California State Prison, Centinela Medical Inspection Report Cycle 4

Robert A. Barton Office of the Inspector General Inspector General California State Prison, Centinela Medical Inspection Results Cycle 4 February 2016 Medical Inspection Unit Page 1 Office of the Inspector General State of California Office of the Inspector General CALIFORNIA STATE PRISON, CENTINELA Medical Inspection Results Cycle 4 Robert A. Barton Inspector General Roy W. Wesley Chief Deputy Inspector General Shaun R. Spillane Public Information Officer February 2016 TABLE OF CONTENTS Executive Summary ............................................................................................................................. i Overall Assessment: Adequate .............................................................................................. iii Clinical Case Review and OIG Clinician Inspection Results ............................................... iii Compliance Testing Results.................................................................................................. iv Population-Based Metrics ...................................................................................................... x Introduction ......................................................................................................................................... 1 About the Institution ........................................................................................................................... 1 Objectives, Scope, and Methodology.................................................................................................. 5 Case Reviews ................................................................................................................................... 6 Patient Selection for Retrospective Case Reviews .................................................................... 6 Benefits and Limitations of Targeted Subpopulation Review .................................................. 7 Case Reviews Sampled ............................................................................................................. 8 Compliance Testing ......................................................................................................................... 9 Sampling Methods for Conducting Compliance Testing .......................................................... 9 Scoring of Compliance Testing Results .................................................................................. 10 Dashboard Comparisons ......................................................................................................... 10 Overall Quality Indicator Rating for Case Reviews and Compliance Testing .............................. 11 Population-Based Metrics .............................................................................................................. 11 Medical Inspection Results ............................................................................................................... 12 Primary (Clinical) Quality Indicators of Health Care .................................................................... 12 Access to Care ......................................................................................................................... 13 Case Review Results ............................................................................................................ 13 Compliance Testing Results................................................................................................. 13 Recommendations ................................................................................................................ 14 Diagnostic Services ................................................................................................................. 15 Case Review Results ............................................................................................................ 15 Compliance Testing Results................................................................................................. 16 Recommendations ................................................................................................................ 16 Emergency Services................................................................................................................. 17 Case Review Results ............................................................................................................ 17 Recommendations ................................................................................................................ 18 Health Information Management (Medical Records) ............................................................. 19 Case Review Results ............................................................................................................ 19 Compliance Testing Results................................................................................................. 20 Recommendations ................................................................................................................ 21 Health Care Environment ....................................................................................................... 22 Compliance Testing Results................................................................................................. 22 Recommendations for CCHCS ............................................................................................ 24 Recommendations for CEN ................................................................................................. 24 California State Prison, Centinela, Cycle 4 Medical Inspection Table of Contents Office of the Inspector General State of California Inter- and Intra-System Transfers ........................................................................................... 25 Case Review Results ............................................................................................................ 25 Compliance Testing Results................................................................................................. 27 Recommendations ................................................................................................................ 28 Pharmacy and Medication Management ................................................................................ 29 Case Review Results ............................................................................................................ 29 Compliance Testing Results................................................................................................. 30 Recommendations ................................................................................................................ 32 Preventive Services ................................................................................................................. 33 Compliance Testing Results................................................................................................. 33 Recommendations ................................................................................................................ 34 Quality of Nursing Performance ............................................................................................. 35 Case Review Results ............................................................................................................ 35 Recommendations ................................................................................................................ 38 Quality of Provider Performance ............................................................................................ 39 Case Review Results ............................................................................................................ 39 Recommendations ................................................................................................................ 41 Specialized Medical Housing (OHU, CTC, SNF, Hospice) .................................................... 42 Case Review Results ............................................................................................................ 42 Compliance Testing Results................................................................................................. 44 Recommendations ................................................................................................................ 45 Specialty Services .................................................................................................................... 46 Case Review Results ............................................................................................................ 46 Compliance Testing Results................................................................................................. 47 Recommendations ................................................................................................................ 48 Secondary (Administrative) Quality Indicators of Health Care..................................................... 49 Internal Monitoring, Quality Improvement, and Administrative Operations ......................... 50 Compliance Testing Results................................................................................................. 50 Recommendations ................................................................................................................ 52 Job Performance, Training, Licensing, and Certifications ..................................................... 53 Compliance Testing Results................................................................................................. 53 Recommendations ................................................................................................................ 54 Population-Based Metrics .............................................................................................................. 55 Appendix A — Compliance Test Results ......................................................................................... 59 Appendix B — Clinical Data ............................................................................................................ 73 Appendix C — Compliance Sampling Methodology ....................................................................... 76 California Correctional Health Care Services’ Response ................................................................. 81 California State Prison, Centinela, Cycle 4 Medical Inspection Table of Contents Office of the Inspector General State of California LIST OF TABLES AND FIGURES Health Care Quality Indicators ........................................................................................................... ii CEN Executive Summary Table ......................................................................................................... ix CEN Health Care Staffing Resources — August 2015 ....................................................................... 2 CEN Master Registry Data as of August 31, 2015 .............................................................................. 3 Commonly Used Abbreviations .......................................................................................................... 4 CEN Results Compared to State and National HEDIS Scores .......................................................... 58 California State Prison, Centinela, Cycle 4 Medical Inspection List of Tables and Figures Office of the Inspector General State of California EXECUTIVE SUMMARY Under the authority of California Penal Code Section 6126, which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), the OIG conducts a comprehensive inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG explicitly makes no determination regarding the constitutionality of care in the prison setting. That determination is left to the Receiver and the federal court. The assessment of care by the OIG is just one factor in the court’s determination whether care in the prisons meets constitutional standards. The court may find that an institution that the OIG found to be providing adequate care still does not meet constitutional standards, depending on the analysis of the underlying data provided by the OIG. Likewise, an institution that has been rated inadequate by the OIG could still be found to pass constitutional muster with the implementation of remedial measures if the underlying data were to reveal easily mitigated deficiencies. The OIG’s inspections are mandated by the Penal Code and not aimed at specifically resolving the court’s questions on constitutional care. To the degree that they provide another factor for the court to consider, the OIG is pleased to provide added value to the taxpayers of California. For this fourth cycle of inspections the OIG added a clinical case review component and significantly enhanced the compliance portion of the inspection process from that used in prior cycles. In addition, the OIG added a population-based metric comparison of selected Healthcare Effectiveness Data Information Set (HEDIS) measures from other State and national health care organizations and compared that data to similar results for California State Prison, Centinela (CEN). The OIG performed its Cycle 4 medical inspection at California State Prison, Centinela, from September to November 2015. The inspection included in-depth reviews of 69 inmate-patient files conducted by clinicians, as well as reviews of documents from 367 inmate-patient files, covering 101 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 CEN using 14 health care quality indicators applicable to the institution, made up of 12 primary clinical indicators and two secondary administrative indicators. To conduct clinical case reviews, the OIG employs a clinician team consisting of a physician and a registered nurse consultant, while compliance testing is done by a team of deputy inspectors general trained in monitoring medical compliance. Of the 12 primary indicators, seven were rated by both case review clinicians and compliance inspectors, three were rated by case review clinicians only, and two were rated by compliance inspectors only; both secondary indicators were rated by compliance inspectors only. See the Health Care Quality Indicators table on page ii. Based on that analysis, OIG experts made a considered and measured overall opinion that the quality of health care at CEN was adequate. California State Prison, Centinela, Cycle 4 Medical Inspection Page i Office of the Inspector General State of California Health Care Quality Indicators All Institutions– Fourteen Primary Indicators (Clinical) CEN Applicability Applicability Both case review 1–Access to Care All institutions and compliance Both case review 2–Diagnostic Services All institutions and compliance 3–Emergency Services All institutions Case review only 4–Health Information Management Both case review All institutions (Medical Records) and compliance 5–Health Care Environment All institutions Compliance only Both case review 6–Inter- and Intra-System Transfers All institutions and compliance Both case review 7–Pharmacy and Medication Management All institutions and compliance Female institutions 8–Prenatal and Post-Delivery Services Not Applicable only 9–Preventive Services All institutions Compliance only 10–Quality of Nursing Performance All institutions Case review only 11–Quality of Provider Performance All institutions Case review only Institutions with 12–Reception Center Arrivals Not Applicable reception centers All institutions with 13–Specialized Medical Housing Both case review an OHU, CTC, SNF, (OHU, CTC, SNF, Hospice) and compliance or Hospice Both case review 14–Specialty Services All institutions and compliance Two Secondary Indicators All Institutions– CEN Applicability (Administrative) Applicability 15–Internal Monitoring, Quality Improvement, and Administrative All institutions Compliance only Operations 16–Job Performance, Training, Licensing, All institutions Compliance only and Certifications California State Prison, Centinela, Cycle 4 Medical Inspection Page ii Office of the Inspector General State of California Overall Assessment: Adequate Based on the clinical case reviews and compliance testing, the OIG’s overall assessment rating for CEN was adequate. For the Overall Assessment 12 primary (clinical) quality indicators applicable to CEN, the Rating: OIG found four proficient, seven adequate, and one inadequate. For the two secondary (administrative) quality indicators, the OIG Adequate found one proficient and one inadequate. To determine the overall assessment for CEN, the OIG considered individual clinical ratings and individual compliance question scores within each of the indicator categories, putting emphasis on the primary indicators. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed at CEN. 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 1,340 patient care events. For the 12 primary indicators applicable to CEN, ten were evaluated by clinician case review; one was proficient, seven were adequate, and two 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. Program Strengths — Case Review  The leadership at CEN was dedicated to continuous quality improvement, and very open and receptive to critiques and constructive criticism.  The chief medical executive (CME) was very “hands-on” with both medical staff and patients. Interviews with the medical providers revealed the CME was very supportive and approachable. Case reviews revealed active involvement with patient education and treatment.  Diagnostic Services was functioning well, with the majority of the services completed, reports reviewed, and results communicated to patients in a timely manner.  Specialty Services was functioning well. The providers reported the Specialty Services Department was very helpful in ensuring appointments were timely and reports were retrieved.  The weekly primary care provider meetings were productive and educational. California State Prison, Centinela, Cycle 4 Medical Inspection Page iii Office of the Inspector General State of California  Morning huddles were comprehensive and constructive.  The primary care providers and nursing staff had good working relationships with each other and with custody. Program Weaknesses — Case Review  Several indicators showed a pattern of incomplete patient assessments or incomplete documentation of health care records by nursing staff. The use of cloned notes was also identified.  The sick call process at CEN was not functioning well. The RNs often failed to see symptomatic patients, and often inappropriately referred patients to the medical provider without an RN evaluation.  Though it was apparent the providers reviewed specialty reports (as evidenced by provider orders and progress note documentation), they often failed to properly sign the specialty reports.  CEN’s emergency medical response review process did not appropriately audit all nonscheduled transports. This resulted in care deficiencies not being identified.  Supervising registered nurses did not review the quality of nursing care in the correctional treatment center. Compliance Testing Results Of the 14 total health care indicators applicable to CEN, 11 were evaluated by compliance inspectors.1 There were 101 individual compliance questions within those 11 indicators, generating 1,183 data points, that tested CEN’s compliance with California Correctional Health Care Services (CCHCS) policies and procedures.2 Those 101 questions are detailed in Appendix A—Compliance Test Results. The institution’s inspection scores for the 11 applicable indicators ranged from 52.3 percent to 98.0 percent, with the secondary (administrative) indicator Internal Monitoring, Quality Improvement, and Administrative Operations receiving the lowest compliance score, and the primary indicator Specialized Medical Housing (OHU, CTC, SNF, Hospice) receiving the highest. For the nine primary indicators applicable to compliance testing, the OIG rated five proficient, three adequate, and one inadequate. For the two secondary indicators, which involve administrative health care functions, one was rated proficient and one inadequate. 1 The OIG’s compliance inspectors are trained deputy inspectors general with expertise in CDCR policies regarding medical staff and processes. 2 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 State Prison, Centinela, Cycle 4 Medical Inspection Page iv Office of the Inspector General State of California Program Strengths — Compliance Testing As the CEN Executive Summary Table on page ix indicates, the institution’s compliance ratings were proficient for the following six indicators: Health Care Environment (85.4 percent), Inter- and Intra-System Transfers (90.0 percent), Preventive Services (85.6 percent), Specialized Medical Housing (OHU, CTC, SNF, Hospice) (98.0 percent), Specialty Services (85.7 percent), and Job Performance Training, Licensing, and Certifications (90.2 percent). The following are some of CEN’s strengths based on its compliance scores for individual questions within all primary health care indicators:  Nursing staff timely reviewed patients’ health service requests and timely completed face-to-face visits.  Providers conducted timely follow-up appointments with patients who were released from a community hospital and returned to the institution.  The institution ensured that inmate-patients timely received their radiology services. In addition, providers communicated radiology test results to inmate-patients within the required time frame.  The institution ensured that inmate-patients timely received their laboratory services. In addition, providers timely reviewed the diagnostic reports and timely communicated the results to their patients.  Institutional staff timely scanned non-dictated progress notes, initial health screening forms, and health care service request forms into patients’ health record files. Staff also timely scanned specialty services consultant reports, community hospital discharge reports, and medication administration records.  The institution ensured that clinical health care areas and their related medical equipment were appropriately disinfected, cleaned, and sanitary.  Clinical staff followed proper hand hygiene practices during patient encounters.  Clinical and non-clinical medical storage areas demonstrated appropriate medical supply storage and management protocols.  Clinical exam rooms and treatment spaces had sufficient space and configuration to allow clinicians to perform proper clinical exams.  For inmate-patients who transferred into CEN from another CDCR institution, RNs properly documented an assessment and disposition of the patient on the Initial Health Screening form (CDCR Form 7277) the same day nursing staff completed an initial screening of the patient. California State Prison, Centinela, Cycle 4 Medical Inspection Page v Office of the Inspector General State of California  Health care staff consistently documented patients’ pending specialty service appointments on the Health Care Transfer Information form (CDCR Form 7371) for those patients who transferred out of CEN to another CDCR institution.  Patients’ transfer packages included the required medications and related documentation for inmate-patients who transferred out of the institution.  The institution employed strong medication security controls over narcotic medications, and properly stored non-narcotic medications at all applicable clinics and all sampled medication line storage locations.  Nursing staff followed proper hand hygiene contamination protocols and practiced appropriate administrative controls and protocols during medication preparation and while distributing medications to inmate-patients.  In its main pharmacy, the institution followed general security, organization, and cleanliness management protocols; properly stored non-refrigerated and refrigerated medications; and maintained adequate controls over and properly accounted for narcotic medications.  The institution timely monitored patients receiving tuberculosis treatments.  Inmate-patients were consistently offered preventive services that included influenza vaccinations and screenings for colorectal cancer.  For patients housed in the correctional treatment center (CTC), nurses timely completed initial patient assessments. In addition, providers timely evaluated patients upon admission, and timely completed each patient’s written history and physical examination and their subjective, objective, assessment, plan, and education (SOAPE) notes at required intervals.  The CTC patient rooms had properly working call buttons, and staff could respond and access inmate-patients’ rooms in less than one minute when an emergent event occurred.  Providers conducted specialty service appointments timely, and providers reviewed the specialists’ reports timely. In addition, the institution completed denials of providers’ requests for specialty services timely. The following are some of the strengths identified within the two secondary administrative indicators:  CEN’s local governing body (LGB) met during all four of the most recent quarters, and all meeting minutes provided a detailed narrative of the LGB’s general management and planning of patient health care.  Institutional responses addressed patients’ second-level medical appeal issues. California State Prison, Centinela, Cycle 4 Medical Inspection Page vi Office of the Inspector General State of California  The institution’s medical staff reviewed and submitted initial inmate death reports to the CCHCS Death Review Unit in a timely manner. Providers, the pharmacist-in-charge, and the pharmacy had current licenses and registrations, and nursing staff were current on required training requirements, licenses, and certifications. Program Weaknesses — Compliance Testing The institution received an inadequate compliance rating for the primary indicator Diagnostic Services (66.7 percent). The institution also received an inadequate score in the secondary indicator Internal Monitoring, Quality Improvement, and Administrative Operations (52.3 percent). The following are some of the weaknesses identified by CEN’s compliance scores for individual questions within all primary health care indicators:  Patients who transferred into CEN from other CDCR institutions and were referred to a PCP for a routine appointment based on nursing staff’s initial health care screening of the patient were not seen timely.  Providers did not always record their name, title, and the date on radiology or pathology reports to evidence their reviews. In addition, providers did not communicate pathology results to their patients.  Medical records staff did not always properly label patient documents scanned into the eUHRs, and did not always timely scan dictated or transcribed provider progress notes into patients’ eUHRs.  Several clinics and exam rooms lacked essential core medical supplies and equipment for comprehensive examinations.  Clinics lacked an overhang or shade protection to shield patients from extreme heat or inclement weather when waiting outdoors to receive their medication.  The institution’s pharmacist-in-charge did not properly process and follow up on all reported medication errors.  Inmate-patients did not always receive a proper tuberculosis skin test; nursing staff did not clearly document the 48-to-72-hour window to read test results; and the skin tests were sometimes read by a licensed vocational nurse (LVN) instead of by a registered nurse, public health nurse, or primary care provider.  The institution did not always provide timely specialty service appointments to inmate-patients who transferred into CEN with previously approved or scheduled specialty appointments at the sending institution. California State Prison, Centinela, Cycle 4 Medical Inspection Page vii Office of the Inspector General State of California  When the institution denied specialty service requests, providers did not always timely communicate the denial status to the patients so that alternative treatment options could be timely pursed. The following are some of the weaknesses identified within the two secondary administrative indicators:  The institution did not always process inmate medical appeals timely.  CEN did not take adequate steps to ensure the accuracy of its Dashboard data reporting; there was no evidence that the Quality Management Committee discussed the methods used to conduct data validation audits or to train staff who collect Dashboard data.  Management did not always timely review incident packages during its monthly Emergency Medical Response Review Committee (EMRRC) meetings. Further, the warden did not always approve meeting minutes, and incident review packages did not include required documentation.  The institution did not have a tracking system in place to determine when custody staff’s emergency response certifications were about to expire. The CEN Executive Summary Table on the following page lists the quality indicators the OIG inspected and assessed during the clinical case reviews and objective compliance tests, and provides the institution’s rating in each area. The overall indicator ratings were based on a consensus decision by the OIG’s clinicians and non-clinical inspectors. California State Prison, Centinela, Cycle 4 Medical Inspection Page viii Office of the Inspector General State of California CEN Executive Summary Table Case Compliance Overall Indicator Primary Indicators (Clinical) Review Rating Rating Rating Access to Care Adequate Adequate Adequate Diagnostic Services Proficient Inadequate Adequate Emergency Services Adequate Not Applicable Adequate Health Information Management Adequate Adequate Adequate (Medical Records) Health Care Environment Not Applicable Proficient Proficient Inter- and Intra-System Transfers Adequate Proficient Proficient Pharmacy and Medication Management Adequate Adequate Adequate Preventive Services Not Applicable Proficient Proficient Quality of Nursing Performance Inadequate Not Applicable Inadequate Quality of Provider Performance Adequate Not Applicable Adequate Specialized Medical Housing Inadequate Proficient Adequate (OHU, CTC, SNF, Hospice) Specialty Services Adequate Proficient Proficient Note: The Prenatal and Post-Delivery Services and Reception Center Arrivals indicators did not apply to this institution. Case Compliance Overall Indicator Secondary Indicators (Administrative) Review Rating Rating Rating Internal Monitoring, Quality Improvement, Not Applicable Inadequate Inadequate and Administrative Operations Job Performance, Training, Licensing, and Not Applicable Proficient Proficient Certifications Compliance ratings for quality indicators are proficient (greater than 85.0 percent), adequate (75.0 percent to 85.0 percent), or inadequate (below 75.0 percent). California State Prison, Centinela, Cycle 4 Medical Inspection Page ix Office of the Inspector General State of California Population-Based Metrics In general, CEN performed adequately for population-based metrics. In four of the five comprehensive diabetes care measures (diabetic monitoring, diabetics considered to be under poor control, diabetics considered to be under good control, and blood pressure control), CEN performed similarly or exceeded other State and national organizations. This included Medi-Cal and Kaiser Permanente, typically one of the highest-scoring health organizations in California, as well as Medicaid, Medicare, national commercial health plans (based on data obtained from health maintenance organizations), and the U.S. Department of Veterans Affairs (VA). For the one remaining diabetes care measure, eye exams for diabetic patients, the institution’s score was mid-range when compared to the other entities. With regard to influenza immunizations for patients under the age of 65, CEN outperformed Kaiser and commercial plans but trailed with a rate lower than the VA; for older patients, CEN’s rates were lower than both the VA and Medicare for influenza and pneumococcal immunizations. The institution’s lower performance for flu shots and pneumococcal vaccinations can be largely attributed to patient refusals. For colorectal cancer screening, CEN scored lower than the rates reported by Kaiser, commercial plans, Medicare, and the VA. Again, this lower performance can be largely attributed to patient refusals. Overall, CEN’s performance demonstrated by the population-based metrics indicated that the chronic care program was adequately run and operating as intended. California State Prison, Centinela, Cycle 4 Medical Inspection Page x Office of the Inspector General State of California INTRODUCTION Under the authority of California Penal Code Section 6126, which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), and at the request of the federal Receiver, the OIG developed a comprehensive medical inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. For this fourth cycle of inspections, the OIG augmented the breadth and quality of its inspection program used in prior cycles, adding a clinical case review component and significantly enhancing the compliance component of the program. California State Prison, Centinela (CEN), was the 12th medical inspection of Cycle 4. During the inspection process, the OIG assessed the delivery of medical care to patients for 12 primary clinical health care indicators and two secondary administrative health care indicators applicable to the institution. It is important to note that while the primary quality indicators represent the clinical care being provided by the institution at the time of the inspection, the secondary quality indicators are purely administrative and are not reflective of the actual clinical care provided. The OIG is committed to reporting on each institution’s delivery of medical care to assist in identifying areas for improvement, but the federal court will ultimately determine whether any institution’s medical care meets constitutional standards. ABOUT THE INSTITUTION CEN is a complex of four separate facilities (A, B, C, and D) within a secure perimeter that primarily houses general population, Level I and Level III sensitive needs, and maximum security (Level IV) custody inmates, including inmates housed in the administrative segregation unit, a high-security unit for inmates segregated for disciplinary or administrative safety and security reasons. The institution runs eight medical clinics where staff handle non-urgent requests for medical services. CEN also treats inmates needing urgent care in its triage and treatment area and those requiring in-patient care in the correctional treatment center. CEN is designated as a “basic care prison,” located in a rural area away from tertiary care centers and specialty care providers whose services are likely to be used frequently by higher-risk patients. Basic institutions have capability to provide limited specialty medical services and consultation for a generally healthy inmate-patient population. In addition, on August 17, 2014, 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. California State Prison, Centinela, Cycle 4 Medical Inspection Page 1 Office of the Inspector General State of California In August 2015, CEN had 77.1 authorized health care positions and an overall vacancy rate of just 5 percent across all health care job classifications, including management, providers, staff nurses, and nurse supervisors. Management positions had the highest average vacancy rate at 50 percent; however, this was attributable to a vacancy in one of its two management positions. The institution also reported that the vacancy (chief nursing executive) was currently being filled by an employee working in an acting capacity. CEN reported that it had six authorized provider positions and that all positions were currently filled; however, one provider position was on long-term medical leave, and the institution had been utilizing one outsourced contract registry provider to cover the absence. As for nursing staff and nursing supervisors, the combined positions accounted for 89 percent of CEN’s total health care staffing resources, and the position types only had a combined 4 percent vacancy rate. While the vacancy rate appeared low, CEN also had nine nurses who were on long-term medical leave, accounting for 13 percent of the total nursing workforce. CEN only slightly mitigated the staffing shortage by employing one outsourced contract registry nurse. Lastly, the CEO reported that there were four nursing staff members under disciplinary review; as of early August 2015, none was redirected to a position away from health care. CEN Health Care Staffing Resources — August 2015 Primary Care Nursing Management Nursing Staff Totals Providers Supervisors Description Number % Number % Number % Number % Number % Authorized 2 3% 6 8% 9.5 12% 59.6 77% 77.1 100% Positions Filled Positions 1 50% 6 100% 9.5 100% 57 96% 73.5 95% Vacancies 1 50% 0 0% 0 0% 2.6 4% 3.6 5% Recent Hires (within 12 0 0% 3 50% 2 21% 15 26% 20 27% months) Staff Utilized 0 0% 1 17% 0 0% 1 2% 2 3% from Registry Redirected Staff (to Non-Patient 0 0% 0 0% 0 0% 0 0% 0 0% Care Areas) Staff on Long-term 0 0% 1 0% 2 21% 7 12% 10 14% Medical Leave Note: CEN Health Care Staffing Resources data was not validated by the OIG. California State Prison, Centinela, Cycle 4 Medical Inspection Page 2 Office of the Inspector General State of California As of August 31, 2015, the Master Registry for CEN showed that the institution had 3,487 inmate-patients. Within that total population, 0.5 percent were designated High-Risk, Priority 1 (High 1), and 1.7 percent were designated High-Risk, Priority 2 (High 2). Patients’ assigned risk levels are based on the complexity of their required medical care related to their specific diagnoses, frequency of higher levels of care, age, and abnormal labs and procedures. High 1 has at least two high-risk conditions; High 2 has only one. High-risk patients are more susceptible to poor health outcomes than medium- or low-risk patients. High-risk patients also typically require more health care services than do patients with lower assigned risk levels. The chart below illustrates the breakdown of the institution’s medical risk levels at the start of the OIG medical inspection. CEN Master Registry Data as of August 31, 2015 Risk Level # of Inmate-Patients Percentage High 1 16 0.5% High 2 61 1.7% Medium 687 19.7% Low 2,723 78.1% Total 3,487 100.0% California State Prison, Centinela, Cycle 4 Medical Inspection Page 3 Office of the Inspector General State of California Commonly Used Abbreviations ACLS Advanced Cardiovascular Life Support HIV Human Immunodeficiency Virus AHA American Heart Association HTN Hypertension ASU Administrative Segregation Unit INH Isoniazid (anti-tuberculosis medication) BLS Basic Life Support IV Intravenous CBC Complete Blood Count KOP Keep-on-Person (in taking medications) CC Chief Complaint LPT Licensed Psychiatric Technician CCHCS California Correctional Health Care Services LVN Licensed Vocational Nurse CCP Chronic Care Program MAR Medication Administration Record California Department of Corrections and CDCR MRI Magnetic Resonance Imaging Rehabilitation CEO Chief Executive Officer MD Medical Doctor CHF Congestive Heart Failure NA Nurse Administered (in taking medications) CME Chief Medical Executive N/A Not Applicable CMP Comprehensive Metabolic (Chemistry) Panel NP Nurse Practitioner CNA Certified Nursing Assistant OB Obstetrician CNE Chief Nurse Executive OHU Outpatient Housing Unit C/O Complains of OIG Office of the Inspector General COPD Chronic Obstructive Pulmonary Disease P&P Policies and Procedures (CCHCS) CP&S Chief Physician and Surgeon PA Physician Assistant CPR Cardio-Pulmonary Resuscitation PCP Primary Care Provider CSE Chief Support Executive POC Point of Contact CT Computerized Tomography PPD Purified Protein Derivative CTC Correctional Treatment Center PRN As Needed (in taking medications) DM Diabetes Mellitus RN Registered Nurse Directly Observed Therapy (in taking DOT Rx Prescription medications) Dx Diagnosis SNF Skilled Nursing Facility Subjective, Objective, Assessment, Plan, EKG Electrocardiogram SOAPE Education ENT Ear, Nose and Throat SOMS Strategic Offender Management System ER Emergency Room S/P Status Post eUHR electronic Unit Health Record TB Tuberculosis FTF Face-to-Face TTA Triage and Treatment Area History and Physical (reception center H&P UA Urinalysis examination) HIM Health Information Management UM Utilization Management California State Prison, Centinela, Cycle 4 Medical Inspection Page 4 Office of the Inspector General State of California OBJECTIVES, SCOPE, AND METHODOLOGY In designing the medical inspection program, the OIG reviewed CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. The OIG also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the Receiver’s office, CDCR, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of the OIG’s inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates medical care delivery by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population-based metrics. To maintain a metric-oriented inspection program that evaluates medical care delivery consistently at each State prison, the OIG identified 14 primary (clinical) and two secondary (administrative) quality indicators of health care to measure. The primary quality indicators cover clinical categories directly relating to the health care provided to patients, whereas the secondary quality indicators address the administrative functions that support a health care delivery system. The 14 primary quality indicators are Access to Care, Diagnostic Services, Emergency Services, Health Information Management (Medical Records), Health Care Environment, Inter- and Intra-System Transfers, Pharmacy and Medication Management, Prenatal and Post-Delivery Services, Preventive Services, Quality of Nursing Performance, Quality of Provider Performance, Reception Center Arrivals, Specialized Medical Housing (OHU, CTC, SNF, Hospice), and Specialty Services. The two secondary quality indicators are Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications. The OIG rates each of the quality indicators applicable to the institution under inspection based on case reviews conducted by OIG clinicians and compliance tests conducted by OIG deputy inspectors general. The ratings may be derived from the case review results alone, the compliance test results alone, or a combination of both these information sources. For example, the ratings for the primary quality indicators Quality of Nursing Performance and Quality of Provider Performance are derived entirely from the case review results, while the ratings for the primary quality indicators Health Care Environment and Preventive Services are derived entirely from compliance test results. As another example, primary quality indicators such as Diagnostic Services and Specialty Services receive ratings derived from both sources. At CEN, 14 of the quality indicators were applicable, consisting of 12 primary clinical indicators and two secondary administrative indicators. Of the 12 primary indicators, seven were rated by both case review clinicians and compliance inspectors, three were rated by case review clinicians only, and two were rated by compliance inspectors only; both secondary indicators were rated by compliance inspectors only. California State Prison, Centinela, Cycle 4 Medical Inspection Page 5 Office of the Inspector General State of California Consistent with the OIG’s agreement with the Receiver, this report only addresses the conditions found related to medical care criteria. The OIG does not review for efficiency and economy of operations. Moreover, if the OIG learns of an inmate-patient needing immediate care, the OIG notifies the chief executive officer of health care services and requests a status report. Additionally, if the OIG learns of significant departures from community standards, it may report such departures to the institution’s chief executive officer or to CCHCS. Because these matters involve confidential medical information protected by State and federal privacy laws, specific identifying details related to any such cases are not included in the OIG’s public report. In all areas, the OIG is alert for opportunities to make appropriate recommendations for improvement. Such opportunities may be present regardless of the 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 has added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders. At the conclusion of Cycle 3, the federal Receiver and the Inspector General determined that the health care provided at the institutions was not fully evaluated by the compliance tool alone, and that the compliance tool was not designed to provide comprehensive qualitative assessments. Accordingly, the OIG added case reviews in which OIG physicians and nurses evaluate selected cases in detail to determine the overall quality of health care provided to the inmate-patients. The OIG’s clinicians perform a retrospective chart review of selected patient files to evaluate the care given by an institution’s primary care providers and nurses. Retrospective chart review is a well-established review process used by health care organizations that perform peer reviews and patient death reviews. Currently, CCHCS uses retrospective chart review as part of its death review process and in its pattern-of-practice reviews. CCHCS also uses a more limited form of retrospective chart review when performing appraisals of individual primary care providers. PATIENT SELECTION FOR RETROSPECTIVE CASE REVIEWS Because retrospective chart review is time consuming and requires qualified health care professionals to perform it, OIG clinicians must carefully sample patient records. Accordingly, the group of patients the OIG targeted for chart review carried the highest clinical risk and utilized the majority of medical services. A majority of the patients selected for retrospective chart review were classified by CCHCS as high-risk patients. The reason the OIG targeted these patients for review is twofold: 1. The goal of retrospective chart review is to evaluate all aspects of the health care system. Statewide, high-risk and high-utilization patients consume medical services at a disproportionate rate; 11 percent of the total patient population are considered high-risk and California State Prison, Centinela, Cycle 4 Medical Inspection Page 6 Office of the Inspector General State of California account for more than half of the institution’s pharmaceutical, specialty, community hospital, and emergency costs. 2. Selecting this target group for chart review provides a significantly greater opportunity to evaluate all the various aspects of the health care delivery system at an institution. Underlying the choice of high-risk patients for detailed case review, 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 care, the OIG utilizes experienced correctional physicians and registered nurses to perform this analysis. 2. The health of less complex patients is more likely to be affected by processes such as timely appointment scheduling, medication management, routine health screening, and immunizations. To review these processes, the OIG simultaneously performs a broad compliance review. 3. Patient charts generated during death reviews, sentinel events (an unexpected occurrence involving death or serious injury, or risk thereof), and hospitalizations are mostly of high-risk patients. BENEFITS AND LIMITATIONS OF TARGETED SUBPOPULATION REVIEW Because the selected patients utilize the broadest range of services offered by the health care system, the OIG’s retrospective chart review provides adequate data for a qualitative assessment of the most vital system processes (referred to as “primary quality indicators”). Retrospective chart review provides an accurate qualitative assessment of the relevant primary quality indicators as applied to the targeted subpopulation of high-risk and high-utilization patients. While this targeted subpopulation does not represent the prison population as a whole, the ability of the institution to provide adequate care to this subpopulation is a crucial and vital indicator of how the institution provides health care to its whole patient population. Simply put, if the institution’s medical system does not adequately care for those patients needing the most care, then it is not fulfilling its obligations, even if it takes good care of patients with less complex medical needs. Since the targeted subpopulation does not represent the institution’s general prison population, the OIG cautions against inappropriate extrapolation of conclusions from the retrospective chart reviews to the general population. For example, if the high-risk diabetic patients reviewed have poorly-controlled diabetes, one cannot conclude that the entire diabetic population is inadequately controlled. Similarly, if the high-risk diabetic patients under review have poor outcomes and require significant specialty interventions, one cannot conclude that the entire diabetic population is having similarly poor outcomes. California State Prison, Centinela, Cycle 4 Medical Inspection Page 7 Office of the Inspector General State of California Nonetheless, the health care system’s response to this subpopulation can be accurately evaluated and yields valuable systems information. In the above example, if the health care system is providing appropriate diabetic monitoring, medication therapy, and specialty referrals for the high-risk patients reviewed, then it can be reasonably inferred that the health care system is also providing appropriate diabetic services to the entire diabetic subpopulation. However, if these same high-risk patients needing monitoring, medications, and referrals are generally not getting those services, it is likely that the health care system is not providing appropriate diabetic services to the greater diabetic subpopulation. CASE REVIEWS SAMPLED As indicated in Appendix B, Table B–1, CEN Sample Sets, the OIG clinicians evaluated medical charts for 69 unique inmate-patients. Appendix B, Table B-4, CEN Case Review Sample Summary clarifies that both nurses and physicians reviewed charts for ten of those patients, for 79 reviews in total. Physicians performed detailed reviews of 30 charts, and nurses performed detailed reviews of 16 charts, totaling 46 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 33 inmate-patients. These generated 1,340 clinical events for review (Appendix B, Table B-3, CEN Event-Program). The reporting format provides details on whether the encounter was adequate or had significant deficiencies, and identifies deficiencies by programs and processes to help the institution focus on improvement areas. While the sample method specifically pulled only six chronic care patient records, i.e., three diabetes patients and three anticoagulation patients (Appendix B, Table B–1, CEN Sample Sets), the 69 unique inmate-patients sampled included patients with 161 chronic care diagnoses, including 11 additional patients with diabetes, for a total of 14 (Appendix B, Table B–2, CEN Chronic Care Diagnoses). The OIG’s sample selection tool evaluated many chronic care programs because the complex and high-risk patients selected from the different categories often had multiple medical problems. While the OIG did not evaluate every chronic disease or health care staff member, the overall operation of the institution’s system and staff were assessed for adequacy. The OIG’s case review methodology and sample size matched other qualitative research. The empirical findings, supported by expert statistical consultants, showed adequate conclusions after 10 to 15 charts had undergone full clinician review. In qualitative statistics, this phenomenon is known as “saturation.” The OIG asserts that the sample size of over 30 detailed reviews certainly far exceeds the saturation point necessary for an adequate qualitative review. With regard to reviewing charts from different providers, the case review is not intended to be a focused search for poorly performing providers; rather, it is focused on how the system cares for those patients who need care the most. Nonetheless, while not sampling cases by each provider at the institution, the OIG inspections adequately review most providers. Primary care providers (PCPs) would only escape OIG case review if institutional management successfully mitigated patient risk by having the more poorly performing PCPs care California State Prison, Centinela, Cycle 4 Medical Inspection Page 8 Office of the Inspector General State of California for the less complicated, low-utilizing, and lower-risk patients. The OIG’s clinicians concluded the case review sample size was 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 CEN 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 September to November 2015, deputy inspectors general attained answers to 101 objective medical inspection test (MIT) questions designed to assess the institution’s compliance with critical policies and procedures applicable to the delivery of medical care. To conduct most tests, inspectors randomly selected samples of inmate-patients for whom the testing objectives were applicable and reviewed their electronic unit health records. In some cases, inspectors used the same samples to conduct more than one test. In total, inspectors reviewed health records for 367 individual inmate-patients and analyzed specific transactions within their records for evidence that critical events occurred. Inspectors also reviewed management reports and meeting minutes to assess certain administrative operations. In addition, during the week of September 14, 2015, field inspectors conducted a detailed onsite inspection of CEN’s medical facilities and clinics; interviewed key institutional employees; and reviewed employee records, logs, medical appeals, death reports, and other documents. This generated 1,183 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 CEN’s plant infrastructure, protocols for tracking medical appeals and local operating procedures, and staffing resources. For details of the compliance results, see Appendix A — Compliance Test Results. For details of the OIG’s compliance sampling methodology, see Appendix C — Compliance Sampling Methodology. California State Prison, Centinela, Cycle 4 Medical Inspection Page 9 Office of the Inspector General State of California SCORING OF COMPLIANCE TESTING RESULTS The OIG rated the institution in the following nine primary (clinical) and two secondary (administrative) quality indicators applicable to the institution for compliance testing:  Primary indicators: Access to Care, Diagnostic Services, Health Information Management (Medical Records), Health Care Environment, Inter- and Intra-System Transfers, Pharmacy and Medication Management, Preventive Services, Specialized Medical Housing (OHU, CTC, SNF, Hospice), and Specialty Services.  Secondary indicators: Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications. After compiling the answers to the 101 questions, the OIG derived a score for each primary and secondary quality indicator identified above by calculating the percentage score of all Yes answers for each of the questions applicable to a particular indicator, then averaging those scores. Based on those results, the OIG assigned a rating to each quality indicator of proficient (greater than 85 percent), adequate (between 75 percent and 85 percent), or inadequate (less than 75 percent). DASHBOARD COMPARISONS In the first ten medical inspection reports of Cycle 4, the OIG identified where similar metrics for some of the individual compliance questions were available within the CCHCS Dashboard, which is a monthly report that consolidates key health care performance measures statewide and by institution. However, there was not complete parity between the metrics due to differing time frames for data collecting and differences in sampling methods, rendering the metrics non-comparable. Some of the OIG’s stakeholders suggested removing the Dashboard comparisons from future reports to eliminate confusion. Dashboard data is available on CCHCS’s website, www.cphcs.ca.gov. California State Prison, Centinela, Cycle 4 Medical Inspection Page 10 Office of the Inspector General State of California OVERALL QUALITY INDICATOR RATING FOR CASE REVIEWS AND COMPLIANCE TESTING The OIG derived the final rating for each quality indicator by combining the ratings from the case reviews and from the compliance testing, as applicable. When combining these ratings, the case review evaluations and the compliance testing results usually agreed, but there were instances when the rating differed for a particular quality indicator. In those instances, the inspection team assessed the quality indicator based on the collective ratings from both components. Specifically, the OIG clinicians and deputy inspectors general discussed the nature of individual exceptions found within that indicator category and considered the overall effect on the ability of patients to receive adequate medical care. To derive an overall assessment rating for the institution’s medical inspection, the OIG evaluated the various rating categories assigned to each of the quality indicators applicable to the institution, giving more weight to the rating results for the primary quality indicators, which directly relate to the health care provided to inmate-patients. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed. POPULATION-BASED METRICS The OIG identified a subset of Healthcare Effectiveness Data Information Set (HEDIS) measures applicable to the CDCR inmate-patient population. To identify outcomes for CEN, the OIG reviewed some of the compliance testing results, randomly sampled additional inmate-patients’ records, and obtained CEN data from the CCHCS Master Registry. The OIG compared those results to HEDIS metrics reported by other statewide and national health care organizations. California State Prison, Centinela, Cycle 4 Medical Inspection Page 11 Office of the Inspector General State of California MEDICAL INSPECTION RESULTS PRIMARY (CLINICAL) QUALITY INDICATORS OF HEALTH CARE The primary quality indicators assess the clinical aspects of health care. As shown on the Health Care Quality Indicators table on page ii of this report, 12 of the OIG’s primary indicators were applicable to CEN. Of those 12 indicators, seven were rated by both the case review and compliance components of the inspection, three were rated by the case review component alone, and two were rated by the compliance component alone. Summary of Case Review Results: The clinical case review component assessed 10 of the 12 primary (clinical) indicators applicable to CEN. For these ten indicators, OIG clinicians rated one proficient, seven adequate, and two inadequate. The OIG physicians rated the overall adequacy of care for each of the 30 detailed case reviews they conducted. Of these 30 cases, 24 were adequate, and six were inadequate. For the 1,340 events reviewed, there were 467 deficiencies, of which 44 were considered to be of such magnitude that, if left unaddressed, they would likely contribute to patient harm. Adverse Events Identified During Case Review: Medical care is a complex dynamic process with many moving parts, subject to human error even within the best health care organizations. Adverse events are typically identified and tracked by all major health care organizations for the purpose of quality improvement. They are not generally representative of medical care delivered by the organization. The OIG identified adverse events for the dual purposes of quality improvement and the illustration of problematic patterns of practice found during the inspection. Because of the anecdotal description of these events, the OIG cautions against drawing inappropriate conclusions regarding the institution based solely on adverse events. There were no adverse sentinel events identified in the case reviews at CEN. Summary of Compliance Results: The compliance component assessed 9 of the 12 primary (clinical) indicators applicable to CEN. For these nine indicators, OIG inspectors rated five proficient, three adequate, and one 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 State Prison, Centinela, Cycle 4 Medical Inspection Page 12 Office of the Inspector General State of California ACCESS TO CARE This indicator evaluates the institution’s ability to provide Case Review Rating: inmate-patients with timely clinical appointments. Areas specific to Adequate inmate-patients’ access to care are reviewed, such as initial Compliance Score: assessments of newly arriving inmates, acute and chronic care Adequate follow-ups, face-to-face nurse appointments when an inmate-patient (80.6%) requests to be seen, provider referrals from nursing lines, and Overall Rating: follow-ups after hospitalization or specialty care. Compliance Adequate testing for this indicator also evaluates whether inmate-patients have Health Care Services Request forms (CDCR Form 7362) available in their housing units. Case Review Results The OIG clinicians reviewed 753 provider and nurse encounters and 153 provider orders (not linked to provider visits), and identified 22 deficiencies relating to Access to Care. The majority of these deficiencies were due to patients not being seen in a timely manner for follow-up after specialty care, and inappropriate scheduling related to Health Care Services Request forms (CDCR Form 7362), which is further addressed in the Quality of Nursing Performance indicator. Appointments were timely in all other aspects reviewed, including triage and treatment area (TTA) and hospital follow-ups, intra-system transfers, and outpatient provider and nursing follow-ups. Other than the deficiencies cited above, CEN’s performance was satisfactory with regard to Access to Care, and the case review rating was adequate. Compliance Testing Results The institution performed in the adequate range in the Access to Care indicator, with a compliance score of 80.6 percent. CEN scored in the proficient range in the following test areas:  Inmates had access to Health Care Services Request forms (CDCR Form 7362) at all six housing units inspected (MIT 1.101).  The institution ensured that all 14 sampled inmate-patients discharged from a community hospital received a PCP follow-up appointment within five days of return (MIT 1.007).  Inspectors sampled 30 health care services request forms submitted by inmate-patients across all facility clinics. Nursing staff reviewed 26 requests (87 percent) the same day the forms were received; delinquent reviews occurred one to two days late for three requests, and the timeliness of a fourth review could not be determined because the nurse did not document the date the request form was originally received (MIT 1.003). Additionally, nursing staff completed a face-to-face visit with 28 of the 30 patients (93 percent) within one California State Prison, Centinela, Cycle 4 Medical Inspection Page 13 Office of the Inspector General State of California business day of reviewing the request. The nurse encounters for two patient visits occurred l one and 13 days late (MIT 1.004). The following test areas received scores in the adequate range:  Of the nine health care services request forms sampled where nursing staff referred the inmate-patient for a PCP appointment, seven patients (78 percent) received a timely appointment, one patient received an appointment nine days late, and another patient was not seen at all (MIT 1.005). In a related area, three of the four inmate-patients for whom the PCP determined a follow-up provider appointment was necessary (75 percent) received a timely appointment, and one patient received his follow-up appointment 12 days late (MIT 1.006).  When the OIG reviewed recent provider appointments for 30 inmate-patients with chronic care conditions, only 23 (77 percent) received or refused their appointments timely; one patient refused the service, but the refusal occurred two days late. Another six patients received their appointments between eight days and two months late (MIT 1.001).  Inspectors sampled 28 inmate-patients who received a specialty service; 21 of them (75 percent) received a timely follow-up appointment with a PCP; untimely appointments ranged from one to 11 days late (MIT 1.008). In the following test area, CEN scored in the inadequate range:  Only 7 of the 17 inmate-patients sampled (41 percent) who transferred into CEN from other institutions and were referred to a PCP for a routine appointment based on nursing staff’s initial health care screening of the patient were seen timely. For eight patients, appointments were held between 4 and 15 days late. The remaining two patients were seen 21 and 67 days late (MIT 1.002). Recommendations No specific recommendations. California State Prison, Centinela, Cycle 4 Medical Inspection Page 14 Office of the Inspector General State of California DIAGNOSTIC SERVICES This indicator addresses several types of diagnostic services. Case Review Rating: Specifically, it addresses whether radiology and laboratory Proficient services were timely provided to inmate-patients, whether the Compliance Score: primary care provider (PCP) timely reviewed the results, and Inadequate whether the results were communicated to the inmate-patient (66.7%) within the required time frames. In addition, for pathology services, the OIG determines whether the institution received a Overall Rating: final pathology report and whether the PCP timely reviewed and Adequate communicated the pathology results to the patient. The case reviews also factor in the appropriateness, accuracy, and quality of the diagnostic test(s) ordered and the clinical response to the results. For this indicator, the OIG’s case review and compliance review processes yielded different results, with the case review giving a proficient rating and the compliance testing resulting in an inadequate score. As noted below, the primary reasons for the compliance testing’s score of inadequate were radiology and pathology reports not being both received and reviewed timely, and pathology reports results also not being communicated to patients in a timely manner. The handling of pathology reports was similar to that of hospital reports (the majority of the pathology reports were for biopsies performed at hospitals). As noted in the Health Information Management indicator, hospital reports were routinely scanned into the eUHR without provider signatures. While providers did not properly sign the pathology reports, the provider progress notes often indicated the findings and recommendations were reviewed and the results were ultimately communicated to patients. However, as the compliance testing results demonstrated, providers often made late communications to their patients. After considering both case review and compliance testing results, the OIG inspection team concluded that the final overall rating for this indicator was adequate. Case Review Results The OIG clinicians reviewed 184 diagnostic-related events and found 21 minor deficiencies, the majority of which related to health information management. There were no significant problems with diagnostic services. In general, diagnostic services were successfully completed and performed timely. Provider progress notes indicated that most reports were reviewed timely by primary care providers, and providers notified patients of the test results. CEN performed well with regard to Diagnostic Services, and the clinicians rated this indicator as proficient. California State Prison, Centinela, Cycle 4 Medical Inspection Page 15 Office of the Inspector General State of California Compliance Testing Results The institution received an inadequate compliance score of 66.7 percent in the Diagnostic Services indicator, which encompasses radiology, laboratory, and pathology services. For clarity, each type of diagnostic service is discussed separately below. Radiology Services  All ten sampled patients received timely radiology services and corresponding test results (MIT 2.001, 2.003). However, providers only timely reviewed six of the ten test results (60 percent). While providers initialed three of the four deficient reports, they did not date any of these documents to evidence a timely review (MIT 2.002). Laboratory Services  For nine of ten inmate-patients sampled (90 percent), the institution timely provided laboratory services, and after which the providers timely reviewed the laboratory reports and timely communicated the results to their patients. However, one patient received his laboratory service two days late and he also never received notification of the results. Additionally, the provider did not indicate the review date for another patient’s laboratory report (MIT 2.004, 2.005, 2.006). Pathology Services  The institution timely received the final diagnostic pathology reports for only seven of ten inmate-patients sampled (70 percent); one report was three days late, and there was no evidence that two other pathology reports were received at all or that CEN attempted to obtain them (MIT 2.007). Further, providers did not sign or date any of the corresponding pathology reports sampled to evidence their timely review, and providers also did not timely communicate results to any of the sampled patients, resulting in scores of zero for both tests. While all of the sampled patients were notified of the pathology results, they were notified between one and 28 days late, averaging eight days late (MIT 2.008, 2.009). Recommendations No specific recommendations. California State Prison, Centinela, Cycle 4 Medical Inspection Page 16 Office of the Inspector General State of California EMERGENCY SERVICES An emergency medical response system is essential to providing Case Review Rating: effective and timely emergency medical response, assessment, Adequate treatment, and transportation 24 hours per day. Provision of Compliance Score: urgent/emergent care is based on a patient’s emergency situation, Not Applicable clinical condition, and need for a higher level of care. The OIG reviews emergency response services including first aid, basic life Overall Rating: support (BLS), and advanced cardiac life support (ACLS) Adequate consistent with the American Heart Association guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care, and the provision of services by knowledgeable staff appropriate to each individual’s training, certification, and authorized scope of practice. The OIG evaluates this quality indicator entirely through clinicians’ reviews of case files and conducts no separate compliance testing element. Case Review Results The OIG clinicians reviewed 90 urgent/emergent events and found 50 deficiencies, mainly in the area of nursing care and nursing review. The majority of these deficiencies were minor and did not contribute to patient harm. A few notable exceptions are discussed below. In general, CEN performed well with emergency response times, BLS and ALCS care, and 9-1-1 call activation times. Despite the deficiencies noted, the case reviews showed that most patients requiring urgent or emergent services received timely and adequate care. Provider Performance Providers in the triage and treatment area (TTA) generally made appropriate triage decisions and sent patients to the appropriate levels of care. The few exceptions related to inadequate management of a possible gastrointestinal bleed (also discussed in the Quality or Provider Performance indicator), two instances of an inappropriate method of transport to the local hospital, and two occasions where chest pain management was poor. Nursing Performance The OIG clinicians found a few cases in which nurses did not respond in a timely manner, perform adequate assessments, or promptly initiate care.  In case 3, a medical alarm was activated for an unresponsive person. The TTA RN failed to promptly reassess a low oxygen saturation of 86 percent, failed to assess the blood sugar, and failed to monitor the patient until the community hospital transport arrived. A supervising registered nurse (SRN) also reviewed this event and failed to identify these deficiencies. California State Prison, Centinela, Cycle 4 Medical Inspection Page 17 Office of the Inspector General State of California  In case 4, a medical alarm was activated for a patient with an altered level of consciousness. The patient was disoriented, unable to speak or follow commands, and was “foaming at the mouth.” The TTA RN failed to respond within 8 minutes to the housing unit (arriving 17 minutes after alarm activation), did not promptly assess vital signs, and did not administer oxygen timely. Additionally, the nurse failed to assess the patient for signs of trauma or pupil reaction and response, and failed to establish intravenous access. Emergency Medical Response Review Committee  Most urgent/emergent unscheduled transfers did not contain thorough clinical reviews. While SRNs reviewed TTA flow sheets, they failed to identify deficiencies within the events. Also, the institution’s Emergency Medical Response Review Committee most often performed only a timeline review. In addition to cases 3 and 4 discussed above, the SRNs also failed to identify nursing care deficiencies in cases 1, 5, 6, 7, 8, and 18.  In cases 1, 46, 47, and 80, the emergency events were reviewed in either the Patient Safety Committee or the Emergency Medical Response Review Committee and both committees failed to identify nursing care deficiencies. Conclusion CEN staff provided adequate emergency services to patients during the time frame reviewed. The majority of deficiencies found relating to emergency services were due to inadequate assessment or documentation by nursing staff and inadequate clinical evaluations by nursing supervisors and the Emergency Medical Response Review Committee. Recommendations  The OIG recommends that nursing supervisors receive training in the appropriate methodology of performing post emergency response audits. Management should consider reviewing the audit results to ensure adequacy.  The OIG further recommends that CEN leadership review the emergency medical response review process, and include a clinical review by the chief medical executive and chief nurse executive; and, maintain a record or log that includes a brief description of events, areas of deficiency, any resulting action or training, as well as proof of practice documentation. California State Prison, Centinela, Cycle 4 Medical Inspection Page 18 Office of the Inspector General State of California HEALTH INFORMATION MANAGEMENT (MEDICAL RECORDS) Health information management is a crucial link in the delivery of Case Review Rating: medical care. Medical personnel require accurate information in Adequate order to make sound judgments and decisions. This indicator Compliance Score: examines whether the institution adequately manages its health care Adequate information. This includes determining whether the information is (76.0%) correctly labeled and organized and available in the electronic unit Overall Rating: health record (eUHR); whether the various medical records Adequate (internal and external, e.g., hospital and specialty reports and progress notes) are obtained and scanned timely into the inmate-patient’s eUHR; whether records routed to clinicians include legible signatures or stamps; and whether hospital discharge reports include key elements and are timely reviewed by providers. Case Review Results CEN displayed mostly minor Health Information Management deficiencies and only a small number of moderate deficiencies during case review. Out of the 466 deficiencies for all indicators identified from the case reviews, 75 related to this indicator. The majority of the deficiencies were reports not properly signed by primary care providers. However, the providers did review the reports, as evidenced by orders and documentation in progress notes. The vast majority of Health Information Management deficiencies were considered unlikely to contribute to patient harm, so this indicator was rated adequate. Inter-Departmental Transmission A small number of deficiencies related to intended orders not being carried out across various departments. Examples included tests not performed or test results not scanned into a patient’s eUHR. Hospital Records There were five deficiencies related to primary care providers not properly signing hospital records prior to eUHR scanning. However, it was apparent the providers reviewed the records, as evidenced by provider orders and documentation in progress notes. Specialty Services The OIG clinicians identified 43 Health Information Management deficiencies related to specialty services. The majority were providers not properly signing specialty reports. Again, it was apparent the reports were reviewed, as evidenced by provider orders and documentation in progress notes. Providers rarely failed to follow specialists’ recommendations. There were three occurrences when specialists were not provided with the patients’ most recent diagnostic test results or medication lists. These findings are also discussed in the Specialty Services indicator. California State Prison, Centinela, Cycle 4 Medical Inspection Page 19 Office of the Inspector General State of California Diagnostic Reports There were nine Health Information Management deficiencies related to diagnostic reports. Most of these deficiencies were instances where diagnostic reports were not found in the eUHR. One deficiency was a diagnostic report not properly signed by a primary care provider. Scanning Performance The majority of the 11 case reviews identified Health Information Management deficiencies related to scanning performance were either absent, mislabeled, or misfiled documents in patients’ eUHR files. There were several instances when provider and nursing notes were not found in the eUHR. Legibility Most providers had both dictated and transcribed progress notes. However, there were a few occurrences of illegible signatures and progress notes, by both providers and nurses. Miscellaneous The OIG also noted some deficiencies relating to transcription errors. Compliance Testing Results The institution received an adequate compliance score of 76.0 percent in the Health Information Management (Medical Records) indicator and performed well in the following areas:  The institution timely scanned non-dictated progress notes, patients’ initial health screening forms, and requests for health care services into patients’ eUHRs for all 20 documents sampled (MIT 4.001). CEN also timely scanned all 20 sampled specialty services consultant reports and 20 sampled medication administration records into the inmate-patients’ eUHRs (MIT 4.003, 4.005). As a result, CEN scored 100 percent in these test areas.  CEN timely scanned community hospital discharge reports or treatment records into the patient’s eUHR for 13 of the 14 sampled reports (93 percent); one report was scanned two days late (MIT 4.004).  Inspectors reviewed eUHR files for 14 patients sent or admitted to the hospital and found that providers reviewed the hospital discharge reports or treatment records within three calendar days of discharge for 12 patient files (86 percent). Providers reviewed the discharge report one day late for one patient and two days late for another (MIT 4.008).  When the OIG reviewed various medical documents such as hospital discharge reports, initial health screening forms, certain medication records, and specialty services reports to ensure that clinical staff legibly documented their names on the forms, 27 of 32 samples California State Prison, Centinela, Cycle 4 Medical Inspection Page 20 Office of the Inspector General State of California (84 percent) showed compliance. Five of the sampled documents contained signatures that were too illegible to ascertain the clinician’s identity (MIT 4.007). The institution scored poorly in the following two areas:  The institution scored zero in its labeling and filing of documents scanned into inmate-patients’ electronic unit health records; some documents were mislabeled, such as a primary care provider note that was scanned and labeled as a physician’s orders, and other documents that were missing from the eUHR altogether. For this test, once the OIG identifies 12 mislabeled or misfiled documents, the maximum points are lost and the resulting score is zero. For the CEN medical inspection, inspectors identified a total of 13 documents that medical records staff either mislabeled or misfiled. The resulting score was zero (MIT 4.006).  The institution scored 45 percent for the timely scanning of dictated or transcribed provider progress notes into inmate-patients’ electronic health records. While sampled progress notes were timely scanned within five calendar days for 9 of 20 sampled documents, 11 sampled progress notes were scanned between one and eight days late (MIT 4.002). Recommendations The OIG recommends the following:  CEN leadership review the current processes to ensure that primary care providers properly sign hospital and specialty reports. If the processes are absent or ineffective, the OIG further recommends new processes be developed and implemented to ensure providers sign these reports.  Medical records management improve its quality control process to help reduce the number of mislabeled and improperly scanned documents entered into the eUHR, even while the institution awaits the implementation of CDCR’s new electronic health record system.  Health care management review the current document flow process to improve the scanning timeliness of dictated and transcribed provider progress notes records management staff enter into patients’ charts. California State Prison, Centinela, Cycle 4 Medical Inspection Page 21 Office of the Inspector General State of California HEALTH CARE ENVIRONMENT This indicator addresses the general operational aspects of the Case Review Rating: institution’s clinics, including certain elements of infection control Not Applicable and sanitation, medical supplies and equipment management, the Compliance Score: availability of both auditory and visual privacy for inmate-patient Proficient visits, and the sufficiency of facility infrastructure to conduct (85.4%) comprehensive medical examinations. Rating of this component is based entirely on the compliance testing results from the visual Overall Rating: observations inspectors make at the institution during their onsite Proficient visit. Compliance Testing Results The institution received a proficient compliance score of 85.4 percent in the Health Care Environment indicator, scoring well in most test areas, as described below:  Clinical health care staff in nine applicable clinics ensured that reusable invasive and non-invasive medical equipment were properly sterilized or disinfected (MIT 5.102).  OIG inspectors observed clinicians’ encounters with patients in eight clinics, and all clinicians employed proper hand hygiene practices (MIT 5.104).  The institution’s non-clinic bulk medical supply storage areas met the supply management process and support the needs of the medical health care program, resulting in a score of 100 percent (MIT 5.106).  The institution appropriately disinfected, cleaned, and sanitized nine of the ten clinics observed (90 percent); the cleaning log for one clinic indicated one day of missed cleaning in the RN examination room (MIT 5.101).  The OIG inspected up to two exam rooms in each of CEN’s ten clinics and found that the rooms in nine of those clinics (90 percent) had sufficient space and configuration to allow clinicians to perform a proper exam. The placement of the exam table in one clinic’s exam room did not allow the patient to lie in a fully extended supine position on the table (Figure 1) (MIT 5.110). Figure 1: Hindered exam table space California State Prison, Centinela, Cycle 4 Medical Inspection Page 22 Office of the Inspector General State of California  Nine of the ten clinics inspected followed proper protocols to mitigate exposure to blood-borne pathogens and contaminated waste; one clinic’s exam rooms did not have sharps containers (puncture resistant containers used for expended syringes) (MIT 5.105).  Inspectors examined emergency response bags to determine if the bags were inspected daily and inventoried monthly and whether they contained all essential items. The bags were compliant in eight of the nine sampled clinical locations (89 percent) where they were stored. While medical staff inspected and inventoried all emergency response bags at required intervals, one bag did not contain a required glucose tube (an emergency medication to increase low blood sugar, a common diabetic condition) (MIT 5.111). CEN scored in the adequate range in the following three test areas:  Eight of the ten clinics inspected (80 percent) had operable sinks and sufficient quantities of hand hygiene supplies in clinical areas. In two clinics, hand sanitizer was in short supply. In one of these clinics, clinicians mixed the sanitizer with water to make it last longer, and in another clinic nursing staff reported that hand sanitizer had recently been unavailable and on back order for approximately four months (MIT 5.103).  Eight of the ten clinic areas observed (80 percent) had an adequate environment conducive to providing medical services. In two clinic areas, health care staff performed vital sign checks in the main hallway near the holding cell where other patients waited, compromising privacy (MIT 5.109).  Eight of the ten clinics (80 percent) followed adequate medical supply storage and management protocols. However, medical supply cabinets were not clearly labeled in one clinic, and personal food items such as sugar and coffee were stored adjacent to a medical supply storage unit in a second clinic (MIT 5.107). The institution scored in the inadequate range in the following area:  The institution furnished only four of ten clinics (40 percent) with essential supplies and core equipment necessary to conduct a comprehensive exam. Examples of missing items included a bio-hazard waste can, hemoccult cards and developer, lubricating jelly, nebulization unit, peak flow meter, exam table, and Snellen vision chart (MIT 5.108). Other Information Obtained from Non-Scored Results The OIG gathered information to determine if the institution’s physical infrastructure was maintained in a manner that supported health care management’s ability to provide timely or adequate health care. This question was not scored. When OIG inspectors interviewed health care management, staff did not have concerns about the facility’s infrastructure or its effect on the staff’s ability to provide adequate health care. The institution had a master infrastructure project underway California State Prison, Centinela, Cycle 4 Medical Inspection Page 23 Office of the Inspector General State of California that included renovation of CEN’s existing clinics in facilities A, B, C, and D, and its central health services building, and construction of a separate new clinical treatment space in the administrative segregation unit. The project was on track with completion dates targeted for December 2017 (MIT 5.999). Recommendations for CCHCS  Develop a statewide policy to identify required core equipment and supplies for all clinical settings, including the TTA, R&R, inpatient units, and primary care clinics. Recommendations for CEN The OIG recommends the institution do the following:  Properly stock and maintain all clinic areas with a full complement of core equipment such as Snellen vision charts (with established distance markers), nebulization units, and peak flow meters. In addition, all exam areas should have an exam table, and exam rooms where providers work should be stocked with lubricating jelly and hemoccult cards and developer.  Stock all clinical areas with adequate disinfectant supplies where appropriate, and ensure that all exam rooms have a sharps container and bio-hazard waste container to mitigate exposure to blood-borne pathogens and contaminated waste.  Require supervisors to routinely inspect all medication and medical supply storage areas to ensure that personal food and beverage items are only stored temporarily in approved designated areas and that personal items are not stored overnight or temporarily stored in medication and medical supply storage areas. California State Prison, Centinela, Cycle 4 Medical Inspection Page 24 Office of the Inspector General State of California INTER- AND INTRA-SYSTEM TRANSFERS This indicator focuses on the management of inmate-patients’ Case Review Rating: medical needs and continuity of patient care during the inter- and Adequate intra-facility transfer process. The patients reviewed for Inter- and Compliance Score: Intra-System Transfers include inmates received from other CDCR Proficient facilities and inmates transferring out of CEN to another CDCR (90.0%) facility. The OIG review includes evaluation of the institution’s Overall Rating: ability to provide and document health screening assessments, Proficient initiation of relevant referrals based on patient needs, and the continuity of medication delivery to patients arriving from another institution. For those patients, the OIG clinicians also review the timely completion of pending health appointments, tests, and requests for specialty services. For inmate-patients who transfer out of the facility, the OIG evaluates the ability of the institution to document transfer information that includes pre-existing health conditions, pending appointments, tests and requests for specialty services, medication transfer packages, and medication administration prior to transfer. The OIG clinicians also evaluate the care provided to patients returning to the institution from an outside hospital and check to ensure appropriate implementation of the hospital assessment and treatment plans. 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 the factors leading to both scores and ultimately rated this indicator as proficient. The key factors were that the OIG’s case review showed most deficiencies were minor and related to incomplete Health Care Transfer Information forms (CDCR Form 7371). However, these deficiencies ultimately did not affect patient care, as the information on these forms was also on the electronic Patient Summary in the Patient Health Information Portal. After considering the test results for both compliance and case review, the OIG inspection team concluded that the compliance rating of proficient was the correct overall rating for this indicator. Case Review Results Clinicians reviewed 52 encounters relating to Inter- and Intra-System Transfers, including information from both the sending and receiving institutions. These included 29 hospitalization and emergency room events, each of which resulted in a transfer back to the institution. In general, the inter- and intra-system transfer processes at CEN were adequate, with the majority of inmates transferring to CEN receiving timely continuity of health care services. While there were no major issues found in the cases reviewed, there were a few deficiencies regarding nursing assessment and documentation and the thorough completion of transfer forms. Some examples are listed below. California State Prison, Centinela, Cycle 4 Medical Inspection Page 25 Office of the Inspector General State of California Transfers Out  In case 42, the receiving and release (R&R) nurse failed to thoroughly complete the Health Care Transfer Information form (CDCR Form 7371). The ophthalmology follow-up was not listed. Further, the mobility device (cane), ankle and knee braces, and orthotic shoes were also not listed.  In case 43, the R&R nurse failed to thoroughly complete the CDCR Form 7371. The colonoscopy and ophthalmology due dates were not listed. Hospitalizations Patients returning from hospitalizations are some of the highest risk encounters due to two factors. First, these patients are generally hospitalized for a severe illness or injury. Second, they are at risk due to potential lapses in care that can occur during any transfer. At CEN, patients returning from the hospital were processed by the TTA nurse and then seen timely by the primary care provider. This process worked well for the majority of hospitalization events reviewed. However, the OIG identified some deficiencies in nursing assessment and documentation.  In cases 6 and 56, the nurse failed to document receipt and review of hospital discharge recommendations.  In case 47, the nurse failed to assess brain and spinal surgical incision sites.  In case 57, the nurse failed to document the location of pain and provide a corresponding assessment. Additionally, the nurse failed to document the presence of a cervical collar. Onsite Visit During the onsite visit, the OIG clinicians confirmed previous conclusions reached during the case reviews related to inter- and intra-system transfer processes. Those conclusions were that the transfer system generally functioned well and that nursing leadership reported full implementation of the statewide transfer process. However, the following areas of concern were identified:  While the nursing supervisors audit medication continuity, they do not proactively assess the intake nursing care and thoroughness of transfer information. Additionally, the RNs assigned to conduct initial intake assessments do not receive structured training. California State Prison, Centinela, Cycle 4 Medical Inspection Page 26 Office of the Inspector General State of California Compliance Testing Results The institution obtained a proficient compliance score of 90.0 percent in the Inter- and Intra-System Transfers indicator, scoring 100 percent in three of the five areas tested, as described below:  Transfer packages included the required medications and related documentation for all five applicable inmate-patients who transferred out of the institution during onsite testing at the inspection (MIT 6.101).  Inspectors sampled 30 patients who transferred into CEN from another institution to ensure that the patient received a timely health screening upon arrival at the institution. Twenty- four of these patents required that an RN timely perform an assessment of the patient. In each applicable instance, the RN properly timely completed the assessment and disposition section of the Initial Health Screening (CDCR Form 7277) on the day of arrival (MIT 6.002).  Health care staff correctly listed the patients’ pending specialty service appointments on the Health Care Transfer Information form (CDCR Form 7371) for all 20 sampled inmate-patients who transferred out of CEN to another CDCR institution (MIT 6.004). The institution scored within the adequate range for the following test:  The OIG reviewed the initial health screening forms for 30 inmate-patients who transferred into CEN from another CDCR institution. Nursing staff conducted timely and complete screenings for 25 of those patients sampled (83 percent). However, inspectors found five sampled patient forms with inadequately documented screening information. For four of the patient screenings, nurses did not properly answer all of the required screening questions. Examples of unanswered or insufficiently completed questions related to medications prescribed, mental health and medical conditions, health care needs or complaints, and primary language spoken. For one additional sampled patient, either nursing staff did not complete or medical records staff did not correctly scan the first page of the patient’s initial health screening form into the eUHR (MIT 6.001). The institution has an opportunity for improvement in the following area:  Six of 30 sampled inmate-patients who transferred into CEN had an existing medication order that required nursing staff to administer or deliver the medication upon the patients’ arrival. Four of those six patients (67 percent) received their medications without interruption. One patient received his medication four days after arrival, and no eUHR evidence was found to demonstrate that another patient ever received or refused his medication (MIT 6.003). California State Prison, Centinela, Cycle 4 Medical Inspection Page 27 Office of the Inspector General State of California Recommendations  The OIG recommends that nursing staff undergo structured training and complete competency testing prior to conducting initial R&R intake assessments.  The OIG recommends that health care management ensure that a standardized methodology and process is followed by supervising registered nurses to better assess the nursing care and completeness of R&R transfer forms. California State Prison, Centinela, Cycle 4 Medical Inspection Page 28 Office of the Inspector General State of California PHARMACY AND MEDICATION MANAGEMENT This indicator is an evaluation of the institution’s ability to provide appropriate pharmaceutical administration and security Case Review Rating: management, encompassing the process from the written Adequate prescription to the administration of the medication. By combining Compliance Score: Adequate both a quantitative compliance test with case review analysis, this (78.2%) assessment identifies issues in various stages of the medication management process, including ordering and prescribing, Overall Rating: transcribing and verifying, dispensing and delivering, Adequate administering, and documenting and reporting. Because effective medication management is affected by numerous entities across various departments, this assessment considers internal review and approval processes, pharmacy, nursing, health information systems, custody processes, and actions taken by the PCP prescriber, staff, and patient. Case Review Results Case review results indicated that for the majority of cases, patients received their medications timely and as prescribed. CEN also adequately maintained medication continuity for patients returning from a hospitalization. The following few deficiencies were found:  Six deficiencies related to nurses not documenting administration of medications in the medication administration records.  Four deficiencies related to nurses not administering prescribed medications.  A patient with a possible gastrointestinal bleed received aspirin, which can increase bleeding. Another patient received inappropriately dispensed omeprazole (a medication to reduce stomach acid).  There were a few instances when medication refusal forms were not completed. California State Prison, Centinela, Cycle 4 Medical Inspection Page 29 Office of the Inspector General State of California Compliance Testing Results The institution received an adequate compliance score of 78.2 percent for the Pharmacy and Medication Management indicator. For discussion purposes below, this MIT is divided into three sub-indicators: Medication Administration, Observed Medication Practices and Storage Controls, and Pharmacy Protocols. Medication Administration For this sub-indicator, the institution received an average score of 67 percent and could improve in the following two areas:  Nursing staff did not document any medical administration record (MAR) evidence that they administered the prescribed medications to the only inmate-patient who, during the sample test period, was en route from one institution to another and who had a temporary layover at CEN. As a result, the institution received a zero for this test. There were no other transferring patients with prescribed medications identified for this test (MIT 7.006).  The institution timely provided hospital discharge medications to 10 of 14 patients sampled (71 percent) who had returned from a community hospital; the remaining four patients received their medications from one to three days late (MIT 7.003). CEN performed well in the following three areas of this sub-indicator:  The institution timely administered patients’ new medication orders for 27 of 30 samples inspectors selected for review, receiving a proficient score of 90 percent for this test. Two patients received medications 2 and 41 days late, and one patient did not receive his medication at all (MIT 7.002).  CEN ensured that 27 of 30 patients sampled (90 percent) received their medications without interruption when they transferred from one housing unit to another; the remaining three patients either had unexplained missed doses or a lack of eUHR evidence to demonstrate they timely received their medication at the proper dosing interval (MIT 7.005).  Patients timely received chronic care medications for 24 of 29 samples reviewed (83 percent). One patient did not receive all ordered medications or receive required counseling for any of the four dates in which he missed medication doses. Another patient received his medications one and two days late, while a third patient continued to receive an incorrect insulin dosage amount for 13 days after the provider initially changed the order. Finally, two patients did not receive their medications at all (MIT 7.001). California State Prison, Centinela, Cycle 4 Medical Inspection Page 30 Office of the Inspector General State of California Observed Medication Practices and Storage Controls For this sub-indicator, the institution received an average score of 86 percent, and performed well in five areas:  The institution employed strong medication security controls over narcotic medications in nine applicable clinic and medication line locations sampled that stored narcotics (MIT 7.101).  The institution properly stored non-narcotic medications that do not require refrigeration at all 13 of the applicable clinics and medication line storage locations inspected (MIT 7.102).  The institution properly stored non-narcotic medications that require refrigeration at eight of the nine applicable clinics, receiving a score of 89 percent. At one clinic location, a medication refrigerator was periodically operating outside of the approved temperature range (MIT 7.103).  Nursing staff followed proper hand hygiene contamination control protocols at six of the seven inspected medication preparation and medication administration locations (86 percent) (MIT 7.104). Further, the clinical staff employed appropriate administrative controls and followed proper protocols during medication preparation at all seven of the areas (MIT 7.105). CEN has an opportunity for improvement in the following area:  OIG inspectors observed medication protocols at seven different CEN medication locations or medication times, including all four of the institution’s outdoor medication line locations. Inspectors found that none of the outdoor medication locations had adequate overhang or shade protection to shield patients from extreme heat or inclement weather while waiting to receive their medications (Figure 2). As a result, the institution only scored 43 percent for this test (MIT 7.106). Figure 2: Unprotected medication pickup window with no shade cover for waiting patients California State Prison, Centinela, Cycle 4 Medical Inspection Page 31 Office of the Inspector General State of California Pharmacy Protocols For this sub-indicator, the institution received an average score of 80 percent, including individual test scores of 100 percent in the following test areas:  In its main pharmacy, the institution followed general security, organization, and cleanliness management protocols; properly stored both refrigerated and non-refrigerated medications; and maintained adequate controls and properly accounted for narcotic medications (MIT 7.107, 7.108, 7.109, 7.110). While the institution performed proficiently in most of the tests in this sub-indicator, the following area presents opportunity for improvement:  The institution’s pharmacist-in-charge (PIC) did not follow key medication error reporting protocols. More specifically, the PIC followed required protocols for zero of the 17 sampled medication errors reviewed. For 15 of these errors, the PIC did not complete the required error follow-up reports at all. For two other medication errors, the PIC completed the required follow-up report, but failed to date it. As a result, inspectors could not establish whether the PIC timely completed either of the medication error follow-up reports (MIT 7.111). Other Information Obtained from Non-Scored Results In addition to testing reported medication errors, OIG inspectors follow up on any significant medication errors found during the case reviews or compliance testing to determine whether the institution properly identified and reported errors. At CEN, the OIG did not find any applicable medication errors subject to this test (MIT 7.998). The OIG tested inmate-patients in isolation units to determine if they had immediate access to their prescribed KOP rescue inhalers and nitroglycerin medications. Each of the four applicable inmates interviewed indicated he had possession of his prescribed rescue medication or cited “refusal” as the reason the medication was not in his possession (MIT 7.999). Recommendations No specific recommendations. California State Prison, Centinela, Cycle 4 Medical Inspection Page 32 Office of the Inspector General State of California PREVENTIVE SERVICES This indicator assesses whether various preventive medical Case Review Rating: services are offered or provided to inmate-patients. These include Not Applicable cancer screenings, tuberculosis screenings, and influenza and Compliance Score: chronic care immunizations. This indicator also assesses whether Proficient certain institutions take preventive actions to relocate (85.6%) inmate-patients identified as being at higher risk for contracting Overall Rating: coccidioidomycosis (valley fever). Proficient Compliance Testing Results The institution performed well in the Preventive Services indicator, with a proficient compliance score of 85.6 percent. The stronger areas are described below:  Inmate-patients timely received or were offered influenza vaccinations during the most recent influenza season for all 30 patients sampled (MIT 9.004).  The institution scored 89 percent for administering anti-tuberculosis medications (INH) to inmate-patients; 24 of 27 patients sampled timely received all required INH doses during the three-month test period. The medication administration records indicated one missed dose (each) for two patients, and the entire month’s medication administration record was missing from a third patient’s record. In a related area, the institution completed the required monthly tuberculosis monitoring for all 27 patients reviewed (MIT 9.001, 9.002).  CEN offered colorectal cancer screenings to 27 of 30 sampled inmate-patients subject to the annual screening requirement (90 percent). For three sampled patients, there was no evidence the institution offered a colon cancer screening within the previous twelve months or that the patient received a normal colonoscopy within the previous ten years. Additionally, one of those patients received a colonoscopy with negative results in 2011, but the institution did not provide a follow-up procedure in one year as recommended by the specialist (MIT 9.005). The institution scored within the adequate range for the following test:  The OIG tested whether the institution offered required influenza, pneumonia, and hepatitis vaccinations to patients who suffered from a chronic care condition; 11 of the 13 patients sampled (85 percent) received them; two patients were not offered a pneumonia vaccination (MIT 9.008). California State Prison, Centinela, Cycle 4 Medical Inspection Page 33 Office of the Inspector General State of California The institution could improve in the following area:  OIG inspectors sampled 30 inmate-patients to determine whether they received a tuberculosis screening within the last year. Fifteen of the sampled patients were classified as Code 34 (subject only to an annual signs and symptoms check), and 15 sampled patients were classified as a Code 22 (requiring an annual tuberculosis skin test in addition to a signs and symptoms check). CEN scored 50 percent for conducting annual tuberculosis screenings. Although the institution screened all 30 sampled patients for tuberculosis within the prior year all, only the 15 patients classified as Code 34 were properly screened. Zero of the 15 inmate-patients classified as Code 22 were properly tested. More specifically, for each Code 22 patient sampled, inspectors identified one or more of the following exceptions: nursing staff did not document either the specific administered (start) or read (end) date and time to evidence the test was completed within the required 48-to-72-hour time frame; an LVN read the test results rather than an RN, public health nurse, or primary care provider; or nursing staff who read the test results did not indicate whether they were RNs or LVNs (MIT 9.003). Recommendations No specific recommendations. California State Prison, Centinela, Cycle 4 Medical Inspection Page 34 Office of the Inspector General State of California QUALITY OF NURSING PERFORMANCE The Quality of Nursing Performance indicator is a qualitative Case Review Rating: evaluation of the institution’s nursing services. The evaluation is Inadequate completed entirely by OIG nursing clinicians within the case Compliance Score: review process, and, therefore, does not have a score under the Not Applicable compliance testing component. The OIG nurses conduct case reviews that include reviewing face-to-face encounters related to Overall Rating: nursing sick call requests identified on the Health Care Services Inadequate Request form (CDCR Form 7362), urgent walk-in visits, referrals for medical services by custody staff, registered nurse (RN) case management, RN utilization management, clinical encounters by licensed vocational nurses (LVNs) and licensed psychiatric technicians (LPTs), and any other nursing service performed on an outpatient basis. The OIG case review also includes activities and processes performed by nursing staff that are not considered direct patient encounters, such as the initial receipt and review of CDCR Form 7362 service requests and follow-up with primary care providers and other staff on behalf of the patient. Key focus areas for evaluation of outpatient nursing care include appropriateness and timeliness of patient triage and assessment, identification and prioritization of health care needs, use of the nursing process to implement interventions including patient education and referrals, and documentation that is accurate, thorough, and legible. Nursing services provided in the correctional treatment center (CTC) are reported under the Specialized Medical Housing indicator. Nursing services provided in the triage and treatment area (TTA) or related to emergency medical responses are reported under Emergency Services. Case Review Results The OIG clinicians reviewed 85 CEN outpatient nursing encounters and identified 42 deficiencies related to nursing performance. As a whole, the institution’s outpatient nursing performance was rated inadequate. The outpatient nurses at CEN consistently failed to perform face-to-face assessments when Health Care Services Request forms (CDCR Form 7362) noted symptom complaints. Frequently the outpatient nurses initiated primary care provider (PCP) appointments without performing face-to-face assessments, and inmate-patients often waited weeks to see a provider. Additionally, the outpatient nurses sometimes failed to perform immediate face-to-face assessments when necessary, and did not always formulate an appropriate plan of care. While many of these patients had chronic stable complaints, and ultimately received adequate care, the pattern of failing to perform face-to-face assessments appropriately increased the potential for patient harm. California State Prison, Centinela, Cycle 4 Medical Inspection Page 35 Office of the Inspector General State of California Some noted examples where a nursing face-to-face encounter did not occur included the following:  In case 27, the patient had wrist pain and submitted a Health Services Request form (CDCR Form 7362). The RN failed to perform a face-to-face assessment. A PCP appointment occurred 12 days later.  In case 28, the patient complained of headaches and dizziness and submitted a CDCR Form 7362. The RN failed to perform a face-to-face assessment.  In case 32, the patient had testicular pain and submitted a CDCR Form 7362. The RN received and reviewed the complaint but failed to perform an immediate RN assessment. Instead, The RN made a PCP referral that occurred 11 days later.  In case 33, the patient had a foot complaint and requested shoe support or a “different type of shoe.” The RN failed to perform a face-to-face assessment.  In case 34, the patient had shoulder and knee pain and submitted a CDCR Form 7362. The RN failed to perform a face-to-face assessment.  In case 50, the patient submitted a CDCR Form 7362. He had foot pain, inquired about the status of his glasses, and requested to see a cardiologist regarding his heart and chest pain. The RN failed to perform a face-to-face assessment. Instead, his PCP saw him three weeks later.  In case 51, the patient reported foot complaints and that he thought his toe was infected. The RN failed to perform a face-to-face assessment.  In case 52, the patient requested medication for toenail fungus. The RN failed to perform a face-to-face assessment. Instead, a PCP saw him 17 days later. Some noted examples where nursing face-to-face encounters occurred, but not within the time frame warranted by the patient’s symptomology:  In case 57, a CDCR Form 7362 was submitted for a penile infection. The next business day, an RN visit occurred. The nurse initiated a routine PCP visit. Ten days later an additional CDCR Form 7362 was submitted for severe penile pain. On both occasions, the nurse failed to perform an immediate face-to-face assessment.  In case 58, a CDCR Form 7362 was submitted for headache and “irregular heartbeats.” The RN failed to perform a same-day face-to-face assessment. At the RN visit, the patient also complained of chest discomfort. The RN failed to perform a thorough assessment which lacked details about duration and activity at the time of chest pain and examination of the chest and lungs. However, the RN referred the patient to a PCP on the same day as the face-to-face visit. California State Prison, Centinela, Cycle 4 Medical Inspection Page 36 Office of the Inspector General State of California  In case 16, the patient had chest pain radiating to the left arm. The supervising registered nurse (SRN) failed to assess the chest pain duration and activity at the time of pain. Additionally, the nurse failed to perform an electrocardiogram (EKG) or contact the PCP. The nurse instead ordered a 14-day PCP appointment. The following are two notable examples of when nursing face-to-face encounters resulted in nurses not formulating an appropriate care plan:  In case 23, the nurse saw the patient for hip pain. The nurse inappropriately issued naproxen when the patient had an allergy to ibuprofen. Patients are often allergic to both of these two pain medications.  In case 25, the nurse saw a patient who had been experiencing foot numbness, bruising, and pain for two weeks. The patient had diabetes and chronic hepatitis C. The nurse inappropriately advised the patient to apply heat or ice to his feet and to continue pain medications (aspirin and ibuprofen). The nurse failed to assess the patient’s bruises and use of pain medication, and also failed to recognize that the application of heat or ice to a patient with diabetic neuropathy could potentially cause harm. Additionally, the nurse failed to initiate a PCP referral. Onsite Visit During the onsite visit, the OIG clinicians visited the outpatient medical clinics. Clinics A, B, and C were undergoing renovation, with the mediation lines and health care appointments temporarily conducted in the gymnasium. A daily morning huddle occurred and included the PCP, RN, medication LVN, clinic LVN, office technician, a custody officer, and a dental staff member. While reviewing the scheduling process, 20 original CDCR Form 7362s were found in the medical clinics. These sick call forms with symptom complaints had been reviewed by an outpatient RN or SRN and referred to a PCP without a nurse face-to-face appointment. The RN paper review dated back to September 5, 2015 (the OIG clinician’s onsite visit took place on November 3 and 4, 2015). The patient complaints included abdominal pain, chest pain, high blood pressure, headaches, musculoskeletal pain, throat concerns, dandruff, and medication side effects or reactions. At one of the yard clinics, the RN stated that on weekends, the SRN received and reviewed each yard’s CDCR Form 7362s. The SRN then documented on each form whether the patient required an RN or PCP appointment. The RN further told OIG clinicians that RN referrals were often changed to PCP referrals, bypassing nursing visits. This practice was unsafe and concerning as there was an unacceptable delay in having symptomatic patients seen by health care staff. The OIG clinicians provided copies of the 20 original documents to the chief nurse executive and discussed them with the CEO. California State Prison, Centinela, Cycle 4 Medical Inspection Page 37 Office of the Inspector General State of California Conclusion The institution performed poorly for this indicator. While the OIG clinicians identified only two significant deficiencies (cases 32 and 50), the pattern of inappropriate and untimely triage showed a major system deficiency. Fortunately, for most patients with acute high-risk conditions, other aspects of the health care system allowed them to ultimately receive needed care. Recommendations  The OIG recommends training for nurses, providers, and office technicians in the sick call process, with an emphasis on the need for symptomatic patients to be seen in a timely manner.  The OIG recommends the chief nurse executive develop specific clinic supervising RN expectations to improve accuracy, monitoring, and auditing activity, such as that of the sick call performance, in the medical clinics. California State Prison, Centinela, Cycle 4 Medical Inspection Page 38 Office of the Inspector General State of California QUALITY OF PROVIDER PERFORMANCE In this indicator, the OIG physicians provide a qualitative Case Review Rating: evaluation of the adequacy of provider care at the institution. Adequate Appropriate evaluation, diagnosis, and management plans are Compliance Score: reviewed for programs including, but not limited to, nursing sick Not Applicable call, chronic care programs, TTA, specialized medical housing, and specialty services. The assessment of provider care is Overall Rating: performed entirely by OIG physicians. There is no compliance Adequate testing component associated with this quality indicator. Case Review Results The OIG clinicians reviewed 417 CEN medical provider encounters and 153 provider orders (not associated with provider visits) and identified 72 deficiencies related to provider performance. The OIG clinicians also reviewed 30 cases, concluding that 24 were adequate and 6 were inadequate. As a whole, CEN provider performance was adequate. Assessment and Decision-Making The large majority of provider encounters and orders reviewed demonstrated adequate assessment and sound medical decision-making. While the OIG noted numerous provider performance deficiencies related to assessment and medical decision-making, the majority of which had a low potential for patient harm. The more serious deficiencies are discussed below.  Several cases displayed inappropriate management of medications. Some medications, such as narcotics and non-steroidal anti-inflammatory drugs, were prescribed when they should not have been (cases 51 and 60). In other instances, the provider inappropriately discontinued antibiotics or diabetes medications (cases 55 and 64).  In case 48, the provider failed to adequately address diagnostic tests that indicated kidney failure. Additionally, the patient was not transferred out of the institution in a timely manner, despite the possibility of sepsis.  Cases 54 and 58 involved patients with signs and symptoms of gastrointestinal bleeding. The providers failed to adequately assess the patients (including history-taking and physical examinations); failed to appropriately order diagnostic tests; and failed to order appropriate follow-up intervals.  Case 64 involved a patient who complained of ear pain and hearing loss. The investigation into the possible causes of his symptoms was inadequate, as were the prescribed treatments for his complaints. California State Prison, Centinela, Cycle 4 Medical Inspection Page 39 Office of the Inspector General State of California Review of Records As noted in the Health Information Management indicator, providers generally reviewed diagnostic reports, specialty reports, and hospital reports in a timely manner when available, and with adequate thoroughness. However, there were a few deficiencies:  There were several occasions when providers failed to review nursing visits and diagnostic tests, which occurred adjacent to provider visits. As a result, various issues that should have been addressed were not.  Case 60 involved a patient who was being treated for a number of medical issues. Several of his blood pressure and eye disease medications were not renewed in a timely manner. Emergency Care Providers generally made appropriate triage decisions when patients presented emergently to the TTA. There were two notable exceptions (also discussed in the Emergency Services indicator).  Case 3 involved an inappropriate method of transportation (State vehicle rather than an ambulance) for a patient who had overdosed and had responded to the temporary antidote naloxone.  Case 60 involved inadequate treatment of possible cardiac chest pain. Chronic Care The chronic care performance was adequate, with appropriate monitoring, assessments, and interventions. A few negative patterns emerged:  The management of anticoagulation (using medication to treat blood clots) was sometimes suboptimal (cases 59, 60, and 61), although these patients ultimately reached their therapeutic goals.  The management of diabetic care was also suboptimal at times. Providers routinely failed to review fasting blood glucose levels, interventions for uncontrolled diabetes were not always adequate, and the follow-up intervals were not always appropriate (cases 63 and 64). Specialty Services Review of records pertaining to specialty services revealed that CEN providers requested specialty services appropriately. As is noted in the Specialty Services indicator, while specialty reports were not always properly signed by a primary care provider, it was evident the reports were reviewed. Providers only rarely failed to implement specialty recommendations. The majority of specialty recommendations resulted in appropriate actions by the primary care providers. California State Prison, Centinela, Cycle 4 Medical Inspection Page 40 Office of the Inspector General State of California Health Information Management The majority of provider notes were dictated and, therefore, legible. As noted in the Health Information Management indicator, OIG clinicians did not find some providers’ progress notes in the eUHR. Onsite Inspection The providers at CEN were content with their work, leadership, and ancillary services. Despite the remote location of CEN, the providers expressed that the setting was tolerable, due in part to the four 10-hour work days per week, and also due to the cordial working relationships with nursing and custody staff. The OIG’s discussion with the providers and the medical management team revealed a leadership dedicated to excellence and continuous quality improvement. Provider meetings occurred once weekly at CEN and were informative and educational. Clinician huddles occurred every morning in the respective yards, and were also informative and thorough. Multiple issues were covered daily, including which yard patients were seen by the provider-on-call or in the TTA the day prior, which patients were transferred in or out from specialty appointments or hospitals, significant diagnostic reports, patients transferring to or from other institutions, medication-related issues, miscellaneous issues needing to be addressed, scheduling, and clinic efficiency. Pharmacy and Medication Management CEN’s medication continuity for patients returning from a hospital was satisfactory. As noted previously, while specialty reports were not always properly signed, the recommendations (including medications) were usually implemented. Recommendations The OIG recommends providing additional provider training in the management of anticoagulation, diabetes, and gastrointestinal bleeding. California State Prison, Centinela, Cycle 4 Medical Inspection Page 41 Office of the Inspector General State of California SPECIALIZED MEDICAL HOUSING (OHU, CTC, SNF, HOSPICE) This indicator addresses whether the institution follows appropriate Case Review Rating: policies and procedures when admitting inmate-patients to onsite Inadequate inpatient facilities, including completion of timely nursing and Compliance Score: provider assessments. The chart review assesses all aspects of Proficient medical care related to these housing units, including quality of (98.0%) provider and nursing care. CEN’s only specialized medical housing Overall Rating: unit is a correctional treatment center (CTC). Adequate For 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 testing resulting in a proficient score. While each area’s results are discussed in detail below, the result variance is readily explained by the different testing approaches. For example, CTC documents may have been present in the medical record as required by policy, and the finding was positively reflected in the compliance score. However, the clinical quality of those same documents may have been poor and negatively reflected in the case review rating. After considering both case review and compliance testing results, the OIG inspection team determined the final overall rating was adequate. Case Review Results The CTC at California State Prison, Centinela, contained 13 licensed beds at the time of our inspection. A total of 194 provider encounters, 27 provider orders, and 221 nursing encounters were reviewed in 14 cases. These included admissions for medical conditions (including palliative care) and admissions for patients requiring assistance with their activities of daily living. Provider Performance Provider performance in the CTC was acceptable. Of the 194 encounters and 27 provider orders, only 15 deficiencies were identified, and of those, three were serious enough to potentially cause patient harm.  In case 48, there were two significant deficiencies. First, the provider failed to address diagnostic test results indicating kidney failure. Second, a provider noted the possibility of sepsis but did not send the patient out for further evaluation and treatment in a timely manner. This case is also discussed in the Quality of Provider Performance indicator.  In case 54, the provider failed to adequately address the signs of symptoms of possible gastrointestinal bleeding. This case is also discussed in the Quality of Provider Performance indicator. California State Prison, Centinela, Cycle 4 Medical Inspection Page 42 Office of the Inspector General State of California Nursing Performance Nursing performance in the CTC was inadequate. Within the 221 nursing encounters reviewed, 172 deficiencies were identified; 20 of these deficiencies were serious enough to potentially cause patient harm. The nursing care teams in the CTC consisted of a registered nurse (RN), a licensed vocational nurse (LVN), and a certified nursing assistant (CNA). Consistently, the documentation varied and displayed disparities. During case review, RN assessments were usually inadequate. For example, the cardiac assessment was most often recorded as “denies chest pain.” In addition, wounds were not thoroughly assessed or documented. When acute events occurred, the nurses often failed to recognize the gravity of the events, and failed to appropriately intervene. Some examples are listed below.  In case 48, the patient had abnormal respirations at 2:00 a.m., and the nurse noted “chest x- ray normal” two days prior. The nurse failed to take vital signs or examine the lungs. At 7:00 a.m., the patient’s respirations were shallow and he complained of difficulty breathing. Another nurse documented, “inmate-patient has COPD, oxygen saturation within normal limits. No oxygen at this time.” This nurse also failed to examine the chest and lungs adequately or administer oxygen. At 12:45 p.m., a breathing treatment was initiated. Again, the nurse failed to examine the patient’s lungs before or after treatment. At 2:00 p.m., the patient had increased respirations and shortness of breath. The LVN failed to document the respiratory rate. A provider was contacted, who ordered oxygen and an electrocardiogram (EKG). At 3:00 p.m., the provider ordered the patient to be transferred to an emergency department to rule out a pulmonary embolism (blood clot in the lungs). The nurse also failed to examine the vital signs, chest, lungs, and check for leg swelling or tenderness, obtain intravenous access, or start cardiac monitoring. In addition, the CTC staff failed to provide adequate care of the patient’s bedsore.  In case 54, the patient was admitted to the CTC with end-stage pulmonary disease. He had multiple medical diagnoses, including congestive heart failure and arthritis. On several occasions, nurses failed to examine his lungs before and after breathing treatments. The patient had symptoms of internal bleeding on several occasions. The LVN did not inform the RN about these symptoms; as a result, assessments and appropriate interventions were not completed. The nurses continued to administer aspirin despite this evidence of bleeding. The OIG identified legacy notes during this time, which may have contributed to the lack of proper care.  In case 55, the patient was admitted to the CTC for poorly controlled end-stage liver disease, seizures, poor mobility, and generalized weakness. When the patient had a prolonged seizure, the CTC RN failed to promptly assess his airway, breathing, and circulation; failed to assess vital signs for 22 minutes; failed to assess pupils, obtain a blood glucose level, or California State Prison, Centinela, Cycle 4 Medical Inspection Page 43 Office of the Inspector General State of California initiate continuous oxygen saturation monitoring; and failed to obtain intravenous access. Throughout the review of this case, the CTC nurses often failed to perform some focused assessments, such as when the patient’s abdomen was distended. In addition, when the patient had multiple lacerations on his forehead, forearm, and thumb, the patient was documented to have normal skin. When the patient (with a recent history of two falls) was dizzy and disoriented, the nurses failed to assess vital signs, and one encounter lacked any nursing assessment. In addition, this case showed poor communication among health care staff. When this patient with end-stage liver disease and epilepsy developed symptoms of confusion, the nurses failed to alert the providers.  In case 56, the patient was admitted to the CTC for a worsening rash and painful, swollen arms. The nurses on more than one occasion failed to provide a detailed skin assessment. The RN failed to assess for neck swelling or difficulty swallowing. The nurse also failed to examine the throat. Additionally, the nurse did not check the patient’s blood pressure because both arms were swollen and painful; a leg blood pressure check should have been performed. For this problem, a provider was contacted, who ordered the patient transported to an emergency room.  In case 56, the first shift RN used the same computer-generated, “cloned” or legacy documentation on 14 occasions. Legacy documentation was also identified in cases 54 and 55. Onsite Visit During the onsite interview, OIG clinicians asked the CTC’s SRN how nursing quality was measured. OIG clinicians learned that the first watch RN only performed a nursing chart audit. This audit consisted of various items, such as whether or not a history and physical examination was completed within 24 hours of admission; whether all medications, diet, and activities were reordered after 30 days; and, whether all labs were ordered, noted, and followed up upon; etc. Unfortunately, this audit was not reviewed by the CTC SRN to ensure accuracy. Further, there was no formal protocols in place that require CTC SRNs to perform clinical care audits that measure the quality of care provided. Compliance Testing Results The institution received a proficient compliance score of 98.0 percent for the Specialized Medical Housing indicator, which focused on the institution’s correctional treatment center. The institution scored in the proficient range for all of the indicator’s test areas, including the following:  When the OIG sample tested the working order of call buttons in CTC patient rooms, all inspected call buttons were working properly. In addition, according to staff interviews, custody officers and clinicians were able to efficiently respond and access inmate-patients’ rooms in less than one minute when an emergent event occurred (MIT 13.101). California State Prison, Centinela, Cycle 4 Medical Inspection Page 44 Office of the Inspector General State of California  For all ten inmate-patients sampled, nursing staff timely completed an initial assessment on the day the patient was admitted to the CTC (MIT 13.001).  Based on a sample of ten applicable patients, providers evaluated all ten within 24 hours of the patient’s admission to the CTC and completed a history and physical within 72 hours of admission (MIT 13.002, 13.003).  Providers also completed their subjective, objective, assessment, plan, and education (SOAPE) notes at required three-day intervals for nine of the ten sampled patients who had a stay long enough to require them (90 percent). For one of the sampled patients, one required provider encounter interval was inadequate. While the patient’s corresponding eUHR indicated a timely provider visit may have occurred, the provider failed to document the required SOAPE note to evidence the encounter (MIT 13.004). Recommendations The OIG recommends the institution implement a process to evaluate the CTC’s nursing assessment, intervention, and documentation. This quality improvement initiative should be ongoing, measurable, and reported in a manner that CEN leadership can effectively monitor. California State Prison, Centinela, Cycle 4 Medical Inspection Page 45 Office of the Inspector General State of California SPECIALTY SERVICES This indicator focuses on specialist care from the time a request for Case Review Rating: services or physician’s order for specialist care is completed to the Adequate time of receipt of related recommendations from specialists. This Compliance Score: indicator also evaluates the providers’ timely review of specialist Proficient records and documentation reflecting the patients’ care plans, (85.7%) including course of care when specialist recommendations were not Overall Rating: ordered, and whether the results of specialists’ reports are Proficient communicated to the patients. For specialty services denied by the institution, the OIG determines whether the denials are timely and appropriate, and whether the inmate-patient is updated on the plan of care. For this indicator, the 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 as proficient. The key factors were that the case review only identified two cases with noteworthy deficiencies that had the potential to cause harm (see discussion below); had neither of these deficiencies occurred, the case review rating would most likely have been proficient. As a result, the OIG’s inspection team concluded that the appropriate overall rating for this indicator should be proficient to match the compliance score’s rating. Case Review Results The OIG clinicians reviewed 196 events related to Specialty Services, the majority of which were specialty consultations and procedures. The OIG clinicians found 53 deficiencies in this category, the majority of which were minor due to specialty reports not properly signed by primary care providers. Only two deficiencies within specialty services had the potential to cause patient harm (when records revealed specialists were not provided with the most recent patient information, such as labs and medications). Access to Specialty Services Urgent and routine Specialty Services were generally timely and adequate. The OIG found a few delays in specialty follow-up appointments. Nursing Performance Nursing performance for Specialty Services was adequate. The OIG clinicians found a few deficiencies related to assessment, documentation, and legibility. California State Prison, Centinela, Cycle 4 Medical Inspection Page 46 Office of the Inspector General State of California Provider Performance Three of the deficiencies found in Specialty Services were related to providers not following through with specialty recommendations. These deficiencies did not result in patient harm. Health Information Management Forty-five of the deficiencies found in Specialty Services were related to Health Information Management, the majority of which were due to specialty reports not being properly signed by primary care providers. As noted in the Health Information Management indicator, it was apparent providers reviewed most reports as evidenced by provider orders and documentation in progress notes. Three deficiencies were due to pertinent patient information, i.e., labs, medications, etc., not being made available to specialists. Onsite Inspection Onsite discussions revealed CEN’s processes for specialty services, including appointments, out to medical returns, and obtaining specialty reports, flowed smoothly. The primary care providers reported access to specialty services was not an issue, and when reports were not available, the specialty services department was easily accessible and willing to track down these reports. Compliance Testing Results The institution received a compliance score of 85.7 percent in the Specialty Services indicator, scoring within the proficient range in five of the seven test areas:  All 15 inmate-patients sampled received their high-priority specialty services appointment within 14 calendar days of the provider’s order. Following patients’ high-priority specialty services appointments, providers reviewed the specialists’ reports within three business days for 13 of the 15 sampled reports (87 percent). The provider reviewed one report three days late, and there was no report in the eUHR for another specialty service (MIT 14.001, 14.002).  All 15 of the inmate-patients sampled received their routine specialty service appointment within 90 calendar days of the provider’s order. Following patients’ routine specialty services appointments, providers reviewed the specialists’ reports within three business days for 13 of the 14 applicable reports (93 percent). One report was reviewed nine days late (MIT 14.003, 14.004).  The institution timely denied provider specialty services requests for 19 of the 20 denials sampled, resulting in a score of 95 percent. One patient’s service request was denied 20 days late (MIT 14.006). California State Prison, Centinela, Cycle 4 Medical Inspection Page 47 Office of the Inspector General State of California The institution has opportunity for improvement in the following two areas:  Providers timely informed inmate-patients of the denial status for requested specialty services for only 12 of the 20 denials sampled (60 percent). The remaining eight patients received untimely communications regarding the denial status. On average, they were ten days late (MIT 14.007).  When an institution approves or schedules a patient for specialty services appointments and then transfers the patient to another institution, policy requires that the receiving institution ensure a patient’s appointment occurs timely. At CEN, only 13 of the 20 sampled patients (65 percent) received their specialty services appointment within the required action date. Four patients received their appointments between one and 16 days late, two patients received appointments 37 and 59 days late, and one patient did not receive an appointment at all (MIT 14.005). Recommendations No specific recommendations. Refer to the Recommendations section of the Health Information Management (Medical Records) indicator for suggested areas for improvement related to specialty services. California State Prison, Centinela, Cycle 4 Medical Inspection Page 48 Office of the Inspector General State of California SECONDARY (ADMINISTRATIVE) QUALITY INDICATORS OF HEALTH CARE The last two quality indicators (Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications) involve health care administrative systems and processes. Testing in these areas applies only to the compliance component of the process. Therefore, there is no case review assessment associated with either of the two indicators. As part of the compliance component for the first of these two indicators, the OIG did not score several questions. Instead, the OIG presented the findings for informational purposes only. For example, the OIG described certain local processes in place at CEN. To test both the scored and non-scored areas within these two secondary quality indicators, OIG inspectors interviewed key institutional employees and reviewed documents during their onsite visit to CEN in September 2015. They also reviewed documents obtained from the institution and from CCHCS prior to the start of the inspection. The test questions used to assess compliance for each indicator are detailed in Appendix A. For comparative purposes, the CEN Executive Summary Table on page ix of this report shows the case review and compliance ratings for each applicable indicator. California State Prison, Centinela, Cycle 4 Medical Inspection Page 49 Office of the Inspector General State of California INTERNAL MONITORING, QUALITY IMPROVEMENT, AND ADMINISTRATIVE OPERATIONS This indicator focuses on the institution’s administrative health care Case Review Rating: oversight functions. The OIG evaluates whether the institution Not Applicable promptly processes inmate-patient medical appeals and addresses Compliance Score: all appealed issues. Inspectors also verify that the institution follows Inadequate reporting requirements for adverse/sentinel events and inmate (52.3%) deaths, and whether the institution is making progress toward its Performance Improvement Work Plan initiatives. In addition, the Overall Rating: Inadequate OIG verifies that the Emergency Medical Response Review Committee (EMRRC) performs required reviews and that staff perform required emergency response drills. Inspectors also assess whether the Quality Management Committee (QMC) meets regularly and adequately addresses program performance. For those institutions with licensed facilities, inspectors also verify that required committee meetings are held. Compliance Testing Results CEN scored in the inadequate range for the Internal Monitoring, Quality Improvement, and Administrative Operations indicator, receiving a score of 52.3 percent, even though it received a proficient score of 100 percent in two of the nine applicable indicator test areas and an adequate score in two other test areas. The institution scored poorly in five of the indicator test areas, including three tests that scored zero, as discussed below:  CEN did not sufficiently document its efforts to ensure the accuracy of Dashboard data reporting, resulting in zero for this test. Inspectors reviewed six recent months of Quality Management Committee (QMC) meeting minutes and other information received from the institution. Inspectors concluded that CEN acted to correct problems with Dashboard indictors when they were identified; however, there was no documented evidence found in QMC meeting minutes or other similar forums of the methodologies used by CEN to conduct data validation audits or to train staff who collect Dashboard data (MIT 15.004).  OIG inspectors reviewed CEN’s 2014 Performance Improvement Work Plan and found that none of the quality improvement performance objectives contained a corresponding progress status update that clearly demonstrated the institution either improved or reached targeted performance objectives in each area (MIT 15.005).  The OIG inspected documentation for 12 emergency medical response incidents reviewed by the EMRRC during the prior six-month period and found the incident packages never included the use of the required checklist form or followed the required case review template format. In addition, the EMRRC did not review seven of the critical incidents California State Prison, Centinela, Cycle 4 Medical Inspection Page 50 Office of the Inspector General State of California timely, and the institution’s warden did not sign the meeting minutes for one of the sampled months. As a result, CEN received a score of zero for this test (MIT 15.007).  For the 12-month period ending July 2015, CEN timely processed at least 95 percent of the monthly inmate medical appeals during only four of those sampled months (33 percent). Based on data received from the institution, 8 of the 12 sampled months had overdue appeals, which ranged from 5 to 19 percent of each month’s total reviewed appeals. However, in the more recent months of June and July 2015, the institution reported that it had reviewed all of the submitted medical appeals timely (MIT 15.001).  Inspectors reviewed the summary reports and related documentation for three medical emergency response drills conducted in the prior quarter. While the institution conducted a comprehensive response drill for its second and third watch staff, the response drill during the first watch lacked the completion of required forms. Therefore, the institution received a score of 67 percent for this test (MIT 15.101). The institution performed in the adequate range for one test area:  Inspectors reviewed six recent months of Quality Management Committee (QMC) meeting minutes and confirmed that the institution’s QMC did meet monthly, but the corresponding meeting minutes did not always include required information. More specifically, during five of the meeting minutes reviewed (83 percent), the QMC evaluated program performance and took action when improvement opportunities were identified. However, one month’s meeting minutes did not include evidence that performance data was used to evaluate program performance (MIT 15.003). The institution scored in the proficient range in the following three test areas:  CEN’s local governing body (LGB) met during all four of the most recent quarters, and all meeting minutes provided a detailed narrative of the LGB’s general management and planning of patient health care (MIT 15.006).  When the OIG sampled ten second-level medical appeals, inspectors found that the institution’s responses addressed all of the patients’ appealed issues (MIT 15.102).  Medical staff prepared and submitted the Initial Inmate Death Report (CDCR Form 7229A) to CCHCS’s Death Review Unit timely for seven of the eight inmate deaths (88 percent) that occurred during the OIG’s review period. The reports are required to be submitted by noon on the first business day following the date of death; the institution submitted one report less than two hours late (MIT 15.103). California State Prison, Centinela, Cycle 4 Medical Inspection Page 51 Office of the Inspector General State of California Other Information Obtained from Non-Scored Areas  The OIG gathered non-scored data regarding the completion of death review reports. During the time frame of the OIG’s review, the CCHCS’s Death Review Committee (DRC) was required to complete a death review summary within 30 business days of an inmate’s death and to further communicate the results to the institution’s CEO within five additional business days. Regarding the DRC’s completion of CEN death review reports, the OIG found that the DRC both timely completed its reports and timely notified the CEO for only three of the five sampled reviews (60 percent). For one inmate death OIG, the DRC completed its summary 18 business days late (or 72 calendar days after the date of death). Consequently, the DRC did not provide timely results to the CEO. For one other inmate death reviewed by the DRC, the review summary was completed timely, but it was provided to the CEO ten business days late (MIT 15.996).  Inspectors met with the institution’s CEO to inquire about CEN’s protocols for tracking appeals. Each week, an analyst distributes an appeals tracking log to management that contains open action items and response due dates. The CEO monitors the appeals for patterns or trends and works with appropriate health care staff to remedy identified problem areas. The institution provides training when needed, and management reevaluates progress once a change has been implemented. The OIG does not score this area or validate staff’s assertions regarding the processes the institution follows to track medical appeals (MIT 15.997).  Non-scored data gathered regarding the institution’s practices for implementing local operating procedures (LOPs) indicated that the institution has a good process in place for developing LOPs. The institution’s health program specialist monitors new and revised CCHCS policies and procedures and distributes them to the applicable subcommittee to determine whether they impact existing LOPs or require new ones. Ultimately, as updates are made, the Quality Management Committee reviews and finalizes LOPs; once approved, staff receive training within 30 days. Currently, CEN has implemented 31 of the 49 applicable stakeholder recommended LOPs, or 63 percent (MIT 15.998).  The OIG discusses the institution’s health care staffing resources in the About the Institution section on page 2 (MIT 15.999). Recommendations No specific recommendations. California State Prison, Centinela, Cycle 4 Medical Inspection Page 52 Office of the Inspector General State of California JOB PERFORMANCE, TRAINING, LICENSING, AND CERTIFICATIONS In this indicator, the OIG examines whether the institution Case Review Rating: adequately manages its health care staffing resources by evaluating Not Applicable whether job performance reviews are completed as required; Compliance Score: specified staff possess current, valid credentials and professional Proficient licenses or certifications; nursing staff receive new employee (90.2%) orientation training and annual competency testing; and clinical and Overall Rating: custody staff have current medical emergency response Proficient certifications. Compliance Testing Results The institution received a proficient compliance score of 90.2 percent in the Job Performance Training, Licensing, and Certifications indicator. The institution scored 100 percent in five of the indicator’s eight tests, as follows:  All providers were current with their professional licenses, and nursing staff and the pharmacist-in-charge were current with their professional licenses and certification requirements (MIT 16.001, 16.105).  Nursing staff who administer medications possessed current clinical competency validations for all ten of their training records reviewed, and all nursing staff hired within the last year timely received new employee orientation training (MIT 16.102, 16.107).  The institution’s pharmacy and providers who prescribe controlled substances were current with their Drug Enforcement Agency registrations (MIT 16.106). The institution scored in the adequate range in the following two areas:  Nursing supervisors completed the required number of nursing reviews for four of the five nurses the OIG sampled (80 percent). However, there was no evidence of any completed nursing reviews for one nurse (MIT 16.101).  The OIG reviewed performance evaluation packets of four of the institution’s applicable providers and found the institution met all performance review requirements for three of them (75 percent). Although one provider had been out on a long-term leave since April 2015, a performance appraisal had not been completed for the three years preceding the absence (MIT 16.103). California State Prison, Centinela, Cycle 4 Medical Inspection Page 53 Office of the Inspector General State of California The institution scored in the inadequate range in the following area:  While all applicable providers and nursing staff were found to be current with their emergency response certifications, the institution did not have a current system in place to easily track when custody officers’ emergency medical response certifications expired. As a result, the institution received a score of 67 percent for this test. The institution’s custody staff reported that the deficiency would be corrected with the planned implementation of a new training program tracking system currently under development (MIT 16.104). Recommendations No specific recommendations. California State Prison, Centinela, Cycle 4 Medical Inspection Page 54 Office of the Inspector General State of California POPULATION-BASED METRICS The compliance testing and the case reviews give an accurate assessment of how the institution’s health care systems are functioning with regard to the patients with the highest risk and utilization. This information is vital to assess the capacity of the institution to provide sustainable, adequate care. However, one significant limitation of the case review methodology is that it does not give a clear assessment of how the institution performs for the entire population. For better insight into this performance, the OIG has turned to population-based metrics. For comparative purposes, the OIG has selected several Healthcare Effectiveness Data and Information Set (HEDIS) measures for disease management to gauge the institution’s effectiveness in outpatient health care, especially chronic disease management. The Healthcare Effectiveness Data and Information Set is a set of standardized performance measures developed by the National Committee for Quality Assurance with input from over 300 organizations representing every sector of the nation’s health care industry. It is used by over 90 percent of the nation’s health plans as well as many leading employers and regulators. It was designed to ensure that the public (including employers, the Centers for Medicare and Medicaid Services, and researchers) has the information it needs to accurately compare the performance of health care plans. Healthcare Effectiveness Data and Information Set data is often used to produce health plan report cards, analyze quality improvement activities, and create performance benchmarks. Methodology For population-based metrics, the OIG used a subset of HEDIS measures applicable to the CDCR inmate-patient population. Selection of the measures was based on the availability, reliability, and feasibility of the data required for performing the measurement. The OIG collected data utilizing various information sources, including the eUHR, the Master Registry (maintained by CCHCS), as well as a random sample of patient records analyzed and abstracted by trained personnel. Data obtained from the CCHCS Master Registry and Diabetic Registry was not independently validated by the OIG and is presumed to be accurate. For some measures, the OIG used the entire population rather than statistically random samples. While the OIG is not a certified HEDIS compliance auditor, the OIG uses similar methods to ensure that measures are comparable to those published by other organizations. Comparison of Population-Based Metrics For the California State Prison, Centinela, nine HEDIS measures were selected and are listed in the following CEN 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 State Prison, Centinela, Cycle 4 Medical Inspection Page 55 Office of the Inspector General State of California Results of Population-Based Metric Comparison Comprehensive Diabetes Care For chronic care management, the OIG chose measures related to the management of diabetes. Diabetes is the most complex common chronic disease requiring a high level of intervention on the part of the health care system in order to produce optimal results. CEN performed very well with its management of diabetes. When compared statewide, CEN significantly exceeded the Medi-Cal scores in all five diabetic measures selected. When compared to Kaiser Permanente, CEN also outperformed Kaiser North in all five diabetic measures, and the institution outperformed Kaiser South in four of five measures. Kaiser South did better in eye exams. When compared nationally, CEN outperformed Medicaid, Medicare, and commercial health plans (based on data obtained from health maintenance organizations) in all five of the diabetic measures listed. CEN exceeded the U.S. Department of Veterans Affairs (VA) for diabetic patients’ blood pressure control and for diabetic monitoring, and outperformed the VA for its diabetic patients considered to be under poor control. For eye exams, CEN trailed the VA. Immunizations Comparative data for immunizations was only fully available for the VA and partially available for Kaiser Permanente, commercial plans, and Medicare. For influenza shots for adults up to age 64, CEN scored slightly higher than Kaiser’s highest regional average and higher than commercial plans, but trailed the VA by 7 percentage points. With respect to influenza vaccinations for patients 65 and older, CEN scored significantly lower than both the VA and Medicare (33 percentage points and 29 percentage points respectively). For pneumococcal vaccinations for older adults, CEN scored slightly lower than Medicare and, again, much lower than the VA (26 percentage points). Of the 56 patients tested, CEN’s low scores for influenza and pneumococcal vaccinations were attributed to 24 patients who were all offered the immunizations but who refused them. Cancer Screening For colorectal cancer screening, CEN scored lower than all entities that reported comparative data (Kaiser, commercial plans, Medicare, and the VA). Of the 38 patients sampled, 36 patients were offered the screening timely; however, 12 of them had subsequently refused the test. California State Prison, Centinela, Cycle 4 Medical Inspection Page 56 Office of the Inspector General State of California Summary While the population-based metrics performance of California State Prison, Centinela was strong for most diabetic measures, the institution performed below other State and national results for most immunization and cancer screening measures, although those scores were negatively impacted by patient refusals. Overall, CEN’s HEDIS performance reflects an adequately performing chronic care program, further corroborated by the institution’s adequate score in the Access to Care indicator and proficient score in the Preventive Services indicator. With regard to CEN’s performance in the immunization and colorectal screening measures, the institution should make interventions to lower the rate of patient refusal for influenza shots, pneumococcal vaccinations, and colorectal cancer screening. California State Prison, Centinela, Cycle 4 Medical Inspection Page 57 Office of the Inspector General State of California CEN Results Compared to State and National HEDIS Scores California National HEDIS Clinical Measures CEN HEDIS Kaiser HEDIS HEDIS Medi- (No. Kaiser HEDIS Com- HEDIS VA Cycle 4 Cal CA) (So.CA) Medicaid mercial Medicare Average Results1 20142 20153 20153 20154 20154 20154 20125 Comprehensive Diabetes Care HbA1c Testing (Monitoring) 100% 83% 95% 94% 86% 91% 93% 99% Poor HbA1c Control (>9.0%)6, 7 8% 44% 18% 24% 44% 31% 25% 19% HbA1c Control (<8.0%)6 81% 47% 70% 62% 47% 58% 65% - Blood Pressure Control (<140/90)6 85% 60% 84% 85% 62% 65% 65% 80% Eye Exams 72% 51% 69% 81% 54% 56% 69% 90% Immunizations Influenza Shots - Adults (18–64)8 58% - 54% 55% - 50% - 65% Influenza Shots - Adults (65+) 43% - - - - - 72% 76% Immunizations: Pneumococcal 67% - - - - - 70% 93% Cancer Screening Colorectal Cancer Screening 63% - 80% 82% - 64% 67% 82% 1. Unless otherwise stated, data was collected in September and October 2015 by reviewing medical records from a sample of CEN's population of applicable inmate-patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. 2. HEDIS Medi-Cal data was obtained from the California Department of Health Care Services 2014 HEDIS Aggregate Report for the Medi-Cal Managed Care Program. 3. Data was obtained from Kaiser Permanente November 2015 reports for the Northern and Southern California regions. 4. National HEDIS data for Medicaid, commercial plans, and Medicare was obtained from the 2015 State of Health Care Quality Report, available on the NCQA website: www.ncqa.org. The results for commercial plans were based on data received from various health maintenance organizations. 5. The Department of Veterans Affairs (VA) data was obtained from the VHA Facility Quality and Safety Report - Fiscal Year 2012 Data. 6. For this indicator, the entire applicable CEN population was tested. 7. For this measure only, a lower score is better. For Kaiser, the OIG derived the Poor HbA1c Control indicator using the reported data for the <9.0% HbA1c control indicator. 8. The VA data is for the age range 50–64. California State Prison, Centinela, Cycle 4 Medical Inspection Page 58 Office of the Inspector General State of California APPENDIX A — COMPLIANCE TEST RESULTS California State Prison, Centinela Range of Summary Scores: 52.31% - 98.00% Indicator Overall Score (Yes %) Access to Care 80.62% Diagnostic Services 66.67% Emergency Services Not Applicable Health Information Management (Medical Records) 75.99% Health Care Environment 85.35% Inter- and Intra-System Transfers 90.00% Pharmacy and Medication Management 78.23% Prenatal and Post-Delivery Services Not Applicable Preventive Services 85.58% Quality of Nursing Performance Not Applicable Quality of Provider Performance Not Applicable Reception Center Arrivals Not Applicable Specialized Medical Housing (OHU, CTC, SNF, Hospice) 98.00% Specialty Services 85.65% Internal Monitoring, Quality Improvement, and Administrative Operations 52.31% Job Performance, Training, Licensing, and Certifications 90.21% California State Prison, Centinela, Cycle 4 Medical Inspection Page 59 Office of the Inspector General State of California Scored Answers Yes Reference + Access to Care Number Yes No No Yes % N/A 1.001 Chronic care follow-up appointments: Was the inmate-patient’s most 23 7 30 76.67% 0 recent chronic care visit within the health care guideline’s maximum allowable interval or within the ordered time frame, whichever is shorter? 1.002 For endorsed inmate-patients received from another CDCR 7 10 17 41.18% 13 institution: If the nurse referred the inmate-patient to a provider during the initial health screening, was the inmate-patient seen within the required time frame? 1.003 Clinical appointments: Did a registered nurse review the 26 4 30 86.67% 0 inmate-patient’s request for service the same day it was received? 1.004 Clinical appointments: Did the registered nurse complete a 28 2 30 93.33% 0 face-to-face visit within one business day after the CDCR Form 7362 was reviewed? 1.005 Clinical appointments: If the registered nurse determined a referral to 7 2 9 77.78% 21 a primary care provider was necessary, was the inmate-patient seen within the maximum allowable time or the ordered time frame, whichever is the shorter? 1.006 Sick call follow-up appointments: If the primary care provider 3 1 4 75.00% 26 ordered a follow-up sick call appointment, did it take place within the time frame specified? 1.007 Upon the inmate-patient’s discharge from the community hospital: 14 0 14 100.00% 0 Did the inmate-patient receive a follow-up appointment within the required time frame? 1.008 Specialty service follow-up appointments: Do specialty service 21 7 28 75.00% 2 primary care physician follow-up visits occur within required time frames? 1.101 Clinical appointments: Do inmate-patients have a standardized 6 0 6 100.00% 0 process to obtain and submit health care services request forms? Overall Percentage: 80.62% California State Prison, Centinela, Cycle 4 Medical Inspection Page 60 Office of the Inspector General State of California Scored Answers Yes Reference + Diagnostic Services Number Yes No No Yes % N/A 2.001 Radiology: Was the radiology service provided within the time frame 10 0 10 100.00% 0 specified in the provider’s order? 2.002 Radiology: Did the primary care provider review and initial the 6 4 10 60.00% 0 diagnostic report within specified time frames? 2.003 Radiology: Did the primary care provider communicate the results of 10 0 10 100.00% 0 the diagnostic study to the inmate-patient within specified time frames? 2.004 Laboratory: Was the laboratory service provided within the time 9 1 10 90.00% 0 frame specified in the provider’s order? 2.005 Laboratory: Did the primary care provider review and initial the 9 1 10 90.00% 0 diagnostic report within specified time frames? 2.006 Laboratory: Did the primary care provider communicate the results of 9 1 10 90.00% 0 the diagnostic study to the inmate-patient within specified time frames? 2.007 Pathology: Did the institution receive the final diagnostic report within 7 3 10 70.00% 0 the required time frames? 2.008 Pathology: Did the primary care provider review and initial the 0 8 8 0.00% 2 diagnostic report within specified time frames? 2.009 Pathology: Did the primary care provider communicate the results of 0 8 8 0.00% 2 the diagnostic study to the inmate-patient within specified time frames? Overall Percentage: 66.67% California State Prison, Centinela, Cycle 4 Medical Inspection Page 61 Office of the Inspector General State of California Emergency Services Scored Answers Assesses reaction times and responses to emergency situations. The OIG RN clinicians will use detailed information obtained from the institution’s incident Not Applicable packages to perform focused case reviews. Scored Answers Health Information Management Yes Reference + (Medical Records) Number Yes No No Yes % N/A 4.001 Are non-dictated progress notes, initial health screening forms, and 20 0 20 100.00% 0 health care service request forms scanned into the eUHR within three calendar days of the inmate-patient encounter date? 4.002 Are dictated / transcribed documents scanned into the eUHR within 9 11 20 45.00% 0 five calendar days of the inmate-patient encounter date? 4.003 Are specialty documents scanned into the eUHR within five calendar 20 0 20 100.00% 0 days of the inmate-patient encounter date? 4.004 Are community hospital discharge documents scanned into the eUHR 13 1 14 92.86% 0 within three calendar days of the inmate-patient date of hospital discharge? 4.005 Are medication administration records (MARs) scanned into the eUHR 20 0 20 100.00% 0 within the required time frames? 4.006 During the eUHR review, did the OIG find that documents were 0 12 12 0.00% 0 correctly labeled and included in the correct inmate-patient’s file? 4.007 Did clinical staff legibly sign health care records, when required? 27 5 32 84.38% 0 4.008 For inmate-patients discharged from a community hospital: Did 12 2 14 85.71% 0 the preliminary hospital discharge report include key elements and did a PCP review the report within three calendar days of discharge? Overall Percentage: 75.99% California State Prison, Centinela, Cycle 4 Medical Inspection Page 62 Office of the Inspector General State of California Scored Answers Yes Reference + Health Care Environment Number Yes No No Yes % N/A 5.101 Infection Control: Are clinical health care areas appropriately 9 1 10 90.00% 0 disinfected, cleaned and sanitary? 5.102 Infection control: Do clinical health care areas ensure that reusable 9 0 9 100.00% 1 invasive and non-invasive medical equipment is properly sterilized or disinfected as warranted? 5.103 Infection Control: Do clinical health care areas contain operable sinks 8 2 10 80.00% 0 and sufficient quantities of hygiene supplies? 5.104 Infection control: Does clinical health care staff adhere to universal 8 0 8 100.00% 2 hand hygiene precautions? 5.105 Infection control: Do clinical health care areas control exposure to 9 1 10 90.00% 0 blood-borne pathogens and contaminated waste? 5.106 Warehouse, Conex and other non-clinic storage areas: Does the 1 0 1 100.00% 0 medical supply management process adequately support the needs of the medical health care program? 5.107 Clinical areas: Does each clinic follow adequate protocols for 8 2 10 80.00% 0 managing and storing bulk medical supplies? 5.108 Clinical areas: Do clinic common areas and exam rooms have 4 6 10 40.00% 0 essential core medical equipment and supplies? 5.109 Clinical areas: Do clinic common areas have an adequate environment 8 2 10 80.00% 0 conducive to providing medical services? 5.110 Clinical areas: Do clinic exam rooms have an adequate environment 9 1 10 90.00% 0 conducive to providing medical services? 5.111 Emergency response bags: Are TTA and clinic emergency medical 8 1 9 88.89% 1 response bags inspected daily and inventoried monthly, and do they contain essential items? 5.999 For Information Purposes Only: Does the institution’s health care management believe that all clinical areas have physical plant Information Only infrastructures sufficient to provide adequate health care services? Overall Percentage: 85.35% California State Prison, Centinela, Cycle 4 Medical Inspection Page 63 Office of the Inspector General State of California Scored Answers Yes Reference + Inter- and Intra-System Transfers Number Yes No No Yes % N/A 6.001 For endorsed inmate-patients received from another CDCR 25 5 30 83.33% 0 institution or COCF: Did nursing staff complete the initial health screening and answer all screening questions on the same day the inmate-patient arrived at the institution? 6.002 For endorsed inmate-patients received from another CDCR 24 0 24 100.00% 6 institution or COCF: When required, did the RN complete the assessment and disposition section of the health screening form; refer the inmate-patient to the TTA, if TB signs and symptoms were present; and sign and date the form on the same day staff completed the health screening? 6.003 For endorsed inmate-patients received from another CDCR 4 2 6 66.67% 24 institution or COCF: If the inmate-patient had an existing medication order upon arrival, were medications administered or delivered without interruption? 6.004 For inmate-patients transferred out of the facility: Were scheduled 20 0 20 100.00% 0 specialty service appointments identified on the Health Care Transfer Information Form 7371? 6.101 For inmate-patients transferred out of the facility: Do medication 5 0 5 100.00% 4 transfer packages include required medications along with the corresponding Medical Administration Record (MAR) and Medication Reconciliation? Overall Percentage: 90.00% California State Prison, Centinela, Cycle 4 Medical Inspection Page 64 Office of the Inspector General State of California Scored Answers Yes Reference + Pharmacy and Medication Management Number Yes No No Yes % N/A 7.001 Did the inmate-patient receive all chronic care medications within the 24 5 29 82.76% 1 required time frames or did the institution follow departmental policy for refusals or no-shows? 7.002 Did health care staff administer or deliver new order prescription 27 3 30 90.00% 0 medications to the inmate-patient within the required time frames? 7.003 Upon the inmate-patient’s discharge from a community hospital: 10 4 14 71.43% 0 Were all medications ordered by the institution’s primary care provider administered or delivered to the inmate-patient within one calendar day of return? 7.004 For inmate-patients received from a county jail: Were all medications ordered by the institution’s reception center provider Not Applicable administered or delivered to the inmate-patient within the required time frames? 7.005 Upon the inmate-patient’s transfer from one housing unit to 27 3 30 90.00% 0 another: Were medications continued without interruption? 7.006 For inmate-patients en route who lay over at the institution: If the 0 1 1 0.00% 3 temporarily housed inmate-patient had an existing medication order, were medications administered or delivered without interruption? 7.101 All clinical and medication line storage areas for narcotic 9 0 9 100.00% 8 medications: Does the institution employ strong medication security controls over narcotic medications assigned to its clinical areas? 7.102 All clinical and medication line storage areas for non-narcotic 13 0 13 100.00% 4 medications: Does the institution properly store non-narcotic medications that do not require refrigeration in assigned clinical areas? 7.103 All clinical and medication line storage areas for non-narcotic 8 1 9 88.89% 8 medications: Does the institution properly store non-narcotic medications that require refrigeration in assigned clinical areas? 7.104 Medication preparation and administration areas: Do nursing staff 6 1 7 85.71% 10 employ and follow hand hygiene contamination control protocols during medication preparation and medication administration processes? 7.105 Medication preparation and administration areas: Does the 7 0 7 100.00% 10 institution employ appropriate administrative controls and protocols when preparing medications for inmate-patients? 7.106 Medication preparation and administration areas: Does the 3 4 7 42.86% 10 institution employ appropriate administrative controls and protocols when distributing medications to inmate-patients? California State Prison, Centinela, Cycle 4 Medical Inspection Page 65 Office of the Inspector General State of California 7.107 Pharmacy: Does the institution employ and follow general security, 1 0 1 100.00% 0 organization, and cleanliness management protocols in its main and satellite pharmacies? 7.108 Pharmacy: Does the institution’s pharmacy properly store 1 0 1 100.00% 0 non-refrigerated medications? 7.109 Pharmacy: Does the institution’s pharmacy properly store refrigerated 1 0 1 100.00% 0 or frozen medications? 7.110 Pharmacy: Does the institution’s pharmacy properly account for 1 0 1 100.00% 0 narcotic medications? 7.111 Pharmacy: Does the institution follow key medication error reporting 0 17 17 0.00% 8 protocols? 7.998 For Information Purposes Only: During eUHR compliance testing and case reviews, did the OIG find that medication errors were Information Only properly identified and reported by the institution? 7.999 For Information Purposes Only: Do inmate-patients in isolation housing units have immediate access to their KOP prescribed rescue Information Only inhalers and nitroglycerin medications? Overall Percentage: 78.23% California State Prison, Centinela, Cycle 4 Medical Inspection Page 66 Office of the Inspector General State of California Prenatal and Post-Delivery Services Scored Answers This indicator is not applicable to this institution. Not Applicable Scored Answers Yes Reference + Preventive Services Number Yes No No Yes % N/A 9.001 Inmate-patients prescribed INH: Did the institution administer the 24 3 27 88.89% 0 medication to the inmate-patient as prescribed? 9.002 Inmate-patients prescribed INH: Did the institution monitor the 27 0 27 100.00% 0 inmate-patient monthly for the most recent three months he or she was on the medication? 9.003 Annual TB Screening: Was the inmate-patient screened for TB within 15 15 30 50.00% 0 the last year? 9.004 Were all inmate-patients offered an influenza vaccination for the most 30 0 30 100.00% 0 recent influenza season? 9.005 All inmate-patients from the age 50 through the age of 75: Was the 27 3 30 90.00% 0 inmate-patient offered colorectal cancer screening? 9.006 Female inmate-patients from the age of 50 through the age of 74: Was the inmate-patient offered a mammogram in compliance with Not Applicable policy? 9.007 Female inmate-patients from the age of 21 through the age of 65: Not Applicable Was the inmate-patient offered a pap smear in compliance with policy? 9.008 Are required immunizations being offered for chronic care 11 2 13 84.62% 0 inmate-patients? 9.009 Are inmate-patients at the highest risk of coccidioidomycosis (valley Not Applicable fever) infection transferred out of the facility in a timely manner? Overall Percentage: 85.58% California State Prison, Centinela, Cycle 4 Medical Inspection Page 67 Office of the Inspector General State of California Quality of Nursing Performance Scored Answers The quality of nursing performance will be assessed during case reviews, conducted by OIG clinicians, and is not applicable for the compliance portion of the medical inspection. The methodologies OIG clinicians use to evaluate the quality of nursing Not Applicable performance are presented in a separate inspection document entitled OIG MIU Retrospective Case Review Methodology. Quality of Provider Performance Scored Answers The quality of provider performance will be assessed during case reviews, conducted by OIG clinicians, and is not applicable for the compliance portion of the medical inspection. The methodologies OIG clinicians use to evaluate the quality of provider Not Applicable performance are presented in a separate inspection document entitled OIG MIU Retrospective Case Review Methodology. Reception Center Arrivals Scored Answers This indicator is not applicable to this institution. Not Applicable California State Prison, Centinela, Cycle 4 Medical Inspection Page 68 Office of the Inspector General State of California Scored Answers Specialized Medical Housing Yes Reference + (OHU, CTC, SNF, Hospice) Number Yes No No Yes % N/A 13.001 For all higher-level care facilities: Did the registered nurse complete 10 0 10 100.00% 0 an initial assessment of the inmate-patient on the day of admission, or within eight hours of admission to CEN’s CTC? 13.002 For OHU, CTC, & SNF only: Did the primary care provider for OHU 10 0 10 100.00% 0 or attending physician for a CTC & SNF evaluate the inmate-patient within 24 hours of admission? 13.003 For OHU, CTC, & SNF only: Was a written history and physical 10 0 10 100.00% 0 examination completed within 72 hours of admission? 13.004 For all higher-level care facilities: Did the primary care provider 9 1 10 90.00% 0 complete the Subjective, Objective, Assessment, Plan, and Education (SOAPE) notes on the inmate-patient at the minimum intervals required for the type of facility where the inmate-patient was treated? 13.101 For OHU and CTC Only: Do inpatient areas either have properly 1 0 1 100.00% 0 working call systems in its OHU & CTC or are 30-minute patient welfare checks performed; and do medical staff have reasonably unimpeded access to enter inmate-patient’s cells? Overall Percentage: 98.00% California State Prison, Centinela, Cycle 4 Medical Inspection Page 69 Office of the Inspector General State of California Scored Answers Yes Reference + Specialty Services Number Yes No No Yes % N/A 14.001 Did the inmate-patient receive the high-priority specialty service within 15 0 15 100.00% 0 14 calendar days of the PCP order? 14.002 Did the PCP review the high priority specialty service consultant report 13 2 15 86.67% 0 within the required time frame? 14.003 Did the inmate-patient receive the routine specialty service within 90 15 0 15 100.00% 0 calendar days of the PCP order? 14.004 Did the PCP review the routine specialty service consultant report 13 1 14 92.86% 1 within the required time frame? 14.005 For endorsed inmate-patients received from another CDCR 13 7 20 65.00% 0 institution: If the inmate-patient was approved for a specialty services appointment at the sending institution, was the appointment scheduled at the receiving institution within the required time frames? 14.006 Did the institution deny the primary care provider request for specialty 19 1 20 95.00% 0 services within required time frames? 14.007 Following the denial of a request for specialty services, was the 12 8 20 60.00% 0 inmate-patient informed of the denial within the required time frame? Overall Percentage: 85.65% California State Prison, Centinela, Cycle 4 Medical Inspection Page 70 Office of the Inspector General State of California Scored Answers Internal Monitoring, Quality Improvement, Yes Reference + and Administrative Operations Number Yes No No Yes % N/A 15.001 Did the institution promptly process inmate medical appeals during the 4 8 12 33.33% 0 most recent 12 months? 15.002 Does the institution follow adverse/sentinel event reporting Not Applicable requirements? 15.003 Did the institution Quality Management Committee (QMC) meet at 5 1 6 83.33% 0 least monthly to evaluate program performance, and did the QMC take action when improvement opportunities were identified? 15.004 Did the institution’s Quality Management Committee (QMC) or other 0 1 1 0.00% 0 forum take steps to ensure the accuracy of its Dashboard data reporting? 15.005 For each initiative in the Performance Improvement Work Plan 0 5 5 0.00% 0 (PIWP), has the institution performance improved or reached the targeted performance objective(s)? 15.006 For institutions with licensed care facilities: Does the local 4 0 4 100.00% 0 governing body (LGB), or its equivalent, meet quarterly and exercise its overall responsibilities for the quality management of patient health care? 15.007 Does the Emergency Medical Response Review Committee perform 0 12 12 0.00% 0 timely incident package reviews that include the use of required review documents? 15.101 Did the institution complete a medical emergency response drill for 2 1 3 66.67% 0 each watch and include participation of health care and custody staff during the most recent full quarter? 15.102 Did the institution’s second level medical appeal response address all 10 0 10 100.00% 0 of the inmate-patient’s appealed issues? 15.103 Did the institution’s medical staff review and submit the initial inmate 7 1 8 87.50% 0 death report to the Death Review Unit in a timely manner? 15.996 For Information Purposes Only: Did the CCHCS Death Review Committee submit its inmate death review summary to the institution Information Only timely? 15.997 For Information Purposes Only: Identify the institution’s protocols Information Only for tracking medical appeals. 15.998 For Information Purposes Only: Identify the institution’s protocols Information Only for implementing health care local operating procedures. 15.999 For Information Purposes Only: Identify the institution’s healthcare Information Only staffing resources. Overall Percentage: 52.31% California State Prison, Centinela, Cycle 4 Medical Inspection Page 71 Office of the Inspector General State of California Scored Answers Job Performance, Training, Licensing, Yes Reference + and Certifications Number Yes No No Yes % N/A 16.001 Do all providers maintain a current medical license? 11 0 11 100.00% 0 16.101 Does the institution’s Supervising Registered Nurse conduct periodic 4 1 5 80.00% 0 reviews of nursing staff? 16.102 Are nursing staff who administer medications current on their clinical 10 0 10 100.00% 0 competency validation? 16.103 Are structured clinical performance appraisals completed timely? 3 1 4 75.00% 2 16.104 Are staff current with required medical emergency response 2 1 3 66.67% 0 certifications? 16.105 Are nursing staff and the Pharmacist-in-Charge current with their 5 0 5 100.00% 1 professional licenses and certifications? 16.106 Do the institution’s pharmacy and authorized providers who prescribe 1 0 1 100.00% 0 controlled substances maintain current Drug Enforcement Agency (DEA) registrations? 16.107 Are nursing staff current with required new employee orientation? 1 0 1 100.00% 0 Overall Percentage: 90.21% California State Prison, Centinela, Cycle 4 Medical Inspection Page 72 Office of the Inspector General State of California APPENDIX B — CLINICAL DATA Table B-1: CEN Sample Sets Sample Set Total Anticoagulation 3 Death Review/Sentinel Events 5 Diabetes 3 Emergency Services - CPR 2 Emergency Services - Non-CPR 6 High Risk 5 Hospitalization 5 Intra-system Transfers-In 3 Intra-system Transfers-Out 3 RN Sick Call 30 Specialty Services 4 69 California State Prison, Centinela, Cycle 4 Medical Inspection Page 73 Office of the Inspector General State of California Table B-2: CEN Chronic Care Diagnoses Diagnosis Total Anemia 4 Anticoagulation 3 Arthritis/Degenerative Joint Disease 7 Asthma 8 COPD 7 Cancer 4 Cardiovascular Disease 7 Chronic Kidney Disease 2 Chronic Pain 4 Cirrhosis/End Stage Liver Disease 3 Deep Venous Thrombosis/Pulmonary Embolism 3 Diabetes 14 Gastroesophageal Reflux Disease 18 Gastrointestinal Bleed 2 Hepatitis C 16 Hyperlipidemia 16 Hypertension 30 Mental Health 4 Seizure Disorder 5 Sleep Apnea 4 161 California State Prison, Centinela, Cycle 4 Medical Inspection Page 74 Office of the Inspector General State of California Table B-3: CEN Event - Program Program Total Diagnostic Services 184 Emergency Care 60 Hospitalization 55 Intra-system Transfers-In 11 Intra-system Transfers-Out 10 Not Specified 3 Outpatient Care 411 Specialized Medical Housing 456 Specialty Services 150 1340 Table B-4: CEN Case Review Sample Summary Total MD Reviews Detailed 30 MD Reviews Focused 0 RN Reviews Detailed 16 RN Reviews Focused 33 Total Reviews 79 Total Unique Cases 69 Overlapping Reviews (MD & RN) 10 California State Prison, Centinela, Cycle 4 Medical Inspection Page 75 Office of the Inspector General State of California APPENDIX C — COMPLIANCE SAMPLING METHODOLOGY California State Prison, Centinela Sample Category Quality (number of Indicator patients) Data Source Filters Access to Care Chronic Care Master Registry  Chronic care conditions (at least one condition per inmate-patient—any risk level) (30)  Randomize Nursing Sick Call MedSATS  Clinic (each clinic tested) (5 per clinic)  Appt. date (2–9 months) (30)  Randomize Returns from Inpatient Claims  See Health Information Management (Medical Community Hospital Data Records) (returns from community hospital) (14 – all applicable) Diagnostic Radiology Radiology Logs  Appt. Date (90 days–9 months) Services  Randomize (10)  Abnormal Laboratory Quest  Appt. date (90 days–9 months)  Order name (CBC or CMPs only)  Randomize (10)  Abnormal Pathology InterQual  Appt. date (90 days–9 months)  Service (pathology related) (10)  Randomize Health Timely Scanning OIG Qs: 1.001,  Non-dictated documents Information 1.002, & 1.004  First 5 inmate-patients selected for questions Management (20) 1.002, 1.004; First 10 inmate-patients selected for (Medical question 1.001 Records) OIG Q: 1.001  Dictated documents (20)  First 20 inmate-patients selected OIG Qs: 14.002  Specialty documents (20) & 14.004  First 10 inmate-patients selected for each question OIG Q: 4.008  Community hospital discharge documents (14 – all applicable)  First 20 inmate-patients selected for the question OIG Q: 7.001  MARs (20)  First 20 inmate-patients selected Legible Signatures OIG Qs: 4.008,  First 8 inmates sampled and Review 6.001/6.002,  One source document per inmate-patient 7.001, 12.001/ (32) 12.002, & 14.002 Complete and Documents for  Any incorrectly scanned eUHR document Accurate Scanning any tested inmate identified during OIG eUHR file review, e.g., mislabeled, misfiled, illegibly scanned, or missing Returns from Inpatient Claims  Date (2–8 months) Community Hospital Data  Most recent 6 months provided (within date range)  Rx count  Discharge date  Randomize (each month individually)  First 5 inmate-patients from each of the 6 months (if not 5 in a month, supplement from another, as (14 – all applicable) needed) California State Prison, Centinela, Cycle 4 Medical Inspection Page 76 Office of the Inspector General State of California Sample Category Quality (number of Indicator patients) Data Source Filters Health Care Clinical Areas OIG Inspector  Identify and inspect all onsite clinical areas. Environment (10) Onsite Review Inter- and Intra-System SOMS  Arrival date (3–9 months) Intra-System transfers  Arrived from (another CDCR facility) Transfers  Rx count (30)  Randomize Specialty Service MedSATS  Date of Transfer (3–9 months) Send-outs  Randomize (20) Pharmacy and Chronic Care OIG Q: 1.001 See Access to Care Medication Medication  (At least one condition per inmate-patient—any Management risk level) (29)  Randomize New Medication Master Registry  Rx Count Orders  Randomize  Ensure no duplication of inmate-patients tested in (30) chronic care medications Intra-Facility 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 (high–low)–inmate-patient must have NA/DOT meds to qualify for testing (30)  Randomize En Route SOMS  Date of transfer (2–8 months)  Sending institution (another CDCR facility)  Randomize  Length of stay (minimum of 2 days) (1)  NA/DOT meds Returns from Inpatient Claims  See Health Information Management (Medical Community Hospital Data Records) (returns from community hospital) (14) Medication OIG Inspector  Identify and inspect onsite clinical areas that Preparation and Onsite Review prepare and administer medications Administration Areas (7) Pharmacy OIG Inspector  Identify and inspect onsite pharmacies (1) Onsite Review Medication Error OIG Inspector  Any medication error identified during OIG eUHR Reporting Review file review, e.g., case reviews and/or compliance (17) testing Prenatal and Recent Deliveries OB Roster  Delivery date (2–12 months) Post-Delivery  Most recent deliveries (within date range) Services N/A at this institution Pregnant Arrivals OB Roster  Arrival date (2–12 months)  Earliest arrivals (within date range) N/A at this institution California State Prison, Centinela, Cycle 4 Medical Inspection Page 77 Office of the Inspector General State of California Sample Category Quality (number of Indicator patients) Data Source Filters Preventive Chronic Care OIG Q: 1.001  Chronic care conditions (at least 1 condition per Services Vaccinations inmate-patient—any risk level)  Randomize (13)  Condition must require vaccination(s) INH Maxor  Dispense date (past 9 months)  Time period on INH (at least a full 3 months) (27)  Randomize Colorectal Screening SOMS  Arrival date (at least 1 year prior to inspection)  Date of birth (51 or older) (30)  Randomize Influenza SOMS  Arrival date (at least 1 year prior to inspection) Vaccinations  Randomize  Filter out inmate-patients tested in chronic care (30) vaccination sample TB Code 22, annual SOMS  Arrival date (at least 1 year prior to inspection) TST  TB Code (22) (15)  Randomize TB Code 34, annual SOMS  Arrival date (at least 1 year prior to inspection) screening  TB Code (34) (15)  Randomize Mammogram SOMS  Arrival date (at least 2 years prior to inspection)  Date of birth (age 52–74) N/A at this institution  Randomize Pap Smear SOMS  Arrival date (at least three years prior to inspection)  Date of birth (age 24–53) N/A at this institution  Randomize Valley Fever Cocci Transfer  Reports from past 2–8 months Status Report  Institution  Ineligibility date (60 days prior to inspection date) N/A at this institution  All Reception RC SOMS  Arrival date (2–8 months) Center Arrivals  Arrived from (county jail, return from parole, etc.) N/A at this institution  Randomize Specialized CTC CADDIS  Admit date (1–6 months) Medical  Type of stay (no MH beds) Housing  Length of stay (minimum of 5 days) (10)  Randomize California State Prison, Centinela, Cycle 4 Medical Inspection Page 78 Office of the Inspector General State of California Sample Category Quality (number of Indicator patients) Data Source Filters Specialty High-Priority MedSATS  Approval date (3–9 months) Services Access (15)  Randomize Routine MedSATS  Approval date (3–9 months)  Remove optometry, physical therapy or podiatry (15)  Randomize Specialty Service MedSATS  Arrived from (other CDCR institution) Arrivals  Date of transfer (3–9 months) (20)  Randomize Denials InterQual  Review date (3–9 months) (11)  Randomize IUMC/MAR  Meeting date (9 months) Meeting Minutes  Denial upheld (9)  Randomize Internal Medical Appeals Monthly Medical  Medical appeals (12 months) Monitoring, (12) Appeals Reports Quality Adverse/Sentinel Adverse/Sentinel  Adverse/sentinel events (2–8 months) Improvement, Events Events Report and N/A at this institution Administrative QMC Meetings Quality  Meeting minutes (6 months) Operations Management Committee (6) Meeting Minutes Performance Performance  Performance Improvement Work Plan with Improvement Plans Improvement updates (12 months) (5) Work Plan Local Governing Local Governing  Meeting minutes (12 months) Body Body Meeting (4) Minutes EMRRC EMRRC  Meeting minutes (6 months) (12) Meeting Minutes Medical Emergency OIG Inspector  Most recent full quarter Response Drills Onsite Review  Each watch (3) 2nd Level Medical OIG Inspector  Medical appeals denied (6 months) Appeals Onsite Review (10) Death Reports OIG Inspector  Death reports (12 months) (8) Onsite Review Local Operating OIG Inspector  Review all Procedures Onsite Review (all) California State Prison, Centinela, Cycle 4 Medical Inspection Page 79 Office of the Inspector General State of California Sample Category Quality (number of Indicator patients) Data Source Filters Job Performance, RN Review OIG Inspector  Current Supervising RN reviews Training, Evaluations Onsite Review Licensing, and (5) Certifications Nursing Staff OIG Inspector  Review annual competency validations Validations Onsite Review  Randomize (10) Provider Annual OIG Inspector  All required performance evaluation documents Evaluation Packets Onsite Review (all) Medical Emergency OIG Inspector  All staff Response Onsite Review o Providers (ACLS) Certifications o Nursing (BLS/CPR) (all) o Custody (CPR/BLS) Nursing staff and OIG Inspector  All licenses and certifications Pharmacist-in-charge Onsite Review Professional Licenses and Certifications (all) Pharmacy and OIG Inspector  All current DEA registrations Providers’ Drug Onsite Review Enforcement Agency (DEA) Registrations (all) Nursing Staff New OIG Inspector  New employees (within the last 12 months) Employee Onsite Review Orientations (all) California State Prison, Centinela, Cycle 4 Medical Inspection Page 80 Office of the Inspector General State of California C C ALIFORNIA ORRECTIONAL H C S ’ EALTH ARE ERVICES R ESPONSE California State Prison, Centinela, Cycle 4 Medical Inspection Page 81 Office of the Inspector General State of California