California Correctional Institution Cycle 7 Medical Inspection Report

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Connect with us on social media Cycle 7, California Correctional Institution | iii Contents Illustrations iv Introduction 1 Summary: Ratings and Scores 3 Medical Inspection Results 5 Deficiencies Identified During Case Review 5 Case Review Results 5 Compliance Testing Results 5 Institution-Specific Metrics 6 Population-Based Metrics 9 HEDIS Results 9 Recommendations 11 Indicators 14 Access to Care 14 Diagnostic Services 20 Emergency Services 25 Health Information Management 30 Health Care Environment 36 Transfers 45 Medication Management 52 Preventive Services 60 Nursing Performance 63 Provider Performance 68 Specialized Medical Housing 74 Specialty Services 80 Administrative Operations 86 Appendix A: Methodology 89 Case Reviews 90 Compliance Testing 93 Indicator Ratings and the Overall Medical Quality Rating 94 Appendix B: Case Review Data 95 Appendix C: Compliance Sampling Methodology 99 California Correctional Health Care Services’ Response 107 Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | iv Illustrations Tables 1. CCI Summary Table: Case Review Ratings and Policy Compliance Scores 4 2. CCI Master Registry Data as of October 2023 7 3. CCI Health Care Staffing Resources as of October 2023 8 4. CCI Results Compared With State HEDIS Scores 10 5. Access to Care 17 6. Other Tests Related to Access to Care 18 7. Diagnostic Services 23 8. Health Information Management 33 9. Other Tests Related to Health Information Management 34 10. Health Care Environment 43 11. Transfers 49 12. Other Tests Related to Transfers 50 13. Medication Management 57 14. Other Tests Related to Medication Management 58 15. Preventive Services 61 16. Specialized Medical Housing 78 17. Specialty Services 83 18. Other Tests Related to Specialized Services 84 19. Administrative Operations 87 A–1. Case Review Definitions 90 B–1. CCI Case Review Sample Sets 95 B–2. CCI Case Review Chronic Care Diagnoses 96 B–3. CCI Case Review Events by Program 97 B–4. CCI Case Review Sample Summary 97 Figures A–1. Inspection Indicator Review Distribution for CCI 89 A–2. Case Review Testing 92 A–3. Compliance Sampling Methodology 93 Photographs 1. Indoor Waiting Area 36 2. Expired Medical Supplies 37 3. Incomplete EMRB Glucometer Logs 38 4. Compromised EMRB Medical Supply 38 5. Expired Supplies in the Warehouse 39 6. Warehouse Supplies With Temperature Guidelines 39 7. Laboratory Equipment and Supplies Stored in the Soiled Utility Room (photo 1 of 3) 40 8. Laboratory Equipment and Supplies Stored in the Soiled Utility Room (photo 2 of 3) 41 9. Laboratory Equipment and Supplies Stored in the Soiled Utility Room (photo 3 of 3) 41 10. Peeling Paint on the Clinic Ceiling 42 Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 1 Introduction Pursuant to California Penal Code section 6126 et seq., the Office of the Inspector General (the OIG) is responsible for periodically reviewing and reporting on the delivery of the ongoing medical care provided to incarcerated people1 in the California Department of Corrections and Rehabilitation (the department).2 In Cycle 7, the OIG continues to apply the same assessment methodologies used in Cycle 6, including clinical case review and compliance testing. Together, these methods assess the institution’s medical care on both individual and system levels by providing an accurate assessment of how the institution’s health care systems function regarding patients with the highest medical risk, who tend to access services at the highest rate. Through these methods, the OIG evaluates the performance of the institution in providing sustainable, adequate care. We continue to review institutional care using 15 indicators as in prior cycles.3 Using each of these indicators, our compliance inspectors collect data in answer to compliance- and performance-related questions as established in the medical inspection tool (MIT). In addition, our clinicians complete document reviews of individual cases and also perform on-site inspections, which include interviews with staff. The OIG determines a total compliance score for each applicable indicator and considers the MIT scores in the overall conclusion of the institution’s compliance performance. In conducting in-depth quality-focused reviews of randomized cases, our case review clinicians examine whether health care staff used sound medical judgment in the course of caring for a patient. In the event we find errors, we determine whether such errors were clinically significant or led to a significantly increased risk of harm to the patient. At the same time, our clinicians consider whether institutional medical processes led to identifying and correcting individual or system errors, and we examine whether the institution’s medical system mitigated the error. The OIG rates each applicable indicator proficient, adequate, or inadequate, and considers each rating in the overall conclusion of the institution’s health care performance. In contrast to Cycle 6, the OIG will provide individual clinical case review ratings and compliance testing scores in Cycle 7, rather than aggregate all findings into a single overall institution rating. This change will clarify the distinctions between these differing quality measures and the results of each assessment. 1 In this report, we use the terms patient and patients to refer to incarcerated people. 2 The OIG’s medical inspections are not designed to resolve questions about the constitutionality of care, and the OIG explicitly makes no determination regarding the constitutionality of care that the department provides to its population. 3 In addition to our own compliance testing and case reviews, the OIG continues to offer selected Healthcare Effectiveness Data and Information Set (HEDIS) measures for comparison purposes. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 2 As we did during Cycle 6, our office continues to inspect both those institutions remaining under federal receivership and those delegated back to the department. There is no difference in the standards used for assessing a delegated institution versus an institution not yet delegated. At the time of the Cycle 7 inspection of California Correctional Institution, the institution had been delegated back to the department by the receiver. We completed our seventh inspection of the institution, and this report presents our assessment of the health care provided at this institution during the inspection period from March 2023 to August 2023.4 4 Samples are obtained per case review methodology shared with stakeholders in prior cycles. The case reviews include death reviews between August 2022 and April 2023 and transfer reviews between March 2023 and June 2023. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 3 Summary: Ratings and Scores We completed the Cycle 7 inspection of CCI in January 2024. OIG inspectors monitored the institution’s delivery of medical care that occurred between March 2023 and August 2023. The OIG rated the case review The OIG rated the compliance component of the overall health care component of the overall health care quality at CCI adequate. quality at CCI inadequate. OIG case review clinicians (a team of physicians and nurse consultants) reviewed 45 cases, which contained 763 patient-related events. They performed quality control reviews; their subsequent collective deliberations ensured consistency, accuracy, and thoroughness. Our OIG clinicians acknowledged institutional structures that catch and resolve mistakes, which may occur throughout the delivery of care. After examining medical records, our clinicians completed a follow-up on-site inspection in January 2024 to verify their initial findings. The OIG physicians rated the quality of care for 20 comprehensive case reviews. Of these 20 cases, our physicians rated 18 adequate and two inadequate. To test the institution’s policy compliance, our compliance inspectors (a team of registered nurses) monitored the institution’s compliance with its medical policies by answering a standardized set of questions that measure specific elements of health care delivery. Our compliance inspectors examined 344 patient records and 1,014 data points, and we used the data to answer 90 policy questions. In addition, we observed CCI’s processes during an on-site inspection in October 2023. The OIG then considered the results from both case review and compliance testing, and drew overall conclusions, which we report in 13 health care indicators.5 5 The indicators for Reception Center and Prenatal and Postpartum Care did not apply to CCI. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 4 We list the individual indicators and ratings applicable for this institution in Table 1 below. Table 1. CCI Summary Table: Case Review Ratings and Policy Compliance Scores Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 5 Medical Inspection Results Deficiencies Identified During Case Review Deficiencies are medical errors that increase the risk of patient harm. Deficiencies can be minor or significant, depending on the severity of the deficiency. An adverse event occurs when the deficiency caused harm to the patient. All major health care organizations identify and track adverse events. We identify deficiencies and adverse events to highlight concerns regarding the provision of care and for the benefit of the institution’s quality improvement program to provide an impetus for improvement.6 The OIG found no adverse events at CCI during the Cycle 7 inspection. Case Review Results OIG case reviewers (a team of physicians and nurse consultants) assessed 10 of the 13 indicators applicable to CCI. Of these 10 indicators, OIG clinicians rated one proficient and nine adequate. The OIG physicians also rated the overall adequacy of care for each of the 20 detailed case reviews they conducted. Of these 20 cases, 18 were adequate, and two were inadequate. In the 763 events reviewed, we found 275 deficiencies, 21 of which the OIG clinicians considered to be of such magnitude that, if left unaddressed, would likely contribute to patient harm. Our clinicians found the following strengths at CCI: • Staff provided excellent access to nursing, provider, and specialty appointments. • Staff handled STAT laboratory tests appropriately. • Clinic staff provided good continuity of care. Our clinicians found the following weaknesses at CCI: • Providers did not consistently communicate diagnostic test results to patients with complete test result letters. • Staff inconsistently retrieved or scanned specialty reports into patient records timely. Compliance Testing Results Our compliance inspectors assessed 10 of the 13 indicators applicable to CCI. Of these 10 indicators, our compliance inspectors rated one proficient, two adequate, and seven inadequate. We tested policy compliance in Health Care Environment, Preventive 6 For a further discussion of an adverse event, see Table A–1. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 6 Services, and Administrative Operations as these indicators do not have a case review component. CCI showed a high rate of policy compliance in the following areas: • Nursing staff often processed sick call request forms, performed face-to-face evaluations, and completed nurse-to-provider referrals within required time frames. • Primary care providers usually evaluated their patients returning from outside community hospitals or specialty service appointments within specified time frames. Moreover, staff scheduled patients within required time frames to see their providers upon arrival at the institution. • Staff offered influenza vaccinations and provided colorectal cancer screenings to patients timely. CCI showed a low rate of policy compliance in the following areas: • Staff frequently failed to maintain medication continuity for chronic care patients, patients discharged from the hospital, and patients admitted to a specialized medical housing unit. In addition, staff intermittently maintained medication continuity for patients who transferred into the institution, transferred within the institution, or had a temporary layover at CCI. • Health care staff did not follow hand hygiene precautions before or after patient encounters. • CCI’s medical warehouse and clinical areas had multiple expired medical supplies. • Nurses did not regularly inspect emergency medical response bags. • Providers sporadically communicated results of diagnostic services timely. Most patient notification letters communicating these results were missing the date of the diagnostic service, the date of the results, and whether the results were within normal limits. Institution-Specific Metrics The California Correctional Institution (CCI) is located in Cummings Valley, west of the city of Tehachapi in Kern County. CCI consists of five separate facilities, housing incarcerated persons of varying security levels, from minimum to maximum security. The institution operates three medical clinics where staff members handle nonurgent requests for medical services. Each of the three facilities has a minor procedure room that functions as a triage and treatment area (TTA). The TTA is used for urgent and emergency care. CCI has been designated by California Correctional Health Care Services (CCHCS) as a basic care institution. Basic care institutions are located in rural areas, away from tertiary care centers and specialty care providers whose services would likely be used frequently by high-risk patients. Basic care institutions are capable of Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 7 providing limited specialty medical services and consultation for a generally healthy patient population.7 As of July 18, 2024, the department reports on its public tracker that 78 percent of CCI’s incarcerated population is fully vaccinated for COVID-19 while 55 percent of CCI’s staff is fully vaccinated for COVID-19. In October 2023, the Health Care Services Master Registry showed that CCI had a total population of 1,718. A breakdown of the medical risk level of the CCI population as determined by the department is set forth in Table 2 below.8 Table 2. CCI Master Registry Data as of October 2023 Medical Risk Level Number of Patients Percentage* High 1 21 1.2% High 2 87 5.1% Medium 826 48.1% Low 784 45.6% Total 1,718 100.0% * Percentages may not total 100% due to rounding. Source: Data for the population medical risk level were obtained from the CCHCS Master Registry dated October 9, 2023. 7 For more information, see the department’s statistics on its website page titled Population COVID‑19 Tracking. 8 For a definition of medical risk, see CCHCS HCDOM 1.2.14, Appendix 1.9. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 8 According to staffing data the OIG obtained from California Correctional Health Care Services (CCHCS), as identified in Table 3 below, CCI had 2.0 executive leadership vacancies, 1.0 primary care provider vacancy, 0.7 nursing supervisor vacancy, and 2.0 nursing staff vacancies. Table 3. CCI Health Care Staffing Resources as of October 2023 Executive Primary Care Nursing Nursing Positions Leadership * Providers Supervisors Staff † Total Authorized Positions 5.0 6.5 10.7 85.0 107.2 Filled by Civil Service 3.0 5.5 10.0 83.0 101.5 Vacant 2.0 1.0 0.7 2.0 5.7 Percentage Filled by Civil Service 60.0% 84.6% 93.5% 97.6% 94.7% Filled by Telemedicine 0 0 0 0 0 Percentage Filled by Telemedicine 0 0 0 0 0 Filled by Registry 0 0 0 0 0 Percentage Filled by Registry 0 0 0 0 0 Total Filled Positions 3.0 5.5 10.0 83.0 101.5 Total Percentage Filled 60.0% 84.6% 93.5% 97.6% 94.7% Appointments in Last 12 Months 0 0 1.0 4.0 5.0 Redirected Staff 0 0 0 0 0 Staff on Extended Leave ‡ 0 0 0 3.0 3.0 Adjusted Total: Filled Positions 3.0 5.5 10.0 80.0 98.5 Adjusted Total: Percentage Filled 60.0% 84.6% 93.5% 94.1% 91.9% * Executive Leadership includes the Chief Physician and Surgeon. † Nursing Staff includes the classifications of Senior Psychiatric Technician and Psychiatric Technician. ‡ In Authorized Positions. Notes: The OIG does not independently validate staffing data received from the department. Positions are based on fractional time-base equivalents. Source: Cycle 7 medical inspection preinspection questionnaire received on October 9, 2023, from California Correctional Health Care Services. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 9 Population-Based Metrics In addition to our own compliance testing and case reviews, as noted above, the OIG presents selected measures from the Healthcare Effectiveness Data and Information Set (HEDIS) for comparison purposes. The HEDIS is a set of standardized quantitative performance measures designed by the National Committee for Quality Assurance to ensure that the public has the data it needs to compare the performance of health care plans. Because the Veterans Administration no longer publishes its individual HEDIS scores, we removed them from our comparison for Cycle 7. Likewise, Kaiser (commercial plan) no longer publishes HEDIS scores. However, through the California Department of Health Care Services’ Medi‑Cal Managed Care Technical Report, the OIG obtained California Medi-Cal and Kaiser Medi-Cal HEDIS scores to use in conducting our analysis, and we present them here for comparison. HEDIS Results We considered CCI’s performance with population-based metrics to assess the macroscopic view of the institution’s health care delivery. Currently, only two HEDIS measures are available for review: poor HbA1c control, which measures the percentage of diabetic patients who have poor blood sugar control, and colorectal cancer screening rates for patients ages 45 to 75. For poor HBA1c control, CCI’s results compared favorably with those found in State health plans. We list the applicable HEDIS measures in Table 4. Comprehensive Diabetes Care When compared with statewide Medi-Cal programs—California Medi-Cal, Kaiser Northern California (Medi-Cal), and Kaiser Southern California (Medi-Cal)—CCI’s percentage of patients with poor HbA1c control was significantly lower, indicating very good performance on this measure. Immunizations Statewide comparative data were not available for immunization measures; however, we include these data for informational purposes. CCI had a 38 percent influenza immunization rate for adults 18 to 64 years old and a 55 percent influenza immunization rate for adults 65 years of age and older.9 The pneumococcal vaccination rate was 95 percent.10 Cancer Screening When compared with statewide Medi-Cal programs—California Medi-Cal, Kaiser Northern California (Medi-Cal), and Kaiser Southern California (Medi-Cal)—CCI’s 9 The HEDIS sampling methodology requires a minimum sample of 10 patients to have a reportable result. 10 The pneumococcal vaccines administered are the 13, 15, and 20 valent pneumococcal vaccines (PCV13, PCV15, and PCV20), or 23 valent pneumococcal vaccine (PPSV23), depending on the patient’s medical conditions. For the adult population, the influenza or pneumococcal vaccine may have been administered at a different institution other than where the patient was currently housed during the inspection period. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 10 colorectal cancer screening rate of 69% was only lower than Kaiser Southern California (Medi-Cal). Table 4. CCI Results Compared With State HEDIS Scores CCI California California Kaiser Kaiser Cycle 7 California NorCal SoCal HEDIS Measure Results * Medi-Cal † Medi-Cal † Medi-Cal † HbA1c Screening 93% – – – Poor HbA1c Control (> 9.0%) ‡,§ 7.4% 36% 31% 22% HbA1c Control (< 8.0%) ‡ 88% – – – Blood Pressure Control (< 140/90) ‡ 82% – – – Eye Examinations 50% – – – Influenza – Adults (18 – 64) 38% – – – Influenza – Adults (65 +) 55% – – – Pneumococcal – Adults (65 +) 95% – – – Colorectal Cancer Screening 69% 37% 68% 70% Notes and Sources * Unless otherwise stated, data were collected in October 2023 by reviewing medical records from a sample of SVSP’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. † HEDIS Medi-Cal data were obtained from the California Department of Health Care Services publication Medi-Cal Managed Care External Quality Review Technical Report, dated July 1, 2022– June 30, 2023 (published March - April 2024); https://www.dhcs.ca.gov/dataandstats/reports/Documents/Medi-Cal-Managed-Care-Technical-Report- Volume-1.pdf ‡ For this indicator, the entire applicable SVSP population was tested. § For this measure only, a lower score is better. Source: Institution information provided by the California Department of Corrections and Rehabilitation. Health care plan data were obtained from the CCHCS Master Registry. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 11 Recommendations As a result of our assessment of CCI’s performance, we offer the following recommendations to the department: Diagnostic Services • Medical leadership should ascertain causative factors related to the untimely provision of laboratory services and implement remedial measures as appropriate. • The department should consider developing strategies, such as potentially an electronic solution, to ensure providers create patient test result notification letters when they endorse test results and ensure patient letters contain all elements required by CCHCS policy. Emergency Services • Nursing leadership should determine the root cause of challenges that prevent nurses from accurately documenting the time and sequence of events during emergency responses and should implement remedial measures as appropriate. • Nursing and medical leadership should determine the challenges to identifying all documentation and timeline deficiencies in the emergency medical response clinical review process and should implement remedial measures as appropriate. Health Information Management • The institution should identify the challenges to properly labeling and scanning documents into the medical record and should implement remedial measures as appropriate. Health Care Environment • Medical leadership should determine the root cause(s) for staff not following all required universal hand hygiene precautions and should take necessary remedial measures. • Executive leadership should determine the root cause(s) for staff not ensuring medical supply storage areas, located inside and outside the clinics, store medical supplies adequately and should take necessary remedial measures. • Nursing leadership should determine the root cause(s) for staff not ensuring clinic examination rooms contain essential core medical equipment and should take necessary remedial measures that include verifying staff follow equipment and medical supply management protocols. • Nursing leadership should determine the root cause(s) for staff not ensuring the emergency medical response bags (EMRBs) are regularly inventoried and Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 12 sealed, or staff failing to properly complete the monthly logs, and should take necessary remedial measures. Transfers • Nursing leadership should determine the root cause of challenges preventing nurses from thoroughly completing the initial health screening process, including documenting a complete set of vital signs, answering all questions, and documenting an explanation for all “Yes” answers before the patient is transferred to the housing unit. Leadership should implement remedial measures as appropriate. • Nursing leadership should develop strategies to ensure newly arrived patients receive medications without interruption. In addition, nursing leadership should develop strategies to ensure nurses document reasons for patient refusals on the MAR summaries in accordance with CCHCS policies and procedures. Medication Management • The institution should develop and implement measures to ensure staff timely make available and administer chronic care medications and community hospital discharge medications. Measures should also ensure timely administering medications to patients temporarily housed at the institution, patients transferring within the institution, and patients returning from off-site specialty appointments. • Nursing leadership should develop and implement measures to ensure nursing staff document administering medications, patient refusals, and no- shows in the electronic health record, in accordance with CCHCS’s policies and procedures. Preventive Services • Nursing leadership should develop and implement measures to ensure nursing staff administer TB medications to patients as prescribed and monitor the patients according to CCHCS policy. • Medical leadership should determine the root cause(s) for challenges to timely providing vaccinations to chronic care patients and should implement appropriate remedial measures. Nursing Performance • Nursing leadership should determine the challenges preventing nurses from performing complete assessments and documentation and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 13 Specialized Medical Housing • Medical leadership should determine the root cause of challenges to providers completing thorough assessments and clear treatment plans for specialized medical housing patients and should implement remedial measures as appropriate. • The institution should ascertain the causes related to the untimely availability and administration of medications to specialized medical housing patients and should implement remedial measures as appropriate. Specialty Services • Medical leadership should determine the root cause(s) of challenges to the timely provision of specialty appointments for newly transferred patients and should implement remedial measures as appropriate. • Medical leadership should ascertain the challenges to the timely receipt and provider review of specialty reports and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 14 Indicators Access to Care In this indicator, OIG inspectors evaluated the institution’s performance in providing patients with timely clinical appointments. Our inspectors reviewed scheduling and appointment timeliness for newly arrived patients, sick calls, and nurse follow-up appointments. We examined referrals to primary care providers, provider follow-ups, and specialists. Furthermore, we evaluated the follow-up appointments for patients who received specialty care or returned from an off-site hospitalization. Ratings and Results Overview Case Review Rating Compliance Rating and Score Proficient Proficient (89.1%) Compared with Cycle 6, case review found access to care at CCI had greatly improved. In many respects, patients had excellent access to nurses, providers, and specialists. Follow- up appointments after emergency care, hospital care, and specialty care were also timely and appropriate. Overall, the OIG rated the case review component of this indicator proficient. Compliance testing showed CCI performed excellently in this indicator. Access to providers was very good for newly transferred patients and for patients returning from hospitalization and specialty service appointments. Nurses frequently reviewed patient sick call requests and completed face-to-face encounters within required time frames. However, staff needed improvement in providing chronic care appointments and in maintaining an adequate system of replenishing health care request forms in housing units. Based on the overall compliance score result, the OIG rated this indicator proficient. Case Review and Compliance Testing Results OIG clinicians reviewed 187 provider, nursing, specialty, and hospital events requiring the institution to generate appointments. We identified three deficiencies relating to Access to Care, none of which were significant.11 Access to Clinic Providers CCI’s performance was generally good in providing access to clinic providers. In compliance testing, provider follow-up appointments frequently occurred when requested by a nurse (MIT 1.005, 90.9%) and always occurred when ordered by a provider (MIT 1.006, 100%). However, chronic care follow-up appointments only sometimes occurred within required time frames (MIT 1.001, 72.0%). Case review found no deficiencies related to outpatient provider access. 11 Deficiencies occurred in cases 8, 23, and 44. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 15 Access to Specialized Medical Housing Providers Patients in specialized medical housing had excellent access to providers. Compliance testing showed providers were generally prompt in completing history and physical examinations within required time frames (MIT 13.002, 80.0%). Case review found providers almost always evaluated patients upon arrival to the outpatient housing unit (OHU) and rounded on patients appropriately. Providers also always assessed patients after specialist appointments and hospital encounters. Case review identified only one deficiency related to provider access in the OHU: • In case 44, a provider completed an OHU admission history and physical one day late. Access to Clinic Nurses CCI performed excellently in access to nurse sick calls and provider-to-nurse referrals. Compliance testing showed nursing reviewed almost all sick call requests on the same day they were received (MIT 1.003, 96.7%), and nurses completed nearly all face-to-face encounters within one day after the sick call requests were reviewed (MIT 1.004, 93.1%). OIG clinicians reviewed 33 nursing sick call requests in 20 cases and identified only two minor deficiencies related to clinic nurse access.12 The following is an example: • In case 8, a nurse triaged a health care request with a patient complaint of constipation and a request for stool softener. However, the order for the nursing evaluation appointment was scheduled incorrectly, resulting in the patient not being timely seen. Access to Specialty Services CCI provided good access to specialists. Compliance testing showed outstanding completion rates for high-priority (MIT 14.001, 93.3%), routine-priority (MIT 14.007, 100%) referrals, as well as for high-priority follow-up appointments (MIT 14.003, 100%). However, medium-priority (MIT 14.004, 86.7%) referrals, and medium-priority (MIT 14.006, 60.0%) and routine-priority (MIT 14.009, 80.0%) follow-up appointments occurred less timely. OIG clinicians reviewed 61 specialty events and identified no deficiencies related to patient access for specialty referrals. Follow-Up After Specialty Services CCI also delivered good access to providers after specialty appointments. Compliance testing showed patients were regularly seen within the expected time frames (MIT 1.008, 86.7%). Case review found no deficiencies related to scheduling a provider follow-up after a specialty encounter. Follow-Up After Hospitalization CCI provided excellent follow-up for patients after a hospitalization. Compliance testing showed all discharged patients were seen within the required time frame (MIT 1.007, 12 Nursing access deficiencies occurred in cases 8 and 9. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 16 100%). OIG clinicians reviewed 14 hospital events and did not identify any deficiencies related to follow-up appointments after a hospitalization. Follow-Up After Urgent or Emergent Care (TTA) OIG clinicians reviewed 12 triage and treatment area (TTA) and emergency events with no access deficiencies. Follow-Up After Transferring Into CCI Access to care for patients who had recently transferred into CCI was excellent. Compliance testing showed providers consistently evaluated new patients within required time frames (MIT 1.002, 95.7%). OIG clinicians reviewed six transfer-in events and found no deficiencies related to provider access. Clinician On-Site Inspection CCI had three medical clinics at the time of our inspection: Facilities A, B, and C. Facilities D and E had been closed in the prior year, but had offices used for administrative purposes only. The providers worked a variety of schedules, including full- time and part-time, two to five days per week. CCI also utilized telemedicine and registry providers. Staff reported no backlog in any of the clinics at the time of our inspection. Clinic supervisors stated evening clinics were occasionally held in Facility B if a significant backlog developed, typically two to three times per month. Clinic staff reported no custodial issues when patients are added to the clinic schedule or with transporting patients. Morning huddles were organized and collegial. Staff members attended either in-person or through virtual conferencing. Office technicians participated in the huddles to ensure timely scheduling of necessary appointments. Staff scheduled 10 to 12 appointments per day for each provider with up to five additional nurse co-consultations. Clinic huddles started at the beginning of the shift, with the huddle for OHU occurring approximately one hour later to allow involved patient care team members to attend more than one huddle if appropriate. Compliance On-Site Inspection Four of six housing units randomly tested at the time of inspection had access to Health Care Services Request Forms (CDCR Form 7362) (MIT 1.101, 66.7%). In two housing units, custody officers did not have a system in place for restocking the forms. The custody officers reported reliance on medical staff to replenish the forms in the housing units. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 17 Compliance Score Results Table 5. Access to Care Scored Answer Compliance Questions Yes No N/A Yes % Chronic care follow-up appointments: Was the patient’s most recent chronic care visit within the health care guideline’s maximum allowable interval or 18 7 0 72.0% within the ordered time frame, whichever is shorter? (1.001) For endorsed patients received from another CDCR institution: Based on the patient’s clinical risk level during the initial health screening, was the 22 1 2 95.7% patient seen by the clinician within the required time frame? (1.002) Clinical appointments: Did a registered nurse review the patient’s request 29 1 0 96.7% for service the same day it was received? (1.003) Clinical appointments: Did the registered nurse complete a face-to-face visit 27 2 1 93.1% within one business day after the CDCR Form 7362 was reviewed? (1.004) Clinical appointments: If the registered nurse determined a referral to a primary care provider was necessary, was the patient seen within the 10 1 19 90.9% maximum allowable time or the ordered time frame, whichever is the shorter? (1.005) Sick call follow-up appointments: If the primary care provider ordered a follow-up sick call appointment, did it take place within the time frame 1 0 29 100% specified? (1.006) Upon the patient’s discharge from the community hospital: Did the patient 5 0 0 100% receive a follow-up appointment within the required time frame? (1.007) Specialty service follow-up appointments: Did the clinician follow-up visits 39 6 0 86.7% occur within required time frames? (1.008) * Clinical appointments: Do patients have a standardized process to obtain 4 2 0 66.7% and submit health care services request forms? (1.101) Overall percentage (MIT 1): 89.1% * CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician follow-up visits following specialty services. As a result, we tested MIT 1.008 only for high-priority specialty services or when staff ordered follow-ups. The OIG continued to test the clinical appropriateness of specialty follow-ups through its case review testing. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 18 Table 6. Other Tests Related to Access to Care Scored Answer Compliance Questions Yes No N/A Yes % For patients received from a county jail: If, during the assessment, the nurse referred the patient to a provider, was the patient seen within the required N/A N/A N/A N/A time frame? (12.003) For patients received from a county jail: Did the patient receive a history and physical by a primary care provider within seven calendar days (prior to N/A N/A N/A N/A 07/2022) or five working days (effective 07/2022)? (12.004) Was a written history and physical examination completed within the 8 2 0 80.0% required time frame? (13.002) Did the patient receive the high-priority specialty service within 14 calendar days of the primary care provider order or the Physician Request for 14 1 0 93.3% Service? (14.001) Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care 7 0 8 100% provider? (14.003) Did the patient receive the medium-priority specialty service within 15-45 calendar days of the primary care provider order or the Physician Request 13 2 0 86.7% for Service? (14.004) Did the patient receive the subsequent follow-up to the medium-priority specialty service appointment as ordered by the primary care provider? 3 2 10 60.0% (14.006) Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician Request 15 0 0 100% for Service? (14.007) Did the patient receive the subsequent follow-up to the routine-priority specialty service appointment as ordered by the primary care 4 1 10 80.0% provider? (14.009) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 19 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 20 Diagnostic Services In this indicator, OIG inspectors evaluated the institution’s performance in timely completing radiology, laboratory, and pathology tests. Our inspectors determined whether the institution properly retrieved the resultant reports and whether providers reviewed the results correctly. In addition, in Cycle 7, we examined the institution’s performance in timely completing and reviewing immediate (STAT) laboratory tests. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Inadequate (63.6%) As in Cycle 6, case review found CCI staff managed diagnostic services satisfactorily. The timeliness of both test completion and results retrieval were exceptional. However, providers performed poorly when creating patient test result notification letters. Despite the large number of notification letter deficiencies, patient care was not significantly affected. Considering all factors, the OIG rated the case review component of this indicator adequate. CCI’s compliance testing scored low for diagnostic services. Staff performed excellently in completing radiology tests and retrieving pathology test results; however, staff performed poorly in completing laboratory tests. Providers promptly endorsed diagnostic results but only sporadically generated patient test result notification letters with all required elements. Based on the overall compliance score result, the OIG rated this indicator inadequate. Case Review and Compliance Testing Results The OIG clinicians reviewed 124 diagnostic events and identified 80 deficiencies.13 All 80 deficiencies related to health information management, two of which were significant.14 Test Completion CCI performed well in completing diagnostic tests. Compliance testing showed CCI completed all radiology tests within specified time frames (MIT 2.001, 100%) but completed laboratory tests as specified only half the time (MIT 2.004, 50.0%). Compliance testing did not have any STAT laboratory tests in their samples (MIT 2.007, N/A). Case review found no deficiencies in the completion of laboratory tests, EKGs, or on-site radiology studies. Staff completed all tests within the requested time frames. OIG 13 Deficiencies occurred in cases 1, 2, 8, 11, 13–15, 17–24, 44, and 45. 14 Deficiencies occurred in cases 1, 2, 8, 11, 13–15, 17–24, 44, and 45. Significant deficiencies occurred in cases 17 and 44. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 21 clinicians identified one STAT X-ray sample, which was completed within the required time frame.15 Health Information Management CCI’s performance in managing diagnostic test results was mixed between compliance testing and case review. Compliance testing showed providers frequently reviewed and endorsed radiology tests (MIT 2.002, 88.9%) and laboratory tests (MIT 2.005, 80.0%) within required time frames. CCI staff performed perfectly in retrieving (MIT 2.010, 100%), and satisfactorily in endorsing (MIT 2.011, 80.0%) pathology results. However, providers performed poorly when communicating to patients with their test result letters, whether for radiology (MIT 2.003, 33.3%), laboratory (MIT 2.006, 30.0%), or pathology (MIT 2.012, 10.0%) results. Case review found no deficiencies related to retrieving diagnostic results. Providers generally endorsed results promptly, although OIG clinicians identified two significantly late endorsements. • In case 17, a provider endorsed laboratory results six weeks late. • In case 44, a provider endorsed laboratory results seven days late. Case review found 71 of the 80 health information management deficiencies involved patient notification letters.16 While the deficiencies were minor, their large number revealed a widespread pattern. The following are examples: • In case 1, a provider endorsed x-ray results but did not send the patient a results notification letter. • In case 2, a provider sent the patient a results notification letter but did not include the date of the test or whether the results were normal. • In case 19, a provider endorsed urine test results but did not send the patient a test result notification letter. • In case 21, a provider sent the patient a test result notification letter but did not include whether the results were normal or whether a follow-up appointment was necessary. • In case 24, a provider endorsed ultrasound results but did not generate a test result notification letter to the patient. • In case 45, a provider endorsed laboratory results stating, “no suitable specimen received.” However, the provider did not send the patient a test result notification letter. 15 This event occurred in case 22. 16 Deficiencies occurred in cases 1, 2, 8, 11, 13–15, 17–24, 44, and 45. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 22 Clinician On-Site Inspection We interviewed the diagnostic services supervisor and staff. A phlebotomist was assigned to each of the three facilities at CCI for daily laboratory blood test collections. Facility C housed the laboratory’s centralized office. Either a laboratory technician or a nurse collected STAT laboratory tests at each facility. The ordering provider would access the STAT laboratory results from a contracted vendor. Staff explained STAT laboratory tests were not common, as most patients were transferred to the community hospital if they required a STAT laboratory test. Staff in Facility B conducted plain-film radiology services. CCI also offered ultrasound, CT imaging, and MRI imaging, both on-site and off-site, depending on scheduling needs.17 Staff reported no backlog for diagnostic services at the time of our inspection. 17 A CT scan is a computed, or computerized, tomography imaging scan. An MRI is a magnetic resonance imaging scan. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 23 Compliance Score Results Table 7. Diagnostic Services Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Was the radiology service provided within the time frame 10 0 0 100% specified in the health care provider’s order? (2.001) Radiology: Did the ordering health care provider review and endorse the 8 1 1 88.9% radiology report within specified time frames? (2.002) Radiology: Did the ordering health care provider communicate the results 3 6 1 33.3% of the radiology study to the patient within specified time frames? (2.003) Laboratory: Was the laboratory service provided within the time frame 5 5 0 50.0% specified in the health care provider’s order? (2.004) Laboratory: Did the health care provider review and endorse the laboratory 8 2 0 80.0% report within specified time frames? (2.005) Laboratory: Did the health care provider communicate the results of the 3 7 0 30.0% laboratory test to the patient within specified time frames? (2.006) Laboratory: Did the institution collect the STAT laboratory test and receive N/A N/A N/A N/A the results within the required time frames? (2.007) Laboratory: Did the provider acknowledge the STAT results, OR did nursing N/A N/A N/A N/A staff notify the provider within the required time frames? (2.008) Laboratory: Did the health care provider endorse the STAT laboratory N/A N/A N/A N/A results within the required time frames? (2.009) Pathology: Did the institution receive the final pathology report within the 10 0 0 100% required time frames? (2.010) Pathology: Did the health care provider review and endorse the pathology 8 2 0 80.0% report within specified time frames? (2.011) Pathology: Did the health care provider communicate the results of the 1 9 0 10.0% pathology study to the patient within specified time frames? (2.012) Overall percentage (MIT 2): 63.6% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 24 Recommendations • Medical leadership should ascertain causative factors related to the untimely provision of laboratory services and implement remedial measures as appropriate. • The department should consider developing strategies, such as potentially an electronic solution, to ensure providers create patient test result notification letters when they endorse test results and ensure patient letters contain all elements required by CCHCS policy. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 25 Emergency Services In this indicator, OIG clinicians evaluated the quality of emergency medical care. Our clinicians reviewed emergency medical services by examining the timeliness and appropriateness of clinical decisions made during medical emergencies. Our evaluation included examining the emergency medical response, cardiopulmonary resuscitation (CPR) quality, triage and treatment area (TTA) care, provider performance, and nursing performance. Our clinicians also evaluated the Emergency Medical Response Review Committee’s (EMRRC) performance in identifying problems with its emergency services. The OIG assessed the institution’s emergency services through case review only and performed no compliance testing for this indicator. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Not Applicable CCI generally provided good emergency care. OIG clinicians found nursing staff responded promptly to all emergent events and provided appropriate interventions. Although OIG clinicians identified opportunities for improvement in patient assessments, only one finding was clinically significant. As in Cycle 6, nurses continued to struggle with documentation, which increased in frequency in Cycle 7. Moreover, the EMRRC did not always identify these documentation discrepancies when conducting clinical reviews of the emergency medical alarm activations and unscheduled transports to a higher level of care. Compared with Cycle 6, in Cycle 7, OIG clinicians reviewed more urgent and emergent events but found a similar number of emergency care deficiencies. Taking this into consideration, the OIG rated this indicator adequate. Case Review Results OIG clinicians reviewed 54 events, 29 of which were urgent or emergent events. We found 29 deficiencies in various aspects of overall emergency care, one of which was significant.18 Emergency Medical Response CCI custody and health care staff responded promptly to all emergencies throughout the institution. Staff activated emergency medical services (EMS) when clinically indicated and notified TTA staff in a timely manner. Cardiopulmonary Resuscitation Quality In our CPR sample case, custody and medical staff collaborated to provide care, transport the patient to the TTA for additional interventions, and transfer the patient 18 Deficiencies occurred in cases 1–4, 7–9, 15, and 19–21. A significant deficiency occurred in case 2. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 26 to a higher level of care. We identified a deficiency with the automatic external defibrillator (AED) activation, described below: • In case 4, custody staff activated an emergency medical alarm for this unconscious patient. Upon the nurse’s arrival, custody was performing CPR. The TTA RN documented a thready pulse and an irregular cardiac rhythm. The TTA RN applied the AED pads to the patient. However, the nursing staff did not activate the AED to assess for a shockable rhythm, although CPR continued for five additional minutes. The significance of this deficiency was mitigated by the nurse’s documentation of improvements to the patient’s Glasgow Coma Scale (GCS) with each administration of nasal naloxone prior to discontinuation of CPR.19 Provider Performance CCI’s providers performed very well in urgent and emergent situations, and in after- hours care. They made accurate diagnoses and completed documentation. Providers were available for consultation with nurses when necessary and were involved in treatment decisions. However, case review identified two deficiencies with provider performance. Both are described below, with the latter considered significant: • In case 1, a provider ordered the patient to be placed in a holding cell for observation and to have vital signs taken every 30 minutes. However, the provider did not enter the order, so the patient was not monitored as intended. • In case 2, a provider received a call from a TTA nurse for this patient who fell, resulting in injuries. The right-handed patient had deformities of his right fingers and a laceration. The provider did not examine the patient to assess the possibility of an open fracture, the severity of the laceration, or the risk of infection.20 Nursing Performance CCI’s nurses performed well during emergency events. They responded to emergencies timely, and frequently provided good interventions. Although we did not identify any patterns or trends, OIG clinicians found opportunities for improvement in nursing assessments. The following are examples: • In case 2, the nurse evaluated the patient for a right-hand blunt-force trauma related to a sustained fall. The nurse documented the patient’s fingers were deformed with a laceration. However, the nurse did not assess the hand and finger circulation, movement, and sensation (CMS) or advocate for a tetanus shot. 19 The Glasgow Coma Scale is a clinical scale used to reliably measure a person’s level of consciousness and is based on ability to perform eye movements, speak, and move the body. GCS is a vital assessment tool used internationally and significantly affects the level of care needed for the patient. 20 An open fracture is a bone fracture with an open wound or break in the skin near the site of a broken bone. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 27 • In case 20, the patient was referred to the TTA for suspected cardiac chest pain during a telemedicine encounter. The TTA nurse did not take the patient’s pulse, listen to the patient’s heart or lungs, or describe the presentation of the patient’s skin. Nursing Documentation Compared with Cycle 6, CCI had double the amount of documentation discrepancies in the same number of cases in Cycle 7.21 The majority of deficiencies in emergency services related to nursing documentation. Although documentation did not affect overall patient care, the nurses did not always document the actual time of interventions provided, resulting in the sequence of events being out of order or difficult to follow. The following are examples: • In case 7, staff activated an emergency medical alarm for an unconscious patient suspected of an overdose. From the time of the TTA nurse’s arrival to the scene, staff performed CPR for an additional nine minutes and discontinued when the patient’s pulse was palpable. However, the TTA nurse incorrectly documented the patient had palpable pulses with a heart rate of 78 at the time the nurse arrived at the scene, nine minutes before the pulse was detected. • In case 21, OHU staff directly referred the patient to the TTA for further evaluation of brown vomit. Staff documented multiple conflicting times for the initial TTA notification, patient departure and arrival to the TTA, and the start and end times of nursing interventions. • In case 21, on a separate occasion, OHU staff directly referred the patient to the TTA. The nurses’ timeline documentation did not include the times of transfer or arrival to the TTA. In addition, the TTA nurses did not document the actual time of the initial evaluation. Furthermore, nurses documented EMS activation 13 minutes prior to when EMS documentation showed they received the initial dispatched call. Emergency Medical Response Review Committee The EMRRC met monthly and discussed emergency responses and unscheduled send outs. However, compliance testing revealed incident packages were often deficient due to cases not being reviewed within required time frames or being incomplete (MIT 15.003, 30.0%). Similarly, OIG clinicians found, in one case, the clinical review was not conducted timely and was performed after the date of the OIG’s initial request. In addition, in a total of five cases with unscheduled send outs, nursing and medical leadership did not identify the same opportunities for improvement as OIG clinicians.22 • In case 1, an emergency event occurred on June 12, 2023, for which OIG clinicians requested a clinical review on December 22, 2023. However, the clinical review was not started until December 23, 2023. 21 Deficiencies in TTA nursing documentation occurred in cases 1–3, 7–9, 15, and 21. 22 Deficiencies occurred in cases 1, 2, 9, 20, and 21. None of the deficiencies in these cases were significant. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 28 • In cases 1, 9, and in two separate emergency events in case 21, the nursing and medical leadership did not identify the same nursing documentation deficiencies as the OIG. Clinician On-Site Inspection CCI had a vast layout with a considerable distance between the five separated facilities. At the time of the inspection, CCI had three active facilities with patient populations. Each facility maintained its own TTA. OIG clinicians toured the TTA areas at facilities A and B. Facility B contained three independent emergency bays, while Facility A utilized a single minor procedure room. All areas provided ample space for emergency care and treatment. Facility B assigned two TTA RNs on second and third watch. In addition, Facility B assigned one RN on first watch and assigned the receiving and release (R&R) RN to report to the TTA to assist during emergencies. Facility A assigned one RN on each shift. At both facilities, the primary care provider was designated as the point-of- contact for emergencies. However, if a telemedicine provider was staffed during business hours, a primary care provider available on-site from another yard would be contacted. For after-hours emergencies, staff would coordinate the care with the on-call provider. OIG clinicians inquired about community ambulance response times. The TTA RNs reported that response times varied due to only having approximately two ambulances available city-wide. A typical response time was estimated to be between 20 to 25 minutes. In addition, we asked about the assigned health care first responders. Nursing staff reported all available staff respond to emergencies. OIG clinicians learned the medication LVNs did not have an AED available to respond to medical emergencies and were asked whether this presented any challenges. The LVN reported no challenges because the TTA RN had an assigned radio on person and was responsible for responding with the AED. In addition, the response times by both LVNs and the TTA RN were within close proximity throughout the facility. OIG clinicians posed the same question to nursing leadership, who reported this topic was already in discussion. Nursing leadership further reported members of the nursing team on each shift were delegated an emergency response task, such as scribing, CPR compression relief, airway management, or other responsibilities. Due to each facility having an assigned TTA RN, the nurses at both facilities A and B reported regular attendance at the individual clinic huddles to report on recent events. Upon further interview, the TTA RN at Facility A reported facilities A and C were unique in that they did not have a designated R&R RN like Facility B. This, in turn, made the TTA RNs responsible for processing patients who transferred in and out of the institution. They did, however, report the Facility B R&R RN was available to assist for large volume transfers on facilities A and C. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 29 Recommendations • Nursing leadership should determine the root cause of challenges that prevent nurses from accurately documenting the time and sequence of events during emergency responses and should implement remedial measures as appropriate. • Nursing and medical leadership should determine the challenges to identifying all documentation and timeline deficiencies in the emergency medical response clinical review process and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 30 Health Information Management In this indicator, OIG inspectors evaluated the flow of health information, a crucial link in high-quality medical care delivery. Our inspectors examined whether the institution retrieved and scanned critical health information (progress notes, diagnostic reports, specialist reports, and hospital discharge reports) into the medical record in a timely manner. Our inspectors also tested whether clinicians adequately reviewed and endorsed those reports. In addition, our inspectors checked whether staff labeled and organized documents in the medical record correctly. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Inadequate (72.0%) Similar to Cycle 6, case review found CCI sufficiently managed their health information. Staff frequently retrieved and scanned hospital and emergency records timely. Although staff sometimes scanned or endorsed some specialty reports late, these did not significantly affect patient care. However, providers performed poorly in communicating diagnostic results with test result notification letters to patients. After careful consideration, the OIG rated the case review component of this indicator adequate. CCI’s compliance testing performance was mixed. Staff always scanned patient health care request forms. They also retrieved most hospital records and specialty reports within required time frames. However, staff performed poorly in labeling medical documents. Based on the overall compliance score result, the OIG rated the compliance component of this indicator inadequate. Case Review and Compliance Testing Results The OIG clinicians reviewed 763 events and identified 99 deficiencies related to health information management. Of these 99 deficiencies, four were significant.23 Hospital Discharge Reports CCI staff often retrieved and scanned hospital discharge records timely. Compliance testing showed staff generally scanned hospital discharge documents within required time frames (MIT 4.003, 80.0%). All discharge documents contained key elements and were endorsed by a provider within five days (MIT 4.005, 100%). OIG clinicians reviewed 14 off-site emergency department and hospital encounters. We identified only two examples of a missing or late report as follows: 23 Deficiencies occurred in cases 1, 2, 8, 9, 11, 13–15, 17–24, 44, and 45. Significant deficiencies occurred in cases 11, 17, 24, and 44. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 31 • In case 21, a biopsy report was pending at the time of the patient’s hospital discharge. Staff never scanned the report into the electronic health record system (EHRS).24 • In case 24, CCI staff retrieved and scanned the emergency room records late, 13 days after the patient’s evaluation. • Also in case 24, staff never forwarded an emergency room report to a provider for review. Specialty Reports CCI’s performance in handling specialty reports was scattered but poor overall. Compliance testing showed staff scanned most specialty reports timely (MIT 4.002, 80.0%). Additionally, most high-priority specialty reports were retrieved and endorsed timely (MIT 14.002, 80.0%). However, staff occasionally retrieved medium-priority (MIT 14.005, 40.0%), and sometimes retrieved routine-priority (MIT 14.008, 60.0%), specialty reports within required time frames. Similarly, OIG clinicians reviewed 85 specialty reports and identified 14 deficiencies.25 Although the deficiencies were generally not significant, we identified a few patterns. For example, off-site specialty reports were retrieved late or were missing in five of the 14 deficiencies.26 In addition, we found late provider endorsements in seven of the 14 deficiencies.27 We also discuss these findings in the Specialty Services indicator. Diagnostic Reports CCI had mixed performance in managing diagnostic reports. Compliance testing showed CCI staff generally retrieved and endorsed results timely, but providers performed poorly in communicating results with test result notification letters to patients. Case review found similar results. OIG clinicians reviewed 124 diagnostic events and identified 80 health information management deficiencies.28 While only two were significant, 71 of the 80 deficiencies involved missing or incomplete patient test result notification letters.29 This pattern was observed in the previous cycle and remained an area to improve. Please refer to the Diagnostics indicator for more details. Urgent and Emergent Records OIG clinicians reviewed 29 emergency care events and found CCI providers and nurses recorded these events exceptionally well. We identified no deficiencies in this area. The Emergency Services indicator provides additional information regarding emergency care documentation. 24 EHRS is the Electronic Health Records System. The department’s electronic health record system is used for storing the patient’s medical history and health care staff communication. 25 Deficiencies occurred in cases 19, 21, 22, 44, and 45. 26 Deficiencies occurred in cases 21, 22, and 44. 27 Deficiencies occurred in cases 21, 22, and 44. 28 Deficiencies occurred in cases 1, 2, 8, 11, 13–15, 17–24, 44, and 45. 29 Deficiencies occurred in cases 1, 2, 8, 11, 13–15, 17–24, 44, and 45. Significant deficiencies occurred in cases 17 and 44. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 32 Scanning Performance CCI performed variably in scanning. Compliance testing revealed no sampled documents were scanned properly (MIT 4.004, zero). Yet, OIG clinicians reviewed 763 encounters and identified only two mislabeled records. The following is an example: • In case 9, staff mislabeled a urology specialty consultation report as a hematology consultation report, and a neurology consultation report as a surgical consultation report. OIG clinicians found no misfiled or duplicated documents. Clinician On-Site Inspection We discussed health information management (HIM) processes with executive leadership, the health information management supervisor, the utilization management supervisor, specialty nursing managers, ancillary staff, and providers. Utilization management and specialty services staff reported being vigilant about tracking reports from off-site encounters. However, specialty services nurses erroneously stated the time frame for retrieving specialty reports as 72 hours, instead of 48 hours as required in the department’s Health Care Department Operations Manual (HCDOM).30 Utilization management supervisors expressed frustration in retrieving timely records from one particular hospital. This challenge was echoed by multiple staff members. Scanning of admission documents in the OHU was also problematic. Nursing staff used a previous CTC form for admission. However, the health information management supervisor explained the CTC inpatient forms could not be scanned into the record as outpatient forms. Therefore, HIM staff did not scan these forms into the EHRS at all. The OIG notes, as of the date of publishing this report, the HCDOM contains no record of such a policy. 30 See HCDOM (3.1.11.c.4.k) at https://www.cdcr.ca.gov/hcdom/dom/chapter-3-health-care-operations/. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 33 Compliance Score Results Table 8. Health Information Management Scored Answer Compliance Questions Yes No N/A Yes % Are health care service request forms scanned into the patient’s electronic 20 0 10 100% health record within three calendar days of the encounter date? (4.001) Are specialty documents scanned into the patient’s electronic health record 24 6 15 80.0% within five calendar days of the encounter date? (4.002) Are community hospital discharge documents scanned into the patient’s electronic health record within three calendar days of hospital discharge? 4 1 0 80.0% (4.003) During the inspection, were medical records properly scanned, labeled, 0 24 0 0 and included in the correct patients’ files? (4.004) For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements and did a provider 5 0 0 100% review the report within five calendar days of discharge? (4.005) Overall percentage (MIT 4): 72.0% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 34 Table 9. Other Tests Related to Health Information Management Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Did the ordering health care provider review and endorse the 8 1 1 88.9% radiology report within specified time frames? (2.002) Laboratory: Did the health care provider review and endorse the laboratory 8 2 0 80.0% report within specified time frames? (2.005) Laboratory: Did the provider acknowledge the STAT results, OR did nursing N/A N/A N/A N/A staff notify the provider within the required time frame? (2.008) Pathology: Did the institution receive the final pathology report within the 10 0 0 100% required time frames? (2.010) Pathology: Did the health care provider review and endorse the pathology 8 2 0 80.0% report within specified time frames? (2.011) Pathology: Did the health care provider communicate the results of the 1 9 0 10.0% pathology study to the patient within specified time frames? (2.012) Did the institution receive and did the primary care provider review the high-priority specialty service consultant report within the required time 12 3 0 80.0% frame? (14.002) Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the required time 6 9 0 40.0% frame? (14.005) Did the institution receive and did the primary care provider review the routine-priority specialty service consultant report within the required time 9 6 0 60.0% frame? (14.008) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 35 Recommendations • The institution should identify the challenges to properly labeling and scanning documents into the medical record and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 36 Health Care Environment In this indicator, OIG compliance inspectors tested clinics’ waiting areas, infection control, sanitation procedures, medical supplies, equipment management, and examination rooms. Inspectors also tested clinics’ performance in maintaining auditory and visual privacy for clinical encounters. Compliance inspectors asked the institution’s health care administrators to comment on their facility’s infrastructure and its ability to support health care operations. The OIG rated this indicator solely on the compliance score. Case review does not rate this indicator. Because none of the tests in this indicator directly affected clinical patient care (it is a secondary indicator), the OIG did not consider this indicator’s rating when determining the institution’s overall compliance rating. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Inadequate (51.9%) Overall, CCI performed poorly with respect to its health care environment. In this cycle, multiple aspects of CCI’s health care environment needed improvement: medical supply storage areas in and outside of the clinics did not follow protocols for managing and storing medical supplies; staff did not ensure medical equipment or health care areas were properly disinfected; patient restrooms in the clinics were missing hand hygiene supplies; several clinics did not meet the requirements for essential core medical equipment and supplies; emergency medical response bag (EMRB) logs were missing evidence of inventory or had compromised supplies; and staff did not properly sanitize their hands throughout the patient encounters. Based on the overall compliance score result, the OIG rated this indicator inadequate. Compliance Testing Results Patient Waiting Areas We inspected only indoor waiting areas as CCI had no outdoor waiting areas (see Photo 1). Health care and custody staff reported the existing waiting areas contained sufficient seating capacity. During our inspection, we did not observe overcrowding in any of the clinics’ indoor waiting areas. Clinic Environment All clinic environments were sufficiently conducive for medical care; they provided reasonable auditory Photo 1. Indoor waiting area (photographed on 10-26-23). Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 37 privacy, appropriate waiting areas, wheelchair accessibility, and nonexamination room workspace (MIT 5.109, 100%). Of the eight applicable clinics we observed, five contained appropriate space, configuration, supplies, and equipment to allow their clinicians to provide proper medical services (MIT 5.110, 62.5%). The remaining three clinics had one or more of the following deficiencies: an examination table had a torn vinyl cover; examination room furniture, ceiling, or soap dispenser were in disrepair; and an examination room had unsecured confidential medical records. Clinic Supplies Four of the nine clinics followed adequate medical supply storage and management protocols (MIT 5.107, 44.4%). We found one or more of the following deficiencies in the remaining five clinics: expired medical supplies (Photo 2); unidentified, unorganized, or inaccurately labeled supplies; cleaning materials stored with medical supplies; and long-term storage of staff’s food in a medical supply storage area. Two of the nine clinics met requirements for essential core medical equipment and supplies (MIT 5.108, 22.2%). We found one or more deficiencies in the remaining seven clinics: improperly calibrated or nonfunctional equipment; missing items including examination table paper and oto- ophthalmoscope; and incomplete or inaccurate documentation of defibrillator or AED performance tests within the last 30 days. Photo 2. Expired medical supplies (photographed on 10-25-23). We examined EMRBs to determine if they contained all essential items. We checked whether staff inspected the bags daily and inventoried them monthly. Four of the seven applicable EMRBs passed our test (MIT 5.111, 57.1%). We found one or more of the following deficiencies with three EMRBs: staff failed to inventory the EMRBs when seal tags were replaced; EMRB daily glucometer logs were either inaccurate or incomplete; or EMRB contained compromised supplies (see Photos 3 and 4, next page). Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 38 Photo 3. Incomplete EMRB glucometer logs (photographed on 10-24-23). Photo 4. Compromised EMRB medical supply (photographed on 10-26-23). Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 39 Medical Supply Management None of the medical supply storage areas located outside the medical clinics stored medical supplies adequately (MIT 5.106, zero). In the medical warehouse, we found expired medical supplies (see Photo 5). In addition, the warehouse manager reported they did not maintain a temperature log allowing them to monitor the current temperature for medical supplies with manufacturer temperature guidelines stored in the medical warehouse (see Photo 6). Photo 5. Expired supplies in the warehouse (photographed on 10-25-23). According to the CEO, the institution did not have any concerns about the medical supply process. Health care managers and medical warehouse managers expressed no concerns about the medical supply chain or their communication process. Infection Control and Sanitation Staff appropriately cleaned and disinfected five of eight applicable clinics (MIT 5.101, 62.5%). In three clinics, we found one or more of the following deficiencies: cleaning logs were not maintained; a medical supply cabinet was unsanitary; and a gurney was unsanitary. Staff in five of nine clinics properly sterilized or disinfected medical Photo 6. Warehouse supplies with temperature guidelines equipment (MIT 5.102, 55.6%). In three (photographed on 10-25-23). clinics, staff did not mention disinfecting the examination table as part of their daily start-up protocol. In the remaining clinic, we found compromised sterilized medical equipment packaging. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 40 We found operational sinks and hand hygiene supplies in the examination rooms in six of nine clinics (MIT 5.103, 66.7%). The patient restrooms in three clinics lacked antiseptic soap and disposable hand towels. We observed patient encounters in seven clinics. In all clinics, none of the clinicians properly washed or sanitized their hands before or after examining their patients, before and after performing an invasive procedure, or during subsequent regloving (MIT 5.104, zero). Health care staff in all clinics followed proper protocols to mitigate exposure to blood- borne pathogens and contaminated waste (MIT 5.105, 100%). Physical Infrastructure At the time of the compliance inspection, CCI did not have any ongoing Health Care Facility Improvement Program projects. The institution’s health care management and plant operations manager reported infrastructure in all clinical areas was in good working order (MIT 5.999). Compliance On-Site Inspection In addition to the above findings, our compliance inspectors observed some notable findings in clinics during their on-site inspection. In one clinic, laboratory supplies were being stored in the soiled utility room with biohazardous waste (Photos 7–9, this page and next page). In a different clinic, we found peeling paint on the ceiling (Photo 10, page 42). Photo 7. Laboratory equipment and supplies stored in the soiled utility room (photo 1 of 3, photographed on 10-24-23). Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 41 Photo 8. Laboratory equipment and supplies stored in the soiled utility room (photo 2 of 3, photographed on 10-24-23). Photo 9. Laboratory equipment and supplies stored in the soiled utility room (photo 3 of 3, photographed on 10-24-23). Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 42 Photo 10. Peeling paint on the clinic ceiling (photographed on 10-25-23). Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 43 Compliance Score Results Table 10. Health Care Environment Scored Answer Compliance Questions Yes No N/A Yes % Infection control: Are clinical health care areas appropriately disinfected, 5 3 6 62.5% cleaned, and sanitary? (5.101) Infection control: Do clinical health care areas ensure that reusable invasive and noninvasive medical equipment is properly sterilized or disinfected as 5 4 5 55.6% warranted? (5.102) Infection control: Do clinical health care areas contain operable sinks and 6 3 5 66.7% sufficient quantities of hygiene supplies? (5.103) Infection control: Does clinical health care staff adhere to universal hand 0 7 7 0 hygiene precautions? (5.104) Infection control: Do clinical health care areas control exposure to blood- 9 0 5 100% borne pathogens and contaminated waste? (5.105) Warehouse, conex, and other nonclinic storage areas: Does the medical supply management process adequately support the needs of the medical 0 1 0 0 health care program? (5.106) Clinical areas: Does each clinic follow adequate protocols for managing and 4 5 5 44.4% storing bulk medical supplies? (5.107) Clinical areas: Do clinic common areas and exam rooms have essential core 2 7 5 22.2% medical equipment and supplies? (5.108) Clinical areas: Are the environments in the common clinic areas conducive 9 0 5 100% to providing medical services? (5.109) Clinical areas: Are the environments in the clinic exam rooms conducive to 5 3 6 62.5% providing medical services? (5.110) Clinical areas: Are emergency medical response bags and emergency crash carts inspected and inventoried within required time frames, and do they 4 3 7 57.1% contain essential items? (5.111) Does the institution’s health care management believe that all clinical areas This is a nonscored test. Please see the have physical plant infrastructures that are sufficient to provide adequate indicator for discussion of this test. health care services? (5.999) Overall percentage (MIT 5): 51.9% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 44 Recommendations • Medical leadership should determine the root cause(s) for staff not following all required universal hand hygiene precautions and should take necessary remedial measures. • Executive leadership should determine the root cause(s) for staff not ensuring medical supply storage areas, located inside and outside the clinics, store medical supplies adequately and should take necessary remedial measures. • Nursing leadership should determine the root cause(s) for staff not ensuring clinic examination rooms contain essential core medical equipment and should take necessary remedial measures that include verifying staff follow equipment and medical supply management protocols. • Nursing leadership should determine the root cause(s) for staff not ensuring the emergency medical response bags (EMRBs) are regularly inventoried and sealed, or staff failing to properly complete the monthly logs, and should take necessary remedial measures. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 45 Transfers In this indicator, OIG inspectors examined the transfer process for those patients who transferred into the institution as well as for those who transferred to other institutions. For newly arrived patients, our inspectors assessed the quality of health care screenings and the continuity of provider appointments, specialist referrals, diagnostic tests, and medications. For patients who transferred out of the institution, inspectors checked whether staff reviewed patient medical records and determined the patient’s need for medical holds. They also assessed whether staff transferred patients with their medical equipment and gave correct medications before patients left. In addition, our inspectors evaluated the performance of staff in communicating vital health transfer information, such as preexisting health conditions, pending appointments, tests, and specialty referrals; and inspectors confirmed whether staff sent complete medication transfer packages to receiving institutions. For patients who returned from off-site hospitals or emergency rooms, inspectors reviewed whether staff appropriately implemented recommended treatment plans, administered necessary medications, and scheduled appropriate follow-up appointments. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Inadequate (67.1%) Case Review found CCI performed overall sufficiently in the transfer indicator. Compared with Cycle 6, case review identified a substantial improvement in the total number of significant deficiencies, with only one deficiency related to the scanning and endorsement of hospital discharge records. Although in Cycle 7, OIG clinicians reviewed fewer events in fewer cases than in Cycle 6, we found a notable improvement in the number of clinical-related deficiencies. OIG clinicians found a few deficiencies with medication continuity upon patient arrival to and departure from the institution, as well as with CCI notifying the receiving institution of pending specialty appointments for patients transferring out of CCI. However, OIG clinicians also found minimal deficiencies related to patient assessments upon arrival to the institution and upon return from a community hospital or emergency department encounter. After reviewing all aspects, the OIG rated the case review component of this indicator adequate. Compared with Cycle 6, compliance testing similarly showed CCI’s overall performance improved for this indicator. CCI performed excellently in completing the assessment and disposition section of the screening process. However, CCI still needs substantial improvement in completing initial health screening forms and ensuring medication continuity for newly transferred patients. Based on the overall compliance score result, the OIG rated the compliance component of this indicator inadequate. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 46 Case Review and Compliance Testing Results We reviewed 34 events in 16 cases in which patients transferred into or out of the institution or returned from off-site hospitalizations or emergency room encounters. We identified 13 deficiencies, one of which was significant.31 Transfers In CCI had a mixed performance in the transfer-in process. Compliance testing showed that R&R nurses performed poorly in completing the initial health screening form thoroughly (MIT 6.001, 16.0%). However, nurses always completed the assessment and disposition section of the form in its entirety (MIT 6.002, 100%). Compliance testing also found staff sometimes ensured medication continuity occurred at the time of transfer (MIT 6.003, 52.4%) but performed poorly in medication continuity for patient layovers at the institution (MIT 7.006, 50.0%). In addition, compliance testing showed newly arrived patients were almost always seen by a provider within necessary time frames (MIT 1.002, 95.7%). While compliance testing results varied, OIG clinicians found CCI’s transfer-in process to be satisfactory. We reviewed six events in four cases in which patients transferred into the facility from other institutions. We identified only two minor deficiencies.32 The following is an example: • In case 27, the nurse conducting the initial health screening for the newly arrived patient did not obtain the patient’s vital signs. The additional deficiency is addressed further in the Medication Management indicator. Transfers Out CCI also had a mixed performance in the transfer-out process. Compliance testing showed patients who transferred out of the institution always had their medications, durable medical equipment (DME), and required documents (MIT 6.101, 100%). In contrast, OIG clinicians found only one medication deficiency. This is addressed further in the Medication Management indicator. OIG clinicians reviewed a total of seven transfer-out events in four cases in which patients transferred out of the facility to other institutions. We identified four minor deficiencies.33 In addition to the deficiency mentioned above, the following are examples: • In cases 29 through 31, the nurses did not always document notifying the receiving institutions of pending specialty consultations. Hospitalizations Patients returning from an off-site hospitalization or emergency room are at high risk for lapses in care quality. These patients typically experienced severe illness or injury. They 31 Deficiencies occurred in cases 2, 9, 19–21, 24, 27, 29–31, and 44. A significant deficiency occurred in case 24. 32 Transfer in deficiencies occurred in cases 27 and 44. 33 Transfer out deficiencies occurred in cases 29–31. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 47 require more care and place a strain on the institution’s resources. In addition, because these patients have complex medical issues, successful health information transfer is necessary for good quality care. Any transfer lapse can result in serious consequences for these patients. CCI had a mixed performance in the return process for hospitalizations and emergency room encounters. Compliance testing showed follow-up appointments were always completed within required time frames for patients returning from hospitalizations and emergency room encounters (MIT 1.007, 100%). In most samples, staff scanned hospital discharge documents into the patient’s electronic health record within three calendar days of discharge (MIT 4.003, 80.0%). Compliance testing also found providers always reviewed and endorsed documents in a timely manner (MIT 4.005, 100%). In contrast to compliance testing, case review discovered opportunities for improvement. We reviewed 21 hospitalization events in nine cases, 13 of which were community hospital or emergency room encounter returns. We identified seven deficiencies, one of which was significant.34 In one case, the follow-up appointment was not scheduled within the time frame recommended by the hospital. We found a significant deficiency in which staff did not scan the hospital record within 13 days after the patient was seen in the emergency department and did not forward it to the provider for review. Additional deficiencies related to hospital records are further addressed in the Health Information Management indicator. Case review did not find any significant patterns or trends. However, we identified some clinical deficiencies. The following are examples: • In case 2, the patient returned from the community emergency room with elevated blood pressure. However, the nurse did not subjectively assess whether the patient had taken their blood pressure medication that day. • In case 21, the patient returned from a hospital admission for a gastrointestinal bleed. Although the nurse documented the patient did not complain of any symptoms, the nurse did not listen for bowel sounds and did not describe the appearance of or palpate the abdomen. Compliance testing showed CCI performed poorly in ensuring ordered medications were administered, made available, or delivered to patients within the required time frames (MIT 7.003, 20.0%). OIG clinicians also found two deficiencies related to continuity of medication upon return from a hospitalization or emergency department encounter. This is addressed further in the Medication Management indicator. Clinician On-Site Inspection OIG clinicians toured the R&R and TTA areas located in facilities A and B. We interviewed the R&R nurse in Facility B. The nurse was knowledgeable and described both the transfer-in and transfer-out processes. The nurse shared the R&R staffed one RN on each shift, and all nurses were responsible for the transfer-in and transfer-out processes. Although the R&R RN position was designated for Facility B, the TTA nurse in Facility A reported the TTA RNs in facilities A and C perform the transfer processes 34 Hospital deficiencies occurred in cases 2, 19–21, and 24. A significant deficiency occurred in case 24. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 48 for their respective facilities. The R&R nurse and TTA RN reported they received a list from custody on a weekly basis that included the upcoming transfers, both incoming and outgoing, for the subsequent week. Additionally, the nurses reported revisions to the list were provided throughout the week. The R&R nurse in Facility B reported the average number of patients transferring varied, with a weekly average of 25 to 30 patients transferring in and an average of more than 40 patients transferring out. The R&R RN further described the processes in place to maintain continuity of care for patients who transferred into CCI without their prescribed medications or with pending specialty consultations. The process included having an assigned office technician (OT) send a list to the primary care providers to notify them of patients who required medication reconciliation. The R&R nurse was responsible for contacting the pharmacy to ensure the pharmacist reconciled and dispensed the patient medications, notifying the medication line LVNs to ensure they administered the next dose of medication, and educating the patient to report to the medication line. For patients with pending specialty consultations, the R&R RN notified the specialty nurse. To maintain continuity during the transfer-out process, the R&R RN reported they manually reviewed and counted KOP transfer medications to ensure patients had a current order for each medication, the medication was within expiration dates, and patients had a five-day supply of medications.35 Additionally, the R&R nurse reported they would call the receiving institution and send a message in the electronic health record to notify of any pending specialty consultations. Compliance On-Site Inspection R&R nursing staff always ensured patients transferring out of the institution had the required medications, transfer documents, and assigned DME (MIT 6.101, 100%). 35 KOP means “keep on person” and refers to medications in which a patient can keep and self-administer according to the directions provided. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 49 Compliance Score Results Table 11. Transfers Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution: Did nursing staff complete the initial health screening and answer all screening 4 21 0 16.0% questions within the required time frame? (6.001) For endorsed patients received from another CDCR institution: When required, did the RN complete the assessment and disposition section of the initial health screening form; refer the patient to the TTA if TB signs and 25 0 0 100% symptoms were present; and sign and date the form on the same day staff completed the health screening? (6.002) For endorsed patients received from another CDCR institution: If the patient had an existing medication order upon arrival, were medications 11 10 4 52.4% administered or delivered without interruption? (6.003) For patients transferred out of the facility: Do medication transfer packages include required medications along with the corresponding transfer packet 2 0 0 100% required documents? (6.101) Overall percentage (MIT 6): 67.1% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 50 Table 12. Other Tests Related to Transfers Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution: Based on the patient’s clinical risk level during the initial health screening, was the 22 1 2 95.7% patient seen by the clinician within the required time frame? (1.002) Upon the patient’s discharge from the community hospital: Did the patient receive a follow-up appointment with a primary care provider within the 5 0 0 100% required time frame? (1.007) Are community hospital discharge documents scanned into the patient’s electronic health record within three calendar days of hospital discharge? 4 1 0 80.0% (4.003) For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements and did a provider 5 0 0 100% review the report within five calendar days of discharge? (4.005) Upon the patient’s discharge from a community hospital: Were all ordered medications administered, made available, or delivered to the patient 1 4 0 20.0% within required time frames? (7.003) Upon the patient’s transfer from one housing unit to another: Were 18 7 0 72.0% medications continued without interruption? (7.005) For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications 5 5 0 50.0% administered or delivered without interruption? (7.006) For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the sending 2 3 0 40.0% institution, was the appointment scheduled at the receiving institution within the required time frames? (14.010) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 51 Recommendations • Nursing leadership should determine the root cause of challenges preventing nurses from thoroughly completing the initial health screening process, including documenting a complete set of vital signs, answering all questions, and documenting an explanation for all “Yes” answers before the patient is transferred to the housing unit. Leadership should implement remedial measures as appropriate. • Nursing leadership should develop strategies to ensure newly arrived patients receive medications without interruption. In addition, nursing leadership should develop strategies to ensure nurses document reasons for patient refusals on the MAR summaries in accordance with CCHCS policies and procedures. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 52 Medication Management In this indicator, OIG inspectors evaluated the institution’s performance in administering prescription medications on time and without interruption. The inspectors examined this process from the time a provider prescribed medication until the nurse administered the medication to the patient. When rating this indicator, the OIG strongly considered the compliance test results, which tested medication processes to a much greater degree than case review testing. In addition to examining medication administration, our compliance inspectors also tested many other processes, including medication handling, storage, error reporting, and other pharmacy processes. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Inadequate (67.8%) Case review found CCI performed well overall in medication management, with improvement since Cycle 6. CCI improved in administering new medication prescriptions and hospital discharge medications, with only one significant deficiency identified. However, OIG clinicians found lapses in chronic care medication continuity and a new challenge related to continuity of medication for patients attending off-site specialty appointments. After reviewing all aspects, the OIG rated the case review component of this indicator adequate. Compliance testing showed CCI needed improvement in this indicator. CCI scored low in providing patients with chronic care medications, community hospital discharge medications, and medications for patients temporarily housed at the institution as well as providing medication continuity for patients transferring within the institution. Based on the overall compliance score result, the OIG rated the compliance component of this indicator inadequate. Case Review and Compliance Testing Results We reviewed 126 events in 25 cases related to medications and found 26 medication deficiencies, one of which was significant.36 New Medication Prescriptions Compliance testing showed CCI had opportunities for improvement in ensuring timely administration and availability of new prescription medications (MIT 7.002, 76.0%). Similarly, OIG clinicians found six deficiencies related to new prescriptions, one of which was significant.37 The following are examples: 36 Deficiencies occurred in cases 11, 14, 15, 18–23, 31, and 44. A significant deficiency occurred in case 14. 37 New medication prescription deficiencies occurred in cases 11, 14, 18, and 19. A significant deficiency occurred in case 14. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 53 • In case 14, the renewal orders for two glaucoma eye drop prescriptions were designated as auto-refill. However, the prescription instructions stated, “Request refill.” Consequently, the patient did not consistently receive the medication used to decrease eye pressure, prevent optic nerve damage, and preserve vision. • In case 18, a provider ordered a new prescription for an antibiotic to start in the evening; however, the patient did not receive it until the following day. • In case 19, an order for an opioid use disorder treatment medication ended prior to the patient’s morning medication administration. However, a provider did not order a new prescription until two days later, to start on the following day; this resulted in a four-day lapse in medication administration. Chronic Medication Continuity Compliance testing showed CCI needed improvement in chronic medication continuity. Patients intermittently received their chronic care medications within required time frames (MIT 7.001, 68.8%). Similarly, OIG clinicians also found 10 chronic care deficiencies in which medications were not provided timely or were not received at all.38 The following are examples: • In cases 11, 14, 15, and 23, patients did not receive their KOP chronic care medications timely or at all. • In case 19, 20, and 22, patients did not receive one or more doses of nurse administered chronic care medication. Hospital Discharge Medications Compliance testing also showed CCI performed poorly in ensuring patients received their medications upon return from an off-site hospital or emergency room encounter (MIT 7.003, 20.0%). Similarly, OIG clinicians also found, in two cases, patients did not receive the hospital recommended medications timely or at all.39 We identified the following deficiencies: • In case 19, the hospital recommended an iron supplement and constipation medication to start the following day. However, the patient did not receive the medications. • In case 20, the hospital recommended a new hypertension medication. However, the patient did not receive the medication until seven days after returning to the institution. Specialized Medical Housing Medications OIG clinicians found CCI had opportunities for improvement in ensuring patients received their needed medications while housed in the outpatient housing unit (OHU). 38 Patients did not receive chronic care medications timely or at all in cases 11, 14, 15, 19, 20, 22, and 23. 39 Patients did not receive hospital discharge medications timely or at all occurred in cases 19 and 20. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 54 Case review found OHU nurses generally administered medications timely; however, we identified four medication deficiencies.40 The following are examples: • In case 21, a prostate medication order ended prior to the morning administration time. However, the provider did not order the prescription until two days later, resulting in the patient not receiving two doses. • In case 44, on two occasions, the patient did not receive an antibiotic topical cream. Additionally, on one occasion, the patient did not receive a dose of a medication to treat insomnia. Transfer Medications Compliance testing showed CCI needed improvement in transfer medications. Nurses intermittently ensured patients who transferred into the institution received their medications timely (MIT 6.003, 52.4%). In addition, CCI needed improvement in medication continuity for patients transferring from yard to yard (MIT 7.005, 72.0%). Moreover, CCI performed poorly with patients who were on layover and temporarily housed at CCI, as they only occasionally received their medications within required time frames (MIT 7.006, 50.0%). In contrast, OIG clinicians found only two minor medication deficiencies within the transfer processes. The following are examples: • In case 31, the transfer nurse documented the patient’s KOP prostate prescription was missing for transport. However, the nurse did not administer the medication to the patient prior to departure from the institution. • In case 44, the patient arrived to CCI with transfer medications. However, the patient did not receive the first two doses of a topical antibiotic cream. Medication Administration Compliance found CCI nurses needed improvement in administering tuberculosis (TB) medications within required time frames (MIT 9.001, 57.1%). For case review, OIG clinicians did not have any case review samples with events related to TB medications. OIG clinicians found CCI nurses generally administered medications properly. However, in nine cases, we reviewed 30 events of patients returning from off-site specialty consultations and found, on three occasions, nurses did not ensure the patient received their scheduled medications prior to transfer from, or upon return to, the institution.41 The following are examples: • In cases 20 and 21, the patients returned from prescheduled off-site specialty procedures; however, they did not receive scheduled daily medications upon return to the institution. 40 OHU medication deficiencies occurred in cases 21 and 44. 41 Deficiencies occurred in cases 20 and 21. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 55 Clinician On-Site Inspection During the on-site inspection, OIG clinicians toured select medication areas to include the Facility B medication room and the on-site pharmacy. We conducted interviews with medication nurses. We also met with the pharmacist and nursing leadership to discuss case review findings. In addition, the OIG clinicians attended huddles for all three facilities, noting discussion of medication compliance, medication expiration, and other care-related information. The medication room on Facility B had three medication line windows, each of which had their own separate automatic drug delivery system (ADDS). Facility B also had an additional window connected to a private room for patients requiring injections. During the tour, two nurses were present; however, they informed us three nurses are typically assigned to this area. We found the nurses were knowledgeable about the medication processes. We also observed the medication lines were distributed by patients’ last names. However, the nurses explained they work as a team and would administer medication to any patient reporting to their line. Medication Practices and Storage Controls CCI adequately stored and secured narcotic medications in all 10 applicable clinic and medication line locations (MIT 7.101, 100%). In contrast, CCI appropriately stored and secured nonnarcotic medications in only four of 10 applicable clinic and medication line locations (MIT 7.102, 40.0%). In six locations, we observed one or more of the following deficiencies: the medication storage cart was unsanitary; the medication area either lacked a system in place to separate returned medications (previously in possession by a patient) from other medications; the medication area lacked a designated location for medications with expired pharmacy labels that could potentially be restocked and reissued by the pharmacy; nurses did not maintain unissued medication in its original labeled packaging; and daily security check log entries for the treatment cart were incomplete. Similarly, CCI staff kept medications protected from physical, chemical, and temperature contamination in only one of the 10 applicable clinic and medication line locations (MIT 7.103, 10.0%). In nine locations, we found one or more of the following deficiencies: staff did not consistently record the room or refrigerator temperatures; staff did not store internal and external medications separately; and the medication refrigerator was unsanitary. In addition, in one location, the provider refused to allow our inspectors access to the staff supplies cabinet to conduct our inspection. Staff successfully stored valid, unexpired medications in all 10 applicable medication line locations (MIT 7.104, 100%). Nurses exercised proper hand hygiene and contamination control protocols in only one of six applicable locations (MIT 7.105, 16.7%). In the remaining locations, nurses neglected to wash or sanitize their hands when required. These occurrences included before preparing and administering medications and before each subsequent regloving. In addition, some nurses did not resanitize their hands and change gloves when gloves were compromised. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 56 Staff in four of six applicable medication preparation and administration areas demonstrated appropriate administrative controls and protocols (MIT 7.106, 66.7%). In two locations, medication nurses did not describe the process they followed when reconciling a newly received medication and the medication administration record (MAR) against the corresponding physician’s order. Staff in only two of six applicable medication areas used appropriate administrative controls and protocols when distributing medications to their patients (MIT 7.107, 33.3%). In four locations, we observed one or more of the following deficiencies: medication nurses did not verbalize the medication error reporting process; medication nurses did not reliably observe patients while they swallowed direct observation therapy medications; medication nurses did not properly disinfect the insulin vial’s port prior to withdrawing medication; and medication nurses did not follow CCHCS care guide when administering Suboxone medication. Pharmacy Protocols CCI always followed general security, organization, and cleanliness management protocols for nonrefrigerated and refrigerated medications stored in its pharmacy (MITs 7.108, 7.109, and 7.110, 100%). The pharmacist-in-charge (PIC) correctly accounted for narcotic medications stored in CCI’s pharmacy (MIT 7.111, 100%). We examined 14 pharmacy-related medication error reports. The PIC timely and correctly processed all reports (MIT 7.112, 100%). Nonscored Tests In addition to testing the institution’s self-reported medication errors, our inspectors also follow up on any significant medication errors found during compliance testing. We did not score this test; we provide these results for informational purposes only. At CCI, the OIG did not find any applicable medication errors (MIT 7.998). The OIG interviewed patients in restricted housing units to determine whether they had immediate access to their prescribed asthma rescue inhalers or nitroglycerin medications. Nine of 10 applicable patients interviewed indicated they had access to their rescue medications. One patient reported he finished his medication one day prior and had requested a refill. We promptly notified the CEO of this concern, and health care management immediately reissued a replacement rescue inhaler to the patient (MIT 7.999). Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 57 Compliance Score Results Table 13. Medication Management Scored Answer Compliance Questions Yes No N/A Yes % Did the patient receive all chronic care medications within the required time frames 11 5 9 68.8% or did the institution follow departmental policy for refusals or no‑shows? (7.001) Did health care staff administer, make available, or deliver new order prescription 19 6 0 76.0% medications to the patient within the required time frames? (7.002) Upon the patient’s discharge from a community hospital: Were all ordered medications administered, made available, or delivered to the patient within 1 4 0 20.0% required time frames? (7.003) For patients received from a county jail: Were all medications ordered by the institution’s reception center provider administered, made available, or delivered to N/A N/A N/A N/A the patient within the required time frames? (7.004) Upon the patient’s transfer from one housing unit to another: Were medications 18 7 0 72.0% continued without interruption? (7.005) For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications administered or delivered 5 5 0 50.0% without interruption? (7.006) All clinical and medication line storage areas for narcotic medications: Does the institution employ strong medication security controls over narcotic medications 10 0 6 100% assigned to its storage areas? (7.101) All clinical and medication line storage areas for nonnarcotic medications: Does the institution properly secure and store nonnarcotic medications in the assigned 4 6 6 40.0% storage areas? (7.102) All clinical and medication line storage areas for nonnarcotic medications: Does the institution keep nonnarcotic medication storage locations free of contamination in 1 9 6 10.0% the assigned storage areas? (7.103) All clinical and medication line storage areas for nonnarcotic medications: Does the institution safely store nonnarcotic medications that have yet to expire in the 10 0 6 100% assigned storage areas? (7.104) Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols during medication preparation and 1 5 10 16.7% medication administration processes? (7.105) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when preparing medications for 4 2 10 66.7% patients? (7.106) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when administering medications 2 4 10 33.3% to patients? (7.107) Pharmacy: Does the institution employ and follow general security, organization, and 1 0 0 100% cleanliness management protocols in its main and remote pharmacies? (7.108) Pharmacy: Does the institution’s pharmacy properly store nonrefrigerated 1 0 0 100% medications? (7.109) Pharmacy: Does the institution’s pharmacy properly store refrigerated or frozen 1 0 0 100% medications? (7.110) Pharmacy: Does the institution’s pharmacy properly account for narcotic 1 0 0 100% medications? (7.111) Pharmacy: Does the institution follow key medication error reporting protocols? 14 0 0 100% (7.112) Pharmacy: For Information Purposes Only: During compliance testing, did the OIG This is a nonscored test. Please see the indicator find that medication errors were properly identified and reported by the institution? for discussion of this test. (7.998) Pharmacy: For Information Purposes Only: Do patients in restricted housing units This is a nonscored test. Please see the indicator have immediate access to their KOP prescribed rescue inhalers and nitroglycerin for discussion of this test. medications? (7.999) Overall percentage (MIT 7): 67.8% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 58 Table 14. Other Tests Related to Medication Management Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution: If the patient had an existing medication order upon arrival, were medications 11 10 4 52.4% administered or delivered without interruption? (6.003) For patients transferred out of the facility: Do medication transfer packages include required medications along with the corresponding transfer-packet 2 0 0 100% required documents? (6.101) Patients prescribed TB medication: Did the institution administer the 4 3 0 57.1% medication to the patient as prescribed? (9.001) Patients prescribed TB medication: Did the institution monitor the patient per policy for the most recent three months he or she was on the 5 2 0 71.4% medication? (9.002) Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient 2 7 1 22.2% within required time frames? (13.003) Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 59 Recommendations • The institution should develop and implement measures to ensure staff timely make available and administer chronic care medications and community hospital discharge medications. Measures should also ensure timely administering medications to patients temporarily housed at the institution, patients transferring within the institution, and patients returning from offsite specialty appointments. • Nursing leadership should develop and implement measures to ensure nursing staff document administering medications, patient refusals, and no- shows in the electronic health record, in accordance with CCHCS’s policies and procedures. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 60 Preventive Services In this indicator, OIG compliance inspectors tested whether the institution offered or provided cancer screenings, tuberculosis (TB) screenings, influenza vaccines, and other immunizations. If the department designated the institution as being at high risk for coccidioidomycosis (Valley Fever), we tested the institution’s performance in transferring out patients quickly. The OIG rated this indicator solely according to the compliance score. Case review does not rate this indicator. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Adequate (75.0%) CCI had a mixed performance in preventive services. Staff performed very well in screening patients annually for TB, offering patients an influenza vaccine for the most recent influenza season, and offering colorectal cancer screening for patients from ages 45 through 75. The institution transferred out patients who had the highest risk of contracting coccidioidomycosis (Valley Fever) within the required time frames. However, staff only sometimes administered TB medications as prescribed, intermittently monitored patients taking prescribed TB medications, and sporadically offered required immunizations to chronic care patients. These findings are set forth in the table on the next page. Based on the overall compliance score result, the OIG rated this indicator adequate. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 61 Compliance Score Results Table 15. Preventive Services Scored Answer Compliance Questions Yes No N/A Yes % Patients prescribed TB medication: Did the institution administer the 4 3 0 57.1% medication to the patient as prescribed? (9.001) Patients prescribed TB medication: Did the institution monitor the patient per policy for the most recent three months he or she was on the 5 2 0 71.4% medication? (9.002) Annual TB screening: Was the patient screened for TB within the last year? 23 2 0 92.0% (9.003) Were all patients offered an influenza vaccination for the most recent 22 2 1 91.7% influenza season? (9.004) All patients from the age of 45 through the age of 75: Was the patient 22 3 0 88.0% offered colorectal cancer screening? (9.005) Female patients from the age of 50 through the age of 74: Was the patient N/A N/A N/A N/A offered a mammogram in compliance with policy? (9.006) Female patients from the age of 21 through the age of 65: Was patient N/A N/A N/A N/A offered a pap smear in compliance with policy? (9.007) Are required immunizations being offered for chronic care patients? (9.008) 2 6 17 25.0% Are patients at the highest risk of coccidioidomycosis (Valley Fever) 5 0 0 100% infection transferred out of the facility in a timely manner? (9.009) Overall percentage (MIT 9): 75.0% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 62 Recommendations • Nursing leadership should develop and implement measures to ensure nursing staff administer TB medications to patients as prescribed and monitor the patients according to CCHCS policy. • Medical leadership should determine the root cause(s) for challenges to timely providing vaccinations to chronic care patients and should implement appropriate remedial measures. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 63 Nursing Performance In this indicator, the OIG clinicians evaluated the quality of care delivered by the institution’s nurses, including registered nurses (RN), licensed vocational nurses (LVN), psychiatric technicians (PT), certified nursing assistants (CNA), and medical assistants (MA). Our clinicians evaluated nurses’ performance in making timely and appropriate assessments and interventions. We also evaluated the institution’s nurses’ documentation for accuracy and thoroughness. Clinicians reviewed nursing performance across many clinical settings and processes, including sick call, outpatient care, care coordination and management, emergency services, specialized medical housing, hospitalizations, transfers, specialty services, and medication management. The OIG assessed nursing care through case review only and performed no compliance testing for this indicator. When summarizing nursing performance, our clinicians understand that nurses perform numerous aspects of medical care. As such, specific nursing quality issues are discussed in other indicators, such as Emergency Services, Specialty Services, and Specialized Medical Housing. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Not Applicable Case Review found a significant improvement in nursing performance from Cycle 6 to Cycle 7, with a notable decrease in the number of overall nursing deficiencies as well as significant deficiencies. However, our clinicians still identified opportunities for improvement in nursing assessment and documentation. Considering all factors, the OIG rated this indicator adequate. Case Review Results We reviewed 184 nursing encounters in 44 cases. Of the nursing encounters we reviewed, 76 occurred in the outpatient setting, and 33 were nursing sick call requests. We identified 75 nursing performance deficiencies, none of which were significant.42 Outpatient Nursing Assessment and Interventions A critical component of nursing care is the quality of nursing assessment, which includes both subjective (patient interviews) and objective (observation and examination) elements. A comprehensive assessment allows nurses to gather essential information about their patients and develop appropriate interventions. Nurses generally provided timely and appropriate care. OIG clinicians identified 27 outpatient nursing deficiencies, none of which were significant.43 Although, we identified 42 Deficiencies occurred in cases 1–4, 7–9, 15–23, 27, 29–32, 34, 38, and 40–45. 43 Outpatient nursing deficiencies occurred in cases 1, 2, 8, 9, 15–20, 23, 32, 34, 38, 40–43, and 45. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 64 no particular trends or patterns of deficiencies, nurses had opportunities for improvement in performing thorough patient assessments and carrying out appropriate nursing interventions. The following are examples: • In case 9, a nurse triaged a health care request for a patient with complaint of “bad” toenails and medication not working. The nurse requested a follow-up with the provider within 14 days without performing a face-to-face assessment of the patient’s toes. • In case 20, the patient diagnosed with asthma, sleep apnea, and diabetes complained of excessive sleepiness, no energy, and the inability to stay awake. The nurse did not listen to the patient’s lungs and did not palpate pulses and check capillary refill to ensure proper circulation. Additionally, the nurse did not inquire about the patient’s knowledge and use of a prescribed CPAP machine, asthma-related incidences, or inhaler use. In addition, the nurse did not perform peak flows, obtain a blood sugar reading, or inquire about the patient’s eating habits or daily activity participation. Furthermore, the nurse did not refer the patient to the primary care provider for evaluation. However, the severity of this deficiency was mitigated due to mental health staff also monitoring the patient for the same complaints. • In case 40, the patient complained of right eye pain with redness and irritation for three days. The nurse documented right eyelid swelling. However, the nurse did not inquire about the activity at onset or cause of the swelling, conduct a visual acuity exam, or describe the appearance of the eye and cornea (e.g., white, redness, foreign body, injury, or drainage). Additionally, the nurse did not educate the patient. Outpatient Nursing Documentation Complete and accurate nursing documentation is an essential component of patient care. Without proper documentation, health care staff can overlook changes in patients’ conditions. Although nurses often documented their assessment findings and interventions satisfactorily, emergency services showed opportunities for improvement. This is discussed further in the Emergency Services indicator. The following are examples of outpatient documentation deficiencies: • In case 15, the nurse documented the patient ambulated to the clinic after an altercation, and the nurse completed an injury report. However, the nurse did not document the assessment findings or whether the patient sustained any injuries in the electronic health record. • In cases 2 and 19, the nurses documented the patients refused their medications; however, both patients were not at the institution and were off- site at a community emergency room. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 65 Case Management OIG clinicians reviewed eight cases in which patients met with a care coordinator.44 Care coordinators are LVNs who perform duties such as chronic care education. We did not identify any deficiencies in scheduling or evaluating patients for care management appointments. Wound Care OIG clinicians reviewed five cases involving wound care, dressing changes, PICC line care, or drain care.45 We identified three cases in which care was not performed as ordered or in accordance with community standards. These concerns are discussed further in the Specialized Medical Housing indicator. Emergency Services OIG clinicians reviewed 29 urgent or emergent events. Nurses responded promptly to emergent events and frequently provided good interventions. Although no patterns or trends were identified, OIG clinicians found opportunities for improvement in nursing assessment and documentation, which we detail further in the Emergency Services indicator. Hospital Returns OIG clinicians reviewed 13 nursing events in which patients returned from a community hospital or emergency room. OIG clinicians identified two nursing deficiencies, neither of which was significant.46 The nurses generally performed good nursing assessments, which we detail further in the Transfers indicator. Transfers OIG clinicians reviewed eight cases that involved transfer-in and transfer-out processes. Nurses evaluated patients appropriately and initiated provider appointments within appropriate time frames. However, nurses did not always document pertinent information when patients transferred out of the institution. Please refer to the Transfers indicator for further details. Specialized Medical Housing OIG clinicians reviewed four cases with a total of 84 events, 28 of which were nursing encounters. In the OHU, OIG clinicians found nurses generally provided good care. Please refer to the Specialized Medical Housing indicator for further details. Specialty Services OIG clinicians reviewed 19 cases with a total of 113 events, 30 of which included nurse evaluations of patients prior to a procedure or upon return from an off-site specialist 44 Care coordinator encounters occurred in cases 11-14, 16, 17, 19, and 20. 45 Wound care, dressing changes, PICC line, or renal drain care occurred in cases 2, 19, 21, 23 and 24. 46 Deficiencies occurred in cases 2 and 21. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 66 appointment. OIG clinicians identified seven minor nursing deficiencies related to specialty services. Please refer to the Specialty Services indicator for additional details. Medication Management OIG clinicians reviewed 126 events involving medication management and administration. We identified 26 deficiencies, one of which was significant. Nurses generally administered medications timely and as ordered; however, on three occasions, medication was not administered to patients prior to or upon return from off-site specialty appointments. Further details are provided in the Medication Management indicator. Clinician On-Site Inspection Our clinicians toured each facility, which included TTAs, R&R, OHU, medical clinics, and select medication administration areas. OIG clinicians also conducted interviews with staff and supervisors. We learned nursing leadership had been in their respective roles for over two years. Both the chief nurse executive (CNE) and supervising registered nurse (SRN) III had started with the institution in various nursing roles and had promoted into their current positions. The CNE reported challenges with morale due to increased overdose incidents and the recent closures of two of the institution’s facilities as well as the closure of a nearby prison. The closures resulted in staff transfers and resignations. She mentioned, although they had lost good talent, she was proud of the staff, and recently the institution had been highlighted by CCHCS headquarters for reducing the specialty appointment backlogs. Although the CNE described morale as poor, interviews with nursing staff and supervisors reflected differently. Nurses in various roles reported the working environment was “decent” and “great,” and they felt they had established good rapport with custody staff. Nurses interviewed also felt supported by their leadership. The CNE additionally discussed many CCHCS headquarters initiatives, such as offering COVID-19 vaccines to patients who had previously refused and then reoffering vaccination to those over the age of 65. In addition, while touring Facility B, our clinicians observed an in-progress initiative: nurses issuing nasal naloxone and educating patients regarding the medication’s use for overdoses. OIG clinicians inquired whether patients had been using the naloxone for the intended purpose. Interviews with medication line nurses indicated, while they did not have direct knowledge of the patient actual use, they had not experienced an increase in requests for refills in housing units for those who had already had them issued in previous months. The nurses indicated this may be because the patients are using naloxone as intended; however, patients may also be hesitant to request refills to avoid investigation into the medication’s use. However, the CNE reported the program had resulted in fewer staff-administered naloxone medications. In addition to staff interviews, our clinicians also attended the facility huddles and the OHU huddle. The huddles were offered remotely and were well attended by staff from various disciplines. The huddles were organized, and teams discussed patient needs and were familiar with their patient panels. Our OIG clinicians further had the opportunity to attend the Facility B Population Management meeting, which was well structured and provided valuable information regarding specific patient needs. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 67 Recommendations • Nursing leadership should determine the challenges preventing nurses from performing complete assessments and documentation and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 68 Provider Performance In this indicator, OIG case review clinicians evaluated the quality of care delivered by the institution’s providers: physicians, physician assistants, and nurse practitioners. Our clinicians assessed the institution’s providers’ performance in evaluating, diagnosing, and managing their patients properly. We examined provider performance across several clinical settings and programs, including sick call, emergency services, outpatient care, chronic care, specialty services, intake, transfers, hospitalizations, and specialized medical housing. We assessed provider care through case review only and performed no compliance testing for this indicator. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Not Applicable CCI providers delivered acceptable medical care; an improvement compared with Cycle 6. Providers mostly performed well with chronic conditions and emergency clinical settings, while providing continuity for patients. Providers usually reviewed medical records carefully and ordered appropriate specialty referrals. However, we found providers needed improvement with outpatient assessments, caring for OHU patients, following up with specialists, thoroughly documenting, and sending complete patient test result notification letters. The majority of the deficiencies did not significantly affect patient care. After carefully considering all aspects of provider care, the OIG rated this indicator adequate. Case Review Results OIG clinicians reviewed 113 provider encounters and identified 60 deficiencies, 16 of which were significant.47 In addition, our clinicians examined the quality of care in 20 comprehensive case reviews. Of these 20 cases, we found 18 adequate and two inadequate. Outpatient Assessment and Decision-Making Providers generally made appropriate assessments and sound decisions. Most providers obtained thorough histories, performed pertinent examinations, and developed reasonable differential diagnoses. Providers typically ordered necessary tests and specialty referrals. However, case review identified 25 deficiencies related to outpatient provider assessments, six of which were significant.48 Half of the six deficiencies involved a patient with poorly controlled diabetes, who was not appropriately managed.49 The following are three additional examples of poor assessment or decision-making: 47 Deficiencies occurred in cases 1, 2, 8, 13, 15–25, 44, and 45. Significant deficiencies occurred in cases 2, 8, 13, 19, 21, 23, and 44. 48 Deficiencies occurred in cases 1, 8, 13, 15–20, 22, 23, and 25. Significant deficiencies occurred in cases 8, 13, 19, and 23. 49 Deficiencies occurred in case 13. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 69 • In case 8, the patient complained of neck pain. However, the provider did not document a detailed history of the pain or perform a neck examination. The provider also failed to give a clear rationale for diagnosing this patient’s neck pain as “nerve pain.” • In case 19, a provider evaluated the patient after hospitalization for a kidney infection. The hospital staff recommended weekly blood tests; however, the provider did not order the blood tests and gave no rationale. • In case 23, the patient had high blood pressure and a thyroid disorder. Although the patient admitted he had stopped taking his medications, a provider continued to order the medications for months. The provider also failed to order follow-up blood pressure checks or thyroid laboratory testing to reassess whether the medications were still medically indicated. Outpatient Review of Records Providers generally reviewed medical records carefully. Case review identified only two minor deficiencies related to record review as follows: • In case 1, a provider ordered a lower dose of Suboxone for the patient.50 However, the provider did not review the patient’s medication record to verify when the last dose was given. As a result, the patient received two doses of Suboxone on the day of the medication change. • In case 2, a provider evaluated the patient after a finger laceration. However, the provider did not document the patient’s tetanus immunization status. As a result, the patient did not receive a tetanus vaccine booster after his injury. Emergency Care TTA providers delivered good patient care. Most providers triaged patients appropriately and were available for phone consultations with nurses. Case review identified only two deficiencies, one of which was significant.51 We discuss both deficiencies in the Emergency Services indicator. Chronic Care In most instances, providers appropriately managed patients with chronic health conditions. In addition to the assessment deficiencies mentioned above, we identified three deficiencies in which providers did not address all the patient’s chronic conditions or document them properly in their progress notes.52 50 Suboxone is a medication containing buprenorphine and naloxone. Suboxone is used to treat opioid dependence and addiction. 51 Deficiencies occurred in cases 1 and 2. A significant deficiency occurred in case 2. 52 Deficiencies occurred in cases 15, 16, and 22. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 70 Specialized Medical Housing Providers delivered suboptimal care for OHU patients. Providers completed admission and discharge documents thoroughly and generally timely. In addition, providers often evaluated patients after specialty and hospital encounters. However, the primary OHU provider did not always address specialists’ recommendations and often poorly documented physical examinations and treatment plans, which lacked thoroughness.53 The providers also tended to focus on the patients’ acute conditions, while deferring their chronic conditions. Although most of the identified deficiencies were not significant, they showed a worrisome pattern involving complex patients. We discussed the deficiencies further in the Specialized Medical Housing indicator. Specialty Services CCI providers generally referred and consulted appropriately with off-site and telemedicine specialists, as well as with eConsult providers.54 However, case review identified nine deficiencies related to the provider responses to specialty reports, six of which were significant.55 Provider endorsements of eConsult responses were late or missing, as in the following two examples: • In case 13, one provider reviewed the recommendations from an eConsult endocrinologist over a month after the response was available. • Also in case 13, another provider received a message about the endocrinologist’s recommendations but did not respond to the message or acknowledge the recommendations at the patient’s next appointment. We also found providers endorsed specialists’ reports but did not follow or address the recommendations. • In case 2, the patient had multiple right hand finger fractures. The orthopedic surgeon recommended orthopedic follow-up in six weeks and physical therapy. However, a provider did not order physical therapy and did not order orthopedic specialty follow-up until 14 weeks later. • In case 13, the patient with diabetes was prescribed diabetic medications. An endocrinologist had recommended stopping one of the medications as it could cause low blood sugar. However, a provider continued to refill this medication. • In case 23, the patient had surgery for a ruptured Achilles tendon. The podiatrist recommended the patient use a wheelchair for optimal healing and not bear weight on his foot or use crutches. However, even after multiple patient encounters and nurse notifications, the provider did not order a wheelchair. 53 Deficiencies occurred in cases 21, 44, and 45. 54 eConsult is an electronic specialty consulting service whereby providers can inquire of specialists about medical questions and receive advice and recommendations for patient care. 55 Deficiencies occurred in cases 2, 8, 13, 19, and 23. Significant deficiencies occurred in cases 2, 8, 13, and 23. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 71 Potentially dangerous situations can arise when medical staff do not make an effort to clarify specialists’ recommendations that either are not communicated or are unclear. A significant example follows: • In case 8, a neurologist evaluated a patient with seizures. The neurologist recommended medication changes, instructing the patient’s medical staff to taper one medication off and to start a second medication. However, the neurologist did not specify the parameters for tapering the first medication or starting the second medication. The provider did not clarify the recommendations with the neurologist but instead ordered a lower dose of the first medication for one week and a follow-up with the primary provider in two weeks. As a result, the first medication expired abruptly, rather than being tapered off. Documentation Quality Providers were generally careful to document their patient encounters and nurse interactions. Case review did not find any evidence of missing progress notes from on- call providers or of providers cloning past progress notes. However, we identified three deficiencies related to other missing documentation. • In case 13, the patient refused a change in medication, but the provider did not complete an informed refusal form. • In case 22, a provider evaluated the patient after two specialty appointments. However, the provider did not include vital signs, a physical examination, current diagnoses, or treatment plans in their progress note. • In case 24, a provider canceled a request for services (RFS) for an ophthalmology specialist.56 However, the provider did not document discussions with ophthalmology specialist, nurses, or the patient to explain why the provider canceled the appointment. Patient Notification Letters Providers often did not send patient test result notification letters to patients. When they did, the letters only sometimes contained the four elements required by policy. Please refer to the Diagnostic Services indicator for details. Provider Continuity Provider continuity at CCI was excellent. OIG clinicians did not identify any deficiencies related to the lack of provider continuity. Clinician On-Site Inspection The medical provider staff at CCI was unique at the time of our inspection. The chief physician and surgeon (CP&S) position was vacant. The CCI providers included on-site providers (physician and advanced practitioners), one telemedicine physician, and one 56 The request for service (RFS) is a referral order for a specialty consultation. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 72 registry physician. Even with provider vacancies, morale was positive and united. Although several providers had been assigned to one yard for a long period, provider schedules often created the need for cross-coverage. No clinics had a backlog of appointments, and all eligible providers, including the CME, assisted with the overnight on-call duties. Staff reported two effects on hiring: another local institution had recently closed, and two of the five yards at CCI had also closed due to the decreased patient population. Thus, providers felt uncertain about job security. In addition, CCI’s remote location may also have contributed to recruitment challenges. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 73 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 74 Specialized Medical Housing In this indicator, OIG inspectors evaluated the quality of care in the specialized medical housing units. We evaluated the performance of the medical staff in assessing, monitoring, and intervening for medically complex patients requiring close medical supervision. Our inspectors also evaluated the timeliness and quality of provider and nursing intake assessments and care plans. We assessed staff members’ performance in responding promptly when patients’ conditions deteriorated and looked for good communication when staff consulted with one another while providing continuity of care. At the time of our inspection, CCI’s specialized medical housing consisted of an Outpatient Housing Unit (OHU). Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Inadequate (48.1%) In Cycle 7, the OHU was reopened after being temporarily closed in Cycle 6. During Cycle 7, CCI performed sufficiently in the care of OHU patients. However, both providers and nurses had opportunities for improvement in performing thorough and focused physical assessments, implementing relevant interventions, and documenting the care planned or provided. After reviewing all aspects, the OIG rated the case review component of this indicator adequate. Compliance testing showed mixed performance in this indicator. Although staff often timely completed admission assessments and history with physical examinations, staff needed improvement in medication administration. The nursing staff also needed to complete documentation when conducting rounds in the OHU due to a nonfunctional call light system. Based on the overall compliance score result, the OIG rated the compliance component of this indicator inadequate. Case Review and Compliance Testing Results We reviewed 84 OHU events, which included 34 provider encounters and 28 nursing encounters. Due to the frequency of nursing and provider contacts in specialized medical housing, the OIG bundles up to two weeks of patient care into a single event. We identified 41 deficiencies, three of which were significant.57 Provider Performance Providers needed improvement in delivering medical care for OHU patients. Compliance testing showed providers generally completed admission history and physicals without delay (MIT 13.002, 80.0%). Case review also found providers completed these timely, along with conducting prompt patient rounds and follow-ups after off-site encounters. However, we found providers only sometimes completed thorough physical exams, 57 Deficiencies occurred in cases 19, 21, 44, and 45. Significant deficiencies occurred in cases 21 and 44. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 75 documented clear treatment plans, and addressed specialists’ recommendations. We identified 16 provider deficiencies, three of which were significant.58 The following are examples: • In case 21, the patient initially had an abnormal blood test; subsequently, the provider referred the patient for a bone marrow biopsy, a painful and invasive procedure. However, the repeat blood test was normal. In addition, the blood specialist recommended a face-to-face appointment before the biopsy. Nevertheless, the bone marrow biopsy was performed with normal results, indicating the procedure was unnecessary. • In case 44, the patient had rectal cancer and finished radiation therapy, resulting in rectal burns. A provider evaluated this patient five times in the following month but never examined the affected area, even when the patient complained of rectal pain. • Also in case 44, after the patient’s final radiation treatment, the radiation specialist recommended follow-up with the patient’s medical oncologist and rectal surgeon. A provider endorsed the radiation specialist’s report timely but did not order either of the follow-up appointments until the provider received a message from a nurse one month later. • In case 45, during multiple patient encounters over a two-month period, the provider conducted patient rounds but failed to document clear treatment plans. Nursing Performance Compliance testing and case review found OHU nurses almost always performed timely admission assessments (MIT 13.001, 90.0%). OIG clinicians also found OHU nurses conducted regular rounds and generally provided good care. However, our clinicians found opportunities for improvement in nursing assessments, interventions, and documentation. We identified 18 nursing deficiencies, none of which were significant.59 The following are examples: • In case 19, the patient was admitted to the OHU with a PICC line and renal drain.60 The OHU nurse did not measure the length of the PICC line, document the presence of the renal drain and its contents, or describe the condition of the surrounding dressings.61 Furthermore the nurse inaccurately documented the location of the renal abscess. 58 Provider deficiencies occurred in cases 21, 44, and 45. Significant deficiencies occurred in cases 21 and 44. 59 Nursing deficiencies occurred in cases 19, 21, 44, and 45. 60 A peripherally inserted central catheter (PICC) provides intravenous access to administer fluids and medication. A renal drain is a flexible tube that drains urine from the kidney into a bag outside the body. 61 The PICC line is measured to ensure proper placement or determine if it has been dislodged prior to medication or fluid administration. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 76 • In case 21, the patient was housed in the OHU after surgical repair of a left inguinal hernia.62 However, nurses did not perform wound care consistently, as ordered. • In case 23, the patient had an order for daily dressing changes for 14 days. However, due to errors in order entry, the patient’s dressing changes did not occur at the frequency specified. • In case 44, on multiple occasions throughout the patient’s OHU admission, certified nursing assistants (CNAs) documented abnormal vital signs; however, they did not document if the patient was asymptomatic, recheck the vital signs, or notify the RN or provider on duty. Medication Administration Compliance testing revealed CCI performed poorly in ensuring patients admitted to the OHU received their medications within required time frames (MIT 13.003, 22.2%). OIG clinicians identified four deficiencies related to medication management, none of which were significant.63 These are addressed further in the Medication Management indicator. Clinician On-Site Inspection The OIG clinicians toured CCI’s OHU, attended the huddle, and interviewed the OHU staff. The huddle was well organized and detailed, with great multidisciplinary staff participation. Nursing staff reported the OHU had 14 medical beds and two designated rooms for mental health observation. The institution had no negative pressure rooms. At the time of the inspection, all 14 medical beds were occupied. The RN reported full occupancy was typical, with most beds occupied by chronic care patients or patients returning from the hospital. The OHU had 24-hour nursing staff with one RN assigned to second watch and one LVN assigned to first and third watches. All watches also had two assigned CNAs, although on the day of the tour, only one CNA was present. According to the RN, an additional LVN assisted on second watch when available. Staff reported having designated providers for coverage, with after-hours coverage handled by the on-call provider. During the tour, we observed a call light system; however, it was not functional. Nursing staff reported they conducted 30-minute rounds since the call light had been inoperable for quite some time. In addition, staff reported a team approach during daily nursing rounds, with the CNA and the LVN or RN conducting patient encounters together. The staff also reported providers conducted rounds daily during weekdays. The OHU staff reported challenges on first watch with custody staff being unable to open patient doors without first receiving permission from the watch commander. The staff reported this could result in a delay of care in an emergent situation. In addition, 62 Inguinal hernia is a protrusion of the abdominal cavity in groin area due to a defect or opening on abdominal wall. 63 Medication administration deficiencies occurred in cases 21 and 44. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 77 although staff reported morale was good, they also reported the OHU RN post is not desirable due to the full census, workload, and limited staffing. Compliance On-Site Inspection At the time of the compliance on-site inspection, the OHU did not have a functioning call light communication system in place (MIT 13.101, N/A). Although the institution had a local operating procedure (LOP) in an event a call light system was unavailable, compliance testing revealed the OHU nurse did not perform safety checks as indicated in the LOP for all patients admitted to the OHU (MIT 13.102, zero). Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 78 Compliance Score Results Table 16. Specialized Medical Housing Scored Answer Compliance Questions Yes No N/A Yes % For OHU, CTC, and SNF: Did the registered nurse complete an initial 9 1 0 90.0% assessment of the patient on the day of admission? (13.001) Was a written history and physical examination completed within the 8 2 0 80.0% required time frame? (13.002) Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient 2 7 1 22.2% within required time frames? (13.003) For specialized health care housing (CTC, SNF, hospice, OHU): Do specialized health care housing maintain an operational call 0 0 1 N/A system? (13.101) For specialized health care housing (CTC, SNF, hospice, OHU): Do health care staff perform patient safety checks according to institution’s local 0 1 0 0 operating procedure or within the required time frames? (13.102) Overall percentage (MIT 13): 48.1% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 79 Recommendations • Medical leadership should determine the root cause of challenges to providers completing thorough assessments and clear treatment plans for specialized medical housing patients and should implement remedial measures as appropriate. • The institution should ascertain the causes related to the untimely availability and administration of medications to specialized medical housing patients and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 80 Specialty Services In this indicator, OIG inspectors evaluated the quality of specialty services. The OIG clinicians focused on the institution’s performance in providing needed specialty care. Our clinicians also examined specialty appointment scheduling, providers’ specialty referrals, and medical staff’s retrieval, review, and implementation of any specialty recommendations. Ratings and Results Overview Case Review Rating Compliance Rating and Score Adequate Inadequate (74.6%) Case review found patients received good specialty care at CCI. Providers appropriately ordered specialty and procedure referrals, while nurses usually made sound assessments. Staff scheduled provider follow-up appointments within requested time frames and generally addressed recommendations promptly. Although we identified some late provider endorsements of specialty reports, they did not significantly increase medical risks for the patients. Considering all factors, the OIG rated the case review component of this indicator adequate. Compared with Cycle 6, compliance testing showed CCI generally improved overall in this indicator. Access to specialists ranged from excellent to poor, depending on the appointment priority. Preapproved specialty referrals for newly arrived patients sporadically occurred within recommended time frames. In addition, retrieval of medium-priority and routine-priority specialty reports and prompt provider endorsements both needed improvements. Based on the overall compliance score result, the OIG rated this indicator inadequate. Case Review and Compliance Testing Results Our clinicians reviewed 85 events related to specialty services, which included 30 nursing encounters and 50 specialty consultations or procedures. We identified 22 deficiencies in this category, only one of which was significant.64 Access to Specialty Services Compliance testing showed the timeliness of specialty referrals was variable. Although specialty access for new transfers to CCI was low (MIT 14.010, 40.0%), access for established patients was outstanding. CCI patients with high-priority (MIT 14.001, 93.3%), medium-priority (MIT 14.004, 86.7%), and routine-priority (MIT 14.007, 100%) specialty referrals were typically seen within required time frames. Even follow-up appointments with specialists were always timely for high-priority (MIT 14.003, 100%), and often timely for routine-priority (MIT 14.009, 80.0%), patients. However, the 64 Deficiencies occurred in cases 2, 11, 19, 21, 22, 44, and 45. A significant deficiency occurred in case 11. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 81 timeliness of follow-up appointments for medium-priority patients was insufficient (MIT 14.006, 60.0%). Case review found no deficiencies with specialty access. Nursing Performance CCI nurses performed sufficiently in assessing patients who returned to the facility from off-site specialty appointments. OIG clinicians identified seven minor deficiencies related to specialty services. The following are examples: • In case 19, the RN performed a COVID-19 symptom screening for the patient returning from an off-site specialty appointment. The nurse documented the patient had a nonproductive cough but did not perform a COVID-19 test or refer the patient for testing as a precaution. • In case 21, the RN documented the patient’s blood pressure was elevated upon return from an off-site specialty appointment; however, the nurse did not obtain vital signs to recheck the elevated blood pressure. • In case 22, the RN evaluated the patient upon return from a high-priority off- site specialty consultation. The nurse scheduled the patient for a 14-day provider follow-up appointment, rather than an appointment within five days as required. Provider Performance CCI providers ordered appropriate specialty consultations and time frames. However, providers did not always implement specialty recommendations or order the requested follow-up consultations. We discuss specific examples in the Provider Performance indicator. Health Information Management CCI staff experienced challenges in managing specialty records. As shown in our compliance testing, staff often retrieved and reviewed high-priority reports timely (MIT 14.002, 80.0%), but staff did not manage medium-priority (MIT 14.005, 40.0%) and routine- priority (MIT 14.008, 60.0%) reports as well. Case review also found mixed performance. We found only one missing specialty report and one report that was retrieved but not sent to a provider for review.65 However, we commonly found late provider endorsements of specialty reports. Our clinicians identified seven cases involving a late endorsement, one of which was significant.66 The following are examples: • In case 11, a provider endorsed an endocrinology eConsult report 22 days after the report was available. • In case 22, a provider endorsed an orthopedic report eight days late. • In case 44, a provider endorsed an off-site radiology report seven days late. 65 Deficiencies occurred in cases 19 and 44. 66 Deficiencies occurred in cases 11, 19, 21, 22, and 44. A significant deficiency occurred in case 11. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 82 Clinician On-Site Inspection OIG clinicians discussed the specialty services process with CCI medical and nursing leadership, specialty nurses, utilization management nurses, and providers. They reported CCI provided on-site specialty services for optometry, orthotics, and physical therapy. Some radiology services were also available on-site. Off-site specialists were generally accessible and flexible in scheduling appointments. Gastroenterology specialists, in particular, agreed to bundle appointments for procedures to accommodate multiple CCI patients in a single day. Neurosurgery specialty appointments posed an occasional challenge due to the more distant location of this specialty. Case review found RFS denials were relatively common, with providers being asked to use eConsult as an option. However, providers were not entirely familiar with this resource and its benefits to the patient and the institution. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 83 Compliance Score Results Table 17. Specialty Services Scored Answer Compliance Questions Yes No N/A Yes % Did the patient receive the high-priority specialty service within 14 calendar days of the primary care provider order or the Physician Request for 14 1 0 93.3% Service? (14.001) Did the institution receive and did the primary care provider review the high-priority specialty service consultant report within the required time 12 3 0 80.0% frame? (14.002) Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care provider? 7 0 8 100% (14.003) Did the patient receive the medium-priority specialty service within 15-45 calendar days of the primary care provider order or Physician Request for 13 2 0 86.7% Service? (14.004) Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the required time 6 9 0 40.0% frame? (14.005) Did the patient receive the subsequent follow-up to the medium-priority specialty service appointment as ordered by the primary care provider? 3 2 10 60.0% (14.006) Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician Request for 15 0 0 100% Service? (14.007) Did the institution receive and did the primary care provider review the routine-priority specialty service consultant report within the required time 9 6 0 60.0% frame? (14.008) Did the patient receive the subsequent follow-up to the routine-priority specialty service appointment as ordered by the primary care provider? 4 1 10 80.0% (14.009) For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the sending 2 3 0 40.0% institution, was the appointment scheduled at the receiving institution within the required time frames? (14.010) Did the institution deny the primary care provider’s request for specialty 19 1 0 95.0% services within required time frames? (14.011) Following the denial of a request for specialty services, was the patient 12 8 0 60.0% informed of the denial within the required time frame? (14.012) Overall percentage (MIT 14): 74.6% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 84 Table 18. Other Tests Related to Specialty Services Scored Answer Compliance Questions Yes No N/A Yes % Specialty service follow-up appointments: Did the clinician follow-up visits 39 6 0 86.7% occur within required time frames? (1.008) * Are specialty documents scanned into the patient’s electronic health record 24 6 15 80.0% within five calendar days of the encounter date? (4.002) * CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician follow-up visits following specialty services. As a result, we tested MIT 1.008 only for high-priority specialty services or when staff ordered follow-ups. The OIG continued to test the clinical appropriateness of specialty follow-ups through its case review testing. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 85 Recommendations • Medical leadership should determine the root cause(s) of challenges to the timely provision of specialty appointments for newly transferred patients and should implement remedial measures as appropriate. • Medical leadership should ascertain the challenges to the timely receipt and provider review of specialty reports and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 86 Administrative Operations In this indicator, OIG compliance inspectors evaluated health care administrative processes. Our inspectors examined the timeliness of the medical grievance process and checked whether the institution followed reporting requirements for adverse or sentinel events and patient deaths. Inspectors checked whether the Emergency Medical Response Review Committee (EMRRC) met and reviewed incident packages. We investigated and determined whether the institution conducted required emergency response drills. Inspectors also assessed whether the Quality Management Committee (QMC) met regularly and addressed program performance adequately. In addition, our inspectors determined whether the institution provided training and job performance reviews for its employees. We checked whether staff possessed current, valid professional licenses, certifications, and credentials. The OIG rated this indicator solely based on the compliance score. Case review does not rate this indicator. Because none of the tests in this indicator directly affected clinical patient care (it is a secondary indicator), the OIG did not consider this indicator’s rating when determining the institution’s overall quality rating. Ratings and Results Overview Case Review Rating Compliance Rating and Score Not Applicable Adequate (80.3%) CCI’s overall performance was satisfactory in administrative operations. Although CCI scored excellently in most applicable tests, it needed improvement in several areas. The Emergency Medical Response Review Committee (EMRRC) only sporadically completed the required checklists and reviewed the cases within required time frames. In addition, staff conducted all medical emergency response drills with incomplete or inconsistent documentation. Lastly, physician managers only occasionally completed annual performance appraisals in a timely manner. These findings are set forth in the table on the next page. Based on the overall compliance score result, the OIG rated this indicator adequate. Compliance Testing Results Nonscored Results At CCI, the OIG did not have any applicable adverse sentinel events requiring root cause analysis during our inspection period (MIT 15.001). We obtained CCHCS Mortality Case Review reporting data. In our inspection, for four patients, we found no evidence in the submitted documentation the preliminary mortality reports had been completed. These reports were overdue at the time of the OIG’s inspection. (MIT 15.998). Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 87 Compliance Score Results Table 19. Administrative Operations Scored Answer Compliance Questions Yes No N/A Yes % For health care incidents requiring root cause analysis (RCA): Did the This is a nonscored test. Please refer to the institution meet RCA reporting requirements? (15.001) discussion in this indicator. Did the institution’s Quality Management Committee (QMC) meet 6 0 0 100% monthly? (15.002) For Emergency Medical Response Review Committee (EMRRC) reviewed cases: Did the EMRRC review the cases timely, and did the incident 3 7 0 30.0% packages the committee reviewed include the required documents? (15.003) For institutions with licensed care facilities: Did the Local Governing Body (LGB) or its equivalent meet quarterly and discuss local operating N/A N/A N/A N/A procedures and any applicable policies? (15.004) Did the institution conduct medical emergency response drills during each watch of the most recent quarter, and did health care and custody staff 0 3 0 0 participate in those drills? (15.101) Did the responses to medical grievances address all of the patients’ 10 0 0 100% appealed issues? (15.102) Did the medical staff review and submit initial patient death reports to the 4 0 0 100% CCHCS Mortality Case Review Unit on time? (15.103) Did nurse managers ensure the clinical competency of nurses who 10 0 0 100% administer medications? (15.104) Did physician managers complete provider clinical performance appraisals 2 4 0 33.3% timely? (15.105) Did the providers maintain valid state medical licenses? (15.106) 10 0 0 100% Did the staff maintain valid Cardiopulmonary Resuscitation (CPR), Basic Life Support (BLS), and Advanced Cardiac Life Support (ACLS) certifications? 2 0 1 100% (15.107) Did the nurses and the pharmacist-in-charge (PIC) maintain valid professional licenses and certifications, and did the pharmacy maintain a 6 0 1 100% valid correctional pharmacy license? (15.108) Did the pharmacy and the providers maintain valid Drug Enforcement Agency (DEA) registration certificates, and did the pharmacy maintain valid 1 0 0 100% Automated Drug Delivery System (ADDS) licenses? (15.109) Did nurse managers ensure their newly hired nurses received the required 1 0 0 100% onboarding and clinical competency training? (15.110) Did the CCHCS Death Review Committee process death review reports This is a nonscored test. Please refer to the timely? Effective 05/2022: Did the Headquarters Mortality Case Review discussion in this indicator. process mortality review reports timely? (15.998) What was the institution’s health care staffing at the time of the OIG This is a nonscored test. Please refer to Table 3 medical inspection? (15.999) for CCHCS-provided staffing information. Overall percentage (MIT 15): 80.3% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 88 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 89 Appendix A: Methodology In designing the medical inspection program, the OIG met with stakeholders to review CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. We 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, the department, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of our inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates the delivery of medical care 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. We rate each of the quality indicators applicable to the institution under inspection based on case reviews conducted by our clinicians or compliance tests conducted by our registered nurses. Figure A–1 below depicts the intersection of case review and compliance. Figure A–1. Inspection Indicator Review Distribution for CCI Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 90 Case Reviews The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders, which continues in the Cycle 7 medical inspections. Below, Table A–1 provides important definitions that describe this process. Table A–1. Case Review Definitions Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 91 The OIG eliminates case review selection bias by sampling using a rigid methodology. No case reviewer selects the samples he or she reviews. Because the case reviewers are excluded from sample selection, there is no possibility of selection bias. Instead, nonclinical analysts use a standardized sampling methodology to select most of the case review samples. A randomizer is used when applicable. For most basic institutions, the OIG samples 20 comprehensive physician review cases. For institutions with larger high-risk populations, 25 cases are sampled. For the California Health Care Facility, 30 cases are sampled. Case Review Sampling Methodology We obtain a substantial amount of health care data from the inspected institution and from CCHCS. Our analysts then apply filters to identify clinically complex patients with the highest need for medical services. These filters include patients classified by CCHCS with high medical risk, patients requiring hospitalization or emergency medical services, patients arriving from a county jail, patients transferring to and from other departmental institutions, patients with uncontrolled diabetes or uncontrolled anticoagulation levels, patients requiring specialty services or who died or experienced a sentinel event (unexpected occurrences resulting in high risk of, or actual, death or serious injury), patients requiring specialized medical housing placement, patients requesting medical care through the sick call process, and patients requiring prenatal or postpartum care. After applying filters, analysts follow a predetermined protocol and select samples for clinicians to review. Our physician and nurse reviewers test the samples by performing comprehensive or focused case reviews. Case Review Testing Methodology An OIG physician, a nurse consultant, or both review each case. As the clinicians review medical records, they record pertinent interactions between the patient and the health care system. We refer to these interactions as case review events. Our clinicians also record medical errors, which we refer to as case review deficiencies. Deficiencies can be minor or significant, depending on the severity of the deficiency. If a deficiency caused serious patient harm, we classify the error as an adverse event. On the next page, Figure A–2 depicts the possibilities that can lead to these different events. After the clinician inspectors review all the cases, they analyze the deficiencies, then summarize their findings in one or more of the health care indicators in this report. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 92 Figure A–2. Case Review Testing Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 93 Compliance Testing Compliance Sampling Methodology Our analysts identify samples for both our case review inspectors and compliance inspectors. Analysts follow a detailed selection methodology. For most compliance questions, we use sample sizes of approximately 25 to 30. Figure A–3 below depicts the relationships and activities of this process. Figure A–3. Compliance Sampling Methodology Compliance Testing Methodology Our inspectors answer a set of predefined medical inspection tool (MIT) questions to determine the institution’s compliance with CCHCS policies and procedures. Our nurse inspectors assign a Yes or a No answer to each scored question. OIG headquarters nurse inspectors review medical records to obtain information, allowing them to answer most of the MIT questions. Our regional nurses visit and inspect each institution. They interview health care staff, observe medical processes, test the facilities and clinics, review employee records, logs, medical grievances, death reports, and other documents, and obtain information regarding plant infrastructure and local operating procedures. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 94 Scoring Methodology Our compliance team calculates the percentage of all Yes answers for each of the questions applicable to a particular indicator, then averages the scores. The OIG continues to rate these indicators based on the average compliance score using the following descriptors: proficient (85.0 percent or greater), adequate (between 84.9 percent and 75.0 percent), or inadequate (less than 75.0 percent). Indicator Ratings and the Overall Medical Quality Rating The OIG medical inspection unit individually examines all the case review and compliance inspection findings under each specific methodology. We analyze the case review and compliance testing results for each indicator and determine separate overall indicator ratings. After considering all the findings of each of the relevant indicators, our medical inspectors individually determine the institution’s overall case review and compliance ratings. Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 95 Appendix B: Case Review Data Table B–1. CCI Case Review Sample Sets Sample Set Total CTC/OHU 2 Death Review/Sentinel Events 2 Diabetes 4 Emergency Services – CPR 5 Emergency Services – Non-CPR 2 High Risk 4 Hospitalization 4 Intrasystem Transfers In 3 Intrasystem Transfers Out 3 RN Sick Call 12 Specialty Services 4 45 Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 96 Table B–2. CCI Case Review Chronic Care Diagnoses Sample Set Total Anemia 1 Anticoagulation 2 Arthritis/Degenerative Joint Disease 1 Asthma 3 COPD 1 Cancer 3 Cardiovascular Disease 1 Chronic Kidney Disease 1 Chronic Pain 5 Cirrhosis/End Stage Liver Disease 4 Deep Vein Thrombosis/Pulmonary Embolism 1 Diabetes 10 Gastroesophageal Reflux Disease 7 Hepatitis C 19 Hyperlipidemia 8 Hypertension 16 Mental Health 25 Migraine Headaches 1 Seizure Disorder 2 Substance Abuse 22 Thyroid Disease 2 135 Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 97 Table B–3. CCI Case Review Events by Program Diagnosis Total Diagnostic Services 157 Emergency Care 54 Hospitalization 21 Intrasystem Transfers In 6 Intrasystem Transfers Out 7 Outpatient Care 319 Specialized Medical Housing 84 Specialty Services 115 763 Table B–4. CCI Case Review Sample Summary Sample Set Total MD Reviews Detailed 20 MD Reviews Focused 2 RN Reviews Detailed 12 RN Reviews Focused 25 Total Reviews 59 Total Unique Cases 45 Overlapping Reviews (MD & RN) 14 Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 98 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 99 Appendix C: Compliance Sampling Methodology California Correctional Institution Quality No. of Indicator Sample Category Samples Data Source Filters Access to Care MIT 1.001 Chronic Care 25 Master Registry • Chronic care conditions (at least one Patients condition per patient — any risk level) • Randomize MIT 1.002 Nursing Referrals 25 OIG Q: 6.001 • See Transfers MITs 1.003 – 006 Nursing Sick Call 30 Clinic • Clinic (each clinic tested) (6 per clinic) Appointment List • Appointment date (2 – 9 months) • Randomize MIT 1.007 Returns From 5 OIG Q: 4.005 • See Health Information Management Community (Medical Records) (returns from Hospital community hospital) MIT 1.008 Specialty Services 45 OIG Q: 14.001, • See Specialty Services Follow-Up 14.004 & 14.007 MIT 1.101 Availability of 6 OIG on-site review • Randomly select one housing unit Health Care from each yard Services Request Forms Diagnostic Services MITs 2.001 – 003 Radiology 10 Radiology Logs • Appointment date (90 days – 9 months) • Randomize • Abnormal MITs 2.004 – 006 Laboratory 10 Quest • Appt. date (90 days – 9 months) • Order name (CBC, BMP, or CMPs only) • Randomize • Abnormal MITs 2.007 – 009 Laboratory STAT 0 Quest • Appt. date (90 days – 9 months) • Order name (CBC, BMP, or CMPs only) • Randomize • Abnormal MITs 2.010 – 012 Pathology 10 InterQual • Appt. date (90 days – 9 months) • Service (pathology-related) • Randomize Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 100 Quality No. of Indicator Sample Category Samples Data Source Filters Health Information Management (Medical Records) MIT 4.001 Health Care Services 30 OIG Qs: 1.004 • Nondictated documents Request Forms • First 20 IPs for MIT 1.004 MIT 4.002 Specialty Documents 45 OIG Qs: 14.002, • Specialty documents 14.005 & 14.008 • First 10 IPs for each question MIT 4.003 Hospital Discharge 5 OIG Q: 4.005 • Community hospital discharge Documents documents • First 20 IPs selected MIT 4.004 Scanning Accuracy 24 Documents for • Any misfiled or mislabeled document any tested identified during incarcerated OIG compliance review person (24 or more = No) MIT 4.005 Returns From 5 CADDIS off-site • Date (2 – 8 months) Community Hospital admissions • Most recent 6 months provided (within date range) • Rx count • Discharge date • Randomize Health Care Environment MITs 5.101 – 105 Clinical Areas 14 OIG inspector • Identify and inspect all on-site clinical MITs 5.107 – 111 on-site review areas Transfers MITs 6.001 – 003 Intrasystem Transfers 25 SOMS • Arrival date (3 – 9 months) • Arrived from (another departmental facility) • Rx count • Randomize MIT 6.101 Transfers Out 2 OIG inspector • R&R IP transfers with medication on-site review Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 101 Quality No. of Indicator Sample Category Samples Data Source Filters Pharmacy and Medication Management MIT 7.001 Chronic Care 25 OIG Q: 1.001 • See Access to Care Medication • At least one condition per patient — any risk level • Randomize MIT 7.002 New Medication 25 Master Registry • Rx count Orders • Randomize • Ensure no duplication of IPs tested in MIT 7.001 MIT 7.003 Returns From 5 OIG Q: 4.005 • See Health Information Management Community Hospital (Medical Records) (returns from community hospital) MIT 7.004 RC Arrivals — N/A at this OIG Q: 12.001 • See Reception Center Medication Orders institution MIT 7.005 Intrafacility Moves 25 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) • Randomize MIT 7.006 En Route 10 SOMS • Date of transfer (2– 8 months) • Sending institution (another departmental facility) • Randomize • NA/DOT meds MITs 7.101 – 103 Medication Storage Varies OIG inspector • Identify and inspect clinical & med Areas by test on-site review line areas that store medications MITs 7.104 – 107 Medication Varies OIG inspector • Identify and inspect on-site clinical Preparation and by test on-site review areas that prepare and administer Administration Areas medications MITs 7.108 – 111 Pharmacy 1 OIG inspector • Identify & inspect all on-site on-site review pharmacies MIT 7.112 Medication Error 14 Medication error • All medication error reports with Reporting reports Level 4 or higher • Select total of 25 medication error reports (recent 12 months) MIT 7.999 Restricted Unit 10 On-site active • KOP rescue inhalers & nitroglycerin KOP Medications medication listing medications for IPs housed in restricted units Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 102 Quality No. of Indicator Sample Category Samples Data Source Filters Prenatal and Postpartum Care MITs 8.001 – 007 Recent Deliveries N/A at this OB Roster • Delivery date (2 – 12 months) institution • Most recent deliveries (within date range) Pregnant Arrivals N/A at this OB Roster • Arrival date (2 – 12 months) institution • Earliest arrivals (within date range) Preventive Services MITs 9.001 – 002 TB Medications 7 Maxor • Dispense date (past 9 months) • Time period on TB meds (3 months or 12 weeks) • Randomize MIT 9.003 TB Evaluation, 25 SOMS • Arrival date (at least 1 year prior to Annual Screening inspection) • Birth month • Randomize MIT 9.004 Influenza 25 SOMS • Arrival date (at least 1 year prior to Vaccinations inspection) • Randomize • Filter out IPs tested in MIT 9.008 MIT 9.005 Colorectal Cancer 25 SOMS • Arrival date (at least 1 year prior to Screening inspection) • Date of birth (45 or older) • Randomize MIT 9.006 Mammogram N/A at this SOMS • Arrival date (at least 2 yrs. prior to institution inspection) • Date of birth (age 52 – 74) • Randomize MIT 9.007 Pap Smear N/A at this SOMS • Arrival date (at least three yrs. prior to institution inspection) • Date of birth (age 24 – 53) • Randomize MIT 9.008 Chronic Care 25 OIG Q: 1.001 • Chronic care conditions (at least Vaccinations 1 condition per IP — any risk level) • Randomize • Condition must require vaccination(s) MIT 9.009 Valley Fever 5 Cocci transfer • Reports from past 2 – 8 months status report • Institution • Ineligibility date (60 days prior to inspection date) • All Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 103 Quality No. of Indicator Sample Category Samples Data Source Filters Reception Center MITs 12.001 – 007 RC N/A at this SOMS • Arrival date (2 – 8 months) institution • Arrived from (county jail, return from parole, etc.) • Randomize Specialized Medical Housing MITs 13.001 – 003 Specialized Health 10 CADDIS • Admit date (2 – 8 months) Care Housing Unit • Type of stay (no MH beds) • Length of stay (minimum of 5 days) • Rx count • Randomize MITs 13.101 – 102 Call Buttons All OIG inspector • Specialized Health Care Housing on-site review • Review by location Specialty Services MITs 14.001 – 003 High-Priority 15 Specialty Services • Approval date (3 – 9 months) Initial and Follow-Up Appointments • Remove consult to audiology, RFS chemotherapy, dietary, Hep C, HIV, orthotics, gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, physiatry, podiatry, radiology, follow-up wound care / addiction medication, narcotic treatment program, and transgender services • Randomize MITs 14.004 – 006 Medium-Priority 15 Specialty Services • Approval date (3 – 9 months) Initial and Follow-Up Appointments • Remove consult to audiology, RFS chemotherapy, dietary, Hep C, HIV, orthotics, gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, physiatry, podiatry, radiology, follow-up wound care/addiction medication, narcotic treatment program, and transgender services • Randomize Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 104 Quality No. of Indicator Sample Category Samples Data Source Filters Specialty Services (continued) MITs 14.007 – 009 Routine-Priority 15 Specialty Services • Approval date (3 – 9 months) Initial and Follow-Up Appointments • Remove consult to audiology, RFS chemotherapy, dietary, Hep C, HIV, orthotics, gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, physiatry, podiatry, radiology, follow-up wound care/addiction medication, narcotic treatment program, and transgender services • Randomize MIT 14.010 Specialty Services 5 Specialty Services • Arrived from (other departmental Arrivals Arrivals institution) • Date of transfer (3 – 9 months) • Randomize MITs 14.011 – 012 Denials 20 InterQual • Review date (3 – 9 months) • Randomize N/A IUMC/MAR • Meeting date (9 months) Meeting Minutes • Denial upheld • Randomize Administrative Operations MIT 15.001 Adverse/sentinel 0 Adverse/sentinel • Adverse/Sentinel events events events report (2 – 8 months) MIT 15.002 QMC Meetings 6 Quality • Meeting minutes (12 months) Management Committee meeting minutes MIT 15.003 EMRRC 10 EMRRC meeting • Monthly meeting minutes minutes (6 months) MIT 15.004 LGB N/A at this LGB meeting • Quarterly meeting minutes institution minutes (12 months) MIT 15.101 Medical Emergency 3 On-site summary • Most recent full quarter Response Drills reports & • Each watch documentation for ER drills MIT 15.102 Institutional Level 10 On-site list of • Medical grievances closed Medical Grievances grievances/closed (6 months) grievance files MIT 15.103 Death Reports 4 Institution-list of • Most recent 10 deaths deaths in prior • Initial death reports 12 months Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 105 Quality Sample Category No. of Data Source Filters Indicator Samples Administrative Operations (continued) MIT 15.104 Nursing Staff 10 On-site nursing • On duty one or more years Validations education files • Nurse administers medications • Randomize MIT 15.105 Provider Annual 6 On-site provider • All required performance evaluation Evaluation Packets evaluation files documents MIT 15.106 Provider Licenses 10 Current provider • Review all listing (at start of inspection) MIT 15.107 Medical Emergency All On-site certification • All staff Response tracking logs • Providers (ACLS) Certifications • Nursing (BLS/CPR) • Custody (CPR/BLS) MIT 15.108 Nursing Staff and All On-site tracking • All required licenses and Pharmacist in Charge system, logs, or certifications Professional Licenses employee files and Certifications MIT 15.109 Pharmacy and All On-site listing of • All DEA registrations Providers’ Drug provider DEA Enforcement Agency registration #s & (DEA) Registrations pharmacy registration document MIT 15.110 Nursing Staff New All Nursing staff • New employees (hired within last Employee training logs 12 months) Orientations MIT 15.998 CCHCS Mortality 4 OIG summary log: • Between 35 business days & Case Review deaths 12 months prior • California Correctional Health Care Services mortality reviews Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 106 (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7, California Correctional Institution | 107 California Correctional Health Care Services’ Response February 3, 2025 Amarik Singh, Inspector General Office of the Inspector General 10111 Old Placerville Road, Suite 110 Sacramento, CA 95827 Dear Ms. Singh: California Correctional Health Care Services has reviewed the draft Medical Inspection Report for California Correctional Institution conducted by the Office of the Inspector General from March 2023 to August 2023. Thank you for preparing the report. While CCHCS disagrees with the findings for the compliance portion of the OIG Inspection for California Correctional Institution, we understand that the OIG is forming a workgroup to revise the Medical Inspection Tool to reduce or eliminate subjectivity and complex, compound questions that make it difficult for CCHCS to determine areas of policy non-compliance. CCHCS looks forwardto participating in such efforts and urges the OIG to begin the process as soon as possible. If you have any questions or concerns, please contact me at (916) 691-3747. Sincerely, DeAnna Gouldy Deputy Director Policy and Risk Management Services California Correctional Health Care Services cc: Diana Toche, D.D.S., Undersecretary, Health Care Services, CDCR Clark Kelso, Receiver Jeff Macomber, Secretary, CDCR Directors, CCHCS Roscoe Barrow, Chief Counsel, CCHCS Office of Legal Affairs Renee Kanan, M.D., Deputy Director, Medical Services, CCHCS Barbara Barney-Knox, R.N., Deputy Director, Nursing Services, CCHCS Annette Lambert, Deputy Director, Quality Management, CCHCS Robin Hart, Associate Director, Risk Management Branch, CCHCS Regional Executives, Region IV, CCHCS Chief Executive Officer, CCI Heather Pool, Chief Assistant Inspector General, OIG Doreen Pagaran, R.N., Nurse Consultant Program Review, OIG Amanda Elhardt, Report Coordinator, OIG P.O. Box 588500 Elk Grove, CA 95758 Office of the Inspector General, State of California Inspection Period: March 2023 – August 2023 Report Issued: February 2025 Cycle 7 Medical Inspection Report for California Correctional Institution OFFICE of the INSPECTOR GENERAL Amarik K. Singh Inspector General STATE of CALIFORNIA February 2025 OIG