California Men’s Colony Cycle 6 Medical Inspection Report

Amarik K. Singh, Inspector General Neil Robertson, Chief Deputy Inspector General OFFICE of the OIG INSPECTOR GENERAL Independent Prison Oversight July 2022 Cycle 6 Medical Inspection Report California Men’s Colony 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 Men’s Colony | 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 9 HEDIS Results 9 Recommendations 12 Indicators 15 Access to Care 15 Diagnostic Services 22 Emergency Services 27 Health Information Management 31 Health Care Environment 37 Transfers 44 Medication Management 51 Preventive Services 59 Nursing Performance 62 Provider Performance 67 Specialized Medical Housing 72 Specialty Services 77 Administrative Operations 83 Appendix A: Methodology 87 Case Reviews 87 Compliance Testing 91 Indicator Ratings and the Overall Medical Quality Rating 92 Appendix B: Case Review Data 93 Appendix C. Compliance Sampling Methodology 96 California Correctional Health Care Services’ Response 105 Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | iv Illustrations Tables 1. CMC Summary Table 3 2. CMC Policy Compliance Scores 4 3. CMC Master Registry Data as of August 20, 2021 5 4. CMC Health Care Staffing Resources as of August 2021 6 5. CMC Results Compared with State HEDIS Scores 11 6. Access to Care 19 7. Other Tests Related to Access to Care 20 8. Diagnostic Services 25 9. Health Information Management 34 10. Other Tests Related to Health Information Management 35 11. Health Care Environment 42 12. Transfers 48 13. Other Tests Related to Transfers 49 14. Medication Management 56 15. Other Tests Related to Medication Management 57 16. Preventive Services 60 17. Specialized Medical Housing 75 18. Specialty Services 80 19. Other Tests Related to Specialty Services 81 20. Administrative Operations 84 A–1. Case Review Definitions 88 B–1. Case Review Sample Sets 93 B–2. Case Review Chronic Care Diagnoses 94 B–3. Case Review Events by Program 95 B–4. Case Review Sample Summary 95 Figures A-1. Inspection Indicator Review Distribution for CMC 87 A–2. Case Review Testing 90 A–3. Compliance Sampling Methodology 91 Photographs 1. East Clinic Indoor Waiting Area 37 2. Expired Medical Supplies 38 3. Expired Medical Supplies 38 4. Medical Supplies Stored With Staff’s Personal Items 39 5. Medical Supplies Stored With Staff’s Personal Items and Food 39 6. Record of Staff Inaccurately Logging Codes When Performing Inventories 40 7. Snellen Eye Chart Mounted Inside the Patient’s Room 40 8. Snellen Eye Chart Not Mounted on Wall 40 9. Warehouse Medical Supplies Were Found Stored Directly on the Floor 41 Cover: Rod of Asclepius courtesy of Thomas Shafee Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 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. 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 (HEDIS) 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: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 2 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 the care; and 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 California Men’s Colony (CMC), the receiver had delegated this institution back to the department. We completed our sixth inspection of CMC, and this report presents our assessment of the health care provided at that institution during the inspection period between January 2021 and June 2021.6 The data obtained for CMC and the on-site inspections occurred during the COVID-19 pandemic.7 California Men’s Colony (CMC) is located northwest of the city of San Luis Obispo, in San Luis Obispo County. The institution has two separate housing facilities, commonly referred to as “East” and “West.” At both facilities, medical staff members run multiple clinics where patients are seen for nonurgent care. East Facility houses medium security and general population patients, and is divided into four facilities, including a triage and treatment area (TTA) where medical staff members see patients requiring urgent and emergent care, and a correctional treatment center (CTC) which provides inpatient care. West Facility houses minimum-security and general population patients. CDCR has designated CMC as an intermediate care prison; these institutions are predominantly located in urban areas, close to tertiary care centers and specialty care providers for the most cost-effective care. 6 Sample are obtained per case review methodology shared with stakeholders in prior cycles. The case reviews include emergency noncardiopulmonary reviews between November 2020 and May 2021, emergency CPR reviews between August 2020 and June 2021, death reviews between June 2020 and December 2020, anticoagulation reviews between January 2021 and June 2021, diabetes reviews between December 2020 and June 2021, high risk reviews between November 2020 and June 2021, hospitalization reviews between October 2020 and May 2021, transfer reviews between October 2020 and May 2021 and RN sick call reviews between November 2020 and July 2021. 7 As of March 24, 2022, the department reports on its public tracker that 85% of the incarcerated population at CMC is fully vaccinated while 69% of CMC staff are fully vaccinated: Population COVID 19 Tracking. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 3 Summary We completed the Cycle 6 inspection of CMC in November 2021. OIG inspectors monitored the institution’s medical care that occurred between January 2021 and June 2021. The OIG rated the overall quality of health care at CMC as adequate. We list the individual indicators and ratings applicable for this institution in Table 1 below. Table 1. CMC 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 Adequate Inadequate Inadequate Diagnostic Services Inadequate Inadequate Inadequate Emergency Services Adequate N/A Adequate Health Information Management Adequate Adequate Adequate Health Care Environment N/A Inadequate Inadequate Transfers Adequate Proficient Adequate Medication Management Adequate Inadequate Inadequate Prenatal and Postpartum Care N/A N/A N/A N/A Preventive Services N/A Inadequate Inadequate Nursing Performance Adequate N/A Adequate Provider Performance Adequate N/A Adequate Reception Center N/A N/A N/A N/A Specialized Medical Housing Adequate Proficient Adequate 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: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 4 The OIG completed the Cycle 6 inspection for California Men’s Colony in November 2021. OIG inspectors monitored the institution’s medical care that occurred between January 2021 and June 2021. 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 375 patient records and1,158 data points and used the data to answer 95 policy questions. In addition, we observed CMC processes during an on-site inspection in September 2021. Table 2 below lists CMC’s average scores from Cycles 4, 5, and 6. Scoring Ranges Table 2. CMC Policy Compliance Scores 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 76.8% 76.4% 63.1% 2 Diagnostic Services 79.7% 62.2% 44.7% 4 Health Information Management 65.1% 65.7% 82.7% 5 Health Care Environment 81.8% 67.6% 65.4% 6 Transfers 87.0% 76.9% 94.4% 7 Medication Management 71.9% 62.8% 69.3% 8 Prenatal and Postpartum Care N/A N/A N/A 9 Preventive Services 61.1% 77.4% 68.7% 12 Reception Center N/A N/A N/A 13 Specialized Medical Housing 88.0% 90.0% 88.0% 14 Specialty Services 75.7% 59.0% 75.9% 15 Administrative Operations 76.2%* 88.5% 70.6% * 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: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 5 The OIG clinicians (a team of physicians and nurse consultants) reviewed 67 cases, which contained 1,245 patient-related events. After examining the medical records, our clinicians conducted a follow-up on-site inspection in November 2021 to verify their initial findings. The OIG physicians rated the quality of care for 24 comprehensive case reviews. Of these 24 cases, our physicians rated 18 adequate and six inadequate. Our physicians did not find any adverse deficiencies 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 health care indicators.8 Multiple OIG physicians and nurses performed quality control reviews; their subsequent collective deliberations ensured consistency, accuracy, and thoroughness. Our clinicians acknowledged institutional structures that catch and resolve mistakes that may occur throughout the delivery of care. As noted above, we listed the individual indicators and ratings applicable for this institution in Table 1, the CMC Summary Table. In August 2021, the Health Care Services Master Registry showed that CMC had a total population of 3,094. A breakdown of the medical risk level of the CMC population as determined by the department is set forth in Table 3 below.9 Table 3. CMC Master Registry Data as of August 20, 2021 Medical Risk Level Number of Patients Percentage High 1 287 9.3% High 2 544 17.6% Medium 1,203 38.9% Low 1,060 34.3% Total 3,094 100.0% Source: Data for the population medical risk level were obtained from the CCHCS Master Registry dated 8-20-21. 8 The indicators for Reception Center and Prenatal Care do not apply to CMC. 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: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 6 According to staffing data the OIG obtained from California Correctional Health Care Services (CCHCS), as identified in Table 4 below, CMC had zero vacant executive leadership positions, zero primary care provider vacancies, 1.7 nursing supervisor vacancies, and 1.3 nursing staff vacancies. Table 4. CMC Health Care Staffing Resources as of August 2021 Executive Primary Care Nursing Nursing Positions Leadership* Providers Supervisors Staff† Total Authorized Positions 4.0 12.0 20.2 143.3 179.5 Filled by Civil Service 4.0 12.5 18.5 142.0 177.0 Vacant 0 0 1.7 1.3 3.0 Percentage Filled by Civil Service 100.0% 104.2% 91.6% 99.1% 98.6% Filled by Telemedicine 0 0 0 0 0 Percentage Filled by Telemedicine 0% 0% 0% 0% 0% Filled by Registry 0 1 0 8 9 Percentage Filled by Registry 0% 8.3% 0% 5.6% 5.0% Total Filled Positions 4.0 13.5 18.5 150.0 186.0 Total Percentage Filled 100.0% 112.5% 91.6% 104.7% 103.6% Appointments in Last 12 Months 0 0 4.0 22.0 26.0 Redirected Staff 0 0 0 0 7.0 Staff on Extended Leave‡ 0 0 0 2.0 2.0 Adjusted Total: Filled Positions 4.0 13.5 18.5 148.0 184.0 Adjusted Total: Percentage Filled 100% 112.5% 91.6% 103.3% 102.5% * 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 August 2021, from California Correctional Health Care Services. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 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 CMC during the Cycle 6 inspection. Case Review Results OIG case reviewers assessed 10 of the 13 indicators applicable to CMC. Of these 10 indicators, OIG clinicians rated none proficient, nine adequate, and one inadequate. The OIG physicians also rated the overall adequacy of care for each of the 24 detailed case reviews they conducted. Of these 24 cases, none were proficient, 18 were adequate, and six were inadequate. In the 1,245 events reviewed, there were 319 deficiencies, 33 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 CMC: • Nursing staff performed well in initial assessment and screening when patients arrived at CMC, and they performed well in assessment, review of reports, and notification to providers when patients returned from hospital and specialty services visits. • Staff performed well in health care information management, as most hospital discharge records, diagnostic results, and specialty reports were retrieved and scanned within the required time frames. • Providers performed well in providing treatment plans during the COVID-19 pandemic in the dedicated isolation unit and in transferring patients to higher level of care when needed. Our clinicians found the following weaknesses at CMC: • Providers did not timely communicate all test results with patients and ensure that the patient notification letters contain all required elements. 10 For a further discussion of an adverse event, see Table A-1. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 8 • Staff did not adequately process STAT laboratory tests and notify providers of STAT test results. • Nursing staff did not provide adequate assessment, intervention, and documentation when providing care in the Triage and Treatment Area (TTA) and the Correctional Treatment Center (CTC). • Pharmacy and nursing staff did not adequately provide patients with their newly ordered, chronic care, and hospital discharge medications timely. Compliance Testing Results Our compliance inspectors assessed 10 of the 13 indicators applicable to CMC. Of these 10 indicators, our compliance inspectors rated two proficient, two adequate, and six inadequate. We tested policy compliance in the Health Care Environment, Preventive Services, and Administrative Operations, as these indicators do not have a case review component. CMC demonstrated a high rate of policy compliance in the following areas: • Nursing staff timely completed initial health screening forms for newly transferred patients. In addition, the institution ensured that patients received previously ordered medications without interruption. • The institution’s nursing staff and providers performed well in completing initial health assessments and evaluating patients admitted to specialized medical housing unit within the required timeframe. • Medical staff timely and accurately scanned medical records into patient files. • The institution completed high-priority, medium-priority, and routine specialty services within the required time frames. CMC demonstrated a low rate of policy compliance in the following areas: • The institution did not consistently provide routine and STAT (immediate) laboratory services within specified time frames. • Providers did not often communicate results of diagnostic services timely. Most patient letters were missing key elements required by CCHCS policy. • The institution did not consistently provide appointments within required time frames for chronic care patients, newly transferred patients, and patients returning from specialty services appointments. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 9 • Health care staff did not practice universal hand hygiene precautions during observed patient encounters. 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 used population-based metrics in considering CMC’s performance to assess the macroscopic view of the institution’s health care delivery. CMC’s results compared favorably with those found in State health plans for diabetic care measures. We list the applicable HEDIS measures in Table 5. Comprehensive Diabetes Care When compared with statewide Medi-Cal programs—California Medi-Cal, Kaiser Northern California (Medi-Cal), and Kaiser Southern California (Medi-Cal)—CMC performed better in two of the three diabetic measures that have statewide comparative data: HbA1c screening and poor HbA1c control. Kaiser NorCal and Kaiser SoCal outperformed CMC in blood pressure control. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 10 Immunizations Statewide comparative data were not available for immunization measures; however, we include this data for informational purposes. CMC had a 67 percent influenza immunization rate for adults 18 to 64 years old and a 62 percent influenza immunization rate for adults 65 years of age and older.11 The pneumococcal vaccine rate was 85 percent.12 Cancer Screening Statewide comparative data were not available for colorectal cancer screening; however, we include these data for informational purposes. CMC had an 83 percent colorectal cancer screening rate. 11 The HEDIS sampling methodology requires a minimum sample of 10 patients to have a reportable result. 12 The pneumococcal vaccines administered are the 13 valent pneumococcal vaccine (PCV13), 15 valent pneumococcal vaccine (PCV15), 20 valent pneumococcal vaccine (PCV20), or 23 valent pneumococcal vaccine (PPSV23), depending on the patient’s medical conditions. For the adult population, the influenza or pneumococcal vaccine may have been administered at an institution other than the one in which the patient was housed during the inspection period. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 11 Table 5. CMC Results Compared with State HEDIS Scores California California CMC 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%) ‡, § 18% 34% 25% 18% HbA1c Control (< 8.0%) ‡ 68% – – – Blood Pressure Control (< 140/90) ‡ 77% 65% 78% 84% Eye Examinations 15% – – – Influenza – Adults (18–64) 67% – – – Influenza – Adults (65+) 62% – – – Pneumococcal – Adults (65+) 85% – – – Colorectal Cancer Screening 83% – – – Notes and Sources * Unless otherwise stated, data were collected in September 2021 by reviewing medical records from a sample of CMC’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 CMC population was tested. § For this measure only, a lower score is better. Source: Institution information provided by the California Department of Corrections and Rehabilitation. Health care plan data were obtained from the CCHCS Master Registry. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 12 Recommendations As a result of our assessment of CMC’s performance, we offer the following recommendations to the department: Access to Care • Medical leadership should ensure that when providers perform chart reviews instead of face-to-face chronic care visits, providers document the results of chart reviews to include appropriate care plans, required follow-up diagnostic tests, and referrals. • Medical leadership should determine the root cause(s) of untimely clinic nursing visits after sick call requests, sick call follow-up appointments with clinic providers, and subsequent follow-up specialty appointments, and should monitor remedial measures once implemented. • Medical leadership should determine the root cause(s) of challenges to the timely provision of chronic care follow-up appointments with providers, provider follow-up visits, and nurse-to-provider referrals, and should implement remedial measures as appropriate. Diagnostic Services • Medical leadership should ensure that providers endorse all diagnostic results timely and communicate the results with patients. • Medical leadership should ascertain causative factors related to the untimely provision of laboratory services, including strategies to mitigate laboratory staffing shortages, and should implement remedial measures as appropriate. • Medical leadership should ensure that STAT laboratory services are completed within the required time frame. • Medical leadership should determine the root cause(s) of challenges to reviewing and /endorsing STAT laboratory and pathology reports timely and should implement remedial measures as appropriate. Emergency Services • Nursing leadership should ensure that nurses perform complete assessments, provide interventions, and thoroughly document their actions. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 13 Health Information Management • Medical leadership should ensure that providers communicate all test results with patients timely and that patient notification letters contain all required elements. • The department should consider developing and implementing a patient results letter template that autopopulates with all elements required by CCHCS policy. Health Care Environment • 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 that 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) logs to ensure that the EMRBs are regularly inventoried and sealed. Transfers • Nursing leadership should ensure that the receiving and release (R&R) nursing staff thoroughly complete the transfer-out screening process. • Medical, nursing, and pharmacy leadership should ensure that patients returning from a hospitalization receive recommended medications to ensure medication continuity. • Nursing leadership should ensure that receiving and release (R&R) nurses confirm that all patients transferring out of the institution have the required medications, transfer documents, and assigned durable medical equipment (DME). Medication Management • Nursing and pharmacy leadership should ensure that patients receive their newly ordered, chronic care, and hospital discharge medications timely, and that staff document in the medication administration record (MAR) summaries as described in CCHCS policy and procedures. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 14 Preventive Services • Nursing leadership should consider developing and implementing measures to ensure that nursing staff timely screen patients for tuberculosis (TB) and that nursing staff completely address the signs and symptoms on their TB monthly monitoring form for patients taking LTBI medications.13 • Medical leadership should ascertain causative factors related to the untimely transfers of high-risk patients for coccidioidomycosis (valley fever) and should implement remedial measures as appropriate. Nursing Performance • Nursing leadership should ensure that nurses perform thorough face-to-face assessments and triage sick calls appropriately. Provider Performance • Medical leadership should ensure that on-call providers timely complete appropriate progress notes for consultations provided to nursing staff. • Medical leadership should ensure that providers are using polypharmacy medication reviews for patients who may be at risk for adverse effects due to medication regimens involving multiple drugs (polypharmacy) by collaborating with clinical pharmacists. Specialized Medical Housing • Nursing leadership should ensure that nursing staff perform thorough patient assessments, recognize changes in patient status, and intervene timely and appropriately. Specialty Services • Medical leadership should ensure that providers are endorsing the specialty reports timely. • Medical leadership should ensure that providers communicate all diagnostic test results with patients, including anticoagulation laboratory work performed by the anticoagulation clinic. 13 LTBI is latent tuberculosis infection. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 15 Access to Care Overall Rating In this indicator, OIG inspectors evaluated the institution’s performance in Inadequate providing patients with timely clinical appointments. Our inspectors reviewed the scheduling and appointment timeliness for newly arrived patients, sick call, Case Review and nurse follow-up appointments. We examined referrals to primary care Rating providers, provider follow-ups, and specialists. Furthermore, we evaluated the Adequate follow-up appointments for patients who received specialty care or returned from an off-site hospitalization. Compliance Score Results Overview Inadequate (63.1%) CMC delivered mixed performance in access to care. OIG clinicians found that most appointments and referrals were completed timely, including appointments with correctional treatment center (CTC) providers, nurses, and specialists. However, the institution did not perform well in clinic provider appointments. In this indicator, compliance testing showed poor performance, with a score of 63.1 percent. After reviewing all aspects of the institution’s performance in this indicator, the OIG rated the Access to Care indicator inadequate. Case Review and Compliance Testing Results We reviewed 257 provider, nursing, specialty, and hospital events that required the institution to generate appointments. We identified 23 deficiencies relating to access to care, of which three were significant.14 Access to Clinic Providers Access to clinic providers is an integral part of patient care in health care delivery. Following the patient and staff movement directives from the department in response to the COVID-19 pandemic and CMC institution COVID-19 outbreaks from the beginning of December 2020 to mid-February 2021, CMC medical staff provided care using chart reviews, prioritizing urgent and emergent conditions with appointments to clinic providers. Compliance testing showed that only 24.0 percent of chronic care follow-up appointments occurred on time (MIT 1.001), 72.2 percent of nurse-to-provider follow-up appointments occurred timely as requested (MIT 1.005), and 33.3 percent of sick call follow-up appointments occurred within the specified time frame (MIT 1.006). The OIG clinicians reviewed 115 clinic provider encounters and identified three deficiencies, of which none were significant.15 The following is an example: 14 Deficiencies occurred thrice in case 21, twice in cases 7, 9, and 35, and once in cases 2, 6, 8, 10, 12, 13, 17, 26, 36, 38, 56, 58, 59, and 60. Significant deficiencies occurred in cases 35, 36, and 38. 15 Deficiencies occurred in cases 2, 17, and 21. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 16 • In case 2, the provider requested a procedure appointment within 30 with an on-site provider for follow-up care of severe knee arthritis days. Instead, the appointment occurred 11 weeks late. Access to Specialized Medical Housing Providers CMC performed well in access in the Correctional Treatment Center (CTC). When staff admitted patients to the CTC, providers examined the patients timely and documented their findings in their progress notes within the appropriate time frames. Compliance testing found that 100 percent of the CTC admission history and physical examinations occurred within the required time frame (MIT 13.002). Our clinicians assessed 94 provider encounters and did not identify any deficiencies related to late or missed admission history and physical examinations or follow-up appointments. Access to Clinic Nurses CMC performed satisfactorily in providing access in its nurse sick calls and provider-to-nurse referrals. Compliance testing found that all nurse sick call requests were reviewed on the same day they were received (MIT 1.003, 100%), but nurses did not always complete face-to-face visits within one day after the sick call requests were reviewed (MIT 1.004, 62.2%). Our clinicians assessed 63 sick call triage nursing encounters and identified eight deficiencies, of which one was significant.16 The significant deficiency follows: • In case 35, nursing staff received and triaged a sick call request for a patient with complaints of severe pain in the knee and upper left leg following a fall. However, a nursing face-to-face visit occurred 13 days later. Access to Specialty Services CMC performed well in referrals to specialty services. Compliance testing found that 91.7 percent of the initial high-priority specialty appointments occurred within the required time frame (MIT 14.001), 93.3 percent of the initial medium- priority specialty appointments (MIT 14.004), and 93.3 percent of the initial routine-priority specialty appointments (MIT 14.007). The institution also performed satisfactorily in follow-up specialty appointments. Compliance testing found that 77.8 percent of patients received the subsequent high-priority specialty appointments within the required time frame (MIT 14.003), 83.3 percent of medium-priority specialist appointments (MIT 14.006), and 66.7 percent of routine-priority specialty service appointments (MIT 14.009). Our clinicians assessed 70 specialty service events and identified one deficiency: 16 Deficiencies occurred twice in case 35, and once in cases 6, 7, 56, 58, 59, and 60. A significant deficiency occurred in case 35. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 17 • In case 12, the eye specialist assessed and treated the patient for an eye condition and recommended follow-up in one week. However, the appointment occurred three weeks late. Follow-Up After Specialty Service CMC did not perform well in ensuring that patients see their providers within the required time frames after specialty appointments. Compliance testing revealed that 70.0 percent of provider appointments after specialty services occurred timely (MIT 1.008). Our clinicians evaluated 98 specialty service events and identified one deficiency: • In case 21, the neurosurgeon evaluated the patient, and the nursing staff ordered a provider follow-up to occur within 14 days. Instead, the follow-up appointment with the provider occurred 18 days late. Follow-Up After Hospitalization CMC performed adequately in ensuring that patients saw their providers within the required time frames after hospitalization. Compliance testing found that 85.7 percent of provider appointments after hospitalization occurred within the required time frame (MIT 1.007). Our clinicians reviewed 18 hospital returns and did not identify any missed or delayed appointments. Follow-Up After Urgent or Emergent Care (TTA) CMC performed adequately for patients in provider follow-up appointments after urgent or emergent care at the triage and treatment area (TTA). Our clinicians assessed 15 TTA events and identified one delayed provider follow-up appointment: • In case 9, the provider ordered a provider follow-up within 14 days for a patient who was evaluated in the TTA. The appointment occurred six days late. Follow-Up After Transferring Into the Institution In compliance testing, CMC did not perform adequately in providing appointments for newly arrived patients within the required time frames (MIT 1.002, 37.5%). However, our clinicians evaluated nine transfer-in events and identified only one deficiency: • In case 26, the nurse scheduled a newly arrived patient to be seen by a provider within seven days. Instead, the provider evaluated the patient fifteen days later. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 18 Clinician On-Site Inspection CMC has two physically separated facilities, East Facility and West Facility. East Facility contains four medical clinics (A, B, C, D), each with one provider and ancillary medical staff. The Correctional Treatment Center (CTC), and Triage and Treatment Area (TTA) are located in the East Facility. One designated provider provides care for patients in the CTC, which has 34 beds, including two negative- pressure rooms. West Facility has one medical clinic, with four providers and ancillary medical staff. The OIG clinicians attended three separate morning huddles in both East Facility and West Facility clinics. The morning huddles were well attended by medical staff and included office technicians. The office technician reported scheduling nine appointments each day for each primary care provider and holding open two appointments for same-day access for each provider as needed. During the COVID-19 outbreaks, staff reported that access to specialty services was challenging due to restricted patients’ movements and the limited availability of local and telemedicine specialists’ services. CMC providers completed chronic care appointments through chart reviews. They deferred face- to-face patient appointments to minimize patients’ and staff’s possible exposure to the virus. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 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 6 19 0 24.0% 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, 9 15 1 37.5% was the patient seen by the clinician within the required time frame? (1.002) * Clinical appointments: Did a registered nurse review the patient’s 45 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 28 17 0 62.2% 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 13 5 27 72.2% 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 2 42 33.3% 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 1 2 85.7% frame? (1.007) * Specialty service follow-up appointments: Did the clinician follow-up visits occur within required time frames? (1.008) * , † 28 12 2 70.0% Clinical appointments: Do patients have a standardized process to 5 1 0 83.3% obtain and submit health care services request forms? (1.101) Overall percentage (MIT 1): 63.1% * 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: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 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 10 0 0 100% 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 10 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 11 1 0 91.7% 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? 7 2 3 77.8% (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 14 1 0 93.3% 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 5 1 9 83.3% provider? (14.006) * Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician 14 1 0 93.3% 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? 4 2 9 66.7% (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: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 21 Recommendations • Medical leadership should ensure that when providers perform chart reviews instead of face-to-face chronic care visits, providers document the results of chart reviews to include appropriate care plans, required follow-up diagnostic tests, and referrals. • Medical leadership should determine the root cause(s) of untimely clinic nursing visits after sick call requests, sick call follow-up appointments with clinic providers, and subsequent follow-up specialty appointments, and should monitor remedial measures once implemented. • Medical leadership should determine the root cause(s) of challenges to the timely provision of chronic care follow-up appointments with providers, provider follow-up visits, and nurse-to-provider referrals, and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 22 Diagnostic Services Overall Rating In this indicator, OIG inspectors evaluated the institution’s performance in Inadequate timely completing radiology, laboratory, and pathology tests. Our inspectors determined whether the institution properly retrieved the resultant reports and Case Review whether providers reviewed the results correctly. In addition, in Cycle 6, we Rating examined the institution’s performance in timely completing and reviewing Inadequate immediate (STAT) laboratory tests. Compliance Score Results Overview Inadequate (44.7%) CMC performed unsatisfactorily in completing and retrieving diagnostic tests and performed poorly in communicating results with patients. In particular, CMC had difficulty processing STAT laboratory tests and communicating STAT test results. Compliance testing in this indicator showed poor performance, with a score of 44.7 percent. Taking into account the poor performance in this indicator revealed by both compliance testing and case review analysis, the OIG rated the Diagnostic Services indicator inadequate. Case Review and Compliance Testing Results We reviewed 284 diagnostic events and found 84 deficiencies, of which none were significant. Of those 84 deficiencies, we found 80 related to health information management and two pertaining to the completion of diagnostic tests.17 For health information management, we considered test reports that were never retrieved or reviewed as severe a problem as tests that were not performed. This is discussed further in the Health Information Management indicator. Test Completion CMC performed well in completing radiology services (MIT 2.001, 90.0%) but poorly in completing laboratory services (MIT 2.004, 20.0%) within required time frames. We identified one STAT laboratory services deficiency in case review: • In case 13, the health care team collected a STAT laboratory specimen in the TTA and sent it out to outside laboratory services, but the nursing staff did not receive the results within the required time frames. The OIG clinicians reviewed 236 laboratory tests and identified two deficiencies related to delayed laboratory test specimen collection, as described below: 17 Deficiencies occurred nine times in cases 14 and 15, seven times in case 21, six times in case 6, five times in cases 16 and 35, four times in cases 8, 9, 13, 17, 37, and 38, thrice in cases 11 and 36, twice in cases 2 and 12, and once in cases 1, 7, 10, 18, and 19. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 23 • In case 14, the provider ordered time-sensitive laboratory tests for blood thinner monitoring to be completed; however, two of the laboratory tests were collected two and three days later. Health Information Management CMC providers generally reviewed and endorsed the reports within specified time frames for radiology (MIT 2.002, 90.0%) and laboratory (MIT 2.005, 90.0%). However, nursing struggled to timely notify providers of STAT laboratory test results (MIT 2.008, zero). CMC staff retrieved pathology reports within the required time frames most of the time (MIT 2.010, 80.0%), but providers did not always review and endorse the results in a timely manner (MIT 2.011, 60.0%). Furthermore, providers did not communicate the results of the pathology studies to the patients within specified time frames (MIT 2.012, zero). The OIG clinicians identified 81 deficiencies; most deficiencies were related to health information management, involving incomplete and delays in creating notification letters for patients (63 out of 81 deficiencies).18 We also identified 13 deficiencies involving delays in obtaining providers’ endorsements of the results.19 The following are examples: • In case 6, the provider reviewed and endorsed the results of an X-ray and created a patient notification letter. However, the letter did not indicate whether the results are within normal limits. • In case 9, the provider endorsed laboratory results but did not create a patient notification letter in the EHRS. • In case 13, nursing staff notified the physician on call of STAT laboratory test results over the phone on the same day the specimen was collected. However, the institution did not receive the provider endorsement until five days later. • In case 17, the provider reviewed and endorsed the laboratory results six days after the results became available. Clinician On-Site Inspection The OIG clinicians visited laboratory and radiology departments. At the time of on-site visit, the radiology service was fully staffed and provided on-site X-ray, ultrasound, fibroscan, and mobile CT/ MRI imaging. The institution performed imaging services timely, and the imaging results were ported into the EHRS for providers’ review. The laboratory supervisor reported the laboratory service was not fully staffed; the supervisor shared the challenges of keeping staff employed when staff were 18 Deficiencies occurred in cases 1, 2, 6, 7, 8, 9, 10, 11, 12, 14-18, 21, 35, 36, and 38. 19 Deficiencies occurred in cases 13, 17, 19, 21, 35, and 37. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 24 paid less than their counterparts elsewhere in the community. The supervisor also described scheduling challenges that occurred during the COVID-19 pandemic due to restrictions of patients’ movement in the institution. Once the specimens were processed, the laboratory vendor posted the laboratory and pathology results directly to the EHRS. At the time of inspection, we learned that CMC was engaged with outside vendors to finalize a new contract for STAT laboratory processing. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 25 Compliance Testing Results Table 8. Diagnostic Services Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Was the radiology service provided within the time frame 9 1 0 90.0% specified in the health care provider’s order? (2.001) * Radiology: Did the ordering health care provider review and endorse 9 1 0 90.0% 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 4 6 0 40.0% frames? (2.003) Laboratory: Was the laboratory service provided within the time frame 2 8 0 20.0% specified in the health care provider’s order? (2.004) * Laboratory: Did the health care provider review and endorse the 9 1 0 90.0% laboratory report within specified time frames? (2.005) * Laboratory: Did the health care provider communicate the results of 0 10 0 0 the laboratory test to the patient within specified time frames? (2.006) Laboratory: Did the institution collect the STAT laboratory test and 0 3 0 0 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) 0 3 0 0 * Laboratory: Did the health care provider endorse the STAT laboratory 2 1 0 66.7% results within the required time frames? (2.009) Pathology: Did the institution receive the final pathology report within 8 2 0 80.0% the required time frames? (2.010) * Pathology: Did the health care provider review and endorse the 6 4 0 60.0% 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? 0 10 0 0 (2.012) Overall percentage (MIT 2): 44.7% * 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: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 26 Recommendations • Medical leadership should ensure that providers endorse all diagnostic results timely and communicate the results with patients. • Medical leadership should ascertain causative factors related to the untimely provision of laboratory services, including strategies to mitigate laboratory staffing shortages, and should implement remedial measures as appropriate. • Medical leadership should ensure that STAT laboratory services are completed within the required time frame. • Medical leadership should determine the root cause(s) of challenges to reviewing and /endorsing STAT laboratory and pathology reports timely and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 27 Emergency Services Overall In this indicator, OIG clinicians evaluated the quality of emergency medical care. Rating Our clinicians reviewed emergency medical services by examining the timeliness Adequate and appropriateness of clinical decisions made during medical emergencies. Our evaluation included examining the emergency medical response, Case Review cardiopulmonary resuscitation (CPR) quality, triage and treatment area (TTA) Rating care, provider performance, and nursing performance. Our clinicians also Adequate evaluated the Emergency Medical Response Review Committee’s (EMRRC) performance in identifying problems with its emergency services. The OIG Compliance assessed the institution’s emergency services through case review only; no Score compliance testing was performed for this indicator. (N/A) Results Overview CMC’s overall performance for this indicator was generally good. In comparison to its performance in Cycle 5, CMC showed some improvement. During medical emergencies, CMC delivered prompt life support care. Providers mostly examined, diagnosed, and triaged patients appropriately. Areas for improvement include nursing assessment, intervention, and documentation—specifically, reassessment, use of nursing protocols, and thorough documentation of information during emergencies. On the whole, we rated the Emergency Services indicator as adequate. Case Review Results We reviewed 31 urgent or emergent events in 14 cases and identified 25 emergency care deficiencies, five of which were significant.20 Emergency Medical Response CMC mostly performed well in emergency medical response. During medical emergencies, the first medical responders arrived within the required time frame, assessed the patient, activated emergency medical services, and notified the TTA staff as required. Our clinicians reviewed one CPR case and found CMC’s nursing performance to be adequate during the emergency event.21 We did not identify any significant deficiencies. The nursing staff assessed the patient, initiated CPR immediately, and notified emergency medical services promptly. However, we identified incomplete documentation on the CPR record and inappropriate oxygen 20 We reviewed emergency events in cases 1, 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 23, and 36. Deficiencies occurred in cases 2, 5, 6, 7, 8, 9, 11, 23, and 36. Significant deficiencies occurred in cases 2, 11, and 36. 21 We reviewed case 5 for CPR. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 28 administration during a CPR event. Oxygen should have been administered via an ambubag instead of a nonrebreather mask.22 Provider Performance CMC providers performed well in urgent and emergent situations. Providers were available for consultation with the TTA nursing staff. They generally made appropriate diagnoses and documented well. Our clinicians identified two significant deficiencies.23 This is discussed further in the Provider Performance indicator. Nursing Performance CMC nursing performance during emergency events was fair. OIG clinicians reviewed 31 urgent or emergent events and found 15 deficiencies, of which three were significant. Assessments and interventions are areas that need improvement. OIG case reviewers identified a pattern of nursing assessment problems with vital signs. Vital signs were either incomplete or not reassessed.24 Nurses did not always intervene as needed.25 For example, on two occasions, they did not use the nursing protocols for chest pain or seizures as required. Nurses also did not notify the provider, apply oxygen, and obtain EKGs as required. Significant deficiencies occurred in the follow cases: • In case 2, the nurse did not use the chest pain protocol or document an order to transfer the patient with chest pain to a higher level of care. • In case 2, on another occasion, the patient complained of chest discomfort with a racing heart for three hours and an elevated blood pressure. The nurse did not notify the provider, perform an EKG, reassess the patient’s elevated blood pressure, and schedule a provider follow-up for the TTA encounter. The nurse instructed the patient to continue with the plan of care to see the cardiologist as scheduled and to seek medical attention for difficulty breathing or chest discomfort. • In case 11, the nurse evaluated the patient for unstable vital signs and did not reassess the low oxygen level in the patient who was positive for COVID-19 or timely initiate oxygen. 22 An ambubag delivers a higher amount of oxygenation to the patient. 23 Significant provider deficiencies occurred in cases 11 and 36. 24 Incomplete vital signs or lack of reassessment of vital signs occurred in cases 2, 8, 9, 11, 23, and 36. 25 Nursing interventions were lacking in cases 2, 3, 5, 6, 8, 11, and 36. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 29 Nursing Documentation Complete and accurate documentation illustrates the quality and timeliness of emergency care. CMC nursing documentation was generally adequate. However, we did identify deficiencies.26 Examples of poor documentation include nurses not documenting an order to transfer the patient to a higher level of care, the provider arrival time, the ambulance departure time, the rate of oxygen administered, the oxygen saturation levels, or the patient arrival time in the TTA. Other lapses in documentation include a CPR record missing vital signs, a missing patient cardiac rhythm, an AED analysis, and a provider notification. Emergency Medical Response Review Committee The nursing supervisors and the EMRRC reviewed 16 emergency response events within the required time frame.27 All emergency events are required to be audited to evaluate staff performance, documentation, and policy adherence, and to identify training issues. Although the reviewers usually identified lapses in care, they did not identify the following deficiencies: nurses did not use nursing protocols for chest pain and seizures; nurses gave inappropriate oxygen administration during CPR; and nurses incompletely documented vital signs for unstable patients and a CPR record.28 Compliance testing showed that the EMRRC reviewed incidents within the required time frame and obtained required signatures. However, the incident review packages did not always include completed documents. The Emergency Medical Response and Unscheduled Transport Event Check lists were missing documentation of the dates and times events occurred (MIT 15.003, 50.0%). Clinician On-Site Inspection CMC has two separate complexes, referred to as East and West Facilities. The TTA is located in East Facility and contains two beds. TTA staff use an emergency response vehicle to respond to medical emergencies throughout the institution. The TTA is staffed with two registered nurses on second and third watch and one registered nurse on first watch. A provider is assigned to the TTA during business hours, and an on-call provider is available after hours. During our on-site visit, the TTA was undergoing new construction; staff reported the TTA will be relocating temporarily until new construction is completed. TTA staff also reported a good rapport with administration and custody staff. 26 Documentation deficiencies occurred in cases 2, 5, 6, 7, 8, 9, 23, and 36. 27 Emergency response events occurred in cases 1, 2, 3, 5, 6, 7, 8, 9, 11, and 12. 28 Deficiencies occurred in cases 2, 5, 6, 7, 8, 9, and 11. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 30 Recommendations • Nursing leadership should ensure that nurses perform complete assessments, provide interventions, and thoroughly document their actions. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 31 Health Information Management Overall Rating In this indicator, OIG inspectors evaluated the flow of health information, a Adequate crucial link in high-quality medical care delivery. Our inspectors examined whether the institution retrieved and scanned critical health information Case Review (progress notes, diagnostic reports, specialist reports, and hospital discharge Rating reports) into the medical record in a timely manner. Our inspectors also tested Adequate whether clinicians adequately reviewed and endorsed those reports. In addition, our inspectors checked whether staff labeled and organized documents in the Compliance medical record correctly. Score Adequate Results Overview (82.7%) The OIG found that CMC staff performed well in this indicator. The medical staff retrieved and scanned hospital discharge records, diagnostic results, and specialty reports timely. In this indicator, both compliance testing and case review analysis rated the Health Information Management indicator as adequate. Case Review and Compliance Testing Results The OIG clinicians reviewed 1,245 events and found 109 deficiencies related to health information management, of which one was significant.29 The majority of deficiencies (73 of 109 deficiencies) in health information management pertained to the patient notification letters, either not created or incomplete. Hospital Discharge Reports The CMC staff performed adequately in retrieving community hospital discharge documents and scanning them into the patients’ electronic health record system (EHRS) within the required time frames (MIT 4.003, 75.0%). Most of the hospital discharge reports contained physician discharge summaries, and the providers reviewed the reports timely (MIT 4.005, 77.8%). Our clinicians reviewed 18 off-site emergency department and hospital visits and did not identify any deficiencies. Specialty Reports The CMC staff performed well in retrieving and reviewing the specialty reports. Compliance testing showed that 83.3 percent of specialty reports were scanned into the EHRS within the required time frames (MIT 4.002). CMC staff generally received and providers reviewed the high-priority and routine specialty reports within the required time frame (MIT 14.002, 75.0% and MIT 14.008, 73.3% respectively). However, they did not always receive and review medium-priority 29 Deficiencies occurred eleven times in cases 13 and 15; 10 times in case 6; nine times in case 14; eight times in cases 21 and 37; five times in cases 8, 16, 17, 35, and 38; four times in cases 2, 9, and 36; thrice in case 11; twice in cases 7, 10, 12, and 18; and once in cases 1, 19, and 22. A significant deficiency occurred in case 21. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 32 specialty reports timely (MIT 14.005, 53.3%). These findings are discussed further in the Specialty Services indicator. Our clinicians reviewed 84 specialty reports and identified two deficiencies, of which one was significant:30 • In case 21, the neurosurgery specialist evaluated the patient during a telemedicine appointment, and the institution scanned the report into the EHRS. However, the provider reviewed and endorsed the specialty report almost a month later. Diagnostic Reports The CMC staff performed well in retrieving and endorsing diagnostic reports timely. Compliance testing showed providers endorsed radiology and laboratory reports within the required time frames (MIT 2.002, 90.0% and MIT 2.005, 90.0%). The staff generally received the final pathology reports within the required time frames (MIT 2.010, 80.0%). However, the providers did not always review and endorse the pathology reports in a timely manner (MIT 2.011, 60.0%), and providers performed poorly in communicating the results of the pathology studies to patients during the specified time period (MIT 2.012, zero). Our clinicians identified 80 deficiencies, of which none were significant.31 The majority of deficiencies (68 out of 80 deficiencies) pertained to patient notification letters. The following are examples: • In case 6, the provider reviewed and endorsed laboratory test results for stool antigen but did not create a patient notification letter in the EHRS. • In case 15, the pharmacist created an anticoagulation management progress note in the health record but did not create a patient notification letter for the laboratory test results. The CMC staff performed poorly with provider acknowledgement and in notifying the provider of STAT test results within the required time frame (MIT 2.008, zero). Our clinicians identified one deficiency in STAT laboratory test results: the provider was not notified of the results within the required time frame.32 The deficiencies are further discussed in the Diagnostic Services. 30 Deficiencies occurred twice in cases 2, 6, and once in cases 8, 10, 15, 17, 37, and 83. A significant deficiency occurred in case 21. 31 Deficiencies occurred nine times in cases 14 and 15; seven times in case 21; six times in case 6; five times in cases 16 and 35; four times in cases 8, 9, 13, 17, 37, and 38; thrice in cases 11 and 36; twice in cases 2 and 12; and once in cases 1, 7, 10, 18, and 19. 32 A deficiency occurred in case 13. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 33 Urgent and Emergent Records The OIG clinicians reviewed 31 emergency care events and found that CMC nurses generally recorded these events well. The providers also recorded their emergency care sufficiently most of the time. However, our clinicians found four deficiencies in documentation made by nursing staff and providers.33 The following is an example: • In case 5, during the emergent event, the nursing documentation on the Cardiopulmonary Record was incomplete. The nurses did not properly document vital signs, the patient cardiac rhythm, the AED analysis, or provider notification. The Emergency Services indicator provides additional details. Scanning Performance The CMC staff performed well in the scanning process. Compliance testing showed that the staff often properly scanned and labeled medical files (MIT 4.004, 87.5%). Our clinicians did not find any deficiencies involving mislabeled documents. Clinician On-Site Inspection Our clinicians discussed health information management (HIM) processes with CMC office technicians, the HIM supervisor, HIM ancillary staff, diagnostic services staff, and providers. The providers reported that medical records staff obtained outside records and diagnostic records, which were routed quickly for review. The OIG clinicians reviewed the patient notification letter deficiencies with the pharmacy staff, who planned to make adjustments. The STAT laboratory results were faxed directly to CTC nursing staff to manage the results timely. The laboratory vendor posted laboratory reports directly into the EHRS for providers’ reviews. 33 Deficiencies occurred in cases 5, 7, 9, and 11. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 34 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 18 2 25 90.0% date? (4.001) Are specialty documents scanned into the patient’s electronic health 25 5 12 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 6 2 1 75.0% hospital discharge? (4.003) * During the inspection, were medical records properly scanned, 21 3 0 87.5% 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 7 2 0 77.8% and did a provider review the report within five calendar days of discharge? (4.005) * Overall percentage (MIT 4): 82.7% * 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: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 35 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 9 1 0 90.0% radiology report within specified time frames? (2.002) * Laboratory: Did the health care provider review and endorse the 9 1 0 90.0% laboratory report within specified time frames? (2.005) * Laboratory: Did the provider acknowledge the STAT results, OR did 0 3 0 0 nursing staff notify the provider within the required time frames? (2.008) * Pathology: Did the institution receive the final pathology report within 8 2 0 80.0% the required time frames? (2.010) * Pathology: Did the health care provider review and endorse the 6 4 0 60.0% pathology report within specified time frames? (2.011) * Pathology: Did the health care provider communicate the results of the 0 10 0 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 9 3 0 75.0% frame? (14.002) * Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the required 8 7 0 53.3% 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 11 4 0 73.3% 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: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 36 Recommendations • Medical leadership should ensure that providers communicate all test results with patients timely and that patient notification letters contain all required elements. • The department should consider developing and implementing a patient results letter template that autopopulates with all elements required by CCHCS policy. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 37 Health Care Environment Overall Rating In this indicator, OIG compliance inspectors tested clinics’ waiting areas, Inadequate infection control, sanitation procedures, medical supplies, equipment management, and examination rooms. Inspectors also tested clinics’ performance in maintaining auditory and visual privacy for clinical encounters. Compliance Case Review inspectors asked the institution’s health care administrators to comment on their Rating facility’s infrastructure and its ability to support health care operations. The OIG (N/A) rated this indicator solely on the compliance score, using the same scoring Compliance thresholds used in the Cycle 4 and Cycle 5 medical inspections. Our case review Score clinicians do not rate this indicator. Inadequate (65.4%) Results Overview CMC’s performance in this indicator was similar to its performance in Cycle 5. In the present cycle, multiple aspects of CMC’s health care environment needed improvement: multiple clinics contained expired medical supplies; multiple clinics lacked medical supplies or contained improperly calibrated or nonfunctional equipment; emergency medical response bag (EMRB) logs either were missing staff verification or inventory was not performed; and staff did not regularly sanitize their hands before examining patients. These factors resulted in an inadequate rating for this indicator. Compliance Testing Results Outdoor Waiting Areas CMC had no outdoors waiting areas. Indoor Waiting Areas We inspected indoor waiting areas (see Photo 1). Health care and custody staff reported existing waiting areas contained sufficient seating capacity. During our inspection, we did not observe overcrowding or noncompliance with social distancing requirements in any of the clinics’ indoor waiting areas. Photo 1. East Clinic indoor waiting area (photographed 9-14-21). Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 38 Clinic Environment All clinic environments were sufficiently conducive to medical care: they provided reasonable auditory privacy, appropriate waiting areas, wheelchair accessibility, and nonexamination room work space (MIT 5.109, 100%). Of the 14 clinics we observed, 12 contained appropriate space, configuration, supplies, and equipment to allow clinicians to perform proper clinical examinations (MIT 5.110, 85.7%). In the remaining two clinics, the clinic or examination room contained unsecured confidential medical records. Clinic Supplies Three of the 14 clinics followed adequate medical supply storage and management protocols (MIT 5.107, 21.4%). We found one or more of the following deficiencies in 11 clinics: expired medical supplies (see Photos 2 and 3, this page) unidentified medical supplies, medical supplies stored directly on the floor, or staff members’ personal items and food stored long-term in the medical supply storage room (see Photos 4 and 5, next page). Photo 2. Expired medical supplies dated December 31, 2019 (photographed 9-16-21). Photo 3. Expired medical supplies dated April 30, 2020 (photographed 9-16-21). Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 39 Photo 5. Medical supplies stored with staff’s personal items (photographed 9-16-21). Photo 4. Medical supplies stored with staff’s personal items and food (photographed 9-16-21). Seven of the 14 clinics met requirements for essential core medical equipment and supplies (MIT 5.108, 50.0%). The remaining seven clinics lacked medical supplies or contained improperly calibrated or nonfunctional equipment. The missing items included a nebulizer, a medication refrigerator, and a Snellen reading chart. The staff had not properly calibrated the automated vital sign machine, weight scale, pulse oximeter, or nebulizer. We found a Snellen reading chart that did not have an identified distance line on the floor or wall, a nonfunctional oto-ophthalmoscope, tongue depressors not stored in a sanitary container, and a nonfunctional medication refrigerator. CMC staff had not entirely or properly logged the results of the automated external defibrillator (AED) performance checklist within the last 30 days. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 40 We examined emergency medical response bags (EMRBs) to determine whether they contained all essential items. We checked whether staff inspected the bags daily and inventoried them monthly. Only three of the nine EMRBs passed our test (MIT 5.111, 33.3%). We found one or more of the following deficiencies with six EMRBs: staff failed to ensure that the EMRB’s compartments were sealed and intact; staff had not inventoried the EMRBs when the seal tags were replaced or had not inventoried the EMRBs in the previous 30 days; or staff inaccurately logged the EMRB Photo 6. Record of staff inaccurately logging codes when glucometer control solution lot code when performing inventories (photographed 9-16-21). performing the daily glucometer quality control (see Photo 6). Staff in CTC Mental Health Crisis Bed Unit did not consistently complete the log to ensure that the treatment cart was sealed and intact when not in active use. In addition to the above, our compliance inspectors observed the following in the clinics or examination rooms when they conducted their on-site inspection: • We found the Snellen eye charts in the CTC medical and mental health clinics to be either mounted inside the patient room or not mounted at all (see Photos 7 and 8 below). In addition, neither Snellen chart had an identified distance line on the floor or wall. • We found a nonfunctional medication refrigerator in East TTA clinic. The clinic provided documents that a work order was in place. At the time of inspection, the TTA used the CTC medication refrigerator to temporarily store the TTA’s refrigerated medications. Photo 7. Snellen eye chart mounted inside the patient’s room (photographed 9-16-21). Photo 8. Snellen eye chart not mounted on wall (photographed 9-14-21). Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 41 Medical Supply Management None of the medical supply storage areas located outside the medical clinics stored medical supplies adequately (MIT 5.106, zero). The warehouse stored medical supplies directly on the floor (see Photo 9). According to the CEO, the institution did not have any concern about the medical supplies process. Health care managers and medical warehouse managers expressed no concerns about the medical supply chain or their communication process in the existing system. Photo 9. Warehouse medical supplies were found stored directly on the floor (photographed 9-14-21). Infection Control and Sanitation Staff appropriately cleaned, sanitized, and disinfected 12 of 14 clinics (MIT 5.101, 85.7%). In two clinics, cleaning logs were not maintained. In addition, one of the two clinics had accumulated dirt and grime under the clinic sink. Staff in 13 of 14 clinics (MIT 5.102, 92.9%) properly sterilized or disinfected medical equipment. In one clinic, we observed the clinician using the examination table while providing services; however, the clinician did not use disposable examination table paper. In addition, we found previously sterilized medical equipment with an expired use-by date stamp. We found operating sinks and hand hygiene supplies in the examination rooms in all clinics (MIT 5.103, 100%). We observed patient encounters in eight clinics. In four clinics, clinicians did not wash their hands before examining their patients, before applying gloves, or before performing blood draws (MIT 5.104, 50.0%). Health care staff in all clinics followed proper protocols to mitigate exposure to bloodborne pathogens and contaminated waste (MIT 5.105, 100%). Physical Infrastructure CMC’s health care management and plant operations manager reported all clinical areas infrastructures were in good working order and did not hinder health care services. At the time of our medical inspection, the institution reported the Health Care Facility Improvement Program (HCFIP) project that started January 28, 2021, was adding to and renovating the East Facility C and East TTA clinics. The institution estimated the project would be completed by September 2023 (MIT 5.999). Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 42 Compliance Testing Results Table 11. Health Care Environment Scored Answer Compliance Questions Yes No N/A Yes % Infection control: Are clinical health care areas appropriately 12 2 0 85.7% 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 13 1 0 92.9% disinfected as warranted? (5.102) Infection control: Do clinical health care areas contain operable sinks 14 0 0 100% and sufficient quantities of hygiene supplies? (5.103) Infection control: Does clinical health care staff adhere to universal 4 4 6 50.0% hand hygiene precautions? (5.104) Infection control: Do clinical health care areas control exposure to 14 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 3 11 0 21.4% managing and storing bulk medical supplies? (5.107) Clinical areas: Do clinic common areas and exam rooms have 7 7 0 50.0% essential core medical equipment and supplies? (5.108) Clinical areas: Are the environments in the common clinic areas 12 0 2 100% conducive to providing medical services? (5.109) Clinical areas: Are the environments in the clinic exam rooms 12 2 0 85.7% 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, 3 6 5 33.3% 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): 65.4% * 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: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 43 Recommendations • 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 that 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) logs to ensure that the EMRBs are regularly inventoried and sealed. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 44 Transfers Overall Rating In this indicator, OIG inspectors examined the transfer process for those patients Adequate who transferred into the institution as well as for those who transferred to other institutions. For newly arrived patients, our inspectors assessed the quality of Case Review health screenings and the continuity of provider appointments, specialist Rating referrals, diagnostic tests, and medications. For patients who transferred out of Adequate the institutions, inspectors checked whether staff reviewed patient medical records and determined the patient’s need for medical holds. They also assessed whether staff transferred patients with their medical equipment and gave correct Compliance medications before patients left. In addition, our inspectors evaluated the Score performance of staff in communicating vital health transfer information, such as Proficient preexisting health conditions, pending appointments, tests, and specialty (94.4%) referrals; and inspectors confirmed whether 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 CMC’s performance was good in this indicator. Overall, compliance scores improved compared to those in Cycle 5, and case review findings were similar to Cycle 5’s findings. Compliance testing results were very good for initial health assessments, medication continuity, specialty continuity, and the transfer-out process. Compliance testing resulted in a low score for the timely evaluation of new arrivals into the institution. In contrast, case review found no significant deficiencies for patients transferring into the institution. However, case review findings also showed that nurses did not always complete the required transfer process thoroughly. In this indicator, compliance testing showed a proficient rating, while the case review analysis found an adequate rating. After reviewing all aspects of the institution’s performance in this matter, the OIG rated the Transfers indicator adequate. Case Review and Compliance Testing Results We reviewed 34 events in 18 cases in which patients transferred into or out of the institution or returned from an off-site hospital or emergency room.34 We identified nine deficiencies, of which one was significant.35 34 We reviewed cases 1, 2, 3, 6, 7, 8, 9, 10, 11, 12, 13, 24, 25, 26, 27, 28, 29, and 37. 35 We identified deficiencies in cases 2, 3, 12, 25, 26, 27, 28, 29, and 36. A significant deficiency occurred in case 27. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 45 Transfers In CMC mostly performed well for patients transferring into the institution with health screening, medication continuity, and specialty appointments. Our clinicians reviewed 13 events in three cases and found two deficiencies, which were not significant.36 The deficiencies were related to documentation and did not affect patient care. Case reviewers found that Receiving & Release (R&R) nurses completed the initial health screening within the required time frame. Compliance testing revealed similar results (MIT 6.001, 88.0%). Patients who transferred into CMC frequently received their medications without interruption. Case review did not identify any deficiencies. Compliance test results showed good performance (MIT 6.003, 89.5%). When patients transferred from one housing unit to another, CMC ensured that medications were continued without interruption (MIT 7.005, 100%). Case review findings were similar. CMC’s performance was good for specialty services appointments. Case review did not identify any deficiencies for patients who transferred into the institution, and compliance testing showed that 91.7% (MIT 14.001) of the specialty appointments occurred within the required time frame. However, compliance testing also showed that majority of provider appointments for newly arrived patients did not occur within the required time frames (MIT 1002, 37.5%). Notably, analysis of the compliance data showed that the providers performed chart reviews instead of face-to-face visits during the COVID-19 outbreaks to minimize exposure to patients. Our clinicians identified one deficiency related to provider appointments’ not being completed timely.37 Transfers Out CMC’s performance for the transfer-out process was fair. Our clinicians reviewed three cases and identified three deficiencies, of which one was significant.38 • In case 27, the patient transferred out of CMC to another institution, and the nurse did not obtain a complete set of vital signs within 24 hours of transfer, notify the receiving institution of a pending appointment for hepatitis treatment, or send the patient’s keep-on- person medications to the receiving facility. 36 We reviewed the following Transfer-in cases: 24, 25, and 26. Deficiencies occurred in cases 25 and 26. 37 A deficiency occurred in case 26. 38 We reviewed the following transfer-out cases: 27, 28, and 29. Deficiencies occurred in cases 27, 28, and 29. A significant deficiency occurred in case 27. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 46 Our clinicians identified a pattern that showed nurses did not obtain patient vital signs during the transfer-out process. In cases 28 and 29, the nurse did not obtain a complete set of vital signs prior to the patient’s transferring out of CMC. The nurse did not assess the patient’s heart rate, blood pressure, and oxygen saturations. Compliance testing resulted in a score of 100% for providing all required medications and documents when patients transferred out (MIT 6.101). CMC nurses ensured that the transfer packages included the required medications and documents. Case review found that nurses did not always include the patient’s medication in the transfer package, as illustrated in case 27, above. Hospitalizations Patients returning from an off-site hospitalization or emergency room are at high risk for lapses in care quality. These patients typically experienced severe illness or injury. They require more care and place strain on the institution’s resources. Also, because the patients have complex medical issues, successful health information transfer is necessary for good quality care. Any transfer lapse can result in serious consequences for these patients. CMC performed well in most components of the hospital return process. We reviewed 18 events in 12 cases for which patients were discharged from a hospitalization or returned from an emergency room visit.39 Our clinicians identified five deficiencies, of which none were significant.40 Of those five deficiencies, two were related to nursing documentation and did not pose risk to patient care. Three deficiencies were related to provider care. The following is an example: • In case 12, the patient returned from hospitalization two times during our review period. On the first occasion, the provider did not order the recommended dose of a blood pressure medication. On the second occasion, the provider ordered the blood pressure medication one day late. Compliance testing results showed a low score in continuity of hospital recommended medications (MIT 7.003, 33.3%). Medications were one to two days late. Late medications included anti-inflammatory, cholesterol, blood pressure, and antacid medications. CMC ensured that community hospital discharge documents were scanned into the patient’s electronic health record within three days of discharge (MIT 4.003, 100%); discharge documents were reviewed by the provider within five calendar days (MIT 4.005, 77.8%). Case reviewers did not identify any deficiencies. Face-to- 39 We reviewed the following hospitalization cases: 1, 2, 3, 6, 7, 8, 9, 10, 11, 12, 13, and 37. Deficiencies occurred in cases 3 and 12. 40 Hospitalization deficiencies occurred in cases 2, 3, 12, and 36. Nursing deficiencies occurred in cases 2 and 3. Provider deficiencies occurred in cases 12 and 36. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 47 face provider follow-ups after hospitalizations or emergency room visits mostly occurred within the required time frame (MIT 1.007, 85.7%). Our case reviewers did not identify any deficiencies in provider follow-up for patients returning from the hospital. Clinician On-Site Inspection CMC has one receiving and release (R&R) area, located on the east side of the institution. The R&R is staffed with three nurses: one nurse is scheduled from 0400 to 1200 and one from 1400 to 2200; the hours of the third nurse overlap both shifts and are scheduled from 0900 to 1500. The R&R nurse we interviewed was very knowledgeable about the transfer process. The nurse reported that, on average, 15 patients transfer into the institution and five transfer out of the institution daily. However, these numbers have recently increased. For patients who arrive at CMC with pending specialty appointments, the R&R nurses use the EHRS message pool to communicate with the patient’ care team and the specialty nurse, to ensure the continuity of specialty service appointments. The R&R nurses also schedule the initial provider and nurse care management appointments upon the patient’s arrival. Staff reported that the R&R staff work as a team and communicate well with one another. They have a good rapport with custody staff and find the administration to be supportive. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 48 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 22 3 0 88.0% 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 25 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, 17 2 6 89.5% 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 2 0 0 100% transfer packet required documents? (6.101) * Overall percentage (MIT 6): 94.4% * 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: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 49 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 9 15 1 37.5% 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 1 2 85.7% 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 6 2 1 75.0% discharge? (4.003) * For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements and did a 7 2 0 77.8% 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 3 6 0 33.3% patient within required time frames? (7.003) * Upon the patient’s transfer from one housing unit to another: Were 25 0 0 100% 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 4 1 0 80.0% 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 9 11 0 45.0% 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: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 50 Recommendations • Nursing leadership should ensure that the receiving and release (R&R) nursing staff thoroughly complete the transfer-out screening process. • Medical, nursing, and pharmacy leadership should ensure that patients returning from a hospitalization receive recommended medications to ensure medication continuity. • Nursing leadership should ensure that receiving and release (R&R) nurses confirm that all patients transferring out of the institution have the required medications, transfer documents, and assigned durable medical equipment (DME). Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 51 Medication Management Overall Rating In this indicator, OIG inspectors evaluated the institution’s performance in Inadequate administering prescription medications on time and without interruption. The inspectors examined this process from the time a provider prescribed medication until the nurse administered the medication to the patient. When rating this Case Review indicator, the OIG strongly considered the compliance test results, which tested Rating medication processes to a much greater degree than case review testing. In Adequate addition to examining medication administration, our compliance inspectors also Compliance tested many other processes, including medication handling, storage, error Score reporting, and other pharmacy processes. Inadequate (69.3%) Results Overview CMC performed poorly in medication management. As in Cycle 5, compliance scores were low. The institution had problems receiving new prescription medications timely, ensuring continuity of chronic medications, and providing hospital discharge medications. CMC performed well with medication administration and continuity in Specialized Medical Housing and when patients arrived at CMC or transferred yard-to-yard within the institution. Although case review showed adequate findings for this indicator, our compliance testing presented a more robust assessment of the institution’s poor medication administration and continuity practices. We considered all factors of the institution’s performance in this area and rated the Medication Management indicator inadequate. Case Review and Compliance Testing Results We reviewed 164 events in 32 cases related to medications and found 19 medication deficiencies, two of which were significant.41 New Medication Prescriptions CMC had a mixed performance in new medication prescriptions. Our clinicians reviewed 164 events and identified 19 deficiencies. Ten deficiencies were related to new medication prescriptions. 42 Compliance testing results scored only 56.0% (MIT 7.002). CMC had similar scores in this area in Cycle 5. Patients received medications one to 11 days late. Late medications included a topical antifungal cream, antibiotics, blood pressure medications, and stomach medications. 41 We reviewed the following cases for medication management: 1, 2, 3, 6-24, 26, 35-38, 46, 62, and 70. We identified deficiencies in cases 2, 3, 11, 13, 17, 21, 33, 36, 37, 62, and 70. Significant deficiencies occurred in cases 11 and 13. 42 New medication deficiencies occurred in cases 2, 3, 11, 21, 33, 36, 62, and 70. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 52 Chronic Medication Continuity CMC had mixed performance for chronic medication continuity. Compliance testing showed that only 11.1% (MIT 7.001) of the patients received their chronic care medications within the required time frame. This was a significant drop from the previous compliance score. Most of the patients tested did not receive their keep-on-person medications one business day prior to the exhaustion of their supplies. Case review showed that of the 19 deficiencies identified, seven were related to chronic medication continuity.43 The following two cases had significant deficiencies: • In case 11, the provider ordered multiple keep-on-person chronic care medications due on June 11, 2021, when the patient was discharged from the Correctional Treatment Center. The patient did not receive his medications until June 15, 2021, four days later. • In case 13, the provider ordered a chronic blood pressure medication, amlodipine, to start on January 2, 2021. The patient did not receive the medication during the month of January. Hospital Discharge Medications CMC’s performance in hospital discharge medications was mixed. Compliance testing scored low for patients receiving their discharge medications upon return from an off-site hospitalization or emergency room visit (MIT 7.003, 33.3%). Cycle 5 compliance testing results were similarly low. Patients received their medication up to three days late. Examples include medications for cholesterol, asthma inhalers, a blood pressure medication, an antibiotic, and blood thinners. In contrast, our clinicians found better performance in hospital discharge medications: clinicians reviewed 12 cases and did not identify any deficiencies. Specialized Medical Housing Medications CMC ensured that patients received their needed medications when admitted to the Specialized Medical Housing unit. Case review did not identify any deficiencies involving untimely medication administration. Compliance testing resulted in a low score (MIT 13.004, 50.0%), but the low score was not related to untimely medication administration. Please see the Specialized Medical Housing indicator for further discussion. Transfer Medications CMC performed very well in transfer medications. Both compliance testing and case review showed similar results. CMC compliance scores were very good for new arrival medications (MIT 6.003, 89.5%), intra-facility yard-to-yard transfer medications (MIT 7.005, 100%), and for ensuring that transfer medication packets 43 Chronic medication continuity deficiencies occurred in cases 2, 11, 13, and 17. Cases 11 and 13 had significant deficiencies. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 53 were complete (MIT 6.101, 100%). Transfer layover patients mostly received medications without delay (MIT 7.006, 80.0%). Clinicians identified only one case in which the patient transferred without medications.44 Please refer to the Transfers indicator for further discussion. Medication Administration CMC performed well in medication administration. CMC nurses generally administered medications on time. Compliance testing showed excellent results in TB medication administration (MIT 9.001, 100%). However, CMC nurses did not always monitor as required patients taking TB medications (MIT 9.002, zero). Our OIG case reviewers identified one medication administration deficiency: • In case 37, the nurse in Specialized Medical Housing did not administer the pain medication dose as ordered. Compliance testing showed excellent results in TB medication administration (MIT 9.001, 100%). However, CMC nurses did not always monitor as required the patients taking TB medications (MIT 9.002, zero). Clinician On-Site Inspection The West Facility medication room has a staff of four LVNs assigned on second and third watch. The medication room nurse accurately explained the process for medication administration, for keep-on-person medications, and for patients who transfer in and out of West Facility. The nursing staff reported the medication room Automated Dispensing Cabinet (ADC) stores medications such as narcotics, testosterone, and EpiPens. From Monday through Friday, two LVNs are assigned to respond to medical emergencies in West Facility until 8:45 a.m. After 8:45 a.m., one RN and one LVN respond. The LVN articulated her role in responding to emergencies. The LVN reported that staff morale was good and administrative staff approachable. 44 The patient in case 27 transferred out of CMC without his medications. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 54 Compliance Testing Results 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, medication nurses did not store narcotic medication under double-lock controls when not in active use. CMC appropriately stored and secured nonnarcotic medications in seven of 12 clinic and medication line locations (MIT 7.102, 58.3%). In five locations, we found one or more of the following deficiencies: a medication cart was left unlocked and unattended while a patient remained in the examination room; nonrefrigerated medications, refrigerated medications, or medications with expired prescription labels did not have a designated area for medications to be returned to pharmacy; or medication nurses did not consistently complete the treatment cart daily check sheet (CDCR form 7544). Staff kept medications protected from physical, chemical, and temperature contamination in eight of the 12 clinic and medication line locations (MIT 7.103, 66.7%). In three locations, staff did not store oral and topical medications separately. In one location, the medication refrigerator had accumulated grime. Staff stored valid, unexpired medications in five of the 12 applicable medication line locations (MIT 7.104, 41.7%). In seven locations, medication nurses failed to label the multi-use medication, as required by CCHCS policy. Nurses exercised proper hand hygiene and contamination control protocols in five of six locations (MIT 7.105, 83.3%). In one location, nurses neglected to wash or sanitize their hands before each subsequent re-gloving. Staff in three of six medication preparation and administration areas demonstrated appropriate administrative controls and protocols (MIT 7.106, 50.0%). In three locations, medication nurses did not maintain unissued medications in their original labeled packaging. Staff in five of six medication areas used appropriate administrative controls and protocols when distributing medications to their patients (MIT 7.107, 83.3%). In one location, the medication nurse did not always observe patients while they swallowed direct observation therapy medications. Pharmacy Protocols CMC followed general security, organization, and cleanliness management protocols in its main and remote pharmacies (MIT 7.108, 100%). In its remote pharmacy, CMC properly stored nonrefrigerated medication. However, in CMC’s main pharmacy, we found several staff food items in the medication preparation area. As a result, the institution scored 50.0 percent in this test (MIT 7.109). Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 55 The institution properly stored refrigerated or frozen medications its main and remote pharmacies (MIT 7.110, 100%). The pharmacist-in-charge (PIC) correctly accounted for narcotic medications stored in CMC’s pharmacy (MIT 7.111, 100%). We examined four medication error reports. The PIC correctly processed only three of these four reports (MIT 7.112, 75.0%). In one report, the PIC did not document the date the provider and patient were notified of the error. In addition, the PIC did not document the changes recommended to correct the medication error. Nonscored Tests In addition to testing the institution’s self-reported medication errors, our inspectors also followed up on any significant medication errors found during compliance testing. We did not score this test; we provide these results for informational purposes only. At CMC, the OIG did not find any applicable medication errors (MIT 7.998). We interviewed patients assigned to a restricted housing unit so we could determine whether they had immediate access to their prescribed asthma rescue inhalers or nitroglycerin medications. Eight of 10 patients interviewed indicated they had access to their rescue medications. The remaining two patients reported they did not have the prescribed rescue inhaler in their possession. One patient reported the medication was lost during his transfer to the restricted housing unit. And the other patient refused to respond to our inquiry into the reason the medication was not in his possession. We promptly notified the CEO of these concerns, and health care management immediately reissued a replacement rescue inhaler to the patients (MIT 7.999). Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 56 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 2 16 7 11.1% 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) 14 11 0 56.0% Upon the patient’s discharge from a community hospital: Were all ordered medications administered, made available, or delivered to the patient within 3 6 0 33.3% 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) * 25 0 0 100% For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications administered or 4 1 0 80.0% 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 4 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 7 5 2 58.3% 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 8 4 2 66.7% 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 5 7 2 41.7% the assigned storage areas? (7.104) Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols during medication 5 1 8 83.3% preparation and medication administration processes? (7.105) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when preparing medications 3 3 8 50.0% for patients? (7.106) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when administering 5 1 8 83.3% medications to patients? (7.107) Pharmacy: Does the institution employ and follow general security, organization, and cleanliness management protocols in its main and remote 2 0 0 100% pharmacies? (7.108) Pharmacy: Does the institution’s pharmacy properly store nonrefrigerated medications? (7.109) 1 1 0 50.0% Pharmacy: Does the institution’s pharmacy properly store refrigerated or frozen medications? (7.110) 1 0 1 100% Pharmacy: Does the institution’s pharmacy properly account for narcotic medications? (7.111) 1 0 1 100% Pharmacy: Does the institution follow key medication error reporting protocols? (7.112) 3 1 0 75.0% 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 (MIT 7): 69.3% * 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: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 57 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, 17 2 6 89.5% were medications administered or delivered without interruption? (6.003) * For patients transferred out of the facility: Do medication transfer 2 0 0 100% packages include required medications along with the corresponding transfer-packet required documents? (6.101) * Patients prescribed TB medication: Did the institution administer the 8 0 0 100% medication to the patient as prescribed? (9.001) * Patients prescribed TB medication: Did the institution monitor the 0 8 0 0% patient per policy for the most recent three months he or she was on the medication? (9.002) * Upon the patient’s admission to specialized medical housing: Were all 5 5 0 50.0% medications ordered, made available, and administered to the patient 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: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 58 Recommendations • Nursing and pharmacy leadership should ensure that patients receive their newly ordered, chronic care, and hospital discharge medications timely, and that staff document in the medication administration record (MAR) summaries as described in CCHCS policy and procedures. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 59 Preventive Services Overall Rating In this indicator, OIG compliance inspectors tested whether the institution Inadequate offered or provided cancer screenings, tuberculosis (TB) screenings, influenza vaccines, and other immunizations. If the department designated the institution Case Review as high risk for coccidioidomycosis (valley fever), we tested the institution’s Rating performance in transferring out patients quickly. The OIG rated this indicator (N/A) solely according to the compliance score, using the same scoring thresholds used in the Cycle 4 and Cycle 5 medical inspections. Our case review clinicians do not Compliance rate this indicator. Score Inadequate Results Overview (68.7%) CMC staff had a mixed performance in preventive services. Staff performed well in administering TB medications as prescribed, offering patients an influenza vaccine for the most recent influenza season, offering colorectal cancer screening for all patients ages 45 through 75, and offering required immunizations to chronic care patients. However, they faltered in monitoring patients who were taking prescribed TB medication, screening patients annually for TB, and transferring patients who were at the highest risk of coccidioidomycosis (valley fever) infection. We rated this indicator inadequate. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 60 Compliance Testing Results Table 16. Preventive Services Scored Answer Compliance Questions Yes No N/A Yes % Patients prescribed TB medication: Did the institution administer the 8 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 8 0 0 the medication? (9.002) † Annual TB screening: Was the patient screened for TB within the last 15 10 0 60.0% 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 N/A N/A N/A N/A patient offered a mammogram in compliance with policy? (9.006) Female patients from the age of 21 through the age of 65: Was N/A N/A N/A N/A patient offered a pap smear in compliance with policy? (9.007) Are required immunizations being offered for chronic care patients? 11 2 12 84.6% (9.008) Are patients at the highest risk of coccidioidomycosis (valley fever) 4 7 0 36.4% infection transferred out of the facility in a timely manner? (9.009) Overall percentage (MIT 9): 68.7% * 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: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 61 Recommendations • Nursing leadership should consider developing and implementing measures to ensure that nursing staff timely screen patients for tuberculosis (TB) and that nursing staff completely address the signs and symptoms on their TB monthly monitoring form for patients taking LTBI medications.45 • Medical leadership should ascertain causative factors related to the untimely transfers of high-risk patients for coccidioidomycosis (valley fever) and should implement remedial measures as appropriate. 45 LTBI is latent tuberculosis infection. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 62 Nursing Performance Overall In this indicator, the OIG clinicians evaluated the quality of care delivered by the Rating institution’s nurses, including registered nurses (RNs), licensed vocational nurses Adequate (LVNs), psychiatric technicians (PTs), and certified nursing assistants (CNAs). Our clinicians evaluated nurses’ performance in making timely and appropriate Case Review assessments and interventions. We also evaluated the institution’s nurses’ Rating performance in many clinical settings and processes, including sick call, Adequate outpatient care, care coordinating and management, emergency services, specialized medical housing, hospitalizations, transfers, specialty services, and Compliance medication management. The OIG assessed nursing care through case review Score only and performed no compliance testing for this indicator. (N/A) 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 CMC nursing generally provided satisfactory nursing care. We identified fewer nursing deficiencies overall than we had identified during our Cycle 5 inspection. However, the number of significant deficiencies was similar to our Cycle 5 findings and mostly occurred in the emergency and outpatient areas. Although CMC nurses usually performed appropriate assessments and interventions, our clinicians identified opportunities for improvement in several areas involving assessments. Nursing assessments need to be more thorough during face-to-face encounters and emergency care, daily assessments in specialized medical housing, and in R&R during the transfer-out process. We considered the overall quality of nursing care and rated the Nursing Performance indicator adequate. Case Review Results We reviewed 322 nursing encounters in 65 cases.46 Of the nursing encounters we reviewed, 159 were in the outpatient setting. Most of the outpatient nursing encounters involved sick call requests. We identified 65 nursing performance deficiencies, 15 of which were significant.47 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. Another essential factor for quality nursing care is 46 Nursing deficiencies occurred in cases 1, 2, 3, 5, 6-13, 15-30, 33-41, 43, 44-69, and 70. 47 Outpatient nursing deficiencies occurred in cases 1, 2, 6, 7, 9, 10, 11, 12, 15, 16, 17, 19, 20, 21, 22, 23, 33, 35, 36, 38, 40, 41, 42, 43, 45, 46, 57, 59, 61, 65, 66, 67, 68, and 69. Significant outpatient deficiencies occurred in cases 1, 2, 10, 12, 15, 16, 17, 22, 23, 35, 36, 42, and 68. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 63 nursing intervention. CMC nurses generally performed appropriate assessments and interventions. Areas in which CMC nurses performed well include nursing assessments and interventions when patients arrived at CMC and when patients returned from the hospital and from outside specialty appointments. Opportunities for improvement occurred in the transfer-out process and in the specialized medical housing, emergency, and outpatient clinics. Please refer to specific indicators for further details. Nursing Sick Call The nursing sick call process involves reviewing each sick call request to determine whether the patient’s medical symptoms require an urgent or routine evaluation. Our clinicians reviewed 61 sick call requests and identified 39 deficiencies. Most of the deficiencies were related to incomplete assessments during face-to-face encounters, inappropriate triage, and COVID-19 rounds.48 We identified 10 significant deficiencies related to nursing sick calls.49 The following examples illustrate these deficiencies: • In case 36, the sick call nurse triaged the sick call for symptomatic complaints of swelling in the neck, difficulty swallowing, and pain the chest and ribs. The nurse did not assess the patient for urgent symptoms. Instead, the nurse forwarded the sick call slip to the provider and documented on the request, “patient is Covid positive.” The provider evaluated the patient the following month. • In case 35, the nurse inappropriately triaged the sick call for an animal bite. The patient should have been evaluated the same day. Instead, the patient was evaluated two days later. • In case 68, the patient submitted a sick call for pain in both shoulders and elbows. The nurse inappropriately triaged the sick call as asymptomatic. The patient should have had a face-to-face evaluation within one business day due to his complaint of pain. Instead, the provider evaluated the patient almost a month later. Care Management Care management involves anticipating patient care needs, developing treatment plans, and coordinating care to ensure that services are provided to the patient without interruption or delay. The nurse’s role is to assess, plan, implement, 48 Inappropriate triage of sick call requests occurred once in cases 1,12, 21, 35, 41, 57, and 68, and occurred four times in case 36. Incomplete nursing assessments occurred once in cases 2, 20, 23, 33, 461, 43, 45, 46, 59, 61, 65, 66, 67, and 69, and occurred five times in case 6. COVID-19 rounds did not always occur as ordered in cases 2, 9, 10, 15, 17, 19, 21, 22, 23, and 36. 49 Significant deficiencies related to sick calls occurred in cases 1, 2, 12, 15, 35, 36, 42, and 68. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 64 monitor, and evaluate patient care. Our clinicians reviewed 10 care management events and identified one deficiency, which was not significant.50 During our on-site visit, the care manager reported she had eight to 10 patient appointments scheduled daily. Her duties include vaccine administration, preparing patients for procedures, reviewing new arrivals for previously scheduled specialty appointments, providing education to patients with chronic medical conditions, coordinating with the providers for patients who go out to a higher level of care, and performing screening for the MAT program.51 Wound Care We reviewed two cases involving wound care orders, cases 10 and 37. In case 10, wound care was not performed as ordered. During case review, our clinicians identified several days on which wound care was not provided. The patient was housed in the outpatient area and had an uncomplicated wound. Nursing Documentation CMC nursing documentation was generally good. Emergency event documentation could be more thorough. See the Emergency Services indicator for more details. Emergency Services Emergency nursing performance for CMC was acceptable. However, there were opportunities for improvement for nursing performance and documentation. Refer to the Emergency Services indicator for further discussion. Hospital Returns CMC’s performance was very good. We reviewed 18 events in 12 cases for which patients were discharged from a hospitalization or returned from an emergency room visit. Our clinicians identified five deficiencies, of which none were significant. When patients returned from the hospital, CMC nurses performed complete assessments, reviewed hospital documents, notified the provider of recommendations, and obtained orders for continuity of care. Transfers Overall, the R&R nurses provided good care. We did not identify any significant deficiencies in the transfer-in process. Nurses completed initial health screenings, and assessments were thorough. However, nurses did not always 50 We reviewed care management events in cases 16, 20, 22, 24, 25, and 26. A deficiency occurred in case 22. 51 MAT is the Medication Assisted Treatment program for substance use disorder. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 65 complete vital signs when patients transferred out of CMC. We identified one significant deficiency in the transfer-out process.52 Please refer to Transfers indicator for additional details. Specialized Medical Housing CTC nurses generally provided good care and documentation. However, opportunities for improvement include completion of thorough assessments and timely intervention when patients have a change in condition. Refer to the Specialized Medical Housing indicator for further discussion. Specialty Services Nursing care for specialty services was adequate. Our clinicians reviewed 56 nursing events in nine cases and identified eight deficiencies, of which none were significant.53 Deficiencies consisted of incomplete patient assessments in cases 6 and 36. Inconsistent or incomplete documentation occurred in cases 2, 7, and 36. Medication Management Nursing performance in medication management was adequate. Nurses mostly administered medications as ordered. Our clinicians reviewed 164 events and identified 19 deficiencies, of which two were significant. Please refer to the Medication Management indicator for additional information. Clinician On-Site Inspection During our on-site visit, we attended on-site huddles. Clinic huddles were well organized and well attended, and staff discussed essential information regarding patient care. East and West Facilities clinic nursing staff have monthly meetings together. Staff reported that during the COVID-19 outbreak, they went to the patients’ housing units to assess patients in response to sick call requests. Providers also accompanied nurses to patients’ housing units for sick call assessments when medically necessary. The nurses reported having the necessary medical equipment to take vital signs, and the required personal protective equipment (PPE). During our on-site visit, staff reported they were still using the rotational schedule for clinic visits. If a patient needs to be evaluated and his building is not scheduled to come to the clinic, the nurse must go to the building to evaluate the patient or must request direction from the incident command post to have the patient come to the clinic. The chief nurse executive (CNE) recently assumed the position as CNE (Acting) but has worked at CMC for six years as a nursing manager. 52 A significant deficiency occurred in case 27 in the transfer-out process. 53 We reviewed specialty nursing events in cases 2, 6, 7, 12, 16, 18, 35, 36, and 37. Deficiencies occurred in cases 2, 6, 7, and 36. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 66 Recommendations • Nursing leadership should ensure that nurses perform thorough face-to-face assessments and triage sick calls appropriately. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 67 Provider Performance Overall In this indicator, OIG case review clinicians evaluated the quality of care Rating delivered by the institution’s providers: physicians, physician assistants, and Adequate nurse practitioners. Our clinicians assessed the institution’s providers’ performance in evaluating, diagnosing, and managing their patients properly. We Case Review examined provider performance across several clinical settings and programs, Rating including sick call, emergency services, outpatient care, chronic care, specialty Adequate services, intake, transfers, hospitalizations, and specialized medical housing. We assessed provider care through case review only and performed no compliance Compliance testing for this indicator. Score (N/A) Results Overview As they did in Cycle 5, CMC providers continue to deliver good patient care. Providers generally made appropriate assessments, diagnosed medical conditions correctly, and managed chronic medical conditions effectively. They referred patients appropriately to specialists or to a higher level of care when needed. Overall, the OIG rated this indicator adequate. Case Review Results In our inspection, we reviewed 234 medical provider encounters and identified 53 deficiencies related to provider performance, of which seven were significant.54 In addition, our clinicians examined the care quality in 24 comprehensive case reviews. Of these 24 cases, 18 were rated adequate and six inadequate.55 Assessment and Decision-Making CMC providers generally made appropriate assessments and sound medical decisions for their patients. Most of the time, providers diagnosed medical conditions correctly, ordered appropriate tests, and referred their patients to appropriate specialists when needed. However, our clinicians identified two deficiencies related to poor medical assessment and decision-making: • In case 9, the patient with prostate symptoms received two second-generation alpha-1 adrenergic receptor antagonists (doxazosin and tamsulosin) without the provider’s documenting a clear rationale for using these two medications, which, taken together, may increase the risk of unwanted side effects. 54 Deficiencies occurred 10 times in case 36, nine times in case 11, six times in case 6, four times in case 16, four times in case 18, thrice in cases 9 and 12, twice in cases 2, 13, and 21, and once in cases 14, 15, 17, 19, 22, 23, and 37. Significant deficiencies occurred twice in case 18, and once in cases 9, 11, 16, 22, and 36. 55 Inadequate cases were cases 2, 11, 16, 18, 22, and 36. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 68 • In case 16, the patient with symptoms of itchy skin received two antihistamines (cetirizine and diphenhydramine) without the provider’s articulating a clear rationale clear rationale for using these two medications from the same class, which, taken together, may increase side effects. Review of Records For patients returning from hospitalizations, CMC providers generally performed well in reviewing medical records and addressing the hospitalists’ recommendations. The providers also performed well in reviewing the medication administration records (MAR) and reconciling patients’ medications for medication continuity. However, our clinicians identified the following deficiency: • In case 12, the provider assessed the patient returning from the hospital who was admitted to CTC upon return for continued care for renal failure. Although the patient received antibiotics for urinary infection, the provider did not thoroughly follow the hospital discharge recommendation for increased doses of blood pressure medications (clonidine and nifedipine). Emergency Care CMC providers made appropriate triage decisions when patients arrived at the triage and treatment area (TTA) for emergency treatment. In addition, the providers were always available for consultation with the TTA nursing staff. However, the providers did not always document progress notes for their consultations. Our clinicians identified two significant deficiencies related to emergency care: • In case 11, the patient presented with acute symptoms and signs, including shortness of breath and low blood oxygen levels, suggesting a possible cardiac or respiratory event. The provider performed an incomplete examination, did not order an EKG, and did not thoroughly document a progress note. • In case 36, the patient was seen emergently for chest pain and low energy. Nursing staff contacted the TTA provider, who did not assess the patient face-to-face but instead recommended a follow-up with the patient’s regular provider at a later date. Chronic Care In most instances, CMC providers appropriately managed their patients’ chronic health conditions, such as hypertension, diabetes, asthma, hepatitis C infection, and cardiovascular disease. However, we identified a significant deficiency in managing diabetes and glaucoma: Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 69 • In case 18, the provider assessed the patient for chronic conditions including diabetes and glaucoma. The patient’s previous two Hgb A1c results were not at goal, indicating poorly controlled diabetes. However, the provider did not adjust medications to better control diabetes and did not refer the patient for a regular follow-up evaluation of glaucoma, to prevent complications. CMC has a Coumadin (blood thinning medication) clinic to manage patients on blood thinner medication. Generally, a clinical pharmacist working with a provider appropriately monitored INR (a blood test for monitoring the effects of Coumadin) levels and adjusted oral anticoagulants following CMC Pharmacy Policy and Procedure Manual, Anticoagulation Management (23-0070).56 However, CMC health care services needs to update the procedure manual with the most recent CCHCS Anticoagulation Care Guide September 2021. Furthermore, the pharmacist did not send patient notification letters to communicate when the blood test results became available during the monitoring. This is discussed further in Health Information Management indicator. Specialty Services CMC providers appropriately referred patients to specialists when needed, reviewed specialty consultation reports timely, and followed recommendations adequately. We identified one significant deficiency, in which the provider did not follow specialist recommendation timely.57 This deficiency is discussed in the Specialty Services indicator. Documentation Quality CMC providers generally documented outpatient and TTA encounters on the day of the encounter. Although providers correctly documented most of the time during the encounter, they did not always document on-call progress notes when required. Our clinicians identified six deficiencies that included missing progress notes or documentation.58 The following are examples: • In case 6, the provider had an end-of-life discussion with the patient. After the discussion, the provider placed a “Do Not Resuscitate (DNR)” order and status in the patient’s chart. However, the provider did not create a CDCR 7465, Physician Orders for Life Sustaining Treatment (POLST), in the patient’s EHRS. 56 Coumadin is a blood thinning medication. INR a blood test that monitors the effects of Coumadin. 57 A deficiency occurred in case 22. 58 Deficiencies occurred four times in case 6, and once in cases 9 and 18. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 70 • In case 18, the provider co-consulted with a nurse about the patient with abdominal pain, and prescribed a medication for antacid, but did not document a progress note in the EHRS. Provider Continuity CMC staff assigned providers to specified clinics to ensure patients’ continuity of care. Our clinicians did not identify any deficiencies related to provider continuity. Clinician On-Site Inspection During our on-site inspection, the chief medical executive explained that among many challenges the institution experienced during the COVID-19 pandemic, the severely restricted patient movement policy presented scheduling challenges. Access to medical appointments was limited to urgent and emergent cases, and providers were tasked to perform chart reviews to identify appointments that could be safely deferred to later dates. During the pandemic, two providers retired, and the third CMC provider performed an Out of Class (OOC) assignment as chief physician and surgeon (CP&S), creating staffing challenges. During the COVID-19 pandemic, medical staff provided care in a designated isolation unit to patients who were positive for COVID-19. The unit had a dedicated provider with additional nursing staff and supplemental oxygen. The CMC medical team created a local “CMC COVID-19 Protocol” (the protocol) to guide care for patients with COVID-19 infection. The chief medical executive indicated that the Protocol was created in consultation with the local hospital and with guidance from the College of Urgent Care Medicine and American College of Emergency Physicians. The nursing staff carried a cell phone in the designated isolation unit to consult the provider urgently when needed, and a designated provider was always available. In addition to the usual supportive care, including supplemental oxygen, pharmacotherapies such as steroid, anticoagulation and anti-inflammatory medication, when required, patients were also offered monoclonal antibody treatments to treat COVID-19 in the isolation unit. When patients needed a higher level of care, they were transferred to the community hospitals for needed care. Recently, CMC has onboarded a telemedicine PCP provider and was able to expand local specialty providers by using telemedicine for consults in urology, orthopedic surgery, and general surgery. Providers echoed that they were well supported by the medical leadership at CMC. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 71 Recommendations • Medical leadership should ensure that on-call providers timely complete appropriate progress notes for consultations provided to nursing staff. • Medical leadership should ensure that providers are using polypharmacy medication reviews for patients who may be at risk for adverse effects due to medication regimens involving multiple drugs (polypharmacy) by collaborating with clinical pharmacists. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 72 Specialized Medical Housing Overall Rating In this indicator, OIG inspectors evaluated the quality of care in the specialized Adequate medical housing units. We evaluated the performance of the medical staff in assessing, monitoring, and intervening for medically complex patients requiring Case Review close medical supervision. Our inspectors also evaluated the timeliness and Rating quality of provider and nursing intake assessments and care plans. We assessed Adequate staff members’ performance in responding promptly when patients’ conditions deteriorated, and we looked for good communication when staff consulted with Compliance one another while providing continuity of care. Our clinicians also interpreted Score relevant compliance results and incorporated them into this indicator. At the Proficient time of our inspection, CMC's specialized medical housing consisted of a (88.0%) correctional treatment center (CTC). Results Overview CMC providers and nurses delivered good care to their CTC patients. Providers ensured timely admission history and physicals and timely rounding on patients. Nurses performed well in providing physical examinations upon admission and providing routine patient assessments, and mostly performed well in administering medication. Both case review and compliance testing findings were similar to those in Cycle 5. However, nursing assessments and interventions show room for improvement. After factoring both the compliance testing and case review analysis, the OIG rated the Specialized Medical Housing indicator as adequate. Case Review and Compliance Testing Results We reviewed eight CTC cases, which included 95 provider events and 58 nursing events.59 Because of the care volume that occurs in specialized medical housing units, each provider and nursing event represents up to one month of provider care and two weeks of nursing care. We identified 25 deficiencies, one of which was significant.60 Of the 25 deficiencies, nine were related to provider care, 12 to nursing care, three to health information management, and one to pharmacy and medication management. Provider Performance Compliance testing showed that providers completed admission history and physical examinations timely (MIT 13.002, 100%). Providers generally delivered good patient care, developed good care plans, rounded at clinically appropriate 59 Our OIG clinicians reviewed the following CTC cases: 3, 6, 9, 11, 12, 35, 36, and 37. 60 Deficiencies occurred in cases: 3, 6, 9 11, 12, 36, and 37. A significant deficiency occurred in case 11. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 73 intervals, and made sound medical decisions. We identified nine deficiencies, none of which were significant.61 Nursing Performance CTC nursing performance was adequate. Our clinicians reviewed 58 nursing events and identified 12 deficiencies, of which one was significant.62 OIG case review analysis and compliance testing showed that initial nursing assessments were mostly thorough and completed timely (MIT 13.001, 90.0%). When patients were admitted, the nurses ensured that they were educated on the use of the patient call light system (MIT 13.101, 100%). CTC nurses conducted regular rounds and generally provided good care, and CTC nursing documentation was sufficient. However, daily nursing assessments and nursing interventions showed room for improvement. CTC nurses did not always perform thorough patient assessments. Our case reviewers identified a pattern of nurses not regularly auscultating lung sounds and bowel sounds while performing daily patient assessments.63 Also, when patients had a change in condition, CTC nurses did not at times perform a full assessment or intervene appropriately. This is another pattern our clinicians cited. The following are case review examples: • In case 9, the nurse did not complete a thorough cardiac assessment or notify the provider when the patient reported chest discomfort. The nurse did not inquire about how long the patient had felt chest discomfort, rate the chest discomfort on the pain scale, or describe the chest discomfort. The patient had been discharged the prior day from the community hospital, where he had been hospitalized for meningitis and sepsis.64 • In case 11, the provider ordered oxygen supplementation for a patient with low blood oxygen levels and a history of heart problems. However, the CTC nurses did not always initiate oxygen supplementation as ordered. • In case 12, a patient who was admitted to the CTC vomited and was assessed with elevated blood pressure and heart rate. Initially, the CTC nursing staff responded appropriately. Six hours later, however, the nurse on the following shift did not notify the provider of the patient’s continued elevated blood pressure and heart rate. 61 Deficiencies occurred thrice in case 11, twice in cases 6 and 36, and once in cases 12 and 37. 62 Nursing deficiencies occurred in case 3, 6, 9, 11, 12, 36, and 37. A significant nursing deficiency occurred in case 11. 63 CTC nurses did not assess lung sounds and bowel sounds in cases 6, 12, and 37. 64 Meningitis is a swelling of the brain and spinal cord membranes that can be caused by an infection. Sepsis is an infection in the blood that can cause body organs to fail. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 74 • In case 37, a patient who was admitted to the CTC with bladder cancer had low blood pressure readings on two occasions. The CTC nurse did not reassess the patient’s vital signs nor notify the provider. Medication Administration CTC nurses generally administered prescribed medications timely and without interruption. Compliance testing resulted in a low score (MIT 13.004, 50.0%). In reviewing the compliance data, we found medications were administered timely as ordered, but the pharmacy was not timely in filling and dispensing medications as ordered, thus producing the low score. Our case reviewers identified one deficiency, described below: • In case 37, the nurses did not administer pain medication as prescribed on two occasions. Clinician On-Site Inspection CMC has a 36-bed CTC with two negative-pressure rooms for respiratory isolation. The CTC has two dedicated providers assigned and a census of 24 patients during our visit. The staff reported the CTC average patient census is usually under 30 patients. The CTC uses a staffing matrix. Staffing varies, depending on the number of patients housed in the CTC. Each shift is assigned a lead RN. For the current census, staffing consisted of three RNs and three LVNs on second watch, three RNs and two LVNs on third watch, and two RNs and two LVNs on first watch. Each staff member is assigned delineated duties. The CTC has weekly interdisciplinary treatment team calls to discuss patient care. All patients are discussed every 30 days. The team consists of the CTC provider, a single SRN II, a utilization management RN, and a dietician. The staff reported a good rapport with custody staff, good nursing morale, and a supportive administration. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 75 Compliance Testing Results Table 17. 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? 9 1 0 90.0% 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 10 0 0 100% 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 10 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 5 5 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 1 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 1 100% institution’s local operating procedure or within the required time frames? (13.102) * Overall percentage (MIT 13): 88.0% * 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: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 76 Recommendations • Nursing leadership should ensure that nursing staff perform thorough patient assessments, recognize changes in patient status, and intervene timely and appropriately. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 77 Specialty Services Overall Rating In this indicator, OIG inspectors evaluated the quality of specialty services. The Adequate OIG clinicians focused on the institution’s performance in providing needed specialty care. Our clinicians also examined specialty appointment scheduling, Case Review providers’ specialty referrals, and medical staff’s retrieval, review, and Rating implementation of any specialty recommendations. Adequate Results Overview Compliance Score Adequate CMC provided satisfactory specialty services for their patients. Specialty (75.9%) appointments were completed within the required time frames. Providers made appropriate referrals and follow-ups after specialty services. Telemedicine specialty services were provided when available during the period of COVID-19 movement restriction. Medical staff scanned specialty reports timely. However, providers did not always review and sign specialty reports timely. The OIG rated the Specialty Services indicator as adequate. Case Review and Compliance Testing Results We reviewed 163 events related to specialty services: 84 were specialty consultations and procedures; 23 were on-site specialty services with warfarin clinic for anticoagulation and wound care; and 56 were nursing encounters. There were 38 deficiencies in this category, of which four were significant.65 Access to Specialty Services Compliance testing showed that patients received specialty services timely in high-priority referrals (MIT 14.001, 91.7%), medium-priority referrals (MIT 14.004, 93.3%) and routine referrals (MIT 14.007, 93.3%). Our clinicians identified six deficiencies related to specialty appointments.66 The following are examples: • In case 13, the provider requested cardiology service within 45 days. However, the patient was scheduled over 20 days late. • In case 36, the provider requested ENT specialist service within 45 days for unexplained hoarseness. However, the specialist evaluated the patient in 93 days. 65 Deficiencies occurred eight times in case 13, five times in case 6, four times in cases 2 and 36, thrice in cases 15 and 21, twice in cases 10 and 38, and once in cases 7, 8, 12, 14, 17, 22, and 37. Significant deficiencies occurred in cases 21, 22, 36, and 38. 66 Deficiencies occurred in cases 10, 12, 13, 21, 36, and 38. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 78 Provider Performance CMC providers generally referred patients appropriately and followed the specialists’ recommendations. However, providers did not always follow patients within required time frames after specialty service visits (MIT 1.008, 70.0%). During the COVID-19 pandemic, many provider follow-up visits were performed with chart reviews instead of face-to-face visits. OIG clinicians identified one deficiency in a follow-up specialty appointment, as described below: • In case 22, the provider reviewed the chart and determined that the past due appointment could safely be rescheduled to a future date. However, the patient did not timely receive the required specialty care in monitoring and evaluation of his chronic glaucoma, as recommended by the eye specialist. Nursing Performance Specialty nurses reviewed requests for specialty services and appropriately scheduled for specialty appointments. Nursing staff performed nursing assessments when patients returned from specialists’ appointments, reviewed specialists’ recommendations, and communicated recommendations to the providers. Our clinicians reviewed 56 nursing encounters related to specialty services and identified eight deficiencies, of which none were significant.67 This is discussed further in the Nursing Performance indicator. Health Information Management CMC providers reviewed high-priority specialty reports within the required time frame most of the time (MIT 14.002, 75.0%) but reviewed routine and medium- priority consultant reports within the required time frame less frequently (MIT 14.008, 73.3% and MIT 14.005, 53.3%). CMC staff generally scanned specialty reports into the EHRS timely (MIT 4.002, 83.3%). Our clinicians identified one deficiency related to delay in retrieving and scanning specialist consultant reports within the required time frame: • In case 10, the patient saw a general surgeon for postoperative follow-up care. The specialty consultant report was scanned into the EHRS three days late. Our clinicians also identified eight specialty reports that the providers reviewed and endorsed later than required.68 The following are examples: • In case 8, the provider reviewed and signed the specialty consultation report in five business days, which was two days late. 67 Deficiencies occurred thrice in case 6, twice in cases 2 and 36, and once in case 7. 68 Deficiencies occurred twice in case 2, and once in cases 8, 15, 17, 21, 37, and 38. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 79 • In case 15, the provider endorsed AICD (automatic implantable cardioverter defibrillator) check results from the cardiologist in five business days, which was two days late. Clinician On-Site Inspection We discussed specialty referral management with nursing supervisors, providers, the on-site and off-site specialty RN, and the utilization management RN. The nurses reviewed specialty requests, contacted the specialists for available appointments, and scheduled the appointments. CMC reported offering on-site specialty services, including GI clinic with colonoscopy, optometry, audiology, orthotics, physical therapy, anticoagulation clinic, and a small procedure clinic. The CME noted challenges during the COVID-19 pandemic: that access to off- site specialty services was limited, as some specialists did not offer either telemedicine or office visit appointments, and that the on-site optometrist retired during the pandemic, creating a large backlog of appointments for patients waiting to receive optometry services. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 80 Compliance Testing Results Table 18. 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 11 1 0 91.7% 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 9 3 0 75.0% 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 7 2 3 77.8% 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 14 1 0 93.3% 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 8 7 0 53.3% 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 5 1 9 83.3% provider? (14.006) * Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician 14 1 0 93.3% 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 11 4 0 73.3% 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 4 2 9 66.7% provider? (14.009) * For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the 9 11 0 45.0% 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 20 0 0 100% 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? 11 8 1 57.9% (14.012) Overall percentage (MIT 14): 75.9% * 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: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 81 Table 19. 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 28 12 2 70.0% visits occur within required time frames? (1.008) *, † Are specialty documents scanned into the patient’s electronic health 25 5 12 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: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 82 Recommendations • Medical leadership should ensure that providers are endorsing the specialty reports timely. • Medical leadership should ensure that providers communicate all diagnostic test results with patients, including anticoagulation laboratory work performed by the anticoagulation clinic. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 83 Administrative Operations Overall Rating In this indicator, OIG compliance inspectors evaluated health care Inadequate administrative processes. Our inspectors examined the timeliness of the medical grievance process and checked whether the institution followed reporting Case Review requirements for adverse or sentinel events and patient deaths. Inspectors Rating checked whether the Emergency Medical Response Review Committee (EMRRC) (N/A) met and reviewed incident packages. We investigated and determined whether the institution conducted the required emergency response drills. Inspectors also Compliance assessed whether the Quality Management Committee (QMC) met regularly and Score addressed program performance adequately. In addition, our inspectors Inadequate determined whether the institution provided training and job performance (70.6%) reviews for its employees. We checked whether staff possessed current, valid professional licenses, certifications, and credentials. The OIG rated this indicator solely according to the compliance score, using the same scoring thresholds used 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 CMC’s performance was mixed in this indicator, as the institution scored well in some applicable tests but faltered in others. The Emergency Medical Response Review Committee (EMRRC) did not always complete the required checklists. The institution conducted medical emergency response drills with incomplete documentation. Physician managers did not always complete annual performance appraisals in a timely manner. Nurse managers did not ensure that their newly hired nurses received the required onboarding and clinical competency training timely. These findings are set forth in the table on the next page. Overall, we rated this indicator inadequate. Nonscored Results CMC did not have any applicable adverse sentinel events requiring root cause analysis during our inspection period (MIT 15.001). We obtained CCHCS Death Review Committee (DRC) reporting data. Four unexpected (Level 1) and six expected (Level 2) deaths occurred during our review period. The DRC must complete its death review summary report within 60 calendar days of the death for Level 1 deaths and within 30 calendar days for Level 2 deaths. When the DRC completes the death review summary report, it must submit the report to the institution’s CEO within seven calendar days after its completion. In our inspection, we found that the DRC did not complete any death review reports promptly. The DRC finished five reports 73 to 132 days late and submitted them to the institution’s CEO 66 to 146 days after that. The remaining five reports were overdue at the time of OIG’s inspection (MIT 15.998). Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 84 Compliance Testing Results Table 20. Administrative Operations Scored Answer Compliance Questions Yes No N/A Yes % For health care incidents requiring root cause analysis (RCA): Did the N/A N/A N/A N/A institution meet RCA reporting requirements? (15.001) Did the institution’s Quality Management Committee (QMC) meet 5 1 0 83.3% monthly? (15.002) For Emergency Medical Response Review Committee (EMRRC) reviewed cases: Did the EMRRC review the cases timely, and did 6 6 0 50.0% 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 3 1 0 75.0% 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 10 0 0 100% 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 1 9 0 10.0% appraisals timely? (15.105) Did the providers maintain valid state medical licenses? (15.106) 15 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): 70.6% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 85 Recommendations The OIG offers no specific recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 86 This page left blank for reproduction purposes. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 87 Appendix A: Methodology In designing the medical inspection program, the OIG met with stakeholders to review CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. We also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the receiver’s office, the department, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of our inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates the delivery of medical care by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population-based metrics. We rate each of the quality indicators applicable to the institution under inspection based on case reviews conducted by our clinicians or compliance tests conducted by our registered nurses. Figure A–1 below depicts the intersection of case review and compliance. Figure A-1. Inspection Indicator Review Distribution for CMC Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 88 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 Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 89 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: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 90 Figure A–2. Case Review Testing Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 91 Compliance Testing Compliance Sampling Methodology Our analysts identify samples for both our case review inspectors and our 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: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 92 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: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 93 Appendix B: Case Review Data Table B–1. Case Review Sample Sets Sample Set Total Anticoagulation 3 Death Review/Sentinel Events 3 Diabetes 3 Emergency Services – CPR 1 Emergency Services – Non-CPR 3 High Risk 5 Hospitalization 4 Intrasystem Transfers In 3 Intrasystem Transfers Out 3 RN Sick Call 35 Specialty Services 4 67 Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 94 Table B–2. Case Review Chronic Care Diagnoses Diagnosis Total Anemia 10 Anticoagulation 3 Arthritis/Degenerative Joint Disease 9 Asthma 6 COPD 5 COVID-19 33 Cancer 5 Cardiovascular Disease 8 Chronic Kidney Disease 7 Chronic Pain 23 Cirrhosis/End-Stage Liver Disease 8 Coccidioidomycosis 3 Deep Venous Thrombosis/Pulmonary Embolism 1 Diabetes 12 Gastroesophageal Reflux Disease 10 Gastrointestinal Bleed 2 Hepatitis C 20 Hyperlipidemia 25 Hypertension 30 Mental Health 24 Migraine Headaches 1 Seizure Disorder 4 Sleep Apnea 6 Substance Abuse 13 Thyroid Disease 5 273 Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 95 Table B–3. Case Review Events by Program Diagnosis Total Diagnostic Services 289 Emergency Care 52 Hospitalization 22 Intrasystem Transfers In 13 Intrasystem Transfers Out 3 Outpatient Care 495 Specialized Medical Housing 204 Specialty Services 167 1,245 Table B–4. Case Review Sample Summary Total MD Reviews Detailed 24 MD Reviews Focused 0 RN Reviews Detailed 14 RN Reviews Focused 42 Total Reviews 80 Total Unique Cases 67 Overlapping Reviews (MD & RN) 13 Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 96 This page left blank for reproduction purposes. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 97 Appendix C. Compliance Sampling Methodology California Men’s Colony 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 25 OIG Q: 6.001 • See Transfers MITs 1.003–006 Nursing Sick Call 45 Clinic Appointment • Clinic (each clinic tested) (6 per clinic) List • Appointment date (2–9 months) • Randomize MIT 1.007 Returns From 9 OIG Q: 4.005 • See Health Information Community Management (Medical Records) Hospital (returns from community hospital) MIT 1.008 Specialty Services 42 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 3 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: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 98 Quality No. of Indicator Sample Category Samples Data Source Filters Health Information Management (Medical Records) MIT 4.001 Health Care Services 45 OIG Qs: 1.004 • Nondictated documents Request Forms • First 20 Ips for MIT 1.004 MIT 4.002 Specialty Documents 42 OIG Qs: 14.002, • Specialty documents 14.005 & 14.008 • First 10 Ips for each question MIT 4.003 Hospital Discharge 9 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 9 CADDIS Off-site • Date (2–8 months) Community Hospital Admissions • Most recent 6 months provided (within date range) • Rx count • Discharge date • Randomize Health Care Environment MITs 5.101–105 Clinical Areas 14 OIG inspector • Identify and inspect all on-site MITs 5.107–111 on-site review clinical areas. Transfers MITs 6.001–003 Intrasystem Transfers 25 SOMS • Arrival date (3–9 months) • Arrived from (another departmental facility) • Rx count • Randomize MIT 6.101 Transfers Out 2 OIG inspector • R&R IP transfers with medication on-site review Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 99 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 9 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 2 OIG inspector • Identify & inspect all on-site on-site review pharmacies MIT 7.112 Medication Error 4 Medication error • All medication error reports with Reporting reports Level 4 or higher • Select total of 25 medication error reports (recent 12 months) MIT 7.999 Restricted Unit 10 On-site active • KOP rescue inhalers & KOP Medications medication listing nitroglycerin medications for Ips housed in restricted units Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 100 Quality No. of Indicator Sample Category Samples Data Source Filters Prenatal and Postpartum Care MITs 8.001–007 Recent Deliveries N/A at this OB Roster • Delivery date (2–12 months) institution • Most recent deliveries (within date range) Pregnant Arrivals N/A at this OB Roster • Arrival date (2–12 months) institution • Earliest arrivals (within date range) Preventive Services MITs 9.001–002 TB Medications 8 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 N/A at this SOMS • Arrival date (at least 2 yrs. Prior institution to inspection) • Date of birth (age 52–74) • Randomize MIT 9.007 Pap Smear N/A at this SOMS • Arrival date (at least three yrs. institution 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 11 Cocci transfer • Reports from past 2–8 months status report • Institution • Ineligibility date (60 days prior to inspection date) • All Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 101 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 10 CADDIS • Admit date (2–8 months) Care Housing Unit • Type of stay (no MH beds) • Length of stay (minimum of 5 days) • Rx count • Randomize MITs 13.101–102 Call Buttons All OIG inspector • Specialized Health Care Housing on-site review • Review by location Specialty Services MITs 14.001–003 High-Priority 12 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 Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 102 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 MIT 14.010 Specialty Services 20 Specialty Services • Arrived from (other departmental Arrivals Arrivals institution) • Date of transfer (3–9 months) • Randomize MITs 14.011–012 Denials 20 InterQual • Review date (3–9 months) • Randomize N/A IUMC/MAR • Meeting date (9 months) Meeting Minutes • Denial upheld • Randomize Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 103 Quality No. of Indicator Sample Category Samples Data Source Filters Administrative Operations MIT 15.001 Adverse/sentinel 0 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 10 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 10 On-site • All required performance Evaluation Packets provider evaluation documents evaluation files MIT 15.106 Provider Licenses 15 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: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 104 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 10 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: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 105 California Correctional Health Care Services’ Response Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6, California Men’s Colony | 106 This page left blank for reproduction purposes. Office of the Inspector General, State of California Inspection Period: January 2021 – June 2021 Report Issued: July 2022 Cycle 6 Medical Inspection Report for California Men’s Colony OFFICE of the INSPECTOR GENERAL Amarik K. Singh Inspector General Neil Robertson Chief Deputy Inspector General STATE of CALIFORNIA July 2022 OIG