California State Prison, Centinela Medical Inspection Report Cycle 5

Roy W. Wesley Office of the Inspector General Inspector General C alifornia State Prison, Centinela Medical Inspection Results Cycle 5 January 2018 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 5 Roy W. Wesley Inspector General Bryan B. Beyer Chief Deputy Inspector General Shaun R. Spillane Public Information Officer January 2018 T C ABLE OF ONTENTS Foreword .............................................................................................................................................. i Executive Summary ........................................................................................................................... iii Overall Rating: Adequate................................................................................................................ iii Clinical Case Review and OIG Clinician Inspection Results ................................................ v Compliance Testing Results.................................................................................................. vi Recommendations ................................................................................................................ vii Population-Based Metrics .................................................................................................... vii Introduction ......................................................................................................................................... 1 About the Institution ........................................................................................................................ 1 Objectives, Scope, and Methodology.................................................................................................. 3 Case Reviews ................................................................................................................................... 4 Patient Selection for Retrospective Case Reviews ................................................................. 4 Benefits and Limitations of Targeted Subpopulation Review ............................................... 5 Case Reviews Sampled .......................................................................................................... 5 Compliance Testing ......................................................................................................................... 7 Sampling Methods for Conducting Compliance Testing ....................................................... 7 Scoring of Compliance Testing Results ................................................................................. 8 Overall Quality Indicator Rating for Case Reviews and Compliance Testing ................................ 8 Population-Based Metrics ................................................................................................................ 8 Medical Inspection Results ................................................................................................................. 9 Access to Care ................................................................................................................. 11 Case Review Results ............................................................................................................ 11 Compliance Testing Results................................................................................................. 13 Diagnostic Services ......................................................................................................... 15 Case Review Results ............................................................................................................ 15 Compliance Testing Results................................................................................................. 16 Emergency Services ........................................................................................................ 17 Case Review Results ............................................................................................................ 17 Health Information Management .................................................................................... 20 Case Review Results ............................................................................................................ 20 Compliance Testing Results................................................................................................. 21 Health Care Environment ............................................................................................... 23 Compliance Testing Results................................................................................................. 23 Inter- and Intra-System Transfers ................................................................................... 26 Case Review Results ............................................................................................................ 26 Compliance Testing Results................................................................................................. 27 Pharmacy and Medication Management ........................................................................ 29 Case Review Results ............................................................................................................ 29 Compliance Testing Results................................................................................................. 30 Prenatal and Post-Delivery Services .............................................................................. 34 California State Prison, Centinela, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California Preventive Services ......................................................................................................... 35 Compliance Testing Results................................................................................................. 35 Quality of Nursing Performance .................................................................................. 37 Case Review Results ............................................................................................................ 37 Quality of Provider Performance ................................................................................ 42 Case Review Results ............................................................................................................ 42 Reception Center Arrivals ........................................................................................... 45 Specialized Medical Housing ....................................................................................... 46 Case Review Results ............................................................................................................ 46 Compliance Testing Results................................................................................................. 47 Specialty Services ........................................................................................................ 48 Case Review Results ............................................................................................................ 48 Compliance Testing Results................................................................................................. 49 Administrative Operations (Secondary) ...................................................................... 51 Compliance Testing Results................................................................................................. 51 Recommendations ............................................................................................................................. 54 Population-Based Metrics ................................................................................................................. 55 Appendix A — Compliance Test Results ......................................................................................... 58 Appendix B — Clinical Data ............................................................................................................ 72 Appendix C — Compliance Sampling Methodology ....................................................................... 76 California Correctional Health Care Services’ Response ................................................................. 84 California State Prison, Centinela, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California L T F IST OF ABLES AND IGURES CEN Executive Summary Table ......................................................................................................... iv CEN Health Care Staffing Resources as of June 2017 ........................................................................ 2 CEN Master Registry Data as of June 12, 2017 .................................................................................. 2 CEN Results Compared to State and National HEDIS Scores .......................................................... 57 Table B-1: CEN Sample Sets ............................................................................................................ 72 Table B-2: CEN Chronic Care Diagnoses ......................................................................................... 73 Table B-3: CEN Event – Program ..................................................................................................... 74 Table B-4: CEN Case Review Sample Summary .............................................................................. 75 California State Prison, Centinela, Cycle 5 Medical Inspection List of Tables and Figures Office of the Inspector General State of California This page intentionally left blank. California State Prison, Centinela, Cycle 5 Medical Inspection Office of the Inspector General State of California F OREWORD Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), the OIG conducts a comprehensive inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG explicitly makes no determination regarding the constitutionality of care in the prison setting. That determination is left to the Receiver and the federal court. The assessment of care by the OIG is just one factor in the court’s determination whether care in the prisons meets constitutional standards. The OIG’s inspections are mandated by the Penal Code and not aimed at specifically resolving the court’s questions on constitutional care. To the degree that they provide another factor for the court to consider, the OIG is pleased to provide added value to the taxpayers of California. In Cycle 5, for the first time, the OIG will be inspecting institutions delegated back to CDCR from the Receivership. There is no difference in the standards used for assessment of a delegated institution versus an institution not yet delegated. The receiver delegated California State Prison, Centinela back to CDCR in June 2016. This fifth cycle of inspections will continue evaluating the areas addressed in Cycle 4, which included clinical case review, compliance testing, and a population-based metric comparison of selected Healthcare Effectiveness Data Information Set (HEDIS) measures. In agreement with stakeholders, the OIG made changes to both the case review and compliance components. The OIG found that in every inspection in Cycle 4, larger samples were taken than were needed to assess the adequacy of medical care provided. As a result, the OIG reduced the number of case reviews and sample sizes for compliance testing. Also, in Cycle 4, compliance testing included two secondary (administrative) indicators (Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications). For Cycle 5, these have been combined into one secondary indicator, Administrative Operations. California State Prison, Centinela, Cycle 5 Medical Inspection Page i Office of the Inspector General State of California This page intentionally left blank. California State Prison, Centinela, Cycle 5 Medical Inspection Page ii Office of the Inspector General State of California E S XECUTIVE UMMARY The OIG performed its Cycle 5 medical inspection at California State Prison, Centinela from June to August 2017. The inspection OVERALL RATING: included in-depth reviews of 49 patient files conducted by clinicians, as well as reviews of documents from 374 patient files, Adequate covering 88 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 13 health care quality indicators applicable to the institution. To conduct clinical case reviews, the OIG employs a clinician team consisting of a physician and a registered nurse consultant, while compliance testing is done by a team of registered nurses trained in monitoring medical policy compliance. Of the indicators, seven were rated by both case review clinicians and compliance inspectors, three were rated by case review clinicians only, and three were rated by compliance inspectors only. The CEN Executive Summary Table on the following page identifies the applicable individual indicators and scores for this institution. California State Prison, Centinela, Cycle 5 Medical Inspection Page iii Office of the Inspector General State of California CEN Executive Summary Table Cycle 5 Cycle 4 Case Review Compliance Inspection Indicators Overall Overall Rating Rating Rating Rating 1—Access to Care Adequate Adequate Adequate Adequate 2—Diagnostic Services Proficient Inadequate Adequate Adequate 3—Emergency Services Adequate Not Applicable Adequate Adequate 4—Health Information Proficient Proficient Proficient Adequate Management 5—Health Care Environment Not Applicable Inadequate Inadequate Proficient 6—Inter- and Intra-System Proficient Proficient Proficient Proficient Transfers 7—Pharmacy and Medication I Inadequate Inadequate Inadequate n Adequate Management a 8—Prenatal and Post-Delivery Not Applicable Not Applicable Not Applicable Not Applicable Services 9—Preventive Services Not Applicable Adequate Adequate Proficient 10—Quality of Nursing Adequate Not Applicable Adequate Inadequate Performance 11—Quality of Provider Adequate Not Applicable Adequate Adequate Performance 12—Reception Center Arrivals Not Applicable Not Applicable Not Applicable Not Applicable 13—Specialized Medical Housing Proficient Proficient Proficient Adequate 14—Specialty Services Adequate Adequate Adequate Proficient 15—Administrative Operations Not Applicable Adequate Adequate Inadequate* (Secondary) *In Cycle 4, there were two secondary (administrative) indicators. This score reflects the average of those two scores. California State Prison, Centinela, Cycle 5 Medical Inspection Page iv Office of the Inspector General State of California Clinical Case Review and OIG Clinician Inspection Results The clinicians’ case reviews sampled patients with high medical needs and included a review of more than 900 patient care events.1 Of the 13 indicators applicable to CEN, 10 were evaluated by clinician case review; 4 were proficient, 5 were adequate, and one was inadequate. When determining the overall adequacy of care, the OIG paid particular attention to the clinical nursing and provider quality indicators, as adequate health care staff can sometimes overcome suboptimal processes and programs. However, the opposite is not true; inadequate health care staff cannot provide adequate care, even though the established processes and programs onsite may be adequate. The OIG clinicians identify inadequate medical care based on the risk of significant harm to the patient, not the actual outcome. Program Strengths — Clinical  CEN had effective specialty services access as the specialty service staff timely scheduled specialty appointments and made necessary orders and referrals. The custody staff ensured that escorts and transportation were readily available to all off-site specialty appointments.  CEN was proficient with inter- and intra-system transfers. Nurses performed thorough screening examinations on patients transferred into the institution, as well as processed information, including pertinent diagnoses, current medications, and pending specialty appointments for patients transferring out of the institution. Nurses also added important information on the transfer records, such as phone numbers and addresses for pending specialist appointments.  CEN clinical staff provided proficient care to the patients in specialized medical housing. The correctional treatment center (CTC) was staffed with experienced nurses and sufficient custody staff to support timely access and provision of care. Nursing staff had developed a useful report sheet that included information relevant to all team members including nursing assistants. The information on the report sheet included the patient’s name, diagnoses, care plan information, diet, and TABE (Test of Adult Basic Education) score, which advised staff of the patient’s school grade-level of comprehension. Program Weaknesses — Clinical  CEN performed poorly with pharmacy and medication management, as there were significant problems with medication administration as well as medication continuity when patients returned from an outside hospital. 1 Each OIG clinician team includes a board-certified physician and registered nurse consultant with experience in correctional and community medical settings. California State Prison, Centinela, Cycle 5 Medical Inspection Page v Office of the Inspector General State of California Compliance Testing Results Of the 13 health care indicators applicable to CEN, 10 were evaluated by compliance inspectors.2 They rated three indicators proficient, four adequate, and three inadequate. There were 88 individual compliance questions within those 10 indicators, generating 1,034 data points that tested CEN’s compliance with California Correctional Health Care Services (CCHCS) policies and procedures.3 Those 88 questions are detailed in Appendix A — Compliance Test Results. Program Strengths — Compliance The following are some of CEN’s strengths based on its compliance scores on individual questions in all the health care indicators:  Nursing staff reviewed patient’s health care service requests the same day they were received, and nursing staff also conducted a face-to-face encounter with patients within the required time frame. All housing units inspected had Health Care Services Request forms (CDCR Form 7362) available to patients.  CEN staff scanned non-dictated documents and hospital discharge reports into patients’ electronic medical records within required time frames. In addition, CEN providers reviewed hospital discharge reports timely.  Nursing staff generally completed all questions and properly signed the assessment and disposition sections of the Initial Health Screening form (CDCR Form 7277) for patients who transferred into CEN. For patients that were transferring out of CEN to another CDCR institution, nursing staff ensured all transfer packages had all applicable patient medications.  CTC nursing staff completed initial health assessments on patients upon admission, and providers completed an initial assessment and required encounter visits with patients within required time frames. Additionally, the CTC call button system was in working order.  Patients received their high-priority and routine specialty service appointments within the required time frames. Program Weaknesses — Compliance The following are some of the weaknesses identified by CEN’s compliance scores on individual questions in all health care indicators: 2 The OIG’s compliance inspectors are trained registered nurses with expertise in CDCR policies regarding medical staff and processes. 3 The OIG used its own clinicians to provide clinical expert guidance for testing compliance in certain areas where CCHCS policies and procedures did not specifically address an issue. California State Prison, Centinela, Cycle 5 Medical Inspection Page vi Office of the Inspector General State of California  CEN did not always provide pathology services timely, and providers did not review pathology reports or communicate the results to patients within required time frames.  Several clinic locations did not have all essential medical equipment and supplies available to clinicians and several emergency medical response bags (EMRB) did not have evidence that CEN staff had verified that the bags were sealed and properly inventoried.  The institution did a poor job accounting for narcotic medication at medication line locations, with problems identified with the inventory of narcotic medications. In addition, CEN did not always store non-narcotic medications properly at medication line locations. Recommendations  CEN nurses included important information not usually seen on transfer records, such as phone numbers and addresses for pending specialists’ appointments. The OIG recommends that CCHCS adopt this process statewide.  In the CTC, CEN nurses developed a useful report sheet that contained information relevant to all team members including nursing assistants. The information on the report sheet included the patient’s name, diagnoses, care plan information, diet, and TABE (Test of Adult Basic Education) score. The OIG recommends that CCHCS adopt this process statewide. Population-Based Metrics In general, CEN performed well as measured by population-based metrics. In comprehensive diabetes care, CEN outperformed other statewide and most national health care plans in the five diabetic measures. With regard to immunization measures for both young and older patients, CEN’s rates were slightly lower than other health plans, due to a high patient refusal rate. When administering pneumococcal vaccines, CEN scored similarly to the other reporting entities. CEN outperformed or performed similarly to all other health care plans for colorectal cancer screenings. Overall, CEN’s performance as measured by population-based metrics indicated that the institution performed well in comparison to other health care plans reviewed. The institution may improve its scores for immunizations by reducing patient refusals through patient education. California State Prison, Centinela, Cycle 5 Medical Inspection Page vii Office of the Inspector General State of California This page intentionally left blank. California State Prison, Centinela, Cycle 5 Medical Inspection Page viii Office of the Inspector General State of California I NTRODUCTION Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), and at the request of the federal Receiver, the OIG developed a comprehensive medical inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG conducts a clinical case review and a compliance inspection, ensuring a thorough, end-to-end assessment of medical care within CDCR. California State Prison, Centinela (CEN) was the 18th medical inspection of Cycle 5. During the inspection process, the OIG assessed the delivery of medical care to patients using the primary clinical health care indicators applicable to the institution. The Administrative Operations indicator is secondary because it does not reflect the actual clinical care provided. ABOUT THE INSTITUTION Located in the city of Imperial in Imperial County, CEN was named after “El Centinela,” the Spanish name of Mount Signal on the United States-Mexico border a few miles from the institution. CEN opened in 1993 as a complex of four separate facilities (A, B, C, and D) primarily housing general population, Level I and Level III sensitive needs, and Level IV maximum security custody inmates. The institution runs multiple medical clinics where staff members manage non-urgent requests for medical services. CEN also treats patients requiring urgent or emergent care in its triage and treatment area (TTA) and admits patients needing higher levels of care to its correctional treatment center (CTC). CEN is designated as a “basic care institution”, located in a rural area away from tertiary care centers and specialty care providers whose services would be required frequently by higher-risk patients. Basic care institutions have the capability to provide limited specialty medical services and consultation for a generally healthy patient population. In August 2014, the institution received national accreditation from the Commission on Accreditation for Corrections, and received recertification in March 2017. This accreditation program is a professional peer review process based on national standards set by the American Correctional Association. Based on staffing data the OIG obtained from the institution, CEN’s vacancy rate among medical managers, primary care providers, supervisors, and rank-and-file nurses was only 2 percent in June 2017, with the highest vacancy percentage among primary care providers at 17 percent, representing one vacancy among six authorized positions. At the time of the OIG’s inspection, there were four health care staff members on long-term medical leave. California State Prison, Centinela, Cycle 5 Medical Inspection Page 1 Office of the Inspector General State of California CEN Health Care Staffing Resources as of June 2017 Primary Care Nursing Management Nursing Staff Totals Providers Supervisors Description Number % Number % Number % Number % Number % Authorized 5 6% 6 7% 9.5 11% 64 76% 84.5 100% Positions Filled Positions 5 100% 5 83% 9.5 100% 63 98% 82.5 98% Vacancies 0 0% 1 17% 0 0% 1 2% 2 2% Recent Hires (within 12 1 20% 1 20% 1 11% 15 21% 18 20% months) Staff Utilized 0 0% 0.5 10% 0 0% 5 7% 5.5 6% 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% 0 0% 2 21% 2 3% 4 4% Medical Leave Note: CEN Health Care Staffing Resources data was not validated by the OIG. As of June 12, 2017, the Master Registry for CEN showed that the institution had a total population of 3,548. Within that total population, 0.6 percent were designated as high medical risk, Priority 1 (High 1), and 0.8 percent were designated as high medical risk, Priority 2 (High 2). Patients’ assigned risk levels are based on the complexity of their required medical care related to their specific diagnoses, frequency of higher levels of care, age, and abnormal laboratory results and procedures. High 1 has at least two high-risk conditions; High 2 has only one. Patients at high medical risk are more susceptible to poor health outcomes than those at medium or low medical risk. Patients at high medical risk also typically require more health care services than do patients with lower assigned risk levels. The chart below illustrates the breakdown of the institution’s medical risk levels at the start of the OIG medical inspection. CEN Master Registry Data as of June 12, 2017 Medical Risk Level Number of Patients Percentage High 1 20 0.6% High 2 30 0.8% Medium 588 16.6% Low 2,910 82.0% Total 3,548 100% California State Prison, Centinela, Cycle 5 Medical Inspection Page 2 Office of the Inspector General State of California O , S , M BJECTIVES COPE AND ETHODOLOGY In designing the medical inspection program, the OIG reviewed CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. The OIG also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the Receiver’s office, CDCR, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of the OIG’s inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates medical care delivery by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population-based metrics. To maintain a metric-oriented inspection program that evaluates medical care delivery consistently at each state prison, the OIG identified 15 indicators (14 primary (clinical) indicators and one secondary (administrative) indicator) of health care to measure. The primary quality indicators cover clinical categories directly relating to the health care provided to patients, whereas the secondary quality indicator addresses the administrative functions that support a health care delivery system. These 15 indicators are identified in the CEN Executive Summary Table on page iv of this report. The OIG rates each of the quality indicators applicable to the institution under inspection based on case reviews conducted by OIG clinicians and compliance tests conducted by OIG registered nurses. The ratings may be derived from the case review results alone, the compliance test results alone, or a combination of both these information sources. For example, the ratings for the primary quality indicators Quality of Nursing Performance and Quality of Provider Performance are derived entirely from the case review done by clinicians, while the ratings for the primary quality indicators Health Care Environment and Preventive Services are derived entirely from compliance testing done by registered nurse inspectors. As another example, primary quality indicators such as Diagnostic Services and Specialty Services receive ratings derived from both sources. Consistent with the OIG’s agreement with the Receiver, this report only addresses the conditions found related to medical care criteria. The OIG does not review for efficiency and economy of operations. Moreover, if the OIG learns of a patient needing immediate care, the OIG notifies the chief executive officer of health care services and requests a status report. Additionally, if the OIG learns of significant departures from community standards, it may report such departures to the institution’s chief executive officer or to CCHCS. Because these matters involve confidential medical information protected by state and federal privacy laws, specific identifying details related to any such cases are not included in the OIG’s public report. 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 California State Prison, Centinela, Cycle 5 Medical Inspection Page 3 Office of the Inspector General State of California quality indicator; therefore, recommendations for improvement should not necessarily be interpreted as indicative of deficient medical care delivery. CASE REVIEWS The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders, which continues in Cycle 5 medical inspections. The OIG’s clinicians perform a retrospective chart review of selected patient files to evaluate the care given by an institution’s primary care providers and nurses. Retrospective chart review is a well-established review process used by health care organizations that perform peer reviews and patient death reviews. Currently, CCHCS uses retrospective chart review as part of its death review process and in its pattern-of-practice reviews. CCHCS also uses a more limited form of retrospective chart review when performing appraisals of individual primary care providers. Patient Selection for Retrospective Case Reviews Because retrospective chart review is time consuming and requires qualified health care professionals to perform it, OIG clinicians must carefully sample patient records. Accordingly, the group of patients the OIG targeted for chart review carried the highest clinical risk and utilized the majority of medical services. A majority of the patients selected for retrospective chart review were classified by CCHCS as high-risk patients. The reason the OIG targeted these patients for review is twofold: 1. The goal of retrospective chart review is to evaluate all aspects of the health care system. statewide, high-risk and high-utilization patients consume medical services at a disproportionate rate; 11 percent of the total patient population are considered high-risk and account for more than half of the institution’s pharmaceutical, specialty, community hospital, and emergency costs. 2. Selecting this target group for chart review provides a significantly greater opportunity to evaluate all the various aspects of the health care delivery system at an institution. Underlying the choice of high-risk patients for detailed case review, the OIG clinical experts made the following three assumptions: 1. If the institution is able to provide adequate clinical care to the most challenging patients with multiple complex and interdependent medical problems, it will be providing adequate care to patients with less complicated health care issues. Because clinical expertise is required to determine whether the institution has provided adequate clinical 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 California State Prison, Centinela, Cycle 5 Medical Inspection Page 4 Office of the Inspector General State of California immunizations. To review these processes, the OIG simultaneously performs a broad compliance review. 3. Patient charts generated during death reviews, sentinel events (unexpected occurrences involving death or serious injury, or risk thereof), and hospitalizations are mostly of high-risk patients. Benefits and Limitations of Targeted Subpopulation Review Because the selected patients utilize the broadest range of services offered by the health care system, the OIG’s retrospective chart review provides adequate data for a qualitative assessment of the most vital system processes (referred to as “primary quality indicators”). Retrospective chart review provides an accurate qualitative assessment of the relevant primary quality indicators as applied to the targeted subpopulation of high-risk and high-utilization patients. While this targeted subpopulation does not represent the prison population as a whole, the ability of the institution to provide adequate care to this subpopulation is a crucial and vital indicator of how the institution provides health care to its whole patient population. Simply put, if the institution’s medical system does not adequately care for those patients needing the most care, then it is not fulfilling its obligations, even if it takes good care of patients with less complex medical needs. Since the targeted subpopulation does not represent the institution’s general prison population, the OIG cautions against inappropriate extrapolation of conclusions from the retrospective chart reviews to the general population. For example, if the high-risk diabetic patients reviewed have poorly-controlled diabetes, one cannot conclude that the entire diabetic population is inadequately controlled. Similarly, if the high-risk diabetic patients under review have poor outcomes and require significant specialty interventions, one cannot conclude that the entire diabetic population is having similarly poor outcomes. Nonetheless, the health care system’s response to this subpopulation can be accurately evaluated and yields valuable systems information. In the above example, if the health care system is providing appropriate diabetic monitoring, medication therapy, and specialty referrals for the high-risk patients reviewed, then it can be reasonably inferred that the health care system is also providing appropriate diabetic services to the entire diabetic subpopulation. However, if these same high-risk patients needing monitoring, medications, and referrals are generally not getting those services, it is likely that the health care system is not providing appropriate diabetic services to the greater diabetic subpopulation. Case Reviews Sampled As indicated in Appendix B, Table B–1: CEN Sample Sets, the OIG clinicians evaluated medical charts for 49 unique patients. Appendix B, Table B–4: CEN Case Review Sample Summary, clarifies that both nurses and physicians reviewed charts for 11 of those patients, for 60 reviews in total. Physicians performed detailed reviews of 20 charts, and nurses performed detailed reviews of 12 California State Prison, Centinela, Cycle 5 Medical Inspection Page 5 Office of the Inspector General State of California charts, totaling 32 detailed reviews. For detailed case reviews, physicians or nurses looked at all encounters occurring in approximately six months of medical care. Nurses also performed a limited or focused review of medical records for an additional 28 patients. These generated 922 clinical events for review (Appendix B, Table B–3: CEN Event-Program). The inspection tool provides details on whether the encounter was adequate or had significant deficiencies, and identifies deficiencies by programs and processes to help the institution focus on improvement areas. While the sample method specifically pulled only six chronic care patient records, i.e., three diabetes patients and three anticoagulation patients (Appendix B, Table B–1: CEN Sample Sets), the 49 unique patients sampled included patients with 155 chronic care diagnoses, including 11 additional patients with diabetes (for a total of 14) and one additional anticoagulation patient (for a total of 4) (Appendix B, Table B–2: CEN Chronic Care Diagnoses). The OIG’s sample selection tool allowed evaluation of many chronic care programs because the complex and high-risk patients selected from the different categories often had multiple medical problems. While the OIG did not evaluate every chronic disease or health care staff member, the overall operation of the institution’s system and staff were assessed for adequacy. The OIG’s case review methodology and sample size matched other qualitative research. The empirical findings, supported by expert statistical consultants, showed adequate conclusions after 10 to 15 charts had undergone full clinician review. In qualitative statistics, this phenomenon is known as “saturation.” The OIG found the Cycle 4 medical inspection sample size of 30 for detailed physician reviews far exceeded the saturation point necessary for an adequate qualitative review. At the end of Cycle 4 inspections, the case review results were reanalyzed using 50 percent of the cases; there were no significant differences in the ratings. To improve inspection efficiency while preserving the quality of the inspection, the samples for Cycle 5 medical inspections were reduced in number. In Cycle 5, for basic institutions with small high-risk populations, case review will use a sample size of detailed physician-reviewed cases 67 percent as large as that used in Cycle 4. For intermediate institutions and basic institutions housing many high-risk patients, case review physicians will use a sample 83 percent as large as that in Cycle 4. Finally, for the most medically complex institution, California Health Care Facility (CHCF), the OIG will continue to use a sample size 100 percent as large as that used in Cycle 4. CEN is a basic institution, and the physician sample was 67 percent (20 physician case reviews) of the Cycle 4 sample. 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. Providers would only escape OIG case review if institutional management successfully mitigated patient risk by having the more poorly performing providers care for the less complicated, low-utilizing, and lower-risk patients. The OIG’s clinicians concluded that the case review sample size was more than adequate to assess the quality of services provided. California State Prison, Centinela, Cycle 5 Medical Inspection Page 6 Office of the Inspector General State of California 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 June to August 2017, registered nurse inspectors attained answers to 88 objective medical inspection test (MIT) questions designed to assess the institution’s compliance with critical policies and procedures applicable to the delivery of medical care. To conduct most tests, inspectors randomly selected samples of patients for whom the testing objectives were applicable and reviewed their electronic unit health records. In some cases, inspectors used the same samples to conduct more than one test. In total, inspectors reviewed health records for 374 individual patients and analyzed specific transactions within their records for evidence that critical events occurred. Inspectors also reviewed management reports and meeting minutes to assess certain administrative operations. In addition, during the week of June 26, 2017, registered nurse 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 1,034 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 Cycle 5 medical inspection testing, the OIG reduced the number of compliance samples tested for 18 indicator tests from a sample of 30 patients to a sample of 25 patients. The OIG also removed some inspection tests upon stakeholder agreement that either were duplicated in the case reviews or had limited value. Lastly, for Cycle 4 medical inspections, the OIG tested two secondary (administrative) indicators; Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications, and have combined these tests into one Administrative Operations indicator for Cycle 5 inspections. For details of the compliance results, see Appendix A — Compliance Test Results. For details of the OIG’s compliance sampling methodology, see Appendix C — Compliance Sampling Methodology. California State Prison, Centinela, Cycle 5 Medical Inspection Page 7 Office of the Inspector General State of California Scoring of Compliance Testing Results After compiling the answers to the 88 questions for the ten applicable indicators, the OIG derived a score for each quality indicator by calculating the percentage score of all Yes answers for each of the questions applicable to a particular indicator, then averaging those scores. Based on those results, the OIG assigned a rating to each quality indicator of proficient (greater than 85 percent), adequate (between 75 percent and 85 percent), or inadequate (less than 75 percent). OVERALL QUALITY INDICATOR RATING FOR CASE REVIEWS AND COMPLIANCE TESTING The OIG derived the final rating for each quality indicator by combining the ratings from the case reviews and from the compliance testing, as applicable. When combining these ratings, the case review evaluations and the compliance testing results usually agreed, but there were instances when the rating differed for a particular quality indicator. In those instances, the inspection team assessed the quality indicator based on the collective ratings from both components. Specifically, the OIG clinicians and registered nurse inspectors discussed the nature of individual exceptions found within that indicator category and considered the overall effect on the ability of patients to receive adequate medical care. To derive an overall assessment rating of the institution’s medical inspection, the OIG evaluated the various rating categories assigned to each of the quality indicators applicable to the institution, giving more weight to the rating results of the primary quality indicators, which directly relate to the health care provided to patients. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed. POPULATION-BASED METRICS The OIG identified a subset of Healthcare Effectiveness Data Information Set (HEDIS) measures applicable to the CDCR patient population. To identify outcomes for CEN, the OIG reviewed some of the compliance testing results, randomly sampled additional 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 5 Medical Inspection Page 8 Office of the Inspector General State of California M I R EDICAL NSPECTION ESULTS The quality indicators assess the clinical aspects of health care. As shown on the CEN Executive Summary Table on page iv of this report, 13 of the OIG’s indicators were applicable to CEN. Of those 13 indicators, 7 were rated by both the case review and compliance components of the inspection, 3 were rated by the case review component alone, and 3 were rated by the compliance component alone. The Administrative Operations indicator is a secondary indicator, and, therefore, was not relied upon for the overall score for the institution. Based on the analysis and results in all the primary indicators, the OIG experts made a considered and measured opinion that the quality of health care at CEN was adequate. Summary of Case Review Results: The clinical case review component assessed 10 of the 13 primary and secondary indicators applicable to CEN. Of these ten indicators, OIG clinicians rated four proficient, five adequate, and one inadequate. The OIG physicians rated the overall adequacy of care for each of the 20 detailed case reviews they conducted. Of these 20 cases, 17 were adequate, and 3 were inadequate. In the 922 events reviewed, there were 90 deficiencies, of which 25 were considered to be of such magnitude that, if left unaddressed, they would likely contribute to patient harm. Adverse Events Identified During Case Review: Adverse events are medical errors which cause serious patient harm. Medical care is a complex and dynamic process with many moving parts, subject to human error even within the best health care organizations. Adverse events are typically identified and tracked by all major health care organizations for the purpose of quality improvement. They are not generally representative of medical care delivered by the organization. The OIG identified adverse events for the dual purposes of quality improvement and the illustration of problematic patterns of practice found during the inspection. Because of the anecdotal description of these events, the OIG cautions against drawing inappropriate conclusions regarding the institution based solely on adverse events. There were two adverse events identified in the case reviews at CEN:  In case 21, the patient had an abnormally slow heart rate (bradycardia). The provider diagnosed the patient with anxiety and prescribed atenolol, a medication commonly prescribed for high blood pressure, not for anxiety. Furthermore, atenolol was well known to slow the heart rate and should not have been prescribed for a patient with existing bradycardia. The provider placed the patient at risk for worsening bradycardia, low blood pressure, loss of consciousness, or stroke. Subsequently, the patient became dizzy, fell down, and was transferred to a community hospital. He was found to have severe bradycardia of 35 beats per minute, fractures around his right eye and nose, and multiple facial lacerations. This case is further discussed in the Quality of Provider Performance indicator. California State Prison, Centinela, Cycle 5 Medical Inspection Page 9 Office of the Inspector General State of California  In case 25, the patient had a traumatic eye injury following an altercation. The TTA nurse noted visible blood inside the eyeball. The abnormal finding was suggestive of a serious eye injury; immediate medical attention was needed. The TTA nurse did not immediately consult with a provider or transfer the patient to a community emergency department, but instead sent the patient back to his housing unit. Two days later, the patient was seen at a community hospital where a computerized tomography (CT) scan showed a ruptured right orbit. This case is discussed in the Emergency Services indicator. Summary of Compliance Results: The compliance component assessed 10 of the 13 indicators applicable to CEN. Of these ten indicators, OIG inspectors rated three proficient, four adequate, and three 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 5 Medical Inspection Page 10 Office of the Inspector General State of California ACCESS TO CARE This indicator evaluates the institution’s ability to provide patients Case Review Rating: with timely clinical appointments. Areas specific to patients’ access Adequate to care are reviewed, such as initial assessments of newly arriving Compliance Score: inmates, acute and chronic care follow-ups, face-to-face nurse Adequate appointments when a patient requests to be seen, provider referrals (79.6%) from nursing lines, and follow-ups after hospitalization or specialty Overall Rating: care. Compliance testing for this indicator also evaluates whether Adequate patients have Health Care Services Request forms (CDCR Form 7362) available in their housing units. Case Review Results For the Access to Care indicator, the OIG clinicians reviewed 613 provider, nurse, specialty, and hospital events that required a follow-up appointment. Seven deficiencies were identified, six of which were significant. The case review rating for the Access to Care indicator was adequate. Provider-to-Provider Follow-up Appointments CEN performed well with provider-ordered follow-up appointments, which are important elements for this indicator. The OIG clinicians identified only one significant deficiency whereby a provider appointment did not occur timely:  In case 46, a provider evaluated the patient for lower back pain and requested a follow-up appointment in two weeks, but this appointment occurred in five weeks. RN Sick Call Access The sick call process at CEN was well-organized and provided patients with timely access to health care. RN-to-Provider Referrals Nurses assessed patients and referred them to providers as needed. The OIG clinicians identified one significant deficiency:  In case 21, a registered nurse (RN) evaluated the patient for extreme pain in the right hand and arm and requested a provider appointment in 14 days, but the appointment occurred in 30 days. California State Prison, Centinela, Cycle 5 Medical Inspection Page 11 Office of the Inspector General State of California RN Follow-up Appointments The institution performed well with scheduling and completing RN appointments generated by providers or nurses. Intra-System Transfers CEN performed sufficiently with ensuring patients who transferred in from another CDCR facility were given timely provider and RN care manager appointments. Performance in this area is detailed in the Inter- and Intra-System Transfers indicator. Follow-up after Hospitalization Provider follow-up appointments after hospitalization should occur in a time frame that ensures patient safety and optimal clinical outcomes, and in all cases, no later than five days from the day the patient was discharged from the hospital. CEN performed very well with these appointments, as there were no deficiencies identified. Specialized Medical Housing The provider saw patients in the correctional treatment center (CTC) timely and performed history and physical exams on all newly admitted patients; there were no deficiencies related to follow-up encounters from the CTC. Provider Follow-Up after Specialty Service Visits After specialty service visits, all patients should be evaluated by a provider within 14 days or earlier if indicated. CEN performed well with these appointments; however, there was one significant deficiency:  In case 15, the patient was seen by the ear, nose, and throat specialist. The provider follow-up appointment was required within 14 days to address the specialist’s recommendation, but did not occur for 42 days. Clinician Onsite Inspection During the onsite visit, clinic nurses reported seeing eight to ten patients each day, while the providers saw approximately 16 patients each day. Each clinic had a designated office technician who attended daily clinic huddles and coordinated with the providers to ensure that all important follow-up appointments were scheduled. According to the office technicians, there were no significant backlogs of appointments in any of the five clinics. Case Review Conclusion CEN performed well with regard to the Access to Care indicator, as most provider and nurse appointments occurred timely. The OIG clinicians rated this indicator adequate. California State Prison, Centinela, Cycle 5 Medical Inspection Page 12 Office of the Inspector General State of California Compliance Testing Results The institution performed in the adequate range in the Access to Care indicator, with a compliance score of 79.6 percent. CEN earned proficient scores on the following tests:  Inspectors sampled 30 Health Care Services Request forms (CDCR Form 7362) submitted by patients across all facility clinics. Nursing staff reviewed all of the forms on the same day they were received (MIT 1.003).  Among the five health care services request forms sampled on which nursing staff referred the patient for a provider appointment, all five patients received a timely appointment (MIT 1.005).  For the one patient nursing staff referred to a provider, and for whom that provider subsequently ordered a follow-up appointment, the follow-up appointment occurred timely (MIT 1.006).  Patients had access to health care services request forms at all six housing units the OIG inspected (MIT 1.101).  For 28 of the 30 patients sampled who submitted health care services request forms (93 percent), nursing staff completed or offered a face-to-face encounter with the patient within one business day of reviewing the request form. In one exception, the nurse conducted the encounter two days late; in the other exception, there was no evidence found that a face-to-face encounter occurred (MIT 1.004). The institution showed room for improvement on the following tests:  Among 22 sampled patients who were discharged from a community hospital, only 8 (36 percent) received a timely provider follow-up appointment upon their return to CEN. Eight patients received their follow-up appointments from one to 20 days late, and another patient received his follow-up appointment 44 days late. For five other patients, there was no evidence found to indicate they ever received follow-up appointments (MIT 1.007).  Only 15 of 26 sampled patients who received a high-priority or routine specialty service (58 percent) also received a timely follow-up appointment with a provider. Among the 11 patients who did not receive a timely follow-up appointment, 8 patients’ high-priority specialty service follow-up appointments were 2 to 25 days late, 2 other patients’ follow-up appointments were 39 and 46 days late, and another patient did not receive a follow-up appointment at all (MIT 1.008).  Inspectors sampled 25 patients who suffered from one or more chronic care conditions to ascertain if their follow-up appointments occurred within required time frames. Sixteen California State Prison, Centinela, Cycle 5 Medical Inspection Page 13 Office of the Inspector General State of California patients received their follow-up appointments timely (64 percent). Nine patients received their appointments late or not at all, including five patients whose follow-up appointments occurred between one and 16 days late; two patients whose appointments were 33 and 53 days late; and two patients whose appointments did not occur (MIT 1.001).  Among 23 applicable patients sampled who transferred into CEN from other institutions and were referred to a provider based on nursing staff’s initial health care screening, only 15 (65 percent) were seen timely. Five patients received their provider appointments from 6 to 96 days late; for three other patients, there was no evidence found to indicate they were ever seen (MIT 1.002). California State Prison, Centinela, Cycle 5 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 services Proficient were timely provided to patients, whether the primary care provider Compliance Score: timely reviewed the results, and whether the results were Inadequate communicated to the patient within the required time frames. In (73.3%) addition, for pathology services, the OIG determines whether the Overall Rating: institution received a final pathology report and whether the provider Adequate timely reviewed and communicated the pathology results to the patient. The case reviews also factor in the appropriateness, accuracy, and quality of the diagnostic test(s) ordered and the clinical response to the results. For this indicator, the case review and compliance review processes yielded different results, with the case review giving a proficient rating and the compliance review resulting in an inadequate score. While case review found very few problems, the compliance testing identified problems with provider review of diagnostic reports and pathology report review and communicating pathology results. The OIG’s internal review process considered those factors that led to both scores and ultimately rated this indicator adequate. Case Review Results The OIG clinicians reviewed 131 events in diagnostic services and found only one minor deficiency. Test Completion CEN had an effective laboratory process, as most requested laboratory tests were done timely; however, there was one minor deficiency:  In case 11, a provider started the patient on warfarin (a blood thinner medication) and requested an INR (blood test for monitoring the effects of warfarin) to be done in four days; the test was done one day late. CEN also had an effective diagnostic procedure process; most X-rays, ultrasounds, CT scans, and magnetic resonance imaging (MRI) scans were done timely. Health Information Management Most laboratory reports and diagnostic procedure reports were retrieved and scanned into the electronic medical records. California State Prison, Centinela, Cycle 5 Medical Inspection Page 15 Office of the Inspector General State of California Clinician Onsite Inspection Each of the five main clinics had an assigned phlebotomist for drawing blood, which ensured that laboratory tests were done timely. CEN also had an effective tracking process to ensure that all diagnostic procedures were done timely. Case Review Conclusion Given the lack of deficiencies, the OIG clinicians rated the Diagnostic Services indicator at CEN proficient. Compliance Testing Results The institution received an inadequate compliance score of 73.3 percent in the Diagnostic Services indicator, which encompasses radiology, laboratory, and pathology services. For clarity, each type of diagnostic service is discussed separately, as follows: Radiology Services  All ten of the radiology services sampled were timely performed (MIT 2.001). CEN providers timely reviewed the corresponding diagnostic services reports for only two of the ten patients (20 percent). The other eight reports were not scanned into the patients’ electronic medical records and providers did not evidence review of the reports by initial and date as per CCHCS policy (MIT 2.002). However, providers timely communicated all ten test results to their patients (MIT 2.003). Laboratory Services  Nine of the ten laboratory services sampled were timely performed (90 percent); one service was provided one day late (MIT 2.004). For all ten sampled services, the provider timely reviewed the corresponding diagnostic reports and timely reported those results to the patient (MIT 2.005, 2.006). Pathology Services  CEN timely received seven of the ten sampled final pathology reports (70 percent). Three diagnostic reports were received one, 19, and 25 days late (MIT 2.007). With regard to providers’ review, providers evidenced review by initialing and dating only five out of ten sampled final pathology reports (50 percent); for five reports, there was no evidence of review (MIT 2.008). Further, providers communicated pathology results timely to only three of the ten patients who received services (30 percent). For five patients, the provider communicated the results from one to 41 days late. For two patients, inspectors did not find evidence in the electronic medical record that the patients received notification of their test results (MIT 2.009). California State Prison, Centinela, Cycle 5 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 Overall Rating: reviews emergency response services including first aid, basic life Adequate support (BLS), and advanced cardiac life support (ACLS) 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 22 urgent or emergent events and found 16 deficiencies with various aspects of emergency care, 4 of which were considered significant. CPR Response The medical emergency CPR response was adequate. Minor deficiencies were identified related to emergent event timelines and to nurses not properly documenting reassessment of the patient’s condition after CPR was initiated. These minor deficiencies did not affect patient care. Provider Performance Providers generally made appropriate triage decisions for patients in the TTA and were available for consultation with the TTA nursing staff. However, there was one significant deficiency:  In case 5, the patient was assaulted and sustained a deep laceration to his neck. The patient was losing a great deal of blood and was near death. The TTA staff attempted to contact the on-call provider multiple times, but the provider did not return the call until 23 minutes later. Nursing Performance Nursing performance during emergency responses was appropriate; however, there were two significant deficiencies, as follows:  In case 21, the patient was brought into the TTA for evaluation and treatment of head, eye, ear, and face injuries from a fall; the nurse failed to monitor the patient’s vital signs or neurological status (assessment of speech, level of consciousness, pupil size). Head injures California State Prison, Centinela, Cycle 5 Medical Inspection Page 17 Office of the Inspector General State of California require monitoring of vital signs and neurological status every 15 minutes. The nurse took the patient’s vital signs only twice and assessed the neurological status only once during the patient’s TTA admission and did not reassess the patient before he was sent out to the community hospital emergency department 90 minutes later.  In case 25, the patient had a traumatic eye injury following an altercation, in which the patient sustained serious injuries to his right eye and right hand as well as lacerations to his right eyelid and left ear. The TTA nurse noted visible blood inside the patient’s eyeball, but still failed to notify or consult a provider. CDCR protocols for eye injuries specifically require the nurse to notify the provider immediately when the above condition occurs. Furthermore, head injures require nurses to monitor vital signs and neurological status (assessment of speech, level of consciousness, pupil size) every 15 minutes. The nurse failed to monitor the patient’s vital signs or neurological status before he was sent back to his housing unit. Two days later, the patient was seen at a community hospital and the CT scan showed a ruptured right eyeball. Patient Environment Custody officers and medical staff generally provided coordinated emergent medical care; however, there was one significant deficiency related to this process:  In case 25, the patient sustained a swollen right eye and right hand following an altercation. Seventy-five minutes passed before the patient arrived at the TTA. Since the patient had head and eye injuries, he should have been transported by wheelchair, but instead CEN staff had the patient walk to the TTA. There was also no documented evidence that basic first aid treatment was administered prior to arrival in the TTA for lacerations of the ear, eyelid, or swollen right hand. Emergency Medical Response Review Committee The OIG reviewed six cases in which patients required emergency medical responses, all of which were determined to be appropriate. In all cases, patients were sent out to local emergency rooms. The Emergency Medical Response Review Committee (EMRRC) reviewed cases for compliance to response times, training issues, and compliance with policies for emergency response. When the EMRRC found delayed response times, training issues, or non-compliance with emergency response policies, training was provided. Signature sheets were available and reviewed for individual or group training. The committee reviewed all unscheduled transfers each month. Clinician Onsite Inspection The TTA had two beds and was well staffed with nurses; two nurses were scheduled for all three watches. A provider was assigned to the TTA during working hours, and on-call providers were available during after-hours. TTA nursing staff were knowledgeable and comfortable with California State Prison, Centinela, Cycle 5 Medical Inspection Page 18 Office of the Inspector General State of California emergency procedures. Every morning, the institution emailed a report updating and summarizing all pertinent patient events to providers, SRNs, and facility administrators. The TTA staff was well-organized and prepared to provide emergency medical response. For example, in the TTA, a white board listing seven assigned roles for emergency responders (airway, compressions, medications, scribe, runner, on-call provider, and notations) kept all team members aware of their role during an emergency response. The Chief Nursing Executive (CNE) explained the institution’s current plan to train RNs, LVNs, and PTs in Advanced Trauma Life Support (ATLS), which included the CNE training nurses in the early management of severe trauma. According to the CNE, this training would help ensure confidence and assistance to the LVNs and RNs, since most of the LVNs had never seen or experienced the kind of physical injuries seen in prisons. The CNE confirmed that most of the current TTA nurses had experience working at the local emergency departments and had excellent emergency skills. Case Review Conclusion Providers and nurses delivered good care during emergency responses. Nurses could improve with their assessments and interventions. CEN leadership agreed the TTA nurses needed additional training and were making plans to train them. The OIG clinicians rated the Emergency Services indicator adequate. California State Prison, Centinela, Cycle 5 Medical Inspection Page 19 Office of the Inspector General State of California HEALTH INFORMATION MANAGEMENT Health information management is a crucial link in the delivery of Case Review Rating: medical care. Medical personnel require accurate information in Proficient order to make sound judgments and decisions. This indicator Compliance Score: examines whether the institution adequately manages its health care Proficient information. This includes determining whether the information is (89.3%) correctly labeled and organized and available in the electronic health Overall Rating: record; whether the various medical records (internal and external, Proficient e.g., hospital and specialty reports and progress notes) are obtained and scanned timely into the patient’s electronic health record; whether records routed to clinicians include legible signatures or stamps; and whether hospital discharge reports include key elements and are timely reviewed by providers. CEN converted to the new Electronic Health Record System (EHRS) in February 2017; therefore, the institution is considered to be a hybrid, with testing occurring in both the EHRS and the electronic Unit Health Record (eUHR). Case Review Results The OIG clinicians identified three deficiencies related to health information management, none of which were significant. Interdepartmental Transmission The OIG did not identify any deficiencies in medical records transmitted between the departments within the institution. Hospital Records The OIG clinicians reviewed 25 community hospital events, including emergency department visits. In all events reviewed, hospital records were timely retrieved, reviewed, and scanned into the electronic medical records. Missing Documents (Progress Notes and Forms) Most nursing and provider progress notes were scanned into the electronic medical records; however, there was one missing document:  In case 9, during a TTA event, a provider ordered for the patient to be administered naloxone, but the order was neither retrieved nor scanned into the medical record. California State Prison, Centinela, Cycle 5 Medical Inspection Page 20 Office of the Inspector General State of California Laboratory and Diagnostic Reports Laboratory and diagnostic procedure reports were properly retrieved and scanned into the electronic medical records. No deficiencies were identified in this area. Specialty Services Reports Specialty services reports were timely retrieved and scanned into the electronic medical records. No deficiencies were identified in this area. Legibility Most provider and nursing progress notes were dictated or legible. Scanning Performance Two minor deficiencies related to scanning performance were identified:  In case 6, a nursing assessment was mislabeled as a TTA provider progress note.  In case 25, one patient’s health care services request (CDCR Form 7362) was scanned into the electronic medical record of another patient. Clinician Onsite Inspection The OIG clinicians observed the care team’s daily huddle. Detailed information was shared and included laboratory values, radiology results, and pending procedures. The team also discussed patients who required medical care after-hours as well as those patients that were hospitalized. The clinical team shared information to ensure team members were up to date and aware of anticipated patient care needs for the next few days. Case Review Conclusion Health information deficiencies were rarely identified in the case reviews. The OIG clinicians rated the Health Information Management indicator proficient. Compliance Testing Results CEN received a proficient compliance score of 89.3 percent in the Health Information Management indicator, earning proficient scores on the following three tests:  The institution scanned all 13 non-dictated healthcare documents sampled into patients’ electronic medical records as per policy guidelines (MIT 4.001).  The OIG tested 20 patients’ discharge records to determine whether staff timely scanned the records into patients’ electronic medical records, and all 20 samples were compliant (MIT 4.004). California State Prison, Centinela, Cycle 5 Medical Inspection Page 21 Office of the Inspector General State of California  Among 22 sampled patients admitted to a community hospital and then returned to the institution, providers reviewed 21 patients’ corresponding hospital discharge reports (95 percent) within three calendar days of the patient’s discharge. For one sampled patient, the provider reviewed the discharge report two days late (MIT 4.007). One test earned an adequate score:  The institution’s health information management staff timely scanned 16 of 20 specialty service consultant reports sampled into the patients’ electronic medical records (80 percent). Three specialty reports were each scanned one day late; one other report was scanned 66 days late (MIT 4.003). One test scored in the inadequate range:  The institution scored 71 percent in its labeling and filing of documents scanned into patients’ electronic medical records. For this test, once the OIG identifies 24 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 seven documents with scanning errors; five documents were mislabeled and two documents were missing from the electronic medical record (MIT 4.006). California State Prison, Centinela, Cycle 5 Medical Inspection Page 22 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 patient visits, and Inadequate (74.6%) the sufficiency of facility infrastructure to conduct comprehensive medical examinations. Rating of this component is based entirely on Overall Rating: the compliance testing results from the visual observations inspectors Inadequate make at the institution during their onsite visit. This indicator is evaluated entirely by compliance testing. There is no case review portion. Compliance Testing Results The institution received an inadequate compliance score of 74.6 percent in the Health Care Environment indicator, showing room for improvement in the following areas:  The inspectors examined multiple emergency medical response bags (EMRBs) to determine if they were inspected daily and inventoried monthly and whether they contained all essential items. Emergency medical response bags were compliant in only three of the eight clinical locations (38 percent). In five clinical locations, there was no documentation indicating that an inventory of the EMRB had been completed in the previous 30 days, and one EMRB was missing multiple entries from staff verifying the bag’s compartments were sealed and intact (MIT 5.111).  Only four of the nine applicable clinic locations met compliance requirements for essential core medical equipment and supplies (44 percent). The remaining five clinics were missing one or more functional pieces of properly calibrated core equipment or other medical Figure 1: Food stored in supplies necessary to conduct a comprehensive exam. The same area as medical missing items included an exam table, disposable exam supplies table paper, a nebulization unit, an oto-ophthalmoscope, hemoccult cards and developers, lubricating jelly, and a peak flow meter. In addition, one exam room had an oto-ophthalmoscope that was not operational at the time of the inspection (MIT 5.108).  Only five of the ten clinics inspected followed adequate medical supply storage and management protocols (50 percent). In five clinics, one or more of the following deficiencies were identified: staff’s personal items were stored long term in the same area as medical supplies (Figure 1), and several medical supplies were stored beyond the manufacturers’ guidelines (MIT 5.107). California State Prison, Centinela, Cycle 5 Medical Inspection Page 23 Office of the Inspector General State of California  Six of the ten clinic exam rooms observed had appropriate space, configuration, supplies, and equipment to allow clinicians to perform a proper clinical examination (60 percent). In four clinics, one or more deficiencies were identified: exam tables had torn vinyl covers (Figure 2); clinicians’ access to exam tables was impeded; patients were unable to lie fully extended on the exam tables due to physical obstructions (Figure 3); and confidential records Figure 2: Exam table with were visible and easily accessible to inmate porters torn vinyl (MIT 5.110).  Clinicians followed good hand hygiene practices in seven of the ten clinics observed (70 percent). At three clinic locations, clinicians failed to wash their hands before or after patient contact or before applying gloves (MIT 5.104). One test scored in the adequate range:  When inspecting for proper protocols to mitigate exposure to Figure 3: Exam table with blood-borne pathogens and contaminated waste, eight of the impeded access ten clinics (80 percent) followed acceptable protocols. In two clinics, exam rooms did not have a puncture-resistant container available to medical staff for expended needles and sharps (MIT 5.105). The following tests received proficient scores:  All ten clinics examined were appropriately disinfected, cleaned, and sanitary. More specifically, in all clinics, inspectors observed areas that were clean and not visibly dusty or dirty. In addition, cleaning logs were present and completed, indicating cleaning crews regularly cleaned the areas (MIT 5.101).  Clinical health care staff at all ten applicable clinics ensured that reusable invasive and non-invasive medical equipment was properly sterilized or disinfected (MIT 5.102).  The non-clinic bulk medical supply storage areas met the supply management process and support needs of the medical health care program, earning CEN a score of 100 percent on this test (MIT 5.106).  All ten clinic locations inspected had operable sinks. Of those ten clinic locations, nine had sufficient quantities of hygiene supplies in the exam areas (90 percent). In one clinic, the patient restroom did not have sufficient quantities of hygiene supplies, such as antiseptic soap (MIT 5.103). California State Prison, Centinela, Cycle 5 Medical Inspection Page 24 Office of the Inspector General State of California  Clinic common areas at eight of the nine applicable clinics had environments conducive to providing medical services (89 percent). In one clinic, the location of the vital signs station compromised patients’ auditory privacy (MIT 5.109). 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. The OIG does not score this question. When OIG inspectors interviewed health care managers, they did not identify any significant concerns. At the time of the OIG’s medical inspection, CEN had several significant infrastructure projects underway, which included increasing clinic spaces and renovating the central health clinic. These projects started in fall 2017, and the institution estimated that they would be completed by fall 2019 (MIT 5.999). California State Prison, Centinela, Cycle 5 Medical Inspection Page 25 Office of the Inspector General State of California INTER- AND INTRA-SYSTEM TRANSFERS This indicator focuses on the management of patients’ medical needs Case Review Rating: and continuity of patient care during the inter- and intra-system Proficient transfer process. The patients reviewed for this indicator include Compliance Score: those received from, as well as those transferring out to, other CDCR Proficient (89.9%) institutions. The OIG review includes evaluation of the institution’s ability to provide and document health screening assessments, Overall Rating: initiation of relevant referrals based on patient needs, and the Proficient continuity of medication delivery to patients arriving from another institution. For those patients, the OIG clinicians also review the timely completion of pending health appointments, tests, and requests for specialty services. For patients who transfer out of the institution, the OIG evaluates the ability of the institution to document transfer information that includes pre-existing health conditions, pending appointments, tests and requests for specialty services, medication transfer packages, and medication administration prior to transfer. The OIG clinicians also evaluate the care provided to patients returning to the institution from an outside hospital and check to ensure appropriate implementation of the hospital assessment and treatment plans. Case Review Results The OIG clinicians reviewed 47 inter- and intra-system transfer events, which included information from both the sending and receiving institutions. These cases included 25 hospitalizations and outside emergency room events, of which 17 resulted in a transfer back to the institution. There were eight deficiencies identified, of which three were significant. Transfers In Nurses performed thorough screening examinations on the 16 patients arriving to CEN. Review of medication administration records showed that patients received medications without a lapse in continuity. In the cases reviewed, nurses at CEN ensured that patients received all of their medical equipment, such as canes and diabetic supplies.  In case 28, on the morning of the diabetic patient’s arrival, the nurse discovered an elevated blood glucose level. The patient refused his insulin. The nurse demonstrated excellent care by documenting the problem and notifying the other team members of the new patient’s situation. Most patients who transferred into CEN were seen and evaluated within the clinical time frames established by CCHCS. However, the OIG found three exceptions to this otherwise reliable process.  In case 26, the high-risk patient with asthma, hypertension, seizures, dyslipidemia, and obesity arrived at CEN from another institution. The RN care manager appointment did not occur. California State Prison, Centinela, Cycle 5 Medical Inspection Page 26 Office of the Inspector General State of California  In case 28, the receiving nurse requested a provider follow-up appointment within 19 days for the high-risk patient with skin cancer, diabetes, hypertension, and high cholesterol. However, the appointment did not occur for 44 days (25 days late).  Additionally, in case 28, the RN care manager did not see the high-risk patient within the 30-day time frame established by CCHCS. The RN care manager was supposed to evaluate the patient to develop and implement a plan of care for the patient’s diabetes, high blood pressure, and high cholesterol. The appointment did not occur. Transfers Out Five patients transferred to other facilities. CEN’s nurses who completed transfer information added important information not usually seen on transfer records, such as phone numbers and addresses for pending specialists’ appointments. 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. Nurses in CEN’s TTA did very well scheduling follow-up appointments for patients returning from hospitalizations and outside treatments, reviewing hospital discharge recommendations with the provider, and in completing patient assessments, such as current pain status and need for starting new medication orders. Clinician Onsite Inspection The TTA nurses assessed all patients who returned from hospitalization. In addition to verbal instructions, nurses provided appropriate written materials to educate patients, and gave patients the opportunity to discuss information and ask questions. Case Review Conclusion The institution performed well with regard to Inter- and Intra-System Transfers; therefore, the indicator rating was proficient. Compliance Testing Results The institution obtained a proficient score of 89.9 percent in the Inter- and Intra-System Transfers indicator, receiving proficient scores on the following tests:  Nursing staff timely completed the assessment and disposition sections of the screening form for all 22 applicable patients sampled (MIT 6.002). California State Prison, Centinela, Cycle 5 Medical Inspection Page 27 Office of the Inspector General State of California  The OIG inspected the transfer packages of nine patients who were transferring out of the institution to determine whether the packages included required medications and support documentation. All packages were compliant (MIT 6.101).  The OIG inspectors tested 20 patients who transferred out of CEN to another CDCR institution to determine whether their scheduled specialty service appointments were listed on the health care transfer form. CEN nursing staff identified the scheduled appointments for 19 of the sampled patients (95 percent). For one patient, nursing staff did not document a pending specialty service on the transfer form (MIT 6.004).  For 22 of 25 sampled patients (88 percent) who transferred into CEN from another CDCR institution, nursing staff completed an initial health screening form (CDCR Form 7277) on the same day the patient arrived. Three patients’ forms had questions with affirmative answers, but lacked the required explanatory language (MIT 6.001). CEN showed room for improvement on the following test:  Among the three applicable sampled patients who transferred to CEN with an existing medication order, two patients received their medications without interruption (67 percent). Upon arrival, one patient incurred a medication interruption of more than one dosing period (MIT 6.003). California State Prison, Centinela, Cycle 5 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 Case Review Rating: appropriate pharmaceutical administration and security Inadequate management, encompassing the process from the written Compliance Score: prescription to the administration of the medication. By combining Inadequate (61.2%) both a quantitative compliance test with case review analysis, this assessment identifies issues in various stages of the medication Overall Rating: management process, including ordering and prescribing, Inadequate transcribing and verifying, dispensing and delivering, administering, and documenting and reporting. Because effective medication management is affected by numerous entities across various departments, this assessment considers internal review and approval processes, pharmacy, nursing, health information systems, custody processes, and actions taken by the prescriber, staff, and patient. Case Review Results The OIG clinicians evaluate pharmacy and medication management as secondary processes as they relate to the quality of clinical care provided. Compliance testing is a more targeted approach and is heavily relied on for the overall rating of this indicator. The OIG clinicians evaluated 42 events related to medication management and identified 7 deficiencies, of which 5 were significant. Intra-System and Intra-Facility Transfers and Medication Continuity CEN performed appropriately to ensure medication continuity in newly arriving patients. Most patients transferring from other institutions into CEN arrived with their medications. Nurses were diligent in ensuring patients received missing medications, and retrieved these medications from the Omnicell (drug storage cabinet). Nurses also ensured patients had ample doses of keep-on-person (KOP) medications until they were evaluated by the providers. Provider Notification Nurses generally informed CEN’s providers when patients refused their medications or did not show up at the pill lines. Medication Administration The institution’s medication staff performed poorly with medication administration; there were strong patterns of deficiencies related to nurse-administered medications.  In case 10, a provider prescribed warfarin (a blood thinner medication) for two consecutive days. The patient did not receive warfarin on the second day. California State Prison, Centinela, Cycle 5 Medical Inspection Page 29 Office of the Inspector General State of California  Also in case 10, the patient returned from the hospital with pneumonia. A provider prescribed an antibiotic to be given to the patient once a day for five days. The medication nurses only dispensed the medication to the patient for four days; therefore, the patient was undertreated.  In case 22, the patient had pneumonia and was admitted to the CTC. A provider ordered antibiotics to be given to the patient twice a day. The patient did not receive his evening dose of antibiotic on the following day.  Later in case 22, a provider discharged the patient from the CTC and again prescribed antibiotics be given to the patient twice a day. The patient did not receive his evening dose of antibiotic on that same day.  In case 29, the patient had hypotension (low blood pressure) and was admitted to the CTC. A provider prescribed an oral corticosteroid to be given the following day. The patient did not receive the medication until the second day. Clinician Onsite Inspection During the onsite visit, the patient care teams discussed medication issues in the morning huddles. The nurses disclosed problems with medications or patient refusals of medications. The provider was informed of medications that needed to be refilled to ensure timely renewal. Numerous clinical staff contributed information to assure continuity of medication administration. Case Review Conclusion CEN performed poorly with medication administration. The OIG clinicians rated the Pharmacy and Medication Management indicator inadequate. Compliance Testing Results The institution received an inadequate compliance score of 61.2 percent in the Pharmacy and Medication Management indicator. For discussion purposes below, this indicator is divided into three sub-indicators: medication administration, observed medication practices and storage controls, and pharmacy protocols. Medication Administration In this sub-indicator, the institution received an inadequate score of 60.9 percent, with room for improvement on the following tests:  Nursing staff administered medications without interruption to only two of eight patients (25 percent) who were en route from one institution to another and had a temporary layover at CEN. Six patients missed multiple doses of their medication during the layover period (MIT 7.006). California State Prison, Centinela, Cycle 5 Medical Inspection Page 30 Office of the Inspector General State of California  CEN timely provided prescribed medications to only 10 of 22 sampled patients (45 percent) who had been discharged from a community hospital and returned to the institution. For 12 patients, medications were either ordered outside of the required time frame, provided late, or administered late (MIT 7.003).  Among 13 applicable patients sampled, only 7 (54 percent) timely received their chronic care medications. Four patients did not receive their KOP medications on time. For one other patient, there were unexplained missing doses, and there was no provider referral made for one final patient who refused multiple doses of medication (MIT 7.001). The institution scored in the proficient range on the following tests:  Of the 25 sampled patients at CEN who had transferred from one housing unit to another, 23 (92 percent) received their prescribed medications without interruption. Two patients each missed one dose of medication at the next dosing interval after their transfers occurred (MIT 7.005).  Among 25 patients sampled, 22 (88 percent) received their newly ordered medication in a timely manner. One patient received his nurse-administered medication one day late. One other patient received his supply of KOP medication 30 days late, and for one final patient, there was no evidence found that he received his ordered supply of KOP medication (MIT 7.002). Observed Medication Practices and Storage Controls In this sub-indicator, the institution received an inadequate score of 49.8 percent, with improvement needed on the following tests:  Non-narcotic refrigerated medications were properly stored at only one of nine clinics and medication line storage locations (11 percent). At eight locations, one or more deficiencies were identified: refrigerator temperatures were not kept within the acceptable range or the temperature logbook was not being completed; the refrigerator contained an open vial of insulin with an expired date; and medication line locations did not have designated areas for refrigerated medication to be returned to the pharmacy (MIT 7.103).  The institution employed adequate security controls over narcotic medications in only one of the eight applicable clinic and medication line locations (13 percent). At seven clinics, the narcotics log book lacked evidence on multiple dates that a controlled substance inventory was performed by two licensed nursing staff (MIT 7.101).  CEN properly stored non-narcotic medications not requiring refrigeration in two of the eight applicable clinics and medication line locations (25 percent). In six locations, one or more deficiencies were observed: lack of a designated area for medications to be returned to the pharmacy; external and internal medications were not properly separated; multi-use California State Prison, Centinela, Cycle 5 Medical Inspection Page 31 Office of the Inspector General State of California medications were not labeled with the date they were opened; and medication was found stored beyond the manufacturers’ guidelines (MIT 7.102).  At three of six applicable medication preparation and administration locations (50 percent), staff followed appropriate administrative controls and protocols when distributing medication to patients. At one location, the nurse did not crush and float medication as ordered. At another location, the nurse did not always ensure patients had swallowed direct observation therapy (DOT) medications. At another location, patients did not have sufficient outdoor cover to protect them from heat or inclement weather (MIT 7.106). CEN received proficient scores of 100 percent on the following two tests:  At all six of the inspected medication line locations, nursing staff were compliant with proper hand hygiene protocols (MIT 7.104).  Nursing staff at all six of the inspected medication line locations employed appropriate administrative controls and followed protocols during medication preparation (MIT 7.105). Pharmacy Protocols In this sub-indicator, CEN received an adequate score of 75.2 percent, comprised of scores received at the institution’s main pharmacy. CEN received proficient scores on the following tests:  In its main pharmacy, the institution followed general security, organization, and cleanliness management protocols; properly stored and monitored non-narcotic medications that required refrigeration; and maintained adequate controls over and properly accounted for narcotic medications (MIT 7.107, 7.109, 7.110). The institution received an adequate score of the following test:  Out of 25 medication error follow-up reports the OIG reviewed, 19 were timely and correctly processed (76 percent). One report’s review was completed two days late. The monthly medication error statistical report for August 2016 was submitted to the chief of pharmacy services eight days late, which accounted for five other untimely reports (MIT 7.111). CEN showed room for improvement on the test below:  In its main pharmacy, CEN did not properly store non-refrigerated medication. Inspectors found medication boxes stored on the floor of the pharmacy (MIT 7.108). California State Prison, Centinela, Cycle 5 Medical Inspection Page 32 Office of the Inspector General State of California Non-Scored Tests  In addition to testing reported medication errors, OIG inspectors follow up on any significant medication errors found during compliance testing to determine whether the errors were properly identified and reported. The OIG provides those results for information purposes only. At CEN, the OIG did not find any applicable medication errors (MIT 7.998).  The OIG interviewed patients in isolation units to determine if they had immediate access to their prescribed KOP rescue medications. All 10 of the sampled patients had access to their rescue medications (MIT 7.999). California State Prison, Centinela, Cycle 5 Medical Inspection Page 33 Office of the Inspector General State of California PRENATAL AND POST-DELIVERY SERVICES This indicator evaluates the institution’s capacity to provide timely Case Review Rating: and appropriate prenatal, delivery, and postnatal services to pregnant Not Applicable patients. This includes the ordering and monitoring of indicated Compliance Score: screening tests, follow-up visits, referrals to higher levels of care, e.g., Not Applicable high-risk obstetrics clinic, when necessary, and postnatal follow-up. Overall Rating: Not Applicable Because CEN is a male-only institution, this indicator did not apply. California State Prison, Centinela, Cycle 5 Medical Inspection Page 34 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 patients. These include cancer Not Applicable screenings, tuberculosis screenings, and influenza and chronic Compliance Score: care immunizations. This indicator also assesses whether certain Adequate institutions take preventive actions to relocate patients identified (78.8 %) as being at higher risk for contracting coccidioidomycosis Overall Rating: (valley fever). Adequate The OIG rates this indicator entirely through the compliance testing component; the case review process does not include a separate qualitative analysis for this indicator. Compliance Testing Results The institution performed in the adequate range in the Preventive Services indicator, with a compliance score of 78.8 percent. CEN received proficient scores on the following tests:  All 25 sampled patients timely received or were offered influenza vaccinations during the most recent influenza season (MIT 9.004).  The OIG tested whether patients who suffered from a chronic care condition were offered vaccinations for influenza, pneumonia, and hepatitis. All 15 of the sampled patients with applicable chronic conditions were timely offered the vaccinations (MIT 9.008).  CEN offered colorectal cancer screenings to 24 of 25 sampled patients (96 percent) subject to the annual screening requirement. For one patient, there was no medical record evidence either that health care staff offered a colorectal cancer screening within the previous 12 months or that the patient had a normal colonoscopy within the last ten years (MIT 9.005). The institution received an adequate score on the following test:  CEN scored 80 percent for administering timely tuberculosis (TB) medications to patients. Four of five patients received their medication timely, while one patient was given an extra dose in one week; and in another week, there was no evidence that he received a required dose (MIT 9.001). CEN showed room for improvement in the following test areas:  The institution scored poorly for monitoring of patients on TB medications. Only two of five patients sampled (40 percent) received monitoring at all required intervals. For three patients, the monitoring was not completed per policy guidelines (MIT 9.002). California State Prison, Centinela, Cycle 5 Medical Inspection Page 35 Office of the Inspector General State of California  The OIG sampled 30 patients to determine whether they received a TB screening within the last year and found that all 30 received the annual screening, but only 17 patients (57 percent) received the screening in their birth month, as per CCHCS policy guidelines (MIT 9.003). California State Prison, Centinela, Cycle 5 Medical Inspection Page 36 Office of the Inspector General State of California QUALITY OF NURSING PERFORMANCE The Quality of Nursing Performance indicator is a qualitative Case Review Rating: evaluation of the institution’s nursing services. The evaluation is Adequate completed entirely by OIG nursing clinicians within the case review Compliance Score: process and does not have a score under the OIG compliance testing Not Applicable component. Case reviews include face-to-face encounters and Overall Rating: indirect activities performed by nursing staff on behalf of the Adequate patient. Review of nursing performance includes all nursing services performed on site, such outpatient, inpatient, urgent/emergent, patient transfers, care coordination, and medication management. The key focus areas for evaluation of nursing care include appropriateness and timeliness of patient triage and assessment, identification and prioritization of health care needs, use of the nursing process to implement interventions, and accurate, thorough, and legible documentation. Although nursing services provided in specialized medical housing units are reported in the Specialized Medical Housing indicator, and those provided in the TTA or related to emergency medical responses are reported in the Emergency Services indicator, all areas of nursing services are summarized in this Quality of Nursing Performance indicator. Case Review Results The OIG clinicians reviewed 298 nursing encounters, of which 137 were outpatient nursing encounters. Most outpatient nursing encounters were for sick call requests, walk-in visits, and nurse follow-up appointments. In all encounters reviewed, 55 deficiencies were identified related to nursing care performance, with 6 being significant. OIG clinicians rated this indicator adequate. Nursing Assessment A major part of providing adequate nursing care involves the quality of nursing assessments, which includes both the subjective (patient interview) and the objective (evaluation and observation) portions. Generally, nurses at CEN included both subjective and objective nursing assessments when assessing patients especially when using the new electronic medical record. However, the OIG found minor nursing assessment deficiencies for incomplete assessment, which did not significantly contribute to risk of patient harm. CTC nurses either did not perform an appropriate physical examination to address the patient’s specific complaints, or did not assess pain relief effectiveness or reassess the patient’s vital signs following the administration of pain medication. Only one significant deficiency was identified for outpatient nursing care.  In case 33, the patient complained the internal pacemaker he recently had inserted was “feeling weird.” The nurse referred the patient to the provider and did not conduct an assessment on the patient. The nurse should have assessed the patient on the same day the patient’s health care request was reviewed. The patient was not evaluated by a provider until three days later. California State Prison, Centinela, Cycle 5 Medical Inspection Page 37 Office of the Inspector General State of California Nursing Interventions Nursing interventions are based on appropriate nursing assessments and actions, including provider notification, treatments, and referrals to help patients reach their health care goals and alleviate illness and injury conditions. The majority of nursing interventions implemented by nurses at CEN were satisfactory; however, two significant deficiencies occurred when nurses did not contact providers regarding patients with potentially serious medical conditions.  In case 15, nursing staff did not inform the provider when the diabetic patient had critically high blood glucose levels, which if left untreated could result in complications affecting the patient’s eyes, kidneys, nerves, and heart, as well as serious complications requiring emergency care.  In case 25, the patient sustained serious injuries to his face, eye, ear, and hand during an altercation. The following day, the patient continued to complain about eye pain and a new sensation of burning in his eye. Nurses did not refer the patient to the provider for evaluation and treatment, which put the patient at risk for vision impairment or blindness. Nursing Documentation The quality of nursing documentation at CEN was acceptable. In general, nursing documentation for outpatient care was comprehensive and addressed the specific needs of the patient; however, several patterns of minor nursing deficiencies were identified in the cases reviewed. Some of these documentation errors were related to the new electronic medical record; for example, chronological timelines were missing from nursing documentation. Details such as type of fluid, volume, and rate of infusion for intravenous infusions were often lacking in nursing documentation. Additionally, nursing documentation was sometimes incomplete for provider-ordered daily, weekly, or monthly monitoring of vital signs, weights, and blood pressures. Sick Call The OIG clinicians reviewed 49 nursing sick calls. Generally, nurses reviewed sick call requests promptly, assessed the patient timely, and provided adequate care. The sick call process at CEN was much improved over the Cycle 4 inspection. Most deficiencies were not considered significant, but at times did reflect a pattern of incomplete nursing assessments.  In case 16, the diabetic patient complained of a swollen toe, but the nurse did not assess the patient’s foot or toe for redness, heat, or range of motion.  In case 37, the patient complained of shortness of breath, but the nurse did not assess the patient’s perceived level of breathing difficulty or ask the patient if he had been exposed to peanut products, as peanut allergy was listed on the patient’s medical record. California State Prison, Centinela, Cycle 5 Medical Inspection Page 38 Office of the Inspector General State of California The following is an example of a significant deficiency that occurred in outpatient care when the nurse did not notify the provider about abnormal assessments:  In case 21, nursing staff did not inform the provider when the patient had a dangerously low heart rate of 40 beats per minute, a condition which can cause dangerously low blood pressure, loss of consciousness, and risk for the formation of blood clots leading to strokes. Care Management The role of the RN primary care manager includes assessing patients, initiating appropriate interventions to support goals in the patient’s treatment plan, and monitoring patients with chronic health needs as well as those at increased risk for developing serious health complications. Review of nursing documentation indicated RN care managers at CEN did not take an active role in patient care management. The RN care managers documented updated notes regarding optometry and telemedicine visits, but did not assess, monitor, or evaluate patients’ chronic conditions such as diabetes, hypertension, or sleep apnea. During the onsite visit, nurses confirmed that RN care managers did not assess, monitor, or evaluate patients with chronic conditions. Urgent/Emergent Overall, nursing services provided in the TTA were satisfactory. The EMRRC audited all non-scheduled transports out of the institution. Additional information about emergency care is discussed in the Emergency Services indicator. Post Hospital Returns The OIG clinicians reviewed 12 patient returns following community hospital visits. In the cases reviewed, all patients returning to CEN after hospital discharge received appropriate nursing assessment and follow-up referrals by a TTA nurse. The TTA nurses provided adequate education and written teaching materials to patients and reconciled discharge recommendations from the hospital with the provider. See the Intra-and Inter System Transfers indicator for additional information. Out-to-Medical Returns and Specialty Care The OIG clinicians reviewed 49 nursing encounters when patients returned from their specialty pre-scheduled appointments and hospital admissions, and identified only three minor deficiencies. Overall, nurses appropriately assessed and provided pertinent interventions for these returning patients in the TTA. For example, when a provider was not present in the TTA, nurses appropriately contacted the on-call provider about hospital discharge and specialty consultation recommendations. Additional details are described in the Specialty Services indicator. California State Prison, Centinela, Cycle 5 Medical Inspection Page 39 Office of the Inspector General State of California Specialized Medical Housing The OIG reviewed 124 medical and nursing encounters for the CTC, which is the only specialized medical housing unit at CEN. Nine minor nursing deficiencies were identified, none of which put patients at risk of harm. The CTC nurses provided satisfactory nursing care services. See the Specialized Medical Housing indicator for additional information. Transfers and Reception Center The OIG reviewed 22 patient encounters for transfers into and out of the institution and found the care provided during the inter- and intra -system transfer process excellent. There were only three minor deficiencies involving the delay of initial provider evaluations and nurse care manager assessments. These delays are discussed further in the Inter- and Intra-System Transfers indicator. Medication Administration In the cases reviewed, OIG clinicians found that CEN nurses generally administered the correct medications within acceptable time frames. This is discussed in more detail in the Pharmacy and Medication Management indicator. Clinician Onsite Inspection The CNE and chief medical executive (CME) met with the OIG clinicians and answered all questions related to patient care and nursing operations. The OIG clinicians interviewed nurses from utilization management (UM), specialty services, telemedicine, and receiving and release. The nurses at CEN were knowledgeable about their clinical positions, had been cross-trained for various positions, and felt comfortable covering nursing staff vacancies. The nurses in the outpatient clinic settings were active participants in the primary care team’s morning huddles. During the OIG’s visit, the morning huddle was well attended and included providers, sick call nurses, medication line nurses, mental health staff, schedulers, and other care team members. Huddle content was comprehensive and allowed time for meaningful discussion. For example, schedulers reported add-ons to the day’s clinic schedule, including patients for follow up in the RN clinic. The UM nurse reported on patients returning after hospital discharge. Each huddle participant contributed to the discussion by providing concise reports on their specific area of responsibility. The OIG clinicians also visited clinics in each yard of the institution. Nurse staffing was appropriate for the patient acuity (intensity of nursing care required by a patient) and some yard clinics had two nurses depending on the patient population. According to nursing staff, there were no major barriers to initiating communication with nursing supervisors, providers, or custody officers regarding patient care needs. Nurses were enthusiastic about their assignments and working conditions. California State Prison, Centinela, Cycle 5 Medical Inspection Page 40 Office of the Inspector General State of California Case Review Conclusion The outpatient nursing care demonstrated timely and appropriate nurse triage. The nursing deficiencies identified as significant were isolated incidents and did not display a pattern of poor nursing practices. The OIG clinicians rated the Quality of Nursing Performance indicator adequate. California State Prison, Centinela, Cycle 5 Medical Inspection Page 41 Office of the Inspector General State of California QUALITY OF PROVIDER PERFORMANCE In this indicator, the OIG physicians provide a qualitative evaluation Case Review Rating: of the adequacy of provider care at the institution. Appropriate Adequate evaluation, diagnosis, and management plans are reviewed for Compliance Score: programs including, but not limited to, nursing sick call, chronic Not Applicable care programs, TTA, specialized medical housing, and specialty Overall Rating: services. The assessment of provider care is performed entirely by Adequate OIG physicians. There is no compliance testing component associated with this quality indicator. Case Review Results OIG clinicians reviewed 179 medical provider encounters and identified 16 deficiencies related to provider performance, 7 of which were considered significant. Assessment and Decision-Making In most cases, providers made appropriate assessments and sound medical plans. However, there was a significant deficiency related to poor medical decision-making:  In case 21, the patient had an abnormally slow heart rate (bradycardia). The provider diagnosed the patient with anxiety and prescribed atenolol, which is commonly prescribed for high blood pressure, not for anxiety. Furthermore, atenolol is well known to slow the heart rate and should not have been prescribed for a patient with existing bradycardia. The provider placed the patient at risk for worsening bradycardia, low blood pressure, loss of consciousness, and stroke. Subsequently, the patient became dizzy, fell down, and was transferred to a community hospital. He was found to have severe bradycardia of 35 beats per minute, fractures around his right eye and nose, and multiple facial lacerations. Emergency Care Providers usually made appropriate triage decisions when patients presented emergently to the TTA and were generally available for consultation with the TTA nursing staff. Hospital Return Providers properly reviewed hospital discharge summaries and timely addressed all recommendations; however, there was one significant deficiency:  In case 21, a provider evaluated the patient after a recent hospitalization, but did not thoroughly review the medical records. Therefore, the provider did not recognize that the patient had bradycardia of 45 beats per minute during the hospitalization. The provider inappropriately started the patient on atenolol, a medication that could have slowed the heart further and caused dangerous complications. California State Prison, Centinela, Cycle 5 Medical Inspection Page 42 Office of the Inspector General State of California Chronic Care Chronic care performance was adequate as most providers demonstrated good care in regard to hypertension, asthma, hepatitis C, and cardiovascular disease. The providers documented thoroughly and demonstrated sound assessments and plans. There were no significant deficiencies in chronic care performance, with the exception of diabetic management, which was generally sufficient. However, there were three significant deficiencies:  In case 14, during the review period of more than six months, the diabetic patient had blood tests indicating poorly controlled diabetes. The providers assessed the patient five times and did not optimize the diabetic oral medications the patient was currently taking or add another medication. The uncontrolled diabetes placed the patient at risk for further diabetic complications such as heart attacks, strokes, kidney failure, and blindness.  In case 15, the diabetic patient had poorly controlled diabetes. Over six months, the providers evaluated the patient five times, but his insulin dose was only increased twice. The lack of intervention increased the patient’s risk of hyperglycemic complications.  Also in case 15, one provider recognized the poorly controlled diabetes, but purposely did not increase the insulin, citing the medication’s side effect of weight gain. The provider should have increased the patient’s insulin regimen because the benefits of increasing insulin outweighed the side effect of weight gain. The patient already had one diabetic complication of eye damage. The uncontrolled diabetes placed the patient at risk of further diabetic complications such as heart attacks, strokes, kidney failure, or blindness. CEN did not have a formal anticoagulation clinic; however, the CME managed all of the anticoagulation cases. The CME appropriately monitored the warfarin (anticoagulation medication) levels and properly adjusted the dosages. Specialty Services Providers referred their patients to specialists appropriately and reviewed the specialty reports timely. The specialist recommendations were properly addressed. Clinician Onsite Inspection At the time of the OIG inspection, there were five full-time providers and one vacancy. All providers were satisfied with nursing, diagnostic, and specialty services. Each provider was usually assigned to only one clinic to assure continuity of care. Morning huddles were productive, led by providers, and well attended. The providers were supportive of the CME and expressed general job satisfaction with their positions. Overall morale was good. California State Prison, Centinela, Cycle 5 Medical Inspection Page 43 Office of the Inspector General State of California The CME performed the annual evaluation for all providers except the telemedicine provider, who had the annual evaluation performed by a CCHCS headquarters supervisor. There were weekly provider meetings in which providers discussed new policies, managing difficult cases, and pertinent medical topics. Case Review Conclusion The CEN providers delivered good care. Of the 20 cases reviewed by the OIG physicians, 17 were adequate and 3 were inadequate. There was room for improvement in diabetic management. The OIG clinicians rated the Quality of Provider Performance indicator adequate. California State Prison, Centinela, Cycle 5 Medical Inspection Page 44 Office of the Inspector General State of California RECEPTION CENTER ARRIVALS This indicator focuses on the management of medical needs and Case Review Rating: continuity of care for patients arriving from outside the CDCR Not Applicable system. The OIG review includes evaluation of the ability of the Compliance Score: institution to provide and document initial health screenings, Not Applicable initial health assessments, continuity of medications, and Overall Rating: completion of required screening tests; address and provide Not Applicable significant accommodations for disabilities and health care appliance needs; and identify health care conditions needing treatment and monitoring. The patients reviewed for reception center cases are those received from non-CDCR facilities, such as county jails. For CEN, this indicator did not apply because the institution had no reception center. California State Prison, Centinela, Cycle 5 Medical Inspection Page 45 Office of the Inspector General State of California SPECIALIZED MEDICAL HOUSING This indicator addresses whether the institution follows appropriate Case Review Rating: policies and procedures when admitting patients to onsite inpatient Proficient facilities, including completion of timely nursing and provider Compliance Score: assessments. The chart review assesses all aspects of medical care Proficient related to these housing units, including quality of provider and (100%) nursing care. The only specialized medical housing unit at CEN is a Overall Rating: correctional treatment center (CTC). Proficient Case Review Results The specialized medical housing unit at CEN is a 13-bed CTC, in which all beds were for medical patients. The OIG clinicians reviewed 161 events among the ten CTC patients. The events reviewed included 53 provider and 71 nursing encounters. The OIG clinicians identified 11 deficiencies, none of which were significant. Provider Performance The provider performance in the CTC was good. There OIG clinicians reviewed 53 provider encounters and identified no deficiencies. Nursing Performance The institution’s nursing staff provided excellent nursing care to patients in the CTC. There were 71 nursing encounters reviewed and nine minor deficiencies identified. Nurses generally conducted appropriate daily patient assessments that included physical examinations, observations regarding activities of daily living, and re-assessments after providing an intervention for pain, such as pain medication. Nursing documentation commonly included subjective information from the patient, changes in patient status, medication compliance, and provider contacts. Nurses made patient rounds every two hours to assess patients and ascertain patient needs. Clinician Onsite Inspection During the onsite visit, the OIG clinicians found the CTC to be well staffed with experienced nurses and sufficient custody staff to support patient care. Nursing staff developed a useful report sheet that contained information relevant to all team members including nursing assistants. The information on the report sheet included the patient’s name, diagnoses, care plan information, diet, and TABE (Test of Adult Basic Education) score. The TABE score advises staff of the patient’s school grade-level of comprehension and a suggested grade-level for teaching or training. Case Review Conclusion Provider and nursing care in the CTC was well done. The OIG clinicians rated the Specialized Medical Housing indicator proficient. California State Prison, Centinela, Cycle 5 Medical Inspection Page 46 Office of the Inspector General State of California Compliance Testing Results CEN received a proficient compliance score of 100 percent in the Specialized Medical Housing indicator, which focused on the institution’s CTC. CEN received proficient scores on all four tests for this indicator:  For all ten patients sampled, nursing staff timely completed an initial health assessment on the day the patient was admitted to the CTC (MIT 13.001).  Providers evaluated all ten sampled patients within 24 hours of admission and timely completed the required history and physical (MIT 13.002).  The OIG tested whether providers completed their Subjective, Objective, Assessment, Plan, and Education (SOAPE) notes at required three day intervals. The institution’s providers completed timely SOAPE notes for all ten sampled patients (MIT 13.003).  Inspectors tested the working order of sampled call buttons in the CTC patient rooms and found all working properly. In addition, according to staff members, during an emergent event, custody officers and clinicians were able to expeditiously access patients’ locked rooms (MIT 13.101). California State Prison, Centinela, Cycle 5 Medical Inspection Page 47 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 Adequate records and documentation reflecting the patients’ care plans, (80.8%) including course of care when specialist recommendations were not Overall Rating: ordered, and whether the results of specialists’ reports are Adequate communicated to the patients. For specialty services denied by the institution, the OIG determines whether the denials are timely and appropriate, and whether the patient is updated on the plan of care. Case Review Results The OIG clinicians reviewed 170 events related to specialty services, including 133 specialty consultations and procedures, and 37 nursing encounters. There were three deficiencies identified, one of which was significant. Access to Specialty Services CEN performed well with specialty access. Most specialty appointments occurred within the requested time frame and no patterns of deficiencies were identified in specialty appointments. Nursing Performance Nursing care was good in out-to-medical-return assessments, interventions, and documentation as there were only two minor deficiencies in this category. Provider Performance Case review showed that patients were referred to specialists appropriately by the providers. The providers addressed most of the specialists’ recommendations, except on one occasion. The one exception was considered a significant deficiency and is detailed below:  In case 21, a neurologist recommended the patient have an X-ray of his right hand because of nerve damage. The provider did not address the neurologist’s recommendation, did not order the X-ray, and did not explain why the recommendation was not followed. Health Information Management Specialty reports were timely retrieved and scanned into the medical record. California State Prison, Centinela, Cycle 5 Medical Inspection Page 48 Office of the Inspector General State of California Clinician Onsite Inspection At the time of the OIG inspection, there were specialty service staff assigned to off-site, on-site, and telemedicine specialty services. The specialty service staff scheduled the specialty appointments and processed the necessary orders and referrals. The custody staff ensured that patient transportation was readily available for all off-site specialty appointments. Case Review Conclusion Specialty appointments were appropriately scheduled, and the specialty reports were retrieved timely and scanned into electronic medical records. Provider and nursing care was satisfactory, with few deficiencies identified. The OIG clinicians rated the Specialty Services indicator adequate. Compliance Testing Results The institution received an adequate compliance score of 80.8 percent in the Specialty Services indicator, receiving proficient scores on the following tests:  For all 15 patients sampled, their high-priority specialty services appointments occurred within 14 calendar days. In addition, all 15 patients sampled with routine specialty service appointments received their appointments within 90 calendar days of the provider’s order (MIT 14.001, 14.003).  The institution timely denied all 18 sampled provider requests for specialty services (MIT 14.006).  When patients are approved or scheduled for specialty services at one institution and then transfer to another institution, policy requires that the receiving institution reschedule and provide the patient’s appointment within the required time frame. At CEN, 19 of 20 patients sampled (95 percent) received their specialty services appointments timely. One patient’s specialty service appointment was 165 days late (MIT 14.005).  Providers timely received and reviewed specialists’ reports for 12 of 14 applicable patients with high-priority services (86 percent). CEN received one patient’s report 65 days late, and for another patient, no evidence was found of a timely provider review (MIT 14.002). CEN showed room for improvement on the following tests:  Among 18 patients sampled who had a specialty service denied by CEN’s health care management, only 5 (28 percent) received timely notification of their denied service, including the provider meeting with the patient within 30 days to discuss alternate treatment strategies. Four patients’ provider follow-up visits occurred 3, 19, 25, and 51 days late. For nine other patients, there was no evidence found in the patients’ electronic medical records to indicate a provider followed up to discuss their denials (MIT 14.007). California State Prison, Centinela, Cycle 5 Medical Inspection Page 49 Office of the Inspector General State of California  Providers timely received and reviewed 8 of the 14 applicable routine specialists’ reports that inspectors sampled (57 percent). For two patients, providers reviewed the reports 7 and 39 days late, and for the remaining four patients, a report was never received (MIT 14.004). California State Prison, Centinela, Cycle 5 Medical Inspection Page 50 Office of the Inspector General State of California ADMINISTRATIVE OPERATIONS (SECONDARY) 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 patient medical appeals and addresses all Compliance Score: appealed issues. Inspectors also verify that the institution follows Adequate reporting requirements for adverse/sentinel events and inmate (77.6%) deaths. The OIG verifies that the Emergency Medical Response Overall Rating: Review Committee (EMRRC) performs required reviews and that Adequate staff perform required emergency response drills. Inspectors also assess whether the Quality Management Committee (QMC) meets regularly and adequately addresses program performance. For those institutions with licensed facilities, inspectors also verify that required committee meetings are held. In addition, OIG examines whether the institution adequately manages its health care staffing resources by evaluating whether job performance reviews are completed as required; specified staff possess current, valid credentials and professional licenses or certifications; nursing staff receive new employee orientation training and annual competency testing; and clinical and custody staff have current medical emergency response certifications. The Administrative Operations indicator is a secondary indicator, and, therefore, was not relied on for the overall score for the institution. Compliance Testing Results The institution received an adequate compliance score of 77.6 percent in the Administrative Operations indicator, and scored in the proficient range on the following tests:  CEN took adequate steps to ensure the accuracy of its Dashboard data reporting (MIT 15.004).  Based on a sample of ten second-level medical appeals, the institution’s responses addressed all of the patients’ appealed issues (MIT 15.102).  Medical staff promptly submitted the initial Inmate Death Report (CDCR Form 7229A) to CCHCS’s Death Review Unit for all three applicable deaths that occurred at CEN in the prior 12-month period (MIT 15.103).  The OIG reviewed performance evaluation packets for CEN’s four providers; CEN met all performance review requirements for its providers (MIT 15.106).  All providers at the institution were current with their professional licenses. Similarly, all nursing staff and the pharmacist in charge were current with their professional licenses and certification requirements (MIT 15.107, 15.109). California State Prison, Centinela, Cycle 5 Medical Inspection Page 51 Office of the Inspector General State of California  All providers and nurses on active duty were current with their emergency response certifications (MIT 15.108).  All pharmacy staff and providers who prescribed controlled substances had current Drug Enforcement Agency registrations (MIT 15.110).  All nursing staff hired within the last year timely received new employee orientation training (MIT 15.111). CEN received adequate scores on the following tests:  The institution promptly processed inmate medical appeals in 10 of the most recent 12 months (83 percent). In two separate months, more than 5 percent of appeals were not timely processed (MIT 15.001).  CEN’s QMC met monthly, evaluated program performance, and took action when management identified areas for improvement opportunities for five of the six months tested (83 percent). For one month’s meeting, there was no evidence found that the QMC reviewed the institutional scorecard performance data (MIT 15.003).  Of the 12 sampled incident packages for emergency medical responses reviewed by the institution’s EMRRC during the prior 12-month period, nine (75 percent) complied with policy. Three of the incident review packages contained incompleteEMRRC checklists (MIT 15.005). The institution received inadequate scores on the following tests:  CEN’s local governing body (LGB) was required to meet quarterly during the four-quarter period ending June 2017, but evidence was found of only two meetings in that period. Furthermore, the two meetings’ minutes were incomplete as they did not contain discussion of the adoption of Local Operating Procedures (LOP) as set forth by CCHCS policy guidelines. These deficiencies resulted in a score of zero for this test (MIT 15.006).  The institution did not meet the emergency response drill requirements for the most recent quarter for all three watches, resulting in a score of zero percent. More specifically, the institutions’ first, second, and third watch drill packages did not contain the Medical Report of Injury of Unusual Occurrence (CDCR Form 7219) as required by CCHCS policy. The third watch drill package did not include evidence that custody staff participated in the drill (MIT 15.101). California State Prison, Centinela, Cycle 5 Medical Inspection Page 52 Office of the Inspector General State of California  The OIG inspected records from April 2017 for five nurses, to determine if their nursing supervisors properly completed monthly performance reviews. Inspectors identified the following deficiencies for all five the nursing reviews sampled (MIT 15.104): o The supervisor did not complete the required number of reviews for one nurse. o The supervisor’s review did not summarize aspects that were well done for four nurses and did not summarize aspects that were needing improvement for one nurse. Non-Scored Results  The OIG gathered non-scored data regarding the completion of death review reports by CCHCS’s Death Review Committee (DRC). Four deaths occurred at CEN during the OIG’s review period, three unexpected (Level 1) deaths and one death with no level assigned. The DRC was required to complete its death review summary report within 60 days from the date of death for the Level 1 deaths; the reports should have been submitted to the institution’s chief executive officer (CEO) within seven calendar days thereafter. However, for the Level 1 deaths, the DRC completed its reports 26, 52, and 75 days late (86, 112, and 135 days after death) and submitted them to CEN’s CEO 32, 61, and 87 days late. For the one death that did not have a level assigned, there was no data found other than the date of death (MIT 15.998).  The OIG discusses the institution’s health care staffing resources in the About the Institution section of this report (MIT 15.999). California State Prison, Centinela, Cycle 5 Medical Inspection Page 53 Office of the Inspector General State of California R ECOMMENDATIONS  CEN nurses included important information not usually seen on transfer records, such as phone numbers and addresses for pending specialists’ appointments. The OIG recommends that CCHCS adopt this process statewide.  In the CTC, CEN nurses developed a useful report sheet that contained information relevant to all team members including nursing assistants. The information on the report sheet included the patient’s name, diagnoses, care plan information, diet, and TABE (Test of Adult Basic Education) score. The OIG recommends that CCHCS adopt this process statewide. California State Prison, Centinela, Cycle 5 Medical Inspection Page 54 Office of the Inspector General State of California P -B M OPULATION ASED ETRICS The compliance testing and the case reviews give an accurate assessment of how the institution’s health care systems are functioning with regard to the patients with the highest risk and utilization. This information is vital to assess the capacity of the institution to provide sustainable, adequate care. However, one significant limitation of the case review methodology is that it does not give a clear assessment of how the institution performs for the entire population. For better insight into this performance, the OIG has turned to population-based metrics. For comparative purposes, the OIG has selected several Healthcare Effectiveness Data and Information Set (HEDIS) measures for disease management to gauge the institution’s effectiveness in outpatient health care, especially chronic disease management. The Healthcare Effectiveness Data and Information Set is a set of standardized performance measures developed by the National Committee for Quality Assurance with input from over 300 organizations representing every sector of the nation’s health care industry. It is used by over 90 percent of the nation’s health plans as well as many leading employers and regulators. It was designed to ensure that the public (including employers, the Centers for Medicare and Medicaid Services, and researchers) has the information it needs to accurately compare the performance of health care plans. Healthcare Effectiveness Data and Information Set data is often used to produce health plan report cards, analyze quality improvement activities, and create performance benchmarks. Methodology For population-based metrics, the OIG used a subset of HEDIS measures applicable to the CDCR patient population. Selection of the measures was based on the availability, reliability, and feasibility of the data required for performing the measurement. The OIG collected data utilizing various information sources, including patients’ electronic medical records, 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 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 5 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 well with its management of diabetes. When compared statewide, CEN outperformed all plans by scoring higher in all five of the diabetic measures tested. When compared nationally, CEN outperformed Medicaid, Medicare, and commercial plans in all five diabetic measures. CEN outperformed the United States Department of Veterans Affairs (VA) in three of the four applicable measures, but scored slightly lower for diabetic monitoring. Immunizations Comparative data for immunizations was only fully available for the VA and partially available for Kaiser, commercial plans, Medicaid, and Medicare. With respect to administering influenza vaccinations to younger adults, CEN scored lower than all health care plans except Medicaid, in which CEN scored slightly higher. The 60 percent refusal rate negatively affected the institutions score for this measure. When administering influenza vaccinations to older adults, CEN scored lower than both Medicare and the VA, this again due to the high patient refusal rate of 36 percent. With respect to pneumococcal immunizations, CEN performed better than Medicare, but performed less well than the VA. Cancer Screening CEN performed better than commercial and Medicare health plans with colorectal cancer screening, but lower than Kaiser and the VA. If not for the 24 percent refusal rate, CEN would have scored higher than all health plans. Summary CEN’s population-based metrics performance was good in comparison to the other health care plans reviewed. CEN may improve its scores for influenza immunizations and colorectal cancer screening by reducing patient refusals through patient education. California State Prison, Centinela, Cycle 5 Medical Inspection Page 56 Office of the Inspector General State of California CEN Results Compared to State and National HEDIS Scores California National HEDIS Clinical Measures CEN Kaiser HEDIS HEDIS HEDIS (No. Kaiser HEDIS Com- HEDIS VA Cycle 5 Medi-Cal CA) (So.CA) Medicaid mercial Medicare Average Results1 20152 20163 20163 20164 20164 20164 20155 Comprehensive Diabetes Care HbA1c Testing (Monitoring) 97% 86% 94% 94% 86% 90% 93% 98% Poor HbA1c Control (>9.0%)6, 7 7% 39% 20% 23% 45% 34% 27% 19% HbA1c Control (<8.0%)6 79% 49% 70% 63% 46% 55% 63% - Blood Pressure Control (<140/90)6 88% 63% 83% 83% 59% 60% 62% 74% Eye Exams 93% 53% 68% 81% 53% 54% 69% 89% Immunizations Influenza Shots - Adults (18–64) 40% - 56% 57% 39% 48% - 55% Influenza Shots - Adults (65+) 64% - - - - - 72% 76% Immunizations: Pneumococcal 79% - - - - - 71% 93% Cancer Screening Colorectal Cancer Screening 71% - 79% 82% - 63% 67% 82% 1. Unless otherwise stated, data was collected in June 2017 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 2015 HEDIS Aggregate Report for Medi-Cal Managed Care. 3. Data was obtained from Kaiser Permanente November 2016 reports for the Northern and Southern California regions. 4. National HEDIS data for Medicaid, commercial plans, and Medicare was obtained from the 2016 State of Health Care Quality Report, available on the NCQA website: www.ncqa.org. The results for commercial plans were based on data received from various health maintenance organizations. 5. The Department of Veterans Affairs (VA) data was obtained from the VA’s website, www.va.gov. For the Immunizations: Pneumococcal measure only, the data was obtained from the VHA Facility Quality and Safety Report - Fiscal Year 2012 Data. 6. For this indicator, the entire applicable 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. California State Prison, Centinela, Cycle 5 Medical Inspection Page 57 Office of the Inspector General State of California A A — C T R PPENDIX OMPLIANCE EST ESULTS California State Prison, Centinela Range of Summary Scores: 61.18% - 100.00% Indicator Compliance Score (Yes %) 1–Access to Care 79.62% 2–Diagnostic Services 73.33% 3–Emergency Services Not Applicable 4–Health Information Management (Medical Records) 89.26% 5–Health Care Environment 74.62% 6–Inter- and Intra-System Transfers 89.93% 7–Pharmacy and Medication Management 61.18% 8–Prenatal and Post-Delivery Services Not Applicable 9–Preventive Services 78.78% 10–Quality of Nursing Performance Not Applicable 11–Quality of Provider Performance Not Applicable 12–Reception Center Arrivals Not Applicable 13–Specialized Medical Housing (OHU, CTC, SNF, Hospice) 100.00% 14–Specialty Services 80.81% 15–Administrative Operations 77.60% California State Prison, Centinela, Cycle 5 Medical Inspection Page 58 Office of the Inspector General State of California Scored Answers Yes Reference + 1–Access to Care Number Yes No No Yes % N/A Chronic care follow-up appointments: Was the patient’s most recent chronic care visit within the health care guideline’s 1.001 16 9 25 64.00% 0 maximum allowable interval or within the ordered time frame, whichever is shorter? For endorsed patients received from another CDCR institution: If 1.002 the nurse referred the patient to a provider during the initial health 15 8 23 65.22% 2 screening, was the patient seen within the required time frame? Clinical appointments: Did a registered nurse review the patient’s 1.003 30 0 30 100.00% 0 request for service the same day it was received? Clinical appointments: Did the registered nurse complete a 1.004 face-to-face visit within one business day after the CDCR Form 28 2 30 93.33% 0 7362 was reviewed? Clinical appointments: If the registered nurse determined a referral to a primary care provider was necessary, was the patient 1.005 5 0 5 100.00% 25 seen within the maximum allowable time or the ordered time frame, whichever is the shorter? Sick call follow-up appointments: If the primary care provider 1.006 ordered a follow-up sick call appointment, did it take place within 1 0 1 100.00% 29 the time frame specified? Upon the patient’s discharge from the community hospital: Did 1.007 the patient receive a follow-up appointment within the required 8 14 22 36.36% 0 time frame? Specialty service follow-up appointments: Do specialty service 1.008 primary care physician follow-up visits occur within required time 15 11 26 57.69% 4 frames? Clinical appointments: Do patients have a standardized process to 1.101 6 0 6 100.00% 0 obtain and subMIT health care services request forms? Overall percentage: 79.62% California State Prison, Centinela, Cycle 5 Medical Inspection Page 59 Office of the Inspector General State of California Scored Answers Yes Reference + 2–Diagnostic Services Number Yes No No Yes % N/A Radiology: Was the radiology service provided within the time 2.001 10 0 10 100.00% 0 frame specified in the provider’s order? Radiology: Did the primary care provider review and initial the 2.002 2 8 10 20.00% 0 diagnostic report within specified time frames? Radiology: Did the primary care provider communicate the results 2.003 10 0 10 100.00% 0 of the diagnostic study to the patient within specified time frames? Laboratory: Was the laboratory service provided within the time 2.004 9 1 10 90.00% 0 frame specified in the provider’s order? Laboratory: Did the primary care provider review and initial the 2.005 10 0 10 100.00% 0 diagnostic report within specified time frames? Laboratory: Did the primary care provider communicate the 2.006 results of the diagnostic study to the patient within specified time 10 0 10 100.00% 0 frames? Pathology: Did the institution receive the final diagnostic report 2.007 7 3 10 70.00% 0 within the required time frames? Pathology: Did the primary care provider review and initial the 2.008 5 5 10 50.00% 0 diagnostic report within specified time frames? Pathology: Did the primary care provider communicate the results 2.009 3 7 10 30.00% 0 of the diagnostic study to the patient within specified time frames? Overall percentage: 73.33% 3–Emergency Services This indicator is evaluated only by case review clinicians. There is no compliance testing component. California State Prison, Centinela, Cycle 5 Medical Inspection Page 60 Office of the Inspector General State of California Scored Answers Yes Reference + 4–Health Information Management Number Yes No No Yes % N/A Are non-dictated healthcare documents (provider progress notes) 4.001 13 0 13 100.00% 0 scanned within 3 calendar days of the patient encounter date? Are dictated/transcribed documents scanned into the patient’s 4.002 electronic health record within five calendar days of the encounter Not Applicable date? Are High-Priority specialty notes (either a Form 7243 or other 4.003 scanned consulting report) scanned within the required time 16 4 20 80.00% 0 frame? Are community hospital discharge documents scanned into the 4.004 patient’s electronic health record within three calendar days of 20 0 20 100.00% 0 hospital discharge? Are medication administration records (MARs) scanned into the 4.005 Not Applicable patient’s electronic health record within the required time frames? During the inspection, were medical records properly scanned, 4.006 17 7 24 70.83% 0 labeled, and included in the correct patients’ files? For patients discharged from a community hospital: Did the preliminary hospital discharge report include key elements and 4.007 21 1 22 95.45% 0 did a primary care provider review the report within three calendar days of discharge? Overall percentage: 89.26% 0 California State Prison, Centinela, Cycle 5 Medical Inspection Page 61 Office of the Inspector General State of California Scored Answers Yes Reference + 5–Health Care Environment Number Yes No No Yes % N/A Are clinical health care areas appropriately disinfected, cleaned 5.101 10 0 10 100.00% 0 and sanitary? Do clinical health care areas ensure that reusable invasive and 5.102 non-invasive medical equipment is properly sterilized or 10 0 10 100.00% 0 disinfected as warranted? Do clinical health care areas contain operable sinks and sufficient 5.103 9 1 10 90.00% 0 quantities of hygiene supplies? Does clinical health care staff adhere to universal hand hygiene 5.104 7 3 10 70.00% 0 precautions? Do clinical health care areas control exposure to blood-borne 5.105 8 2 10 80.00% 0 pathogens and contaminated waste? Warehouse, Conex and other non-clinic storage areas: Does the 5.106 medical supply management process adequately support the needs 1 0 1 100.00% 0 of the medical health care program? Does each clinic follow adequate protocols for managing and 5.107 5 5 10 50.00% 0 storing bulk medical supplies? Do clinic common areas and exam rooms have essential core 5.108 4 5 9 44.44% 1 medical equipment and supplies? Do clinic common areas have an adequate environment conducive 5.109 8 1 9 88.89% 1 to providing medical services? Do clinic exam rooms have an adequate environment conducive 5.110 6 4 10 60.00% 0 to providing medical services? Emergency response bags: Are TTA and clinic emergency 5.111 medical response bags inspected daily and inventoried monthly, 3 5 8 37.50% 2 and do they contain essential items? Overall percentage: 74.62% California State Prison, Centinela, Cycle 5 Medical Inspection Page 62 Office of the Inspector General State of California Reference Scored Answers N/A Number Yes No Yes Yes % + 6–Inter- and Intra-System Transfers No 6.001 For endorsed patients received from another CDCR institution or 22 3 25 88.00% 0 COCF: Did nursing staff complete the initial health screening and answer all screening questions on the same day the patient arrived at the institution? 6.002 For endorsed patients received from another CDCR institution or 22 0 22 100.00% 3 COCF: When required, did the RN complete the assessment and disposition section of the health screening form; refer the 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 patients received from another CDCR institution or 2 1 3 66.67% 22 COCF: If the patient had an existing medication order upon arrival, were medications administered or delivered without interruption? 6.004 For patients transferred out of the facility: Were scheduled 19 1 20 95.00% 0 specialty service appointments identified on the patient’s health care transfer information form? 6.101 For patients transferred out of the facility: Do medication transfer 9 0 9 100.00% 1 packages include required medications along with the corresponding transfer packet required documents? Overall percentage: 89.93% California State Prison, Centinela, Cycle 5 Medical Inspection Page 63 Office of the Inspector General State of California Reference 7–Pharmacy and Medication Scored Answers N/A Number Management Yes No Yes Yes % + No 7.001 Did the patient receive all chronic care medications within the 7 6 13 53.85% 12 required time frames or did the institution follow departmental policy for refusals or no-shows? 7.002 Did health care staff administer, make available, or deliver new 22 3 25 88.00% 0 order prescription medications to the patient within the required time frames? 7.003 Upon the patient’s discharge from a community hospital: Were all 10 12 22 45.45% 0 ordered medications administered, made available, or delivered to the patient within required time frames? 7.004 For patients received from a county jail: Were all medications Not Applicable ordered by the institution’s reception center provider administered, made available, or delivered to the patient within the required time frames? 7.005 Upon the patient’s transfer from one housing unit to another: 23 2 25 92.00% 0 Were medications continued without interruption? 7.006 For patients en route who lay over at the institution: If the 2 6 8 25.00% 0 temporarily housed patient had an existing medication order, were medications administered or delivered without interruption? 7.101 All clinical and medication line storage areas for narcotic 1 7 8 12.50% 2 medications: Does the Institution employ strong medication security over narcotic medications assigned to its clinical areas? 7.102 All clinical and medication line storage areas for non-narcotic 2 6 8 25.00% 2 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 1 8 9 11.11% 1 medications: Does the institution properly store non-narcotic medications that require refrigeration in assigned clinical areas? 7.104 Medication preparation and administration areas: Do nursing staff 6 0 6 100.00% 0 employ and follow hand hygiene contamination control protocols during medication preparation and medication administration processes? 7.105 Medication preparation and administration areas: Does the 6 0 6 100.00% 0 institution employ appropriate administrative controls and protocols when preparing medications for patients? 7.106 Medication preparation and administration areas: Does the 3 3 6 50.00% 0 Institution employ appropriate administrative controls and protocols when distributing medications to patients? 7.107 Pharmacy: Does the institution employ and follow general 1 0 1 100.00% 0 security, organization, and cleanliness management protocols in its main and satellite pharmacies? California State Prison, Centinela, Cycle 5 Medical Inspection Page 64 Office of the Inspector General State of California Reference 7–Pharmacy and Medication Scored Answers N/A Number Management Yes No Yes Yes % + No 7.108 Pharmacy: Does the institution’s pharmacy properly store 0 1 0 0.00% 0 non-refrigerated medications? 7.109 Pharmacy: Does the institution’s pharmacy properly store 1 0 1 100.00% 0 refrigerated or frozen medications? 7.110 Pharmacy: Does the institution’s pharmacy properly account for 1 0 1 100.00% 0 narcotic medications? 7.111 Does the institution follow key medication error reporting 19 6 25 76.00% 0 protocols? Overall percentage: 61.18% California State Prison, Centinela, Cycle 5 Medical Inspection Page 65 Office of the Inspector General State of California 8–Prenatal and Post-Delivery Services The institution has no female patients, so this indicator is not applicable. Scored Answers Yes Reference + 9–Preventive Services Number Yes No No Yes % N/A Patients prescribed TB medication: Did the institution administer 9.001 4 1 5 80.00% 0 the medication to the patient as prescribed? Patients prescribed TB medication: Did the institution monitor the 9.002 patient monthly for the most recent three months he or she was on 2 3 5 40.00% 0 the medication? Annual TB Screening: Was the patient screened for TB within the 9.003 17 13 30 56.67% 0 last year? Were all patients offered an influenza vaccination for the most 9.004 25 0 25 100.00% 0 recent influenza season? All patients from the age of 50 - 75: Was the patient offered 9.005 24 1 25 96.00% 0 colorectal cancer screening? Female patients from the age of 50 through the age of 74: Was the 9.006 Not Applicable patient offered a mammogram in compliance with policy? Female patients from the age of 21 through the age of 65: Was 9.007 Not Applicable patient offered a pap smear in compliance with policy? Are required immunizations being offered for chronic care 9.008 15 0 15 100.00% 0 patients? Are patients at the highest risk of coccidioidomycosis (valley 9.009 Not Applicable fever) infection transferred out of the facility in a timely manner? Overall percentage: 78.78% California State Prison, Centinela, Cycle 5 Medical Inspection Page 66 Office of the Inspector General State of California 10–Quality of Nursing Performance This indicator is evaluated only by case review clinicians. There is no compliance testing component. 11–Quality of Provider Performance This indicator is evaluated only by case review clinicians. There is no compliance testing component. California State Prison, Centinela, Cycle 5 Medical Inspection Page 67 Office of the Inspector General State of California 12–Reception Center Arrivals The institution has no reception center, so this indicator is not applicable. Scored Answers Yes Reference + 13–Specialized Medical Housing Number Yes No No Yes % N/A For OHU, CTC, and SNF: Did the registered nurse complete an 13.001 initial assessment of the patient on the day of admission, or within 10 0 10 100.00% 0 eight hours of admission to CMF’s Hospice? For CTC and SNF only: Was a written history and physical 13.002 10 0 10 100.00% 0 examination completed within the required time frame? For OHU, CTC, SNF, and Hospice: Did the primary care provider complete the Subjective, Objective, Assessment, Plan, and 13.003 10 0 10 100.00% 0 Education (SOAPE) notes on the patient at the minimum intervals required for the type of facility where the patient was treated? For OHU and CTC Only: Do inpatient areas either have properly working call systems in its OHU & CTC or are 30-minute patient 13.101 1 0 1 100.00% 0 welfare checks performed; and do medical staff have reasonably unimpeded access to enter patient’s cells? Overall percentage: 100.00% California State Prison, Centinela, Cycle 5 Medical Inspection Page 68 Office of the Inspector General State of California Scored Answers Yes Reference + 14–Specialty Services Number Yes No No Yes % N/A Did the patient receive the high priority specialty service within 14.001 14 calendar days of the primary care provider order or the 15 0 15 100.00% 0 Physician Request for Service? Did the primary care provider review the high priority specialty 14.002 12 2 14 85.71% 1 service consultant report within the required time frame? Did the patient receive the routine specialty service within 90 14.003 calendar days of the primary care provider order or Physician 15 0 15 100.00% 0 Request for Service? Did the primary care provider review the routine specialty service 14.004 8 6 14 57.14% 1 consultant report within the required time frame? For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at 14.005 19 1 20 95.00% 0 the sending institution, was the appointment scheduled at the receiving institution within the required time frames? Did the institution deny the primary care provider request for 14.006 18 0 18 100.00% 0 specialty services within required time frames? Following the denial of a request for specialty services, was the 14.007 5 13 18 27.78% 0 patient informed of the denial within the required time frame? Overall percentage: 80.81% California State Prison, Centinela, Cycle 5 Medical Inspection Page 69 Office of the Inspector General State of California Scored Answers Yes Reference 15–Administrative Operations + Number Yes No No Yes % N/A Did the institution promptly process inmate medical appeals 15.001 10 2 12 83.33% 0 during the most recent 12 months? Does the institution follow adverse / sentinel event reporting 15.002 Not Applicable requirements? Did the institution Quality Management Committee (QMC) meet at least monthly to evaluate program performance, and did the 15.003 5 1 6 83.33% 0 QMC take action when improvement opportunities were identified? Did the institution’s Quality Management Committee (QMC) or 15.004 other forum take steps to ensure the accuracy of its Dashboard 1 0 1 100.00% 0 data reporting? Does the Emergency Medical Response Review Committee 15.005 perform timely incident package reviews that include the use of 9 3 12 75.00% 0 required review documents? For institutions with licensed care facilities: Does the Local Governing Body (LGB), or its equivalent, meet quarterly and 15.006 0 4 4 0.00% 0 exercise its overall responsibilities for the quality management of patient health care? Did the institution complete a medical emergency response drill 15.101 for each watch and include participation of health care and 0 3 3 0.00% 0 custody staff during the most recent full quarter? Did the institution’s second level medical appeal response address 15.102 10 0 10 100.00% 0 all of the patient’s appealed issues? Did the institution’s medical staff review and subMIT the initial 15.103 3 0 3 100.00% 0 inmate death report to the Death Review Unit in a timely manner? Does the institution’s Supervising Registered Nurse conduct 15.104 0 5 5 0.00% 0 periodic reviews of nursing staff? Are nursing staff who administer medications current on their 15.105 10 0 10 100.00% 0 clinical competency validation? 15.106 Are structured clinical performance appraisals completed timely? 4 0 4 100.00% 1 15.107 Do all providers maintain a current medical license? 6 0 6 100.00% 1 Are staff current with required medical emergency response 15.108 2 0 2 100.00% 1 certifications? Are nursing staff and the Pharmacist-in-Charge current with their professional licenses and certifications, and is the pharmacy licensed as a correctional pharmacy by the California State Board 15.109 6 0 6 100.00% 1 of Pharmacy? California State Prison, Centinela, Cycle 5 Medical Inspection Page 70 Office of the Inspector General State of California Scored Answers Yes Reference 15–Administrative Operations + Number Yes No No Yes % N/A Do the institution’s pharmacy and authorized providers who 15.110 prescribe controlled substances maintain current Drug 1 0 1 100.00% 0 Enforcement Agency (DEA) registrations? 15.111 Are nursing staff current with required new employee orientation? 1 0 1 100.00% 0 Overall percentage: 77.60% California State Prison, Centinela, Cycle 5 Medical Inspection Page 71 Office of the Inspector General State of California A B — C D PPENDIX LINICAL ATA Table B-1: CEN Sample Sets Sample Set Total Anticoagulation 3 Death Review/Sentinel Events 2 Diabetes 3 Emergency Services – CPR 5 Emergency Services – Non-CPR 2 High Risk 4 Hospitalization 4 Intra-System Transfers In 3 Intra-System Transfers Out 3 RN Sick Call 18 Specialty Services 2 49 California State Prison, Centinela, Cycle 5 Medical Inspection Page 72 Office of the Inspector General State of California Table B-2: CEN Chronic Care Diagnoses Diagnosis Total Anemia 4 Anticoagulation 4 Arthritis/Degenerative Joint Disease 7 Asthma 6 COPD 5 Cancer 4 Cardiovascular Disease 12 Chronic Kidney Disease 4 Chronic Pain 14 Coccidioidomycosis 1 Diabetes 14 Gastroesophageal Reflux Disease 13 Hepatitis C 16 Hyperlipidemia 17 Hypertension 24 Mental Health 2 Rheumatological Disease 1 Seizure Disorder 3 Sleep Apnea 3 Thyroid Disease 1 155 California State Prison, Centinela, Cycle 5 Medical Inspection Page 73 Office of the Inspector General State of California Table B-3: CEN Event – Program Program Total Diagnostic Services 138 Emergency Care 34 Hospitalization 38 Intra-System Transfers In 16 Intra-System Transfers Out 6 Not Specified 1 Outpatient Care 348 Specialized Medical Housing 161 Specialty Services 180 922 California State Prison, Centinela, Cycle 5 Medical Inspection Page 74 Office of the Inspector General State of California Table B-4: CEN Case Review Sample Summary Total MD Reviews Detailed 20 MD Reviews Focused 0 RN Reviews Detailed 12 RN Reviews Focused 28 Total Reviews 60 Total Unique Cases 49 Overlapping Reviews (MD & RN) 11 California State Prison, Centinela, Cycle 5 Medical Inspection Page 75 Office of the Inspector General State of California A C — C S M PPENDIX OMPLIANCE AMPLING ETHODOLOGY California State Prison, Centinela (CEN) Sample Category Quality (number of Indicator samples) Data Source Filters Access to Care MIT 1.001 Chronic Care Patients Master Registry  Chronic care conditions (at least one condition per patient—any risk level) (25)  Randomize MIT 1.002 Nursing Referrals OIG Q: 6.001  See Intra-system Transfers (25) MITs 1.003-006 Nursing Sick Call MedSATS  Clinic (each clinic tested) (5 per clinic)  Appointment date (2–9 months) (30)  Randomize MIT 1.007 Returns from OIG Q: 4.007  See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (22) MIT 1.008 Specialty Services OIG Q: 14.001 &  See Specialty Services Follow-up 14.003 (30) MIT 1.101 Availability of Health OIG onsite  Randomly select one housing unit from each yard Care Services review Request Forms (6) Diagnostic Services MITs 2.001–003 Radiology Radiology Logs  Appointment date (90 days–9 months)  Randomize (10)  Abnormal MITs 2.004–006 Laboratory Quest  Appt. date (90 days–9 months)  Order name (CBC or CMPs only)  Randomize (10)  Abnormal MITs 2.007–009 Pathology InterQual  Appt. date (90 days–9 months)  Service (pathology related) (10)  Randomize California State Prison, Centinela, Cycle 5 Medical Inspection Page 76 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Health Information Management (Medical Records) MIT 4.001 Timely Scanning OIG Qs: 1.001,  Non-dictated documents (13) 1.002, & 1.004  1st 10 IPs MIT 1.001, 1st 5 IPs MITs 1.002, 1.004 MIT 4.002 OIG Q: 1.001  Dictated documents (0)  First 20 IPs selected MIT 4.003 OIG Qs: 14.002  Specialty documents (20) & 14.004  First 10 IPs for each question MIT 4.004 OIG Q: 4.007  Community hospital discharge documents (20)  First 20 IPs selected MIT 4.005 OIG Q: 7.001  MARs (0)  First 20 IPs selected MIT 4.006 Documents for  Any misfiled or mislabeled document identified (7) any tested inmate during OIG compliance review (24 or more = No) MIT 4.007 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 patients from each of the 6 months (if not 5 in a month, supplement from another, as needed) (22) Health Care Environment MIT 5.101-105 Clinical Areas OIG inspector  Identify and inspect all onsite clinical areas. MIT 5.107–111 (10) onsite review Inter- and Intra-System Transfers MIT 6.001-003 Intra-System SOMS  Arrival date (3–9 months) Transfers  Arrived from (another CDCR facility)  Rx count  Randomize (25) MIT 6.004 Specialty Services MedSATS  Date of transfer (3–9 months) Send-Outs  Randomize (20) MIT 6.101 Transfers Out OIG inspector  R&R IP transfers with medication (10) onsite review California State Prison, Centinela, Cycle 5 Medical Inspection Page 77 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Pharmacy and Medication Management MIT 7.001 Chronic Care OIG Q: 1.001 See Access to Care Medication  At least one condition per patient—any risk level  Randomize (25) MIT 7.002 New Medication Master Registry  Rx count Orders  Randomize (25)  Ensure no duplication of IPs tested in MIT 7.001 MIT 7.003 Returns from OIG Q: 4.007  See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (22) MIT 7.004 RC Arrivals – OIG Q: 12.001  See Reception Center Arrivals Medication Orders (N/A at this institution) MIT 7.005 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 (and risk level) (25)  Randomize MIT 7.006 En Route SOMS  Date of transfer (2–8 months)  Sending institution (another CDCR facility)  Randomize (8)  NA/DOT meds MITs 7.101-103 Medication Storage OIG inspector  Identify and inspect clinical & med line areas that Areas onsite review store medications (varies by test) MITs 7.104–106 Medication OIG inspector  Identify and inspect onsite clinical areas that Preparation and onsite review prepare and administer medications Administration Areas (varies by test) MITs 7.107-110 Pharmacy OIG inspector  Identify & inspect all onsite pharmacies (1) onsite review MIT 7.111 Medication Error Monthly  All monthly statistic reports with Level 4 or higher Reporting medication error  Select a total of 5 months (25) reports MIT 7.999 Isolation Unit KOP Onsite active  KOP rescue inhalers & nitroglycerin medications Medications medication for IPs housed in isolation units (10) listing Prenatal and Post-Delivery Services MIT 8.001-007 Recent Deliveries OB Roster  Delivery date (2–12 months) (N/A at this  Most recent deliveries (within date range) institution) Pregnant Arrivals OB Roster  Arrival date (2–12 months) (N/A at this  Earliest arrivals (within date range) institution) California State Prison, Centinela, Cycle 5 Medical Inspection Page 78 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Preventive Services MITs 9.001–002 TB Medications Maxor  Dispense date (past 9 months)  Time period on TB meds (3 months or 12 weeks) (5)  Randomize MIT 9.003 TB Evaluation, SOMS  Arrival date (at least 1 year prior to inspection) Annual Screening  Birth Month (30)  Randomize MIT 9.004 Influenza SOMS  Arrival date (at least 1 year prior to inspection) Vaccinations  Randomize (25)  Filter out IPs tested in MIT 9.008 MIT 9.005 Colorectal Cancer SOMS  Arrival date (at least 1 year prior to inspection) Screening  Date of birth (51 or older) (25)  Randomize MIT 9.006 Mammogram SOMS  Arrival date (at least 2 yrs prior to inspection) (N/A at this  Date of birth (age 52–74) institution)  Randomize MIT 9.007 Pap Smear SOMS  Arrival date (at least three yrs prior to inspection) (N/A at this  Date of birth (age 24–53) institution)  Randomize MIT 9.008 Chronic Care OIG Q: 1.001  Chronic care conditions (at least 1 condition per Vaccinations IP—any risk level)  Randomize (25)  Condition must require vaccination(s) MIT 9.009 Valley Fever Cocci transfer  Reports from past 2–8 months (number will vary) status report  Institution (N/A at this  Ineligibility date (60 days prior to inspection date) institution)  All California State Prison, Centinela, Cycle 5 Medical Inspection Page 79 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Reception Center Arrivals MITs 12.001–008 RC SOMS  Arrival date (2–8 months) (N/A at this  Arrived from (county jail, return from parole, etc.) institution)  Randomize Specialized Medical Housing MITs 13.001–004 CTC CADDIS  AdMIT date (1–6 months)  Type of stay (no MH beds)  Length of stay (minimum of 5 days) (10)  Randomize MIT 13.101 Call Buttons OIG inspector  Review by location CTC onsite review (all) Specialty Services MITs 14.001–002 High-Priority MedSATS  Approval date (3–9 months) (15)  Randomize MITs 14.003–004 Routine MedSATS  Approval date (3–9 months)  Remove optometry, physical therapy or podiatry (15)  Randomize MIT 14.005 Specialty Services MedSATS  Arrived from (other CDCR institution) Arrivals  Date of transfer (3–9 months) (20)  Randomize MIT 14.006-007 Denials InterQual  Review date (3–9 months) (18)  Randomize IUMC/MAR  Meeting date (9 months) Meeting Minutes  Denial upheld (0)  Randomize California State Prison, Centinela, Cycle 5 Medical Inspection Page 80 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.001 Medical Appeals Monthly medical  Medical appeals (12 months) (all) appeals reports MIT 15.002 Adverse/Sentinel Adverse/sentinel  Adverse/sentinel events (2–8 months) Events events report (0) MITs 15.003–004 QMC Meetings Quality  Meeting minutes (12 months) Management Committee (6) meeting minutes MIT 15.005 EMRRC EMRRC meeting  Monthly meeting minutes (6 months) (12) minutes MIT 15.006 LGB LGB meeting  Quarterly meeting minutes (12 months) (4) minutes MIT 15.101 Medical Emergency Onsite summary  Most recent full quarter Response Drills reports &  Each watch documentation (3) for ER drills MIT 15.102 2nd Level Medical Onsite list of  Medical appeals denied (6 months) Appeals appeals/closed (10) appeals files MIT 15.103 Death Reports Institution-list of  Most recent 10 deaths deaths in prior 12  Initial death reports (3) months MIT 15.104 RN Review Onsite supervisor  RNs who worked in clinic or emergency setting Evaluations periodic RN six or more days in sampled month reviews  Randomize (5) MIT 15.105 Nursing Staff Onsite nursing  On duty one or more years Validations education files  Nurse administers medications (10)  Randomize MIT 15.106 Provider Annual provider  All required performance evaluation documents Evaluation Packets evaluation files (5) MIT 15.107 Provider licenses Current provider  Review all listing (at start of (6) inspection) MIT 15.108 Medical Emergency Onsite  All staff Response certification o Providers (ACLS) Certifications tracking logs o Nursing (BLS/CPR) (all)  Custody (CPR/BLS) MIT 15.109 Nursing staff and Onsite tracking  All required licenses and certifications Pharmacist in system, logs, or Charge Professional employee files Licenses and Certifications (all) California State Prison, Centinela, Cycle 5 Medical Inspection Page 81 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.110 Pharmacy and Onsite listing of  All DEA registrations Providers’ Drug provider DEA Enforcement registration #s & Agency (DEA) pharmacy Registrations registration document (all) MIT 15.111 Nursing Staff New Nursing staff  New employees (hired within last 12 months) Employee training logs  Orientations (all) MIT 15.998 Death Review OIG summary  Between 35 business days & 12 months prior Committee log - deaths  CCHCS death reviews (4) California State Prison, Centinela, Cycle 5 Medical Inspection Page 82 Office of the Inspector General State of California This page intentionally left blank. California State Prison, Centinela, Cycle 5 Medical Inspection Page 83 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 5 Medical Inspection Page 84 Office of the Inspector General State of California