California Correctional Institution Medical Inspection Report Cycle 4

Robert A. Barton Office of the Inspector General Inspector General California Correctional Institution Medical Inspection Results Cycle 4 January 2016 Medical Inspection Unit Page 1 Office of the Inspector General State of California Office of the Inspector General CALIFORNIA CORRECTIONAL INSTITUTION Medical Inspection Results Cycle 4 Robert A. Barton Inspector General Roy W. Wesley Chief Deputy Inspector General Shaun R. Spillane Public Information Officer January 2016 TABLE OF CONTENTS Executive Summary ............................................................................................................................. i Overall Assessment: Adequate .............................................................................................. iii Clinical Case Review and OIG Clinician Inspection Results ............................................... iii Compliance Testing Results.................................................................................................. iv Population-Based Metrics ..................................................................................................... ix Introduction ......................................................................................................................................... 1 About the Institution ........................................................................................................................... 1 Objectives, Scope, and Methodology.................................................................................................. 5 Case Reviews ................................................................................................................................... 6 Patient Selection for Retrospective Case Reviews .................................................................... 6 Benefits and Limitations of Targeted Subpopulation Review .................................................. 7 Case Reviews Sampled ............................................................................................................. 8 Compliance Testing ......................................................................................................................... 9 Sampling Methods for Conducting Compliance Testing .......................................................... 9 Scoring of Compliance Testing Results .................................................................................... 9 Dashboard Comparisons ......................................................................................................... 10 Overall Quality Indicator Rating for Case Reviews and Compliance Testing .............................. 11 Population-Based Metrics .............................................................................................................. 11 Medical Inspection Results ............................................................................................................... 12 Primary (Clinical) Quality Indicators of Health Care .................................................................... 12 Access to Care ......................................................................................................................... 13 Case Review Results ............................................................................................................ 13 Compliance Testing Results................................................................................................. 13 CCHCS Dashboard Comparative Data ................................................................................ 15 Recommendations ................................................................................................................ 15 Diagnostic Services ................................................................................................................. 16 Case Review Results ............................................................................................................ 16 Compliance Testing Results................................................................................................. 16 Recommendations ................................................................................................................ 17 Emergency Services................................................................................................................. 18 Case Review Results ............................................................................................................ 18 Recommendations ................................................................................................................ 21 Health Information Management (Medical Records) ............................................................. 22 Case Review Results ............................................................................................................ 22 Compliance Testing Results................................................................................................. 24 CCHCS Dashboard Comparative Data ................................................................................ 25 Recommendations ................................................................................................................ 26 Health Care Environment ....................................................................................................... 27 Compliance Testing Results................................................................................................. 27 Recommendations ................................................................................................................ 29 California Correctional Institution, Cycle 4 Medical Inspection Table of Contents Office of the Inspector General State of California Inter- and Intra-System Transfers ........................................................................................... 31 Case Review Results ............................................................................................................ 31 Compliance Testing Results................................................................................................. 32 Recommendations ................................................................................................................ 33 Pharmacy and Medication Management ................................................................................ 34 Case Review Results ............................................................................................................ 34 Compliance Testing Results................................................................................................. 35 CCHCS Dashboard Comparative Data ................................................................................ 37 Recommendations ................................................................................................................ 37 Preventive Services ................................................................................................................. 38 Compliance Testing Results................................................................................................. 38 CCHCS Dashboard Comparative Data ................................................................................ 39 Recommendations ................................................................................................................ 39 Quality of Nursing Performance ............................................................................................. 40 Case Review Results ............................................................................................................ 40 Recommendations ................................................................................................................ 41 Quality of Provider Performance ............................................................................................ 42 Case Review Results ............................................................................................................ 42 Recommendations ................................................................................................................ 46 Specialized Medical Housing (OHU, CTC, SNF, Hospice) .................................................... 48 Case Review Results ............................................................................................................ 48 Compliance Testing Results................................................................................................. 50 Recommendations ................................................................................................................ 50 Specialty Services .................................................................................................................... 51 Case Review Results ............................................................................................................ 51 Compliance Testing Results................................................................................................. 52 Recommendations ................................................................................................................ 53 Secondary (Administrative) Quality Indicators of Health Care..................................................... 54 Internal Monitoring, Quality Improvement, and Administrative Operations ......................... 55 Compliance Testing Results................................................................................................. 55 CHCS Dashboard Comparative Data ................................................................................... 57 Recommendations ................................................................................................................ 57 Job Performance, Training, Licensing, and Certifications ..................................................... 58 Compliance Testing Results................................................................................................. 58 Recommendations ................................................................................................................ 59 Population-Based Metrics .............................................................................................................. 60 Appendix A — Compliance Test Results ......................................................................................... 64 Appendix B — Clinical Data ............................................................................................................ 77 Appendix C — Compliance Sampling Methodology ....................................................................... 80 California Correctional Health Care Services’ Response ................................................................. 85 California Correctional Institution, Cycle 4 Medical Inspection Table of Contents Office of the Inspector General State of California LIST OF TABLES AND FIGURES Health Care Quality Indicators ........................................................................................................... ii CCI Executive Summary Table ....................................................................................................... viii CCI Health Care Staffing Resources — July 2015 .............................................................................. 2 CCI Master Registry Data as of June 8, 2015 ...................................................................................... 3 Commonly Used Abbreviations .......................................................................................................... 4 Access to Care — CCI Dashboard and OIG Compliance Results..................................................... 15 Health Information Management — CCI Dashboard and OIG Compliance Results ........................ 25 Pharmacy and Medication Management — CCI Dashboard and OIG Compliance Results ............ 37 Preventive Services — CCI Dashboard and OIG Compliance Results ............................................. 39 Internal Monitoring, Quality Improvement, and Administrative Operations — CCI Dashboard and OIG Compliance Results ............................................................................ 57 CCI Results Compared to State and National HEDIS Scores ........................................................... 63 California Correctional Institution, Cycle 4 Medical Inspection List of Tables and Figures Office of the Inspector General State of California EXECUTIVE SUMMARY Under the authority of California Penal Code Section 6126, which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), the OIG conducts a comprehensive inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG explicitly makes no determination regarding the constitutionality of care in the prison setting. That determination is left to the Receiver and the federal court. The assessment of care by the OIG is just one factor in the court’s determination whether care in the prisons meets constitutional standards. The court may find that an institution that the OIG found to be providing adequate care still does not meet constitutional standards, depending on the analysis of the underlying data provided by the OIG. Likewise, an institution that has been rated inadequate by the OIG could still be found to pass constitutional muster with the implementation of remedial measures if the underlying data were to reveal easily mitigated deficiencies. The OIG’s inspections are mandated by the Penal Code and not aimed at specifically resolving the court’s questions on constitutional care. To the degree that they provide another factor for the court to consider, the OIG is pleased to provide added value to the taxpayers of California. For this fourth cycle of inspections, the OIG added a clinical case review component and significantly enhanced the compliance portion of the inspection process from that used in prior cycles. In addition, the OIG added a population-based metric comparison of selected Healthcare Effectiveness Data Information Set (HEDIS) measures from other State and national health care organizations and compared that data to similar results for the California Correctional Institution (CCI). The OIG performed its Cycle 4 medical inspection at CCI from July to September 2015. The inspection included in-depth reviews of 63 inmate-patient files conducted by clinicians, as well as reviews of documents from 415 inmate-patient files, covering 93 objectively scored tests of compliance with policies and procedures applicable to the delivery of medical care. The OIG assessed the case review and compliance results at CCI using 14 health care quality indicators applicable to the institution, made up of 12 primary clinical indicators and two secondary administrative indicators. To conduct clinical case reviews, the OIG employs a clinician team consisting of a physician and a registered nurse consultant, while compliance testing is done by a team of deputy inspectors general trained in monitoring medical compliance. Of the 12 primary indicators, seven were rated by both case review clinicians and compliance inspectors, three were rated by case review clinicians only, and two were rated by compliance inspectors only; both secondary indicators were rated by compliance inspectors only. See the Health Care Quality Indicators table on page ii. Based on that analysis, OIG experts made a considered and measured overall opinion that the quality of health care at CCI was adequate. California Correctional Institution, Cycle 4 Medical Inspection Page i Office of the Inspector General State of California Health Care Quality Indicators All Institutions– Fourteen Primary Indicators (Clinical) CCI Applicability Applicability Both case review 1–Access to Care All institutions and compliance Both case review 2–Diagnostic Services All institutions and compliance 3–Emergency Services All institutions Case review only 4–Health Information Management Both case review All institutions (Medical Records) and compliance 5–Health Care Environment All institutions Compliance only Both case review 6–Inter- and Intra-System Transfers All institutions and compliance Both case review 7–Pharmacy and Medication Management All institutions and compliance Female institutions 8–Prenatal and Post-Delivery Services Not Applicable only 9–Preventive Services All institutions Compliance only 10–Quality of Nursing Performance All institutions Case review only 11–Quality of Provider Performance All institutions Case review only Institutions with 12–Reception Center Arrivals Not Applicable reception centers All institutions with 13–Specialized Medical Housing Both case review an OHU, CTC, SNF, (OHU, CTC, SNF, Hospice) and compliance or Hospice Both case review 14–Specialty Services All institutions and compliance Two Secondary Indicators All Institutions– CCI Applicability (Administrative) Applicability 15–Internal Monitoring, Quality Improvement, and Administrative All institutions Compliance only Operations 16–Job Performance, Training, Licensing, All institutions Compliance only and Certifications California Correctional Institution, Cycle 4 Medical Inspection Page ii Office of the Inspector General State of California Overall Assessment: Adequate Based on the clinical case reviews and compliance testing, the OIG’s overall assessment rating for CCI was adequate. For the Overall Assessment 12 primary (clinical) quality indicators applicable to CCI, the OIG Rating: found two proficient, nine adequate, and one inadequate. For the two secondary (administrative) quality indicators, the OIG found Adequate one proficient and one inadequate. To determine the overall assessment for CCI, the OIG considered individual clinical ratings and individual compliance question scores within each of the indicator categories, putting emphasis on the primary indicators. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed at CCI. Clinical Case Review and OIG Clinician Inspection Results The clinicians’ case reviews sampled patients with high medical needs and included a review of 1,075 patient care events.1 For the 12 primary indicators applicable to CCI, clinicians evaluated ten by case review; two were proficient, seven were adequate, and one was inadequate. When determining the overall adequacy of care, the OIG paid particular attention to the clinical nursing and provider quality indicators, as adequate health care staff can sometimes overcome suboptimal processes and programs. However, the opposite is not true; inadequate health care staff cannot provide adequate care, even though the established processes and programs onsite may be adequate. The OIG clinicians identify inadequate medical care based on the risk of significant harm to the patient, not the actual outcome. While the clinicians rated most indicators proficient or adequate for the case reviews, they had significant concerns with the quality of both nursing and provider care, with both of these indicators actually performing only marginally adequately. Program Strengths — Case Review  Generally, CCI provided excellent access to primary care services.  CCI provided excellent diagnostic services, with diagnostic tests being performed, results being reviewed by providers, and patients being notified of results in a timely manner.  The institution’s providers mitigated some of the deficiencies identified in this report, especially with regard to nursing performance. 1 Each OIG clinician team includes a board certified physician and a registered nurse consultant with experience in both correctional and community medical settings. California Correctional Institution, Cycle 4 Medical Inspection Page iii Office of the Inspector General State of California Program Weaknesses — Case Review  Emergency services were inadequate. Specifically, nurses routinely failed to provide thorough and appropriate “chest pain” care, and there were problems with the management of respiratory distress.  Several indicators revealed a pattern of incomplete patient assessment and incomplete documentation of health care records by nursing staff.  Multiple providers utilized legacy (“cloned”) notes during the period reviewed, which resulted in deficient patient care.  The internal audits performed at CCI were inadequate. Nursing audits failed to detect patterns of inadequate care and documentation. The inconsistent process for emergency medical response review failed to identify deficiencies. Compliance Testing Results Of the 14 total indicators of health care applicable to CCI, 11 were evaluated by compliance inspectors.2 There were 93 individual compliance questions within those 11 indicators, generating 1,221 data points, that tested CCI’s compliance with California Correctional Health Care Services (CCHCS) policies and procedures.3 Those 93 questions are detailed in Appendix A — Compliance Test Results. The institution’s inspection scores for the 11 applicable indicators ranged from 71.7 percent to 100 percent, with the secondary (administrative) indicator Internal Monitoring, Quality Improvement, and Administrative Operations receiving the lowest score, and the primary (clinical) indicator Specialized Medical Housing (OHU, CTC, SNF, Hospice) receiving the highest. For the nine primary indicators applicable to compliance testing, the OIG rated four proficient and five adequate. For the two secondary indicators, which involve administrative health care functions, one was rated proficient and one inadequate. Program Strengths — Compliance Testing As the CCI Executive Summary Table on page viii indicates, the institution’s compliance scores were in the proficient range for the following five indicators: Pharmacy and Medication Management (93.2 percent), Preventive Services (88.8 percent), Specialized Medical Housing (OHU, CTC, SNF, Hospice) (100 percent), Specialty Services (85.7 percent), and Job Performance, Training, Licensing, and Certifications (95.8 percent). The following are some of CCI’s strengths based on its compliance scores on individual questions within all primary health care indicators: 2 The OIG’s compliance inspectors are trained deputy inspectors general with expertise in CDCR policies regarding medical staff and processes. 3 The OIG used its own clinicians to provide clinical expert guidance for testing compliance in certain areas where CCHCS policies and procedures did not specifically address an issue. California Correctional Institution, Cycle 4 Medical Inspection Page iv Office of the Inspector General State of California  Inmate-patients had a standardized process to obtain and submit health care service request forms, and nursing staff timely reviewed patients’ requests.  Providers conducted timely follow-up appointments with patients who were discharged from a community hospital.  The institution ensured that patients timely received their radiology and laboratory diagnostic services.  Health information management staff timely scanned non-dictated progress notes, initial health screening forms, health care service request forms, and medication administration records into patients’ health records.  All of the institution’s clinics were appropriately disinfected, cleaned, and sanitized; all applicable clinics had operable sinks and sufficient quantities of hygiene supplies.  Health care staff employed strong medication security controls over narcotic medications in the clinics and medication line locations that stored them.  Nursing staff followed proper protocols when preparing medications and administering them to patients.  In its main pharmacy, the institution followed general security, organization, and cleanliness management protocols; properly stored non-refrigerated and refrigerated medications; maintained adequate controls and properly accounted for narcotic medications; and followed key medication error reporting protocols.  CCI provided all sampled patients with annual tuberculosis screenings, and timely provided or offered all sampled patients influenza vaccinations and annual colorectal cancer screenings, when required.  For all patients sampled who were admitted to the OHU, nursing staff and providers conducted initial assessments, evaluations, and history and physical examinations within required time frames.  Patients received their routine specialty services timely, and providers timely reviewed high-priority specialists’ reports. When the institution denied specialty service requests, it processed them timely and providers timely communicated the denial status to patients. The following are some of the strengths identified within the two secondary administrative indicators:  CCI promptly processed all inmate medical appeals timely in each of the most recent 12 months reviewed. California Correctional Institution, Cycle 4 Medical Inspection Page v Office of the Inspector General State of California  The Quality Management Committee met monthly, evaluated program performance and took action when improvement opportunities were identified, and took adequate steps to ensure the accuracy of its Dashboard data reporting.  All providers were current with their professional licenses; nursing staff and the pharmacist-in-charge were current with their professional licenses and certification requirements; and the institution’s pharmacy and providers who prescribed controlled substances were current with their Drug Enforcement Agency registrations.  The institution met all performance review requirements for its providers. Also, nursing supervisors completed required nursing reviews, nursing staff who administered medications possessed current clinical competency validations, and nursing staff hired within the last year timely received new employee orientation training. Program Weaknesses — Compliance Testing The only indicator that received a compliance score in the inadequate range was the secondary administrative indicator Internal Monitoring, Quality Improvement, and Administrative Operations (71.6 percent). However, the following are some of the weaknesses identified by CCI’s compliance scores on individual questions within the primary health care indicators:  When patients transferred into CCI from another institution and nursing staff referred them to a primary care provider (PCP), many did not receive their PCP appointment timely. Also, PCPs frequently failed to conduct timely appointments with patients who suffered from chronic care conditions.  Health information management staff often failed to scan documents timely into inmate-patients’ electronic health records, and did not always appropriately label them. Clinicians’ signatures on health care records were often illegible.  In several clinics, sterilized medical equipment was not appropriately stored, or essential medical equipment showed no evidence of current calibration.  Nursing staff did not always obtain all required information during initial health screenings of patients who transferred into CCI from another CDCR institution.  Providers often failed to timely review consultant reports for patients’ routine specialty services.  The institution frequently failed to provide timely specialty service appointments to inmate-patients who transferred into CCI with previously approved or scheduled specialty appointments at the sending institution. California Correctional Institution, Cycle 4 Medical Inspection Page vi Office of the Inspector General State of California The following are some of the weaknesses identified within the two secondary administrative indicators:  The Emergency Medical Response Review Committee minutes did not include all required documents for incidents discussed at meetings, and the warden and chief executive officer did not sign the meeting minutes as required by policy.  Medical emergency response drill packets did not include all required documentation.  Custody managers did not have current emergency response certifications as required by CCHCS policy. The CCI Executive Summary Table on the following page lists the quality indicators the OIG inspected and assessed during the clinical case reviews and objective compliance tests, and provides the institution’s rating in each area. The overall indicator ratings were based on a consensus decision by the OIG’s clinicians and non-clinical inspectors. California Correctional Institution, Cycle 4 Medical Inspection Page vii Office of the Inspector General State of California CCI Executive Summary Table Case Compliance Overall Indicator Primary Indicators (Clinical) Review Score Rating Rating Access to Care Proficient 81.1% Adequate Diagnostic Services Proficient 84.4% Proficient Emergency Services Inadequate Not Applicable Inadequate Health Information Management Adequate 78.2% Adequate (Medical Records) Health Care Environment Not Applicable 84.4% Adequate Inter- and Intra-System Transfers Adequate 84.1% Adequate Pharmacy and Medication Management Adequate 93.2% Adequate Preventive Services Not Applicable 88.8% Proficient Quality of Nursing Performance Adequate Not Applicable Adequate Quality of Provider Performance Adequate Not Applicable Adequate Specialized Medical Housing (OHU, CTC, Adequate 100.0% Adequate SNF, Hospice) Specialty Services Adequate 85.7% Adequate Note: The Prenatal and Post-Delivery Services and Reception Center Arrivals indicators did not apply to this institution. Case Compliance Overall Indicator Secondary Indicators (Administrative) Review Score Rating Rating Internal Monitoring, Quality Improvement, Not Applicable 71.7% Inadequate and Administrative Operations Job Performance, Training, Licensing, and Not Applicable 95.8% Proficient Certifications Compliance ratings for quality indicators are proficient (greater than 85.0 percent), adequate (75.0 percent to 85.0 percent), or inadequate (below 75.0 percent). California Correctional Institution, Cycle 4 Medical Inspection Page viii Office of the Inspector General State of California Population-Based Metrics In general, CCI performed well for population-based metrics. In three of the five comprehensive diabetes care measures, CCI outperformed other State and national organizations. This included Medi-Cal as well as Kaiser Permanente, typically one of the highest-scoring health organizations in California; and Medicaid, Medicare, national commercial health plans (based on data obtained from health maintenance organizations), and the U.S. Department of Veterans Affairs (VA). For the two remaining diabetes care measures, the institution’s scores were mid-range when compared to the other entities. With regard to influenza immunizations for patients under the age of 65, CCI outperformed all organizations reporting data, which included Kaiser, commercial plans, and the VA; for older patients, CCI’s rates were higher than Medicare but lower than the VA. However, CCI’s lower performance for older adults’ flu shots can be attributed to patient refusals. The institution’s rates for pneumococcal immunizations were lower than both Medicare and the VA. For colorectal cancer screening, CCI’s rates closely matched or were higher than rates reported by Kaiser, commercial plans, and Medicare; but the institution’s rates were lower than the VA’s. Again, this lower performance can be attributed to patient refusals. Overall, CCI’s performance demonstrated by the population-based metrics indicated that the chronic care program was well run and operating as intended. California Correctional Institution, Cycle 4 Medical Inspection Page ix Office of the Inspector General State of California INTRODUCTION Under the authority of California Penal Code Section 6126, which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), and at the request of the federal Receiver, the OIG developed a comprehensive medical inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. For this fourth cycle of inspections, the OIG augmented the breadth and quality of its inspection program used in prior cycles, adding a clinical case review component and significantly enhancing the compliance component of the program. The California Correctional Institution (CCI) was the ninth medical inspection of Cycle 4. During the inspection process, the OIG assessed the delivery of medical care to patients using 12 primary clinical health care indicators and two secondary administrative health care indicators applicable to the institution. It is important to note that while the primary quality indicators represent the clinical care being provided by the institution at the time of the inspection, the secondary quality indicators are purely administrative and are not reflective of the actual clinical care provided. The OIG is committed to reporting on each institution’s delivery of medical care to assist in identifying areas for improvement, but the federal court will ultimately determine whether any institution’s medical care meets constitutional standards. ABOUT THE INSTITUTION The California Correctional Institution (CCI) is made up of five separate facilities housing inmates of varying security levels, from minimum to maximum security, including inmates housed in CCI’s security housing unit (SHU), the highest level of security in California State prisons. The institution runs seven medical clinics where staff members handle non-urgent requests for medical services, including five facility clinics, a specialty clinic, and a 16-bed onsite outpatient housing unit (OHU). CCI treats patients who require assistance with the activities of daily living but who do not require a higher level of inpatient care in its OHU. The institution treats inmates needing urgent or emergency care in its triage and treatment area (TTA). CCI has been designated as a “basic care prison,” located in a rural area away from tertiary care centers and specialty care providers whose services would likely be used frequently by higher-risk patients. At the time of the inspection, CCI had not yet received a review from the Commission on Accreditation for Corrections, a professional peer review process based on national standards set by the American Correctional Association. The institution’s first review is planned for late 2016 or early 2017. California Correctional Institution, Cycle 4 Medical Inspection Page 1 Office of the Inspector General State of California Based on staffing data the OIG obtained from the institution, CCI’s vacancy rate among licensed medical managers, primary care providers (PCPs), supervisors, and rank-and-file nurses was 17 percent in July 2015, with the highest vacancy percentages among nursing supervisors (26 percent) and nursing staff (18 percent). According to the chief executive officer, an offer was pending for one supervising registered nurse II (SRN II) position, and two other positions were being advertised. Also, CCI received approval to hire 10.6 registered nurses in April 2015, and of 13 positions being advertised, five had offers pending. CCI Health Care Staffing Resources — July 2015 Primary Care Nursing Management Nursing Staff Totals Providers Supervisors Description Number % Number % Number % Number % Number % Authorized 5 4% 10 9% 11.5 10% 89.5 77% 116 100% Positions Filled Positions 5 100% 10 100% 8.5 74% 73 82% 96.5 83% Vacancies 0 0% 0 0% 3 26% 16.5 18% 19.5 17% Recent Hires (within 12 1 20% 2 20% 2 24% 4 5% 9 9% months) Staff Utilized 0 0% 0 0% 0 0% 0 0% 0 0% from Registry Redirected Staff (to Non-Patient 0 0% 0 0% 0 0% 0 0% 0 0% Care Areas) Staff under Disciplinary 0 0% 0 0% 0 0% 2 3% 2 2% Review Staff on Long-term 0 0% 0 0% 1 12% 8 11% 9 9% Medical Leave Note: CCI Health Care Staffing Resources data was not validated by the OIG. California Correctional Institution, Cycle 4 Medical Inspection Page 2 Office of the Inspector General State of California As of June 8, 2015, the Master Registry for CCI showed that the institution had 3,696 inmate-patients. Within that total population, 0.6 percent were designated High-Risk, Priority 1 (High 1), and 3.4 percent were designated High-Risk, Priority 2 (High 2). Patients’ assigned risk levels are based on the complexity of their required medical care related to their specific diagnoses, frequency of higher levels of care, age, and abnormal labs and procedures. High 1 has at least two high-risk conditions; High 2 has only one. High-risk patients are more susceptible to poor health outcomes than medium- or low-risk patients. High-risk patients also typically require more health care services than do patients with lower assigned risk levels. The chart below illustrates the breakdown of the institution’s medical risk levels at the start of the OIG medical inspection. CCI Master Registry Data as of June 8, 2015 Risk Level # of Inmate-Patients Percentage High 1 21 0.57% High 2 124 3.36% Medium 1,725 46.67% Low 1,826 49.40% Total 3,696 100.0% California Correctional Institution, Cycle 4 Medical Inspection Page 3 Office of the Inspector General State of California Commonly Used Abbreviations ACLS Advanced Cardiovascular Life Support HIV Human Immunodeficiency Virus AHA American Heart Association HTN Hypertension ASU Administrative Segregation Unit INH Isoniazid (anti-tuberculosis medication) BLS Basic Life Support IV Intravenous CBC Complete Blood Count KOP Keep-on-Person (in taking medications) CC Chief Complaint LPT Licensed Psychiatric Technician CCHCS California Correctional Health Care Services LVN Licensed Vocational Nurse CCP Chronic Care Program MAR Medication Administration Record California Department of Corrections and CDCR MRI Magnetic Resonance Imaging Rehabilitation CEO Chief Executive Officer MD Medical Doctor CHF Congestive Heart Failure NA Nurse Administered (in taking medications) CME Chief Medical Executive N/A Not Applicable CMP Comprehensive Metabolic (Chemistry) Panel NP Nurse Practitioner CNA Certified Nursing Assistant OB Obstetrician CNE Chief Nurse Executive OHU Outpatient Housing Unit C/O Complains of OIG Office of the Inspector General COPD Chronic Obstructive Pulmonary Disease P&P Policies and Procedures (CCHCS) CP&S Chief Physician and Surgeon PA Physician Assistant CPR Cardio-Pulmonary Resuscitation PCP Primary Care Provider CSE Chief Support Executive POC Point of Contact CT Computerized Tomography PPD Purified Protein Derivative CTC Correctional Treatment Center PRN As Needed (in taking medications) DM Diabetes Mellitus RN Registered Nurse Directly Observed Therapy (in taking DOT Rx Prescription medications) Dx Diagnosis SNF Skilled Nursing Facility Subjective, Objective, Assessment, Plan, EKG Electrocardiogram SOAPE Education ENT Ear, Nose and Throat SOMS Strategic Offender Management System ER Emergency Room S/P Status post eUHR electronic Unit Health Record TB Tuberculosis FTF Face-to-Face TTA Triage and Treatment Area History and Physical (reception center H&P UA Urinalysis examination) HIM Health Information Management UM Utilization Management California Correctional Institution, Cycle 4 Medical Inspection Page 4 Office of the Inspector General State of California OBJECTIVES, SCOPE, AND METHODOLOGY In designing the medical inspection program, the OIG reviewed CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. The OIG also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the Receiver’s office, CDCR, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of the OIG’s inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates medical care delivery by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population-based metrics. To maintain a metric-oriented inspection program that evaluates medical care delivery consistently at each State prison, the OIG identified 14 primary (clinical) and two secondary (administrative) quality indicators of health care to measure. The primary quality indicators cover clinical categories directly relating to the health care provided to patients, whereas the secondary quality indicators address the administrative functions that support a health care delivery system. The 14 primary quality indicators are Access to Care, Diagnostic Services, Emergency Services, Health Information Management (Medical Records), Health Care Environment, Inter- and Intra-System Transfers, Pharmacy and Medication Management, Prenatal and Post-Delivery Services, Preventive Services, Quality of Nursing Performance, Quality of Provider Performance, Reception Center Arrivals, Specialized Medical Housing (OHU, CTC, SNF, Hospice), and Specialty Services. The two secondary quality indicators are Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications. The OIG rates each of the quality indicators applicable to the institution under inspection based on case reviews conducted by OIG clinicians and compliance tests conducted by OIG deputy inspectors general. The ratings may be derived from the case review results alone, the compliance test results alone, or a combination of both these information sources. For example, the ratings for the primary quality indicators Quality of Nursing Performance and Quality of Provider Performance are derived entirely from the case review results, while the ratings for the primary quality indicators Health Care Environment and Preventive Services are derived entirely from compliance test results. As another example, primary quality indicators such as Diagnostic Services and Specialty Services receive ratings derived from both sources. At CCI, 14 of the quality indicators were applicable, consisting of 12 primary clinical indicators and two secondary administrative indicators. Of the 12 primary indicators, seven were rated by both case review clinicians and compliance inspectors, three were rated by case review clinicians only, and two were rated by compliance inspectors only; both secondary indicators were rated by compliance inspectors only. California Correctional Institution, Cycle 4 Medical Inspection Page 5 Office of the Inspector General State of California Consistent with the OIG’s agreement with the Receiver, this report only addresses the conditions found related to medical care criteria. The OIG does not review for efficiency and economy of operations. Moreover, if the OIG learns of an inmate-patient needing immediate care, the OIG notifies the chief executive officer of health care services and requests a status report. Additionally, if the OIG learns of significant departures from community standards, it may report such departures to the institution’s chief executive officer or to CCHCS. Because these matters involve confidential medical information protected by State and federal privacy laws, specific identifying details related to any such cases are not included in the OIG’s public report. In all areas, the OIG is alert for opportunities to make appropriate recommendations for improvement. Such opportunities may be present regardless of the rating awarded to any particular quality indicator; therefore, recommendations for improvement should not necessarily be interpreted as indicative of deficient medical care delivery. CASE REVIEWS The OIG has added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders. At the conclusion of Cycle 3, the federal Receiver and the Inspector General determined that the health care provided at the institutions was not fully evaluated by the compliance tool alone, and that the compliance tool was not designed to provide comprehensive qualitative assessments. Accordingly, the OIG added case reviews in which OIG physicians and nurses evaluate selected cases in detail to determine the overall quality of health care provided to the inmate-patients. The OIG’s clinicians perform a retrospective chart review of selected patient files to evaluate the care given by an institution’s primary care providers and nurses. Retrospective chart review is a well-established review process used by health care organizations that perform peer reviews and patient death reviews. Currently, CCHCS uses retrospective chart review as part of its death review process and in its pattern-of-practice reviews. CCHCS also uses a more limited form of retrospective chart review when performing appraisals of individual primary care providers. PATIENT SELECTION FOR RETROSPECTIVE CASE REVIEWS Because retrospective chart review is time consuming and requires qualified health care professionals to perform it, OIG clinicians must carefully sample patient records. Accordingly, the group of patients the OIG targeted for chart review carried the highest clinical risk and utilized the majority of medical services. A majority of the patients selected for retrospective chart review were classified by CCHCS as high-risk patients. The reason the OIG targeted these patients for review is twofold: 1. The goal of retrospective chart review is to evaluate all aspects of the health care system. Statewide, high-risk and high-utilization patients consume medical services at a disproportionate rate; 11 percent of the total patient population are considered high-risk and California Correctional Institution, Cycle 4 Medical Inspection Page 6 Office of the Inspector General State of California account for more than half of the institution’s pharmaceutical, specialty, community hospital, and emergency costs. 2. Selecting this target group for chart review provides a significantly greater opportunity to evaluate all the various aspects of the health care delivery system at an institution. Underlying the choice of high-risk patients for detailed case review are three assumptions: 1. If the institution is able to provide adequate clinical care to the most challenging patients with multiple complex and interdependent medical problems, it will be providing adequate care to patients with less complicated health care issues. Because clinical expertise is required to determine whether the institution has provided adequate clinical care, the OIG utilizes experienced correctional physicians and registered nurses to perform this analysis. 2. The health of less complex patients is more likely to be affected by processes such as timely appointment scheduling, medication management, routine health screening, and immunizations. To review these processes, the OIG simultaneously performs a broad compliance review. 3. Patient charts generated during death reviews, sentinel events (an unexpected occurrence involving death or serious injury, or risk thereof), and hospitalizations are mostly of high-risk patients. BENEFITS AND LIMITATIONS OF TARGETED SUBPOPULATION REVIEW Because the selected patients utilize the broadest range of services offered by the health care system, the OIG’s retrospective chart review provides adequate data for a qualitative assessment of the most vital system processes (referred to as “primary quality indicators”). Retrospective chart review provides an accurate qualitative assessment of the relevant primary quality indicators as applied to the targeted subpopulation of high-risk and high-utilization patients. While this targeted subpopulation does not represent the prison population as a whole, the ability of the institution to provide adequate care to this subpopulation is a crucial and vital indicator of how the institution provides health care to its whole patient population. Simply put, if the institution’s medical system does not adequately care for those patients needing the most care, then it is not fulfilling its obligations, even if it takes good care of patients with less complex medical needs. Since the targeted subpopulation does not represent the institution’s general prison population, the OIG cautions against inappropriate extrapolation of conclusions from the retrospective chart reviews to the general population. For example, if the high-risk diabetic patients reviewed have poorly-controlled diabetes, one cannot conclude that the entire diabetic population is inadequately controlled. Similarly, if the high-risk diabetic patients under review have poor outcomes and require significant specialty interventions, one cannot conclude that the entire diabetic population is having similarly poor outcomes. California Correctional Institution, Cycle 4 Medical Inspection Page 7 Office of the Inspector General State of California Nonetheless, the health care system’s response to this subpopulation can be accurately evaluated and yields valuable systems information. In the above example, if the health care system is providing appropriate diabetic monitoring, medication therapy, and specialty referrals for the high-risk patients reviewed, then it can be reasonably inferred that the health care system is also providing appropriate diabetic services to the entire diabetic subpopulation. However, if these same high-risk patients needing monitoring, medications, and referrals are generally not getting those services, it is likely that the health care system is not providing appropriate diabetic services to the greater diabetic subpopulation. CASE REVIEWS SAMPLED As indicated in Appendix B, Table B–1, CCI Sample Sets, the OIG clinicians evaluated medical charts for 63 unique inmate-patients. Both nurses and physicians reviewed charts for 18 of those patients, for 81 reviews in total. Appendix B–4, CCI Case Review Sample Summary, clarifies that physicians performed detailed reviews of 30 charts, and nurses performed detailed reviews of 15 charts, totaling 45 detailed reviews. For detailed case reviews, the clinicians looked at all encounters occurring in approximately six months of medical care. Nurses also performed a limited or focused review of medical records for an additional 36 inmate-patients. These generated 1,075 clinical events for review (Appendix B, Table B–3: CCI Event-Program). The reporting format provides details on whether the encounter was adequate or had significant deficiencies, and identifies deficiencies by programs and processes to help the institution focus on improvement areas. While the sample method specifically pulled only six chronic care patient records, three diabetes patients and three anticoagulation patients (Appendix B, Table B–1, CCI Sample Sets), the 63 unique inmate-patients sampled included patients with 159 chronic care diagnoses, including 11 additional patients with diabetes (for total of 14), and one additional anticoagulation patient (for a total of four) (Appendix B, Table B–2, CCI Chronic Care Diagnoses). The OIG’s sample selection tool evaluated many chronic care programs because the complex and high-risk patients selected from the different categories often had multiple medical problems. While the OIG did not evaluate every chronic disease or health care staff member, the overall operation of the institution’s system and staff were assessed for adequacy. The OIG’s case review methodology and sample size matched other qualitative research. The empirical findings, supported by expert statistical consultants, showed adequate conclusions after 10 to 15 charts had undergone full clinician review. In qualitative statistics, this phenomenon is known as “saturation.” The OIG asserts that the sample size of over 30 detailed reviews certainly far exceeds the saturation point necessary for an adequate qualitative review. With regard to reviewing charts from different providers, the case review is not intended to be a focused search for poorly performing providers; rather, it is focused on how the system cares for those patients who need care the most. Nonetheless, while not sampling cases by each provider at the institution, the OIG’s inspections adequately review most providers. Providers would only escape OIG case review if institutional management successfully mitigated patient risk by having the more poorly performing PCPs care for the less complicated, low-utilizing, and lower-risk California Correctional Institution, Cycle 4 Medical Inspection Page 8 Office of the Inspector General State of California patients. The OIG concluded that the case review sample size was more than adequate to assess the quality of services provided. Based on the collective results of clinicians’ case reviews, the OIG rated each quality indicator as either proficient (excellent), adequate (passing), inadequate (failing), or not applicable. A separate confidential CCI Supplemental Medical Inspection Results: Individual Case Review Summaries report details the case reviews OIG clinicians conducted and is available to specific stakeholders. For further details regarding the sampling methodologies and counts, see Appendix B — Clinical Data, Table B–1; Table B–2; Table B–3; and Table B–4. COMPLIANCE TESTING SAMPLING METHODS FOR CONDUCTING COMPLIANCE TESTING From July to August 2015, deputy inspectors general attained answers to 93 objective medical inspection test (MIT) questions designed to assess the institution’s compliance with critical policies and procedures applicable to the delivery of medical care. To conduct most tests, inspectors randomly selected samples of inmate-patients for whom the testing objectives were applicable and reviewed their electronic unit health records. In some cases, inspectors used the same samples to conduct more than one test. In total, inspectors reviewed health records for 415 individual inmate-patients and analyzed specific transactions within their records for evidence that critical events occurred. Inspectors also reviewed management reports and meeting minutes to assess certain administrative operations. In addition, during the week of July 13, 2015, field inspectors conducted a detailed onsite inspection of CCI’s medical facilities and clinics; interviewed key institutional employees; and reviewed employee records, logs, medical appeals, death reports, and other documents. This generated 1,221 scored data points to assess care. In addition to the scored questions, the OIG obtained information from the institution that it did not score. This included, for example, information about CCI’s plant infrastructure, protocols for tracking medical appeals and local operating procedures, and staffing resources. For details of the compliance results, see Appendix A — Compliance Test Results. For details of the OIG’s compliance sampling methodology, see Appendix C — Compliance Sampling Methodology. SCORING OF COMPLIANCE TESTING RESULTS The OIG rated the institution in the following nine primary (clinical) and two secondary (administrative) quality indicators applicable to the institution for compliance testing:  Primary indicators: Access to Care, Diagnostic Services, Health Information Management (medical records), Health Care Environment, Inter- and Intra-System Transfers, Pharmacy California Correctional Institution, Cycle 4 Medical Inspection Page 9 Office of the Inspector General State of California and Medication Management, Preventive Services, Specialized Medical Housing (OHU, CTC, SNF, Hospice), and Specialty Services.  Secondary indicators: Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications. After compiling the answers to the 93 questions, the OIG derived a score for each primary and secondary quality indicator identified above by calculating the percentage score of all Yes answers for each of the questions applicable to a particular indicator, then averaging those scores. Based on those results, the OIG assigned a rating to each quality indicator of proficient (greater than 85 percent), adequate (between 75 percent and 85 percent), or inadequate (less than 75 percent). DASHBOARD COMPARISONS For some of the individual compliance questions, the OIG identified where similar metrics were available within the CCHCS Dashboard, which is a monthly report that consolidates key health care performance measures statewide and by institution. There is not complete parity between the metrics due to time frames when data was collected. As a result, there is some difference between the OIG’s findings and the Dashboard results. The OIG compared its compliance test results with the institution’s Dashboard results and reported on that comparative data under various applicable quality indicators within the Medical Inspection Results section of this report. California Correctional Institution, Cycle 4 Medical Inspection Page 10 Office of the Inspector General State of California OVERALL QUALITY INDICATOR RATING FOR CASE REVIEWS AND COMPLIANCE TESTING The OIG derived the final rating for each quality indicator by combining the ratings from the case reviews and from the compliance testing, as applicable. When combining these ratings, the case review evaluations and the compliance testing results usually agreed, but there were instances when the rating differed for a particular quality indicator. In those instances, the inspection team assessed the quality indicator based on the collective ratings from both components. Specifically, the OIG clinicians and deputy inspectors general discussed the nature of individual exceptions found within that indicator category and considered the overall effect on the ability of patients to receive adequate medical care. To derive an overall assessment rating for the institution’s medical inspection, the OIG evaluated the various rating categories assigned to each of the quality indicators applicable to the institution, giving more weight to the rating results for the primary quality indicators, which directly relate to the health care provided to inmate-patients. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed. POPULATION-BASED METRICS The OIG identified a subset of Healthcare Effectiveness Data Information Set (HEDIS) measures applicable to the CDCR inmate-patient population. To identify outcomes for CCI, the OIG reviewed some of the compliance testing results, randomly sampled additional inmate-patients’ records, and obtained CCI data from the CCHCS Master Registry. The OIG compared those results to HEDIS metrics reported by other statewide and national health care organizations. California Correctional Institution, Cycle 4 Medical Inspection Page 11 Office of the Inspector General State of California MEDICAL INSPECTION RESULTS PRIMARY (CLINICAL) QUALITY INDICATORS OF HEALTH CARE The primary quality indicators assess the clinical aspects of health care. As shown on the Health Care Quality Indicators table on page ii of this report, 12 of the OIG’s primary indicators were applicable to CCI. Of those 12 indicators, seven were rated by both the case review and compliance components of the inspection, three were rated by the case review component alone, and two were rated by the compliance component alone. Summary of Case Review Results: The clinical case review component assessed 10 of the 12 primary (clinical) indicators applicable to CCI. For these ten indicators, two were proficient, seven were adequate, and one was inadequate. The OIG physicians rated the overall adequacy of care for each of the 30 detailed case reviews they conducted. Of these 30 cases, zero were proficient, 21 were adequate, and 9 were inadequate. For the 1,075 events reviewed, there were 351 deficiencies, of which 21 were considered to be of such magnitude that they would likely contribute to patient harm if left unaddressed. Adverse Events Identified During Case Review: Medical care is a complex dynamic process with many moving parts, subject to human error even within the best health care organizations. Adverse events are typically identified and tracked by all major health care organizations for the purpose of quality improvement. They are not generally representative of medical care delivered by the organization. The OIG identified adverse events for the dual purposes of quality improvement and the illustration of problematic patterns of practice found during the inspection. Because of the anecdotal description of these events, the OIG cautions against drawing inappropriate conclusions regarding the institution based solely on adverse events. OIG clinicians identified one adverse event during the case reviews at CCI; the event was not reflective of the overall quality of care at CCI:  In case 20, the provider reviewed a blood test that showed that the patient’s blood was too thin and ordered the blood thinner (warfarin) to be held for two days. CCI did not process the order, and the patient continued to receive the medication. This error temporarily caused further thinning of the patient’s blood, but fortunately did not harm the patient. Summary of Compliance Results: The compliance component assessed 9 of the 12 primary (clinical) indicators applicable to CCI. For these nine indicators, OIG inspectors rate four proficient and five adequate; there were no inadequate ratings in the primary indicators. The results of those assessments are summarized within this section of the report. The test questions used to assess compliance for each indicator are detailed in Appendix A. California Correctional Institution, Cycle 4 Medical Inspection Page 12 Office of the Inspector General State of California ACCESS TO CARE This indicator evaluates the institution’s ability to provide Case Review Rating: inmate-patients with timely clinical appointments. Areas specific to Proficient inmate-patients’ access to care are reviewed, such as initial Compliance Score: assessments of newly arriving inmates, acute and chronic care 81.1% follow-ups, face-to-face nurse appointments when an inmate-patient Overall Rating: requests to be seen, provider referrals from nursing lines, and Adequate follow-ups after hospitalization or specialty care. Compliance testing for this indicator also evaluates whether inmate-patients have Health Care Services Request forms (CDCR Form 7362) available in their housing units. For this indicator, the OIG case review and compliance review processes yielded different results, with the case review giving a proficient rating and the compliance review resulting in an adequate score. The OIG’s internal review process considered those factors that led to both scores and ultimately rated this indicator adequate. Although OIG clinicians found few deficiencies in this indicator, compliance testing of randomly sampled patients revealed many deficiencies regarding untimely provider appointments. As a result, the compliance testing score was deemed a more accurate reflection of the appropriate overall rating. Case Review Results The OIG clinicians reviewed 774 provider and nurse encounters at CCI and identified only nine deficiencies relating to Access to Care, eight of which involved the patient not being seen as ordered. One deficiency was a result of a delay in provider follow-up after a specialty care visit. The OIG’s case review found no significant problems with Access to Care. Appointments were generally timely in all aspects reviewed, including nurse-to-provider sick call referrals, triage and treatment area (TTA) and hospital follow-ups, intra-system transfers, specialty appointment follow-ups, and outpatient provider and nursing follow-ups. CCI performed very well with regard to Access to Care, and the case review rating was thus proficient. Compliance Testing Results The institution performed in the adequate range in the Access to Care compliance indicator, with a compliance score of 81.1 percent. While CCI scored well in three of the nine tests conducted, it performed just adequately in three areas and inadequately in three others. As indicated below, CCI scored 100 percent in each of the following three areas tested:  Inmates had access to Health Care Services Request forms (CDCR Form 7362) at all five housing units inspected (MIT 1.101). California Correctional Institution, Cycle 4 Medical Inspection Page 13 Office of the Inspector General State of California  Inspectors sampled 30 CDCR Form 7362s submitted by inmate-patients across all facility clinics. Nursing staff reviewed all service request forms on the same day they were received (MIT 1.003).  The institution offered a follow-up appointment with a PCP to inmate-patients within five days of discharge from a community hospital for the 30 inmate-patients sampled by the OIG (MIT 1.007). The following areas scored in the adequate range:  For 25 of the 30 inmate-patients sampled who submitted CDCR Form 7362s (83 percent), nursing staff completed a face-to-face encounter with the inmate-patient within one business day of reviewing the service request form. In all five exceptions, the nurse conducted the visit one day late (MIT 1.004).  Out of five inmate-patients for whom the PCP determined a follow-up sick call appointment was necessary, four (80 percent) received a timely appointment; one patient received his follow-up appointment 24 days late (MIT 1.006).  Inspectors also sampled 24 inmate-patients who received a specialty service; 19 of them (79 percent) received a timely follow-up appointment with a PCP. One patient received an appointment that was two days late, and another, eight days late. Two additional patients had timely initial follow-up appointments, but the PCP notes revealed the patients’ specialty reports were not available at the time of their appointment and the patients were ultimately seen 29 and 78 days late. A provider did not see one patient for a specialty service follow-up appointment at all (MIT 1.008). The following areas were rated inadequate:  Only 11 of the 25 inmate-patients sampled who transferred into CCI from other institutions and were referred to a PCP for a routine appointment based on nursing staff’s initial health care screening of the patient were seen timely (44 percent). For 13 patients, appointments were held between 7 and 27 days late, and one patient was seen for a routine appointment over four months late (MIT 1.002).  When the OIG reviewed recent appointments for 30 inmate-patients with chronic care conditions, only 21 of the patients (70 percent) received timely routine appointments. One patient’s appointment occurred one day late, three patients’ appointments occurred between 21 and 26 days late, and five patients’ appointments occurred more than three months late (MIT 1.001).  For 15 health care service requests sampled where the nursing staff referred the inmate-patient for a PCP appointment, 11 of the inmate-patients (73 percent) received a California Correctional Institution, Cycle 4 Medical Inspection Page 14 Office of the Inspector General State of California timely appointment. For three patients the follow-up appointment occurred between one and 13 days late. For another inmate-patient, there was no evidence the appointment occurred at all (MIT 1.005). CCHCS Dashboard Comparative Data The Dashboard uses the average of nine medical access measure indicators to calculate the score for Scheduling & Access to Care: Medical Services. The OIG compared applicable CCI compliance scores with that Dashboard average. As indicated in the table below, the OIG test results were based on a review of documents from the most recent month as well as documents from the preceding 11 months; CCI’s July Dashboard data reflected only the institution’s June 2015 results. Nevertheless, the OIG and Dashboard results were consistent and within the proficient range. Access to Care — CCI Dashboard and OIG Compliance Results CCI DASHBOARD RESULTS OIG COMPLIANCE RESULTS Scheduling & Access to Care: Access to Care (1.001, 1.004, 1.005, 1.007) Medical Services Diagnostic Services (2.001, 2.004) Specialty Services (14.001, 14.003) July 2015 August 2014 – July 2015 96% 89% Note: The CCHCS Dashboard data includes access to care for inmate-patients returning from CDCR inpatient housing units and from emergency departments, whereas the OIG does not test follow-up appointments for these patients. Recommendations No specific recommendations. California Correctional Institution, Cycle 4 Medical Inspection Page 15 Office of the Inspector General State of California DIAGNOSTIC SERVICES This indicator addresses several types of diagnostic services. Case Review Rating: Specifically, it addresses whether radiology and laboratory Proficient services were timely provided to inmate-patients, whether the Compliance Score: primary care provider (PCP) timely reviewed the results, and 84.4% whether the results were communicated to the inmate-patient within the required time frames. In addition, for pathology Overall Rating: services, the OIG determines whether the institution received a Proficient final pathology report and whether the PCP timely reviewed and communicated the pathology results to the patient. The case reviews also factor in the appropriateness, accuracy, and quality of the diagnostic test(s) ordered and the clinical response to the results. For this indicator, the OIG’s case review and compliance review processes yielded different results, with the case review giving a proficient rating and the compliance review resulting in an adequate score. The OIG’s internal review process considered those factors that led to both scores and ultimately rated this indicator proficient. The case review found few deficiencies in this indicator, and the deficient areas revealed by compliance testing related to providers not always timely communicating diagnostic test results to patients. Also, the compliance score of 84.4 percent was very close to the proficient range. Case Review Results The OIG clinicians reviewed 199 diagnostic events and found 12 deficiencies. Six deficiencies related to diagnostic tests not completed as ordered; three deficiencies related to inappropriate provider review (discussed in the Quality of Provider Performance section); three deficiencies related to health information management. The OIG found no significant problems with diagnostic services. In general, staff successfully and timely completed diagnostic services, primary care providers reviewed reports timely, and patients were notified of the test results quickly. CCI performed very well with regard to Diagnostic Services, and the case review indicator rating is thus proficient. Compliance Testing Results The institution received an adequate compliance score of 84.4 percent in the Diagnostic Services indicator, which encompasses radiology, laboratory, and pathology services. For clarity, each type of diagnostic service is discussed separately below. Radiology Services  All ten of the radiology services sampled were timely performed (MIT 2.001). Additionally, providers timely reviewed and communicated the diagnostic test results to eight of the ten California Correctional Institution, Cycle 4 Medical Inspection Page 16 Office of the Inspector General State of California patients (80 percent). The provider both reviewed the diagnostic report and communicated the results only one day late to one patient; for another, the provider reviewed the report eight days late and communicated the results to the patient ten days late (MIT 2.002, 2.003). Laboratory Services  Patients received timely laboratory services for all ten inmate-patients sampled (MIT 2.004). Providers also timely reviewed diagnostic test results for eight of those patients (80 percent); the provider reviewed one document one day late, and another, seven days late (MIT 2.005). Finally, providers timely communicated the results to seven of the patients (70 percent); delinquent communications were between one and seven days late (MIT 2.006). Pathology Services  For nine of ten inmate-patients sampled (90 percent), the institution timely received the final diagnostic pathology reports and the providers timely reviewed the results. The institution received a final report 28 days late for one patient, and a provider reviewed a final report 37 days late for another patient (MIT 2.007, 2.008). Also, providers timely communicated the final results to seven of the ten inmate-patients (70 percent); one patient received his results eight days late; another, 37 days late; and one patient did not receive results from the provider at all (MIT 2.009). Recommendations No specific recommendations. California Correctional Institution, Cycle 4 Medical Inspection Page 17 Office of the Inspector General State of California EMERGENCY SERVICES An emergency medical response system is essential to providing Case Review Rating: effective and timely emergency medical response, assessment, Inadequate treatment, and transportation 24 hours per day. Provision of Compliance Score: urgent/emergent care is based on a patient’s emergency situation, Not Applicable clinical condition, and need for a higher level of care. The OIG reviews emergency response services including first aid, basic life Overall Rating: support (BLS), and advanced cardiac life support (ACLS) Inadequate consistent with the American Heart Association guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care, and the provision of services by knowledgeable staff appropriate to each individual’s training, certification, and authorized scope of practice. The OIG evaluates this quality indicator entirely through clinicians’ reviews of case files and conducts no separate compliance testing element. Case Review Results The OIG clinicians reviewed 63 urgent/emergent events and found 52 deficiencies, mainly in the area of nursing care. Provider Performance While providers covering the triage and treatment area (TTA) generally made appropriate triage decisions and sent patients to the appropriate levels of care, there were some notable exceptions. These cases are also addressed in the Quality of Provider Performance section.  In case 7, a patient with possible epiglottitis (a potentially life-threatening illness) was transferred to the local hospital by State vehicle rather than by ambulance.  In case 9, a patient with a possible drug overdose was not given activated charcoal and was transferred to the local hospital by State vehicle rather than by ambulance.  In case 10, the patient complained of chest pain, throat pressure, cough, and shortness of breath, and the TTA RN noted he was in “mild distress” with “much coughing.” This patient was also transferred to the local hospital by State vehicle rather than by ambulance.  In case 62, the patient presented with complaints of headache and dizziness; an exam revealed left upper extremity weakness. With the provider’s documentation indicating a possible stroke, aspirin should not have been given until bleeding in the brain had been ruled out. California Correctional Institution, Cycle 4 Medical Inspection Page 18 Office of the Inspector General State of California Nursing Performance Several concerns were identified regarding nursing performance within urgent/emergent services. Nurses routinely failed to provide thorough, appropriate “chest pain” care. Assessments were often incomplete and lacked necessary documentation. There were delays in provider notification and ambulance request.  In case 1, the patient had chest pain on two occasions. In both events the nurse failed to administer additional nitroglycerin when chest pain continued and vital signs were stable. Additionally, the nursing assessments were incomplete.  In case 2, the patient had left chest pain at rest for which only one dose of nitroglycerin was administered. The nurse failed to administer additional nitroglycerin when chest pain continued and vital signs were stable.  In case 10, the patient had chest pain with radiation at rest. An EKG was performed and was abnormal. The nurse failed to promptly contact a provider, failed to administer aspirin and nitroglycerin, and failed to assess vital signs for 40 minutes. Also in case 10 but during a separate event, the patient presented with chest pain, shortness of breath, anxiety, dizziness, and tingling hands. The RN noted the patient was anxious and hyperventilating. An EKG was performed. The nurse inappropriately released the patient without reassessing his blood pressure or contacting a PCP.  In case 12, three emergency events displayed deficiencies. The first event occurred when the patient was transported by wheelchair to the TTA. He had become dizzy and had fallen. The nurse failed to document details of the event, such as who transported the patient to the TTA and whether the patient was “man down.” In the second event, he presented to the TTA with chest pain and was found to be hypertensive and tachycardic. One dose of nitroglycerin was administered without relief. The nurse failed to administer additional nitroglycerin. In the third event, he also had chest pain and was hypertensive. The nurse failed to perform a thorough assessment and administer additional nitroglycerin.  In case 15, the patient presented with chest pain at rest. The patient’s EKG was abnormal. The nurse failed to administer aspirin and nitroglycerin, failed to assess vital signs for 31 minutes, and failed to obtain intravenous access prior to transferring the patient to a community hospital.  In case 62, the patient was assessed as being “near syncope” (nearly unconscious). He was found face down, heavily perspiring, and pale, and he could not independently answer questions or follow commands. The nurse failed to assess extremities for weakness and did not attempt to contact a provider for approximately 90 minutes. California Correctional Institution, Cycle 4 Medical Inspection Page 19 Office of the Inspector General State of California Some concerns were also noted in the management of respiratory distress.  In case 4, the patient was short of breath. Documentation did not clearly indicate events prior to the patient’s arrival to the TTA. Upon arrival to the TTA, the nurse noted the patient was pale and “gasping for air,” his oxygen saturation was low at 83 percent, he was not able to speak normally, and he was using accessory muscles to breathe. The nurse failed to reassess blood pressure, pulse, and respirations for 23 minutes; failed to monitor cardiac rate and rhythm and the amount of oxygen given; failed to obtain intravenous access; failed to document the time of physician contact; and failed to promptly arrange a higher level of care transport, which occurred after 1 hour and 20 minutes. Events prior to patients’ TTA arrivals were frequently not found in the eUHR. This lack of documentation affected the OIG’s ability to assess the totality of these events and form conclusions.  In case 3, the patient was referred to the TTA to prepare for an unscheduled ambulance transport. The nurse failed to perform an assessment, did not assess vital signs, and did not document the site at which intravenous access was established or the time of ambulance arrival and departure.  In case 10, the patient presented to the TTA with abdominal pain. The nurse failed to document that the patient was “man down” and required wheelchair transport. In addition, the first medical response documentation was not present in the eUHR. Emergency Medical Response Review Committee The Emergency Medical Response Review Committee (EMRRC) reviewed all death incidents but often failed to review the unscheduled urgent/emergent medical transfers out to community hospitals for higher levels of care. During the onsite visit, the chief nurse executive and director of nursing explained that the purpose of reviewing TTA nursing care by nursing supervisors was to identify training needs. However, the supervising RN (SRN) responsible for these reviews indicated that clinical reviews were not being completed. The following cases support the need for clinical review of all unscheduled urgent/emergent medical transfers out for higher level of care:  In case 1, two emergency events occurred. The patient experienced chest pain and was sent to a community hospital. A nursing supervisor performed an audit of this event and failed to identify the incomplete assessment and interventions. The second chest pain event occurred 18 days later, and involved deficiencies in nursing assessment and intervention. This second event was not reviewed.  In cases 2 and 5, the patients had chest pain and were sent to a community hospital for further treatment. These events were not reviewed. California Correctional Institution, Cycle 4 Medical Inspection Page 20 Office of the Inspector General State of California  In case 3, two unscheduled transports occurred in one month. The first event was not reviewed. The second event, which occurred in the OHU, was reviewed by the EMRRC. The delays in oxygen administration and lack of cardiac monitoring were not identified. The delay in ambulance request was inappropriately justified with the note “this gap pertains to doctor treatment.”  In case 4, the patient had difficulty breathing and was transferred to a community hospital. This event was not reviewed.  In case 10, the patient had chest pain and was transferred to a community hospital. The SRN performed an audit of this event but failed to identify the nurse’s deficiencies.  Case 12 had two urgent/emergent events, which led to unscheduled transports; neither was appropriately reviewed.  In cases 15 and 62, the unscheduled transports were not appropriately reviewed. Conclusion Emergency Services at CCI were found to be inadequate. The nurses routinely failed to demonstrate appropriate assessment and interventions. SRN audits failed to identify events with inadequate care. The leadership at CCI failed to follow the Emergency Medical Response Review process, and frequently failed to address incidents with inadequacies. Recommendations  The OIG recommends the cases identified above regarding provider performance be reviewed with the providers involved.  The OIG recommends nurses receive training in the appropriate assessment and treatment of chest pain and respiratory distress, and appropriate documentation; nursing supervisors responsible for performing audits receive training in the appropriate methodology for performing audits; and leadership at CCI review these audits to ensure adequacy.  The OIG recommends leadership implement a process to ensure that clinical staff document the events leading to patients’ arrivals at the TTA (CCHCS has first responder forms for these types of events). The OIG also recommends CCI leadership revise its EMRRC review process to expand the types of events requiring reviews, such as non-scheduled emergency transfers, to improve the adequacy of reviews and to enhance training for events found to be deficient. California Correctional Institution, Cycle 4 Medical Inspection Page 21 Office of the Inspector General State of California HEALTH INFORMATION MANAGEMENT (MEDICAL RECORDS) Health information management is a crucial link in the delivery of Case Review Rating: medical care. Medical personnel require accurate information in Adequate order to make sound judgments and decisions. This indicator Compliance Score: examines whether the institution adequately manages its health care 78.2% information. This includes determining whether the information is correctly labeled and organized and available in the electronic unit Overall Rating: Adequate health record (eUHR); whether the various medical records (internal and external, e.g., hospital and specialty reports and progress notes) are obtained and scanned timely into the inmate-patient’s eUHR; whether records routed to clinicians include legible signatures or stamps; and whether hospital discharge reports include key elements and are timely reviewed by providers. Case Review Results The OIG clinicians found minor to moderate deficiencies during case review of California Correctional Institution’s Health Information Management. Out of the 347 (total) deficiencies identified from the case reviews, 64 related to health information management processes. The OIG considered all but one of the deficiencies (case 28) unlikely to contribute to patient harm, so the case review rating is adequate. The OIG clinicians’ findings are identified in the following indicator subcategories: Inter-Departmental Transmission  The OIG clinicians found deficiencies related to orders not carried through to various departments. Examples include test results not found in the eUHR (it was unclear if they were performed) and specialty visits not being scheduled as requested. Hospital Records  Hospital records were generally retrieved, reviewed, and scanned into the eUHR in a timely manner. Specialty Services  Two Health Information Management deficiencies were related to providers failing to properly sign specialty services reports and the reports not being scanned into the eUHR in a timely manner. For case 28, the provider failed to sign a consult note prior to eUHR scanning. This resulted in a two-day delay for the patient receiving the recommended eye drops. Another deficiency related to a specialty report not found in the eUHR and one CCI provider’s illegible signature on a referral form. There was also one instance when a California Correctional Institution, Cycle 4 Medical Inspection Page 22 Office of the Inspector General State of California specialty or diagnostic report was not available for the specialist to review at the time of the specialty appointment. These findings are also discussed in the Specialty Services indicator. Diagnostic Reports  Diagnostic reports were generally reviewed and scanned into the eUHR in a timely manner. Urgent/Emergent Records  The handful of Health Information Management deficiencies relating to urgent/emergent records were due to illegible signatures and lack of time stamps. There were also some issues regarding the lack of first responder records prior to the patient’s arrival in the TTA. These issues are addressed in the Emergency Services section. Scanning Performance  While scanning times for most documents were adequate, there were a few deficiencies relating to scanning performance. As already noted, some documents were mislabeled or misfiled. Legibility  More than one-fourth of the Health Information Management deficiencies were related to illegible notes and signatures (without name stamps) for providers. This can pose a significant medical risk to patients, especially when these notes are required to be reviewed by other staff, such as when a patient is transferred to another care team or another institution. Legacy Notes  More than one-third of the Health Information Management deficient cases contained legacy notes. These notes were either cloned copies of prior notes with a few changes made or a compilation of notes from prior visits with a few sentences added. In many of these cases, portions of the notes were misleading as they had not been changed from prior visits. For example, in one case, physical exam notes documented a moderate-sized prostate after the patient had undergone surgery to remove the entire prostate. In another example, physical exam notes documented an ingrown nail even after it was removed. In yet another example, a patient who suffered from a lower extremity skin infection was repeatedly noted to have “moderate swelling, mild redness, tenderness, peeling, dried blisters.” In these same notes, it was noted the skin infection had resolved. In cases like these, the use of legacy notes brought into question whether providers were actually performing physical exams. Not only could this cause confusion for subsequent providers, it ultimately created a risk for harm to patients. California Correctional Institution, Cycle 4 Medical Inspection Page 23 Office of the Inspector General State of California Miscellaneous  There were a number of instances when provider and nursing notes, and sometimes other documents (referrals, refusals, etc.), were not found in the eUHR or were incorrectly filled out. With these notes not being found in the eUHR, the OIG clinicians could not ascertain whether they were lost prior to scanning or if they were written at all. Compliance Testing Results The institution received an adequate compliance score of 78.2 percent in the Health Information Management (Medical Records) indicator and has an opportunity for improvement in the following areas:  The institution scored 50 percent in its labeling and filing of documents scanned into inmate-patients’ electronic unit health records; the most common error was mislabeled documents, such as a radiology report scanned and labeled as a lab report (MIT 4.006).  The institution timely scanned specialty services consultant reports into the inmate-patient’s eUHR file within five days of the appointment (or service) for only 11 of the 20 documents reviewed (55 percent). Untimely scanning for eight specialty reports was between one and eight days late; one was untimely by 40 days (MIT 4.003).  When the OIG reviewed various medical documents, including hospital discharge reports, initial health screening forms, certain medication records, and specialty services reports, to ensure that clinical staff legibly documented their names on the forms, only 22 of 32 samples (69 percent) showed compliance (MIT 4.007).  The institution scored 70 percent for the timely scanning of dictated or transcribed provider progress notes into inmate-patients’ eUHR files. Timely scanning occurred within five days of the PCP visit with the patient for seven of the ten sampled documents; three exceptions were scanned between three and five days late (MIT 4.002). The institution performed well in its management of the following health care documents:  The institution timely scanned miscellaneous non-dictated documents into patients’ eUHRs, including providers’ progress notes and inmate-patients’ initial health screening forms and requests for health care services, for all 20 documents sampled (MIT 4.001). CCI also timely scanned all 20 medication administration records reviewed into patients’ eUHRs (MIT 4.005).  CCI timely scanned community hospital discharge reports or treatment records into patients’ eUHRs for 19 of the 20 sampled reports (95 percent); one report was untimely by 25 days (MIT 4.004). California Correctional Institution, Cycle 4 Medical Inspection Page 24 Office of the Inspector General State of California  The OIG reviewed eUHR files for 30 sampled patients sent or admitted to the hospital to determine if a CCI provider reviewed the patients’ hospital discharge reports or treatment records within three calendar days of discharge. Providers timely reviewed the records for 26 patients (87 percent). The provider reviewed the discharge report one day late for two patients and did not document the review date for another. Also, the institution did not receive a discharge report at all for one patient, and the OIG did not find evidence that CCI followed up with the hospital to obtain the information (MIT 4.008). CCHCS Dashboard Comparative Data As indicated below, the compliance results for CCI’s availability of non-dictated medical documents and community hospital discharge documents were consistent with CCI’s July 2015 Dashboard data; results varied only by three and five percentage points, respectively. However, for the two remaining measures, dictated and specialty documents, the OIG’s compliance results were much lower than the July Dashboard results. As noted in the following tables, the OIG testing results were based on its review of sampled documents that were up to 11 months old; CCI’s July Dashboard data reflected only the institution’s June 2015 results. This disparity in the sampling review periods for OIG compliance scores and Dashboard results may have contributed to the inconsistencies for those two measures. Health Information Management — CCI Dashboard and OIG Compliance Results CCI DASHBOARD RESULTS OIG COMPLIANCE RESULTS Availability of Health Information: Health Information Management (4.001) Non-Dictated Documents Non-Dictated Medical Documents July 2015 October 2014 – July 2015 97% 100% Note: The Dashboard results were obtained from the Non-Dictated Documents Drilldown data for “Medical Documents 3 Days.” CCI DASHBOARD RESULTS OIG COMPLIANCE RESULTS Availability of Health Information: Health Information Management (4.002) Dictated Documents Dictated Documents July 2015 August 2014 – July 2015 100% 70% Note: The Dashboard results were obtained from the Dictated Documents Drilldown data for “Medical Dictated Documents 5 Days.” California Correctional Institution, Cycle 4 Medical Inspection Page 25 Office of the Inspector General State of California CCI DASHBOARD RESULTS OIG COMPLIANCE RESULTS Availability of Health Information: Health Information Management (4.003) Specialty Notes Specialty Documents July 2015 October 2014 – March 2015 93% 55% Note: The Dashboard measure includes specialty notes from dental, optometry, and physical therapy appointments, which the OIG omits from its sample. CCI DASHBOARD RESULTS OIG COMPLIANCE RESULTS Availability of Health Information: Health Information Management (4.004) Community Hospital Records Community Hospital Discharge Documents July 2015 January 2015 – May 2015 100% 95% Recommendations Although the OIG found numerous issues related to Health Information Management, these issues are easily remedied.  The OIG recommends clinicians who review medical documents print their names or use name stamps in addition to their signatures or initials to improve legibility on all health care documents. For providers with illegible handwriting, the OIG recommends they be mandated to dictate or type notes.  The OIG recommends CCI implement a process requiring administrative staff members who scan health care documents to send notes and orders back to the provider if they are not time-stamped. The OIG further recommends that mislabeled and improperly scanned documents be targeted for accuracy improvement, even while the institution awaits the implementation of CDCR’s new electronic health record system.  The OIG recommends CCI prohibit clinicians’ use of legacy or cloned notes. California Correctional Institution, Cycle 4 Medical Inspection Page 26 Office of the Inspector General State of California HEALTH CARE ENVIRONMENT This indicator addresses the general operational aspects of the Case Review Rating: institution’s clinics, including certain elements of infection control Not Applicable and sanitation, medical supplies and equipment management, the Compliance Score: availability of both auditory and visual privacy for inmate-patient 84.4% visits, and the sufficiency of facility infrastructure to conduct comprehensive medical examinations. Overall Rating: Adequate Rating of this component is based entirely on the compliance testing results from the visual observations inspectors make at the institution during their onsite visit. Compliance Testing Results The institution received an adequate compliance score of 84.4 percent in the Health Care Environment indicator, scoring well in several test areas, as described below:  The institution appropriately disinfected, cleaned, and sanitized all seven clinics observed (MIT 5.101). Also, the seven clinics all had operable sinks and sufficient quantities of hygiene supplies in clinical areas (MIT 5.103).  OIG inspectors observed clinicians’ encounters with patients in six clinics and found that all clinicians followed good hand hygiene practices (MIT 5.104).  The institution’s non-clinic bulk medical supply storage area properly followed the supply management process and supported the needs of the medical health care program, resulting in a score of 100 percent (MIT 5.106).  All seven of CCI’s clinics had an adequate environment conducive to providing medical services (MIT 5.109).  When inspecting for proper protocols to mitigate exposure to blood-borne pathogens and contaminated waste, the OIG inspectors found six of the seven clinics (86 percent) compliant. In one clinic, the PCP exam room did not have a puncture-resistant container available to medical staff for expended needles/sharps (MIT 5.105). California Correctional Institution, Cycle 4 Medical Inspection Page 27 Office of the Inspector General State of California  Inspectors found that six of the seven clinics (86 percent) followed adequate medical supply storage and management protocols. As shown in Figure 1, one clinic’s storage room for bulk medical supplies was not orderly, making it difficult to easily identify supplies; the room was cluttered and some supplies were stored on the floor (MIT 5.107).  Inspectors examined emergency response bags to Figure 1: Disorganized bulk supply determine if the bags were inspected daily and storage room inventoried monthly, and whether they contained all essential items; bags were compliant in six of the seven clinical locations where they were stored (86 percent). While medical staff timely inspected and inventoried all emergency response bags, one bag did not contain a required non-rebreather oxygen mask (MIT 5.111). The institution has room for improvement in the following three areas:  Inspectors found the institution furnished three of the seven clinics (43 percent) with essential supplies and core equipment necessary to conduct a comprehensive exam. Examples of deficiencies included missing hemoccult cards and a developer in one PCP exam room, expired or unmarked equipment calibrations, and no permanent distance marker for the Snellen vision chart. Moreover, inspectors noted that, based on the eye chart’s fixed location, the maximum distance available to a patient from the chart was approximately 14 feet instead of the standard distance of 20 feet (MIT 5.108).  In only four of seven applicable clinics inspected (57 percent), clinical health care staff ensured that reusable invasive and non-invasive medical equipment was properly sterilized or disinfected. Inspectors observed sterilized instruments hung by their packaging in specialty clinics; at each of three clinic locations, inspectors noted one instrument bag with a hook or nail puncture below its seal (see Figure 2), resulting in contamination Figure 2: Equipment contamination of the instrument. Inspectors also observed that a PCP failed to change the exam table paper between examinations in one clinic (MIT 5.102). California Correctional Institution, Cycle 4 Medical Inspection Page 28 Office of the Inspector General State of California  The OIG inspected exam rooms in CCI’s clinics and found that five of the seven clinical exam rooms or treatment spaces observed (71 percent) had sufficient space, configuration, supplies, and equipment to allow clinicians to perform a proper clinical exam. One treatment space was too small to allow for adequate inmate-patient examinations, and as shown in Figure 3, the placement of the exam table in another room did not allow the patient to lie in a fully extended supine position on the table (MIT 5.110). Figure 3: Poor exam table placement Other Information Obtained from Non-Scored Results The OIG gathered information to determine if the institution’s physical infrastructure was maintained in a manner that supported health care management’s ability to provide timely or adequate health care. This question is not scored and is only collected and reported for informational purposes. When OIG inspectors interviewed health care management, staff did not express concerns about the facility’s infrastructure or its effect on staff’s ability to provide adequate health care. At the time of the inspection, the institution had a master infrastructure project underway, which included renovating CCI’s radiology room and enlarging multiple primary care clinics, as well as constructing new buildings for two primary care clinics, a pharmacy, and laboratory services. According to management staff, the project was on track with completion dates targeted for September 2017 (MIT 5.999). Recommendations While most compliance scores were within the proficient range for this indicator, the institution had deficiencies in a few areas and could easily improve its overall score by implementing the following specific recommendations:  To mitigate contamination of reusable invasive and non-invasive medical equipment, store this equipment in a protected area that does not involve puncturing the equipment packaging.  Properly maintain and stock clinic areas with a full complement of core equipment, including permanent distance markers for Snellen vision charts at the standard distance of 20 feet. Stock the exam rooms where providers work with hemoccult cards and a developer.  Monitor calibration expiration dates for applicable medical equipment to ensure equipment items are calibrated within required time frames and calibration dates are clearly documented. California Correctional Institution, Cycle 4 Medical Inspection Page 29 Office of the Inspector General State of California  Position exam tables in exam rooms so a patient can lie fully extended on the exam table and clinicians can have unimpeded access to the patient. California Correctional Institution, Cycle 4 Medical Inspection Page 30 Office of the Inspector General State of California INTER- AND INTRA-SYSTEM TRANSFERS This indicator focuses on the management of inmate-patients’ Case Review Rating: medical needs and continuity of patient care during the inter- and Adequate intra-facility transfer process. The patients reviewed for Inter- and Compliance Score: Intra-System Transfers include inmates received from other CDCR 84.1% facilities and inmates transferring out of CCI to another CDCR Overall Rating: facility. The OIG review includes evaluation of the institution’s Adequate ability to provide and document health screening assessments, initiation of relevant referrals based on patient needs, and the continuity of medication delivery to patients arriving from another institution. For those patients, the OIG clinicians also review the timely completion of pending health appointments, tests, and requests for specialty services. For inmate-patients who transfer out of the facility, the OIG evaluates the ability of the institution to document transfer information that includes pre-existing health conditions, pending appointments, tests and requests for specialty services, medication transfer packages, and medication administration prior to transfer. The OIG clinicians also evaluate the care provided to patients returning to the institution from an outside hospital and check to ensure appropriate implementation of the hospital assessment and treatment plans. Case Review Results The OIG clinicians reviewed 42 encounters relating to Inter- and Intra-System Transfers, including information from both the sending and receiving institutions. Additionally, the clinicians reviewed 60 hospitalization-related events. Twenty-eight of these events were actual hospitalizations or emergency room visits, the majority of which resulted in transfers back to the institution (a few events resulted in transfers to other hospitals or patient deaths). In general, CCI’s Inter- and Intra-System Transfers processes were adequate. The majority of the deficiencies found related to incomplete Health Care Transfer Information forms (CDCR 7371) for patients leaving CCI. Specifically, the medical history, significant events, and pending appointments were not always complete. Specific examples of case review findings are listed below. Transfers In Nurses generally performed adequate intake assessments and ensured continuity of medications. Transfers Out  In case 3, the nurse failed to list the medical diagnoses of esophagitis and gastritis. The nurse also omitted the patient’s last chronic care visit.  In case 34, the nurse failed to list pending endocrinology and cardiology specialty appointments. California Correctional Institution, Cycle 4 Medical Inspection Page 31 Office of the Inspector General State of California  In case 35, the nurse failed to document a recent suicide attempt. Hospitalizations Patients returning from hospitalizations are some of the highest risk encounters due to two factors. First, these patients are generally hospitalized for a severe illness or injury. Second, they are at risk due to potential lapses in care that can occur during any transfer. At CCI, Facility B TTA or OHU nurses assessed patients returning from hospitals. Follow-up by the primary care providers was generally timely. A few minor deficiencies were noted:  In case 12, a medication reconciliation did not occur, resulting in failure to discontinue ibuprofen and to start nitroglycerin as the hospital recommended. Failure to perform a medication reconciliation also occurred in case 5.  In cases 2 and 10, the nurses failed to document review and receipt of hospital discharge records and recommendations. Onsite Visit While the OIG was onsite, nursing supervisors shared recent nurse training documentation specific to patient transfers. This training was conducted in June 2015. Since that training, nurses were utilizing the “Patient Care Summary” to assist in completing the Health Care Transfer form (CDCR 7371). The OIG believes this training will improve some of the transfer problems. Compliance Testing Results The institution obtained an adequate compliance score of 84.1 percent in the Inter- and Intra-System Transfers indicator; however, it scored within the proficient range in three of the five areas tested, as described below:  The institution scored 100 percent when the OIG tested one inmate-patient who transferred out of the institution during the onsite inspection to determine whether his transfer package included the required medications and related documentation. Although two inmates transferred out on the testing day, only one was prescribed medications (MIT 6.101).  Inspectors tested 29 inmate-patients who transferred into CCI from another CDCR institution and found that for 26 of them (90 percent), nursing staff completed the assessment and disposition section of the Initial Health Screening (CDCR Form 7277) on the same day staff completed an initial screening of the patient. For three patients, nursing staff did not sign and date the form in the “RN Assessment/Disposition” section. Additionally, for one of those patients, the initial screening revealed that the patient experienced unexplained signs and symptoms associated with tuberculosis, but the nurse failed to immediately refer the inmate-patient to the TTA for a clinical evaluation (MIT 6.002). California Correctional Institution, Cycle 4 Medical Inspection Page 32 Office of the Inspector General State of California  Fourteen of the sampled inmate-patients who transferred into CCI had an existing medication order upon arrival. Inspectors found that 12 of those patients (86 percent) received their medications without interruption; nursing staff failed to reissue medications to two patients upon their arrival (MIT 6.003). The institution scored within the adequate range for the following test:  The institution scored 75 percent when the OIG tested 20 inmate-patients who transferred out of CCI to another CDCR institution to determine whether CCI listed the patients’ pending specialty service appointments on the Health Care Transfer Information form (CDCR Form 7371). The institution failed to include specialty service appointments on the transfer forms for five patients (MIT 6.004). The institution has an opportunity to improve in the following area:  The OIG reviewed the initial health screenings for 30 inmate-patients who transferred into CCI from another CDCR institution and found nursing staff conducted timely and complete screenings for only 21 of the patients sampled (70 percent). For nine patients, the nurse neglected to answer or insufficiently completed one or more of the screening form questions. Missing information related to medications prescribed, mental health and medical conditions, specialty appointments pending, and allergies (MIT 6.001). Recommendations The institution can easily improve its overall rating of adequate for this indicator. The OIG makes the following specific recommendations:  Leadership has an opportunity to improve continuity of health care information by developing a transfer audit tool. This tool should assess each component essential for transfer continuity and evaluate data accuracy and thoroughness.  Improvement can also occur for patients arriving without essential medications by tracking these omissions and reporting them to the sending institution. This practice (already underway at the California Rehabilitation Center), if implemented statewide, can be the first step in creating statewide medication accountability.  The OIG recommends that CCI implement formal training, along with audits and competency testing, for nurses who complete Initial Health Screening forms (CDCR Form 7277) and Health Care Transfer Information forms (CDCR Form 7371). California Correctional Institution, Cycle 4 Medical Inspection Page 33 Office of the Inspector General State of California PHARMACY AND MEDICATION MANAGEMENT This indicator is an evaluation of the institution’s ability to provide Case Review Rating: appropriate pharmaceutical administration and security Adequate management, encompassing the process from the written Compliance Score: prescription to the administration of the medication. By combining 93.2% both a quantitative compliance test with case review analysis, this assessment identifies issues in various stages of the medication Overall Rating: Adequate management process, including ordering and prescribing, transcribing and verifying, dispensing and delivering, administering, and documenting and reporting. Because effective medication management is affected by numerous entities across various departments, this assessment considers internal review and approval processes, pharmacy, nursing, health information systems, custody processes, and actions taken by the PCP prescriber, staff, and patient. For this indicator, the OIG’s case review and compliance review processes yielded different results, with the case review giving an adequate rating and the compliance review resulting in a proficient score. The OIG’s internal review process considered those factors that led to both scores and ultimately rated this indicator adequate. The key factor was the failure of this system to assure medications were timely discontinued, when required. As a result, the case review results were deemed a more accurate reflection of the appropriate overall indicator rating. Case Review Results Case review found that for the majority of cases, patients received their medications timely and as prescribed. However, the following four cases are examples in which patients mistakenly received medications despite providers’ orders that the medications were to be discontinued or held.  In case 9, the ophthalmologist recommended a certain eye drop be stopped. This eye drop continued despite the order to discontinue.  In case 12, the patient received ibuprofen on three separate occasions after an order to discontinue.  In case 13, orders were given to stop medications for pain and cancer treatment as the patient was found to be noncompliant. This order was not followed, and the patient continued to receive these medications.  In case 20, the provider ordered blood-thinning medication stopped due to excessive levels as measured by the INR test at 4.7. Because of this order not being followed, the INR further increased to 6.2 and placed the patient at a higher risk for bleeding. California Correctional Institution, Cycle 4 Medical Inspection Page 34 Office of the Inspector General State of California Compliance Testing Results The institution received a proficient compliance score of 93.2 percent for the Pharmacy and Medication Management indicator. For discussion purposes below, this indicator is divided into three sub-indicators: Medication Administration, Observed Medication Practices and Storage Controls, and Pharmacy Protocols. Medication Administration For this sub-indicator, the institution received an average score of 85 percent and performed well in the following areas:  Nursing staff administered medications without interruption to one inmate-patient who was en route from one institution to another and had a temporary layover at CCI, resulting in a score of 100 percent. The four other patients en route during the testing time period were not taking medications (MIT 7.006).  The institution administered new medication orders to patients timely for 26 of 30 samples the OIG reviewed, receiving a proficient score of 87 percent for this test. Three patients received medications between one and six days late, while one patient did not receive his medication at all (MIT 7.002).  CCI ensured that 25 of 30 patients sampled (83 percent) received their medications without interruption when they transferred from one housing unit to another; the remaining five patients did not receive their medication at the proper dosing interval (MIT 7.005).  Inmate-patients timely received chronic care medications for 21 of 27 samples the OIG reviewed (78 percent). One patient did not receive all ordered medications or receive required counseling for missed doses, and five patients did not receive their medications at all (MIT 7.001).  The institution timely provided hospital discharge medications to 23 of 30 patients sampled who had returned from a community hospital (77 percent); the remaining seven patients received their medications from one to three days late (MIT 7.003). California Correctional Institution, Cycle 4 Medical Inspection Page 35 Office of the Inspector General State of California Observed Medication Practices and Storage Controls For this sub-indicator, the institution received an average score of 94 percent and performed well in the following four areas:  The institution employed strong medication security controls over narcotic medications in all seven clinic and medication line locations inspected that stored narcotics (MIT 7.101).  The institution properly stored non-narcotic medications that do not require refrigeration at all 13 of the applicable clinics and medication line storage locations sampled (MIT 7.102).  At all six medication preparation and administration locations inspectors observed, nursing staff followed proper hand hygiene protocols when administering medications to patients (MIT 7.104).  Nursing staff also practiced appropriate administrative controls and protocols during medication preparation at all six locations tested (MIT 7.105). CCI has an opportunity for improvement in the following two areas:  The institution properly stored non-narcotic medications that require refrigeration at five of the six applicable clinics, receiving a score of 83 percent (MIT 7.103).  When observing the medication distribution process at six pill line locations, inspectors found that five (83 percent) were compliant with appropriate administrative controls and protocols. One clinic postponed the morning pill-pass time by over an hour, thereby compromising dosing intervals (MIT 7.106). Pharmacy Protocols For this sub-indicator, the institution received 100 percent in all five of the main pharmacy related tests, as follows:  In its main pharmacy, the institution followed general security, organization, and cleanliness management protocols; properly stored non-refrigerated and refrigerated medications; and maintained adequate controls and properly accounted for narcotic medications (MIT 7.107, 7.108, 7.109, 7.110).  The pharmacist-in-charge followed key medication error reporting protocols (MIT 7.111). Other Information Obtained from Non-Scored Results In addition to testing reported medication errors, OIG inspectors follow up on any significant medication errors found during the case reviews or compliance testing to determine whether the California Correctional Institution, Cycle 4 Medical Inspection Page 36 Office of the Inspector General State of California institution properly identified and reported errors. At CCI, the OIG did not find any applicable medication errors (MIT 7.998). The OIG tested inmate-patients in isolation units to determine if they had immediate access to their prescribed keep-on-person (KOP) rescue inhalers and nitroglycerin medications. Fourteen of the 15 inmates interviewed (94 percent) had access to their rescue medications; custody confiscated one patient’s asthma rescue inhaler because it did not have proper labeling. While the patient had been without his rescue inhaler for two weeks, the institution reissued a new one while the OIG was onsite (MIT 7.999). CCHCS Dashboard Comparative Data The Dashboard uses performance measures from the Medication Administration Process Improvement Program (MAPIP) audit tool to calculate the average score for its Medication Administration measure. The OIG compared similar CCI compliance scores with applicable July 2015 Dashboard results. As noted in the table below, the OIG based its compliance on a review of current documents as well as documents dating up to nine months back; CCI’s July Dashboard data reflected only the institution’s June 2015 results. Given these variable time frames, the OIG’s score was 14 percentage points lower than the Dashboard score with regard to medication administration. Pharmacy and Medication Management — CCI Dashboard and OIG Compliance Results CCI DASHBOARD RESULTS OIG COMPLIANCE RESULTS Medication Administration (7.001, 7.002) Medication Management: (Chronic Care & New Meds) Medication Administration Preventive Services (9.001) (Administering INH Medication) July 2015 October 2014 – July 2015 98% 84% Note: The Dashboard results were obtained from the Medication Administration Drilldown data for Chronic Care Meds — Medical; New Outpatient Orders — Medical; New Outpatient Orders — Psychiatric; and Administration — TB Medications. Variances may exist because CCHCS includes medication administration of KOP medications only for the first two drilldown measures, while the OIG tests KOP, DOT, and nurse-administered (NA) medication administration. Recommendations No specific recommendations. California Correctional Institution, Cycle 4 Medical Inspection Page 37 Office of the Inspector General State of California PREVENTIVE SERVICES This indicator assesses whether the institution offers or provides Case Review Rating: various preventive medical services to inmate-patients. These Not Applicable include cancer screenings, tuberculosis screenings, and influenza Compliance Score: and chronic care immunizations. This indicator also assesses 88.8% whether certain institutions take preventive actions to relocate Overall Rating: inmate-patients identified as being at higher risk for contracting Proficient coccidioidomycosis (valley fever). Compliance Testing Results The institution performed proficiently with a score of 88.8 percent in the Preventive Services indicator. As indicated below, the institution scored at the proficient level in all but one test for this indicator:  The OIG found that all 30 inmate-patients sampled received annual tuberculosis screenings (MIT 9.003).  Inmate-patients timely received or were timely offered influenza vaccinations during the most recent influenza season for all 30 patients sampled (MIT 9.004).  The institution offered colorectal cancer screenings to all 30 sampled inmate-patients subject to the annual screening requirement (MIT 9.005).  The OIG tested whether the institution offered required influenza, pneumonia, and hepatitis vaccinations to patients who suffered from a chronic care condition and found that 19 of the 20 patients sampled (95 percent) received them; one patient was not offered one or more of the vaccinations (MIT 9.008).  The institution scored 87 percent for administering anti-tuberculosis medications (INH) to inmate-patients; 26 of 30 patients sampled timely received all required INH doses during the three-month test period, while the medication administration records indicated one or more missed doses for the remaining four patients (MIT 9.001). Also, the institution completed the required monthly tuberculosis monitoring for 27 of the patients (90 percent), but failed to consistently document the patient’s weight and applicable weight change for three patients during the test period (MIT 9.002). The institution scored low in the following key preventive services test:  The OIG tested two inmate-patients who during the test period were medically restricted from CCI because of their high risk of coccidioidomycosis infection (valley fever). California Correctional Institution, Cycle 4 Medical Inspection Page 38 Office of the Inspector General State of California Inspectors found CCI transferred one patient from the institution timely, scoring 50 percent; the other patient tested was transferred 15 days late (MIT 9.009). CCHCS Dashboard Comparative Data As indicated below, the OIG’s proficient compliance results for colon cancer screening agreed with the data reported within the CCHCS Dashboard for CCI. Preventive Services — CCI Dashboard and OIG Compliance Results CCI DASHBOARD RESULTS OIG COMPLIANCE RESULTS Colon Cancer Screening Colon Cancer Screening (9.005) July 2015 July 2015 100% 100% Recommendations No specific recommendations. California Correctional Institution, Cycle 4 Medical Inspection Page 39 Office of the Inspector General State of California QUALITY OF NURSING PERFORMANCE The Quality of Nursing Performance indicator is a qualitative Case Review Rating: evaluation of the institution’s nursing services. The evaluation is Adequate completed entirely by OIG nursing clinicians within the case Compliance Score: review process, and, therefore, does not have a score under the Not Applicable compliance testing component. The OIG nurses conduct case reviews that include reviewing face-to-face encounters related to Overall Rating: nursing sick call requests identified on the Health Care Services Adequate Request form (CDCR Form 7362), urgent walk-in visits, referrals for medical services by custody staff, RN case management, RN utilization management, clinical encounters by licensed vocational nurses (LVNs) and licensed psychiatric technicians (LPTs), and any other nursing service performed on an outpatient basis. The OIG case review also includes activities and processes performed by nursing staff that are not considered direct patient encounters, such as the initial receipt and review of CDCR Form 7362 service requests and follow-up with primary care providers and other staff on behalf of the patient. Key focus areas for evaluation of outpatient nursing care include appropriateness and timeliness of patient triage and assessment, identification and prioritization of health care needs, use of the nursing process to implement interventions including patient education and referrals, and documentation that is accurate, thorough, and legible. Nursing services provided in the outpatient housing unit (OHU), correctional treatment center (CTC), or other inpatient units are reported under the Specialized Medical Housing indicator. Nursing services provided in the triage and treatment area (TTA) or related to emergency medical responses are reported under Emergency Services. Case Review Results OIG nursing clinicians rated the Quality of Nursing Performance at CCI adequate. The OIG clinicians evaluated 346 nursing encounters for CCI case reviews; 128 of these were outpatient-nursing encounters with 52 deficiencies. Despite the large number of deficiencies relative to encounters, case reviews demonstrated most triage RN deficiencies were minor in nature and resulted in generally satisfactory outcomes. However, case reviews also revealed deficiency patterns that affected the quality of outpatient nursing performance in the areas of triage, assessment, and documentation. The Quality of Nursing Performance deficiencies included the following: Nursing Assessment/Documentation  In case 8, the patient submitted a complaint for ear pain and “multiple muscle pain.” The nurse failed to assess both complaints. Failure to assess all complaints was also seen in cases 11, 18, and 48. The OIG clinicians also found two encounters with deficiencies in case 11. A supervising registered nurse (SRN) at CCI audited the same encounters, but found them adequate. California Correctional Institution, Cycle 4 Medical Inspection Page 40 Office of the Inspector General State of California  In case 12, the patient was seen for postsurgical pain with high blood pressure (168/100). The nurse failed to conduct a thorough assessment prior to contacting the primary care provider and did not recognize an elevated blood pressure as a potential sign of pain.  In case 13, the patient submitted a complaint for a dressing change, dry hands, and chest pain. The triage nurse failed to conduct an urgent face-to-face assessment. The next day the patient was seen in the medical clinic, and the nurse failed to document a chest pain assessment. A SRN audited this event and found adequate care.  In case 16, the patient complained of left leg inflammation and swelling after an injury two days prior. The nurse failed to conduct an urgent face-to-face assessment. Failure to provide urgent triage was also seen in case 15. Onsite Inspection The OIG clinicians reviewed selected face-to-face nursing supervisor audits during the onsite visit. The OIG found SRNs failed to identify deficiencies the OIG clinicians identified during the case reviews. Similar concerns emerged regarding audits of urgent/emergent events and are discussed in the Emergency Services section. Conclusion The outpatient nursing care at CCI was rated adequate. However, nursing performance displayed patterns of poor nursing assessment, documentation, and triage. Because most complaints were minor in nature, these failures did not negatively affect the overall care. Still, a thorough assessment is an essential nursing function and must be accurately completed and documented. The pattern of poor nursing performance was compounded by inadequate nursing supervisor audits that failed to identify these deficiencies. Recommendations The OIG recommends the nursing sick call audit process be revised, as the method being used at the time of the inspection did not identify nursing deficiencies. The audit process should include documentation of the supervisors’ evaluation of the nurse’s knowledge and ability to assess patients and perform appropriate nursing services, and the interventions carried out to improve the quality of nursing care. California Correctional Institution, Cycle 4 Medical Inspection Page 41 Office of the Inspector General State of California QUALITY OF PROVIDER PERFORMANCE In this indicator, the OIG physicians provide a qualitative Case Review Rating: evaluation of the adequacy of provider care at the institution. Adequate Appropriate evaluation, diagnosis, and management plans are Compliance Score: reviewed for programs including, but not limited to, nursing sick Not Applicable call, chronic care programs, TTA, specialized medical housing, and specialty services. The assessment of provider care is Overall Rating: performed entirely by OIG physicians. There is no compliance Adequate testing component associated with this quality indicator. Case Review Results The OIG clinicians reviewed 528 medical provider encounters at CCI and identified 76 deficiencies related to provider performance. Of those 76, 15 were considered serious enough to put patients at an increased risk of harm. Five of these 15 more serious deficiencies were caused by one provider. Assessment and Decision-Making Twenty-five of the provider deficiencies were related to provider assessments and decision-making. These deficiencies ranged from incomplete documentation (to support assessments and plans) to assessments and plans being inappropriate.  In case 3, a patient’s recent hospital diagnosis of severe esophagitis and gastritis was lost after another hospitalization for a possible transient ischemic attack (temporary stroke). As a result, in addition to proper medications not being prescribed for the esophagitis and gastritis, medications known to exacerbate esophagitis and gastritis were prescribed.  In the same case, a provider failed to perform and document a neurological exam despite the patient recently being discharged with a possible transient ischemic attack (symptoms of impending stroke), and still complaining of right-sided weakness.  In case 12, a provider failed to document a pertinent history when the patient presented with abdominal pain. Despite a urinalysis showing the possibility of a urinary tract infection, the provider failed to provide treatment.  In case 18, documentation in the progress note failed to support a diagnosis of purulent rhino-sinusitis (a sinus infection that requires antibiotics), for which antibiotics was prescribed.  In case 27, the patient’s urinary incontinence and urinary tract infections (following surgery for prostate cancer) were not adequately treated. Documentation of progress notes was also insufficient. California Correctional Institution, Cycle 4 Medical Inspection Page 42 Office of the Inspector General State of California Review of Records Thirteen of the provider care deficiencies were related to records not being adequately reviewed. This resulted in unnecessary send-outs (to the local hospitals), unnecessary tests, and inappropriate orders. This also led to inaccurate notifications of test results to patients and follow-up with specialists not occurring. Some examples are listed below:  In case 1, incomplete review of records led to the patient being sent out for a possible heart attack just a few weeks after a negative cardiac stress test (indicating a healthy heart). This incomplete review of records also resulted in unnecessarily repeating certain diagnostic tests, i.e., a chest x-ray and labs.  In case 4, a provider sent notification to the patient indicating his chest x-ray was “essentially within normal limits” or “unchanged and no other provider follow-up is required.” The chest x-ray actually showed a right central fullness versus mass, for which a follow-up chest x-ray or CT scan was recommended (there were no prior imaging studies in the eUHR to indicate this was an “unchanged” or stable finding).  In case 7, a “stat” neck x-ray was not reviewed until the following day. When it was reviewed, the provider sent notification to the patient noting the cervical spine x-ray was negative or unchanged, when, in fact, the results noted a possibility of epiglottitis (a potentially life-threatening infection of the throat).  In cases 12 and 29, it was apparent providers did not review records as the assessments and plans were not up to date.  In case 17, warfarin was adjusted twice after a provider failed to note another provider had already made adjustments for an abnormally high blood coagulation test (indicating a high bleeding risk).  In case 27, insufficient provider documentation indicated a provider did not review records, which should have prompted a discussion with the patient to encourage follow-up with specialists (this patient with recent surgery for prostate cancer had failed to follow-up with urology and oncology). The lack of adequate review of records may have also contributed to suboptimal treatment of urinary tract infections.  In case 29, after more recent labs were not reviewed, the same labs were unnecessarily reordered. In case 30, a lack of review resulted in a CT being reordered despite one having been done just three weeks prior. California Correctional Institution, Cycle 4 Medical Inspection Page 43 Office of the Inspector General State of California Emergency Care The quality of provider performance as it related to emergency care was generally adequate. However, a few deficiencies were noted. The seriousness of some of these deficiencies is reflected in the Emergency Services indicator summary.  In case 7, a provider noted the patient had possible epiglottitis and admitted the patient to the outpatient housing unit. As epiglottitis is a life-threatening condition, the patient should have immediately transferred to a higher level of care (instead of the outpatient housing unit).  In the same case, after a nurse contacted another provider and recommended the patient be transferred out, the provider ordered the patient be transferred via State vehicle rather than by ambulance.  In case 9, the patient was seen in the TTA for a possible drug overdose. Activated charcoal (which can be effective at reducing drug absorption) should have been administered but was not. In addition, when the patient was sent out for further evaluation and treatment, the transfer should have been via ambulance rather than State vehicle.  In case 10, based on the patient’s symptoms (“epigastric chest pain, throat pressure, dyspnea, and cough”) and exam (“mild distress, much coughing”), the patient should have been transferred out in an ambulance rather than a State vehicle.  In case 62, the patient presented with complaints of headache and dizziness, and exam revealed left hand weakness. With the provider’s documentation indicating a possible stroke, aspirin should not have been given until bleeding in the brain had been ruled out. Chronic Care Twenty of the provider deficiencies noted were due to the delivery of chronic care being inadequate. Six of these deficiencies were the result of inadequate anticoagulation management by one provider (in case 21).  The management of anticoagulation was inadequate in cases 14, 17, and 21. In case 21, various aspects of this patient’s anticoagulation were repeatedly mismanaged; the warfarin dosing was deficient despite pharmacy recommendations (which appeared to have been ignored by the providers); and CCHCS guidelines were not followed, with timing of lab draws and follow-up intervals being inappropriate.  Elevated blood pressures were not adequately addressed in cases 16 and 29.  In cases 7, 24, 25, and 29, the management of diabetes was suboptimal at times. California Correctional Institution, Cycle 4 Medical Inspection Page 44 Office of the Inspector General State of California  In case 22, this patient with uncontrolled gastroesophageal reflux disease (GERD) continued to receive naproxen (known to exacerbate GERD). Specialty Services Review of the specialty services referrals revealed that CCI providers generally requested specialty services appropriately. When patients were seen by providers for follow-up after specialty services, providers usually reviewed the reports adequately and took appropriate actions. A few exceptions were noted:  In case 9, the patient was referred to an ophthalmologist for a suspected pending retinal detachment. The referral should have been ordered “emergent” rather than “urgent,” as a retinal detachment is an emergency requiring prompt action.  In case 13, a prostate cancer medication was mistakenly ordered for six months instead of one month.  In case 27, a medication recommended by urology was not renewed by a provider during a follow-up visit. This resulted in the patient not receiving this medication despite ongoing urinary symptoms.  In case 30, a provider allowed the patient to walk using orthopedic boots. This was in contradiction to the orthopedic recommendation that the patient not bear weight at all. Health Information Management As noted in the Health Information Management indicator, a culture of legacy or cloned notes was pervasive among the providers at CCI. It was notable that six of the ten regular providers at CCI at least once utilized a form of legacy notes during the time frame reviewed. Providers also did not always time-stamp their progress notes and orders. Onsite Inspection CCI providers were generally content with their work, leadership, and ancillary services. They felt their workload was appropriate and manageable. They felt the ancillary services, including laboratory, pharmacy, radiology, and specialty services, were functioning well. Discussion with some providers revealed concerns regarding the working relationship between providers and nursing staff. Challenging relationships between providers and nurses could result in poor communication and contribute to inadequate patient care. Further review of some deficiencies revealed poor communication may have been a contributing factor. The providers at CCI did not have access to the eUHR when on call. Compounded with possible communication issues with nursing, this could create situations in which the provider did not have California Correctional Institution, Cycle 4 Medical Inspection Page 45 Office of the Inspector General State of California all the necessary information, e.g., medical history, to appropriately order treatment for patients when the provider was not onsite. Pharmacy and Medication Management Pharmacy and medication management by providers was adequate. A few cases with deficiencies were noted above, e.g., anticoagulation and prostate cancer medications. Conclusion Of the 30 detailed case reviews, 21 were adequate, and 9 were inadequate. Of the 528 provider encounters, 76 deficiencies were found, 15 of which were likely to put patients at increased risk of harm. Analysis of the CCI case reviews revealed three of the inadequate cases were due to one provider. Two case reviews had inadequate appointments and scheduling. The remaining four inadequate cases involved different providers. Further analysis revealed that 5 of the 15 more serious deficiencies found for Quality of Provider Performance were attributed to the same one provider, who was responsible for three of the inadequate cases. The OIG made the leadership at CCI and CCHCS aware of these findings, and requested further review of this provider. While some of the above deficiencies illustrated in this section were serious, they did not represent the large majority of care that was delivered, which was good. Still, based on the number and types of deficiencies found relating to provider performance, the OIG expects these issues will be reviewed and hopes to see marked improvements in subsequent inspection cycles. After taking all factors into consideration, the OIG rated CCI’s provider performance adequate. Recommendations  The OIG recommends that providers be educated on the dangers of legacy notes, and that CCI management prohibit the use of these notes.  The OIG recommends that CCI’s medical leadership review their provider evaluation processes to ensure detection of deficient patterns of practice in assessment and management of all chronic patient care issues.  The OIG recommends that CCI’s medical leadership analyze the poor communication process between some providers and nurses, and work to improve the relationships.  The OIG recommends CCI management provide training for its providers on conducting a more complete review of patients’ medical records to improve patient care and avoid unnecessary send-outs and diagnostic testing.  The OIG recommends that providers review the CCHCS care guides for anticoagulation and diabetes management. California Correctional Institution, Cycle 4 Medical Inspection Page 46 Office of the Inspector General State of California  The OIG recommends that on-call providers have access to the eUHR to ensure they have all necessary information when decisions are made.  The OIG recommends that providers time-stamp their progress notes and orders. California Correctional Institution, Cycle 4 Medical Inspection Page 47 Office of the Inspector General State of California SPECIALIZED MEDICAL HOUSING (OHU, CTC, SNF, HOSPICE) This indicator addresses whether the institution follows appropriate Case Review Rating: policies and procedures when admitting inmate-patients to onsite Adequate inpatient facilities, including completion of timely nursing and Compliance Score: provider assessments. The chart review assesses all aspects of 100% medical care related to these housing units, including quality of Overall Rating: provider and nursing care. CCI’s only specialized medical housing Adequate unit is an onsite 16-bed outpatient housing unit (OHU). For this indicator, the OIG’s case review and compliance review processes yielded different results, with the case review giving an adequate rating and the compliance testing resulting in a proficient score. The OIG’s internal review process considered those factors that led to both scores and ultimately rated this indicator adequate. The key factors were that the case review had a larger sample size, and the case review focused on the quality of care provided. As a result, the case review testing results were deemed a more accurate reflection of the appropriate overall rating. Case Review Results The OIG clinicians reviewed 87 provider encounters and 104 nursing encounters relating to the OHU for 12 cases. These included admissions to the medical OHU for medical and mental health conditions. Provider Performance In general, OHU provider performance was adequate. Of the 87 OHU provider encounters reviewed, only nine deficiencies were identified. Of those nine deficiencies, two were considered serious enough to place the patient at increased risk for harm.  In case 7, this patient with possible epiglottitis (a potentially life-threatening condition) was inappropriately admitted to the OHU. Upon nursing recommendations, the patient was transferred to a higher level of care. However, the provider ordered the patient be transferred via State vehicle rather than via ambulance. This case is also discussed in the Emergency Services and Quality of Provider Performance sections.  In case 2, the patient was admitted to the OHU after hospital discharge, but the admission history and physical was sparse and incomplete and did not address the full spectrum of the patient’s health problems, as would be expected for this type of encounter. In cases 17 and 21, the anticoagulation management was suboptimal. Case 21, in which the patient also received care in the OHU, is discussed in more detail in the Quality of Provider Performance indicator. California Correctional Institution, Cycle 4 Medical Inspection Page 48 Office of the Inspector General State of California  Provider documentation in the OHU was sometimes illegible (cases 17 and 21). Nursing Performance The majority of practice issues for nursing performance in the OHU related to inadequate assessment and documentation and failure to consistently perform tasks such as dressing changes and thorough neurological assessments. While most of the 64 deficiencies in the OHU nursing services were not likely to contribute to patient harm, the number of these deficiencies was cause for concern.  In case 3, the patient returned from a community hospital; his wrist showed signs of prior IV infiltration. The nurse failed to document assessment of pain, temperature, and degree of swelling at the prior IV site. The nurse also failed to notify a provider and apply a warm compress.  In case 16, the nurse failed to adequately assess an elevated blood pressure of 160/102.  In case 17, the provider wrote admission orders the day after the patient was admitted to the OHU. The nurse performed an incomplete admission assessment, failing to assess his upper-respiratory complaint. In addition, the nurses failed several times to document the degree of lower extremity edema and to assess circulation.  In case 62, nurses failed to perform thorough assessments. The patient complained of headache and congestion. He had a fever and abnormal lung sounds. The nurse failed to perform a thorough respiratory assessment and failed to contact a provider. Two days later, he had a fever, elevated pulse, and dark urine. The nurse failed to assess his skin, mucus membranes, and oral intake, and failed to reassess his vital signs. Additionally, nurses failed to perform neurological assessments for several days.  In case 63, nurses did not always perform dressing changes at the proper intervals and often documented incomplete assessments and interventions. This diabetic patient had two wounds on his right foot, but documentation often reflected only one wound. The nurses assessed the patient’s pulse but failed to document the location his pulse was taken. Also, on one encounter, despite three very low blood sugar results (34, 36, and 39 mg per deciliter), the nurse failed to reassess his blood sugar after a meal. Onsite Inspection During their onsite interviews, OIG clinicians asked CCI’s supervising registered nurses how they measured nursing quality in the OHU. The supervisors produced two audit tools, both of which focused on compliance measures solely. While compliance measures, such as a functioning call light system and cell access, are important, they are insufficient to assess the quality of nursing care in the OHU. California Correctional Institution, Cycle 4 Medical Inspection Page 49 Office of the Inspector General State of California Clinician Summary The providers’ performance in the indicator compensated for the poor nursing performance. Therefore, the case review portion was rated adequate. The nursing performance in this section was weak due to the high number of repeated failures in adequate assessment, documentation, and interventions. Fortunately, the majority of deficiencies were not likely to put patients at increased risk for harm. The pattern of these failures is also discussed in the Quality of Nursing Performance and Emergency Services indicators. Compliance Testing Results The institution received a proficient compliance score of 100 percent for the Specialized Medical Housing indicator, which focused on the institution’s outpatient housing unit (OHU). The five test results for this indicator consisted of the following:  For all ten inmate-patients sampled, nursing staff timely completed an initial assessment on the day the patient was admitted to the OHU (MIT 13.001).  Providers evaluated all ten inmate-patients within 24 hours of admission and completed a history and physical within 72 hours of admission (MIT 13.002, 13.003). Providers also completed their subjective, objective, assessment, plan, and education (SOAPE) notes at required 14-day intervals for each of the nine patients who had a stay long enough to require one (MIT 13.004).  When the OIG observed the working order of a sample of call buttons in OHU patient rooms, inspectors found the call buttons were working properly. According to staff during interviews, custody officers and clinicians respond and access inmate-patients’ rooms in less than one minute when an emergent event occurs (MIT 13.101). Recommendations The OIG recommends a process to evaluate nursing assessment, intervention, and documentation in the OHU be implemented. This quality improvement initiative should be ongoing, measurable, reported on, and reviewed by leadership. California Correctional Institution, Cycle 4 Medical Inspection Page 50 Office of the Inspector General State of California SPECIALTY SERVICES This indicator focuses on specialist care from the time a request for Case Review Rating: services or physician’s order for specialist care is completed to the Adequate time of receipt of related recommendations from specialists. This Compliance Score: indicator also evaluates the providers’ timely review of specialist 85.7% records and documentation reflecting the patients’ care plans, including course of care when specialist recommendations were not Overall Rating: Adequate ordered, and whether the results of specialists’ reports are communicated to the patients. For specialty services denied by the institution, the OIG determines whether the denials are timely and appropriate, and whether the inmate-patient is updated on the plan of care. For this indicator, the case review and compliance review processes yielded different results, with the case review giving an adequate rating and the compliance review resulting in a proficient score. The OIG’s internal review process considered those factors that led to both scores and ultimately rated this indicator adequate. The key factors were that compliance testing revealed deficiencies in two areas, and the compliance score of 85.7 percent was very close to the adequate range. As a result, the OIG’s inspection team concluded that the appropriate overall rating for this indicator was adequate. Case Review Results The OIG clinicians reviewed 127 events related to Specialty Services, the majority of which were specialty consultations and procedures. The OIG clinicians found 21 deficiencies in this indicator and noted findings in the following indicator subcategories: Access to Specialty Services  Urgent and routine specialty services were generally timely and adequate, although there were occasional minor delays in specialty follow-up appointments. Nursing Performance  Nursing performance as it related to Specialty Services was adequate. Provider Performance  Six provider deficiencies were identified. Three related to providers not ordering referrals appropriately, and three related to recommendations not being followed (or failure to document reasons for not following the recommendations). California Correctional Institution, Cycle 4 Medical Inspection Page 51 Office of the Inspector General State of California Health Information Management  Five of the deficiencies found in Specialty Services were related to health information management. Two of these deficiencies were due to a delay in specialty reports being retrieved, reviewed by a provider, or scanned into the eUHR. One deficiency related to a specialty report not being found in the eUHR. One deficiency related to a provider signature not being legible on a referral form. Lastly, one deficiency was due to diagnostic results not being available to the specialist during a follow-up consultation. These deficiencies are also discussed in the Health Information Management section. Onsite Inspection The onsite visit and discussions with the specialty services department at CCI during case review confirmed the adequacy of Specialty Services. Personnel responsible for onsite specialty care, offsite specialty care, telemedicine services, and utilization management were located in the same geographical vicinity. They regularly communicated with each other and provided coverage for each other when needed. There was also good communication with the providers. The staff indicated that when a pending specialty appointment not included in transfer forms was discovered after a patient had already transferred out, the staff contacted the receiving facility to make staff there aware of this. Compliance Testing Results The institution received a proficient compliance score of 85.7 percent in the Specialty Services indicator. While CCI received an inadequate rating for two areas, the institution scored in the proficient range for five other areas, including three scored at 100 percent:  For 13 of the 15 inmate-patients sampled (87 percent), their high-priority specialty services appointment occurred within 14 calendar days of the provider’s order. One patient received his specialty service 4 days late, and another, 14 days late (MIT 14.001). Providers reviewed the specialists’ reports within three business days of the services for all 14 applicable patients sampled (MIT 14.002).  All 15 of the inmate-patients sampled received their routine specialty service appointment within 90 calendar days of the provider’s order (MIT 14.003).  The OIG tested the timeliness of CCI’s denials of provider specialty services requests for 17 patients; all of the denials occurred within the required time frame (MIT 14.006). However, providers did not always communicate the denial status to patients within 30 calendar days; 15 of the 16 patients (94 percent) were notified timely. The provider informed one patient one day late (MIT 14.007). California Correctional Institution, Cycle 4 Medical Inspection Page 52 Office of the Inspector General State of California The institution has opportunity for improvement in the following two areas:  When the institution ordered routine specialty services, providers did not always review the specialists’ reports within three business days after the service occurred. A provider timely reviewed only 6 of the 11 reports sampled (55 percent); the provider reviewed four reports from two to five days late and did not review another report at all (MIT 14.004).  When an institution approves or schedules a patient for specialty services appointments and then transfers the patient to another institution, policy requires that the receiving institution ensure a patient’s appointment occurs timely. At CCI, only 13 of the 20 patients sampled (65 percent) received their specialty services appointment within the required action date. Five patients received their appointments between 4 and 28 days late, and two additional patients did not receive an appointment at all (MIT 14.005). Recommendations No specific recommendations. California Correctional Institution, Cycle 4 Medical Inspection Page 53 Office of the Inspector General State of California SECONDARY (ADMINISTRATIVE) QUALITY INDICATORS OF HEALTH CARE The last two quality indicators (Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications) involve health care administrative systems and processes. Testing in these areas applies only to the compliance component of the process. Therefore, there is no case review assessment associated with either of the two indicators. As part of the compliance component for the first of these two indicators, the OIG did not score several questions. Instead, the OIG presented the findings for informational purposes only. For example, the OIG described certain local processes in place at CCI. To test both the scored and non-scored areas within these two secondary quality indicators, OIG inspectors interviewed key institutional employees and reviewed documents during their onsite visit to CCI in July 2015. They also reviewed documents obtained from the institution and from CCHCS prior to the start of the inspection. For comparative purposes, the CCI Executive Summary Table on page viii of this report shows the case review ratings and compliance scores for each applicable indicator. California Correctional Institution, Cycle 4 Medical Inspection Page 54 Office of the Inspector General State of California INTERNAL MONITORING, QUALITY IMPROVEMENT, AND ADMINISTRATIVE OPERATIONS This indicator focuses on the institution’s administrative health care Case Review Rating: oversight functions. The OIG evaluates whether the institution Not Applicable promptly processes inmate-patient medical appeals and addresses Compliance Score: all appealed issues. Inspectors also verify that the institution follows 71.7% reporting requirements for adverse/sentinel events and inmate deaths, and whether the institution is making progress toward its Overall Rating: Inadequate Performance Improvement Work Plan initiatives. In addition, the OIG verifies that the Emergency Medical Response Review Committee (EMRRC) performs required reviews and that staff perform required emergency response drills. Inspectors also assess whether the Quality Management Committee (QMC) meets regularly and adequately addresses program performance. For those institutions with licensed facilities, inspectors also verify that required committee meetings are held. Compliance Testing Results CCI scored in the inadequate range for the Internal Monitoring, Quality Improvement, and Administrative Operations indicator, receiving a compliance score of 71.7 percent. Although CCI scored 100 percent in three of the eight test areas applicable to the institution, improvement could be achieved in several areas.  When the OIG inspected documentation for nine emergency medical response incidents reviewed by the Emergency Medical Response Review Committee (EMRRC) during the prior six-month period, the incident packages did not include one or both of the required documents for each of the incidents reviewed. Inspectors also determined that the EMRRC did not review one critical incident timely, and the warden or CEO, or both, failed to sign the meeting minutes for all incidents. As a result, CCI received a score of zero for this test (MIT 15.007).  Medical staff reviewed and timely submitted the Initial Inmate Death Report (CDCR Form 7229A) to CCHCS’s Death Review Unit for two of four cases tested, resulting in a score of 50 percent. The CEO or chief medical executive (CME) failed to review and sign the death report for one patient. For another patient, the institution did not submit the death report by noon on the business day following the patient’s death; it was submitted 20 minutes late (MIT 15.103).  CCI improved or reached targeted performance objectives for four of the six quality improvement initiatives identified in its 2014 Performance Improvement Work Plan, resulting in a score of 67 percent. Performance results declined for one initiative, and the institution failed to provide any meaningful status for the targeted performance measures for another (MIT 15.005). California Correctional Institution, Cycle 4 Medical Inspection Page 55 Office of the Inspector General State of California  Inspectors reviewed the summary reports and related documentation for three medical emergency response drills conducted in the prior quarter. The institution conducted a comprehensive response drill for the first and second watch, but the response drill during the third watch lacked the completion of multiple required forms. Therefore, the institution received a score of 67 percent for this test (MIT 15.101). The institution scored in the proficient range in the following areas:  CCI promptly processed all inmate medical appeals timely in each of the most recent 12 months. Based on data received from the institution, only one of 1,112 medical appeals was overdue during that period (MIT 15.001).  Inspectors reviewed six recent months of Quality Management Committee (QMC) meeting minutes and confirmed that the institution’s QMC did meet monthly. During those meetings, the QMC evaluated program performance and took action when improvement opportunities were identified. Consequently, the institution received a score of 100 percent for this test (MIT 15.003). Additionally, CCI scored 100 percent for taking adequate steps to ensure the accuracy of its Dashboard data reporting (MIT 15.004).  For nine of the ten sampled second-level medical appeals (90 percent), the institution’s response addressed all of the patient’s appealed issues (MIT 15.102). Other Information Obtained From Non-Scored Areas  The OIG gathered non-scored data regarding the completion of death review reports. The Death Review Committee at CCHCS headquarters did not timely complete its death review summary for any of the four deaths that occurred during the testing period. The Death Review Committee is required to complete a death review summary within 30 business days of the death and submit it to the institution’s CEO. The committee completed all four CCI death review summaries late; delinquent completions were from 22 to 89 days late (66 to 132 calendar days after the death). Consequently, the committee did not submit any of the summaries to CCI timely (MIT 15.996).  Inspectors met with the institution’s CEO to inquire about CCI’s protocols for tracking appeals. The medical appeals coordinator reviewed all health care appeals; when the coordinator or management identified a problem, the Quality Management Committee discussed it and took action as needed, such as development of a quality improvement initiative (MIT 15.997).  Non-scored data gathered regarding the institution’s practices for implementing local operating procedures (LOPs) indicated that the institution has a good process in place for developing LOPs. The institution’s standards compliance coordinator (SCC) monitors new and revised CCHCS policies and procedures and their possible impact on the institution’s California Correctional Institution, Cycle 4 Medical Inspection Page 56 Office of the Inspector General State of California LOPs. A clinical subcommittee initially determines whether action is warranted, then CCI’s subject matter experts work with the SCC to develop revisions to existing LOPs or draft new LOPs. Ultimately, the Quality Management Committee reviews and finalizes the LOPs and submits them to the CEO and warden for approval and signature. Once approved, staff members receive training within 30 days and sign an on-the-job training form as proof that training occurred. At the time of the inspection, the institution had implemented 45 of the 48 applicable stakeholder-recommended LOPs (94 percent) (MIT 15.998).  The institution’s health care staffing resources are discussed in the About the Institution section on page 1 (MIT 15.999). CHCS Dashboard Comparative Data Both the Dashboard and the OIG testing results show that CCI demonstrated a high level of compliance for timely processing its medical appeals. Internal Monitoring, Quality Improvement, and Administrative Operations — CCI Dashboard and OIG Compliance Results CCI DASHBOARD RESULTS OIG COMPLIANCE RESULTS Timely Appeals Medical Appeals-Timely Processing (15.001) July 2015 12-months ending May 2015 100% 100% Note: The CCHCS Dashboard data includes appeal data for American Disability Act (ADA), mental health, dental, and staff complaint areas; the OIG excluded these appeal areas. Recommendations No specific recommendations. California Correctional Institution, Cycle 4 Medical Inspection Page 57 Office of the Inspector General State of California JOB PERFORMANCE, TRAINING, LICENSING, AND CERTIFICATIONS In this indicator, the OIG examines whether the institution Case Review Rating: adequately manages its health care staffing resources by evaluating Not Applicable whether job performance reviews are completed as required; Compliance Score: specified staff possess current, valid credentials and professional 95.8% licenses or certifications; nursing staff receive new employee orientation training and annual competency testing; and clinical and Overall Rating: Proficient custody staff have current medical emergency response certifications. Compliance Testing Results The institution received a proficient compliance score of 95.8 percent in the Job Performance Training, Licensing, and Certifications indicator. The institution scored 100 percent in seven of the indicator’s eight tests, as follows:  All providers were current with their professional licenses, and nursing staff and the pharmacist-in-charge were current with their professional licenses and certification requirements (MIT 16.001, 16.105).  Nursing supervisors completed the required number of nursing reviews for all five of the nurses the OIG sampled (MIT 16.101).  All of the ten nurses sampled who administered medications possessed current clinical competency validations, and all nursing staff hired within the last year timely received new employee orientation training (MIT 16.102, 16.107).  The OIG reviewed performance evaluation packets for the institution’s ten providers; the institution met all performance review requirements for its providers (MIT 16.103).  The institution’s pharmacy and providers who prescribed controlled substances were current with their Drug Enforcement Agency registration (MIT 16.106). There is room for improvement in the following area:  The OIG tested provider, nursing, and custody staff records to determine if the institution ensures that those staff members have current emergency response certifications. The institution’s provider and nursing staff were all compliant, but custody managers were not. While the California Penal Code exempts custody managers who primarily perform managerial duties from medical emergency response certification training, CCHCS policy does not allow for such an exemption. As a result, the institution received a score of 67 percent for this test (MIT 16.104). California Correctional Institution, Cycle 4 Medical Inspection Page 58 Office of the Inspector General State of California Recommendations No specific recommendations. California Correctional Institution, Cycle 4 Medical Inspection Page 59 Office of the Inspector General State of California POPULATION-BASED METRICS The compliance testing and the case reviews give an accurate assessment of how the institution’s health care systems are functioning with regard to the patients with the highest risk and utilization. This information is vital to assess the capacity of the institution to provide sustainable, adequate care. However, one significant limitation of the case review methodology is that it does not give a clear assessment of how the institution performs for the entire population. For better insight into this performance, the OIG has turned to population-based metrics. For comparative purposes, the OIG has selected several Healthcare Effectiveness Data and Information Set (HEDIS) measures for disease management to gauge the institution’s effectiveness in outpatient health care, especially chronic disease management. The Healthcare Effectiveness Data and Information Set is a set of standardized performance measures developed by the National Committee for Quality Assurance with input from over 300 organizations representing every sector of the nation’s health care industry. It is used by over 90 percent of the nation’s health plans as well as many leading employers and regulators. It was designed to ensure that the public (including employers, the Centers for Medicare and Medicaid Services, and researchers) has the information it needs to accurately compare the performance of health care plans. Healthcare Effectiveness Data and Information Set data is often used to produce health plan report cards, analyze quality improvement activities, and create performance benchmarks. Methodology For population-based metrics, the OIG used a subset of HEDIS measures applicable to the CDCR inmate-patient population. Selection of the measures was based on the availability, reliability, and feasibility of the data required for performing the measurement. The OIG collected data utilizing various information sources, including the eUHR, the Master Registry (maintained by CCHCS), as well as a random sample of patient records analyzed and abstracted by trained personnel. Data obtained from the CCHCS Master Registry and Diabetic Registry was not independently validated by the OIG and is presumed to be accurate. For some measures, the OIG used the entire population rather than statistically random samples. While the OIG is not a certified HEDIS compliance auditor, the OIG uses similar methods to ensure that measures are comparable to those published by other organizations. Comparison of Population-Based Metrics For the California Correctional Institution, nine HEDIS measures were selected and are listed in the following CCI Results Compared to State and National HEDIS Scores table. Multiple health plans publish their HEDIS performance measures at the State and national levels. The OIG has provided selected results for several health plans in both categories for comparative purposes. California Correctional Institution, Cycle 4 Medical Inspection Page 60 Office of the Inspector General State of California Results of Population-Based Metric Comparison Comprehensive Diabetes Care For chronic care management, the OIG chose measures related to the management of diabetes. Diabetes is the most complex common chronic disease requiring a high level of intervention on the part of the health care system in order to produce optimal results. CCI performed very well with its management of diabetes. When compared statewide, CCI significantly exceeded the Medi-Cal scores in all five diabetic measures selected. When compared to Kaiser Permanente, CCI also outperformed Kaiser in three of the five diabetic measures (diabetic monitoring, diabetics considered to be under poor control, and diabetics considered to be under good control). CCI’s score for diabetic patients’ blood pressure control was 7 and 10 percentage points lower than the Kaiser North and South scores, respectively. However, for diabetic patient eye exams, CCI was 6 percentage points higher than the Kaiser North regional average score and 7 percentage points lower than the Kaiser South regional average. When compared nationally, CCI outperformed Medicaid, Medicare, and commercial health plans (based on data obtained from health maintenance organizations) in all five of the diabetic measures listed. CCI scored slightly higher than the U.S. Department of Veterans Affairs (VA) for diabetic monitoring and outperformed the VA by 6 percentage points for its diabetic patients considered to be under poor control. For blood pressure control and eye exams, CCI trailed the VA by 5 and 15 percentage points, respectively. Immunizations Comparative data for immunizations was only fully available for the VA (national) and partially available for Kaiser Permanente (statewide), commercial plans (national), and Medicare (national). For influenza shots for adults up to age 64, CCI scored 8 percentage points higher than Kaiser’s highest regional average, 17 percentage points higher than commercial plans, and 2 percentage points higher than the VA. However, with respect to influenza vaccinations for patients 65 and older, CCI scored 3 percentage points lower than the VA and 1 percentage point higher than Medicare; all 26 of the inmate-patients tested were offered the influenza vaccination, but 7 of them (27 percent) refused it. With respect to pneumococcal vaccinations for older adults, CCI scored 5 percentage points lower than Medicare and 28 percentage points lower than the VA. Although one patient tested was offered the immunization but refused it, eight other patients had no record of being offered or receiving the vaccination within the 12-month review period. Cancer Screening For colorectal cancer screening, CCI performed the same as Kaiser North at 78 percent, but trailed Kaiser South by 2 percentage points. The institution achieved scores 14 and 11 percentage points higher than Medicare and commercial plans, respectively, but 4 percentage points lower than the California Correctional Institution, Cycle 4 Medical Inspection Page 61 Office of the Inspector General State of California VA. However, all 41 inmate-patients sampled were offered the screening timely, but nine of them (22 percent) had subsequently refused the test. Summary California Correctional Institution’s population-based metrics performance was strong for most diabetic measures and comparable to other State and national results for most immunizations and cancer screening measures. CCI outperformed all State and national average scores for diabetic monitoring, diabetics considered to be under poor control, and diabetics considered to be under good control. With regard to blood pressure control and eye exams for diabetic patients, CCI’s scores were mid-range when compared to the other entities. For immunization measures, the institution performed well for patients under the age of 65, receiving a higher score than Kaiser, commercial plans, and the VA, which were the only entities that reported data in these areas. In patients 65 and older CCI performed lower than the VA for influenza vaccinations but higher than Medicare, and performed lower than both Medicare and the VA for pneumococcal vaccinations, but the institution’s score for influenza vaccinations was negatively impacted by patients who were offered immunizations and refused them. For colorectal cancer screening, CCI’s performance was mid-range when compared to the other entities’ reporting data. The institution’s score was again negatively impacted by patients who were offered cancer screenings but refused them. Overall, CCI’s HEDIS performance reflects an adequately performing chronic care program, further corroborated by the institution’s adequate score in the Access to Care indicator and proficient score in the Preventive Services indicator. With regard to CCI’s performance in the immunization and colorectal screening measures, the institution should make interventions to lower the rate of patient refusal for influenza shots and colorectal cancer screening. California Correctional Institution, Cycle 4 Medical Inspection Page 62 Office of the Inspector General State of California CCI Results Compared to State and National HEDIS Scores California National CCI HEDIS HEDIS HEDIS HEDIS Clinical Measures Medi - Kaiser Kaiser HEDIS Com- HEDIS VA Cycle 4 Cal (No.CA) (So.CA) Medicaid mercial Medicare Average Results 2014 2014 2014 2015 2015 2015 2012 1 2 3 3 4 4 4 5 Comprehensive Diabetes Care HbA1c Testing (Monitoring) 100% 83% 95% 94% 86% 91% 93% 99% Poor HbA1c Control (>9.0%) 6,7 13% 44% 18% 21% 44% 31% 25% 19% HbA1c Control (<8.0%) 6 77% 47% 70% 67% 47% 58% 65% - Blood Pressure Control (<140/90) 75% 60% 82% 85% 62% 65% 65% 80% Eye Exams 75% 51% 69% 82% 54% 56% 69% 90% Immunizations Influenza Shots - Adults (18–64) 8 67% - 59% 55% - 50% - 65% Influenza Shots - Adults (65+) 73% - - - - - 72% 76% Immunizations: Pneumococcal 65% - - - - - 70% 93% Cancer Screening Colorectal Cancer Screening 78% - 78% 80% - 64% 67% 82% 1. Unless otherwise stated, data was collected in July 2015 by reviewing medical records from a sample of CCI’s population of applicable inmate-patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. 2. HEDIS Medi-Cal data was obtained from the California Department of Health Care Services 2014 HEDIS Aggregate Report for the Medi-Cal Managed Care Program. 3. Data was obtained from Kaiser Permanente November 2014 reports for the Northern and Southern California regions. 4. National HEDIS data for Medicaid, commercial plans, and Medicare was obtained from the 2015 State of Health Care Quality Report, available on the NCQA website: www.ncqa.org. The results for commercial plans were based on data received from various health maintenance organizations. 5. The Department of Veterans Affairs (VA) data was obtained from the VHA Facility Quality and Safety Report - Fiscal Year 2012 Data. 6. For this indicator, the entire applicable CCI population was tested. 7. For this measure only, a lower score is better. For Kaiser, the OIG derived the Poor HbA1c Control indicator using the reported data for the <9.0% HbA1c control indicator. 8. The VA data is for the age range 50–64. California Correctional Institution, Cycle 4 Medical Inspection Page 63 Office of the Inspector General State of California APPENDIX A — COMPLIANCE TEST RESULTS California Correctional Institution Range of Summary Scores: 71.67% - 100.00% Indicator Overall Score (Yes %) Access to Care 81.09% Diagnostic Services 84.44% Emergency Services Not Applicable Health Information Management (Medical Records) 78.18% Health Care Environment 84.42% Inter- and Intra-System Transfers 84.07% Pharmacy and Medication Management 93.2% Prenatal and Post-Delivery Services Not Applicable Preventive Services 88.81% Quality of Nursing Performance Not Applicable Quality of Provider Performance Not Applicable Reception Center Arrivals Not Applicable Specialized Medical Housing (OHU, CTC, SNF, Hospice) 100.00% Specialty Services 85.71% Internal Monitoring, Quality Improvement, and Administrative Operations 71.67% Job Performance, Training, Licensing, and Certifications 95.83% California Correctional Institution, Cycle 4 Medical Inspection Page 64 Office of the Inspector General State of California Scored Answers Yes Reference + Access to Care Number Yes No No Yes % N/A 1.001 Chronic care follow-up appointments: Was the inmate-patient’s most 21 9 30 70.00% 0 recent chronic care visit within the health care guideline’s maximum allowable interval or within the ordered time frame, whichever is shorter? 1.002 For endorsed inmate-patients received from another CDCR 11 14 25 44.00% 5 institution: If the nurse referred the inmate-patient to a provider during the initial health screening, was the inmate-patient seen within the required time frame? 1.003 Clinical appointments: Did a registered nurse review the 30 0 30 100.00% 0 inmate-patient’s request for service the same day it was received? 1.004 Clinical appointments: Did the registered nurse complete a 25 5 30 83.33% 0 face-to-face visit within one business day after the CDCR Form 7362 was reviewed? 1.005 Clinical appointments: If the registered nurse determined a referral to 11 4 15 73.33% 15 a primary care provider was necessary, was the inmate-patient seen within the maximum allowable time or the ordered time frame, whichever is the shorter? 1.006 Sick call follow-up appointments: If the primary care provider 4 1 5 80.00% 25 ordered a follow-up sick call appointment, did it take place within the time frame specified? 1.007 Upon the inmate-patient’s discharge from the community hospital: 30 0 30 100.00% 0 Did the inmate-patient receive a follow-up appointment within the required time frame? 1.008 Specialty service follow-up appointments: Do specialty service 19 5 24 79.17% 6 primary care physician follow-up visits occur within required time frames? 1.101 Clinical appointments: Do inmate-patients have a standardized 5 0 5 100.00% 0 process to obtain and submit health care services request forms? Overall Percentage: 81.09% California Correctional Institution, Cycle 4 Medical Inspection Page 65 Office of the Inspector General State of California Scored Answers Yes Reference + Diagnostic Services Number Yes No No Yes % N/A 2.001 Radiology: Was the radiology service provided within the time frame 10 0 10 100.00% 0 specified in the provider’s order? 2.002 Radiology: Did the primary care provider review and initial the 8 2 10 80.00% 0 diagnostic report within specified time frames? 2.003 Radiology: Did the primary care provider communicate the results of 8 2 10 80.00% 0 the diagnostic study to the inmate-patient within specified time frames? 2.004 Laboratory: Was the laboratory service provided within the time 10 0 10 100.00% 0 frame specified in the provider’s order? 2.005 Laboratory: Did the primary care provider review and initial the 8 2 10 80.00% 0 diagnostic report within specified time frames? 2.006 Laboratory: Did the primary care provider communicate the results of 7 3 10 70.00% 0 the diagnostic study to the inmate-patient within specified time frames? 2.007 Pathology: Did the institution receive the final diagnostic report within 9 1 10 90.00% 0 the required time frames? 2.008 Pathology: Did the primary care provider review and initial the 9 1 10 90.00% 0 diagnostic report within specified time frames? 2.009 Pathology: Did the primary care provider communicate the results of 7 3 10 70.00% 0 the diagnostic study to the inmate-patient within specified time frames? Overall Percentage: 84.44% California Correctional Institution, Cycle 4 Medical Inspection Page 66 Office of the Inspector General State of California Emergency Services Scored Answers Assesses reaction times and responses to emergency situations. The OIG RN clinicians will use detailed information obtained from the institution’s incident Not Applicable packages to perform focused case reviews. Scored Answers Health Information Management (Medical Yes Reference + Records) Number Yes No No Yes % N/A 4.001 Are non-dictated progress notes, initial health screening forms, and 20 0 20 100.00% 0 health care service request forms scanned into the eUHR within three calendar days of the inmate-patient encounter date? 4.002 Are dictated / transcribed documents scanned into the eUHR within 7 3 10 70.00% 0 five calendar days of the inmate-patient encounter date? 4.003 Are specialty documents scanned into the eUHR within five calendar 11 9 20 55.00% 0 days of the inmate-patient encounter date? 4.004 Are community hospital discharge documents scanned into the eUHR 19 1 20 95.00% 0 within three calendar days of the inmate-patient date of hospital discharge? 4.005 Are medication administration records (MARs) scanned into the eUHR 20 0 20 100.00% 0 within the required time frames? 4.006 During the eUHR review, did the OIG find that documents were 6 6 12 50.00% 0 correctly labeled and included in the correct inmate-patient’s file? 4.007 Did clinical staff legibly sign health care records, when required? 22 10 32 68.75% 0 4.008 For inmate-patients discharged from a community hospital: Did 26 4 30 86.67% 0 the preliminary hospital discharge report include key elements and did a PCP review the report within three calendar days of discharge? Overall Percentage: 78.18% California Correctional Institution, Cycle 4 Medical Inspection Page 67 Office of the Inspector General State of California Scored Answers Yes Reference + Health Care Environment Number Yes No No Yes % N/A 5.101 Infection Control: Are clinical health care areas appropriately 7 0 7 100.00% 2 disinfected, cleaned and sanitary? 5.102 Infection control: Do clinical health care areas ensure that reusable 4 3 7 57.14% 2 invasive and non-invasive medical equipment is properly sterilized or disinfected as warranted? 5.103 Infection Control: Do clinical health care areas contain operable sinks 7 0 7 100.00% 2 and sufficient quantities of hygiene supplies? 5.104 Infection control: Does clinical health care staff adhere to universal 6 0 6 100.00% 3 hand hygiene precautions? 5.105 Infection control: Do clinical health care areas control exposure to 6 1 7 85.71% 2 blood-borne pathogens and contaminated waste? 5.106 Warehouse, Conex and other non-clinic storage areas: Does the 1 0 1 100.00% 8 medical supply management process adequately support the needs of the medical health care program? 5.107 Clinical areas: Does each clinic follow adequate protocols for 6 1 7 85.71% 2 managing and storing bulk medical supplies? 5.108 Clinical areas: Do clinic common areas and exam rooms have 3 4 7 42.86% 2 essential core medical equipment and supplies? 5.109 Clinical areas: Do clinic common areas have an adequate environment 7 0 7 100.00% 2 conducive to providing medical services? 5.110 Clinical areas: Do clinic exam rooms have an adequate environment 5 2 7 71.43% 2 conducive to providing medical services? 5.111 Emergency response bags: Are TTA and clinic emergency medical 6 1 7 85.71% 2 response bags inspected daily and inventoried monthly, and do they contain essential items? 5.999 For Information Purposes Only: Does the institution’s health care management believe that all clinical areas have physical plant Information Only infrastructures sufficient to provide adequate health care services? Overall Percentage: 84.42% California Correctional Institution, Cycle 4 Medical Inspection Page 68 Office of the Inspector General State of California Scored Answers Yes Reference + Inter- and Intra-System Transfers Number Yes No No Yes % N/A 6.001 For endorsed inmate-patients received from another CDCR 21 9 30 70.00% 0 institution or COCF: Did nursing staff complete the initial health screening and answer all screening questions on the same day the inmate-patient arrived at the institution? 6.002 For endorsed inmate-patients received from another CDCR 26 3 29 89.66% 1 institution or COCF: When required, did the RN complete the assessment and disposition section of the health screening form; refer the inmate-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? 6.003 For endorsed inmate-patients received from another CDCR 12 2 14 85.71% 16 institution or COCF: If the inmate-patient had an existing medication order upon arrival, were medications administered or delivered without interruption? 6.004 For inmate-patients transferred out of the facility: Were scheduled 15 5 20 75.00% 0 specialty service appointments identified on the Health Care Transfer Information Form 7371? 6.101 For inmate-patients transferred out of the facility: Do medication 1 0 1 100.00% 1 transfer packages include required medications along with the corresponding Medical Administration Record (MAR) and Medication Reconciliation? Overall Percentage: 84.07% California Correctional Institution, Cycle 4 Medical Inspection Page 69 Office of the Inspector General State of California Scored Answers Yes Reference + Pharmacy and Medication Management Number Yes No No Yes % N/A 7.001 Did the inmate-patient receive all chronic care medications within the 21 6 27 77.78% 3 required time frames or did the institution follow departmental policy for refusals or no-shows? 7.002 Did health care staff administer or deliver new order prescription 26 4 30 86.67% 0 medications to the inmate-patient within the required time frames? 7.003 Upon the inmate-patient’s discharge from a community hospital: 23 7 30 76.67% 0 Were all medications ordered by the institution’s primary care provider administered or delivered to the inmate-patient within one calendar day of return? 7.004 For inmate-patients received from a county jail: Were all medications ordered by the institution’s reception center provider Not Applicable administered or delivered to the inmate-patient within the required time frames? 7.005 Upon the inmate-patient’s transfer from one housing unit to 25 5 30 83.33% 0 another: Were medications continued without interruption? 7.006 For inmate-patients en route who lay over at the institution: If the 1 0 1 100.00% 4 temporarily housed inmate-patient had an existing medication order, were medications administered or delivered without interruption? 7.101 All clinical and medication line storage areas for narcotic 7 0 7 100.00% 7 medications: Does the institution employ strong medication security controls over narcotic medications assigned to its clinical areas? 7.102 All clinical and medication line storage areas for non-narcotic 13 0 13 100.00% 1 medications: Does the institution properly store non-narcotic medications that do not require refrigeration in assigned clinical areas? 7.103 All clinical and medication line storage areas for non-narcotic 5 1 6 83.33% 8 medications: Does the institution properly store non-narcotic medications that require refrigeration in assigned clinical areas? 7.104 Medication preparation and administration areas: Do nursing staff 6 0 6 100.00% 8 employ and follow hand hygiene contamination control protocols during medication preparation and medication administration processes? 7.105 Medication preparation and administration areas: Does the 6 0 6 100.00% 8 institution employ appropriate administrative controls and protocols when preparing medications for inmate-patients? California Correctional Institution, Cycle 4 Medical Inspection Page 70 Office of the Inspector General State of California 7.106 Medication preparation and administration areas: Does the institution 5 1 6 83.33% 8 employ appropriate administrative controls and protocols when distributing medications to inmate-patients? 7.107 Pharmacy: Does the institution employ and follow general security, 1 0 1 100.00% 0 organization, and cleanliness management protocols in its main and satellite pharmacies? 7.108 Pharmacy: Does the institution’s pharmacy properly store non-refrigerated 1 0 1 100.00% 0 medications? 7.109 Pharmacy: Does the institution’s pharmacy properly store refrigerated or 1 0 1 100.00% 0 frozen medications? 7.110 Pharmacy: Does the institution’s pharmacy properly account for narcotic 1 0 1 100.00% 0 medications? 7.111 Pharmacy: Does the institution follow key medication error reporting 25 0 25 100.00% 0 protocols? 7.998 For Information Purposes Only: During eUHR compliance testing and case reviews, did the OIG find that medication errors were properly Information Only identified and reported by the institution? 7.999 For Information Purposes Only: Do inmate-patients in isolation housing units have immediate access to their KOP prescribed rescue inhalers and Information Only nitroglycerin medications? Overall Percentage: 93.19% California Correctional Institution, Cycle 4 Medical Inspection Page 71 Office of the Inspector General State of California Prenatal and Post-Delivery Services Scored Answers This indicator is not applicable to this institution. Not Applicable Scored Answers Yes Reference + Preventive Services Number Yes No No Yes % N/A 9.001 Inmate-patients prescribed INH: Did the institution administer the 26 4 30 86.67% 0 medication to the inmate-patient as prescribed? 9.002 Inmate-patients prescribed INH: Did the institution monitor the 27 3 30 90.00% 0 inmate-patient monthly for the most recent three months he or she was on the medication? 9.003 Annual TB Screening: Was the inmate-patient screened for TB within 30 0 30 100.00% 0 the last year? 9.004 Were all inmate-patients offered an influenza vaccination for the most 30 0 30 100.00% 0 recent influenza season? 9.005 All inmate-patients from the age 50 through the age of 75: Was the 30 0 30 100.00% 0 inmate-patient offered colorectal cancer screening? 9.008 Are required immunizations being offered for chronic care 19 1 20 95.00% 0 inmate-patients? 9.009 Are inmate-patients at the highest risk of coccidioidomycosis (valley 1 1 2 50.00% 0 fever) infection transferred out of the facility in a timely manner? Overall Percentage: 88.81% California Correctional Institution, Cycle 4 Medical Inspection Page 72 Office of the Inspector General State of California Quality of Nursing Performance Scored Answers The quality of nursing performance will be assessed during case reviews, conducted by OIG clinicians, and is not applicable for the compliance portion of the medical inspection. The methodologies OIG clinicians use to evaluate the quality of nursing Not Applicable performance are presented in a separate inspection document entitled OIG MIU Retrospective Case Review Methodology. Quality of Provider Performance Scored Answers The quality of provider performance will be assessed during case reviews, conducted by OIG clinicians, and is not applicable for the compliance portion of the medical inspection. The methodologies OIG clinicians use to evaluate the quality of Not Applicable provider performance are presented in a separate inspection document entitled OIG MIU Retrospective Case Review Methodology. Reception Center Arrivals Scored Answers This indicator is not applicable to this institution. Not Applicable Scored Answers Specialized Medical Housing (OHU, CTC, Yes Reference + SNF, Hospice) Number Yes No No Yes % N/A 13.001 For all higher-level care facilities: Did the registered nurse complete 10 0 10 100.00% 0 an initial assessment of the inmate-patient on the day of admission, or within eight hours of admission to CMF’s Hospice? 13.002 For OHU, CTC, & SNF only: Did the primary care provider for 10 0 10 100.00% 0 OHU or attending physician for a CTC & SNF evaluate the inmate-patient within 24 hours of admission? 13.003 For OHU, CTC, & SNF only: Was a written history and physical 10 0 10 100.00% 0 examination completed within 72 hours of admission? 13.004 For all higher level care facilities: Did the primary care provider 9 0 9 100.00% 1 complete the Subjective, Objective, Assessment, Plan, and Education (SOAPE) notes on the inmate-patient at the minimum intervals required for the type of facility where the inmate-patient was treated? 13.101 For OHU and CTC Only: Do inpatient areas either have properly 1 0 1 100.00% 0 working call systems in its OHU & CTC or are 30-minute patient welfare checks performed; and do medical staff have reasonably unimpeded access to enter inmate-patient’s cells? Overall Percentage: 100.00% California Correctional Institution, Cycle 4 Medical Inspection Page 73 Office of the Inspector General State of California Scored Answers Yes Reference + Specialty Services Number Yes No No Yes % N/A 14.001 Did the inmate-patient receive the high-priority specialty service within 13 2 15 86.67% 0 14 calendar days of the PCP order? 14.002 Did the PCP review the high priority specialty service consultant report 14 0 14 100.00% 1 within the required time frame? 14.003 Did the inmate-patient receive the routine specialty service within 90 15 0 15 100.00% 0 calendar days of the PCP order? 14.004 Did the PCP review the routine specialty service consultant report 6 5 11 54.55% 4 within the required time frame? 14.005 For endorsed inmate-patients received from another CDCR 13 7 20 65.00% 0 institution: If the inmate-patient was approved for a specialty services appointment at the sending institution, was the appointment scheduled at the receiving institution within the required time frames? 14.006 Did the institution deny the primary care provider request for specialty 17 0 17 100.00% 0 services within required time frames? 14.007 Following the denial of a request for specialty services, was the 15 1 16 93.75% 1 inmate-patient informed of the denial within the required time frame? Overall Percentage: 85.71% California Correctional Institution, Cycle 4 Medical Inspection Page 74 Office of the Inspector General State of California Scored Answers Internal Monitoring, Quality Improvement, and Yes Reference + Administrative Operations Number Yes No No Yes % N/A 15.001 Did the institution promptly process inmate medical appeals during the 12 0 12 100.00% 0 most recent 12 months? 15.002 Does the institution follow adverse/sentinel event reporting Not Applicable requirements? 15.003 Did the institution Quality Management Committee (QMC) meet at 6 0 6 100.00% 0 least monthly to evaluate program performance, and did the QMC take action when improvement opportunities were identified? 15.004 Did the institution’s Quality Management Committee (QMC) or other 1 0 1 100.00% 0 forum take steps to ensure the accuracy of its Dashboard data reporting? 15.005 For each initiative in the Performance Improvement Work Plan 4 2 6 66.67% 0 (PIWP), has the institution performance improved or reached the targeted performance objective(s)? 15.006 For institutions with licensed care facilities: Does the local governing body (LGB), or its equivalent, meet quarterly and exercise Not Applicable its overall responsibilities for the quality management of patient health care? 15.007 Does the Emergency Medical Response Review Committee perform 0 9 9 0.00% 0 timely incident package reviews that include the use of required review documents? 15.101 Did the institution complete a medical emergency response drill for 2 1 3 66.67% 0 each watch and include participation of health care and custody staff during the most recent full quarter? 15.102 Did the institution’s second level medical appeal response address all 9 1 10 90.00% 0 of the inmate-patient’s appealed issues? 15.103 Did the institution’s medical staff review and submit the initial inmate 2 2 4 50.00% 0 death report to the Death Review Unit in a timely manner? 15.996 For Information Purposes Only: Did the CCHCS Death Review Committee submit its inmate death review summary to the institution Information Only timely? 15.997 For Information Purposes Only: Identify the institution’s protocols Information Only for tracking medical appeals. 15.998 For Information Purposes Only: Identify the institution’s protocols Information Only for implementing health care local operating procedures. 15.999 For Information Purposes Only: Identify the institution’s health care Information Only staffing resources. Overall Percentage: 71.67% California Correctional Institution, Cycle 4 Medical Inspection Page 75 Office of the Inspector General State of California Scored Answers Job Performance, Training, Licensing, and Yes Reference + Certifications Number Yes No No Yes % N/A 16.001 Do all providers maintain a current medical license? 12 0 12 100.00% 0 16.101 Does the institution’s Supervising Registered Nurse conduct periodic 5 0 5 100.00% 0 reviews of nursing staff? 16.102 Are nursing staff who administer medications current on their clinical 10 0 10 100.00% 0 competency validation? 16.103 Are structured clinical performance appraisals completed timely? 10 0 10 100.00% 0 16.104 Is staff current with required medical emergency response 2 1 3 66.67% 0 certifications? 16.105 Are nursing staff and the Pharmacist-in-Charge current with their 5 0 5 100.00% 1 professional licenses and certifications? 16.106 Do the institution’s pharmacy and authorized providers who prescribe 1 0 1 100.00% 0 controlled substances maintain current Drug Enforcement Agency (DEA) registrations? 16.107 Are nursing staff current with required new employee orientation? 1 0 1 100.00% 0 Overall Percentage: 95.83% California Correctional Institution, Cycle 4 Medical Inspection Page 76 Office of the Inspector General State of California APPENDIX B — CLINICAL DATA Table B-1 CCI Sample Sets Sample Set Total Anticoagulation 3 CTC/OHU 2 Death Review/Sentinel Events 4 Diabetes 3 Emergency Services - Non-CPR 5 High Risk 5 Hospitalization 5 Intra-System Transfers in 3 Intra-System Transfers out 3 RN Sick Call 25 Specialty Services 5 63 California Correctional Institution, Cycle 4 Medical Inspection Page 77 Office of the Inspector General State of California Table B-2 CCI Chronic Care Diagnoses Diagnosis Total Anemia 1 Anticoagulation 4 Arthritis/Degenerative Joint Disease 7 Asthma 7 COPD 2 Cardiovascular Disease 3 Chronic Kidney Disease 3 Chronic Pain 8 Cirrhosis/End Stage Liver Disease 3 Coccidioidomycosis 1 Deep Venous Thrombosis/Pulmonary Embolism 2 Diabetes 14 Gastroesophageal Reflux Disease 17 Hepatitis C 18 Hyperlipidemia 10 Hypertension 33 Mental Health 17 Migraine Headaches 1 Seizure Disorder 1 Sleep Apnea 3 Thyroid Disease 4 159 California Correctional Institution, Cycle 4 Medical Inspection Page 78 Office of the Inspector General State of California Table B-3 CCI Event - Program Program Total Diagnostic Services 199 Emergency Care 45 Hospitalization 60 Intra-System Transfers in 21 Intra-System Transfers out 21 Not Specified 1 Outpatient Care 406 Specialized Medical Housing 195 Specialty Services 127 1,075 Table B-4 CCI Case Review Summary Total MD Reviews Detailed 30 MD Reviews Focused 0 RN Reviews Detailed 15 RN Reviews Focused 36 Total Reviews 81 Total Unique Cases 63 Overlapping Reviews (MD & RN) 18 California Correctional Institution, Cycle 4 Medical Inspection Page 79 Office of the Inspector General State of California APPENDIX C — COMPLIANCE SAMPLING METHODOLOGY California Correctional Institution Sample Category Quality (number of Indicator patients) Data Source Filters Access to Care Chronic Care Master Registry  Chronic care conditions (at least one condition per (30—Basic Level) inmate-patient—any risk level) (40—Inter Level)  Randomize Nursing Sick Call MedSATS  Clinic (each clinic tested) (5 per clinic)  Appt. date (2–9 months) (minimum of 30)  Randomize Returns from Inpatient Claims  See Health Information Management (Medical Community Hospital Data Records) (returns from community hospital) (30) Diagnostic Radiology Radiology Logs  Appt. Date (90 days–9 months) Services (10)  Randomize  Abnormal Laboratory Quest  Appt. date (90 days–9 months) (10)  Order name (CBC or CMPs only)  Randomize  Abnormal Pathology InterQual  Appt. date (90 days–9 months) (10)  Service (pathology related)  Randomize Health Timely Scanning OIG Qs: 1.001,  Non-dictated documents Information (20 each) 1.002, 1.006, &  First 5 inmate-patients selected for each question Management 9.004 (Medical OIG Q: 1.001  Dictated documents Records)  First 20 inmate-patients selected OIG Qs: 14.002  Specialty documents & 14.004  First 10 inmate-patients selected for each question OIG Q: 4.008  Community hospital discharge documents  First 20 inmate-patients selected for the question OIG Q: 7.001  MARs  First 20 inmate-patients selected Legible Signatures OIG Qs: 4.008,  First 8 inmates sampled and Review 6.001/6.002,  One source document per inmate-patient (40) 7.001, 12.001/12.002, & 14.002 Complete and Documents for  Any incorrectly scanned eUHR document Accurate Scanning any tested inmate identified during OIG eUHR file review, e.g., mislabeled, misfiled, illegibly scanned, or missing Returns from Inpatient Claims  Date (2–8 months) Community Hospital Data  Most recent 6 months provided (within date range) (30)  Rx count  Discharge date  Randomize (each month individually)  First 5 inmate-patients from each of the 6 months (if not 5 in a month, supplement from another, as needed) California Correctional Institution, Cycle 4 Medical Inspection Page 80 Office of the Inspector General State of California Sample Category Quality (number of Indicator patients) Data Source Filters Health Care Clinical Areas OIG Inspector  Identify and inspect all onsite clinical areas. Environment (number varies by Onsite Review institution) Inter- and Intra-System SOMS  Arrival date (3–9 months) Intra-System transfers  Arrived from (another CDCR facility) Transfers (30)  Rx count  Randomize Specialty Service MedSATS  Date of Transfer (3–9 months) Send-outs  Randomize (20) Pharmacy and Chronic Care OIG Q: 1.001 See Access to Care Medication Medication  (At least one condition per inmate-patient—any Management (30—Basic Level) risk level) (40—Inter Level)  Randomize New Medication Master Registry  Rx Count Orders  Randomize (30—Basic Level)  Ensure no duplication of inmate-patients tested in (40—Inter Level) chronic care medications Intra-Facility moves MAPIP Transfer  Date of transfer (2–8 months) (30) Data  To location/from location (yard to yard and to/from ASU)  Remove any to/from MHCB  NA/DOT meds (high–low)–inmate-patient must have NA/DOT meds to qualify for testing  Randomize En Route SOMS  Date of transfer (2–8 months) (10)  Sending institution (another CDCR facility)  Randomize  Length of stay (minimum of 2 days)  NA/DOT meds Returns from Inpatient Claims  See Health Information Management (Medical Community Hospital Data Records) (returns from community hospital) (30) Medication OIG Inspector  Identify and inspect onsite clinical areas that Preparation and Onsite Review prepare and administer medications Administration Areas Pharmacy OIG Inspector  Identify and inspect onsite pharmacies Onsite Review Medication Error OIG Inspector  Any medication error identified during OIG eUHR Reporting Review file review, e.g., case reviews and/or compliance testing Prenatal and Recent Deliveries OB Roster  Delivery date (2–12 months) Post-Delivery (5)  Most recent deliveries (within date range) Services N/A at this institution Pregnant Arrivals OB Roster  Arrival date (2–12 months) (5)  Earliest arrivals (within date range) N/A at this institution California Correctional Institution, Cycle 4 Medical Inspection Page 81 Office of the Inspector General State of California Sample Category Quality (number of Indicator patients) Data Source Filters Preventive Chronic Care OIG Q: 1.001  Chronic care conditions (at least 1 condition per Services Vaccinations inmate-patient—any risk level) (30—Basic Level)  Randomize (40—Inter Level)  Condition must require vaccination(s) Not all conditions require vaccinations INH Maxor  Dispense date (past 9 months) (all applicable up to  Time period on INH (at least a full 3 months) 30)  Randomize Colorectal Screening SOMS  Arrival date (at least 1 year prior to inspection) (30)  Date of birth (51 or older)  Randomize Influenza SOMS  Arrival date (at least 1 year prior to inspection) Vaccinations  Randomize (30)  Filter out inmate-patients tested in chronic care vaccination sample TB Code 22, annual SOMS  Arrival date (at least 1 year prior to inspection) TST  TB Code (22) (15)  Randomize TB Code 34, annual SOMS  Arrival date (at least 1 year prior to inspection) screening  TB Code (34) (15)  Randomize Mammogram SOMS  Arrival date (at least 2 years prior to inspection) (30)  Date of birth (age 52–74) N/A at this institution  Randomize Pap Smear SOMS  Arrival date (at least three years prior to (30) inspection) N/A at this institution  Date of birth (age 24–53)  Randomize Valley Fever Cocci Transfer  Reports from past 2–8 months (number will vary, up Status Report  Institution to 20)  Ineligibility date (60 days prior to inspection date)  All Reception RC SOMS  Arrival date (2–8 months) Center Arrivals (20)  Arrived from (county jail, return from parole, etc.)  Randomize N/A at this institution Specialized OHU, CTC, SNF, CADDIS  Admit date (1–6 months) Medical Hospice  Type of stay (no MH beds) Housing (10 per housing area)  Length of stay (minimum of 5 days)  Randomize California Correctional Institution, Cycle 4 Medical Inspection Page 82 Office of the Inspector General State of California Sample Category Quality (number of Indicator patients) Data Source Filters Specialty High-Priority MedSATS  Approval date (3–9 months) Services Access (10)  Randomize Routine MedSATS  Approval date (3–9 months) (10)  Remove optometry, physical therapy or podiatry  Randomize Specialty Service MedSATS  Arrived from (other CDCR institution) Arrivals  Date of transfer (3–9 months) (20)  Randomize Denials InterQual  Review date (3–9 months) (20)*  Randomize IUMC/MAR  Meeting date (9 months) *Ten InterQual Meeting Minutes  Denial upheld Ten MARs  Randomize Internal Medical Appeals Monthly Medical  Medical appeals (12 months) Monitoring, (all) Appeals Reports Quality Adverse/Sentinel Adverse/Sentinel  Adverse/sentinel events (2–8 months) Improvement, Events Events Report and (5) Administrative QMC Meetings Quality  Meeting minutes (12 months) Operations (12) Management Committee Meeting Minutes Performance Performance  Performance Improvement Work Plan with Improvement Plans Improvement updates (12 months) (12) Work Plan Local Governing Local Governing  Meeting minutes (12 months) Body Body Meeting (12) Minutes EMRRC EMRRC  Meeting minutes (6 months) (6) Meeting Minutes Medical Emergency OIG Inspector  Most recent full quarter Response Drills Onsite Review  Each watch (3) 2nd Level Medical OIG Inspector  Medical appeals denied (6 months) Appeals Onsite Review (10) Death Reports OIG Inspector  Death reports (12 months) (10) Onsite Review Local Operating OIG Inspector  Review all Procedures Onsite Review (all) California Correctional Institution, Cycle 4 Medical Inspection Page 83 Office of the Inspector General State of California Sample Category Quality (number of Indicator patients) Data Source Filters Job Performance RN Review OIG Inspector  Current Supervising RN reviews and Training, Evaluations Onsite Review Licensing, and (5) Certifications Nursing Staff OIG Inspector  Review annual competency validations Validations Onsite Review  Randomize (10) Provider Annual OIG Inspector  All required performance evaluation documents Evaluation Packets Onsite Review (all) Medical Emergency OIG Inspector  All staff Response Onsite Review o Providers (ACLS) Certifications o Nursing (BLS/CPR) (all) o Custody (CPR/BLS) Nursing staff and OIG Inspector  All licenses and certifications Pharmacist-in-charge Onsite Review Professional Licenses and Certifications (all) Pharmacy and OIG Inspector  All current DEA registrations Providers’ Drug Onsite Review Enforcement Agency (DEA) Registrations (all) Nursing Staff New OIG Inspector  New employees (within the last 12 months) Employee Onsite Review Orientations (all) California Correctional Institution, Cycle 4 Medical Inspection Page 84 Office of the Inspector General State of California C C ALIFORNIA ORRECTIONAL H C S ’ EALTH ARE ERVICES R ESPONSE California Correctional Institution, Cycle 4 Medical Inspection Page 85 Office of the Inspector General State of California