribe the medication. This lapse placed the patient at risk for possible vision impairment. We also discussed this case in the Quality of Provider Performance indicator. Nursing Performance Nursing performance in the OHU was subpar in five of the nine cases reviewed. In many cases, the OHU nurses’ assessments were incomplete. Nurses often did not assess their patients’ specific complaints or notify the provider when they could not carry out an order. We found this pattern of nursing deficiencies in cases 1, 2, 15, 19, and 28: Calipatria State Prison, Cycle 5 Medical Inspection Page 55 Office of the Inspector General State of California • In case 1, the patient was involved in a physical altercation that resulted in facial fractures, swollen eyes and nose, and blurred vision. Although the provider ordered neurological assessments, the nurses did not correctly perform them. The nurses made incomplete assessments or did not assess the patient at the appropriate intervals. • In case 2, the patient recently had a tube placed and removed from his chest due to a collapsed lung. When the patient returned from the hospital, the provider ordered an incentive spirometer (a device used to help prevent lung collapse). The nurse recorded that the incentive spirometer was unavailable, but failed to notify the provider. This error placed the patient at risk for respiratory complications. • In case 15, the patient complained of abdominal pain, knee pain, and swollen feet. The nurse did not examine the patient’s abdomen, knees, or feet. • Also in case 15, the provider ordered IV fluids. However, the nurse administered the wrong concentration of IV fluids. We also discussed this case in the Pharmacy and Medication Management indicator. • In case 19, the patient had a brain tumor removed and complained of headache. The nurse did not evaluate the patient’s neurological status. For patients with headache and recent brain surgery, nurses must perform proper neurological evaluations for proper patient care. Nurses must establish the patient’s neurological baseline status to help determine if the patient’s medical condition improves or worsens. • In case 28, the patient recently had surgical hardware removed from his ankle, and medical staff admitted to him to the OHU due to his poor mobility. The patient complained of severe ankle pain, but the nurse did not examine his ankle, assess his ankle for range of motion, or evaluate his lower extremity strength or gait. In addition to their poor assessments, the OHU nurses also failed to properly transfer patients into and out of the OHU. We discussed these cases (26 and 30) in which the OHU nurses made transfer errors in the Inter- and Intra-System Transfers indicator. Clinician Onsite Inspection During the onsite visit, patients occupied 12 of the 18 available beds. CAL assigned one provider to the OHU. CAL also assigned one RN during the day shift and one LVN during the evening and night shifts. The TTA RN served as backup and support for the OHU LVN during the evenings and nights when the institution did not schedule an RN in the OHU. We believed that CAL staffed the OHU with enough nurses to deliver proper nursing care in the OHU. The OIG clinicians met with nursing managers to discuss some of the case review findings. These managers agreed to retrain their staff to perform complete assessments. The managers also implemented corrective action plans to ensure the availability of incentive spirometers. Calipatria State Prison, Cycle 5 Medical Inspection Page 56 Office of the Inspector General State of California Case Review Conclusion Nurses in the OHU demonstrated substandard performance. On the one hand, in most of the cases we reviewed, OHU nurses made either incomplete assessments or no assessment at all. On the other hand, OHU providers cared diligently for their patients, overcoming the deficient nursing practices and delivering proper care to their patients. Our OIG experts rated the overall level of care in the Specialized Medical Housing indicator adequate. Compliance Testing Results The institution received a score of 93.3 percent in this indicator. Two tests earned scores in the proficient range: • When the OIG tested whether providers completed their Subjective, Objective, Assessment, Plan, and Education (SOAPE) notes at required three-day intervals, providers completed timely SOAPE notes for all seven sampled patients (MIT 13.003). • When inspectors observed the working order of sampled call buttons in OHU patient rooms, inspectors found all working properly. In addition, according to staff members interviewed, custody officers and clinicians were able to expeditiously access patients’ locked rooms when emergent events occurred (MIT 13.101). One test received a score of adequate: • Nurses completed an initial assessment on the day the patient was admitted to the OHU for eight of ten sampled patients (80.0 percent). For one patient, the nurse did not document an initial assessment; and for the other patient, the nurse did not complete a timely initial assessment (MIT 13.001). Calipatria State Prison, Cycle 5 Medical Inspection Page 57 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 (89.1%) 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 The OIG clinicians reviewed 124 events related to Specialty Services, which included 81 specialty consultations and procedures, and 34 nursing encounters. We found only six deficiencies, one of which was significant. The case review rating for Specialty Services was proficient. Access to Specialty Services CAL performed extremely well with scheduling all specialty appointments timely, and ensuring those appointments occurred within the time frames requested by the referring providers. We found no deficiencies in this area. Nursing Performance We reviewed 34 events in which nurses assessed patients when they returned from their specialty appointments. The nurses made good patient assessments, reviewed the specialists’ findings and recommendations, and communicated those results to the provider. Nurses educated their patients appropriately. Only four minor nursing deficiencies were found related to specialty services. Provider Performance We found that providers generally referred patients to specialists appropriately. When their patients returned from their specialty appointments, the providers diligently addressed the specialists’ recommendations. We noted only one significant exception in case 23, which we discussed in the Quality of Provider Performance and the Specialized Medical Housing indicators. Calipatria State Prison, Cycle 5 Medical Inspection Page 58 Office of the Inspector General State of California Health Information Management CAL performed admirably in this area. The institution retrieved, labeled, and scanned all specialty reports into the medical record timely. We observed only one minor deficiency in case 26 related to a mislabeled date of a specialty report. Clinician Onsite Inspection The specialty and utilization management nurses were exceedingly familiar with their patient population, responsibilities, and duties. They used the messaging center in the EHRS extensively to maintain ongoing communication with providers. Both nurses reported having many years of experience serving in their current positions. Case Review Conclusion CAL medical staff completed all specialty appointments timely, and retrieved, labeled, and scanned nearly all specialty reports properly. Providers then reviewed the specialty recommendations and acted on them appropriately. CAL performed exceptionally well with Specialty Services, and we rated this indicator proficient. Compliance Testing Results The institution received a score of 89.1 percent in this indicator, with the following five tests scoring in the proficient range: • For 14 of 15 sampled patients (93.3 percent), high-priority specialty services appointments occurred within 14 calendar days of the provider’s order; however, one patient received his specialty service one day late (MIT 14.001). • Providers timely received and reviewed the high-priority specialists’ reports for 14 of the 15 sampled patients (93.3 percent). For one patient, the provider reviewed the report eight days late (MIT 14.002). • For all 15 sampled patients, routine specialty service appointments occurred within 90 calendar days of the provider’s order (MIT 14.003). • CAL’s health care management denied specialty service requests for nine sampled patients. In each instance, the denial occurred timely. Additionally, providers timely informed their patients of the denials so that they could consider alternate treatment options (MIT 14.006, 14.007). Calipatria State Prison, Cycle 5 Medical Inspection Page 59 Office of the Inspector General State of California One test earned a score in the adequate range: • Providers timely received and reviewed the routine specialists’ reports for 10 of the 13 sampled patients (76.9 percent). Two reports were reviewed 13 and 31 days late. For the third report, the provider did not review it at all (MIT 14.004). One test received an inadequate score: • Of 20 applicable sampled patients who transferred to CAL with an approved specialty service, 12 of them (60.0 percent) received it within the required time frame. The remaining eight sampled patients received their services late or did not receive them at all: seven patients received their approved specialty services between 2 and 84 days late; and one patient never received his services (MIT 14.005). Calipatria State Prison, Cycle 5 Medical Inspection Page 60 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 (84.8%) 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 earned a score of 84.8 percent in this indicator with multiple tests receiving scores in the proficient range: • CAL’s QMC met monthly, evaluated program performance, and took action when management identified areas for improvement opportunities (MIT 15.003). • CAL took adequate steps to ensure the accuracy of its Dashboard data reporting (MIT 15.004). • We inspected incident package documentation for 12 emergency medical responses reviewed by CAL’s EMRRC during the prior six-month period and found all 12 sampled packages complied with policy (MIT 15.005). • Based on a sample of ten second-level medical appeals, the institution’s responses addressed all of the patients’ appealed issues (MIT 15.102). • All ten sampled nurses who administered medications possessed current clinical competency validations, and all nurses hired within the past year timely received new employee orientation training (MIT 15.105, 15.111). Calipatria State Prison, Cycle 5 Medical Inspection Page 61 Office of the Inspector General State of California • All providers at the institution were current with their professional licenses. Similarly, all nurses 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). Three tests received adequate scores: • The institution promptly processed 9 of the 12 patient medical appeals (75.0 percent) during the most recent 12-month period. Of the three months with more than five percent of medical appeals in overdue status, the percentages ranged from 6 to 13 percent (MIT 15.001). • Medical staff reviewed and timely submitted the Initial Inmate Death Report (CDCR Form 7229A/7229B) to CCHCS’ Death Review Unit for five of six cases tested, resulting in a score of 83.3 percent. The CEO or CME did not initial or sign the CDCR Form 7229A for one patient (MIT 15.103). • We examined records to determine whether nursing supervisors were completing the required number of monthly case reviews for subordinate nurses, as well as discussing the results of those reviews with them, and noted that four of five sampled nurse supervisors properly completed their reviews (80.0 percent). For one nurse, the supervisor did not complete the required number of nursing reviews (MIT 15.104). Two tests received scores in the inadequate range: • The institution did not meet the emergency response drill requirements for the most recent quarter for all three watches, resulting in a score of zero. More specifically, we found the following forms incomplete in the institution’s drill packages: the First Medical Responder-Data Collection Tool (CDCR Form 7463), the Triage and Treatment Flow Sheet (CDCR Form 7464), and the Medical Report of Injury or Unusual Occurrence Form (CDCR Form 7219), which did not comply with CCHCS policy (MIT 15.101). • Two of six CAL providers had a proper clinical performance appraisal completed by their supervisors (33.3 percent). The four other providers did not have either timely or properly completed appraisals, including the following: one provider’s supervising physician utilized the incorrect form for an annual review; and for three providers, a clinical appraisal was completed, but the supervising physician did not discuss the results with the provider (MIT 15.106). Calipatria State Prison, Cycle 5 Medical Inspection Page 62 Office of the Inspector General State of California Non-Scored Results • The OIG gathered non-scored data regarding the completion of death review reports. CCHCS’ Death Review Committee (DRC) did not timely complete its death review summary for any of the six deaths that occurred during the OIG’s inspection period. The DRC is generally required to complete a death review summary within either 30 or 60 days of death (depending on whether the death was expected or unexpected) and then notify the institution’s CEO of the review results within seven calendar days so that any needed corrective action may be promptly pursued. For five patient deaths, the committee completed its summary 36 to 132 days late (96 to 192 days after death), and the institution’s CEO was notified of the results 35 to 134 days late. For the one remaining patient death, the DRC completed the death review summary 84 days late, but we found no evidence in the medical record that the CEO received notification within the required time frame (MIT 15.998). • We discuss the institution’s health care staffing resources in the About the Institution section of this report (MIT 15.999). Calipatria State Prison, Cycle 5 Medical Inspection Page 63 Office of the Inspector General State of California R ECOMMENDATIONS The OIG recommends the following: • The chief nurse executive (CNE) should implement training for the triage and treatment area (TTA) and first medical responder nurses regarding documentation, timeline accuracy, and proper nursing assessment due to problems the institution’s nurses demonstrated in the emergency services case reviews. Specifically, the CNE should choose the nursing assessments of patients’ gastrointestinal conditions as a target for improved care. • The CNE should implement a quality improvement program to evaluate and monitor the various transfer-in processes due to errors identified during our case reviews. The CNE should focus on improving the receiving nurses’ performance and ensuring prompt provider appointments. The CNE should audit and track newly arrived patients’ pending diagnostic tests and specialty referrals to ensure that CAL provides those needed services without incurring lapses in care. • The CNE should improve its methods for evaluating the quality of care provided by nurses who assess sick call patients and those who assess new patients transferring in from other facilities due to the various concerns we identified in these areas during our inspection. • The CNE should revamp the way the institution appraises the performance of the OHU nurses. Nursing care was substandard in the majority of OHU cases we reviewed. • CCHCS should examine CAL’s well-run morning huddle process and consider the feasibility of replicating it statewide. Calipatria State Prison, Cycle 5 Medical Inspection Page 64 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 Calipatria State Prison, nine HEDIS measures were selected and are listed in the following CAL 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. Calipatria State Prison, Cycle 5 Medical Inspection Page 65 Office of the Inspector General State of California Results of Population-Based Metric Comparison Comprehensive Diabetes Care For chronic care management, the OIG chose measures related to the management of diabetes. Diabetes is the most complex common chronic disease requiring a high level of intervention on the part of the health care system in order to produce optimal results. CAL performed well with its management of diabetes. When compared statewide, CAL outperformed Medi-Cal in all five diabetic measures. The institution outperformed Kaiser North in four of the five diabetic measures, with CAL scoring lower in blood pressure control. The institution outperformed Kaiser South in three of the five diabetic measures, with CAL scoring lower score in blood pressure control and diabetic eye examinations. When compared nationally, CAL outperformed Medicaid and commercial plans in all five diabetic measures. The institution also outperformed Medicare in four of the five diabetic measures, with CAL scoring slightly lower in diabetic eye examinations. CAL outperformed the United States Department of Veterans Affairs (VA) in two of the four applicable measures, with CAL scoring lower in blood pressure control and diabetic eye examinations. Immunizations Comparative data for immunizations was only fully available for the VA and partially available for Kaiser, commercial plans, and Medicare. Regarding administering influenza vaccinations to younger adults, CAL scored lower than all health care plans except commercial plans and Medicaid. When administering influenza vaccinations to older adults, CAL had a 100 percent immunization rate, higher than both Medicare and the VA, the two health care plans with available data for this clinical measure. Regarding administering pneumococcal vaccines to older adults, CAL also scored 100 percent, higher than Medicare and the VA. Cancer Screening With respect to colorectal cancer screening, CAL scored higher than all health care plans. Summary CAL performed well in the clinical measures tested compared to the other health care plans reviewed. The institution may improve its scores for colorectal cancer screenings by reducing patient refusals through educating patients on the benefits of these preventive services. Calipatria State Prison, Cycle 5 Medical Inspection Page 66 Office of the Inspector General State of California CAL Results Compared to State and National HEDIS Scores California National HEDIS HEDIS CAL HEDIS HEDIS Clinical Measures Kaiser Kaiser HEDIS HEDIS VA Medi- Com- (No. (So. Medicaid Medicare Average Cycle 5 Cal mercial CA) CA) 20174 20174 20165 Results1 20172 20174 20163 20163 Comprehensive Diabetes Care HbA1c Testing (Monitoring) 100% 87% 94% 94% 87% 91% 94% 99% Poor HbA1c Control (>9.0%)6, 7 11% 38% 20% 23% 43% 33% 26% 18% HbA1c Control (<8.0%)6 82% 52% 70% 63% 47% 56% 63% - Blood Pressure Control 68% 63% 83% 83% 60% 62% 64% 76% (<140/90)6 Eye Exams 69% 57% 68% 81% 55% 54% 70% 89% Immunizations Influenza Shots - Adults (18–64) 49% - 56% 57% 39% 48% - 52% Influenza Shots - Adults (65+)6 100% - - - - - 71% 72% Immunizations: Pneumococcal6 100% - - - - - 74% 93% Cancer Screening Colorectal Cancer Screening 84% - 79% 82% - 62% 67% 82% 1.Unless otherwise stated, data was collected in October 2017 by reviewing medical records from a sample of CAL’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 Medi-Cal Managed Care External Quality Review Technical Report (July 1, 2016 – June 30, 2017). 3.Data was obtained from Kaiser Permanente November 2016 reports for the Northern and Southern California regions. 4.National HEDIS data for Medicaid, commercial plans, and Medicare was obtained from the 2017 State of Health Care Quality Report, available on the NCQA website: www.ncqa.org. The results for commercial plans were based on data received from various health maintenance organizations. 5.The Department of Veterans Affairs (VA) data was obtained from the VA’s website, www.va.gov. For the Immunizations: Pneumococcal measure only, the data was obtained from the VHA Facility Quality and Safety Report - Fiscal Year 2012 Data. 6.For this indicator, the entire applicable CAL 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. Calipatria State Prison, Cycle 5 Medical Inspection Page 67 Office of the Inspector General State of California A A — C T R PPENDIX OMPLIANCE EST ESULTS Calipatria State Prison Range of Summary Scores: 57.8% – 93.3% Indicator Compliance Score (Yes %) 1 – Access to Care 73.6% 2 – Diagnostic Services 78.1% 3 – Emergency Services Not Applicable 4 – Health Information Management (Medical Records) 89.6% 5 – Health Care Environment 57.8% 6 – Inter- and Intra-System Transfers 72.8% 7 – Pharmacy and Medication Management 58.4% 8 – Prenatal and Post-Delivery Services Not Applicable 9 – Preventive Services 86.5% 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) 93.3% 14 – Specialty Services 89.1% 15 – Administrative Operations 84.8% Calipatria State Prison, Cycle 5 Medical Inspection Page 68 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 17 8 25 68.0% 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 10 13 23 43.5% 2 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 face- 1.004 to-face visit within one business day after the CDCR Form 7362 29 1 30 96.7% 0 was reviewed? Clinical appointments: If the registered nurse determined a referral to a primary care provider was necessary, was the patient 1.005 8 3 11 72.7% 19 seen within the maximum allowable time or the ordered time frame, whichever is the shorter? Sick call follow-up appointments: If the primary care provider 1.006 ordered a follow-up sick call appointment, did it take place within 3 3 6 50.0% 24 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 6 25 76.0% 0 time frame? Specialty service follow-up appointments: Do specialty service 1.008 primary care physician follow-up visits occur within required time 18 7 25 72.0% 5 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: 73.6% Calipatria State Prison, Cycle 5 Medical Inspection Page 69 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 8 2 10 80.0% 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 8 2 10 80.0% 0 frames? Pathology: Did the institution receive the final diagnostic report 2.007 7 3 10 70.0% 0 within the required time frames? Pathology: Did the primary care provider review and initial the 2.008 7 1 8 87.5% 2 diagnostic report within specified time frames? Pathology: Did the primary care provider communicate the results 2.009 2 6 8 25.0% 2 of the diagnostic study to the patient within specified time frames? Overall percentage: 78.1% 3 – Emergency Services This indicator is evaluated only by case review clinicians. There is no compliance testing component. Calipatria State Prison, Cycle 5 Medical Inspection Page 70 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 12 0 12 100.0% 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 1 0 1 100.0% 0 date? Are High-Priority specialty notes (either a Form 7243 or other 4.003 scanned consulting report) scanned within the required time 18 2 20 90.0% 0 frame? Are community hospital discharge documents scanned into the 4.004 patient’s electronic health record within three calendar days of 17 3 20 85.0% 0 hospital discharge? Are medication administration records (MARs) scanned into the 4.005 Not Applicable patient’s electronic health record within the required time frames? During the inspection, were medical records properly scanned, 4.006 17 7 24 70.8% 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 23 2 25 92.0% 0 did a primary care provider review the report within three calendar days of discharge? Overall percentage: 89.6% Calipatria State Prison, Cycle 5 Medical Inspection Page 71 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 10 0 10 100.0% 0 and sanitary? Do clinical health care areas ensure that reusable invasive and 5.102 non-invasive medical equipment is properly sterilized or 6 3 9 66.7% 1 disinfected as warranted? Do clinical health care areas contain operable sinks and sufficient 5.103 9 1 10 90.0% 0 quantities of hygiene supplies? Does clinical health care staff adhere to universal hand hygiene 5.104 3 7 10 30.0% 0 precautions? Do clinical health care areas control exposure to blood-borne 5.105 6 4 10 60.0% 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 4 6 10 40.0% 0 storing bulk medical supplies? Do clinic common areas and exam rooms have essential core 5.108 1 9 10 10.0% 0 medical equipment and supplies? Do clinic common areas have an adequate environment conducive 5.109 8 2 10 80.0% 0 to providing medical services? Do clinic exam rooms have an adequate environment conducive 5.110 3 7 10 30.0% 0 to providing medical services? Emergency response bags: Are TTA and clinic emergency 5.111 medical response bags inspected daily and inventoried monthly, 2 5 7 28.6% 3 and do they contain essential items? Overall percentage: 57.8% Calipatria State Prison, Cycle 5 Medical Inspection Page 72 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 21 4 25 84.0% 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 17 0 17 100.0% 8 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 2 0 2 100.0% 23 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 16 4 20 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 0 2 0 0.0% 6 corresponding transfer packet required documents? Overall percentage: 72.8% Calipatria State Prison, Cycle 5 Medical Inspection Page 73 Office of the Inspector General State of California Scored Answers 7 – Pharmacy and Medication Yes Reference + Management Number Yes No No Yes % N/A Did the patient receive all chronic care medications within the 7.001 required time frames or did the institution follow departmental 14 1 15 93.3% 10 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 18 7 25 72.0% 0 time frames? Upon the patient’s discharge from a community hospital: Were all 7.003 ordered medications administered, made available, or delivered to 22 3 25 88.0% 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 22 1 23 95.7% 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 4 4 8 50.0% 3 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 4 6 10 40.0% 1 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 1 9 10 10.0% 1 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 3 3 6 50.0% 5 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% 5 protocols when preparing medications for patients? Medication preparation and administration areas: Does the 7.106 Institution employ appropriate administrative controls and 1 5 6 16.7% 5 protocols when distributing medications to patients? Calipatria State Prison, Cycle 5 Medical Inspection Page 74 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 employ and follow general 7.107 security, organization, and cleanliness management protocols in 0 1 0 0.0% 0 its main and satellite pharmacies? 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 15 10 25 60.0% 0 protocols? Overall percentage: 58.4% 8 – Prenatal and Post-Delivery Services The institution had no female patients, so this indicator was not applicable. Calipatria State Prison, Cycle 5 Medical Inspection Page 75 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 10 2 12 83.3% 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 7 5 12 58.3% 0 the medication? Annual TB Screening: Was the patient screened for TB within the 9.003 29 1 30 96.7% 0 last year? Were all patients offered an influenza vaccination for the most 9.004 24 1 25 96.0% 0 recent influenza season? All patients from the age of 50 – 75: Was the patient offered 9.005 25 0 25 100.0% 0 colorectal cancer screening? Female patients from the age of 50 through the age of 74: Was the 9.006 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 11 2 13 84.6% 12 patients? Are patients at the highest risk of coccidioidomycosis (valley 9.009 Not Applicable fever) infection transferred out of the facility in a timely manner? Overall percentage: 86.5% 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. Calipatria State Prison, Cycle 5 Medical Inspection Page 76 Office of the Inspector General State of California 12 – Reception Center Arrivals The institution had no reception center, so this indicator was not applicable. Scored Answers Yes Reference + 13 – Specialized Medical Housing Number Yes No No Yes % N/A For OHU, CTC, and SNF: Did the registered nurse complete an 13.001 initial assessment of the patient on the day of admission, or within 8 2 10 80.0% 0 eight hours of admission to CMF’s Hospice? For CTC and SNF only: Was a written history and physical 13.002 Not Applicable examination completed within the required time frame? For OHU, CTC, SNF, and Hospice: Did the primary care provider complete the Subjective, Objective, Assessment, Plan, and 13.003 7 0 7 100.0% 3 Education (SOAPE) notes on the patient at the minimum intervals required for the type of facility where the patient was treated? For OHU and CTC only: Do inpatient areas either have properly working call systems in its OHU & CTC or are 30-minute patient 13.101 1 0 1 100.0% 0 welfare checks performed; and do medical staff have reasonably unimpeded access to enter patient’s cells? Overall percentage: 93.3% Calipatria State Prison, Cycle 5 Medical Inspection Page 77 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 14 1 15 93.3% 0 Physician Request for Service? Did the primary care provider review the high-priority specialty 14.002 14 1 15 93.3% 0 service consultant report within the required time frame? Did the patient receive the routine specialty service within 90 14.003 calendar days of the primary care provider order or Physician 15 0 15 100.0% 0 Request for Service? Did the primary care provider review the routine specialty service 14.004 10 3 13 76.9% 2 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 12 8 20 60.0% 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 9 0 9 100.0% 0 specialty services within required time frames? Following the denial of a request for specialty services, was the 14.007 9 0 9 100.0% 0 patient informed of the denial within the required time frame? Overall percentage: 89.1% Calipatria State Prison, Cycle 5 Medical Inspection Page 78 Office of the Inspector General State of California Scored Answers Reference Yes 15 – Administrative Operations + Number Yes No No Yes % N/A Did the institution promptly process inmate medical appeals 15.001 9 3 12 75.0% 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 12 0 12 100.0% 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 0 3 3 0.0% 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 5 1 6 83.3% 0 inmate death report to the Death Review Unit in a timely manner? Does the institution’s Supervising Registered Nurse conduct 15.104 4 1 5 80.0% 0 periodic reviews of nursing staff? Are nursing staff who administer medications current on their 15.105 10 0 10 100.0% 0 clinical competency validation? 15.106 Are structured clinical performance appraisals completed timely? 2 4 6 33.3% 0 15.107 Do all providers maintain a current medical license? 15 0 15 100.0% 0 Are staff current with required medical emergency response 15.108 2 0 2 100.0% 1 certifications? Calipatria State Prison, Cycle 5 Medical Inspection Page 79 Office of the Inspector General State of California Scored Answers Yes Reference 15 – Administrative Operations + Number Yes No No Yes % N/A 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? 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: 84.8% Calipatria State Prison, Cycle 5 Medical Inspection Page 80 Office of the Inspector General State of California A B — C D PPENDIX LINICAL ATA Table B-1: CAL Sample Sets Sample Set Total Death Review/Sentinel Events 2 Diabetes 3 Emergency Services – CPR 5 Emergency Services – Non-CPR 2 High Risk 5 Hospitalization 5 Intra-System Transfers In 3 Intra-System Transfers Out 3 RN Sick Call 18 Specialty Services 3 49 Calipatria State Prison, Cycle 5 Medical Inspection Page 81 Office of the Inspector General State of California Table B-2: CAL Chronic Care Diagnoses Diagnosis Total Anemia 3 Arthritis/Degenerative Joint Disease 4 Asthma 12 Cancer 4 Cardiovascular Disease 1 Chronic Pain 17 Diabetes 6 Gastroesophageal Reflux Disease 12 Gastrointestinal Bleed 1 Hepatitis C 23 Hyperlipidemia 9 Hypertension 9 Mental Health 4 Seizure Disorder 3 Sleep Apnea 2 Thyroid Disease 3 113 Calipatria State Prison, Cycle 5 Medical Inspection Page 82 Office of the Inspector General State of California Table B-3: CAL Event – Program Diagnosis Total Diagnostic Services 75 Emergency Care 31 Hospitalization 42 Intra-System Transfers In 13 Intra-System Transfers Out 9 Outpatient Care 308 Specialized Medical Housing 122 Specialty Services 124 724 Calipatria State Prison, Cycle 5 Medical Inspection Page 83 Office of the Inspector General State of California Table B-4: CAL Review Sample Summary Total MD Reviews Detailed 20 MD Reviews Focused 0 RN Reviews Detailed 14 RN Reviews Focused 29 Total Reviews 63 Total Unique Cases 49 Overlapping Reviews (MD & RN) 14 Calipatria State Prison, Cycle 5 Medical Inspection Page 84 Office of the Inspector General State of California A C — C S M PPENDIX OMPLIANCE AMPLING ETHODOLOGY Calipatria State Prison (CAL) Sample Category Quality (number of Indicator samples) Data Source Filters Access to Care MIT 1.001 Chronic Care Patients Master Registry • Chronic care conditions (at least one condition per patient—any risk level) (25) • Randomize MIT 1.002 Nursing Referrals OIG Q: 6.001 • See Intra-system Transfers (25) MITs 1.003–006 Nursing Sick Call MedSATS • Clinic (each clinic tested) (5 per clinic) • Appointment date (2–9 months) (30) • Randomize MIT 1.007 Returns from OIG Q: 4.007 • See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (25) 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 Calipatria State Prison, Cycle 5 Medical Inspection Page 85 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 (12) 1.002, & 1.004 • 1st 10 IPs MIT 1.001, 1st 5 IPs MITs 1.002, 1.004 MIT 4.002 OIG Q: 1.001 • Dictated documents (1) • First 20 IPs selected MIT 4.003 OIG Qs: 14.002 • Specialty documents (20) & 14.004 • First 10 IPs for each question MIT 4.004 OIG Q: 4.007 • Community hospital discharge documents (20) • 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 (7) 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) (25) Health Care Environment MITs 5.101–105 Clinical Areas OIG inspector • Identify and inspect all onsite clinical areas. MITs 5.107–111 (10) onsite review Inter- and Intra-System Transfers MITs 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 (20) MIT 6.101 Transfers Out OIG inspector • R&R IP transfers with medication (8) onsite review Calipatria State Prison, Cycle 5 Medical Inspection Page 86 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) (25) MIT 7.004 RC Arrivals – OIG Q: 12.001 • See Reception Center Arrivals Medication Orders (N/A at this institution) MIT 7.005 Intra-Facility Moves MAPIP transfer • Date of transfer (2–8 months) data • To location/from location (yard to yard and to/from ASU) • Remove any to/from MHCB • NA/DOT meds (and risk level) (23) • 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 (10) listing Prenatal and Post-Delivery Services MITs 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) Calipatria State Prison, Cycle 5 Medical Inspection Page 87 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Preventive Services MITs 9.001–002 TB Medications Maxor • Dispense date (past 9 months) • Time period on TB meds (3 months or 12 weeks) (12) • Randomize MIT 9.003 TB Evaluation, SOMS • Arrival date (at least 1 year prior to inspection) Annual Screening • Birth Month (30) • Randomize MIT 9.004 Influenza SOMS • Arrival date (at least 1 year prior to inspection) Vaccinations • Randomize (25) • Filter out IPs tested in MIT 9.008 MIT 9.005 Colorectal Cancer SOMS • Arrival date (at least 1 year prior to inspection) Screening • Date of birth (51 or older) (25) • Randomize MIT 9.006 Mammogram SOMS • Arrival date (at least 2 yrs prior to inspection) (N/A at this • Date of birth (age 52–74) institution) • Randomize MIT 9.007 Pap Smear SOMS • Arrival date (at least three yrs prior to inspection) (N/A at this • Date of birth (age 24–53) institution) • Randomize MIT 9.008 Chronic Care OIG Q: 1.001 • Chronic care conditions (at least 1 condition per Vaccinations IP—any risk level) • Randomize (25) • Condition must require vaccination(s) MIT 9.009 Valley Fever Cocci transfer • Reports from past 2–8 months status report • Institution (N/A at this • Ineligibility date (60 days prior to inspection date) institution) • All Calipatria State Prison, Cycle 5 Medical Inspection Page 88 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 OHU CADDIS • Admit date (1–6 months) • Type of stay (no MH beds) • Length of stay (minimum of 5 days) (10) • Randomize MIT 13.101 Call Buttons OIG inspector • Review by location OHU onsite review (all) Specialty Services MITs 14.001–002 High-Priority MedSATS • Approval date (3–9 months) (15) • Randomize MITs 14.003–004 Routine MedSATS • Approval date (3–9 months) • Remove optometry, physical therapy or podiatry (15) • Randomize MIT 14.005 Specialty Services MedSATS • Arrived from (other CDCR institution) Arrivals • Date of transfer (3–9 months) (20) • Randomize MIT 14.006–007 Denials InterQual • Review date (3–9 months) (0) • Randomize IUMC/MAR • Meeting date (9 months) Meeting Minutes • Denial upheld (9) • Randomize Calipatria State Prison, Cycle 5 Medical Inspection Page 89 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 (6) 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 (5) evaluation files MIT 15.107 Provider licenses Current provider • Review all listing (at start of (15) 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) Calipatria State Prison, Cycle 5 Medical Inspection Page 90 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 (6) Calipatria State Prison, Cycle 5 Medical Inspection Page 91 Office of the Inspector General State of California C C ALIFORNIA ORRECTIONAL H C S ’ EALTH ARE ERVICES R ESPONSE Calipatria State Prison, Cycle 5 Medical Inspection Page 92 Office of the Inspector General State of California