California Institution for Women Cycle 6 Medical Inspection Report

Revised on 5-18-22; see next page for explanation. Report revised and republished on 5-18-22: On page 15 the recommendation for Administrative Operations was added to the summary list of recommendations. Electronic copies of reports published by the Office of the Inspector General are available free in portable document format (PDF) on our website. We also offer an online subscription service. For information on how to subscribe, visit www.oig.ca.gov. For questions concerning the contents of this report, please contact Shaun Spillane, Public Information Officer, at 916-255-1131. Cycle 6, California Institution for Women | iii Contents Introduction 1 Summary 3 Overall Rating: Adequate 3 Medical Inspection Results 7 Deficiencies Identified During Case Review 7 Case Review Results 7 Compliance Testing Results 8 Population-Based Metrics 10 HEDIS Results 10 Recommendations 13 Indicators 16 Access to Care 16 Diagnostic Services 22 Emergency Services 27 Health Information Management 29 Health Care Environment 34 Transfers 48 Medication Management 54 Prenatal and Postpartum Care 61 Preventive Services 64 Nursing Performance 67 Provider Performance 71 Specialized Medical Housing 76 Specialty Services 81 Administrative Operations 87 Appendix A. Methodology 91 Case Reviews 92 Compliance Testing 95 Indicator Ratings and the Overall Medical Quality Rating 96 Appendix B. Case Review Data 97 Appendix C. Compliance Sampling Methodology 100 California Correctional Health Care Services’ Response 108 Cycle 6, California Institution for Women | iv Illustrations Tables 1. CIW Summary Table 3 2. CIW Policy Compliance Scores 4 3. CIW Master Registry Data as of January 2021 5 4. CIW Health Care Staffing Resources as of January 2021 6 5. CIW Results Compared with State HEDIS Scores 12 6. Access to Care 19 7. Other Tests Related to Access to Care 20 8. Diagnostic Services 25 9. Health Information Management 31 10. Other Tests Related to Health Information Management 32 11. Health Care Environment 46 12. Transfers 51 13. Other Tests Related to Transfers 52 14. Medication Management 58 15. Other Tests Related to Medication Management 59 16. Prenatal and Postpartum Care 63 17. Preventive Services 65 18. Specialized Medical Housing 79 19. Specialty Services 84 20. Other Tests Related to Specialty Services 85 21. Administrative Operations 89 A–1. Case Review Definitions 89 B–1. Case Review Sample Sets 97 B–2. Case Review Chronic Care Diagnoses 98 B–3. Case Review Events by Program 99 B–4. Case Review Sample Summary 99 Figures A–1. Inspection Indicator Review Distribution 91 A–2. Case Review Testing 94 A–3. Compliance Sampling Methodology 95 Photographs 1. Indoor waiting area 35 2. Patients and a custody officer not wearing masks properly 35 3. Examination room lacked auditory privacy 36 4. Torn cover on patient chair in examination room 37 5. Expired medical supplies 38 6. Expired medical supplies 38 7. Snellen reading chart did not have a line marked on the floor or the wall denoting the distance 39 8. Oxygen tank with pressure below 1,000 psi 40 9. Expired Nasal Cannula 41 10. Expired Medical Supplies 42 11. Expired Medical Supplies 42 12. Medical supply room had cockroaches 43 13. Examination room cabinet had vermin droppings 44 14. Unsanitary staff restroom 44 Cover: Rod of Asclepius courtesy of Thomas Shafee Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 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 persons1 in the California Department of Corrections and Rehabilitation (the department).2 In Cycle 6, the OIG continues to apply the same assessment methodologies used in Cycle 5, including clinical case review and compliance testing. These methods provide 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. This information helps to assess the performance of the institution in providing sustainable, adequate care.3 We continue to review institutional care using 15 indicators, as in prior cycles. 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).4 We determine a total compliance score for each applicable indicator and consider the MIT scores in the overall conclusion of the institution’s performance. In addition, our clinicians complete document reviews of individual cases and also perform on-site inspections, which include interviews with staff. In reviewing the cases, our clinicians examine whether providers 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.5 At the same time, our clinicians examine whether the institution’s medical system mitigated the error. The OIG rates the indicators as proficient, adequate, or inadequate. The OIG has adjusted Cycle 6 reporting in two ways. First, commencing with this reporting period, we interpret compliance and case review results together, providing a more holistic assessment of 1 In this report, we use the terms patient and patients to refer to incarcerated persons. 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 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 (HEIDIS) measures for comparison purposes. 4 The department regularly updates its policies. The OIG updates our policy-compliance testing to reflect the department’s updates and changes. 5 If we learn of a patient needing immediate care, we notify the institution’s chief executive officer. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 2 the care. Second, we consider whether institutional medical processes lead to identifying and correcting provider or system errors. The review assesses the institution’s medical care on both system and provider levels. As we did during Cycle 5, our office is continuing 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 6 inspection of California Institution for Women (CIW), the receiver had delegated this institution back to the department. We completed our sixth inspection of CIW, and this report presents our assessment of the health care provided at that institution during the inspection period December 2020 and May 2021.6 The data obtained for CIW, and the on-site inspections occurred during the COVID-19 pandemic.7 The California Institution for Women (CIW) is located in the city of Corona in Riverside County. CIW’s mission is to provide a safe and secure environment for incarcerated female population. The institution houses general population as well as patients with special needs, such as pregnancy, psychiatric care, and medical problems. CIW runs 10 clinics in which health care staff members handle non-urgent requests for medical services. The institution also conducts patient screenings in its receiving and release (R&R) clinical area; treats patients requiring urgent or emergent care in its triage and treatment area (TTA); and treats patients requiring inpatient care in its licensed correctional treatment center (CTC). In its outpatient housing unit (OHU), CIW also treats patients who require assistance with the activities of daily living but do not require a higher level of inpatient care. CCHCS has designated CIW as an intermediate care prison. To provide the most cost-effective care, intermediate care institutions are predominantly located in urban areas, close to tertiary care centers and specialty care providers likely to be used by a patient population with higher medical needs. 6 Samples are obtained per case review methodology shared with stakeholders in prior cycles. The case reviews include emergency non-cardiopulmonary resuscitation (non-CPR) reviews between July 2020 and June 2021, death reviews between January 2020 and May 2021, anticoagulation reviews between December 2020 and June 2021, high-risk reviews between November 2020 and June 2021, hospitalization reviews between September 2020 and May 2021, specialty services reviews between December 2020 and June 2021, transfer reviews between October 2020 and March 2021, and prenatal and postpartum care reviews between January 2020 and March 2021. 7As of January 28, 2022, the department reports on its public tracker that 86% of its incarcerated population at CIW is fully vaccinated while 74% of CIW staff are fully vaccinated: www.cdcr.ca.gov/covid19/population-status-tracking/. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 3 Summary The OIG completed the Cycle 6 inspection for California Institution for Women (CIW) in September 2021. OIG inspectors monitored the institution’s medical care that occurred between December 2020 and May 2021. The OIG rated the overall quality of health care at CIW adequate. We list the individual indicators and ratings applicable for this institution in the Table 1 below. Table 1. CIW Summary Table Cycle 6 Cycle 6 Cycle 6 Change Health Care Indicators Case Review Compliance Overall Since Rating Rating Rating Cycle 5 Access to Care Proficient Proficient Proficient Diagnostic Services Inadequate Inadequate Inadequate Emergency Services Adequate N/A Adequate Health Information Management Adequate Proficient Adequate Health Care Environment N/A Inadequate Inadequate Transfers Adequate Inadequate Adequate Medication Management Adequate Inadequate Inadequate Prenatal & Postpartum Care Proficient Proficient Proficient Preventive Services N/A Adequate Adequate Nursing Performance Adequate N/A Adequate Provider Performance Adequate N/A Adequate Specialized Medical Housing Inadequate Adequate Inadequate Reception Center N/A N/A N/A N/A Specialty Services Adequate Adequate Adequate Administrative Operations† N/A Inadequate Inadequate * The symbols in this column correspond to changes that occurred in indicator ratings between the medical inspections conducted during Cycle 5 and Cycle 6. The equals sign means there was no change in the rating. The single arrow means the rating rose or fell one level, and the double arrow means the rating rose or fell two levels (green, from inadequate to proficient; pink, from proficient to inadequate). † Administrative Operations is a secondary indicator and is not considered when rating the institution’s overall medical quality. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 4 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 354 patient records and 1,084 data points and used the data to answer 99 policy questions. In addition, we observed CIW’s processes during an on-site inspection in July 2021. Table 2 below lists CIW’s average scores from Cycles 4, 5, and 6. Table 2. CIW Policy Compliance Scores Scoring Ranges 100%–85.0% 84.9%–75.0% 74.9%–0 Medical Cycle 4 Cycle 5 Cycle 6 Inspection Policy Compliance Category Average Average Average Tool (MIT) Score Score Score 1 Access to Care 86.9% 88.2% 90.0% 2 Diagnostic Services 85.6% 71.1% 71.2% 4 Health Information Management 49.8% 84.0% 85.8% 5 Health Care Environment 78.3% 69.1% 49.9% 6 Transfers 89.3% 85.5% 68.8% 7 Medication Management 77.9% 68.4% 69.4% 8 Prenatal and Postpartum Care 80.0% 93.3% 100% 9 Preventive Services 92.6% 90.1% 80.2% 12 Reception Center N/A N/A N/A 13 Specialized Medical Housing 78.3% 84.6% 84.0% 14 Specialty Services 84.2% 90.1% 80.9% 15 Administrative Operations 91.4%* 68.7% 70.2% * In Cycle 4, there were two secondary (administrative) indicators, and this score reflects the average of those two scores. In Cycle 5 and moving forward, the two indicators were merged into one, with only one score as the result. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 5 The OIG clinicians (a team of physicians and nurse consultants) reviewed 52 cases, which contained 1,981 patient-related events. After examining the medical records, our clinicians conducted a follow-up on-site inspection in September 2021, to verify their initial findings. The OIG physicians rated the quality of care for 29 comprehensive case reviews. Of these 29 cases, our physicians rated 28 adequate and one inadequate. Our physicians did not find any adverse events during this inspection. The OIG then considered the results from both case review and compliance testing, and drew overall conclusions, which we report in the 14 health care indicators.8 Quality control reviews by multiple OIG clinicians and collective deliberations ensured consistency, accuracy, and thoroughness. The OIG clinicians acknowledged mitigating factors (i.e., the institution’s systemic checks and balances). As noted above, we listed the individual indicators and ratings applicable for this institution in Table 1, the CIW Summary Table. In June 2021, the Health Care Services Master Registry showed that CIW had a total population of 1,007. A breakdown of the medical risk level of the CIW population as determined by the department is set forth in Table 3 below.9 Table 3. CIW Master Registry Data as of June 2021 Medical Risk Level Number of Patients Percentage High 1 139 13.8% High 2 155 15.4% Medium 430 42.7% Low 283 28.1% Total 1,007 100.0% Source: Data for the population medical risk level were obtained from the CCHCS Master Registry dated 6-25-21. 8 The indicator for Reception Center did not apply to CIW. 9 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: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 6 Based on staffing data the OIG obtained from California Correctional Health Care Services (CCHCS), as identified in Table 4 below, CIW had one vacant executive leadership position, zero vacant primary care provider and nursing supervisor positions, and 15.9 vacant nursing staff positions. Table 4. CIW Health Care Staffing Resources as of June 2021 Executive Primary Care Nursing Nursing Positions Leadership* Providers Supervisors Staff† Total Authorized Positions 7 8 19.2 129.5 163.7 Filled by Civil Service 6 8 19 113.6 146.6 Vacant 1 0 0 15.9 16.9 Percentage Filled by Civil Service 85.7% 100% 99.0% 79.7% 89.6% Filled by Telemedicine 0 0 0 0 0 Percentage Filled by Telemedicine 0% 0% 0% 0% 0% Filled by Registry 0 0 0 29 29 Percentage Filled by Registry 0% 0% 0% 20.3% 0% Total Filled Positions 6 8 19 142.6 146.6 Total Percentage Filled 85.7% 100% 99.0% 90.0% 89.6% Appointments in Last 12 Months 1 1 4 32 38 Redirected Staff 0 0 0 0 0 Staff on Extended Leave‡ 0 0 0 0 0 Adjusted Total: Filled Positions 0 0 0 0 0 Adjusted Total: Percentage Filled 85.7% 100% 99.0% 90.0% 89.6% * Executive Leadership includes the Chief Physician and Surgeon. † Nursing Staff includes 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 6 medical inspection preinspection questionnaire received June 25, 2021 from California Correctional Health Care Services. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 7 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.10 The OIG did not find any adverse events at CIW during the Cycle 6 inspection. Case Review Results OIG case reviewers assessed 11 of the 14 indicators applicable to CIW. Of these 11 indicators, OIG clinicians rated two proficient, seven adequate, and two inadequate. The OIG physicians also rated the overall adequacy of care for each of the 29 detailed case reviews they conducted. Of these 29 cases, 28 were adequate and one was inadequate. In the 1,981 events reviewed, there were 160 deficiencies, 31 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 CIW: • CIW performed well with access to care as most provider and nursing appointments occurred within the required time frames. • CIW provided excellent care for their pregnant patients. The staff obstetrician thoroughly assessed these patients and consulted specialists to manage difficult pregnancies. Nursing staff were available to address patients’ needs. Diagnostic tests and specialty appointments occurred within the required time frames. • CIW provided excellent specialty services for their patients. The institution performed well to ensure specialty appointments occurred within the required time frames. Nurses appropriately assessed patient returns from specialty 10 For a further discussion of an adverse event, see Table A-1. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 8 appointments and informed providers of any urgent specialist recommendations. • CIW nurses and providers delivered good emergency care, which improved from Cycle 5. Nursing staff responded promptly to emergent events and provided good nursing assessments. CIW providers were available for consultation and made appropriate decisions. Our clinicians found CIW could improve in the following areas: • CIW had inadequate diagnostic services and performed poorly in completing radiology and time sensitive laboratory tests. The institution also performed poorly in retrieving pathology reports. • Specialized medical housing nurses did not always provide good assessments or interventions for their patients. Compliance Testing Results Our compliance inspectors assessed 11 of the 14 indicators applicable to CIW. Of these 11 indicators, our compliance inspectors rated three proficient, three adequate, and five inadequate. We tested policy compliance in the Health Care Environment, Preventative Services, and Administrative Operations indicators, as these do not have a case review component. CIW demonstrated a high rate of policy compliance in the following areas: • For pregnant patients, CIW provided timely provider visits, and nursing staff documented vital information, such as the patient blood pressure and weight. The institution also offered lower- tier housing and lower-bunk accommodations to these patients and provided them with prenatal screening tests. • Nursing staff processed sick call request forms, performed face- to-face evaluations, and completed nurse-to-provider referrals within required time frames. In addition, CIW housing units contained an adequate supply of health care services request forms. • CIW scheduled timely provider follow-up appointments for patients returning from outside community hospitals and specialty services appointments. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 9 • The institution’s medical staff timely scanned requests for health care services and specialty services reports. CIW staff also accurately scanned medical records into patient files. CIW demonstrated a low rate of policy compliance in the following areas: • Providers seldom communicated results of diagnostic services timely manner. Also, when patient letters were completed, most patient letters communicating these results were missing the date of the diagnostic service, the date of the results, or whether the results were within normal limits. • The institution did not consistently provide radiology services and stat laboratory services within the specified time frames. • Health care staff did not follow proper hand hygiene practices before or after patient encounters. • Nursing staff did not regularly inspect emergency medical response bags (EMRBs). • Patients did not receive their ordered chronic care medications, hospital discharge medications, and newly ordered medications within specified time frames. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 10 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 6. 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 Kaiser Medi-Cal HEDIS scores for three of five diabetic measures to use in conducting our analysis, and we present them here for comparison. HEDIS Results We considered CIW’s performance with population-based metrics to assess the macroscopic view of the institution’s health care delivery. We list the thirteen HEDIS measures in Table 5. Comprehensive Diabetes Care CIW’s results compared favorably with those found in State health plans for diabetic care measures. When compared with statewide Medi- Cal programs (California Medi-Cal, Kaiser Northern California (Medi-Cal), and Kaiser Southern California (Medi-Cal)), CIW performed better in all three diabetic measures that have statewide comparative data: poor HbA1c control, blood pressure control, and HbA1c screening. Immunizations Statewide comparative data were not available for immunization measures; however, we include this data for informational purposes. CIW had a 78 percent influenza immunization rate for adults 18 to 64 years old and an 80 percent influenza immunization rate for adults 65 years of age and older.11 The pneumococcal vaccine rate was 80 percent.12 11 The HEDIS sampling methodology requires a minimum sample of 10 patients to have a reportable result. The sample for older adults did not include a full sample. 12 The pneumococcal vaccines administered are the 13 valent pneumococcal vaccine (PCV13) 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 the one in which the patient was currently housed during the inspection period. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 11 Cancer Screening Statewide comparative data were not available for colorectal cancer screening; however, we include these data for informational purposes. CIW had a 79 percent colorectal cancer screening rate, a 92 percent breast cancer screening rate, and a 78 percent cervical cancer screening rate. CIW performed better than all other statewide plans in breast cancer screening; however, Kaiser NorCal and SoCal outperformed CIW in cervical cancer screening. For prenatal services, CIW scored 100 percent. Postpartum care did not have a testable sample size. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 12 Table 5. CIW Results Compared with State HEDIS Scores California California CIW Kaiser Kaiser California NorCal SoCal Cycle 6 Medi-Cal Medi-Cal Medi-Cal HEDIS Measure Results* 2018† 2018† 2018† HbA1c Screening 100% 90% 94% 96% Poor HbA1c Control (> 9.0%) ‡, § 3% 34% 25% 18% HbA1c Control (< 8.0%) ‡ 87% – – – Blood Pressure Control (< 140/90) ‡ 89% 65% 78% 84% Eye Examinations 97% – – – Influenza – Adults (18–64) 78% – – – Influenza – Adults (65+) 80% – – – Pneumococcal – Adults (65+) 80% – – – Cervical Cancer Screening 78% 65% 87% 83% Colorectal Cancer Screening 79% – – – Breast Cancer Screening (50–74) 92% 62% 82% 84% Prenatal Care 100% 91% 96% 92% Postpartum Care II N/A 78% 82% 81% Notes and Sources * Unless otherwise stated, data were collected in February 2021 by reviewing medical records from a sample of CIW’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 titled, Medi-Cal Managed Care External Quality Review Technical Report, dated July 1, 2019–June 30, 2020 (published April 2021). www.dhcs.ca.gov/documents/MCQMD/CA2019-20-EQR-Technical-Report-Vol3-F2.pdf ‡ For this indicator, the entire applicable CIW population was tested. § For this measure only, a lower score is better. II For this indicator, CIW did not have a testable sample size (fewer than 10 patients) 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: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 13 Recommendations As a result of our assessment of CIW’s performance, we offer the following recommendations to the department: Diagnostic Services • Medical leadership should ensure time-sensitive laboratory orders and radiology tests are completed within the specified time frames. • The department should consider developing an electronic solution to ensure that providers create patient letters at the time of endorsement and the patient results letter auto populates accurately with all required elements per CCHCS policy. • Medical leadership should ascertain causative factors for the untimely provision of radiology and stat laboratory services and implement remedial measures as appropriate. Health Information Management • Medical leadership should ensure that specialty reports and pathology results are retrieved within the required time frames. Health Care Environment • Executive leadership should consider performing random spot checks to ensure medical supply storage areas, located outside the clinics, store medical supplies adequately. • Medical leadership should remind staff to follow universal hand hygiene precautions. Implementing random spot checks could improve compliance. • Nursing leadership should consider performing random spot checks to ensure staff follow equipment and medical supply management protocols. • Nursing leadership should direct each clinic nurse supervisor to review the monthly emergency medical response bag (EMRB) and treatment cart logs to ensure the EMRBs and treatment carts are regularly inventoried and sealed. • Executive leadership should ensure performing random spot checks to ensure clinics, medical storage rooms, and restrooms are cleaned. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 14 Transfers • The department should consider developing and implementing measures to ensure receiving and release (R&R) nursing staff properly complete the initial health screening questions and providers see patients in the required time frames. • Nursing leadership should consider developing strategies to ensure that nursing staff administer medications without interruption to newly arrived patients. • Nursing leadership should consider developing and implementing measures to ensure community hospital discharge documents are scanned into the patient’s electronic health record within three calendar days of hospital discharge. Medication Management • The institution should consider developing and implementing measures to ensure staff timely make available and administer medications to patients and document the medication administration record (MAR) summaries, as described in CCHCS policy and procedures. Preventive Services • Nursing leadership should consider developing and implementing measures to ensure the nursing staff timely screen patients for tuberculosis (TB) and completely address TB signs and symptoms during screening. • Nursing leadership should consider developing and implementing measures to ensure the nursing staff monitor patients who are prescribed TB medications weekly or monthly according to CCHCS policy. • Medical leadership should determine the causes for challenges to the timely provision of chronic care vaccinations. Specialized Medical Housing • Nursing leadership should consider developing and implementing an audit tool to ensure nursing assessments are completed and related to the patient’s complaint and presentation. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 15 Specialty Services • The department should consider developing and implementing measures to ensure institutions timely receive specialty reports and providers timely review these reports. Administrative Operations • Medical leadership should ensure that the institution’s Emergency Medical Response Review Committee (EMRRC) reviews cases within required time frames and includes all required documents. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 16 Access to Care In this indicator, OIG inspectors evaluated the institution’s ability to provide patients with timely clinical appointments. Our inspectors Overall reviewed the scheduling and appointment timeliness for newly arrived Rating Proficient patients, sick calls, and nurse follow-up appointments. We examined referrals to primary care providers, provider follow-ups, and specialists. Case Review Furthermore, we evaluated the follow-up appointments for patients Rating who received specialty care or returned from an off-site hospitalization. Proficient Compliance Results Overview Score Proficient CIW performed well providing access to care. Most appointments were (90.0%) completed timely, including appointments with providers in outpatient clinics and specialized medical housing, nurses, and specialists. The institution’s excellent performance in both compliance testing and case review contributed to the OIG’s rating of proficient for this indicator. Case Review and Compliance Testing Results Our clinicians reviewed 554 provider, nursing, urgent or emergent care, specialty, and hospital events that required the institution to generate appointments. We identified three deficiencies related to access to care, two of which were significant.13 Access to Clinic Providers Access to clinic providers is an integral part of patient care in health care delivery. CIW ensured provider appointments occurred within the required time frames. Compliance testing found 76.0 percent of chronic care follow-up appointments occurred on time (MIT 1.001), 80.0 percent of nurse-to-provider follow-up appointments occurred as requested (MIT 1.005), and 100 percent of provider-ordered sick call follow-up appointments occurred as requested (MIT 1.006). The OIG clinicians reviewed 113 clinic provider appointments and identified one significant deficiency: • In case 1, the provider requested a follow-up for the patient with the substance use disorder provider within 14 days; however, the appointment occurred one month later. 13 Deficiencies occurred in cases 1, 5, and 7. Cases 1 and 7 had significant deficiencies. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 17 Access to Specialized Medical Housing Providers CIW provided good access to care in specialized medical housing, the correctional treatment center (CTC), and the outpatient housing unit (OHU). When staff admitted patients to the CTC or OHU, providers examined the patients timely. Providers evaluated the patients and documented their progress notes within the appropriate time frames. Compliance testing found 90.0 percent of CTC or OHU admission history and physical examinations occurred within the required time frames (MIT 13.002). The OIG clinicians assessed 85 provider encounters and found no deficiencies related to late or missed admission history and physical examinations or follow-up appointments. Access to Clinic Nurses CIW performed well with access for nurse sick calls and provider-to- nurse referrals. Compliance testing found nurse sick call requests were all reviewed on the day they were received (MIT 1.003, 100%). Moreover, the nurses evaluated 90.0 percent of their patients within the required one business day (MIT 1.004). OIG clinicians identified one significant deficiency related to clinic nurse access: • In case 7, the provider diagnosed the patient with a soft tissue infection and requested a nursing follow-up appointment within four days; however, the appointment did not occur. Access to Specialty Services Compliance testing found 86.7 percent of initial high-priority specialty appointments (MIT 14.001), 100 percent of initial medium-priority specialty appointments (MIT 14.004), and 73.3 percent of initial routine- priority specialty appointments (MIT 14.007) occurred within the required time frames. The institution also performed well with follow- up specialty appointments (MIT 14.003, 90.0%, MIT 14.006, 87.5%, and MIT 14.009, 88.9%). OIG clinicians reviewed 117 specialty events and identified one deficiency.14 This deficiency is discussed in the Specialty Services indicator. Follow-Up After Specialty Service The institution provided patients adequate access to providers after specialty appointments. Compliance testing found 91.7 percent of provider appointments after specialty services occurred within the required time frames (MIT 1.008). Our clinicians evaluated 117 specialty 14 The deficiency occurred in case 5. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 18 appointments and did not identify any missed or delayed provider appointments. Follow-up After Hospitalization CIW ensured patients saw their providers after hospitalization within the required time frames. Compliance testing revealed 100 percent of provider appointments after hospitalization occurred within the required time frames (MIT 1.007). The OIG clinicians reviewed 35 hospital returns and did not identify any missed or delayed provider appointments. Follow-up After Urgent or Emergent Care (TTA) CIW providers generally saw their patients as requested after a TTA event. The OIG clinicians assessed 28 TTA events and did not identify any missed or delayed provider follow-up appointments. Follow-up After Transferring into the Institution CIW provided appointments for newly arrived patients within the required time frames at a rate of 72.7 percent (MIT 1.002). The OIG clinicians evaluated seven transfer-in events and did not identify any missed or delayed appointments. Clinician On-Site Inspection CIW had three main clinics located within a central clinic building. Each clinic had assigned providers and an office technician who attended morning huddles and ensured provider appointments occurred. Staff reported that providers saw about eight patients per day. During our on-site inspection, the appointment back-log was seven provider appointments for the three clinics. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 19 Compliance Testing Results Table 6. 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 19 6 0 76.0% allowable interval or 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, 8 3 1 72.7% was the patient seen by the clinician within the required time frame? (1.002) * Clinical appointments: Did a registered nurse review the patient’s 30 0 0 100% request for service the same day it was received? (1.003) * Clinical appointments: Did the registered nurse complete a face-to- face visit within one business day after the CDCR Form 7362 was 27 3 0 90.0% 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 4 1 25 80.0% 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 1 0 29 100% frame specified? (1.006) * Upon the patient’s discharge from the community hospital: Did the patient receive a follow-up appointment within the required time 6 0 0 100% frame? (1.007) * Specialty service follow-up appointments: Did the clinician follow-up visits occur within required time frames? (1.008) * , † 33 3 9 91.7% Clinical appointments: Do patients have a standardized process to 6 0 0 100% obtain and submit health care services request forms? (1.101) Overall percentage (MIT 1): 90.0% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † 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: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 20 Table 7. 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 N/A N/A N/A N/A required 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 N/A N/A N/A N/A days? (12.004) * For CTC and SNF only (effective 4/2019, include OHU): Was a written history and physical examination completed within the required time 18 2 0 90.0% frame? (13.002) * For OHU, CTC, SNF, and Hospice (applicable only for samples prior to 4/2019): Did the primary care provider complete the Subjective, Objective, 0 0 20 N/A Assessment, and Plan notes on the patient at the minimum intervals required for the type of facility where the patient was treated? (13.003) * Did the patient receive the high-priority specialty service within? 14 calendar days of the primary care provider order or the Physician 13 2 0 86.7% Request for Service? (14.001) * Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care provider? 9 1 5 90.0% (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 15 0 0 100% Request 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 7 1 7 87.5% provider? (14.006) * Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician 11 4 0 73.3% Request 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 provider? 8 1 6 88.9% (14.009) * * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † CCHCS changed its policies and removed mandatory minimum rounding intervals for patients located in specialized medical housing. After April 2, 2019, MIT 13.003 only applied to CTCs that still had State-mandated rounding intervals. OIG case reviewers continued to test the clinical appropriateness of provider follow-ups within specialized medical housing units through case reviews. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 21 Recommendations The OIG offers no specific recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 22 Diagnostic Services In this indicator, OIG inspectors evaluated the institution’s ability to Overall timely complete radiology, laboratory, and pathology tests. Our Rating inspectors determined whether the institution properly retrieved the Inadequate resultant reports and whether providers reviewed the results correctly. In addition, in Cycle 6, we examined the institution’s ability to timely Case Review complete and review immediate (stat) laboratory tests. Rating Inadequate Results Overview Compliance Score CIW performed poorly overall in this indicator. Although CIW usually Inadequate completed routine blood tests, it did not perform well in timely (71.2%) completing radiology tests and time-sensitive laboratory tests. The institution also did not perform well in collecting the stat laboratory tests or receiving the results. The institution generally retrieved pathology reports timely; however, the providers did not always send pathology result letters to their patients. Because the institution had both a poor case review rating and a low compliance score, the OIG rated this indicator inadequate. Case Review and Compliance Testing Results Our clinicians reviewed 809 diagnostic events and identified 14 deficiencies, eight of which were significant.15 Identified deficiencies were related to late completion of time-sensitive laboratory tests and an urgent x-ray, not retrieving a pathology report, and not endorsing laboratory results. Test Completion CIW performed poorly in completing timely radiology tests. Compliance testing showed the institution completed 60.0 percent of radiology tests within the required time frames (MIT 2.001). The OIG clinicians reviewed 69 radiology tests and identified two deficiencies, one of which was considered significant:16 • In case 6, the patient had a swollen right hand due to trauma. The on-call provider requested the patient have an urgent hand x-ray completed within two days; however, the radiology test was not performed until approximately three weeks later. 15 Deficiencies occurred twice in cases 7 and 16, and once in cases 2, 4, 6, 8, 11, 12, 14, 20, 24, and 25. Significant deficiencies occurred twice in case 7, and once in cases 6, 8, 11, 16, 24, and 25. 16 Deficiencies occurred in cases 2 and 6. A significant deficiency occurred in case 6. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 23 Compliance testing found that 90.0 percent of the laboratory tests were completed within the requested time frames (MIT 2.004). Our clinicians reviewed 723 laboratory tests and identified six deficiencies related to late laboratory completion, four of which were significant.17 The four significant deficiencies were related to late completion of time- sensitive laboratory tests, as illustrated in the following case: • In case 8, the patient was taking an oral anticoagulant medication. The provider adjusted this medication dose and requested an international normalized ratio (INR) be completed in four days. This INR laboratory test is used to determine the medication’s therapeutic level, and was completed five days later. CIW performed poorly in collecting stat laboratory tests and receiving the results (MIT 2.007, 62.5%). The institution also performed poorly for providers acknowledging stat test results or nurses notifying providers within required time frames (MIT 2.008, 14.3%). Health Information Management Compliance testing showed providers endorsed most radiology and laboratory reports timely (MIT 2.002, 80.0%, and MIT 2.005, 100%). The providers also generally endorsed the stat laboratory results within the required time frames (MIT 2.009, 87.5%). Our clinicians identified one deficiency for not endorsing a laboratory result: • In case 25, a hemoglobin A1c laboratory test result of 13.3 percent, suggesting poorly controlled diabetes, was not endorsed by the provider. The provider only discussed the abnormal laboratory test result during the patient’s appointment two weeks later. Compliance testing found CIW scored low with providers communicating results of radiology studies or laboratory tests to their patients (MIT 2.003, 60.0%, and MIT 2.006, 60.0%). Case review found an occasion in which the provider sent an incomplete radiology result letter to the patient and another occasion in which a provider did not send a pathology laboratory result letter to the patient.18 Compliance testing found the institution timely retrieved and endorsed pathology reports (MIT 2.010, 100% and 2.011, 100%). However, compliance testing also found providers did not send pathology result letters to their patients within the required time frames (MIT 2.012, 17 Deficiencies occurred twice in case 7, and once in cases 8, 11, 12, and 20. Significant deficiencies occurred twice in case 7, and once in cases 8 and 11. 18 Deficiencies occurred in cases 4 and 16. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 24 40.0%). Our clinicians reviewed five events related to pathology reports and identified two significant deficiencies: • In case 16, the provider did not send the required patient letter for a gastric biopsy pathology result. • In case 24, the patient had a bronchoalveolar lavage (BAL).19 The pathology result report was not retrieved or scanned into the patient’s electronic medical record. Clinician On-Site Inspection CIW had three full-time phlebotomists who drew laboratory tests at the central health building and TTA, whereas nursing staff drew laboratory tests for patients in the specialized medical housing units. According to CIW staff, stat laboratory results are received from the laboratory vendor and TTA staff communicate the results to providers. The OIG clinicians discussed the delays in completing INR tests, and the diagnostic supervisor agreed that INR tests are considered as essential and time sensitive tests which should have been completed as ordered. 19 A bronchoalveolar lavage is a diagnostic procedure in which involves instillation of sterile normal saline fluid into a part of the lung. The fluid is then collected for sampling and further testing. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 25 Compliance Testing Results Table 8. Diagnostic Services Scored Answer Comp liance Questions Yes No N/A Yes % Radiology: Was the radiology service provided within the time frame 6 4 0 60.0% specified in the health care provider’s order? (2.001) * Radiology: Did the ordering health care provider review and endorse 8 2 0 80.0% the radiology report within specified time frames? (2.002) * Radiology: Did the ordering health care provider communicate the results of the radiology study to the patient within specified time 6 4 0 60.0% frames? (2.003) Laboratory: Was the laboratory service provided within the time frame 9 1 0 90.0% specified in the health care provider’s order? (2.004) * Laboratory: Did the health care provider review and endorse the 10 0 0 100% laboratory report within specified time frames? (2.005) * Laboratory: Did the health care provider communicate the results of 6 4 0 60.0% the laboratory test to the patient within specified time frames? (2.006) Laboratory: Did the institution collect the STAT laboratory test and 5 3 0 62.5% receive the results within the required time frames? (2.007) * Laboratory: Did the provider acknowledge the STAT results, OR did nursing staff notify the provider within the required time frames (2.008) 1 6 1 14.3% * Laboratory: Did the health care provider endorse the STAT laboratory 7 1 0 87.5% results within the required time frames? (2.009) Pathology: Did the institution receive the final pathology report within 10 0 0 100% the required time frames? (2.010) * Pathology: Did the health care provider review and endorse the 10 0 0 100% pathology report within specified time frames? (2.011) * Pathology: Did the health care provider communicate the results of the pathology study to the patient within specified time frames? 4 6 0 40.0% (2.012) Overall percentage (MIT 2): 71.2% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 26 Recommendations • Medical leadership should ensure time-sensitive laboratory orders and radiology tests are completed within the specified time frames. • The department should consider developing an electronic solution to ensure that providers create patient letters at the time of endorsement and the patient results letter auto populates accurately with all required elements per CCHCS policy. • Medical leadership should ascertain causative factors for the untimely provision of radiology and stat laboratory services and implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 27 Emergency Services In this indicator, OIG clinicians evaluated the quality of emergency Overall medical care. Our clinicians reviewed emergency medical services by Rating examining the timeliness and appropriateness of clinical decisions Adequate made during medical emergencies. Our evaluation included examining the emergency medical response, cardiopulmonary resuscitation (CPR) Case Review quality, triage and treatment area (TTA) care, provider performance, Rating Adequate and nursing performance. Our clinicians also evaluated the Emergency Medical Response Review Committee’s (EMRRC) ability to identify Compliance problems with its emergency services. The OIG assessed the Score institution’s emergency services through case review only; we did not (N/A) perform compliance testing for this indicator. Results Overview Compared to Cycle 5, CIW’s performance in emergency services improved as providers and nurses delivered good emergency care. Nursing staff responded promptly to emergent events and provided good nursing assessments; however, nursing documentation had room for improvement. CIW’s emergency medical response review committee (EMRRC) did not review cases timely and the EMRRC checklists were not completed thoroughly. Overall, the OIG rated this indicator adequate. Case Review Results We reviewed 28 urgent and emergent events and identified 14 emergency care deficiencies, one of which was significant.20 Emergency Medical Response CIW staff responded promptly to emergencies throughout the institution. They initiated cardiopulmonary resuscitation (CPR), activated emergency medical services (EMS), and notified TTA staff timely. Provider Performance CIW providers performed well in urgent and emergent situations. Providers made appropriate decisions for patients who arrived at the TTA for emergency treatment. On-call providers were available for 20 Deficiencies occurred five times in case 5, three times in case 4, twice in case 14, and once in cases 6, 13, 18, and 21. A significant deficiency occurred in case 4. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 28 consultation with the TTA staff. Provider documentation for TTA events was thorough. Nursing Performance CIW nurses generally provided good nursing assessments and interventions. However, we identified one significant deficiency, which is detailed below: • In case 4, the patient complained of shortness of breath and chest pain. Although the patient’s oxygen level was low, the nurse did not promptly administer supplemental oxygen or notify the provider. Nursing Documentation Nursing documentation showed room for improvement. Case reviewers identified seven deficiencies, most of which were related to incomplete documentation and timeline discrepancies.21 Emergency Medical Response Review Committee Compliance testing revealed the EMRRC did not review cases timely. Our clinicians found two deficiencies related to nursing supervisors not identifying incomplete nursing assessments or timeline discrepancies.22 Furthermore, EMRRC checklists were not completed thoroughly (MIT 15.003, 25.0%). This is discussed further in the Administrative Operations indicator. Clinician On-Site Inspection The institution’s TTA had two exam rooms, staffed daily with two registered nurses (RNs) and a provider. The patient care area had sufficient space to provide emergency care. Staff reported that they responded to all emergencies and reported they have good rapport with their supervisors and custody staff. We discussed some case review findings with the nursing leadership, who explained additional training would be provided. Recommendations The OIG has no specific recommendations for this indicator. 21 Documentation deficiencies occurred three times in case 5, and once in cases 4, 13, 18, and 21. 22 Deficiencies occurred in cases 5 and 14. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 29 Health Information Management Overall In this indicator, OIG inspectors evaluated the flow of health Rating information, a crucial link in high-quality medical care delivery. Our Adequate inspectors examined whether the institution retrieved and scanned critical health information (progress notes, diagnostic reports, Case Review specialist reports, and hospital discharge reports) into the medical Rating record in a timely manner. Our inspectors also tested whether Adequate clinicians adequately reviewed and endorsed those reports. In addition, Compliance our inspectors checked whether staff labeled and organized documents Score in the medical record correctly. Proficient (85.8%) Results Overview Overall, CIW performed adequately in this indicator. CIW performed well in retrieving and scanning hospital records, pathology results, and diagnostic reports. However, the institution did not always receive specialty reports within the required time frames. Considering both case review findings and compliance scoring, the OIG rated this indicator adequate. Case Review and Compliance Testing Results The OIG clinicians reviewed 1,981 events and found 13 deficiencies related to health information management, eight of which were significant.23 Hospital Discharge Reports CIW performed adequately in retrieving and scanning hospital records. Compliance testing revealed CIW staff did not always retrieve and scan hospital discharge records within the required time frames (MIT 4.003, 66.7%). Most discharge records included the physician discharge summary and providers reviewed the reports within five days as required by CCHCS policy (MIT 4.005, 83.3%). Our clinicians reviewed 35 hospital events and found no deficiencies. Specialty Reports CIW performed well retrieving and reviewing specialty reports. Compliance testing found 83.3 percent of specialty reports were scanned within the required time frames (MIT 4.002). However, CIW did not always receive the high-priority, medium-priority, and routine- 23 Deficiencies occurred twice in cases 4, 14, 16, and 25, and once in cases 1, 6, 22, 23, and 24. Significant deficiencies occurred twice in case 25, and once in cases 6, 14, 16, 22, 23, and 24. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 30 priority specialty reports within the required time frames (MIT 14.002, 71.4%, MIT 14.005, 71.4%, and MIT 14.008, 40.0%). Out of the 117 specialty reports our clinicians reviewed, two specialty reports were not retrieved and two additional specialty reports were not endorsed. These deficiencies are discussed in more detail in the Specialty Services indicator.24 Diagnostic Reports CIW performed well in retrieving and endorsing diagnostic reports. Compliance testing showed providers endorsed radiology and laboratory reports within the required time frames (MIT 2.002, 80.0%, and MIT 2.005, 100%). Compliance testing found staff retrieved and providers endorsed pathology reports within the required time frames (MIT 2.010, 100%, and 2.011, 100%). Four of the five pathology reports our clinicians reviewed were retrieved in a timely manner. The Diagnostic Services indicator provides more information on the one missing pathology report.25 Urgent and Emergent Records Our clinicians reviewed 28 emergency care events and found nurses and providers recorded these events sufficiently. Our clinicians did not identify any deficiencies. Scanning Performance CIW performed proficiently with the scanning process. Compliance testing found the institution properly scanned and labeled medical files (MIT 4.004, 95.8%). Our clinicians identified one mislabeled document. • In case 14, the patient had a diagnostic procedure and the date of the procedure was mislabeled. Clinician On-Site Inspection According to CIW staff, the central medical record office scanned records as they received them and most patients returning from community hospital had their hospital records with them. TTA nurses were instructed to contact the hospital directly for any missing hospital records. 24 Deficiencies occurred in cases 6, 22, 23, and 25. 25 The missing pathology report occurred in case 24. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 31 According to CIW’s medical staff, on-site specialty nurses scanned reports the same day visits occurred and for off-site specialty reports, hand-written reports were also scanned the same day visits occurred. In addition, the formal specialty reports were scanned as they were received. CIW staff explained specialty nurses also contacted the specialists directly for any missing specialty reports. We discussed the two missing specialty reports with the institution’s medical record supervisor who acknowledged the errors and planned to improve their tracking process. Our clinicians also discussed the missing pathology report with the medical record supervisor who agreed the scanned document was mislabeled as a pathology report and explained the actual pathology report was not retrieved. As a result, the dashboard incorrectly indicated the pathology report had been retrieved. Compliance Testing Results Table 9. Health Information Management Scored Answer Compliance Questions Yes No N/A Yes % Are health care service request forms scanned into the patient’s electronic health record within three calendar days of the encounter 20 0 10 100% date? (4.001) Are specialty documents scanned into the patient’s electronic health 25 5 15 83.3% record 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 4 2 0 66.7% hospital discharge? (4.003) * During the inspection, were medical records properly scanned, 23 1 0 95.8% labeled, 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 5 1 0 83.3% and did a provider review the report within five calendar days of discharge? (4.005) * Overall percentage (MIT 4): 85.8% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 32 Table 10. 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 2 0 80.0% radiology report within specified time frames? (2.002) * Laboratory: Did the health care provider review and endorse the 10 0 0 100% laboratory report within specified time frames? (2.005) * Laboratory: Did the provider acknowledge the STAT results, OR did 1 6 1 14.3% nursing staff notify the provider within the required time frames? (2.008) * Pathology: Did the institution receive the final pathology report within 10 0 0 100% the required time frames? (2.010) * Pathology: Did the health care provider review and endorse the 10 0 0 100% pathology report within specified time frames? (2.011) * Pathology: Did the health care provider communicate the results of the 4 6 0 40.0% 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 10 4 1 71.4% frame? (14.002) * Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the required 10 4 1 71.4% time frame? (14.005) * Did the institution receive and did the primary care provider review the routine-priority specialty service consultant report within the required 6 9 0 40.0% time frame? (14.008) * * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 33 Recommendations • Medical leadership should ensure that specialty reports and pathology results are retrieved within the required time frames. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 34 Health Care Environment In this indicator, OIG compliance inspectors tested clinics’ waiting areas, infection control, sanitation procedures, medical supplies, Overall Rating equipment management, and examination rooms. Inspectors also tested Inadequate clinics’ ability to maintain auditory and visual privacy for clinical encounters. Compliance inspectors asked the institution’s health care Case Review administrators to comment on their facility’s infrastructure and its Rating ability to support health care operations. The OIG rated this indicator (N/A) solely on the compliance score, using the same scoring thresholds as in the Cycle 4 and Cycle 5 medical inspections. Our case review clinicians Compliance do not rate this indicator. Score Inadequate (49.9%) Results Overview For this indicator, multiple aspects of CIW’s health care environment needed improvement: multiple clinics and the medical warehouse contained expired medical supplies, multiple clinics contained noncalibrated or nonfunctional equipment, EMRBs had expired medical supplies or EMRB logs were missing staff verification, and staff did not regularly sanitize their hands before or after examining patients. These factors resulted in an inadequate rating for this indicator. Compliance Testing Results Outdoor Waiting Areas The institution had no waiting areas that require patients to be outdoors. Indoor Waiting Areas We inspected CIW’s indoor waiting areas. Health care and custody staff reported the existing indoor waiting areas had sufficient seating capacity that provided patients protection from inclement weather (see Photo 1). Custody staff also reported they bring in a few patients at a time to prevent overcrowding the indoor waiting areas and to maintain safe social distancing. During our inspection, we did not observe overcrowding in the clinics’ waiting areas. However, we observed patients and a custody officer not wearing their masks properly (see Photo 2). Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 35 Photo 1. Indoor waiting area (photographed on July 16, 2021). Photo 2. Patients and a custody officer not wearing masks properly (photographed on July 16, 2021). Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 36 Clinic Environment All clinic environments were sufficiently conducive for medical care; they provided reasonable auditory privacy, appropriate waiting areas, wheelchair accessibility, and nonexamination room workspace (MIT 5.109, 100%). Of the 13 clinics we observed, seven contained appropriate space, configuration, supplies, and equipment to allow their clinicians to perform proper clinical examinations (MIT 5.110, 53.9%). The remaining six clinics had one or more of the following deficiencies: examination room lacked auditory privacy for conducting clinical examination (see Photo 3), patient chair had torn vinyl cover (see Photo 4), examination room had broken cabinets, did not have an examination room for each clinician on shift, or examination room had unsecured confidential medical records. Photo 3. Examination room lacked auditory privacy (photographed on July 13, 2021). Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 37 Photo 4. Torn cover on patient chair in examination room (photographed on July 15, 2021). Clinic Supplies Only one of the 13 clinics followed adequate medical supply storage and management protocols (MIT 5.107, 7.7%). We found one or more of the following deficiencies in 12 clinics: expired medical supplies (see Photos 5 and 6), unidentified medical supplies, cleaning materials stored with medical supplies, compromised sterile packaging on medical supplies, and medical supplies stored directly on the floor. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 38 Photo 5. Expired medical supplies, dated February 2019 (photographed on July 15, 2021). Photo 6. Expired medical supplies, dated July 2020 (photographed on July 14, 2021). Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 39 Photo 7. Snellen reading chart did not have a line marked on the floor or the wall denoting the distance (photographed on July 13, 2021). Four of the 13 clinics met the requirements for essential core medical equipment and supplies (MIT 5.108, 30.8%). The remaining nine clinics lacked medical supplies or contained improperly calibrated or nonfunctional equipment. The missing medical supplies included: nebulizer, peak flow meter and tips, examination table disposable paper, and tongue depressors. Staff had not properly calibrated the following medical equipment: automated external defibrillator (AED), nebulization unit, and weight scale. We also found the Snellen reading chart did not have a corresponding distance line on the floor or wall (see Photo 7). The non-functional equipment we found included: oto- ophthalmoscopes and overhead light source. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 40 We examined EMRBs to determine if they contained all essential items and checked if staff inspected the bags daily and inventoried them monthly. Only one of the seven EMRBs passed our test (MIT 5.111, 14.3%). We found one or more of the following deficiencies with six EMRBs: staff failed to ensure the EMRB’s compartments were sealed and intact, contained oxygen tank with pressure below 1,000 pounds per square inch (psi) (see Photo 8), or contained expired nasal cannula (see Photo 9). Staff in the TTA and the CTC failed to ensure treatment carts were sealed and intact when not in use. Photo 8. Oxygen tank with pressure below 1,000 psi (photographed on July 16, 2021). Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 41 Photo 9. Expired nasal cannula, dated December 2014 (photographed on July 15, 2021). Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 42 Medical Supply Management None of the medical supply storage areas located outside the medical clinics stored medical supplies adequately (MIT 5.106, zero). We found expired medical supplies (see Photos 10 and 11), food items stored with medical supplies in the medical warehouse (see Photos 12 and 13), and medical supplies stored beyond the manufacturers’ temperature guidelines. In addition, the warehouse manager did not maintain a temperature log for medical supplies that had manufacturer temperature guidelines stored in the Conex box. Photo 10. Expired medical supplies, dated August 2019 (photographed on July 13, 2021). Photo 11. Expired medical supplies, dated June 2020 (photographed on July 13, 2021). Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 43 According to the chief executive officer (CEO), the institution did not have any concerns about the medical supplies process. Health care managers and medical warehouse managers expressed no concerns about the medical supply chain or their communication process with the existing system. Infection Control and Sanitation Staff appropriately cleaned, sanitized, and disinfected seven of 13 clinics (MIT 5.101, 53.9%). In six clinics, we found one or more of the following deficiencies: cleaning logs were not maintained, medical supply room had cockroaches (see Photo 12), examination room cabinet had vermin droppings (see Photo 13), unsanitary staff restroom (see Photo 14), and accumulated dust on restroom vent. Photo 12. Medical supply room had cockroaches (photographed on July 15, 2021). Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 44 Photo 13. Examination room cabinet had vermin droppings (photographed on July 15, 2021). Photo 14. Unsanitary staff restroom (photographed on July 15, 2021). Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 45 Staff in nine of 13 clinics (MIT 5.102, 69.2%) properly sterilized or disinfected medical equipment. In three clinics, staff did not list disinfecting the examination table as part of their daily start-up protocol. In one clinic, staff reported single-use toenail clippers were being reused. In addition, staff mentioned the institution did not have a procedure in place to manually sterilize toenail clippers using a chemical solution. We found operating sinks and hand hygiene supplies in examination rooms in nine of 13 clinics (MIT 5.103, 69.2%). In three clinics, the patient restrooms did not have disposable hand towels. In one clinic, we found a broken antiseptic soap dispenser. We observed patient encounters in ten clinics. In five clinics, clinicians did not wash their hands before or after examining their patients or before applying gloves (MIT 5.104, 50.0%). Health care staff in all 13 clinics followed proper protocols to mitigate exposure to blood-borne pathogens and contaminated waste (MIT 5.105, 100%). Physical Infrastructure CIW’s health care management and plant operations manager reported minor infrastructure issues, included the following: a leaking shower in the OHU, torn vinyl flooring by the entrance to the Central Health Facility, and pending repairs to the medication room in the special housing unit (SHU). According to health care management, these issues do not hinder health care services and the plant operations manager confirmed work orders were scheduled and on track for the repairs. At the time of the compliance inspection, CIW did not have any ongoing Health Care Facility Improvement Program (HCFIP) projects. (MIT 5.999). Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 46 Table 11. Health Care Environment Scored Answer Compliance Questions Yes No N/A Yes % Infection control: Are clinical health care areas appropriately 7 6 0 53.9% disinfected, cleaned, and sanitary? (5.101) Infection control: Do clinical health care areas ensure that reusable invasive and noninvasive medical equipment is properly sterilized or 9 4 0 69.2% disinfected as warranted? (5.102) Infection control: Do clinical health care areas contain operable sinks 9 4 0 69.2% and sufficient quantities of hygiene supplies? (5.103) Infection control: Does clinical health care staff adhere to universal 5 5 3 50.0% hand hygiene precautions? (5.104) Infection control: Do clinical health care areas control exposure to 13 0 0 100% blood-borne pathogens and contaminated waste? (5.105) Warehouse, conex, and other nonclinic storage areas: Does the medical supply management process adequately support the needs 0 1 0 0 of the medical health care program? (5.106) Clinical areas: Does each clinic follow adequate protocols for 1 12 0 7.7% managing and storing bulk medical supplies? (5.107) Clinical areas: Do clinic common areas and exam rooms have 4 9 0 30.8% essential core medical equipment and supplies? (5.108) Clinical areas: Are the environments in the common clinic areas 13 0 0 100% conducive to providing medical services? (5.109) Clinical areas: Are the environments in the clinic exam rooms 7 6 0 53.9% conducive to providing medical services? (5.110) Clinical areas: Are emergency medical response bags and emergency crash carts inspected and inventoried within required time frames, 1 6 6 14.3% and do they contain essential items? (5.111) Does the institution’s health care management believe that all clinical This is a nonscored test. Please areas have physical plant infrastructures that are sufficient to provide see the indicator for discussion adequate health care services? (5.999) of this test. Overall percentage (MIT 5): 49.9% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 47 Recommendations • Executive leadership should consider performing random spot checks to ensure medical supply storage areas, located outside the clinics, store medical supplies adequately. • Medical leadership should remind staff to follow universal hand hygiene precautions. Implementing random spot checks could improve compliance. • Nursing leadership should consider performing random spot checks to ensure staff follow equipment and medical supply management protocols. • Nursing leadership should direct each clinic nurse supervisor to review the monthly emergency medical response bag (EMRB) and treatment cart logs to ensure the EMRBs and treatment carts are regularly inventoried and sealed. • Executive leadership should ensure performing random spot checks to ensure clinics, medical storage rooms, and restrooms are cleaned. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 48 Transfers In this indicator, OIG inspectors examined the transfer process for those patients who transferred into the institution, as well as for those Overall who transferred to other institutions. For newly arrived patients, our Rating inspectors assessed the quality of health screenings and the continuity Adequate of provider appointments, specialist referrals, diagnostic tests, and medications. For patients who transferred out of the institution, Case Review inspectors checked whether staff reviewed patient medical records and Rating determined the patient’s need for medical holds. They also assessed if Adequate staff transferred patients with their medical equipment and gave Compliance correct medications before patients left. In addition, our inspectors Score evaluated the ability of staff to communicate vital health transfer Inadequate information, such as preexisting health conditions, pending (68.8%) appointments, tests, and specialty referrals; and inspectors confirmed if staff sent complete medication transfer packages to the receiving institution. For patients who returned from off-site hospitals or emergency rooms, inspectors reviewed whether staff appropriately implemented the recommended treatment plans, administered necessary medications, and scheduled appropriate follow-up appointments. Results Overview During this inspection, the OIG clinicians reviewed more events and found fewer deficiencies compared to Cycle 5. The institution’s transfer-in process was satisfactory and their hospital return process was good. Considering both case review and compliance results, the OIG rated this indicator adequate. Case Review and Compliance Testing Results In 21 cases, the OIG clinicians reviewed 84 events in which patients transferred into or out of CIW or returned from an off-site hospital or emergency room. We identified nine deficiencies, none of which were significant. 26 Transfers In Our clinicians reviewed seven transfer-in cases and found CIW’s transfer-in process satisfactory. The receiving nurses evaluated the patients appropriately and requested provider appointments within appropriate time frames in all cases we reviewed. However, compliance testing found nurses did not complete the initial health screening forms thoroughly (MIT 6.001, zero). Analysis of the compliance data revealed 26 Deficiencies occurred in cases 5, 13, 21, 26, 27, 28, 31, 32, and 33. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 49 nursing staff did not include fatigue as a sign and symptom of TB during TB screening. In addition, nurses did not always follow up with additional questions when patients responded “yes” to a screening question. CIW generally provided good access to primary care providers for patients who transferred into the institution. The OIG clinicians found all patients were seen timely. Compliance testing showed appointments generally occurred within the required time frames (MIT 1.002, 72.7%). Compliance testing found transfer-in patients generally received their medications timely (MIT 6.003, 75.0%). Our clinicians also found good medication continuity for newly arrived patients, with the exception of one case,27 which is discussed in the Prenatal and Postpartum Care indicator. Both compliance and clinicians testing found appointments occurred within the required time frames for patients who transferred into the institution with preapproved specialty appointments (MIT 14.010, 100%). Transfers Out There were no transfer-out cases for case review during this review period. Compliance on-site testing found only one sample in which CIW had excellent performance providing complete transfer packet (MIT 6.101, 100%). Hospitalizations Patients returning from an off-site hospitalization or emergency room are at high-risk for lapses in care quality. These patients typically experience severe illness or injury and require more care. Also, because these patients have complex medical issues, successful transfer of health information is critical for good quality care. Any lapse can result in serious consequences for these patients. Compliance testing revealed patient discharge documents were generally not scanned within the required time frames (MIT 4.003, 66.7%). However, providers reviewed the discharge documents timely (MIT 4.005, 83.3%) when received. Our clinicians found all documents scanned and reviewed timely. We identified two deficiencies related to incomplete nursing assessments,28 one of which is described below: 27 A deficiency occurred in case 33. 28 Deficiencies occurred in cases 5 and 13. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 50 • In case 13, the patient returned from the hospital and the nurse did not complete a clinical systems assessment. CIW performed well in providing follow-up appointments within the required time frames for patients returning from the hospital and emergency room (MIT 1.007, 100%). The OIG clinicians did not identify any deficiencies. Clinician On-Site Inspection CIW used the licensed correctional clinic’s automated drug delivery system to provide nurse-administered medications to patients upon arrival. Our clinicians found the transfer nurse knowledgeable about the transfer process. When we met with nurse managers to discuss some of our clinical findings, they indicated training would be provided. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 51 Compliance Testing Results Table 12. Transfers Scored Answers Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution or COCF: Did nursing staff complete the initial health screening and 0 12 0 0 answer all screening questions within the required time frame? (6.001) * For endorsed patients received from another CDCR institution or COCF: When required, did the RN complete the assessment and disposition section of the initial health screening form; refer the 12 0 0 100% patient to the TTA if TB signs and symptoms were present; and sign and date the form on the same day staff completed the health screening? (6.002) For endorsed patients received from another CDCR institution or COCF: If the patient had an existing medication order upon arrival, 6 2 4 75.0% were medications 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 1 0 0 100% transfer packet required documents? (6.101) * Overall percentage (MIT 6): 68.8% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 52 Table 13. 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 8 3 1 72.7% 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 6 0 0 100% within the required time frame? (1.007) * Are community hospital discharge documents scanned into the patient’s electronic health record within three calendar days of hospital 4 2 0 66.7% discharge? (4.003) * For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements and did a 5 1 0 83.3% provider 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 2 3 1 40.0% patient within required time frames? (7.003) * Upon the patient’s transfer from one housing unit to another: Were 22 3 0 88.0% 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 1 4 0 20.0% 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 2 0 0 100% sending institution, was the appointment scheduled at the receiving institution within the required time frames? (14.010) * * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 53 Recommendations • The department should consider developing and implementing measures to ensure receiving and release (R&R) nursing staff properly complete the initial health screening questions and providers see patients in the required time frames. • Nursing leadership should consider developing strategies to ensure that nursing staff administer medications without interruption to newly arrived patients. • Nursing leadership should consider developing and implementing measures to ensure community hospital discharge documents are scanned into the patient’s electronic health record within three calendar days of hospital discharge Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 54 Medication Management In this indicator, OIG inspectors evaluated the institution’s ability to Overall administer prescription medications on time and without interruption. Rating The inspectors examined this process from the time a provider Inadequate prescribed medication until the nurse administered the medication to the patient. When rating this indicator, the OIG strongly considered Case Review the compliance test results, which tested medication processes to a Rating much greater degree than case review testing. In addition to examining Adequate medication administration, our compliance inspectors also tested many other processes, including medication handling, storage, error Compliance reporting, and other pharmacy processes. Score Inadequate Results Overview (69.4%) CIW had a mixed performance in this indicator. Compared to Cycle 5, case review identified fewer deficiencies; however, compliance testing found CIW had room for improvement in the following medication processes: continuity of chronic care medications, new medications, hospital discharge medications, and specialized medical housing medications. In contrast, CIW performed well ensuring medication continuity for patients transferring from one housing unit to another as well as with the tuberculosis administration process. After careful consideration of all factors, we rated this indicator inadequate. Case Review and Compliance Testing Results We reviewed 148 events related to medication management and found 20 deficiencies, three of which were significant.29 New Medication Prescriptions Compliance testing showed patients did not receive their newly prescribed medications timely (MIT 7.002, 60.0%). Our clinicians found three significant deficiencies related to newly prescribed medications: • In case 11, the patient received an antibiotic to treat a urinary tract infection one day late. • In case 15, the patient received an antibiotic to treat a leg infection one day late. • In case 17, the patient received eye drops 22 days late and pain medication three days late. 29 Deficiencies occurred twice in cases 1, 2, 14, 17, 19, and 33, and once in cases 3, 4, 11, 13, 15, 18, 31, and 32. Significant deficiencies occurred in cases 11, 15, and 17. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 55 Chronic Medication Continuity Compliance testing found patients did not receive their chronic care medications timely (MIT 7.001, 22.2%). In contrast, our clinicians found most patients received their chronic care medications timely. Hospital Discharge Medications Compliance testing found patients returning from off-site hospitals or emergency rooms did not receive their medications within the required time frames (MIT 7.003, 40.0%). However, our clinicians found most patients received their medications timely. Specialized Medical Housing Medications Compliance testing revealed patients residing in the specialized medical housing did not receive their medications timely (MIT 13.004, 50.0%). Our clinicians identified four deficiencies related to medication management.30 The following is an example: • In case 14, the patient with asthma received her rescue inhaler one day late. Transfer Medications Compliance testing showed patients received their medications within the required time frames when they transferred into the institution (MIT 6.003, 75.0%). Patients transferring from one housing unit to another also received their medications timely (MIT 7.005, 88.0%). Our clinicians found all patients transferring into CIW received their medications timely, except in one case.31 This deficiency is discussed in the Prenatal and Postpartum Care indicator. Medication Administration Compliance testing found nurses administered TB medications as prescribed (MIT 9.001, 100%). Our clinicians found two medication administration errors in the following case: • In case 2, the nurse administered the patient’s asthma medication three times instead of two times a day as prescribed. Also, the provider ordered to hold one dose of the patient’s medication due to diarrhea; however, the nurse administered the medication. 30 Deficiencies occurred twice in case 14, and once in cases 2 and 19. 31 A deficiency occurred in case 33. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 56 Clinician On-Site Inspection We attended CIW’s medication management committee meeting. The committee discussed memorandums, policies, surveys, audits, and performance improvements. Every month the pharmacist in charge (PIC) audited 20 patients who were receiving antibiotics, with the goal of reaching 90 percent compliance rating or greater. The PIC evaluated the prescription orders to determine whether antibiotics were prescribed appropriately, provided in the correct dose, and for the correct duration. The committee provided documentation which showed a compliance rating of 96 percent from January to June 2021. Medication Practices and Storage Controls The institution adequately stored and secured narcotic medications in nine of 10 clinic and medication line locations (MIT 7.101, 90.0%). In one location, nurses could not describe the reporting process for a narcotic medication discrepancy. CIW appropriately stored and secured nonnarcotic medications in 10 of 13 clinic and medication line locations (MIT 7.102, 76.9%). In two locations, the refrigerated medications did not have a designated area for medications to be returned to the pharmacy. In another location, we found a medication stored beyond its expiration date. Staff kept medications protected from physical, chemical, and temperature contamination in six of the 12 clinic and medication line locations (MIT 7.103, 50.0%). In six locations, we found one or more of the following deficiencies: staff did not consistently record refrigerator temperatures, staff did not store oral and topical medications separately, the medication refrigerator had accumulated grime, and staff did not store nonrefrigerated medication within the manufacturer’s recommended temperature range. Staff successfully stored valid, unexpired medications in all applicable medication line locations (MIT 7.104, 100%). Nurses exercised proper hand hygiene and contamination control protocols in three of six locations (MIT 7.105, 50.0%). In three locations, some nurses neglected to wash or sanitize their hands before each subsequent regloving. Staff in two of six medication preparation and administration areas demonstrated appropriate administrative controls and protocols (MIT 7.106, 33.3%). In four locations, medication nurses did not maintain unissued medications in their original packaging. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 57 Staff in four of six medication areas used appropriate administrative controls and protocols when distributing medications to their patients (MIT 7.107, 66.7%). In one location, the medication nurse did not administer patient medication one hour prior to or one hour after the normal daily distribution time and did not always observe patients while they swallowed direct observation therapy medications. In another location, the medication nurse did not administer the medication as ordered by the provider. Pharmacy Protocols Pharmacy staff followed general security, organization, and cleanliness management protocols in its pharmacy (MIT 7.108, 100%). Staff properly stored nonrefrigerated (MIT 7.109, 100%) and refrigerated medications in its pharmacy (MIT 7.110, 100%). The PIC correctly accounted for narcotic medications stored in the institution’s pharmacy (MIT 7.111, 100%). We examined 12 medication error reports. The PIC timely or correctly processed 10 of the 12 reports (MIT 7.112, 83.3%). In one report, the PIC did not document an explanation for not notifying the provider and patient of the error. In another report, the PIC did not document the cause of the pharmacy medication incident error. 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. At CIW, the OIG did not find any applicable medication errors (MIT 7.998). The OIG interviewed patients in a restricted housing unit to determine whether they had immediate access to their prescribed asthma rescue inhalers or nitroglycerin medications. The one applicable patient indicated she had access to her rescue medication (MIT 7.999). Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 58 Compliance Testing Results Table 14. Medication Management Scored Answer Compliance Questions Yes No N/A Yes % Did the patient receive all chronic care medications within the required time frames or did the institution follow departmental policy for refusals or 4 14 7 22.2% no-shows? (7.001) * Did health care staff administer, make available, or deliver new order prescription medications to the patient within the required time frames? (7.002) 15 10 0 60.0% Upon the patient’s discharge from a community hospital: Were all ordered medications administered, made available, or delivered to the patient within 2 3 1 40.0% 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 N/A N/A N/A N/A delivered to the patient within the required time frames? (7.004) * Upon the patient’s transfer from one housing unit to another: Were medications continued without interruption? (7.005) * 22 3 0 88.0% For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications administered or 1 4 0 20.0% delivered without interruption? (7.006) * All clinical and medication line storage areas for narcotic medications: Does the institution employ strong medication security controls over narcotic 9 1 5 90.0% medications 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 10 3 2 76.9% assigned storage areas? (7.102) All clinical and medication line storage areas for nonnarcotic medications: Does the institution keep nonnarcotic medication storage locations free of 6 6 3 50.0% contamination in 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 12 0 3 100% the assigned storage areas? (7.104) Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols during medication 3 3 9 50.0% preparation and medication administration processes? (7.105) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when preparing medications 2 4 9 33.3% for patients? (7.106) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when administering 4 2 9 66.7% medications to patients? (7.107) Pharmacy: Does the institution employ and follow general security, organization, and cleanliness management protocols in its main and remote 1 0 0 100% pharmacies? (7.108) Pharmacy: Does the institution’s pharmacy properly store nonrefrigerated medications? (7.109) 1 0 0 100% Pharmacy: Does the institution’s pharmacy properly store refrigerated or frozen medications? (7.110) 1 0 0 100% Pharmacy: Does the institution’s pharmacy properly account for narcotic medications? (7.111) 1 0 0 100% Pharmacy: Does the institution follow key medication error reporting protocols? (7.112) 10 2 0 83.3% Pharmacy: For Information Purposes Only: During compliance testing, did the This is a nonscored test. Please OIG find that medication errors were properly identified and reported by the see the indicator for discussion of institution? (7.998) this test. Pharmacy: For Information Purposes Only: Do patients in restricted This is a nonscored test. Please housing units have immediate access to their KOP prescribed rescue see the indicator for discussion of inhalers and nitroglycerin medications? (7.999) this test. Overall percentage (MIT8) 69.4% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 59 Table 15. Other Tests Related to Medication Management Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution or COCF: If the patient had an existing medication order upon arrival, 6 2 4 75.0% were medications 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 1 0 0 100% transfer-packet required documents? (6.101) * Patients prescribed TB medication: Did the institution administer the 3 0 0 100% 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 0 3 3 0 the medication? (9.002) * Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient 10 10 0 50.0% within required time frames? (13.004) * * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 60 Recommendations • The institution should consider developing and implementing measures to ensure staff timely make available and administer medications to patients and document the medication administration record (MAR) summaries, as described in CCHCS policy and procedures. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 61 Prenatal and Postpartum Care Preventive Services This indicator evaluates the institution’s capacity to provide timely and Overall appropriate prenatal, delivery, and postnatal services to pregnant Rating patients. This includes the ordering and monitoring of indicated Proficient screening tests, follow-up visits, referrals to higher levels of care, e.g., high-risk obstetrics clinic, when necessary, and postnatal follow-up. Case Review Rating Proficient Results Overview Compliance CIW provided excellent care for their pregnant patients. The staff Score Proficient obstetrician thoroughly assessed these patients and consulted (100%) specialists to manage difficult pregnancies. Nursing staff timely addressed patient complaints and needs. Patients also received their diagnostic tests, vaccinations, specialty appointments, and medications timely. CIW performed well with both compliance testing and case review; as a result, the OIG rated this indicator proficient. Case Review and Compliance Testing Results OIG clinicians reviewed four cases and 82 events related to prenatal or postpartum care. We identified eight deficiencies, one of which was significant.32 Prenatal Care CIW performed well in prenatal care. Compliance testing found all patients identified as pregnant were timely referred to providers (MIT 8.001, 100%) and offered the recommended prenatal vitamins and nutritional supplements (MIT 8.003, 100%). CIW had a full-time obstetrician on staff, who evaluated these patients regularly within the pregnancy encounter guidelines (MIT 8.004, 100%). The staff obstetrician assessed both low-risk and high-risk pregnancies and referred the high-risk patients to an obstetric specialist. Our clinicians found nurses appropriately assessed patients and documented encounters. However, we identified one significant deficiency related to a sick-call request: • In case 31, the pregnant patient complained of toothache and fever. The sick-call nurse only addressed the patient’s request for dental care and scheduled a dental appointment. The nurse did not assess the patient’s complaint of fever. 32 Deficiencies occurred twice in cases 31, 32, 33, and 34. A significant deficiency occurred in case 31. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 62 Patients also received their diagnostic tests, vaccinations, specialty appointments, and medications timely. OIG clinicians identified only one medication management deficiency: • In case 33, the pregnant patient received her pain medication, antacid, and stool softener two days late. Postpartum Care CIW also performed well in postpartum care. All deliveries occurred at a community hospital and CIW’s staff obstetrician timely evaluated patients upon their return to the institution. Compliance testing revealed patients always received their six-week postpartum obstetric visit within the required time frames (MIT 8.007, 100%). Our clinicians did not identify any deficiencies related to postpartum care. Clinician On-Site Inspection CIW had one obstetrician-gynecologist on staff. At the time of our on- site visit, the institution had four pregnant patients, most of whom arrived at CIW during their third trimester of pregnancy. The obstetrician-gynecologist closely monitored the progression of these pregnancies and transferred the patients to community hospital for deliveries. Besides perinatal care, the obstetrician-gynecologist also provided gynecology care for patients. Our clinicians attended the well- organized clinic huddle where medical staff discussed significant events that occurred overnight, scheduled patient appointments, and reviewed diagnostic tests, such as obstetric ultrasounds. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 63 Compliance Testing Results Table 16. Prenatal and Postpartum Care Scored Answer Compliance Questions Yes No N/A Yes % For patients identified as pregnant, did the institution timely offer 5 0 0 100% initial provider visits? (8.001) * Was the pregnant patient timely issued a comprehensive accommodation chrono for a lower bunk and lower-tier housing and 0 0 5 N/A did the patient receive the correct housing placement? (8.002) Did medical staff promptly order recommended vitamins, extra daily 5 0 0 100% nutritional supplements and food for the patient? (8.003) * Did timely patient encounters occur with an OB physician or OB nurse practitioner in accordance with the pregnancy encounter guidelines? 5 0 5 100% (8.004) * Were the results of the patient’s initial prenatal screening tests 0 0 5 N/A timely completed and reviewed? (8.005) * Was the patient’s weight, fundal height, and blood pressure 5 0 0 100% documented at each clinic OB visit? (8.006) * Did the patient receive her six-week postpartum obstetric visit? 1 0 4 100% (8.007) * Overall percentage (MIT 8): 100% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Recommendations The OIG offers no specific recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 64 Preventive Services In this indicator, OIG compliance inspectors tested whether the Overall institution offered or provided cancer screenings, tuberculosis (TB) Rating screenings, influenza vaccines, and other immunizations. If the Adequate department designated the institution as high risk for coccidioidomycosis (valley fever), we tested the institution’s ability to Case Review Rating transfer outpatients quickly. The OIG rated this indicator solely based (N/A) on the compliance score, using the same scoring thresholds as in the Cycle 4 and Cycle 5 medical inspections. Our case review clinicians do Compliance not rate this indicator. Score Adequate (80.2%) Results Overview CIW performed well in administering TB medications to patients, screening patients annually for TB, offering patients an influenza vaccine for the most recent influenza season, offering colorectal cancer screening for patients from ages 50 through 75, offering mammograms for patients from ages 50 through 74, and offering pap smears for patients from ages 21 through 65. However, CIW did not always monitor patients taking prescribed TB medications or offer required immunizations to chronic care patients. The OIG rated this indicator adequate. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 65 Compliance Testing Results Table 17. Preventive Services Scored Answer Compliance Questions Yes No N/A Yes % Patients prescribed TB medication: Did the institution administer the 3 0 0 100% 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 0 3 0 0 the medication? (9.002) † Annual TB screening: Was the patient screened for TB within the last 20 5 0 80.0% year? (9.003) Were all patients offered an influenza vaccination for the most recent 25 0 0 100% influenza season? (9.004) All patients from the age of 50 through the age of 75: Was the 25 0 0 100% patient offered colorectal cancer screening? (9.005) Female patients from the age of 50 through the age of 74: Was the 25 0 0 100% patient offered a mammogram in compliance with policy? (9.006) Female patients from the age of 21 through the age of 65: Was 22 3 0 88.0% patient offered a pap smear in compliance with policy? (9.007) Are required immunizations being offered for chronic care patients? 11 4 10 73.3% (9.008) Are patients at the highest risk of coccidioidomycosis (valley fever) N/A N/A N/A N/A infection transferred out of the facility in a timely manner? (9.009) Overall percentage (MIT 9): 80.2% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † In April 2020, after our review but before this report was published, CCHCS reported adding the symptom of fatigue into the EHRS PowerForm for tuberculosis symptom monitoring. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 66 Recommendations • Nursing leadership should consider developing and implementing measures to ensure the nursing staff timely screen patients for tuberculosis (TB) and completely address TB signs and symptoms during screening. • Nursing leadership should consider developing and implementing measures to ensure the nursing staff monitor patients who are prescribed TB medications weekly or monthly according to CCHCS policy. • Medical leadership should determine the causes for challenges to the timely provision of chronic care vaccinations. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 67 Nursing Performance In this indicator, the OIG clinicians evaluated the quality of care Overall delivered by the institution’s nurses, including registered nurses (RNs), Rating licensed vocational nurses (LVNs), psychiatric technicians (PTs), and Adequate certified nursing assistants (CNAs). Our clinicians evaluated nurses’ ability to make timely and appropriate assessments and interventions. Case Review Rating We also evaluated the institution’s nurses’ documentation for accuracy Adequate and thoroughness. Clinicians reviewed nursing performance in many clinical settings and processes, including sick call, outpatient care, care Compliance coordination and management, emergency services, specialized medical Score housing, hospitalizations, transfers, specialty services, and medication (N/A) management. The OIG assessed nursing care through case review only and performed no compliance testing for this indicator. When summarizing overall 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. Results Overview CIW nurses generally provided appropriate nursing care. The nurses performed good nursing assessment for patients receiving emergent care and returning to the institution from hospitals. However, we identified opportunities for improvement in several areas of the nursing process. The number of deficiencies we found in this indicator were comparable to those we found in Cycle 5. Considering all these factors, the OIG rated this indicator adequate. Case Review Results We reviewed 417 nursing encounters in 52 cases. Of the nursing encounters we reviewed, 147 were in the outpatient setting. We identified 104 nursing performance deficiencies, nine of which were significant.33 Nursing Assessment and Interventions A critical component of nursing care is the quality of nursing assessment, which includes both subjective (patient interview) and objective (observation and examination) elements. CIW nurses generally 33 Deficiencies occurred in cases 1, 2, 3, 4, 5, 6, 7, 13, 14, 15, 16, 17, 18, 19, 20, 21, 23, 26, 27, 28, 30, 31, 32, 33, 34, 35, 37, 40, 41, 43, 44, 46, and 49. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 68 provided appropriate nursing assessments and interventions. However, nursing assessments in outpatient settings and specialized medical housing showed room for improvement. Nursing Documentation Complete and accurate nursing documentation is an essential component of patient care. Without proper documentation, health care staff can overlook changes in a patient’s conditions. CIW nurses generally documented their care appropriately. However, we found room for improvement in emergency services documentation, which we discuss in the Emergency Services indicator. The following are examples of deficiencies we identified in the outpatient setting: • In case 15, the patient complained of foot pain. The nurse noted that the patient’s vital signs were stable but did not document the actual readings. • In case 49, the patient complained of lumps on her legs. However, the nurse did not document the size of the lumps. Nursing Sick Call Our clinicians reviewed 49 sick call requests. Most nurses triaged the sick call requests appropriately and performed timely evaluations for patients with symptoms. However, we found clinic nurses did not always perform thorough triage and assessments. • In case 1, the patient complained of hand numbness and cramps while sleeping. The sick call nurse reviewed the complaint timely but did not perform a face-to-face assessment. The nurse should have assessed the patient but instead sent a patient letter indicating it might be related to the patient’s medication. • In case 7, the patient complained of painful swollen legs. The nurse reviewed the complaint but did not assess the patient until three days later. The patient’s complaint warranted a same-day assessment. • In case 21, the patient complained of a rash. The nurse noted the patient had an elevated heart rate but did not reassess the patient’s heart rate. Emergency Services We reviewed 17 urgent or emergent cases and found nurses responded promptly to emergent events and performed good nursing assessments. However, we found room for improvement in emergency services Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 69 documentation, which we detailed further in the Emergency Services indicator. Hospital Returns We reviewed 17 cases related to hospital returns and found most nurses performed good nursing assessments, which we detailed further in the Transfers indicator. Transfers We reviewed seven cases that involved the transfer-in process at CIW. Nurses evaluated patients and requested provider appointments appropriately. Please refer to the Transfers indicator for further details. Specialized Medical Housing Our clinicians reviewed 16 cases and found nursing care below average. We identified a pattern of incomplete nursing assessments, which we detail further in the Specialized Medical Housing indicator. Specialty Services We reviewed 11 cases in which patients received specialty procedures and consultations. Nurses performed appropriate assessments, reviewed the specialist findings and recommendations, and communicated results to the providers. However, nurses did not always document the patients’ vital signs. The Specialty Services indicator provides further information. Medication Management We reviewed 33 cases and found nurses administered patient medications as prescribed in most cases. The Medication Management indicator provides further information. Clinician On-Site Inspection Our clinicians spoke with nurses and nurse managers in the TTA, CTC, OHU, R&R, specialty services, outpatient clinics, and medication areas. Nursing staff reported generally good morale. According to nursing staff, clinic nurses saw an average of eight patients a day. Staff also reported no appointment backlog. We discussed some of our case review findings with nursing leadership who explained they would use some of our findings for training purposes. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 70 Recommendations The OIG offers no specific recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 71 Provider Performance In this indicator, OIG case review clinicians evaluated the quality of care delivered by the institution’s providers: physicians, physician Overall assistants, and nurse practitioners. Our clinicians assessed the Rating Adequate institution’s providers’ ability to evaluate, diagnose, and manage their patients properly. We examined provider performance across several Case Review clinical settings and programs, including sick call, emergency services, Rating outpatient care, chronic care, specialty services, intake, transfers, Adequate hospitalizations, and specialized medical housing. We assessed Compliance provider care through case review only and performed no compliance Score testing for this indicator. (N/A) Results Overview As in Cycle 5, CIW providers continued to deliver good patient care. Providers generally made appropriate assessments and decisions, managed chronic medical conditions effectively, reviewed medical records thoroughly, and addressed the specialists’ recommendations sufficiently. The OIG rated this indicator adequate. Case Review Results The OIG clinicians examined the care quality in 29 cases and rated 28 cases adequate and one case inadequate. We found nine deficiencies, four of which were considered significant.34 Assessment and Decision-Making CIW providers generally made appropriate assessments and sound medical plans for their patients. They diagnosed medical conditions correctly, ordered appropriate tests, and referred their patients to proper specialists. Our clinicians identified only one significant deficiency related to poor decision-making. • In case 6, the patient complained of a swollen right hand after punching a wall. The provider did not examine the patient’s hand and did not recognize the urgent x-ray for the patient’s hand was not completed until almost one month later. Review of Records CIW providers performed well in reviewing medical records and addressing hospital recommendations for patients returning to CIW 34 Deficiencies occurred three times in case 21, twice in case 6, and once in cases 7, 10, 16, and 22. Significant deficiencies occurred in cases 6, 7, 21, and 22. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 72 from hospitalizations. The providers also performed well in reviewing the medication administration record (MAR) and reconciliating patient medications. However, we found one significant deficiency related to poor medication reconciliation: • In case 21, the patient returned to CIW from a hospitalization for a soft tissue infection of the leg with a hospital recommendation to continue two oral antibiotics. However, the receiving provider did not start one of the antibiotics until two days after the patient’s return from the hospital. Emergency Care CIW providers made appropriate triage decisions when patients arrived at the TTA for emergency treatment. In addition, the providers were available for consultation with the TTA nursing staff. We did not identify any deficiencies related to provider emergency care. Chronic Care CIW providers performed well in managing their patients’ chronic medical conditions, such as hypertension, diabetes, asthma, hepatitis C infection, and cardiovascular disease. Diabetic case managers reviewed blood sugar records weekly for patients with poorly controlled diabetes and consulted the primary care providers for medication adjustments. For patients with controlled diabetes, the diabetic case managers reviewed their blood sugar records monthly. CIW providers monitored the INR levels for patients requiring anticoagulation within the required time frames and adjusted the doses of anticoagulant accordingly.35 However, we found one significant deficiency related to poor anticoagulation management: • In case 7, the patient was taking an oral anticoagulant medication for a prior blood clot in her leg. The nurse consulted the provider for the patient’s complaints of bruises on her thighs and abdomen, which was suggestive of a supra- therapeutic INR level and would require adjusting the anticoagulant medication dosage. However, the provider did not examine the patient for signs of internal bleeding or order an urgent INR level blood test. Specialty Services CIW providers appropriately referred patients to specialists and reviewed specialty reports in a timely manner. Providers also adequately 35 The INR blood test measures the effectiveness of warfarin, an anticoagulant medication. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 73 addressed the specialists’ recommendations. We identified one significant deficiency in which the provider did not address the specialist’s recommendation.36 We discuss this deficiency in the Specialty Services indicator. Documentation Quality CIW providers generally documented outpatient and TTA encounters on the day of the encounters. Our clinicians identified four deficiencies related to missing provider documentation.37 The case below is one example: • In case 21, the provider prescribed an antibiotic for the patient, but did not document the reason for the antibiotic in a progress note. Provider Continuity CIW assigned providers to specified clinics to ensure continuity of care. Our clinicians did not identify any deficiencies related to provider continuity. Clinician Onsite Inspection CIW had seven full-time providers, including an obstetrician- gynecologist, and only one provider vacancy. Providers were enthusiastic about their work and generally satisfied with nursing and diagnostic and specialty services. Providers routinely screened patients for possible opioid abuse and referred them to the substance use disorder treatment program. Our clinicians attended a daily provider meeting, conducted by telephone. The on-call provider discussed events that occurred during the evening and overnight, such as patients returning from hospitalization, specialty visits, and TTA events. Our clinicians also attended morning clinic huddles, which were productive. The patient care team discussed patients returning from hospitalization and the recommendations from specialty appointments. Nurses notified providers of scheduled appointments, expiring medications, and new patients arriving from other institutions. We also attended a population health management meeting. Medical staff discussed difficult patients with mental health issues who were not compliant with medical management. Staff psychiatrists made recommendations to improve patient compliance with medical care. 36 The deficiency occurred in case 22. 37 Deficiencies occurred twice in case 21, and once in cases 6 and 16. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 74 Medical staff also reviewed health care measures during the meeting, such as the hemoglobin A1c to identify patients with poorly controlled diabetes, and strategized solutions to achieve diabetic goals.38 38 Hemoglobin A1c is a laboratory test to evaluate diabetic blood sugar control. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 75 Recommendations The OIG offers no specific recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 76 Specialized Medical Housing In this indicator, OIG inspectors evaluated the quality of care in the Overall specialized medical housing units. We evaluated the performance of the Rating medical staff in assessing, monitoring, and intervening for medically Inadequate complex patients requiring close medical supervision. Our inspectors also evaluated the timeliness and quality of provider and nursing intake Case Review Rating assessments and care plans. We assessed staff members’ performance in Inadequate responding promptly when patients’ conditions deteriorated and looked for good communication when staff consulted with one another while Compliance providing continuity of care. Our clinicians also interpreted relevant Score Adequate compliance results and incorporated them into this indicator. At the (84.0%) time of our inspection, the CIW’s specialized medical housing consisted of a correctional treatment center (CTC) and an outpatient housing unit (OHU). Results Overview CIW had a mixed performance in this indicator. CIW performed well with compliance testing which evaluated the timeliness of the initial nursing and provider assessments. OIG clinicians assessed the quality of medical care delivered at CIW’s specialized medical housing units and found that while the providers delivered good care, there were patterns of nursing deficiencies related to poor assessments and failure to notify the provider or RN when medically required. Furthermore, the patients did not receive their medications timely. Factoring both case review and compliance results, we rated this indicator inadequate. Case Review and Compliance Testing Results OIG clinicians reviewed 85 provider events and 130 nursing events in 13 cases and identified 39 deficiencies, five of which were significant.39 Provider Performance Compliance testing showed providers completed most admission history and physical examinations within the required time frames (MIT 13.002, 90.0%). Our clinicians found providers generally delivered good patient care. Providers followed up on their patients within the required time frames, addressed the specialists’ recommendations, and made sound medical decisions. We identified two deficiencies, one of 39 Deficiencies occurred 13 times in case 5, nine times in cases 2 and 14, four times in case 6, and once in cases 1, 3, 19, and 20. Significant deficiencies occurred twice in case 14, and once in cases 2, 3, and 6. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 77 which was significant.40 The significant deficiency is discussed in the Provider Performance indicator. Nursing Performance CIW nurses usually completed the admission assessments timely (MIT 13.001, 80.0%); however, the quality of nursing performance was below average. Our clinicians found patterns of deficiencies for incomplete nursing assessments as well as failure to notify the RN or provider. The following are examples: • In case 2, the patient with a history of swallowing foreign objects complained of a cough and sore throat twice; however, on both occasions the nurse did not assess the patient’s throat. • In case 3, the patient with a history of refusing meals complained of feeling weak and reported falling and hitting her head; however, the nurse did not obtain vital signs or perform a skin assessment. Three hours later a different nurse assessed the patient and noted a slight swelling on the side of the patient’s head and an elevated pulse. The provider examined the patient, noted abnormal neurological findings, and sent the patient to the hospital. • In case 5, the patient complained of chest pain and abdominal pain. The nurse did not assess the patient’s pain severity or duration. Furthermore, the nurse did not obtain an electrocardiogram (EKG), assess for bowel sounds, or palpate the abdomen for tenderness. • Also in case 5, the patient reported drinking a large amount of coffee and complained of feeling high. The licensed psychiatric technician (LPT) failed to notify the RN so an assessment could be completed. • In case 14, the patient complained of severe abdominal pain. The nurse did not obtain vital signs or assess bowel sounds. In addition, the nurse did not palpate the patient’s abdomen for tenderness or notify the provider. Medication Administration CIW performed poorly in medication administration. Compliance testing showed only 50.0 percent of newly admitted patients received their medications within the required time frames (MIT 13.004). Our clinicians identified five deficiencies related to medication 40 Deficiencies occurred twice in case 6. The significant deficiency occurred in case 6. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 78 management,41 which we discuss in the Medication Management indicator. Clinician On-Site Inspection The institution’s CTC had eight medical beds and the OHU had 16 beds. The CTC and OHU were staffed with a designated provider, RNs, LVNs, LPTs, and certified nursing assistants (CNAs). The RNs performed rounds with providers of patients daily. Compliance testing showed CIW’s call light system was functional (MIT 13.101, 100%). We met with nurse managers to discuss some of our findings, and they reported training had been provided. 41 Deficiencies occurred twice in cases 2 and 14, and once in case 19. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 79 Compliance Testing Results Table 18. Specialized Medical Housing Scored Answer Compliance Questions Yes No N/A Yes % For OHU, CTC, and SNF: Prior to 4/2019: Did the registered nurse complete an initial assessment of the patient on the day of admission, or within eight hours of admission to CMF’s Hospice? 16 4 0 80.0% Effective 4/2019: Did the registered nurse complete an initial assessment of the patient at the time of admission? (13.001) * For CTC and SNF only (effective 4/2019, include OHU): Was a written history and physical examination completed within the required time 18 2 0 90.0% frame? (13.002) * For OHU, CTC, SNF, and Hospice (applicable only for samples prior to 4/2019): Did the primary care provider complete the Subjective, Objective, Assessment, and Plan notes on the patient at the 0 0 20 N/A minimum intervals required for the type of facility where the patient was treated? (13.003) *, † Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the 10 10 0 50.0% patient within required time frames? (13.004) * For OHU and CTC only: Do inpatient areas either have properly working call systems in its OHU & CTC or are 30-minute patient 2 0 1 100% welfare checks performed; and do medical staff have reasonably unimpeded access to enter patient’s cells? (13.101) * For specialized health care housing (CTC, SNF, Hospice, OHU): Do health care staff perform patient safety checks according to 1 0 2 100% institution’s local operating procedure or within the required time frames? (13.102) * Overall percentage (MIT 13): 84.0% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † CCHCS changed its policies and removed mandatory minimum rounding intervals for patients located in specialized medical housing. After April 2, 2019, MIT 13.003 only applied to CTCs that still have State-mandated rounding intervals. OIG case reviewers continued to test the clinical appropriateness of provider follow-ups within specialized medical housing units through case reviews. Source: The Office of the Inspector General medical inspection results Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 80 Recommendations • Nursing leadership should consider developing and implementing an audit tool to ensure nursing assessments are completed and related to the patient’s complaint and presentation. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 81 Specialty Services In this indicator, OIG inspectors evaluated the quality of specialty Overall services. The OIG clinicians focused on the institution’s ability to Rating provide needed specialty care. Our clinicians also examined specialty Adequate appointment scheduling, providers’ specialty referrals, and medical staff’s retrieval, review, and implementation of any specialty Case Review Rating recommendations. Adequate Results Overview Compliance Score Adequate CIW provided good specialty services for their patients. The institution (80.9%) ensured specialty appointments occurred within the required time frames and medical staff generally scanned specialty reports timely. Nurses appropriately assessed patient returns from specialty appointments and notified providers of any urgent specialist recommendations. The OIG rated this indicator adequate. Case Review and Compliance Testing Results Our clinicians reviewed 150 events related to specialty services, including 117 specialty consultations and procedures, and identified 14 deficiencies, six of which were significant.42 The institution performed well in completing specialty appointments and scanning specialty reports. However, two specialty reports were not retrieved. Access to Specialty Services CIW performed well in completing most high-priority, medium- priority, and routine-priority specialty appointments within required time frames (MIT 14.001, 86.7%, MIT 14.004, 100%, and MIT 14.007, 73.3%). The institution also performed well in completing high-priority, medium-priority, and routine-priority follow-up specialty appointments (MIT 14.003, 90.0%, MIT 14.006, 87.5%, and MIT 14.009, 88.9%). Our clinicians identified one delayed specialty appointment: • In case 4, the provider requested an optometry appointment within 45 days; however, the appointment occurred in 60 days. Provider Performance CIW providers generally referred patients appropriately, reviewed specialty reports within the recommended time frames, and addressed 42 Deficiencies occurred three times in case 14, twice in cases 19 and 22, and once in cases 1, 4, 5, 6, 15, 23, and 25. Significant deficiencies occurred twice in case 22, and once in cases 6, 14, 23, and 25. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 82 recommendations from specialists. We identified one deficiency related to the provider not addressing all of the specialist’s recommendations: • In case 22, the provider saw the patient after a pulmonology consultation. The provider addressed all specialist recommendations with the exception of ordering the fungal tests. Nursing Performance Nurses reviewed requests for specialty services and appropriately arranged for specialty appointments. They performed good nursing assessments when patients returned from their specialty appointments. Nurses reviewed the specialists’ findings and recommendations and communicated these results to providers. The nurses also requested provider follow-up appointments. We reviewed 33 nursing encounters related to specialty services and identified six deficiencies, none of which were significant.43 Health Information Management Compliance testing showed 83.3 percent of specialty reports were scanned within the required time frames (MIT 4.002). However, CIW did not always receive the high-priority, medium-priority, and routine- priority specialty reports within the required time frames (MIT 14.002, 71.4%, MIT 14.005, 71.4%, and MIT 14.008, 40.0%). Our clinicians identified two specialty reports that were not retrieved and one specialty report that was retrieved late.44 The following cases are examples of specialty reports retrieved later or not at all: • In case 14, the patient had an esophageal motility study. The report was not retrieved until almost three months later. • In case 25, the patient went to an offsite general surgery; however, the report was not retrieved and scanned into the medical record. Our clinicians also identified two specialty reports that were not endorsed by a provider.45 Clinician On-Site Inspection CIW staffed on-site, offsite, and telemedicine specialty services with several nurses. Nurses reviewed specialty requests, contacted the 43 Deficiencies occurred in twice in cases 14 and 19, and once in cases 2 and 15. 44 Missed specialty reports occurred in cases 23 and 25. A late retrieval of a specialty report occurred in case 14. 45 Specialty reports were not endorsed in cases 6 and 22. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 83 specialists for available appointments, and scheduled appointments. Nurses also assembled diagnostic tests requested by specialists and forwarded these tests to specialists the day of the appointment. CIW’s medical record staff acknowledged the missing specialty reports and also notified the specialty service coordinator. Medical record staff explained the specialists occasionally did not forward their reports to CIW within the required time frames. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 84 Compliance Testing Results Table 19. 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 13 2 0 86.7% Request for Service? (14.001) * Did the institution receive and did the primary care provider review the high-priority specialty service consultant report within the 10 4 1 71.4% required time frame? (14.002) * Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care 9 1 5 90.0% provider? (14.003) * Did the patient receive the medium-priority specialty service within 15-45 calendar days of the primary care provider order or Physician 15 0 0 100% Request for Service? (14.004) * Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the 10 4 1 71.4% required time frame? (14.005) * Did the patient receive the subsequent follow-up to the medium- priority specialty service appointment as ordered by the primary care 7 1 7 87.5% provider? (14.006) * Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician 11 4 0 73.3% Request for Service? (14.007) * Did the institution receive and did the primary care provider review the routine-priority specialty service consultant report within the 6 9 0 40.0% required time frame? (14.008) * Did the patient receive the subsequent follow-up to the routine- priority specialty service appointment as ordered by the primary care 8 1 6 88.9% provider? (14.009) * For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the 2 0 0 100% sending 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 N/A N/A N/A N/A specialty services within required time frames? (14.011) Following the denial of a request for specialty services, was the patient informed of the denial within the required time frame? N/A N/A N/A N/A (14.012) Overall percentage (MIT 14): 80.9% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 85 Table 20. 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 33 3 9 91.7% visits occur within required time frames? (1.008) *, † Are specialty documents scanned into the patient’s electronic health 25 5 15 83.3% record within five calendar days of the encounter date? (4.002) * * The OIG clinicians considered these compliance tests along with their own case review findings when determining the quality rating for this indicator. † CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician follow-up visits following most specialty services. As a result, we test 1.008 only for high- priority specialty services or when the staff orders PCP or PC RN follow-ups. The OIG continues 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: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 86 Recommendations • The department should consider developing and implementing measures to ensure institutions timely receive specialty reports and providers timely review these reports. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 87 Administrative Operations In this indicator, OIG compliance inspectors evaluated health care Overall administrative processes. Our inspectors examined the timeliness of the Rating medical grievance process and checked whether the institution Inadequate followed reporting requirements for adverse or sentinel events and patient deaths. Inspectors checked whether the Emergency Medical Case Review Rating Response Review Committee (EMRRC) met and reviewed incident (N/A) packages. We reviewed and determined whether the institution conducted the required emergency response drills. Inspectors also Compliance assessed whether the Quality Management Committee (QMC) met Score Inadequate regularly and addressed program performance adequately. In addition, (70.2%) the inspectors examined if the institution provided training and job performance reviews for its employees. They checked whether staff possessed current, valid professional licenses, certifications, and credentials. The OIG rated this indicator solely based on the compliance score, using the same scoring thresholds as in the Cycle 4 and Cycle 5 medical inspections. Our case review clinicians do not rate this indicator. Because none of the tests in this indicator affected clinical patient care directly (it is a secondary indicator), the OIG did not consider this indicator’s rating when determining the institution’s overall quality rating. Results Overview CIW had mixed performance in this indicator. The institution scored well in some applicable tests; however, a few areas had room for improvement. The EMRRC seldom reviewed cases within required time frames. CIW did not always include all required documents in incident packages. In addition, the institution conducted medical emergency response drills with incomplete documentation. We found physician managers did not always complete the annual performance appraisals in a timely manner. As a result of these findings, we rated this indicator inadequate. Nonscored Results We reviewed the institution’s root cause analysis of reported incidents. During our testing period, CIW submitted one report to the CCHCS Health Care Incident Review Committee (HCIRC). We found the root cause analysis report submitted did not meet reporting requirements per CCHCS policy (MIT 15.001). Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 88 We obtained CCHCS Death Review Committee (DRC) reporting data. Two unexpected (Level 1) deaths occurred during our review period. The DRC must complete its death review summary report within 60 calendar days of the death. When the DRC completes the death review summary report, it must submit the report to the institution’s CEO within seven calendar days of completion. In our inspection, we found the DRC did not complete either of the death review reports promptly. The DRC finished one report 11 days late, and submitted it to the institution’s CEO 71 days later. For the second death, the DRC had not completed a death review report and there was no evidence a report had been submitted to the CEO at the time of the OIG inspection (MIT 15.998). Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 89 Compliance Testing Results Table 21. Administrative Operations Scored Answer Compliance Questions Yes No N/A Yes % For health care incidents requiring root cause analysis (RCA): Did the 0 0 1 N/A institution meet RCA reporting requirements? (15.001) 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 3 9 0 25.0% the incident 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 4 0 0 100% operating 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 0 3 0 0 custody staff participate in those drills? (15.101) Did the responses to medical grievances address all of the inmates’ 10 0 0 100% appealed issues? (15.102) Did the medical staff review and submit initial inmate death reports 1 1 0 50.0% to the CCHCS Death 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 3 5 0 37.5% appraisals 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) 2 0 1 100% certifications? (15.107) Did the nurses and the pharmacist-in-charge (PIC) maintain valid professional licenses and certifications, and did the pharmacy 6 0 1 100% maintain a valid correctional pharmacy license? (15.108) Did the pharmacy and the providers maintain valid Drug Enforcement 1 0 0 100% Agency (DEA) registration certificates? (15.109) Did nurse managers ensure their newly hired nurses received the 0 1 0 0 required onboarding and clinical competency training? (15.110) This is a nonscored test. Please Did the CCHCS Death Review Committee process death review refer to the discussion in this reports timely? (15.998) indicator. This is a nonscored test. Please What was the institution’s health care staffing at the time of the OIG refer to Table 4 for CCHCS- medical inspection? (15.999) provided staffing information. Overall percentage (MIT 15): 70.2% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 90 Recommendations • Medical leadership should ensure that the institution’s Emergency Medical Response Review Committee (EMRRC) reviews cases within required time frames and includes all required documents. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 91 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. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 92 Case Reviews The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders, which continues in the Cycle 6 medical inspections. Below, Table A–1 provides important definitions that describe this process. Table A–1. Case Review Definitions Case, Sample, The medical care provided to one patient over a specific or Patient period, which can comprise detailed or focused case reviews. A review that includes all aspects of one patient’s medical care assessed over a six-month period. This review allows the OIG Comprehensive clinicians to examine many areas of health care delivery, such as Case Review access to care, diagnostic services, health information management, and specialty services. A review that focuses on one specific aspect of medical care. Focused This review tends to concentrate on a singular facet of patient Case Review care, such as the sick call process or the institution’s emergency medical response. A direct or indirect interaction between the patient and the health care system. Examples of direct interactions include Event provider encounters and nurse encounters. An example of an indirect interaction includes a provider reviewing a diagnostic test and placing additional orders. A medical error in procedure or in clinical judgment. Both Case Review procedural and clinical judgment errors can result in policy Deficiency noncompliance, elevated risk of patient harm, or both. Adverse Event An event that caused harm to the patient. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 93 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: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 94 Figure A–2. Case Review Testing Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 95 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: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 96 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 To reach an overall quality rating, our inspectors collaborate and examine all the inspection findings. We consider the case review, and the compliance testing results for each indicator. After considering all the findings, our inspectors reach consensus on an overall rating for the institution. Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 97 Appendix B: Case Review Data Table B–1. CIW Case Review Sample Sets Sample Set Total Anticoagulation 3 Death Review/Sentinel Events 3 Diabetes 3 Emergency Services – Non–CPR 3 High Risk 5 Hospitalization 4 Intra-system Transfers In 3 Intra-system Transfers Out 2 Perinatal Services 4 RN Sick Call 18 Specialty Services 4 Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 98 Table B–2. CIW Case Review Chronic Care Diagnoses Diagnosis Total Anemia 10 Anticoagulation 4 Arthritis/Degenerative Joint Disease 14 Asthma 12 COPD 6 COVID-19 7 Cancer 4 Cardiovascular Disease 5 Chronic Kidney Disease 3 Chronic Pain 8 Cirrhosis/End-Stage Liver Disease 2 Coccidioidomycosis 0 Deep Venous Thrombosis/Pulmonary Embolism 3 Diabetes 13 Gastroesophageal Reflux Disease 21 Hepatitis C 6 Hyperlipidemia 16 Hypertension 22 Mental Health 27 Migraine Headaches 5 Rheumatological Disease 1 Seizure Disorder 4 Sleep Apnea 1 Substance Abuse 24 Thyroid Disease 7 Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 99 Table B–3. CIW Case Review Events by Program Diagnosis Total Diagnostic Services 830 Emergency Care 45 Hospitalization 65 Intra-system Transfers In 19 Intra-system Transfers Out 4 Not Specified 1 Outpatient Care 440 Prenatal & Postpartum Care 82 Specialized Medical Housing 266 Specialty Services 229 Table B–4. CIW Case Review Sample Summary MD Reviews Detailed 29 MD Reviews Focused 0 RN Reviews Detailed 19 RN Reviews Focused 23 Total Reviews 71 Total Unique Cases 52 Overlapping Reviews (MD & RN) 19 Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 100 Appendix C. Compliance Sampling Methodology California Institution for Women 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 Patients one condition per patient—any risk level) • Randomize MIT 1.002 Nursing Referrals 12 OIG Q: 6.001 • See Transfers MITs 1.003–006 Nursing Sick Call 30 Clinic Appointment • Clinic (each clinic tested) (6 per clinic) List • Appointment date (2–9 months) • Randomize MIT 1.007 Returns From 6 OIG Q: 4.005 • See Health Information Community Management (Medical Records) Hospital (returns from 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 or CMPs only) • Randomize • Abnormal MITs 2.007–009 Laboratory STAT 8 Quest • Appt. date (90 days–9 months) • Order name (CBC 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: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 101 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 6 OIG Q: 4.005 • Community hospital discharge Documents documents • First 20 IPs selected MIT 4.004 Scanning Accuracy 24 Documents for any • Any misfiled or mislabeled tested inmate document identified during OIG compliance review (24 or more = No) MIT 4.005 Returns From 6 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 13 OIG inspector • Identify and inspect all on-site MITs 5.107–111 on-site review clinical areas. Transfers MITs 6.001–003 Intrasystem Transfers 12 SOMS • Arrival date (3–9 months) • Arrived from (another departmental facility) • Rx count • Randomize MIT 6.101 Transfers Out 1 OIG inspector • R&R IP transfers with medication on-site review Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 102 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 6 OIG Q: 4.005 • See Health Information Community Hospital Management (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 5 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 Areas by test on-site review & med line areas that store medications MITs 7.104–107 Medication Varies OIG inspector • Identify and inspect on-site Preparation and by test on-site review clinical areas that prepare and Administration Areas administer medications MITs 7.108–111 Pharmacy 1 OIG inspector • Identify & inspect all on-site on-site review pharmacies MIT 7.112 Medication Error 12 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 1 On-site active • KOP rescue inhalers & KOP Medications medication listing nitroglycerin medications for IPs housed in restricted units Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 103 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 5 OB Roster • Arrival date (2–12 months) • Earliest arrivals (within date range) Preventive Services MITs 9.001–002 TB Medications 3 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 Annual Screening to inspection) • Birth month • Randomize MIT 9.004 Influenza 25 SOMS • Arrival date (at least 1 year prior Vaccinations to inspection) • Randomize • Filter out IPs tested in MIT 9.008 MIT 9.005 Colorectal Cancer 25 SOMS • Arrival date (at least 1 year prior Screening to inspection) • Date of birth (51 or older) • Randomize MIT 9.006 Mammogram 25 SOMS • Arrival date (at least 2 yrs. prior to inspection) • Date of birth (age 52–74) • Randomize MIT 9.007 Pap Smear 25 SOMS • Arrival date (at least three yrs. prior to 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 N/A at this Cocci transfer • Reports from past 2–8 months institution status report • Institution • Ineligibility date (60 days prior to inspection date) • All Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 104 Quality No. of Indicator Sample Category Samples Data Source Filters Reception Center MITs 12.001–008 Reception Center N/A at this SOMS • Arrival date (2–8 months) institution • Arrived from (county jail, return from parole, etc.) • Randomize Specialized Medical Housing MITs 13.001–004 Specialized Health 20 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, and radiology 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, and radiology services • Randomize 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, and radiology services • Randomize Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 105 MIT 14.010 Specialty Services 2 Specialty Services • Arrived from (other departmental Arrivals Arrivals institution) • Date of transfer (3–9 months) • Randomize MITs 14.011–012 Denials 0 InterQual • Review date (3–9 months) • Randomize N/A IUMC/MAR • Meeting date (9 months) Meeting Minutes • Denial upheld • Randomize Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 106 Quality No. of Indicator Sample Category Samples Data Source Filters Administrative Operations MIT 15.001 Adverse/sentinel 1 Adverse/sentinel • Adverse/Sentinel events events (ASE) events report (2–8 months) MIT 15.002 QMC Meetings 6 Quality • Meeting minutes (12 months) Management Committee meeting minutes MIT 15.003 EMRRC 12 EMRRC meeting • Monthly meeting minutes minutes (6 months) MIT 15.004 LGB 4 LGB meeting • Quarterly meeting minutes 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 2 Institution-list of • Most recent 10 deaths deaths in prior • Initial death reports 12 months 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 8 On-site • All required performance Evaluation Packets provider evaluation documents evaluation files MIT 15.106 Provider Licenses 10 Current provider • Review all listing (at start of inspection) MIT 15.107 Medical Emergency All On-site • All staff Response certification ◦ Providers (ACLS) Certifications tracking logs ◦ 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 Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 107 Quality No. of Indicator Sample Category Samples Data Source Filters Administrative Operations MIT 15.109 Pharmacy and All On-site listing • All DEA registrations Providers’ Drug of 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 Death Review 2 OIG summary log: • Between 35 business days & Committee deaths 12 months prior • California Correctional Health Care Services death reviews Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6, California Institution for Women | 108 California Correctional Health Care Services’ Response Office of the Inspector General, State of California Inspection Period: December 2020 – May 2021 Report Issued: April 2022 Cycle 6 Medical Inspection Report for California Institution for Women OFFICE of the INSPECTOR GENERAL Amarik K. Singh Inspector General Neil Robertson Chief Deputy Inspector General STATE of CALIFORNIA April 2022 OIG