California Correctional Institution Medical Inspection Report Cycle 5

Office of the Inspector General Roy W. Wesley Inspector General California Correctional Institution Medical Inspection Results Cycle 5 December 2017 Office of the Inspector General Office of the Inspector General CALIFORNIA CORRECTIONAL INSTITUTION Medical Inspection Results Cycle 5 Roy W. Wesley Inspector General Shaun R. Spillane Public Information Officer December 2017 oig T C ABLE OF ONTENTS Foreword i Executive Summary ii Overall Rating: Adequate ii Clinical Case Review and OIG Clinician Inspection Results iv Compliance Testing Result vi Recommendations vii Population-Based Metrics viii Introduction 1 About the Institution 1 Objectives, Scope, and Methodology 3 Case Reviews 4 Patient Selection for Retrospective Case Reviews 4 Benefits and Limitations of Targeted Subpopulation Review 5 Case Reviews Sampled 6 Compliance Testing 7 Sampling Methods for Conducting Compliance Testing 7 Scoring of Compliance Testing Results 8 Overall Quality Indicator Rating for Case Reviews and Compliance Testing 8 Population-Based Metrics 8 Medical Inspection Results 9 1 — Access to Care 10 Case Review Results 10 Compliance Testing Results 14 2 — Diagnostic Services 16 Case Review Results 16 Compliance Testing Results 17 3 — Emergency Services 19 Case Review Results 19 4 — Health Information Management 21 Case Review Results 21 Compliance Testing Results 22 5 — Health Care Environment 24 Compliance Testing Results 24 6 — Inter and IntraSystem Transfers 27 Case Review Results 27 Compliance Testing Results 29 7 — Pharmacy and Medication Management 31 Case Review Results 31 Compliance Testing Results 32 8 — Prenatal and Post-Delivery Services 36 9 — Preventive Services 37 Compliance Testing Results 37 10 — Quality of Nursing Performance 39 Case Review Results 39 11 — Quality of Provider Performance 43 California Correctional Institution, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California Case Review Results 43 12 — Reception Center Arrivals 48 13 — Specialized Medical Housing 49 Case Review Results 49 Compliance Testing Results 51 14 — Specialty Services 52 Case Review Results 52 Compliance Testing Results 54 15 — Administrative Operations (Secondary) 56 Compliance Testing Results 56 Recommendations 59 Population-Based Metrics 60 Appendix A — Compliance Test Results 63 Appendix B — Clinical Data 74 Appendix C — Compliance Sampling Methodology 77 California Correctional Health Care Services’ Response 84 California Correctional Institution, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California L T F IST OF ABLES AND IGURES CCI Executive Summary Table iii CCI Health Care Staffing Resources as of May 2017 2 CCI Master Registry Data as of May 15, 2017 2 CCI Results Compared to State and National HEDIS Scores 62 Table B-1: CCI Sample Sets 74 Table B-2: CCI Chronic Care Diagnoses 75 Table B-3: CCI Event - Program 76 Table B-4: CCI Review Sample Summary 76 California Correctional Institution, Cycle 5 Medical Inspection List of Tables and Figures Office of the Inspector General State of California F OREWORD Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), the OIG conducts a comprehensive inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG explicitly makes no determination regarding the constitutionality of care in the prison setting. That determination is left to the Receiver and the federal court. The assessment of care by the OIG is just one factor in the court’s determination whether care in the prisons meets constitutional standards. The OIG’s inspections are mandated by the Penal Code and not aimed at specifically resolving the court’s questions on constitutional care. To the degree that they provide another factor for the court to consider, the OIG is pleased to provide added value to the taxpayers of California. In Cycle 5, for the first time, the OIG will be inspecting institutions delegated back to CDCR from the Receivership. There is no difference in the standards used for assessment of a delegated institution versus an institution not yet delegated. The receiver delegated California Correctional Institution back to CDCR in June 2016. This fifth cycle of inspections will continue evaluating the areas addressed in Cycle 4, which included clinical case review, compliance testing, and a population-based metric comparison of selected Healthcare Effectiveness Data Information Set (HEDIS) measures. In agreement with stakeholders, the OIG made changes to both the case review and compliance components. The OIG found that in every inspection in Cycle 4, larger samples were taken than were needed to assess the adequacy of medical care provided. As a result, the OIG reduced the number of case reviews and sample sizes for compliance testing. Also, in Cycle 4, compliance testing included two secondary (administrative) indicators (Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications). For Cycle 5, these have been combined into one secondary indicator, Administrative Operations. California Correctional Institution, Cycle 5 Medical Inspection Page i! Office of the Inspector General State of California E S XECUTIVE UMMARY The OIG performed its Cycle 5 medical inspection at California Correctional Institution (CCI) from May to July 2017. The OVERALL RATING: inspection included in-depth reviews of 45 patient files conducted by clinicians, as well as reviews of documents from 409 patient Adequate files, covering 87 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 13 health care quality indicators applicable to the institution. 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 registered nurses trained in monitoring medical policy compliance. Of the indicators, seven were rated by both case review clinicians and compliance inspectors, three were rated by case review clinicians only, and three were rated by compliance inspectors only. The CCI Executive Summary Table on the following page identifies the applicable individual indicators and scores for this institution. California Correctional Institution, Cycle 5 Medical Inspection Page i!i Office of the Inspector General State of California CCI Executive Summary Table Cycle 5 Cycle 4 Case Review Compliance Inspection Indicators Overall Overall Rating Rating Rating Rating 1—Access to Care Inadequate Inadequate Inadequate Adequate 2—Diagnostic Services Proficient Inadequate Adequate Proficient 3—Emergency Services Adequate Not Applicable Adequate Inadequate 4—Health Information Adequate Adequate Adequate Adequate Management 5—Health Care Environment Not Applicable Inadequate Inadequate Adequate 6—Inter- and Intra-System Inadequate Adequate Inadequate Adequate Transfers 7—Pharmacy and Medication Adequate Inadequate Inadequate Adequate Management 8—Prenatal and Post-Delivery Not Applicable Not Applicable Not Applicable Not Applicable Services 9—Preventive Services Not Applicable Proficient Proficient Proficient 10—Quality of Nursing Adequate Not Applicable Adequate Adequate Performance 11—Quality of Provider Adequate Not Applicable Adequate Adequate Performance 12—Reception Center Arrivals Not Applicable Not Applicable Not Applicable Not Applicable 13—Specialized Medical Adequate Proficient Adequate Adequate Housing 14—Specialty Services Inadequate Inadequate Inadequate Adequate 15—Administrative Operations Not Applicable Proficient Proficient Adequate* (Secondary) *In Cycle 4, there were two secondary (administrative) indicators. This score reflects the average of those two scores. California Correctional Institution, Cycle 5 Medical Inspection Page i!ii Office of the Inspector General State of California Clinical Case Review and OIG Clinician Inspection Results The clinicians’ case reviews sampled patients with high medical needs and included a review of more than 664 patient care events.1 Of the 13 indicators applicable to CCI, 10 were evaluated by clinician case review; one was proficient, 6 were adequate, and 3 were 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. CCI’s performance in Cycle 5 was negatively affected by its transition to the Electronic Health Records System (EHRS), primarily in provider productivity and in the scheduling process. Delays in care, and in some cases dropped care can be directly attributed to the EHRS transition. In addition, the specialty services request process was also poorly implemented, which led to issues with access to specialty care. Despite these new challenges, provider and nursing care performed well. Although there were far fewer medical appointments available, the medical staff was able to triage the chronic care patients that were in most need of health care. Emergency services captured and treated patients that would otherwise not have been able to be accommodated. By the onsite visit, provider productivity had doubled compared to the start of the review period. Provider triage processes were no longer needed and were discontinued. Additionally, specialty services had identified many of the pitfalls in the specialty request process and had begun to resolve the issues. Overall, CCI performed adequately during the period of review. Further training in the EHRS will be needed for the institution to maintain its adequate performance. Program Strengths — Clinical • CCI performed diagnostic tests reliably. With a few critical exceptions, the EHRS had markedly improved the transfer of onsite diagnostic results into the electronic medical record. • CCI health information management improved after the implementation of the EHRS. Medical information was timely retrieved, scanned, and made available to the providers and ancillary staff. 1 Each OIG clinician team includes a board-certified physician and registered nurse consultant with experience in correctional and community medical settings. California Correctional Institution, Cycle 5 Medical Inspection Page i!v Office of the Inspector General State of California • CCI’s ability to manage urgent and emergent medical conditions was often exceptional. The OIG appreciated CCI’s efforts to improve their urgent and emergency services. This improvement was noted in the case reviews as well as at the onsite visit. • The morale at CCI throughout the EHRS transition was excellent. There were many instances of individual acts of persistence and diligence with finding and correcting faulty EHRS processes in an effort to provide better medical care for patients. Program Weaknesses — Clinical • During the review period, CCI displayed poor access to care. At first, access problems were ubiquitous throughout the case reviews, but access to care improved as the medical staff became more familiar with the EHRS. • There was great difficulty with the transition to EHRS in specialty services where the lack of EHRS preparation and training was evident. Specialty services staff at CCI acknowledged the deficits and began working diligently to resolve the deficiencies. • Preparation and training for the EHRS transition was poor at CCI. The institution was not proactive in planning for the decrease in patient access that occurred during the implementation of the new system. When available provider appointments were insufficient, CCI utilized a triage system which was only partially effective in managing the decreased access. This resulted in many significant access to care deficiencies that were still evident during the onsite inspection. Eight months after the EHRS transition, CCI medical staff was still attempting to recover lost medical data and using work- arounds to complete daily tasks. California Correctional Institution, Cycle 5 Medical Inspection Page v! Office of the Inspector General State of California Compliance Testing Results Of the 13 health care indicators applicable to CCI, 10 were evaluated by compliance inspectors.2 Three indicators were proficient, two were adequate, and five were inadequate. There were 87 individual compliance questions within those 10 indicators, generating 1,124 data points, that tested CCI’s compliance with California Correctional Health Care Services (CCHCS) policies and procedures.3 Those 87 questions are detailed in Appendix A — Compliance Test Results. Program Strengths — Compliance The following are some of CCI’s strengths based on its compliance scores on individual questions in all applicable health care indicators: • The institution provided radiology and laboratory services within required time frames. • Initial health care assessment and patient requests for health care services documents were scanned into the electronic medical record within required time frames. • Registered nurses (RNs) completed the assessment and disposition sections of initial health care assessment forms for patients that transferred into CCI, and nursing staff properly completed medication transfer packages for patients that transferred out of CCI. • The institution did a good job providing patients with preventive immunizations and colon cancer screenings. • The institution performed well with administrative operations; specifically, CCI attended to all patient health care appeals timely, and regularly held Quality Management Committee meetings, in which the accuracy of the Dashboard data was addressed. Program Weaknesses — Compliance The following are some of the weaknesses identified by CCI’s compliance scores on individual questions in all applicable health care indicators: • Overall, access to medical care was poor at CCI, including patient chronic care appointments, initial health assessments of patients transferring into the institution, nurse-to-provider referral appointments, and specialty service follow-up appointments. 2 The OIG’s compliance inspectors are trained registered nurses with expertise in CDCR policies regarding medical staff and processes. 3 The OIG used its own clinicians to provide clinical expert guidance for testing compliance in certain areas where CCHCS policies and procedures did not specifically address an issue. California Correctional Institution, Cycle 5 Medical Inspection Page v! i Office of the Inspector General State of California • Providers did not always review diagnostic service reports or communicate results to patients within required time frames. • Several CCI clinic common areas and exam rooms did not have all the necessary supplies available to complete a comprehensive exam and several equipment items were not properly calibrated. In addition, several Emergency Medical Response Bags were not inventoried within required time frames. • CCI’s pharmacy had issues with timely medication administration for patients with chronic care conditions, newly ordered medications, hospital discharge medications, as well as for patients who were temporarily housed at CCI while en route to another facility. • CCI performed poorly with ensuring that high-priority specialty services were either timely provided or reviewed by a provider within the required time frames. Recommendations Based on the results of the Cycle 5 medical inspection at CCI, the OIG recommends the following: • Arrange additional EHRS training for providers, supervisors, nurses, and ancillary staff, specifically targeting all staff involved with appointments, scheduling, specialty services, and utilization management. • Revise current nursing audits to include the EHRS systems processes and competencies. • Ensure the current SRN sick call audit process monitors the quality of all facets of the sick call process, including the initial nurse triage. • Implement audits on arriving and departing patients to ensure providers and nurses are notified of upcoming transfers as well as audit processes for specialty consults and follow-up appointments, to monitor timeliness. Audits should be ongoing, and findings reported directly to the Patient Safety Committee. • Audit the electronic records to determine if radiology information and electronic messages are being processed and received appropriately by each medical provider. During the OIG medical inspection, the CCI providers could not retrieve radiology information from the RIS/PACS and could not effectively cover each other’s messages within the EHRS. California Correctional Institution, Cycle 5 Medical Inspection Page v! ii Office of the Inspector General State of California • Implement OHU-specific continuous quality improvement programs that target the communication processes between nursing staff on all shifts and also between OHU nurses and providers. We recommend that CCI leadership create a system to ensure unusual nursing occurrences are identified daily, documented, and communicated to the provider. This should be part of the daily huddle, but was not occurring. While processes for communication did exist, CCI was not using them. Population-Based Metrics In general, CCI performed well as measured by population-based metrics. In comprehensive diabetes care, CCI outperformed most state and national organizations in most of the five diabetic measures, but scored less well in a few measures, mainly diabetic eye exams.With regard to immunization measures and colorectal cancer screenings, CCI’s comparative scores were mixed and negatively affected by a significant patient refusal rate. Overall, CCI’s performance demonstrated by the population-based metrics indicated that the chronic care program was operating well and that the institution had an opportunity to improve by providing patient education about the benefits of immunizations and cancer screenings. California Correctional Institution, Cycle 5 Medical Inspection Page v! iii Office of the Inspector General State of California I NTRODUCTION Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), and at the request of the federal Receiver, the OIG developed a comprehensive medical inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG conducts a clinical case review and a compliance inspection, ensuring a thorough, end-to-end assessment of medical care within CDCR. California Correctional Institution (CCI) was the 15th medical inspection of Cycle 5. During the inspection process, the OIG assessed the delivery of medical care to patients using the primary clinical health care indicators applicable to the institution. The Administrative Operations indicator is secondary because it does not reflect the actual clinical care provided. ABOUT THE INSTITUTION The California Correctional Institution is located in Cummings Valley, west of the city of Tehachapi in Kern County. CCI consists of five separate facilities, housing inmates of varying security levels, from minimum to maximum security. The institution runs seven clinics where staff members handle non-urgent requests for medical services, including five facility clinics, a specialty clinic, and an onsite outpatient housing unit (OHU). The institution treats patients needing urgent or emergency care in its triage and treatment area (TTA). CCI has been designated by California Correctional Health Care Services (CCHCS) as a “basic” care prison. Basic institutions are located in rural areas, away from tertiary care centers and specialty care providers whose services would likely be used frequently by higher-risk patients. Basic institutions have the capability to provide limited specialty medical services and consultation for a generally healthy patient population. On August 20, 2017, the institution received national accreditation from the Commission on Accreditation for Corrections. This accreditation program is a professional peer review process based on national standards set by the American Correctional Association. Based on staffing data the OIG obtained from the institution, CCI’s vacancy rate among medical managers, primary care providers, supervisors, and rank-and-file nurses was 9 percent in May 2017, with the highest vacancy percentage among nursing supervisors at 22 percent. Additionally, the CEO reported that in May 2017, there were two medical staff members currently under CDCR disciplinary review. California Correctional Facility, Cycle 5 Medical Inspection Page !1 Office of the Inspector General State of California CCI Health Care Staffing Resources as of May 2017 Primary Care Nursing Management Nursing Staff Totals Providers Supervisors Description Number % Number % Number % Number % Number % Authorized 5 4% 10 9% 11.5 10% 86.5 77% 113 100% Positions Filled Positions 5 100% 8 80% 9 78% 81 94% 103 91% Vacancies 0 0% 2 20% 2.5 22% 5.5 6% 10 9% Recent Hires (within 12 1 20% 0 0% 4 50% 10 12% 15 15% months) Staff Utilized 0 0% 1 13% 0 0% 4 5% 5 5% from Registry Redirected Staff 0 0% 0 0% 0 0% 0 0% 0 0% (to NonPatient Care Areas) Staff on Longterm 0 0% 0 0% 1 13% 1 1% 2 2% Medical Leave Note: CCI Health Care Staffing Resources data was not validated by the OIG. As of May 15, 2017, the Master Registry for CCI showed that the institution had a total population of 3,825. Within that total population, 0.7 percent were designated as high medical risk, Priority 1 (High 1), and 2.5 percent were designated as high medical risk, Priority 2 (High 2). Patients’ assigned risk levels are based on the complexity of their required medical care related to their specific diagnoses, frequency of higher levels of care, age, and abnormal laboratory results and procedures. High 1 has at least two high-risk conditions; High 2 has only one. Patients at high medical risk are more susceptible to poor health outcomes than those at medium or low medical risk. Patients at high medical risk also typically require more health care services than do patients with lower assigned risk levels. The 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 May 15, 2017 Medical Risk Level Number of Patients Percentage High 1 27 0.7% High 2 95 2.5% Medium 2,132 55.7% Low 1,571 41.1% Total 3,825 100% California Correctional Institution, Cycle 5 Medical Inspection Page 2! Office of the Inspector General State of California O , S , M BJECTIVES COPE AND ETHODOLOGY In designing the medical inspection program, the OIG reviewed CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. The OIG also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the Receiver’s office, CDCR, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of the OIG’s inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates medical care delivery by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population-based metrics. To maintain a metric-oriented inspection program that evaluates medical care delivery consistently at each state prison, the OIG identified 15 indicators (14 primary (clinical) indicators and one secondary (administrative) indicator) of health care to measure. The primary quality indicators cover clinical categories directly relating to the health care provided to patients, whereas the secondary quality indicator address the administrative functions that support a health care delivery system. These 15 indicators are identified in the CCI Executive Summary Table on page iii of this report. The OIG rates each of the quality indicators applicable to the institution under inspection based on case reviews conducted by OIG clinicians and compliance tests conducted by OIG registered nurses. The 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 done by clinicians, while the ratings for the primary quality indicators Health Care Environment and Preventive Services are derived entirely from compliance testing done by registered nurse inspectors. As another example, primary quality indicators such as Diagnostic Services and Specialty Services receive ratings derived from both sources. 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 a patient needing immediate care, the OIG notifies the chief executive officer of health care services and requests a status report. Additionally, if the OIG learns of significant departures from community standards, it may report such departures to the institution’s chief executive officer or to CCHCS. Because these matters involve confidential medical information protected by state and federal privacy laws, specific identifying details related to any such cases are not included in the OIG’s public report. California Correctional Institution, Cycle 5 Medical Inspection Page 3! Office of the Inspector General State of California In all areas, the OIG is alert for opportunities to make appropriate recommendations for improvement. Such opportunities may be present regardless of the score awarded to any particular quality indicator; therefore, recommendations for improvement should not necessarily be interpreted as indicative of deficient medical care delivery. CASE REVIEWS The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders, which continues in Cycle 5 medical inspections. 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 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, the OIG clinical experts made the following 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 California Correctional Institution, Cycle 5 Medical Inspection Page 4! Office of the Inspector General State of California 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 (unexpected occurrences 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. 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. California Correctional Institution, Cycle 5 Medical Inspection Page 5! Office of the Inspector General State of California Case Reviews Sampled As indicated in Appendix B, Table B–1: CCI Sample Sets, the OIG clinicians evaluated medical charts for 45 unique patients. Appendix B, Table B–4: CCI Case Review Sample Summary, clarifies that both nurses and physicians reviewed charts for 14 of those patients, for 59 reviews in total. Physicians performed detailed reviews of 20 charts, and nurses performed detailed reviews of 12 charts, totaling 32 detailed reviews. For detailed case reviews, physicians or nurses 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 25 patients. These generated 664 clinical events for review (Appendix B, Table B–3: CCI Event-Program). The inspection tool 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 5 chronic care patient records, i.e., 3 diabetes patients and 2 anticoagulation patients (Appendix B, Table B–1: CCI Sample Sets), the 45 unique patients sampled included patients with 150 chronic care diagnoses, including 8 additional patients with diabetes (for a total of 11 ) and one additional anticoagulation patient (for a total of 3) (Appendix B, Table B–2: CCI Chronic Care Diagnoses). The OIG’s sample selection tool allowed evaluation of many chronic care programs because the complex and high-risk patients selected from the different categories often had multiple medical problems. While the OIG did not evaluate every chronic disease or health care staff member, the 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 found the Cycle 4 medical inspection sample size of 30 for detailed physician reviews far exceeded the saturation point necessary for an adequate qualitative review. At the end of Cycle 4 inspections, the case review results were reanalyzed using 50 percent of the cases; there were no significant differences in the ratings. To improve inspection efficiency while preserving the quality of the inspection, the samples for Cycle 5 medical inspections were reduced in number. In Cycle 5, for basic institutions with small high-risk populations, case review will use a sample size of detailed physician-reviewed cases 67 percent as large as that used in Cycle 4. Intermediate institutions and basic institutions housing many high-risk patients, case review physicians will use a sample 83 percent as large as that in Cycle 4. Finally, for the most medically complex institution, California Health Care Facility (CHCF), the OIG will continue to use a sample size 100 percent as large as that used in Cycle 4. For CCI, the OIG used a 67 percent case review sample size, compared to Cycle 4, because it is a basic institution. 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 California Correctional Institution, Cycle 5 Medical Inspection Page 6! Office of the Inspector General State of California those patients who need care the most. Nonetheless, while not sampling cases by each provider at the institution, the OIG 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 providers care for the less complicated, low-utilizing, and lower-risk patients. The OIG’s clinicians 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 May to July 2017, registered nurse inspectors attained answers to 87 objective medical inspection test (MIT) questions designed to assess the institution’s compliance with critical policies and procedures applicable to the delivery of medical care. To conduct most tests, inspectors randomly selected samples of patients for whom the testing objectives were applicable and reviewed their electronic unit health records. In some cases, inspectors used the same samples to conduct more than one test. In total, inspectors reviewed health records for 409 individual patients and analyzed specific transactions within their records for evidence that critical events occurred. Inspectors also reviewed management reports and meeting minutes to assess certain administrative operations. In addition, during the week of June 5, 2017, registered nurse 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 1,124 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 Cycle 5 medical inspection testing, the OIG reduced the number of compliance samples tested for 18 indicator tests from a sample of 30 patients to a sample of 25 patients. The OIG also removed some inspection tests upon stakeholder agreement that either were duplicated in the case reviews or had limited value. Lastly, for Cycle 4 medical inspections, the OIG tested two secondary (administrative) indicators; Internal Monitoring, Quality Improvement, and Administrative California Correctional Institution, Cycle 5 Medical Inspection Page 7! Office of the Inspector General State of California Operations; and Job Performance, Training, Licensing, and Certifications, and have combined these tests into one Administrative Operations indicator for Cycle 5 inspections. For details of the compliance results, see Appendix A — Compliance Test Results. For details of the OIG’s compliance sampling methodology, see Appendix C — Compliance Sampling Methodology. Scoring of Compliance Testing Results After compiling the answers to the 87 questions for the ten applicable indicators, the OIG derived a score for each quality indicator by calculating the percentage score of all Yes answers for each of the questions applicable to a particular indicator, then averaging those scores. Based on those results, the OIG assigned a rating to each quality indicator of proficient (greater than 85 percent), adequate (between 75 percent and 85 percent), or inadequate (less than 75 percent). OVERALL QUALITY INDICATOR RATING FOR CASE REVIEWS AND COMPLIANCE TESTING The OIG derived the final rating for each quality indicator by combining the ratings from the case reviews and from the compliance testing, as applicable. When combining these ratings, the case review evaluations and the compliance testing results usually agreed, but there were 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 registered nurse inspectors discussed the nature of individual exceptions found within that indicator category and considered the overall effect on the ability of patients to receive adequate medical care. To derive an overall assessment rating of the institution’s medical inspection, the OIG evaluated the various rating categories assigned to each of the quality indicators applicable to the institution, giving more weight to the rating results of the primary quality indicators, which directly relate to the health care provided to patients. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed. POPULATION-BASED METRICS The OIG identified a subset of Healthcare Effectiveness Data Information Set (HEDIS) measures applicable to the CDCR patient population. To identify outcomes for CCI, the OIG reviewed some of the compliance testing results, randomly sampled additional 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 5 Medical Inspection Page 8! Office of the Inspector General State of California M I R EDICAL NSPECTION ESULTS The quality indicators assess the clinical aspects of health care. As shown on the CCI Executive Summary Table on page iii of this report, 13 of the OIG’s indicators were applicable to CCI. Of those 13 indicators, 7 were rated by both the case review and compliance components of the inspection, 3 were rated by the case review component alone, and 3 were rated by the compliance component alone. The Administrative Operations indicator is a secondary indicator, and, therefore, was not relied upon for the overall score for the institution. Based on the analysis and results in all the primary indicators, the OIG experts made a considered and measured opinion that the quality of health care at CCI was adequate. Summary of Case Review Results: The clinical case review component assessed ten primary (clinical) indicators applicable to CCI. Of these ten indicators, OIG clinicians rated one proficient, six adequate, and three inadequate. The OIG physicians rated the overall adequacy of care for each of the 20 detailed case reviews they conducted. Of these 20 cases, one was proficient, 14 were adequate, and five were inadequate. In the 664 events reviewed, there were 247 deficiencies, of which 88 were considered to be of such magnitude that, if left unaddressed, they would likely contribute to patient harm. Adverse Events Identified During Case Review: Adverse events are medical errors which cause serious patient harm. Medical care is a complex and dynamic process with many moving parts, subject to human error even within the best health care organizations. 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. There were no adverse events identified in the case reviews at CCI. Summary of Compliance Results: The compliance component assessed 10 of the 13 indicators applicable to CCI. Of these ten indicators, OIG inspectors rated three proficient, two adequate, and five inadequate. The results of those assessments are summarized within this section of the report. The test questions used to assess compliance for each indicator are detailed in Appendix A. California Correctional Institution, Cycle 5 Medical Inspection Page 9! Office of the Inspector General State of California 1 — ACCESS TO CARE This indicator evaluates the institution’s ability to provide patients Case Review Rating: with timely clinical appointments. Areas specific to patients’ access Inadequate to care are reviewed, such as initial assessments of newly arriving Compliance Score: inmates, acute and chronic care followups, face-to-face nurse Inadequate appointments when a patient requests to be seen, provider referrals (70.1%) from nursing lines, and followups after hospitalization or specialty Overall Rating: care. Compliance testing for this indicator also evaluates whether Inadequate patients have Health Care Services Request forms (CDCR Form 7362) available in their housing units. Case Review Results The OIG clinicians reviewed 338 provider, nurse, specialty, and hospital events that required a follow-up appointment, and identified 42 deficiencies related to Access to Care. Among the 42 deficiencies, 30 were significant, or likely to cause patient harm. The OIG clinicians rated the Access to Care indicator inadequate. Provider-to-Provider Follow-up Appointments CCI performed poorly with provider-ordered appointments. Failure to accommodate provider- ordered appointments can often result in a lapse of care. During the review period, 130 outpatient provider appointments were reviewed. The OIG discovered eight deficiencies, four of which were considered significant: • In case 6, the provider ordered a 40-day follow-up appointment for an asthmatic patient. The appointment did not occur. • In case 10, the patient was prescribed a blood thinner for a blood clot and required regular monitoring. The provider ordered a 30-day follow-up appointment, but the appointment occurred two months late. • In case 13, the provider ordered a six-month chronic care follow-up appointment for the patient with uncontrolled diabetes mellitus. The appointment did not occur. • In case 18, the patient had a recent hospitalization for a fungal ear infection. The provider ordered a two-week follow-up appointment, which did not occur until almost a month from the date the provider ordered the appointment to occur. California Correctional Institution, Cycle 5 Medical Inspection Page 1! 0 Office of the Inspector General State of California RN Sick Call Access CCI nurses performed poorly with sick call access. Of the 71 encounters reviewed, 13 deficiencies were identified, nine of which were significant. OIG clinicians identified a pattern of delays resulting from the triage of sick call requests on a weekend or holiday. Sick call access was delayed by one day in three weekend cases reviewed. In multiple cases, the registered nurse (RN) failed to provide face-to-face assessments. This finding was identified in cases 19, 28, 35, and the following: • In case 15, the patient submitted a sick call request for abdominal pain. The nurse noted the patient had been seen multiple times for this chronic issue and was awaiting a diagnostic procedure to evaluate the intestinal tract. The nurse inappropriately assumed the complaint was chronic and did not assess the patient. • In case 21, the diabetic patient complained of a recurring wound. The nurse noted the patient was seen four days prior by a provider and did not assess the patient’s complaint. • In case 44, this patient submitted a sick call request for a skin rash, but the RN did not perform a face-to-face assessment. Fortunately, the patient was referred to a provider who saw him two days later. RN-to-Provider Referrals CCI performed poorly with RN-to-provider referrals. Of the 29 referrals reviewed, ten deficiencies were identified, nine of which were considered significant. Below are examples of these significant deficiencies: • In case 15, the nurse referred the patient to a provider for abdominal pain and diarrhea on two separate occasions. One appointment was three weeks late, and the other appointment never occurred. • In case 21, the nurse referred the patient to a provider on three separate occasions; twice for skin infections and once for chronic feet pain. The patient was never seen by the provider. • In case 34, the nurse referred the patient to a provider for skin lesions and a headache. The appointment occurred five weeks late. • In case 43, the nurse referred the patient to a provider for painful skin lesions. The appointment occurred more than two weeks late. California Correctional Institution, Cycle 5 Medical Inspection Page 1! 1 Office of the Inspector General State of California Nursing Follow-up Appointments On occasion, nurses ordered follow-up appointments with other nurses. CCI also performed poorly in this area. Of the four nursing follow-up appointments reviewed, three deficiencies were identified: • In case 7, weekly blood pressure checks were ordered for four weeks; however, the first weekly blood pressure assessment did not occur for one month. • In case 13, the provider ordered a six-month chronic care follow-up appointment for the patient with uncontrolled diabetes mellitus. The appointment did not occur. • In case 20, a two-week nurse follow-up appointment for an asthmatic patient with upper respiratory symptoms was ordered, but never occurred. Provider Follow-up After Specialty Services CCI performed well with ensuring that providers saw their patients after a specialty service. No significant deficiencies were noted. Intra-System Transfers CCI performed satisfactorily with ensuring that patients that transferred in from or out to another CDCR institution were given timely provider appointments. Of the 16 events the OIG reviewed, three deficiencies were identified, one of which was considered significant: • In case 26, the high-risk patient should have been assessed by a provider within seven days of arrival, but was not seen for four weeks. Follow-up After Hospitalization CCI performed poorly with ensuring patients receive a follow-up appointment with a provider after returning from a community hospital or an outside emergency room. This critical process of safeguarding the transition of care was sub-optimal at CCI. The OIG clinicians reviewed 12 of these encounters and identified 4 significant deficiencies. Some examples of these deficiencies are listed below: • In case 1, the patient with a history of heart and lung disease was sent to the hospital for difficulty breathing and weakness. A provider follow-up appointment should have occurred within five days after the hospitalization, but was delayed an additional eight days. California Correctional Institution, Cycle 5 Medical Inspection Page 1! 2 Office of the Inspector General State of California • In case 18, the patient was admitted to a community hospital for an ear infection that caused progressive hearing loss, drainage, and pain. After the hospitalization, a provider follow-up appointment should have occurred within five days, but was delayed an additional ten days. Follow-up After Urgent/Emergent Care CCI was effective with ensuring providers saw patients following a TTA visit. Of the 31 encounters the OIG reviewed, two significant deficiencies were identified. The following significant deficiency illustrates the importance of these appointments: • In case 46, the patient was seen in the TTA for back pain and unsteady balance. The patient should have received a provider follow-up appointment within seven days, but the appointment was delayed an additional week. During this delay, the patient’s back pain worsened and he could no longer stand from a sitting position. Because there were no available appointments, the provider did not perform a proper evaluation of the patient. However, the provider was able to order the patient an urgent magnetic resonance imaging (MRI) of the back and provide the patient with a cane. Specialized Medical Housing CCI performed appropriately with ensuring that patients within specialized medical housing had access to primary care providers. Specialty Access and Follow-up The institution performed poorly with specialty access and follow-up. Multiple deficiencies were discovered in access to specialty services. Performance in this area is discussed in detail in the Specialty Services indicator. Diagnostic Results Follow-up CCI performed well with ensuring patients saw their providers after a diagnostic study. There were no deficiencies identified related to laboratory or x-ray follow-up appointments. Clinician Onsite Inspection During the OIG inspection, the providers and nurses expressed difficulty with the complexities and nuances of the new EHRS. Throughout the various clinics, TTAs, and specialty units, the providers and ancillary staff lacked confidence with their knowledge of the EHRS. CCI staff reported that their unfamiliarity with the EHRS led to errors with appointment tracking and to lower productivity. Staff became more familiar with the system over time, as processes were created within the institution to capture needed appointments. Since less time was spent trying to learn the system, California Correctional Institution, Cycle 5 Medical Inspection Page 1! 3 Office of the Inspector General State of California CCI staff reported problems with access to care had improved. However, medical staff believe they would become adept in using the system and perform their tasks better with more training in the EHRS. Case Review Conclusion CCI’s performance in the Access to Care indicator differed vastly from Cycle 4 to Cycle 5. In Cycle 5, CCI had 28 significant deficiencies in this indicator compared to zero during the prior cycle. The deficiencies were found in many aspects of health care access, which CCI staff attribute to the EHRS implementation. The OIG clinicians rated the Access to Care indicator inadequate. Compliance Testing Results The institution received an inadequate compliance score of 70.1 percent in the Access to Care indicator, and performed poorly on the following tests: • Only 10 of 24 sampled patients who received a high-priority or routine specialty service (42 percent) also received a timely follow-up appointment with a provider. Among the 14 patients who did not receive a timely follow-up appointment, five patients’ high- priority specialty service follow-up appointments were one to nine days late and one patient did not have medical record evidence that a follow-up appointment occurred. Five patients’ routine specialty service follow-up appointments were 6 to 52 days late and three patients did not have medical record evidence that an appointment occurred (MIT 1.008). • OIG inspectors initially sampled 30 patients who submitted a sick call request. Of the 30 sampled patients, four patients ultimately required a second provider follow-up appointment. However, of these four patients, only two received their follow-up appointments timely (50 percent). One patient’s follow-up appointment was 24 days late, and the other patient’s follow-up appointment never occurred (MIT 1.006). • Among 18 sampled Health Care Services Request forms (CDCR Form 7362) on which nursing staff referred the patient for a provider appointment, only ten patients (56 percent) received a timely appointment. Four patients received their appointments between one and 21 days late, and four other patients did not receive a provider visit at all (MIT 1.005). • Among 25 patients sampled who transferred into CCI from other institutions and were referred to a provider based on nursing staff’s initial health care screening, only 14 (56 percent) were seen timely. Eight patients received their provider appointments from 4 to 90 days late, and one other patient’s appointment was 201 days late. For two other California Correctional Institution, Cycle 5 Medical Inspection Page 1! 4 Office of the Inspector General State of California patients, there was no medical record evidence found to indicate they were ever seen (MIT 1.002). • Inspectors sampled 25 patients who suffered from one or more chronic care conditions. Out of the 25 patients reviewed, only 15 timely received their provider-ordered follow- up appointments (60 percent). Ten other patients received their appointments late or not at all, including six patients whose follow-up appointments occurred between 28 and 80 days late and two patients whose appointments were 113 and 158 days late. For the remaining two patients, there was no evidence the appointments ever occurred (MIT 1.001). The institution scored in the adequate range on the following test: • For 24 of the 30 patients sampled who submitted health care services request forms (80 percent), nursing staff completed a face-to-face encounter with the patient within one business day of reviewing the service request form. For one patient, the nurse conducted the visit 30 days late, and for five other patients, there was no medical record evidence that a face-to-face encounter ever occurred (MIT 1.004). CCI scored in the proficient range on the following tests: • All 30 sampled health care services request forms submitted by patients across all facility clinics were reviewed by nursing staff on the same day they were received (MIT 1.003). • Patients at CCI had access to health care services request forms at all six housing units the OIG inspected (MIT 1.101). • Among 25 sampled patients who were discharged from a community hospital, 22 (88 percent) received a follow-up appointment with a provider within five days of their return to CCI. For one patient, the follow-up appointment was 50 days late, and for two other patients, there was no evidence in their electronic medical records that their follow-up appointments ever occurred (MIT 1.007). California Correctional Institution, Cycle 5 Medical Inspection Page 1! 5 Office of the Inspector General State of California 2 — DIAGNOSTIC SERVICES This indicator addresses several types of diagnostic services. Case Review Rating: Specifically, it addresses whether radiology and laboratory services Proficient were timely provided to patients, whether the primary care provider Compliance Score: timely reviewed the results, and whether the results were Inadequate communicated to the patient within the required time frames. In (69.4%) addition, for pathology services, the OIG determines whether the Overall Rating: institution received a final pathology report and whether the Adequate provider 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. In this indicator, the OIG case review and compliance review processes yielded significantly different results, with the case review giving a proficient rating and the compliance review resulting in an inadequate score. The OIG’s internal review process considered those factors that led to both scores and ultimately rated this indicator adequate. The case review assessments mainly focused on high-risk patients and targeted more recent patient encounters; whereas, the compliance review randomly selected patients across various categories and evaluated the timeliness of provider review and communication of diagnostic testing results from two weeks to nine months prior to the inspection, which provided a more robust overview of the provision of diagnostic services at CCI. As a result, the rating of adequate was deemed the most appropriate reflection of the overall indicator rating. Case Review Results The OIG clinicians reviewed 116 diagnostic events and identified only three deficiencies, two of which were significant. Test Completion CCI successfully completed and performed timely diagnostic services, such as electrocardiograms and X-rays. All imaging studies were performed and reviewed timely. Laboratory tests were performed and sent offsite for processing. CCI provided exemplary diagnostic support to the medical staff. Health Information Management CCI’s performance with diagnostic reports was sufficient; only a few deficiencies were identified out of the numerous diagnostic studies performed. Out of 116 diagnostic studies performed, the OIG identified only three deficiencies, two of which were significant. Since the deficiencies were isolated, they were not representative of the good performance in this area: California Correctional Institution, Cycle 5 Medical Inspection Page 1! 6 Office of the Inspector General State of California • In case 13, an abnormal laboratory result, which indicated the patient had worsening diabetic control, was not reviewed by a primary provider or nurse. • In case 28, the provider did not order a follow-up appointment with a patient whose abnormal laboratory results indicated he had significant kidney disease. One month later, the patient was admitted to the hospital for new symptoms related to the kidney disease. Clinician Onsite Inspection During the onsite inspection, the OIG clinicians noted the institution had three x-ray machines located on separate yards. If an x-ray machine was not functioning in one yard, patients could still get x-rays at another yard. CCI providers praised the diagnostic services staff for being conscientious and resourceful. Frequently, radiology technicians responded timely to provider requests for outside imaging reports, and laboratory tests were drawn and results were provided within appropriate time frames. Within the EHRS, providers were notified via electronic message of new laboratory and diagnostic results available for review, and most providers diligently reviewed their messages. The OIG clinicians found very few instances of providers failing to review their messages and test results, or of providers reviewing them late. Case Review Conclusion CCI performed very well with diagnostic testing. Therefore, the OIG clinicians rated the Diagnostic Services indicator proficient. Compliance Testing Results The institution received an inadequate compliance score of 69.4 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 • Radiology services were timely performed for all ten patients sampled (MIT 2.001). Providers timely initialed and dated the corresponding diagnostic services reports, as required by CCHCS policy, for six of the ten patients (60 percent). For the remaining four patients, the providers reviewed the diagnostic reports one to 20 days late (MIT 2.002). In addition, providers timely communicated the test results to only four of the ten sampled patients (40 percent). For three patients, the provider communicated the results one to eight days late. For the remaining three patients, no evidence was found in their medical records that they ever received their results (MIT 2.003). California Correctional Institution, Cycle 5 Medical Inspection Page 1! 7 Office of the Inspector General State of California Laboratory Services • All ten of the laboratory services sampled were timely performed (MIT 2.004). Providers timely reviewed seven of the ten resulting laboratory services reports (70 percent). Two reports were reviewed one and six days late, and for one other report, there was no evidence that the provider ever reviewed the report (MIT 2.005). Providers timely communicated the laboratory results to only five of the ten patients (50 percent). Three patients received their results between 3 and 29 days late, and two other patients did not receive their results (MIT 2.006). Pathology Services • CCI timely received the final pathology reports for eight of ten patients sampled (80 percent). For two patients, their final pathology reports were missing from their electronic medical records (MIT 2.007). To evidence their review of pathology results, providers properly initialed only five of the eight applicable sampled reports (63 percent). Providers reviewed two reports nine and ten days late, and for one report, there was no evidence found in the medical record that it was reviewed (MIT 2.008). Providers timely communicated the final pathology results to five of the eight patients sampled (63 percent). Two reports were communicated 9 and 10 days late, and one other report was communicated 173 days late (MIT 2.009). California Correctional Institution, Cycle 5 Medical Inspection Page 1! 8 Office of the Inspector General State of California 3 — EMERGENCY SERVICES An emergency medical response system is essential to providing Case Review Rating: effective and timely emergency medical response, assessment, Adequate treatment, and transportation 24 hours per day. Provision of urgent/ Compliance Score: emergent care is based on a patient’s emergency situation, clinical Not Applicable condition, and need for a higher level of care. The OIG reviews emergency response services including first aid, basic life support Overall Rating: (BLS), and advanced cardiac life support (ACLS) consistent with Adequate 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 Of the 32 urgent and emergent events reviewed, 28 deficiencies were identified. Of these deficiencies, seven were considered significant. CPR Response The OIG reviewed six CPR emergency events. In each case, the CPR response was satisfactory. Provider Performance TTA provider performance was good. CCI providers triaged patients appropriately, administered necessary patient care, and devised accurate assessments and sound plans. Providers transferred patients to an outside hospital when needed. Only two provider deficiencies were identified, both were significant and occurred in the same case: • In case 46, on multiple occasions, the patient had breakthrough seizures or seizures that occurred despite being prescribed medications. The provider did not review the seizure medication levels or order laboratory tests to measure those levels. • Also in case 46, the patient was in need of an urgent provider appointment to be considered for a neurology consult due to the patient’s multiple breakthrough seizures, but the TTA provider did not order the follow-up appointment. California Correctional Institution, Cycle 5 Medical Inspection Page 1! 9 Office of the Inspector General State of California Nursing Performance CCI’s nursing care was good. Of the 36 urgent and emergent events reviewed, two significant deficiencies were identified: • In case 2, the patient had chest pain. The nurse administered nitroglycerin, but did not promptly reassess the chest pain level or administer an additional dose when the pain persisted. • In case 20, the RN did not administer oxygen or provide an emergency inhaler for a patient who had asthma, abnormal lung sounds, and low oxygen levels. Emergency Medical Response Review Committee CCI regularly conducted clinical reviews of non-scheduled emergency transports with the supervising registered nurse (SRN), frequently completing the nursing review on the same day of the event. Additionally, the Emergency Medical Response Review Committee (EMRRC) reviewed cases, but on two occasions, the reviews did not capture nursing deficiencies: • In case 4, a medical alarm was activated for a patient with respiratory distress. The emergency response nurse arrived to the housing unit, but did not assess the patient’s vital signs. Furthermore, the SRN and the EMRRC did not capture this deficiency. • In case 20, the SRN reviewed the case; however, the SRN and the EMRRC did not recognize the nurse’s failure to administer oxygen for the patient with low oxygen levels. Clinician Onsite Inspection At CCI, each yard’s medical unit had a designated TTA, staffed with an emergency response RN on every shift, with the exception of the graveyard shift in one facility. At this facility, an emergency response RN from another facility would cover the graveyard shift along with their own facility. During regular clinic hours, medical providers saw patients in each TTA. In addition to providing urgent or emergent care in the TTA, each provider was responsible for completing the scheduled primary care appointments along with occasional nursing consults. While the multiple and potentially conflicting responsibilities appeared arduous, the providers handled the multiple tasks with ease; however, providers admitted that on occasion they did not document nursing and TTA consultations on especially busy days because they felt these tasks were less critical. Case Review Conclusion CCI performed satisfactorily with Emergency Services, and the indicator rating was adequate. California Correctional Institution, Cycle 5 Medical Inspection Page 2! 0 Office of the Inspector General State of California 4 — HEALTH INFORMATION MANAGEMENT Health information management is a crucial link in the delivery of Case Review Rating: medical care. Medical personnel require accurate information in Adequate order to make sound judgments and decisions. This indicator Compliance Score: examines whether the institution adequately manages its health care Adequate information. This includes determining whether the information is (75.5%) correctly labeled and organized and available in the electronic Overall Rating: health record; whether the various medical records (internal and Adequate external, e.g., hospital and specialty reports and progress notes) are obtained and scanned timely into the patient’s electronic health record; whether records routed to clinicians include legible signatures or stamps; and whether hospital discharge reports include key elements and are timely reviewed by providers. During the OIG’s testing period, CCI had already converted to the new Electronic Health Record System (EHRS) in November 2016; therefore, nearly all testing occurred in the EHRS, with a small portion of testing completed in the electronic Unit Health Record (eUHR). Case Review Results The OIG clinicians reviewed 666 events and found 10 deficiencies related to health information management, 5 of which were significant. Interdepartmental Transmission No deficiencies were identified within this category. Hospital Records The institution was sufficient in processing hospital records. Most hospital records were scanned timely into the EHRS and available to the providers to facilitate continuity of care. Out of 12 hospital and emergency room transfers, only one deficiency was identified among the medical records reviewed: • In case 28, the community hospital medical records for the patient's admission were not found in the ERHS. Specialty Services CCI performed well with processing specialty reports. Of 46 specialty consultations and procedures, 4 deficiencies were identified. Three of the four deficiencies were related to specialist reports not being retrieved or scanned. Performance in this area is also discussed in the Specialty Services indicator. California Correctional Institution, Cycle 5 Medical Inspection Page 2! 1 Office of the Inspector General State of California Diagnostic Reports CCI did very well with processing diagnostic reports. This is discussed in more detail in the Diagnostic Services indicator. Urgent/Emergent Records No deficiencies were identified within this category. Scanning Performance Nearly all medical information in the EHRS was scanned to the appropriate record and labelled correctly. Only one deficiency was identified: • In case 23, one patient's medical encounter was misfiled into another patient’s medical record. This increased risk for the patient whose medical documentation was missing from his electronic medical record. Legibility With the introduction of the EHRS, very few problems with legibility occurred. Clinician Onsite Inspection CCI’s utilization management (UM) staff worked closely with community hospitals to gather hospital records on a daily basis. The UM staff ensured the hospital printed a packet of pertinent hospital paperwork, including the discharge summary for CCI providers to review. If further information from the hospital was needed, the UM staff had access to the hospital’s electronic medical record system and could quickly find and deliver the documents to providers. The medical records staff seemed pleased with the new EHRS and noted there was less documentation to scan. Therefore, they had become more efficient and accurate with their scanning. Case Review Conclusion CCI performed well with inter-departmental transmission, hospital records, specialty records, TTA records, and scanning performance. The OIG clinicians rated the Health Information Management indicator adequate. Compliance Testing Results The institution obtained an adequate score of 75.5 percent in the Health Information Management indicator, and performed well on the following test: • The institution timely scanned all ten sampled initial health screening forms and patient requests for health care services into the electronic medical record (MIT 4.001). California Correctional Institution, Cycle 5 Medical Inspection Page 2! 2 Office of the Inspector General State of California CCI scored in the adequate range on the following tests: • The OIG reviewed community hospital discharge reports and treatment records for 25 sampled patients who CCI sent to an outside hospital. For 21 of the 25 patients (84 percent), the discharge summary reports were complete and timely reviewed by CCI providers. For two patients, providers reviewed the hospital discharge summary reports one and eight days late, and for two other patients, there was no evidence found in their electronic medical records that providers ever reviewed their discharge reports (MIT 4.007). • Health information staff at CCI timely scanned community hospital discharge reports and treatment records into patients’ medical records for 16 of 20 sampled reports (80 percent). Four reports were scanned between one and 12 days late (MIT 4.004). CCI showed room for improvement on the following two tests: • CCI staff timely scanned 11 of 20 specialty service consultant reports sampled (55 percent), into the patients’ electronic medical records. Nine other specialty reports were scanned between one and 16 days late (MIT 4.003). • The institution scored 58 percent in its labeling and filing of documents scanned into patients’ electronic medical records. For this test, once the OIG identifies 24 documents that are improperly entered into or missing from the electronic medical record, the maximum points are lost and the resulting score is zero. In total, ten documents were identified with various labeling, filing, or scanning issues. In addition to mislabeling and misfiling eight documents, the institution was missing one health service request form and one other document, was scanned poorly and was not legible (MIT 4.006). California Correctional Institution, Cycle 5 Medical Inspection Page 2! 3 Office of the Inspector General State of California 5 — HEALTH CARE ENVIRONMENT This indicator addresses the general operational aspects of the Case Review Rating: institution’s clinics, including certain elements of infection control Not Applicable and sanitation, medical supplies and equipment management, the Compliance Score: availability of both auditory and visual privacy for patient visits, Inadequate and the sufficiency of facility infrastructure to conduct (58.9%) comprehensive medical examinations. Rating of this component is Overall Rating: based entirely on the compliance testing results from the visual Inadequate observations inspectors make at the institution during their onsite visit. This indicator is evaluated entirely by compliance testing. There is no case review portion. Compliance Testing Results The institution received an inadequate compliance score of 58.9 percent in the Health Care Environment indicator, and has room for improvement in seven test areas, as described below: • The non-clinic bulk medical supply storage areas did not meet the supply management process and support needs of the medical health care program. Several medical supplies were found stored beyond the manufacturers’ guidelines. As a result, the institution received zero for this test (MIT 5.106). • Inspectors examined emergency medical response bags (EMRB) to determine if they were inspected daily and inventoried monthly and whether they contained all essential items. EMRBs were compliant in only one of the six clinic locations where they were stored (17 percent). At five clinic locations, one or more of the following deficiencies were noted at the time of the inspection: no documentation indicating that an inventory of the EMRB had been completed in the previous 30 days, EMRB logs were missing several entries to show staff had verified that the respective bag’s compartments were sealed and intact, an EMRB oxygen tank was empty, and crash carts were missing minimum par levels of the medical supplies randomly inventoried (MIT 5.111). • Only 5 of the 13 clinic locations (38 percent) met compliance requirements for essential core medical equipment and supplies. The remaining eight clinics were missing one or more functional pieces of properly calibrated core equipment or other medical supplies necessary to conduct a comprehensive exam. The missing items included: hemoccult cards and developers, lubricating jelly, tongue depressors, and disposable paper. In addition, an oto-ophthalmoscope, weight scale, nebulization unit, electrocardiogram, and California Correctional Institution, Cycle 5 Medical Inspection Page 2! 4 Office of the Inspector General State of California automated external defibrillator did not have current calibration stickers. A provider expressed concern of not having adequate supplies in the exam room (MIT 5.108). • Only 5 of the 13 clinics inspected followed adequate medical supply storage and management protocols (38 percent). In eight clinics, one or more deficiencies were identified during the inspection: medical supplies were not orderly or clearly identifiable (Figure 1), personal items belonging to nursing staff were stored in the same area as medical supplies, and multiple medical supplies were stored beyond the manufacturers’ guidelines. Providers expressed concern about low quality medical supplies, such as suture kits, and not having a system in place to stock or restock medical supplies in the exam rooms (MIT 5.107). • Eight of the 13 clinic exam rooms observed Figure 1: Unlabeled exam room supplies (62 percent) had appropriate space, configuration, supplies, and equipment, to allow clinicians to perform a proper clinical examination. Five clinics had exam rooms with one or more of the following deficiencies: confidential records were left unsecured and not discarded daily, patients lacked auditory privacy because they were examined at the same time and in the same room, and clinicians shared one exam room and had to share computer terminal access when providing services to patients (MIT 5.110). • Clinical health care staff at 9 of 13 applicable clinics (69 percent) ensured that reusable invasive and non-invasive medical equipment was properly sterilized or disinfected. In four clinics, one or more deficiencies were found: sterilized medical equipment was not routinely logged or properly processed and packaged, and staff did not replace exam table paper after each patient encounter (MIT 5.102). • OIG inspectors observed clinician encounters with patients in 13 clinics. Clinicians followed good hand hygiene practices in nine clinics (69 percent). At three clinic locations, clinicians failed to wash their hands before or after patient contact, or before applying gloves. In another clinic, the provider expressed concern with not having reasonable access to a sink with running water (MIT 5.104). California Correctional Institution, Cycle 5 Medical Inspection Page 2! 5 Office of the Inspector General State of California The institution scored in the adequate range on the following two tests: • Of the 13 clinic locations inspected, 11 (85 percent) had operable sinks and sufficient quantities of hand hygiene supplies in the examination areas. At one clinic location, the examination area where providers perform medical procedures did not have an operable sink, soap, or disposable hand towels nearby. At another clinic location, the patient restroom did not have disposable hand towels and soap (MIT 5.103). • Clinic common areas at 10 of the 13 clinics (77 percent) had environments conducive to providing medical services. In three clinics, one or more deficiencies were found; triage and vital sign stations were located too close to the patients’ waiting area to allow for auditory privacy, and clinical staff and nurses did not have sufficient space to perform their job functions (MIT 5.109). CCI performed in the proficient range on the following two tests: • Staff appropriately disinfected, cleaned, and sanitized all 13 sampled clinic locations (MIT 5.101). • When inspecting for proper protocols to mitigate exposure to blood-borne pathogens and contaminated waste, 12 of the 13 clinics (92 percent) were compliant. One clinic’s exam room did not have a puncture-resistant container to discard needles and sharps (MIT 5.105). Non-Scored Results The OIG gathered information to determine whether the institution’s physical infrastructure was maintained in a manner that supported health care management’s ability to provide timely and adequate health care. The OIG does not score this question. When OIG inspectors interviewed health care managers, they did not identify any significant concerns. At the time of the OIG’s medical inspection, CCI had several significant infrastructure projects underway, which included increasing clinic space at five yards and remodeling the TTA. These projects started during the fall of 2015, and the institution estimated they will be completed by the end of summer 2018 (MIT 5.999). California Correctional Institution, Cycle 5 Medical Inspection Page 2! 6 Office of the Inspector General State of California 6 — INTER- AND INTRA-SYSTEM TRANSFERS This indicator focuses on the management of patients’ medical Case Review Rating: needs and continuity of patient care during the inter- and intra- Inadequate system transfer process. The patients reviewed for this indicator Compliance Score: include those received from, as well as those transferring out to, Adequate other CDCR institutions. The OIG review includes evaluation of the (77.1%) institution’s ability to provide and document health screening Overall Rating: assessments, initiation of relevant referrals based on patient needs, Inadequate and the continuity of medication delivery to patients arriving from another institution. For those patients, the OIG clinicians also review the timely completion of pending health appointments, tests, and requests for specialty services. For patients who transfer out of the institution, the OIG evaluates the ability of the institution to document transfer information that includes preexisting 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. In this indicator, the OIG’s case review and compliance review processes yielded different results, with the case review giving an inadequate 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 inadequate. The combined review revealed problems with nursing assessment and medication continuity for patients transferring into the institution, incomplete information transmittal for those transferring to a different institution, and lapses in continuity for patients returning from an outside hospital. Case Review Results Clinicians reviewed 21 encounters related to the Inter-and Intra-System Transfers indicator, which included information from both the sending and receiving institutions. The reviewed encounters included 12 hospitalization and outside emergency room events, all resulting in a transfer back to CCI. The OIG clinicians identified 20 deficiencies, 9 of which were significant. Transfers In The OIG reviewed four patients who transferred into CCI from another institution and found seven deficiencies, two of which were significant. The deficiencies included incomplete nursing assessment, appointment delays, and one lapse in medication continuity. Both significant deficiencies occurred in the following case: California Correctional Institution, Cycle 5 Medical Inspection Page 2! 7 Office of the Inspector General State of California • In case 26, the patient was prescribed metoprolol, a medication for high blood pressure that also lowered the heart rate. Upon arrival at CCI, the patient’s blood pressure and heart rate were abnormally elevated. The nurse did not reassess the patient’s blood pressure or heart rate and did not refer the patient to the provider within the required time frame. Instead, the nurse referred the patient for a seven-day RN follow-up; however, the patient was seen by an licensed vocational nurse (LVN) instead of an RN. Transfers Out CCI’s performance was poor in regard to transfers out of the institution. The OIG clinicians reviewed three events related to patients transferring out of CCI and identified three deficiencies, two of which were significant. Both significant deficiencies were identified in the following case: • In case 47, the patient with a family history of prostate cancer had a laboratory test result that potentially represented prostate cancer. A CCI provider ordered a prostate biopsy before the patient was transferred, but the pending specialty procedure was not entered into the EHRS and therefore was not listed on the transfer documents. The prostate biopsy was not completed, which was a lapse in care. Additionally, the nurse did not evaluate the patient prior to transferring out of CCI. 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. CCI performed poorly with patient returns following hospitalization and deficiencies of delayed appointments and lapses in medication administration were identified. The OIG clinicians reviewed twelve of these encounters and identified five significant deficiencies, which are illustrated in the following cases: • In case 24, the diabetic patient arrived at CCI after a community hospitalization. The hospital physician recommended stopping three different medications that could have worsened the patient’s kidney function. The hospital physician also recommended follow-up appointments with cardiology, vascular, and podiatry specialists. The patient was admitted to the OHU at CCI for wound care and kidney monitoring. The provider failed to review the hospital recommendations and prescribed all three medications that could have worsened the patient’s kidney function. Additionally, the provider did not order the recommended cardiology, vascular, and podiatry specialty follow-up appointments. The provider did not document why the recommendations were ignored. • In case 28, the patient returned to CCI following a community hospital admission for nephrotic syndrome (a kidney disorder that causes the body to excrete too much protein in the urine). The patient’s hospital records were not retrieved or reviewed by CCI. The California Correctional Institution, Cycle 5 Medical Inspection Page 2! 8 Office of the Inspector General State of California hospital physician had recommended the patient have a seven-day urology follow-up appointment, but the appointment did not occur. Unfortunately, the patient’s condition worsened and he required readmission to the hospital, where he was seen by the urology specialist. When the patient returned from the hospital, the hospital physician recommended that the patient remain on a blood thinner indefinitely for a blood clot in his kidney veins. At CCI, the blood thinner was stopped seven days later when the medication was inappropriately cancelled. The lack of blood thinners increased the patient’s risk of harm, as the patient’s blood clot could have worsened or he could have developed new blood clots. Clinician Onsite Inspection During the onsite inspection, the OIG clinicians found that CCI’s nursing leadership was not familiar with the most current EHRS inter-system transfer workflows and processes. Some of the deficiencies that occurred in transfers resulted from incomplete knowledge and training in the EHRS. For example, patients transferring to other facilities required a “prepare for transfer” communication order, which in turn notified a provider and nurse of the planned transfer. The provider and nurse would review the medical record and decide if the patient was eligible for transfer. If eligible, the nurse would prepare medications, print transfer documents, and perform a face-to-face assessment. Unfortunately, CCI was unaware of this EHRS workflow. CCI’s leadership expressed frustration with the lack of EHRS training and the resultant failures. Case Review Conclusion CCI had significant difficulty with transferring patients, including hospital returns. CCI leadership attributed much of the difficulty to incomplete EHRS knowledge and training. The OIG clinicians rated the Inter- and Intra-System Transfers indicator inadequate. Compliance Testing Results The institution obtained an adequate score of 77.1 percent in the Inter and IntraSystem Transfers indicator, with the following two tests receiving scores of 100 percent: • Nursing staff timely completed the assessment and disposition sections of the health care screening form for all 25 sampled patients (MIT 6.002). • The OIG inspected the transfer packages of six patients who were transferring out of CCI to another CDCR institution to determine whether the packages included required medications and support documentation. All six transfer packages were compliant (MIT 6.101). California Correctional Institution, Cycle 5 Medical Inspection Page 2! 9 Office of the Inspector General State of California CCI scored within the inadequate range on the following tests: • The OIG tested 25 patients who transferred into CCI from another CDCR institution to determine whether they received a complete initial health screening assessment from nursing staff on the day of their arrival. Only 13 of 25 sampled health care service forms (52 percent) were properly reviewed by nursing staff when the patients arrived at CCI. For 11 patients, nursing staff neglected to answer all applicable screening form questions, and for one other patient, there was no evidence found in the patient’s electronic medical record that they ever received the assessment (MIT 6.001). • Eleven patients transferred to CCI from another CDCR institution, and had an existing medication order that required nursing staff to issue or administer medications to them upon their arrival. Seven of those 11 applicable patients (64 percent) received their medications timely. Four patients did not receive their medications at the next dosing interval as required, and for another patient, there was no evidence found in the patient’s electronic medical record that his medication was administered (MIT 6.003). • OIG inspectors sampled 20 patients who transferred out of CCI to another CDCR institution to determine whether their previously scheduled specialty service appointments were listed on the health care transfer form. CCI nursing staff noted the pending specialty service appointments on 14 of 20 patient transfer forms (70 percent). Nursing staff did not document the pending specialty service appointments on five patient transfer forms, and one other patient’s transfer form was not found in their electronic medical record (MIT 6.004). California Correctional Institution, Cycle 5 Medical Inspection Page 3! 0 Office of the Inspector General State of California 7 — 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 Inadequate both a quantitative compliance test with case review analysis, this (61.7%) assessment identifies issues in various stages of the medication Overall Rating: management process, including ordering and prescribing, Inadequate 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 prescriber, staff, and patient. In 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 an inadequate score. The OIG’s internal review process considered those factors that led to both scores and ultimately rated this indicator inadequate. While case review focused on medication administration, the compliance testing was a more robust assessment of medication administration and pharmacy protocols combined with onsite observations of medication and pharmacy operations. As a result, the compliance score of inadequate was deemed appropriate for the overall indicator rating. Case Review Results The OIG clinicians evaluated 31 events related to pharmacy and medication management and identified 14 deficiencies, 5 of which were significant. Medication Continuity Medication continuity was poor at CCI. Of the 31 medication events reviewed, there were 13 lapses in medication continuity. Some of these deficiencies were not identified timely by medical staff and placed the patient at risk of harm: • In case 15, a patient was receiving a chronic pain medication for several months. The same medication was reordered, but at a higher dose. The higher dose required a non- formulary authorization, which resulted in a 15-day break in medication continuity. The abrupt withdrawal of the medication placed the patient at risk of seizures. • In case 24, the patient was admitted to the OHU after a community hospitalization. The day after he returned from the hospital, most of the patient’s essential medications were California Correctional Institution, Cycle 5 Medical Inspection Page 3! 1 Office of the Inspector General State of California not administered. Lapses such as these increase the risk of harm because recently hospitalized patients usually have a much greater need for additional medications to treat their recent illness. • In case 28, the patient required a blood thinner for dangerous blood clots in the kidney veins, but the medication was inappropriately discontinued. The patient did not receive this essential blood thinner until several months later when the error was discovered. This case was also discussed in the Inter-and Intra-System Transfers indicator. Medication Administration Most medications were administered appropriately in the outpatient setting, which constitutes the majority of medication administration. The two severe significant deficiencies in medication administration occurred in the OHU. One of the significant deficiencies was discussed in the Specialized Medical Housing indicator and the other significant deficiency is detailed below: • In case 1, two chronic inhaler medications were not administered for one week. This break in medication continuity could have resulted in an asthma exacerbation. Pharmacy Errors The OIG clinicians did not detect any deficiency pattern in this area. Clinician Onsite Inspection The OIG clinicians interviewed CCI’s pharmacist in charge regarding the process of obtaining non- formulary medications. The PIC was concerned about the inherent delays in this process and believed that improvement was needed to avoid a lapse in medication continuity. Case Review Conclusion CCI performed satisfactorily in Pharmacy and Medication Management indicator and received an adequate rating. Compliance Testing Results The institution received an inadequate compliance score of 61.7 percent in the Pharmacy and Medication Management indicator. For discussion purposes below, this indicator is divided into three sub-indicators: medication administration, observed medication practices and storage controls, and pharmacy protocols. California Correctional Institution, Cycle 5 Medical Inspection Page 3! 2 Office of the Inspector General State of California Medication Administration In this sub-indicator, the institution received an inadequate score of 66.1 percent, showing room for improvement in the following areas: • Clinical staff timely ordered and provided medications to 12 of 25 sampled patients (48 percent) who had been discharged from a community hospital and returned to the institution. Clinical staff did not timely order medications for three patients. For ten patients, their medications were made available or delivered one to nine days late or not at all (MIT 7.003). • Clinical staff timely administered or delivered new medication orders to only 15 of 25 sampled patients (60 percent). Four patients received their medications one to three days late, and another patient received his medication 60 days late. There was no evidence found in six other patients’ electronic medical records that they ever received their medications (MIT 7.002). • Nursing staff administered medications without interruption to six of ten patients who were en route from one institution to another and had a temporary layover at CCI (60 percent). For four patients, there was no evidence found in their electronic medical records that their medications were administered as ordered (MIT 7.006). • Twelve of 18 sampled patients (67 percent) timely received their ordered chronic care medications. Four patients did not receive their ordered keep-on-person (KOP) medications within required time frames. For two other patients, direct observe therapy (DOT) medications were not given as ordered (MIT 7.001). The institution performed in the proficient range in the following test area: • CCI ensured that 24 of 25 sampled patients (96 percent) received their medications without interruption when they transferred from one housing unit to another. One patient did not receive his medication at the next dosing interval following his transfer (MIT 7.005). Observed Medication Practices and Storage Controls In this sub-indicator, the institution received an inadequate score of 62.7 percent and received inadequate test scores on the following tests: • CCI properly stored non-narcotic medications not requiring refrigeration in 4 of the 12 applicable clinic and medication line storage locations (33 percent). In eight locations, one or more of the following deficiencies were observed: rooms and cabinets containing California Correctional Institution, Cycle 5 Medical Inspection Page 3! 3 Office of the Inspector General State of California medication were left unlocked (Figure 2), multi-use medication was not labeled with the date it was opened, medication was stored beyond its expiration date, and the daily log for checking the crash cart seal was missing several entries for the month of June 2017 (MIT 7.102). • Inspectors observed the medication preparation and administration processes at five applicable medication line locations. Nursing staff were compliant regarding proper hand hygiene and contamination control protocols at two of the five locations (40 percent). At three locations, not all nursing staff washed or sanitized their hands before putting on or reapplying gloves, or Figure 2: Cabinets left unlocked handling medication (MIT 7.104). • The institution employed adequate security controls over narcotic medications in five of the ten applicable clinic and medication line locations (50 percent). At five locations, one or more deficiencies were identified: the narcotics log book lacked evidence on multiple dates that an inventory was performed by two licensed nursing staff, the nurse did not update the narcotic log book immediately after administering narcotics, and narcotic medications were not always securely transported (MIT 7.101). • Non-narcotic refrigerated medications were properly stored in 8 of the 11 medication line storage locations (73 percent). At three locations, refrigerated medications were stored without a date opened or expiration date (MIT 7.103). CCI received an adequate score on the following test: • Nursing staff followed appropriate administrative controls and protocols when distributing medications to patients at four of five applicable medication preparation and administrative locations (80 percent). At one location, nursing staff failed to disinfect vials before withdrawing and then administering the medication (MIT 7.106). The institution performed in the proficient range in the following test area: • At all five of the inspected medication line locations, nursing staff employed appropriate administrative controls and followed appropriate protocols during medication preparation (MIT 7.105). California Correctional Institution, Cycle 5 Medical Inspection Page 3! 4 Office of the Inspector General State of California Pharmacy Protocols In this sub-indicator, the institution received an inadequate score of 56.0 percent, comprised of scores received at the institution’s main pharmacy. The institution was inadequate in the following areas: • In its main pharmacy, CCI did not properly store non-refrigerated medication. Medication boxes were stored on the floor of the pharmacy (MIT 7.108). • The OIG inspectors conducted an onsite physical inventory of the pharmacy-controlled substances (narcotics). The pharmacist in charge and pharmacy staff did not appropriately complete the Medication Area Inspection Checklist (CDCR Form 7477). As a result, the institution scored a zero on this test (MIT 7.110). CCI scored in the adequate range on the following test: • CCI’s pharmacist in charge timely processed 20 out of 25 sampled medication error reports and related monthly statistical reports (80 percent). For five medication error reports, the corresponding monthly medication error statistic report was submitted to the chief of pharmacy services one day late (MIT 7.111). The institution received proficient scores in the following test areas: • The institution’s main pharmacy followed general security, organization, and cleanliness management protocols and properly stored and monitored refrigerated non-narcotic medications (MIT 7.107, 7.109). Non-Scored Tests • In addition to testing reported medication errors, OIG inspectors follow up on any significant medication errors found during the compliance testing to determine whether the errors were properly identified and reported. The OIG provides those results for information purposes only; however, at CCI, the OIG found no applicable severe medication errors (MIT 7.998). • The OIG tested patients housed in isolation units to determine if they had immediate access to their prescribed KOP rescue medications. All ten of the sampled patients had access to their to their rescue medications (MIT 7.999). California Correctional Institution, Cycle 5 Medical Inspection Page 3! 5 Office of the Inspector General State of California 8 — PRENATAL AND POST-DELIVERY SERVICES This indicator evaluates the institution’s capacity to provide timely Case Review Rating: and appropriate prenatal, delivery, and postnatal services to Not Applicable pregnant patients. This includes the ordering and monitoring of Compliance Score: indicated screening tests, follow-up visits, referrals to higher levels Not Applicable of care, e.g., high-risk obstetrics clinic, when necessary, and postnatal follow-up. Overall Rating: Not Applicable Because CCI was a male-only institution, this indicator did not apply. California Correctional Institution, Cycle 5 Medical Inspection Page 3! 6 Office of the Inspector General State of California 9 — PREVENTIVE SERVICES This indicator assesses whether various preventive medical services Case Review Rating: are offered or provided to patients. These include cancer screenings, Not Applicable tuberculosis screenings, and influenza and chronic care Compliance Score: immunizations. This indicator also assesses whether certain Proficient institutions take preventive actions to relocate patients identified as (87.1%) being at higher risk for contracting coccidioidomycosis Overall Rating: (valley fever). Proficient The OIG rates this indicator entirely through the compliance testing component; the case review process does not include a separate qualitative analysis for this indicator. Compliance Testing Results The institution performed in the proficient range in the Preventive Services indicator, with a compliance score of 87.1 percent and proficient scores in the following areas: • CCI timely administered tuberculosis (TB) medications to all 13 sampled patients; patients received their required doses of TB medications in the most recent three month period the OIG inspectors reviewed (MIT 9.001). • All 25 sampled patients timely received or were offered influenza vaccinations during the most recent influenza season (MIT 9.004). • Out of 30 sampled patients, 29 received annual tuberculosis screenings (96 percent). For one patient, there was no evidence found in the patient’s electronic medical record that he was screened for TB during his birth month as required by CCHCS policy (MIT 9.003). • CCI offered colorectal cancer screenings to 24 of 25 sampled patients subject to the annual screening requirement (96 percent). For one patient, there was no medical record evidence either that health care staff offered a colorectal cancer screening within the previous 12 months or that the patient had a normal colonoscopy within the last ten years (MIT 9.005). • The OIG tested whether patients who suffered from a chronic care condition were offered vaccinations for influenza, pneumonia, and hepatitis. Among the 16 sampled patients with applicable chronic conditions, 14 patients (88 percent) were timely offered the vaccinations. For two patients, there was no evidence found in the patient’s California Correctional Institution, Cycle 5 Medical Inspection Page 3! 7 Office of the Inspector General State of California electronic medical record that the patient received or refused the required vaccinations (MIT 9.008). CCI showed room for improvement on the following two tests: • The OIG tested ten patients who during the testing period were medically restricted and ineligible to reside at CCI because of their high risk of contracting the coccidioidomycosis infection (valley fever) to determine if the patients were transferred out of the institution within 60 days from the time they were initially determined to be ineligible. The institution transferred six of the ten sampled patients (60 percent) from the institution timely. Four patients were either not timely transferred or were still housed at CCI at the time of the inspection (MIT 9.009). • The institution performed poorly in the monitoring of patients receiving TB medications and met compliance guidelines for only 9 of the 13 patients sampled (69 percent). For four patients, medical staff either failed to document the monitoring or failed to scan the monitoring form into the patient’s medical record timely (MIT 9.002). California Correctional Institution, Cycle 5 Medical Inspection Page 3! 8 Office of the Inspector General State of California 10 — QUALITY OF NURSING PERFORMANCE The Quality of Nursing Performance indicator is a qualitative Case Review Rating: evaluation of the institution’s nursing services. The evaluation is Adequate completed entirely by OIG nursing clinicians within the case review Compliance Score: process and does not have a score under the OIG compliance testing Not Applicable component. Case reviews include face-to-face encounters and indirect activities performed by nursing staff on behalf of the Overall Rating: patient. Review of nursing performance includes all nursing Adequate services performed on site, such outpatient, inpatient, urgent/ emergent, inmate transfers, care coordination, and medication management. The key focus areas for evaluation of nursing care include appropriateness and timeliness of patient triage and assessment, identification and prioritization of health care needs, use of the nursing process to implement interventions, and accurate, thorough, and legible documentation. Although nursing services provided in specialized medical housing units are reported in the Specialized Medical Housing indicator, and those provided in the TTA or related to emergency medical responses are reported in the Emergency Services indicator, all areas of nursing services are summarized in this Quality of Nursing Performance indicator. Case Review Results The OIG nursing clinicians reviewed 212 nursing events and identified 124 deficiencies, 23 of which were significant. Most significant deficiencies occurred in the outpatient nursing area. The OIG clinicians rated the Quality of Nursing Performance indicator adequate. Nursing Assessment and Documentation Complete and accurate nursing assessment and documentation are essential to patient care. Without thorough assessment and documentation, changes in clinical presentation can be missed or delayed, and quality of care can be challenging to assess. Although incomplete nursing assessment and documentation were identified during case review, the majority of deficiencies were considered minor. However, the deficiencies demonstrated the potential for implementing ongoing process improvement strategies with nursing staff. Urgent/Emergent The TTA nurses and emergency medical responders at CCI provided appropriate care. The related case review findings are detailed in the Emergency Services indicator. Post Hospital Returns The OIG clinicians reviewed twelve nursing encounters for patients returning from an outside hospital or emergency room. Four minor deficiencies were identified. The deficiencies were for California Correctional Institution, Cycle 5 Medical Inspection Page 3! 9 Office of the Inspector General State of California incomplete nursing assessment and documentation. Additional information regarding hospital returns is described in the Inter-and Intra-System Transfers indicator. Specialized Medical Housing Nursing care provided to patients in the OHU was mostly appropriate and timely. Performance in this area is further discussed in the Specialized Medical Housing indicator. Inter-and Intra-System Transfers Although the care provided to patients transferring into CCI was considered poor, largely due to delayed appointments and lapses in medication continuity for patients returning after hospital discharges, the nursing staff generally provided acceptable care to arriving patients. Only one significant deficiency was identified in nursing care: • In case 26, the patient had a significantly elevated heart rate and blood pressure upon arrival to CCI. The R&R nurse did not assess blood pressure medication compliance for the patient and did not make timely referrals for follow-up care. This case is also discussed in the Inter- and Intra-System Transfers indictor. Offsite Medical Return and Specialty Care The OIG clinicians reviewed ten nursing encounters for patients returning to CCI from offsite specialty appointments. Nurses reviewed the follow-up recommendations from the specialists and appropriately contacted providers. Medication Administration In general, CCI nurses consistently administered medications to patients as prescribed; however, on a few occasions, medications were not administered timely. During the onsite visit, nurses in the OHU inappropriately removed KOP rescue inhalers and nitroglycerin from patients and stored these medications in the OHU medication room. This increased the risk of harm to these patients who would not have immediate access to their prescribed KOP medications during an onset of asthma exacerbation or chest pain. This is also discussed in the Pharmacy and Medication Management indicator. Sick Call After reviewing 64 nursing sick calls, the OIG clinicians found the sick call process at CCI was problematic. While the majority of deficiencies identified were minor and not likely to contribute to patient harm, 13 of the deficiencies were significant. Out of the 13 significant deficiencies, 9 were for failing to perform a sick call face-to-face assessment for patients complaining of symptoms and four were for inappropriate nursing interventions. Significant deficiencies were identified in cases 15, 21, 35, and in the cases below, which are also discussed in the Access to Care indicator: California Correctional Institution, Cycle 5 Medical Inspection Page 4! 0 Office of the Inspector General State of California • In case 18, the patient had ear pain, drainage, and hearing loss. The nurse failed to arrange a same day provider appointment or contact the provider. Two days later the patient was sent out to the community hospital for a higher level of care and was admitted for four days of treatment for a severe fungal infection in the external ear. • In case 19, the patient had a fractured ankle and developed pressure wounds from a temporary cast. The specialist recommended a soft walking cast, but the nurse did not notify the provider. The patient submitted another sick call request 12 days later, but a nursing face-to-face assessment did not occur. • In case 29, the asthmatic patient complained of difficulty breathing at night and requested an inhaler. The nurse did not provide a rescue inhaler or contact the pharmacy to issue a rescue inhaler to the patient. • In case 43, the patient had diarrhea, abdominal pains, and hemorrhoids. The nurse inappropriately gave the patient a stool softener, which could have exacerbated the patient’s diarrhea. Care Management The role of the RN primary care manager includes assessing patients, initiating appropriate interventions to support goals in the patient’s treatment plan, and monitoring patients with chronic health needs and those at increased risk for developing serious complications. At CCI, each primary care clinic RN served as the care manager. The RN prepared for and actively participated in the daily huddles, reviewed and made decisions about sick call requests, and performed patient sick call assessments. CCI’s performance in care management was satisfactory. The OIG clinicians found that chronic care coordination patient visits were conducted by an LVN who did not always consult with the primary care manager RN or initiate a provider appointment: • In case 2, the LVN performed a care management appointment for a patient with asthma. The patient said he used his inhaler daily and that his asthma frightened him, sometimes affecting his daily activities. This indicated the patient’s asthma may not be under adequate control, but the LVN did not initiate a follow-up appointment with a provider. • In case 19, the LVN performed a care management appointment for seizures. The patient had refused several doses of anti-seizure medication and reported no seizures in the past year. The LVN did not ask the patient why he refused this medication and did not initiate a provider appointment to evaluate the ongoing need for the anti-seizure medication. California Correctional Institution, Cycle 5 Medical Inspection Page 4! 1 Office of the Inspector General State of California Clinician Onsite Inspection The OIG clinicians attended morning huddles facilitated by the clinic RN and attended by custody staff, a dental assistant, LVNs, the primary physician, provider schedulers, and the supervising RN. Staff participated in the huddle discussion and provided information as outlined in the huddle script. The provider was familiar with the patient population and provided appropriate direction during the huddle.The OIG clinicians also visited several clinical areas and spoke with the chief nurse executive (CNE) and various nursing staff, including nurses in specialty services, TTA, OHU, outpatient clinics, and SRNs. The nursing staff identified no communication barriers regarding patient care with providers or custody officers. The SRNs were committed to quality improvement and eager for additional training in the EHRS. The CNE was new to CCI and still acclimating to the large institution. The nursing leadership team readily discussed the OIG case review findings and the institution’s struggle with the EHRS transition. The OIG identified a problem with SRNs at CCI not auditing the entire sick call process. When a patient submits a sick call request, the nurse will initially review the request to determine if the request warrants a face-to-face nursing assessment. At CCI, SRNs only audited sick call requests for patients who had already had face-to-face nursing assessments. Because the SRNs did not audit the sick call request, they could not determine whether the nurses had initially reviewed the sick call requests appropriately. The OIG clinicians also reviewed CCI’s annual nurse education curriculum and competencies training list and found that nurses had received urgent and emergent medical response training, which OIG had recommended for CCI during the Cycle 4 medical inspection. The OIG clinicians commend CCI staff for the various methods they used to ensure patients were able to appropriately access the needed level of health care services. Case Review Conclusion CCI has opportunities for improvement in their nursing sick call process. This area represented the majority of significant nursing deficiencies and appeared isolated. CCI showed improvement from Cycle 4 in emergency services. Most of the other deficiencies identified were isolated and did not display patterns of inadequate nursing practices. Therefore, the OIG clinicians rated the Quality of Nursing Performance indicator adequate. California Correctional Institution, Cycle 5 Medical Inspection Page 4! 2 Office of the Inspector General State of California 11 — QUALITY OF PROVIDER PERFORMANCE In this indicator, the OIG physicians provide a qualitative evaluation of the adequacy of provider care at the institution. Case Review Rating: 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 performed Overall Rating: entirely by OIG physicians. There is no compliance testing Adequate component associated with this quality indicator. Case Review Results The OIG clinicians reviewed 130 medical provider encounters and identified 53 deficiencies related to provider performance, 23 of which were significant. Of the 20 detailed cases reviewed, one was proficient, 14 were adequate, and 5 were inadequate. Assessment and Decision-Making CCI providers often made excellent medical decisions. The CCI providers spent much of the day multitasking activities such as consulting for the clinic and TTA nurses, answering phone calls from various medical staff, and completing a wide array of paperwork while they also provided appropriate medical care. On a few occasions, the providers demonstrated inappropriate medical management of complicated patients. The OIG identified deficiencies such as insufficient time spent on a patient’s individual medical problems and superficial solutions. These deficiencies could have been remedied with a phone consult to the involved specialist or a face-to-face evaluation. The following were examples of when providers uncommonly demonstrated poor assessment and decision making: • In case 28, the patient returned to CCI after a community hospital admission with discharge recommendations including treatment for the patient’s hepatitis C virus and an urgent kidney specialist consult. However, the CCI provider did not initiate treatment for the patient's hepatitis C virus and did not order the urgent kidney specialist consult. • In case 46, the patient had acute back pain associated with lower extremity weakness and numbness. These symptoms required emergent attention because they could have represented a spinal cord compression, which could have led to paralysis. The provider did not perform a face-to-face evaluation or transfer the patient to a higher level of care for an emergent magnetic resonance image (MRI). Instead, the provider inappropriately ordered an MRI to be performed two weeks later. California Correctional Institution, Cycle 5 Medical Inspection Page 4! 3 Office of the Inspector General State of California Review of Records CCI providers did not always thoroughly review medical records. Therefore, on a few occasions, significant events were missed and affected the patient’s plan of care. A superficial review could delay appropriate management and could be harmful to the patient. These deficiencies were identified in cases 21, 28, and the following cases: • In case 17, the patient refused an important provider appointment for a potential bone infection. The provider did not review the patient’s chart or identify the importance of this visit. The provider also did not attempt to reschedule the appointment sooner, which resulted in a five month lapse in care. Fortunately, the provider’s oversight did not result in any harm. • In case 20, because of their difficulty with the EHRS transition, the providers failed to document the patient’s recent history with difficulty swallowing and also failed to review the procedure to treat this condition and the corresponding biopsy reports. On a different encounter, the provider did not address the lung specialist’s medication recommendations and also inappropriately scheduled an untimely provider follow-up appointment. • In case 46, the patient was prescribed phenytoin, a medication for seizures that has a narrow therapeutic range and requires close monitoring to prevent under treatment or medication toxicity. On several occasions, the providers were notified of high phenytoin levels, but failed to reduce the dose or order repeat phenytoin level tests. The providers also did not evaluate the patient for potential phenytoin overdose side effects. Fortunately, the patient did not suffer any harm. Urgent/Emergency Care CCI providers demonstrated reliable emergency and on-call care. Deficiencies were minor and significant deficiencies were uncommon in emergency care and are also discussed in the Emergency Services indicator. Chronic Care At CCI, chronic care management is the crux of the medical well-being of the majority of its patients. During the implementation of the EHRS, diabetic management was delayed. However, after several months, the providers became more adept at using the EHRS and timely diabetic management and follow-up resumed. Other chronic care deficiencies were seldom identified. • In case 11, the patient had diabetes that was out of control. The provider inappropriately ordered a follow-up appointment in six months, which should have been sooner. On a California Correctional Institution, Cycle 5 Medical Inspection Page 4! 4 Office of the Inspector General State of California different occasion, the provider reviewed the patient’s abnormal laboratory result, which indicated poorly controlled blood sugars, but failed to order a timely follow-up appointment. • In case 16, during a chronic care appointment, the provider failed to assess the patient's atrial fibrillation (abnormal heart rhythm), benign prostatic hyperplasia (abnormal prostate enlargement), hyperlipidemia (elevated cholesterol), and gastroesophageal disease. The patient also required liver cancer ultrasound surveillance every six months for a chronic hepatitis B infection; however, the patient had not had an ultrasound in over two years and the provider did not order this test. • In case 30, the patient was scheduled for an elective surgery. However, the patient had an abnormal laboratory result showing low sodium levels, which required intervention. The provider neglected to treat the patient prior to surgery and the low sodium levels unnecessarily increased the patient’s risk of seizures around the time of the operation. Specialty Services CCI providers appropriately ordered specialty referrals. The providers comprehensively reviewed most specialty reports. While provider performance in this area was good, specialty access was poor. Further details are given in the Specialty Services indicator. Health Information Management CCI providers successfully documented pertinent findings and documented valid thought processes that supported their medical plans. This is described in more detail in the Health Information Management indicator. Specialized Medical Housing The providers evaluated the patients satisfactorily in the OHU. Most OHU cases reviewed were of patients’ temporary stays of several days. These patients had returned from the hospital and needed a higher level of care prior to returning to their housing units. The additional care often involved intravenous medications and more frequent observations, which was successfully performed by providers in the OHU. It was uncommon for a patient to be a permanent resident of the OHU, but those patients who were, had medical conditions of a more chronic nature and were monitored by providers monthly. On occasion, communication between providers and nurses lapsed for the permanent patients of the OHU. This is detailed further in the Specialized Medical Housing indicator. California Correctional Institution, Cycle 5 Medical Inspection Page 4! 5 Office of the Inspector General State of California Clinician Onsite Inspection The OIG clinicians attended morning huddles and found them well attended and productive. The OIG clinicians also learned each provider was assigned patients within their medical clinic. During work hours, each provider was responsible for seeing their scheduled appointments in addition to urgent TTA visits and nursing consults. All CCI providers expressed challenges with the EHRS implementation. Initially, provider appointments were reduced from 15 to 4 scheduled patients each day. The providers stated they were given instructions to triage scheduled appointments and reschedule the non-urgent appointments to future dates. During this adjustment period, the providers were able to spend more time learning how to use the EHRS. Weekly physician meetings provided a forum to discuss the difficulties of tracking medical information in the new system. Despite the expressed frustrations with the EHRS, the CCI providers were cordial and expressed enjoyment in their employment. The OIG found the CCI providers to be resourceful and most often successful in obtaining necessary information to perform proper medical care. Providers had little success with retrieving or viewing outside imaging studies from the RIS/PACS website (Radiology Information System/Picture Archiving and Communication System), so they developed a less efficient, but sure way of retrieving the vital information. When providers needed to review the reports, they would call the radiology technician in their assigned clinic and receive a dictated report of the imaging results. Providers also reported covering other providers’ patients to assist in the backlogs during the EHRS implementation. It appeared the providers worked diligently to provide the necessary patient care. Proxies were assignments within the EHRS that allowed other providers the ability to access and review needed medical information when another provider was unavailable. Unfortunately, the providers seemed to have misunderstood how to create a proxy, since they recently learned both the receiving and giving providers have to approve the transaction for the proxy to properly function. During the OIG onsite inspections, the providers discovered medical information in a retired provider’s message inbox that had not been reviewed. The chief medical executive and chief physician and surgeon stated they were committed to patient care and quality improvement. According to providers, CCI’s medical leadership was readily available and continued to find solutions to their concerns. Executive staff and medical providers appeared supportive and maintained good morale during the time of change. Case Review Conclusion Providers at CCI demonstrated appropriate patient care. During the EHRS implementation, the providers worked hard to learn the new system while maintaining good patient care. Frequent California Correctional Institution, Cycle 5 Medical Inspection Page 4! 6 Office of the Inspector General State of California deficiencies were identified during this period of adjustment, yet these were often remedied as the providers became familiar with the EHRS. After taking all factors into consideration, the OIG rated the Quality of Provider Performance indicator adequate. California Correctional Institution, Cycle 5 Medical Inspection Page 4! 7 Office of the Inspector General State of California 12 — RECEPTION CENTER ARRIVALS This indicator focuses on the management of medical needs and Case Review Rating: continuity of care for patients arriving from outside the CDCR Not Applicable system. The OIG review includes evaluation of the ability of the Compliance Score: institution to provide and document initial health screenings, initial Not Applicable health assessments, continuity of medications, and completion of required screening tests; address and provide significant Overall Rating: Not Applicable accommodations for disabilities and health care appliance needs; and identify health care conditions needing treatment and monitoring. The patients reviewed for reception center cases are those received from non-CDCR facilities, such as county jails. Because CCI did not have a reception center, this indicator did not apply. California Correctional Institution, Cycle 5 Medical Inspection Page 4! 8 Office of the Inspector General State of California 13 — SPECIALIZED MEDICAL HOUSING This indicator addresses whether the institution follows appropriate Case Review Rating: policies and procedures when admitting patients to onsite inpatient Adequate facilities, including completion of timely nursing and provider Compliance Score: assessments. The chart review assesses all aspects of medical care Proficient related to these housing units, including quality of provider and (89.2%) nursing care. CCI’s only specialized medical housing unit is an Overall Rating: onsite 16-bed outpatient housing unit (OHU). Adequate 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 At the time of the review, CCI had a 16-bed OHU. The OIG clinicians reviewed 74 specialized medical encounters, including 17 provider and 49 nursing encounters, and identified 35 deficiencies, 10 of which were significant. Provider Performance The quality of provider performance in the OHU was good. The majority of OHU admissions were temporary patient transfers, for which the CCI providers performed frequent evaluations and provided the necessary management to discharge the medically recovered patient timely. In contrast, with the rare permanent OHU patient, the provider had infrequent interactions with nursing staff and performed poor chart review of the nurses’ daily patient encounters. As a result, the provider rarely documented pertinent nurse findings during the monthly patient encounter: • In case 1, the patient was frequently using a rescue inhaler and nitroglycerin for multiple episodes of chest pain and shortness of breath. While the OHU nurses documented these episodes in the patient’s electronic medical record, they did not discuss them with the OHU provider. The provider repeatedly failed to discuss the patient’s medical care with the nurses and did not review the nursing notes. Fortunately, the patient ultimately was found not to have heart disease, the nitroglycerin was discontinued, and the patient did not suffer harm. California Correctional Institution, Cycle 5 Medical Inspection Page 4! 9 Office of the Inspector General State of California Nursing Performance The OIG clinicians reviewed 49 nursing events in the OHU and identified 19 minor deficiencies. Six significant deficiencies were also identified, all occurring in one case: • In case 1, the communication between the nurses and provider in the OHU was lacking. The psychiatric technicians (PTs) and LVNs did not always communicate the patient’s frequent chest pain and shortness of breath episodes to the RN or the provider. Some nursing assessments during these symptomatic periods were deficient. On multiple occasions, the third watch PT administered sublingual nitroglycerin (medication used to treat chest pain) and a rescue inhaler to the patient. However, the PT repeatedly failed to obtain vital signs, assess the effectiveness of the nitroglycerin, or notify the provider. Pharmacy and Medication Management OHU medication administration was generally acceptable. However, four pharmacy and medication management deficiencies were identified, of which two were significant: • In case 1, chronic pulmonary medications were not administered on multiple occasions to the patient with chronic pulmonary disease. The fewer number of times the medication was administered could have led to an exacerbation of shortness of breath and difficulty breathing. • In case 20, the nurses in the OHU did not make the rescue inhaler immediately available to the patient and instead kept the inhaler with the nurse-administered medications. Prescribed rescue medications are to be provided to the patient as KOP medications to ensure the safety of patients who may need immediate access to the rescue medications. Clinician Onsite Inspection During the onsite inspection, the OIG clinicians inquired about the medical care delivered to the permanent OHU patient in case 1. CCI provider and nursing leadership clarified that they expected the LVN and PT in the OHU to contact the RN on the first and third shift when any patient had a change in medical status, such as chest pain, shortness of breath, or evidence of low blood sugar. CCI medical leadership also acknowledged the importance of the second shift RN’s role in primary care and provider collaboration. The provider in the OHU would check in only every 30 days on the chronic, long-term patients, and would come in as needed to evaluate the new patients. The RN confirmed that if a change in a patient’s health was noted, the provider should have been called. The OIG clinicians also learned emergency KOP medications were inappropriately taken from the patient at the time of OHU admission and kept away from the patient until discharge. The medical and pharmacy administrators were made aware of this deviation of practice. California Correctional Institution, Cycle 5 Medical Inspection Page 5! 0 Office of the Inspector General State of California Case Review Conclusion The OIG clinical case reviews showed appropriate care within specialized medical housing for the majority of convalescing, temporary residents. The breakdown in care was rare and found in only one case, but it highlighted the possibility of medical complacency with long-term patients. The OIG clinicians rated the Specialized Medical Housing indicator adequate. Compliance Testing Results CCI received a proficient compliance score of 89.2 percent in the Specialized Medical Housing indicator, performing well in the following two areas: • Although the call light system was not operational during the inspection, call buttons were clearly labeled and identified. A local operating procedure was in place to document 30-minute welfare checks, which the OIG inspectors confirmed the CCI nursing staff conducted in the OHU. According to staff members, custody officers and clinicians were able to expeditiously access patients’ locked rooms when emergent events occurred. As a result, the institution scored 100 percent for this test (MIT 13.101). • The OIG tested whether providers completed their Subjective, Objective, Assessment, Plan, and Education (SOAPE) notes at required intervals. Providers completed timely SOAPE notes for seven of eight applicable sampled patients (88 percent). For one patient, the provider completed his SOAPE note one day late (MIT 13.003). The institution received an adequate score on the following test: • For eight of the ten sampled patients (80 percent), nursing staff timely completed an initial health assessment on the day the patient was admitted to the OHU. For one patient, the nurse did not complete an initial assessment. For one other patient, the assessment was not located in the patient’s electronic medical record (MIT 13.001). California Correctional Institution, Cycle 5 Medical Inspection Page 5! 1 Office of the Inspector General State of California 14 — 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 Inadequate time of receipt of related recommendations from specialists. This Compliance Score: indicator also evaluates the providers’ timely review of specialist Inadequate records and documentation reflecting the patients’ care plans, (68.1%) including course of care when specialist recommendations were Overall Rating: not ordered, and whether the results of specialists’ reports are Inadequate communicated to the patients. For specialty services denied by the institution, the OIG determines whether the denials are timely and appropriate, and whether the patient is updated on the plan of care. Case Review Results The OIG clinicians reviewed 62 events related to Specialty Services, the majority of which were specialist consultations and procedures. Of the 62 reviewed events, 20 deficiencies were identified, 10 of which were significant. Access to Specialty Services Specialty access at the institution was poor. There were multiple instances of delayed or lost consults and follow-up appointments. Of the nine deficiencies identified in this category, seven were significant. The following cases demonstrate how the poor specialty access at CCI increased the risk for lapses in care and the risk for harm: • In case 18, the patient developed a severe fungal infection of his ear. On two separate occasions, the otolaryngology provider (ear, nose, and throat specialist) follow-up appointment for the patient’s complicated ear infection was delayed by three months and two months, respectively. Fortunately, the patient’s condition did not worsen during the lapse in care. • In case 19, the patient was treated at an outside hospital for a right ankle fracture. The orthopedist immobilized the ankle in a boot and wanted the patient back for a follow-up appointment in three weeks. However, this appointment failed to occur during the time of review, which was more than two months after the initial recommendation. • In case 20, the asthmatic patient had been hospitalized on multiple occasions with bacterial and fungal pneumonia. The pulmonologist (lung specialist) recommended timely follow-up appointments for the patient’s repeated problems. On two separate occasions, the pulmonary follow-up appointments were significantly delayed; two months in the first occasion and seven weeks in the second occasion. Fortunately, CCI California Correctional Institution, Cycle 5 Medical Inspection Page 5! 2 Office of the Inspector General State of California providers frequently monitored and aggressively managed the patient's refractory asthma. • In case 46, the provider ordered a neurosurgery consult for the patient with low back pain and additional symptoms of leg weakness and numbness. This consult never occurred. • In case 47, the provider ordered a prostate biopsy to be performed within 60 days for suspected prostate cancer. This biopsy never occurred. The patient transferred to another institution with no plans to pursue the biopsy. Nursing Performance CCI nurses performed satisfactorily with specialty services. They reviewed the specialist recommendations and contacted providers. Five deficiencies were identified, one of which was significant. The deficiencies resulted from superficial assessments and incomplete documentation occurring after the patient returned from a specialty appointment. • In case 19, the patient returned to CCI from an offsite orthopedic appointment for an ankle fracture. The patient complained of pain upon returning to CCI, since he had not had any pain medication due to his early departure. CCI’s RN failed to administer the ordered pain medication. Provider Performance Providers performed well with specialty services at CCI. Their referrals were appropriate and they reviewed the specialty reports with sufficient thoroughness. Two deficiencies were identified, one of which was significant: • In case 21, the provider reviewed the patient’s elevated blood pressure readings during an appointment, but failed to monitor the abnormal finding with further blood pressure checks. The provider also did not order a timely appointment with the patient’s primary provider. Health Information Management CCI’s performance with specialty reports was acceptable. Four deficiencies were identified, one of which was significant: • In case 14, a sleep apnea consult was never scanned into the patient’s electronic medical record. California Correctional Institution, Cycle 5 Medical Inspection Page 5! 3 Office of the Inspector General State of California Clinician Onsite Inspection During the onsite inspection, medical staff identified a number of issues related to processing of specialty orders. These issues contributed to many of the specialty access problems identified. The EHRS required a new way of processing requests for specialist appointments, and providers did not properly order the specialty services within the new system. Specialty staff also had difficulty navigating the system. These factors resulted in orphaned requests for services, which were essentially lost in the system. The specialty staff and providers said they received grossly inadequate EHRS training. The specialty and utilization staff stated that they lacked essential knowledge of the new system and that they were not well prepared to perform their duties. Once the problems were finally discovered, the specialty staff began to create workarounds. For example, when a provider failed to properly order a specialty request, it would be lost in an enigmatic queue. The institution developed a flow-map to assist providers in the complicated process of properly requesting a specialty service, so that it was routed to the correct queue. Additionally, through perseverance and months of trial and error, the specialty services staff had located most of these unknown queues where the previously lost requests for services had landed. At the time of the onsite inspection, the specialty staff were busily processing new specialty requests while reconciling the previously lost requests for specialty appointments. Unfortunately, some of the requests had already been out of compliance, with due dates as far back as December of 2016. The specialty staff was courteous, diligent, and honest with their challenges and successes. Despite their obvious frustrations, they maintained good morale. Case Review Conclusion Access to specialty services is critical to patient care. The ability of a primary provider to timely refer patients for specialty expert opinions is an essential component of medical care. If specialty access is impaired, the patient’s ability to obtain correct diagnosis and treatment becomes limited, which can increase the likelihood of patient harm. CCI demonstrated poor specialty access during the review period, and was just starting to correct their process deficiencies during the onsite inspection. The OIG rated the Specialty Services indicator inadequate. Compliance Testing Results The institution received an inadequate compliance score of 68.1 percent in the Specialty Services indicator, and received poor scores on the following tests: • When patients are approved or scheduled for specialty services at one institution and then transfer to another, policy requires that the receiving institution reschedule and provide the patient’s appointment within the required time frame. Only 7 of the 20 applicable patients sampled who transferred to CCI with an approved specialty service (35 percent) received their appointments within the required time frame. Six patients California Correctional Institution, Cycle 5 Medical Inspection Page 5! 4 Office of the Inspector General State of California received their pending specialty service appointment from five days to four months late. For the remaining seven patients, there was no evidence found in the patients’ electronic medical records that they ever received their specialty service appointments (MIT 14.005). • Of the 15 patients sampled, 9 (60 percent) received their high-priority specialty service appointments within two weeks of the provider’s order. Three patients received their specialty service appointments 2, 8, and 13 days late, respectively. Two other patients received their appointments 24 and 31 days late, and one final patient received his appointment 179 days late (MIT 14.001). • When CCI providers ordered high-priority specialty services for patients, the ordering provider did not always review the resultant specialty report timely. Out of 12 sampled specialty reports, 8 were reviewed timely (67 percent). Four specialty reports were reviewed from one to nine days late (MIT 14.002). • CCI’s health care management timely denied providers’ specialty services requests for 14 of 20 patients sampled (70 percent). Six specialty services requests were denied from one to six days late (MIT 14.006). CCI performed in the adequate range on the following two tests: • Specialists’ reports were timely reviewed by a provider following routine specialty service appointments in 10 of the 13 cases reviewed (77 percent). Three reports were reviewed four to ten days late (MIT 14.004). • Among 20 patients sampled who had a specialty service denied by CCI’s health care management, 15 (75 percent) received timely notification of the denied service, including the provider meeting with the patient within 30 days to discuss alternate treatment strategies. Two patients received a follow-up visit 10 and 85 days late, and for three other patients, there was no medical record evidence that a follow-up visit ever occurred (MIT 14.007). CCI received a proficient score on the following test: • For 14 of 15 sampled patients, routine specialty service appointments occurred timely (93 percent). One patient’s specialty service appointment was ten days late (MIT 14.003). California Correctional Institution, Cycle 5 Medical Inspection Page 5! 5 Office of the Inspector General State of California 15 — ADMINISTRATIVE OPERATIONS (SECONDARY) This indicator focuses on the institution’s administrative health care oversight functions. The OIG evaluates whether the institution Case Review Rating: Not Applicable promptly processes patient medical appeals and addresses all Compliance Score: appealed issues. Inspectors also verify that the institution follows Proficient reporting requirements for adverse/sentinel events and inmate (87.7%) deaths. The OIG verifies that the Emergency Medical Response Overall Rating: Review Committee (EMRRC) performs required reviews and that Proficient 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. In addition, OIG examines whether the institution adequately manages its health care staffing resources by evaluating whether job performance reviews are completed as required; specified staff possess current, valid credentials and professional licenses or certifications; nursing staff receive new employee orientation training and annual competency testing; and clinical and custody staff have current medical emergency response certifications. The Administrative Operations indicator is a secondary indicator, and, therefore, was not relied on for the overall score for the institution. Compliance Testing Results The institution received a proficient compliance score of 87.7 percent in the Administrative Operations indicator. The majority of tests in this indicator scored in the proficient range, as follows: • The institution promptly processed all patient medical appeals in each of the most recent 12 months. In addition, based on a sample of ten second-level medical appeals, the institution’s responses addressed all of the patients’ appealed issues (MIT 15.001, 15.102). • CCI’s QMC met monthly, evaluated program performance, and took action when management identified areas for improvement opportunities. Also, CCI took adequate steps to ensure the accuracy of its Dashboard data reporting (MIT 15.003, 15.004). • The OIG inspected incident package documentation for ten emergency medical responses reviewed by CCI’s EMRRC during the prior six-month period. All ten sampled packages complied with policy (MIT 15.005). • Inspectors reviewed drill packages for three medical emergency response drills conducted in the most recent quarter. The three drill packages contained all required California Correctional Institution, Cycle 5 Medical Inspection Page 5! 6 Office of the Inspector General State of California summary reports and related documentation. In addition, the drills included participation by both health care and custody staff (MIT 15.101). • All providers at the institution were current with their professional licenses. Similarly, all nursing staff and the pharmacist in charge were current with their professional licenses and certification requirements (MIT 15.107, 15.109). • All nurses and active duty providers were current with their emergency response certifications (MIT 15.108). • All pharmacy staff and providers who prescribed controlled substances had current Drug Enforcement Agency registrations (MIT 15.110). • All nursing staff hired within the most recent year timely received new employee orientation training (MIT 15.111). • Out of ten performance evaluations, nine providers had a proper clinical performance appraisal completed by their supervisor (90 percent). One provider's appraisal was overdue by 47 days (MIT 15.106). • Medical staff reviewed and timely submitted the Initial Inmate Death Report (CDCR Form 7229A) to CCHCS’s Death Review Unit for six of seven deaths that occurred at CCI in the prior 12-month period, for a score of 86 percent. For one death that was a suicide, CCI’s medical staff incorrectly submitted the Initial Inmate Death Report instead of the required Initial Inmate Suicide Report (CDCR Form 7229B)(MIT 15.103). The institution showed room for improvement on the following two tests: • The OIG inspected records from April 2017 for five nurses to determine if their nursing supervisors properly completed monthly performance reviews. Out of five nurses, inspectors identified deficiencies for four nurses’ monthly nursing reviews (20 percent) For two nurses, the supervisor did not complete the required number of reviews. For two other nurses, the supervisor’s review did not summarize aspects that were done well (MIT 15.104). • Out of ten nurses sampled, two (20 percent) had current clinical competency validations. Eight nurses did not receive a clinical competency validation within the required time frame (MIT 15.105). California Correctional Institution, Cycle 5 Medical Inspection Page 5! 7 Office of the Inspector General State of California Non-Scored Results • The OIG gathered non-scored data regarding death review reports completed by CCHCS’s Death Review Committee (DRC). Seven deaths occurred during the OIG’s review period, six unexpected (Level 1) deaths and one expected (Level 2) death. The DRC was required to complete its death review summary report within 60 days from the date of death for the Level 1 deaths and within 30 days from the date of death for the Level 2 death; the reports should then be submitted to the institution’s CEO within seven calendar days thereafter. Only one death review at CCI, a Level 1 death review, met CCHCS’s reporting guidelines. For three of the Level 1 deaths, the DRC completed its reports 66, 74, and 133 days late (126, 134, and 193 days after death) and submitted them to CCI’s CEO 75, 89, and 134 days late; for two of the Level 1 deaths, there was no evidence found that the Final Death Review summary had been completed at the time of the OIG’s inspection. For the one Level 2 death that occurred at CCI, the DRC completed its report 14 days late (44 days after death) and submitted it to the CEO 19 days late (MIT 15.998). • The OIG discusses CCI’s health care staffing resources in the About the Institution section of this report (MIT 15.999). California Correctional Institution, Cycle 5 Medical Inspection Page 5! 8 Office of the Inspector General State of California R ECOMMENDATIONS Based on the results of the Cycle 5 medical inspection at CCI, the OIG recommends the following: • Arrange additional EHRS training for providers, supervisors, nurses, and ancillary staff, specifically targeting all staff involved with appointments, scheduling, specialty services, and utilization management. • Revise current nursing audits to include the EHRS systems processes and competencies. • Ensure the current SRN sick call audit process monitors the quality of all facets of the sick call process, including the initial nurse triage. • Implement audits on arriving and departing patients to ensure providers and nurses are notified of upcoming transfers as well as audit processes for specialty consults and follow-up appointments, to monitor timeliness. Audits should be ongoing, and findings reported directly to the Patient Safety Committee. • Audit the electronic records to determine if radiology information and electronic messages are being processed and received appropriately by each medical provider. During the OIG medical inspection, the CCI providers could not retrieve radiology information from the RIS/PACS and could not effectively cover each other’s messages within the EHRS. • Implement OHU-specific continuous quality improvement programs that target the communication processes between nursing staff on all shifts and also between OHU nurses and providers. We recommend that CCI leadership create a system to ensure unusual nursing occurrences are identified daily, documented, and communicated to the provider. This should be part of the daily huddle, but was not occurring. While processes for communication did exist, CCI was not using them. California Correctional Institution, Cycle 5 Medical Inspection Page 5! 9 Office of the Inspector General State of California P -B M OPULATION ASED ETRICS The compliance testing and the case reviews give an accurate assessment of how the institution’s health care systems are functioning with regard to the patients with the highest risk and utilization. This information is vital to assess the capacity of the institution to provide sustainable, adequate care. However, one significant limitation of the case review methodology is that it does not give a clear assessment of how the institution performs for the entire population. For better insight into this performance, the OIG has turned to population-based metrics. For comparative purposes, the OIG has selected several Healthcare Effectiveness Data and Information Set (HEDIS) measures for disease management to gauge the institution’s effectiveness in outpatient health care, especially chronic disease management. The Healthcare Effectiveness Data and Information Set is a set of standardized performance measures developed by the National Committee for Quality Assurance with input from over 300 organizations representing every sector of the nation’s health care industry. It is used by over 90 percent of the nation’s health plans as well as many leading employers and regulators. 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 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 EHRS, 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 5 Medical Inspection Page 6! 0 Office of the Inspector General State of California Results of Population-Based Metric Comparison Comprehensive Diabetes Care For chronic care management, the OIG selected 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 well with its management of diabetes. When compared statewide, CCI outperformed or matched all health care plans in all five measures, with the exception of eye exams, in which CCI performed lower than Kaiser South. When compared nationally, CCI outperformed Medicaid, commercial health plans, and Medicare in all five diabetic measures. CCI outscored the United States Department of Veterans Affairs (VA) in three of the applicable measures, but scored lower than the VA in diabetic eye exams. Immunizations Comparative data for immunizations was only fully available for the VA and partially available for Kaiser, commercial plans, Medicaid, and Medicare. With respect to administering influenza vaccinations to younger adults, CCI outperformed Medicaid and commercial plans, but performed less well than Kaiser, both North and South, and the VA The high patient refusal rate of 51 percent for young adults negatively affected the institution’s score for this measure. However, CCI outperformed both Medicare and the VA for influenza vaccinations for older adults. Lastly, with regard to administering pneumococcal vaccines to older adults, CCI outscored Medicare, but scored slightly lower than the VA. Cancer Screening With respect to colorectal cancer screening, CCI outperformed commercial health plans and Medicare, but performed slightly less well when compared to Kaiser, both North and South, and the VA. The high patient refusal rate of 24 percent for colorectal cancer screening negatively affected the institution’s score. Summary CCI's population-based metrics performance reflected a well-run chronic care program, and is comparable to other state and national health care plans reviewed. The institution may improve its scores for immunizations for young adults and colon cancer screening by reducing patient refusals through patient education concerning the benefits of these preventive services. California Correctional Institution, Cycle 5 Medical Inspection Page 6! 1 Office of the Inspector General State of California CCI Results Compared to State and National HEDIS Scores California National CCI HEDIS HEDIS HEDIS Clinical Measures HEDIS K ( a N is o e . r Kaiser HEDIS Com- HEDIS VA Medi-Cal (So.CA) Medicaid mercial Medicare Average Cycle 5 CA) Results1 20152 20163 20163 20164 20164 20164 20155 Comprehensive Diabetes Care HbA1c Testing (Monitoring) 100% 86% 94% 94% 86% 90% 93% 98% Poor HbA1c Control (>9.0%)6, 7 16% 39% 20% 23% 45% 34% 27% 19% HbA1c Control (<8.0%)6 70% 49% 70% 63% 46% 55% 63% - Blood Pressure Control (<140/90)6 86% 63% 83% 83% 59% 60% 62% 74% Eye Exams 70% 53% 68% 81% 53% 54% 69% 89% Immunizations Influenza Shots - Adults (18–64) 49% - 56% 57% 39% 48% - 55% Influenza Shots - Adults (65+) 6 90% - - - - - 72% 76% Immunizations: Pneumococcal 6 90% - - - - - 71% 93% Cancer Screening Colorectal Cancer Screening 76% - 79% 82% - 63% 67% 82% 1. Unless otherwise stated, data was collected in May 2017 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 2015 HEDIS Aggregate Report for Medi-Cal Managed Care. 3. Data was obtained from Kaiser Permanente November 2016 reports for the Northern and Southern California regions. 4. National HEDIS data for Medicaid, commercial plans, and Medicare was obtained from the 2016 State of Health Care Quality Report, available on the NCQA website: www.ncqa.org. The results for commercial plans were based on data received from various health maintenance organizations. 5. The Department of Veterans Affairs (VA) data was obtained from the VA's website, www.va.gov. For the Immunizations: Pneumococcal measure only, the data was obtained from the VHA Facility Quality and Safety Report - Fiscal Year 2012 Data. 6. For this indicator, the entire applicable 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. California Correctional Institution, Cycle 5 Medical Inspection Page 6! 2 Office of the Inspector General State of California A A — C PPENDIX OMPLIANCE TEST RESULTS California Correctional Institution Range of Summary Scores: 58.86% 89.17% Indicator Compliance Score (Yes %) 1–Access to Care 70.14% 2–Diagnostic Services 69.44% 3–Emergency Services Not Applicable 4–Health Information Management (Medical Records) 75.47% 5–Health Care Environment 58.86% 6–Inter and IntraSystem Transfers 77.13% 7–Pharmacy and Medication Management 61.67% 8–Prenatal and Post-Delivery Services Not Applicable 9–Preventive Services 87.06% 10–Quality of Nursing Performance Not Applicable 11–Quality of Provider Performance Not Applicable 12–Reception Center Arrivals Not Applicable 13–Specialized Medical Housing (OHU, CTC, SNF, Hospice) 89.17% 14–Specialty Services 68.13% 15–Administrative Operations 87.71% California Correctional Institution, Cycle 5 Medical Inspection Page 6! 3 Office of the Inspector General State of California Scored Answers Yes Reference + 1–Access to Care Number Yes No No Yes % N/A Chronic care follow-up appointments: Was the patient’s most recent chronic care visit within the health care guideline’s 1.001 15 10 25 60.00% 0 maximum allowable interval or within the ordered time frame, whichever is shorter? For endorsed patients received from another CDCR institution: If 1.002 the nurse referred the patient to a provider during the initial health 14 11 25 56.00% 0 screening, was the patient seen within the required time frame? Clinical appointments: Did a registered nurse review the patient’s 1.003 30 0 30 100.00% 0 request for service the same day it was received? Clinical appointments: Did the registered nurse complete a face-to- 1.004 face visit within one business day after the CDCR Form 7362 was 24 6 30 80.00% 0 reviewed? Clinical appointments: If the registered nurse determined a referral to a primary care provider was necessary, was the patient seen 1.005 10 8 18 55.56% 12 within the maximum allowable time or the ordered time frame, whichever is the shorter? Sick call follow-up appointments: If the primary care provider 1.006 ordered a follow-up sick call appointment, did it take place within 2 2 4 50.00% 26 the time frame specified? Upon the patient's discharge from the community hospital: Did the 1.007 patient receive a follow-up appointment within the required time 22 3 25 88.00% 0 frame? Specialty service follow-up appointments: Do specialty service 1.008 primary care physician follow-up visits occur within required time 10 14 24 41.67% 6 frames? Clinical appointments: Do patients have a standardized process to 1.101 6 0 6 100.00% 0 obtain and submit health care services request forms? Overall percentage: 70.14% California Correctional Institution, Cycle 5 Medical Inspection Page 6! 4 Office of the Inspector General State of California Scored Answers Yes Reference + 2–Diagnostic Services Number Yes No No Yes % N/A Radiology: Was the radiology service provided within the time 2.001 10 0 10 100.00% 0 frame specified in the provider's order? Radiology: Did the primary care provider review and initial the 2.002 6 4 10 60.00% 0 diagnostic report within specified time frames? Radiology: Did the primary care provider communicate the results 2.003 4 6 10 40.00% 0 of the diagnostic study to the patient within specified time frames? Laboratory: Was the laboratory service provided within the time 2.004 10 0 10 100.00% 0 frame specified in the provider's order? Laboratory: Did the primary care provider review and initial the 2.005 7 3 10 70.00% 0 diagnostic report within specified time frames? Laboratory: Did the primary care provider communicate the results 2.006 5 5 10 50.00% 0 of the diagnostic study to the patient within specified time frames? Pathology: Did the institution receive the final diagnostic report 2.007 8 2 10 80.00% 0 within the required time frames? Pathology: Did the primary care provider review and initial the 2.008 5 3 8 62.50% 2 diagnostic report within specified time frames? Pathology: Did the primary care provider communicate the results 2.009 5 3 8 62.50% 2 of the diagnostic study to the patient within specified time frames? Overall percentage: 69.44% 3–Emergency Services This indicator is evaluated only by case review clinicians. There is no compliance testing component. California Correctional Institution, Cycle 5 Medical Inspection Page 6! 5 Office of the Inspector General State of California Scored Answers Yes Reference + 4–Health Information Management Number Yes No No Yes % N/A Are non-dictated healthcare documents (provider progress notes) 4.001 10 0 10 100.00% 0 scanned within 3 calendar days of the patient encounter date? Are dictated/transcribed documents scanned into the patient’s 4.002 electronic health record within five calendar days of the encounter 0 0 0 N/A 0 date? Are High-Priority specialty notes (either a Form 7243 or other 4.003 scanned consulting report) scanned within the required time 11 9 20 55.00% 0 frame? Are community hospital discharge documents scanned into the 4.004 patient’s electronic health record within three calendar days of 16 4 20 80.00% 0 hospital discharge? Are medication administration records (MARs) scanned into the 4.005 0 0 0 N/A 0 patient’s electronic health record within the required time frames? During the inspection, were medical records properly scanned, 4.006 14 10 24 58.33% 0 labeled, and included in the correct patients’ files? For patients discharged from a community hospital: Did the preliminary hospital discharge report include key elements and did 4.007 21 4 25 84.00% 0 a primary care provider review the report within three calendar days of discharge? Overall percentage: 75.47% California Correctional Institution, Cycle 5 Medical Inspection Page 6! 6 Office of the Inspector General State of California Scored Answers Yes Reference + 5–Health Care Environment Number Yes No No Yes % N/A Are clinical health care areas appropriately disinfected, cleaned and 5.101 13 0 13 100.00% 0 sanitary? Do clinical health care areas ensure that reusable invasive and non- 5.102 invasive medical equipment is properly sterilized or disinfected as 9 4 13 69.23% 0 warranted? Do clinical health care areas contain operable sinks and sufficient 5.103 11 2 13 84.62% 0 quantities of hygiene supplies? Does clinical health care staff adhere to universal hand hygiene 5.104 9 4 13 69.23% 0 precautions? Do clinical health care areas control exposure to blood-borne 5.105 12 1 13 92.31% 0 pathogens and contaminated waste? Warehouse, Conex and other non-clinic storage areas: Does the 5.106 medical supply management process adequately support the needs 0 1 1 0.00% 0 of the medical health care program? Does each clinic follow adequate protocols for managing and 5.107 5 8 13 38.46% 0 storing bulk medical supplies? Do clinic common areas and exam rooms have essential core 5.108 5 8 13 38.46% 0 medical equipment and supplies? Do clinic common areas have an adequate environment conducive 5.109 10 3 13 76.92% 0 to providing medical services? Do clinic exam rooms have an adequate environment conducive to 5.110 8 5 13 61.54% 0 providing medical services? Emergency response bags: Are TTA and clinic emergency medical 5.111 response bags inspected daily and inventoried monthly, and do they 1 5 6 16.67% 7 contain essential items? Overall percentage: 58.86% California Correctional Institution, Cycle 5 Medical Inspection Page 6! 7 Office of the Inspector General State of California Scored Answers Yes Reference + 6–Inter- and Intra-System Transfers Number Yes No No Yes % N/A For endorsed patients received from another CDCR institution or COCF: Did nursing staff complete the initial health screening and 6.001 13 12 25 52.00% 0 answer all screening questions on the same day the patient arrived at the institution? For endorsed patients received from another CDCR institution or COCF: When required, did the RN complete the assessment and disposition section of the health screening form; refer the patient to 6.002 24 0 24 100.00% 1 the TTA, if TB signs and symptoms were present; and sign and date the form on the same day staff completed the health screening? For endorsed patients received from another CDCR institution or 6.003 COCF: If the patient had an existing medication order upon arrival, 7 4 11 63.64% 14 were medications administered or delivered without interruption? For patients transferred out of the facility: Were scheduled 6.004 specialty service appointments identified on the patient’s health 14 6 20 70.00% 0 care transfer information form? For patients transferred out of the facility: Do medication transfer 6.101 packages include required medications along with the 6 0 6 100.00% 0 corresponding transfer packet required documents? Overall percentage: 77.13% California Correctional Institution, Cycle 5 Medical Inspection Page 6! 8 Office of the Inspector General State of California Scored Answers 7–Pharmacy and Medication Yes Reference + Management Number Yes No No Yes % N/A Did the patient receive all chronic care medications within the 7.001 required time frames or did the institution follow departmental 12 6 18 66.67% 7 policy for refusals or no-shows? Did health care staff administer, make available, or deliver new 7.002 order prescription medications to the patient within the required 15 10 25 60.00% 0 time frames? Upon the patient’s discharge from a community hospital: Were all 7.003 ordered medications administered, made available, or delivered to 12 13 25 48.00% 0 the patient within required time frames? For patients received from a county jail: Were all medications ordered by the institution’s reception center provider administered, 7.004 0 0 0 N/A 0 made available, or delivered to the patient within the required time frames? Upon the patient’s transfer from one housing unit to another: Were 7.005 24 1 25 96.00% 0 medications continued without interruption? For patients en route who lay over at the institution: If the 7.006 temporarily housed patient had an existing medication order, were 6 4 10 60.00% 0 medications administered or delivered without interruption? All clinical and medication line storage areas for narcotic 7.101 medications: Does the Institution employ strong medication 5 5 10 50.00% 3 security over narcotic medications assigned to its clinical areas? All clinical and medication line storage areas for non-narcotic medications: Does the Institution properly store non-narcotic 7.102 4 8 12 33.33% 1 medications that do not require refrigeration in assigned clinical areas? All clinical and medication line storage areas for non-narcotic 7.103 medications: Does the institution properly store non-narcotic 8 3 11 72.73% 2 medications that require refrigeration in assigned clinical areas? Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols 7.104 2 3 5 40.00% 8 during medication preparation and medication administration processes? Medication preparation and administration areas: Does the 7.105 institution employ appropriate administrative controls and 5 0 5 100.00% 8 protocols when preparing medications for patients? Medication preparation and administration areas: Does the 7.106 Institution employ appropriate administrative controls and 4 1 5 80.00% 8 protocols when distributing medications to patients? Pharmacy: Does the institution employ and follow general 7.107 security, organization, and cleanliness management protocols in its 1 0 1 100.00% 0 main and satellite pharmacies? California Correctional Institution, Cycle 5 Medical Inspection Page 6! 9 Office of the Inspector General State of California Scored Answers 7–Pharmacy and Medication Yes Reference + Management Number Yes No No Yes % N/A Pharmacy: Does the institution’s pharmacy properly store non- 7.108 0 1 1 0.00% 0 refrigerated medications? Pharmacy: Does the institution’s pharmacy properly store 7.109 1 0 1 100.00% 0 refrigerated or frozen medications? Pharmacy: Does the institution’s pharmacy properly account for 7.110 0 1 1 0.00% 0 narcotic medications? Does the institution follow key medication error reporting 7.111 20 5 25 80.00% 0 protocols? Overall percentage: 61.67% 8–Prenatal and Post-Delivery Services The institution has no female patients, so this indicator is not applicable. California Correctional Institution, Cycle 5 Medical Inspection Page 7! 0 Office of the Inspector General State of California Scored Answers Yes Reference + 9–Preventive Services Number Yes No No Yes % N/A Patients prescribed TB medication: Did the institution administer 9.001 13 0 13 100.00% 0 the medication to the patient as prescribed? Patients prescribed TB medication: Did the institution monitor the 9.002 patient monthly for the most recent three months he or she was on 9 4 13 69.23% 0 the medication? Annual TB Screening: Was the patient screened for TB within the 9.003 29 1 30 96.67% 0 last year? Were all patients offered an influenza vaccination for the most 9.004 25 0 25 100.00% 0 recent influenza season? All patients from the age of 50 - 75: Was the patient offered 9.005 24 1 25 96.00% 0 colorectal cancer screening? Female patients from the age of 50 through the age of 74: Was the 9.006 0 0 0 N/A 0 patient offered a mammogram in compliance with policy? Female patients from the age of 21 through the age of 65: Was 9.007 0 0 0 N/A 0 patient offered a pap smear in compliance with policy? Are required immunizations being offered for chronic care 9.008 14 2 16 87.50% 9 patients? Are patients at the highest risk of coccidioidomycosis (valley 9.009 6 4 10 60.00% 0 fever) infection transferred out of the facility in a timely manner? Overall percentage: 87.06% 10–Quality of Nursing Performance This indicator is evaluated only by case review clinicians. There is no compliance testing component. 11–Quality of Provider Performance This indicator is evaluated only by case review clinicians. There is no compliance testing component. 12–Reception Center Arrivals The institution has no reception center, so this indicator is not applicable. California Correctional Institution, Cycle 5 Medical Inspection Page 7! 1 Office of the Inspector General State of California Scored Answers Yes Reference + 13–Specialized Medical Housing Number Yes No No Yes % N/A For OHU, CTC, and SNF: Did the registered nurse complete an 13.001 initial assessment of the patient on the day of admission, or within 8 2 10 80.00% 0 eight hours of admission to CMF’s Hospice? For CTC and SNF only: Was a written history and physical 13.002 0 0 0 N/A 0 examination completed within the required time frame? For OHU, CTC, SNF, and Hospice: Did the primary care provider complete the Subjective, Objective, Assessment, Plan, and 13.003 7 1 8 87.50% 2 Education (SOAPE) notes on the patient at the minimum intervals required for the type of facility where the patient was treated? For OHU and CTC Only: Do inpatient areas either have properly working call systems in its OHU & CTC or are 30-minute patient 13.101 1 0 1 100.00% 0 welfare checks performed; and do medical staff have reasonably unimpeded access to enter patient’s cells? Overall percentage: 89.17% Scored Answers Yes Reference + 14–Specialty Services Number Yes No No Yes % N/A Did the patient receive the high priority specialty service within 14 14.001 calendar days of the primary care provider order or the Physician 9 6 15 60.00% 0 Request for Service? Did the primary care provider review the high priority specialty 14.002 8 4 12 66.67% 3 service consultant report within the required time frame? Did the patient receive the routine specialty service within 90 14.003 calendar days of the primary care provider order or Physician 14 1 15 93.33% 0 Request for Service? Did the primary care provider review the routine specialty service 14.004 10 3 13 76.92% 2 consultant report within the required time frame? For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at 14.005 7 13 20 35.00% 0 the sending institution, was the appointment scheduled at the receiving institution within the required time frames? Did the institution deny the primary care provider request for 14.006 14 6 20 70.00% 0 specialty services within required time frames? Following the denial of a request for specialty services, was the 14.007 15 5 20 75.00% 0 patient informed of the denial within the required time frame? Overall percentage: 68.13% California Correctional Institution, Cycle 5 Medical Inspection Page 7! 2 Office of the Inspector General State of California Scored Answers Yes Reference 15–Administrative Operations + Number Yes No No Yes % N/A Did the institution promptly process inmate medical appeals during 15.001 12 0 12 100.00% 0 the most recent 12 months? Does the institution follow adverse / sentinel event reporting 15.002 0 0 0 N/A 0 requirements? Did the institution Quality Management Committee (QMC) meet at least monthly to evaluate program performance, and did the 15.003 6 0 6 100.00% 0 QMC take action when improvement opportunities were identified? Did the institution’s Quality Management Committee (QMC) or 15.004 other forum take steps to ensure the accuracy of its Dashboard data 1 0 1 100.00% 0 reporting? Does the Emergency Medical Response Review Committee 15.005 perform timely incident package reviews that include the use of 10 0 10 100.00% 0 required review documents? For institutions with licensed care facilities: Does the Local Governing Body (LGB), or its equivalent, meet quarterly and 15.006 0 0 0 N/A 0 exercise its overall responsibilities for the quality management of patient health care? Did the institution complete a medical emergency response drill for 15.101 each watch and include participation of health care and custody 3 0 3 100.00% 0 staff during the most recent full quarter? Did the institution’s second level medical appeal response address 15.102 10 0 10 100.00% 0 all of the patient's appealed issues? Did the institution's medical staff review and submit the initial 15.103 6 1 7 85.71% 0 inmate death report to the Death Review Unit in a timely manner? Does the institution's Supervising Registered Nurse conduct 15.104 1 4 5 20.00% 0 periodic reviews of nursing staff? Are nursing staff who administer medications current on their 15.105 2 8 10 20.00% 0 clinical competency validation? 15.106 Are structured clinical performance appraisals completed timely? 9 1 10 90.00% 0 15.107 Do all providers maintain a current medical license? 12 0 12 100.00% 0 Are staff current with required medical emergency response 15.108 2 0 2 100.00% 1 certifications? Are nursing staff and the Pharmacist-in-Charge current with their professional licenses and certifications, and is the pharmacy 15.109 6 0 6 100.00% 0 licensed as a correctional pharmacy by the California State Board of Pharmacy? Do the institution’s pharmacy and authorized providers who 15.110 prescribe controlled substances maintain current Drug 1 0 1 100.00% 0 Enforcement Agency (DEA) registrations? 15.111 Are nursing staff current with required new employee orientation? 1 0 1 100.00% 0 Overall percentage: 87.71% California Correctional Institution, Cycle 5 Medical Inspection Page 7! 3 Office of the Inspector General State of California A B — C D PPENDIX LINICAL ATA Table B-1: CCI Sample Sets Sample Sets Total Anticoagulation 2 Death Review/Sentinel Events 2 Diabetes 3 Emergency Services - CPR 4 Emergency Services - Non-CPR 2 High Risk 4 Hospitalization 4 Intra-system Transfers-In 3 Intra-system Transfers-Out 3 RN Sick Call 15 Specialty Services 3 45 California Correctional Institution, Cycle 5 Medical Inspection Page 7! 4 Office of the Inspector General State of California Table B-2: CCI Chronic Care Diagnoses Diagnosis Total Anticoagulation 3 Arthritis/Degenerative Joint Disease 6 Asthma 7 COPD 7 Cancer 1 Cardiovascular Disease 7 Chronic Kidney Disease 2 Chronic Pain 13 Coccidioidomycosis 3 DVT/PE 1 Deep Venous Thrombosis/Pulmonary Embolism 2 Diabetes 11 Gastroesophageal Reflux Disease 12 Hepatitis C 15 Hyperlipidemia 20 Hypertension 18 Mental Health 16 Seizure Disorder 3 Sleep Apnea 2 Thyroid Disease 1 150 California Correctional Institution, Cycle 5 Medical Inspection Page 7! 5 Office of the Inspector General State of California Table B-3: CCI Event - Program Program Total Diagnostic Services 124 Emergency Care 45 Hospitalization 22 Intra-system Transfers-In 5 Intra-system Transfers-Out 4 Not Specified 1 Outpatient Care 321 Specialized Medical Housing 72 Specialty Services 70 664 Table B-4: CCI Case Review Sample Summary Total MD Reviews Detailed 20 MD Reviews Focused 2 RN Reviews Detailed 12 RN Reviews Focused 25 Total Reviews 59 Total Unique Cases 45 Overlapping Reviews (MD & RN) 14 California Correctional Institution, Cycle 5 Medical Inspection Page 7! 6 Office of the Inspector General State of California A C — C S PPENDIX OMPLIANCE AMPLING M ETHODOLOGY California Correctional Institution (CCI) Sample Category Quality (number of Indicator samples) Data Source Filters Access to Care MIT 1.001 Chronic Care Patients Master Registry • Chronic care conditions (at least one condition per patient—any risk level) (25) • Randomize MIT 1.002 Nursing Referrals OIG Q: 6.001 • See Intra-system Transfers (25) MITs 1.003-006 Nursing Sick Call MedSATS • Clinic (each clinic tested) (5 per clinic) • Appointment date (2–9 months) (30) • Randomize MIT 1.007 Returns from OIG Q: 4.007 • See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (25) MIT 1.008 Specialty Services OIG Q: 14.001 & • See Specialty Services Follow-up 14.003 (30) MIT 1.101 Availability of Health OIG onsite • Randomly select one housing unit from each yard Care Services review Request Forms (6) Diagnostic Services MITs 2.001–003 Radiology Radiology Logs • Appointment date (90 days–9 months) • Randomize (10) • Abnormal MITs 2.004–006 Laboratory Quest • Appt. date (90 days–9 months) • Order name (CBC or CMPs only) • Randomize (10) • Abnormal MITs 2.007–009 Pathology InterQual • Appt. date (90 days–9 months) • Service (pathology related) (10) • Randomize California Correctional Institution, Cycle 5 Medical Inspection Page 7! 7 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Health Information Management (Medical Records) MIT 4.001 Timely Scanning OIG Qs: 1.001, • Non-dictated documents (10) 1.002, & 1.004 • 1st 10 IPs MIT 1.001, 1st 5 IPs MITs 1.002, 1.004 MIT 4.002 OIG Q: 1.001 • Dictated documents (0) • First 20 IPs selected MIT 4.003 OIG Qs: 14.002 & • Specialty documents (20) 14.004 • First 10 IPs for each question MIT 4.004 OIG Q: 4.007 • Community hospital discharge documents (20) • First 20 IPs selected MIT 4.005 OIG Q: 7.001 • MARs (0) • First 20 IPs selected • Any misfiled or mislabeled document identified MIT 4.006 Documents for during OIG compliance review (24 or more = No) (10) any tested inmate • Date (2–8 months) MIT 4.007 Returns From Inpatient claims • Most recent 6 months provided (within date range) Community Hospital data • Rx count • Discharge date • Randomize (each month individually) • First 5 patients from each of the 6 months (if not 5 in a month, supplement from another, as needed) (25) Health Care Environment • Identify and inspect all onsite clinical areas. MIT 5.101-105 Clinical Areas OIG inspector MIT 5.107–111 (13) onsite review Inter and IntraSystem Transfers • Arrival date (3–9 months) MIT 6.001-003 IntraSystem SOMS • Arrived from (another CDCR facility) Transfers • Rx count • Randomize (25) • Date of transfer (3–9 months) MIT 6.004 Specialty Services MedSATS • Randomize SendOuts (20) • R&R IP transfers with medication MIT 6.101 Transfers Out OIG inspector (6) onsite review California Correctional Institution, Cycle 5 Medical Inspection Page 7! 8 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Pharmacy and Medication Management MIT 7.001 Chronic Care OIG Q: 1.001 See Access to Care Medication • At least one condition per patient—any risk level (25) • Randomize MIT 7.002 New Medication Master Registry • Rx count Orders • Randomize (25) • Ensure no duplication of IPs tested in MIT 7.001 MIT 7.003 Returns from OIG Q: 4.007 • See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (25) MIT 7.004 RC Arrivals – OIG Q: 12.001 • See Reception Center Arrivals Medication Orders (N/A at CCI) MIT 7.005 IntraFacility Moves MAPIP transfer • Date of transfer (2–8 months) data • To location/from location (yard to yard and to/ from ASU) • Remove any to/from MHCB • NA/DOT meds (and risk level) (25) • Randomize MIT 7.006 En Route SOMS • Date of transfer (2–8 months) • Sending institution (another CDCR facility) • Randomize (10) • NA/DOT meds MITs 7.101-103 Medication Storage OIG inspector • Identify and inspect clinical & med line areas that Areas onsite review store medications (varies by test) MITs 7.104–106 Medication OIG inspector • Identify and inspect onsite clinical areas that Preparation and onsite review prepare and administer medications Administration Areas (varies by test) MITs 7.107-110 Pharmacy OIG inspector • Identify & inspect all onsite pharmacies (1) onsite review MIT 7.111 Medication Error Monthly • All monthly statistic reports with Level 4 or Reporting medication error higher (25) reports • Select a total of 5 months MIT 7.999 Isolation Unit KOP Onsite active • KOP rescue inhalers & nitroglycerin medications Medications medication for IPs housed in isolation units (10) listing Prenatal and Post-Delivery Services MIT 8.001007 Recent Deliveries OB Roster • Delivery date (2–12 months) (N/A at CCI) • Most recent deliveries (within date range) Pregnant Arrivals OB Roster • Arrival date (2–12 months) (N/A at CCI) • Earliest arrivals (within date range) California Correctional Institution, Cycle 5 Medical Inspection Page 7! 9 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Preventive Services MITs 9.001–002 TB Medications Maxor • Dispense date (past 9 months) • Time period on TB meds (3 months or 12 weeks) (13) • Randomize MIT 9.003 TB Evaluation, SOMS • Arrival date (at least 1 year prior to inspection) Annual Screening • Birth Month (30) • Randomize MIT 9.004 Influenza SOMS • Arrival date (at least 1 year prior to inspection) Vaccinations • Randomize (25) • Filter out IPs tested in MIT 9.008 MIT 9.005 Colorectal Cancer SOMS • Arrival date (at least 1 year prior to inspection) Screening • Date of birth (51 or older) (25) • Randomize MIT 9.006 Mammogram SOMS • Arrival date (at least 2 yrs prior to inspection) (N/A at this • Date of birth (age 52–74) institution) • Randomize MIT 9.007 Pap Smear SOMS • Arrival date (at least three yrs prior to inspection) (N/A at this • Date of birth (age 24–53) institution) • Randomize MIT 9.008 Chronic Care OIG Q: 1.001 • Chronic care conditions (at least 1 condition per Vaccinations IP—any risk level) • Randomize (25) • Condition must require vaccination(s) MIT 9.009 Valley Fever Cocci transfer • Reports from past 2–8 months (number will vary) status report • Institution • Ineligibility date (60 days prior to inspection date) (10) • All California Correctional Institution, Cycle 5 Medical Inspection Page 8! 0 Office of the Inspector General State of California Sample Quality Category Indicator (number of Data Source Filters samples) Reception Center Arrivals MITs 12.001–008 RC SOMS • Arrival date (2–8 months) • Arrived from (county jail, return from parole, (N/A at CCI) etc.) • Randomize Specialized Medical Housing MITs 13.001–004 OHU CADDIS • Admit date (1–6 months) • Type of stay (no MH beds) • Length of stay (minimum of 5 days) (10) • Randomize MIT 13.101 OHU OIG inspector • Review by location (all) onsite review Specialty Services MITs 14.001–002 HighPriority MedSATS • Approval date (3–9 months) (15) • Randomize MITs 14.003–004 Routine MedSATS • Approval date (3–9 months) • Remove optometry, physical therapy or podiatry (15) • Randomize MIT 14.005 Specialty Services MedSATS • Arrived from (other CDCR institution) Arrivals • Date of transfer (3–9 months) (20) • Randomize MIT 14.006-007 Denials InterQual • Review date (3–9 months) (20) • Randomize IUMC/MAR • Meeting date (9 months) Meeting Minutes • Denial upheld (0) • Randomize California Correctional Institution, Cycle 5 Medical Inspection Page 8! 1 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.001 Medical Appeals Monthly medical • Medical appeals (12 months) (all) appeals reports MIT 15.002 Adverse/Sentinel Adverse/sentinel • Adverse/sentinel events (2–8 months) Events events report (0) MITs 15.003–004 QMC Meetings Quality • Meeting minutes (12 months) Management Committee (6) meeting minutes MIT 15.005 EMRRC EMRRC meeting • Monthly meeting minutes (6 months) (10) minutes MIT 15.006 LGB LGB meeting • Quarterly meeting minutes (12 months) (0) minutes MIT 15.101 Medical Emergency Onsite summary • Most recent full quarter Response Drills reports & • Each watch documentation (3) for ER drills MIT 15.102 2nd Level Medical Onsite list of • Medical appeals denied (6 months) Appeals appeals/closed (10) appeals files MIT 15.103 Death Reports Institution-list of • Most recent 10 deaths deaths in prior 12 • Initial death reports (7) months MIT 15.104 RN Review Onsite supervisor • RNs who worked in clinic or emergency setting Evaluations periodic RN six or more days in sampled month (5) reviews • Randomize MIT 15.105 Nursing Staff Onsite nursing • On duty one or more years Validations education files • Nurse administers medications (10) • Randomize MIT 15.106 Provider Annual Onsite • All required performance evaluation documents Evaluation Packets provider (10) evaluation files MIT 15.107 Provider licenses Current provider • Review all listing (at start of (12) inspection) MIT 15.108 Medical Emergency Onsite • All staff Response certification o Providers (ACLS) Certifications tracking logs o Nursing (BLS/CPR) (all) • Custody (CPR/BLS) California Correctional Institution, Cycle 5 Medical Inspection Page 8! 2 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.109 Nursing staff and Onsite tracking • All required licenses and certifications Pharmacist in system, logs, or Charge Professional employee files Licenses and Certifications (all) MIT 15.110 Pharmacy and Onsite listing of • All DEA registrations Providers’ Drug provider DEA Enforcement Agency registration #s & (DEA) Registrations pharmacy registration (all) document MIT 15.111 Nursing Staff New Nursing staff • New employees (hired within last 12 months) Employee training logs • Orientations (all) MIT 15.998 Death Review OIG summary • Between 35 business days & 12 months prior Committee log - deaths • CCHCS death reviews (7) California Correctional Institution, Cycle 5 Medical Inspection Page 8! 3 Office of the Inspector General State of California C ALIFORNIA C ORRECTIONAL H EALTH C ARE S ERVICES ’ R ESPONSE California Correctional Institution, Cycle 5 Medical Inspection Page 8! 4 Office of the Inspector General State of California