Centinela State Prison Cycle 6 Medical Inspection Report

Amarik K. Singh, Inspector General OFFICE of the OIG INSPECTOR GENERAL Independent Prison Oversight February 2022 Cycle 6 Medical Inspection Report Centinela State Prison Electronic copies of reports published by the Office of the Inspector General are available free in portable document format (PDF) on our website. We also offer an online subscription service. For information on how to subscribe, visit www.oig.ca.gov. For questions concerning the contents of this report, please contact Shaun Spillane, Public Information Officer, at 916-255-1131. Cycle 6, Centinela State Prison | iii Contents Introduction 1 Summary 3 Overall Rating: Adequate 3 Medical Inspection Results 7 Deficiencies Identified During Case Review 7 Case Review Results 7 Compliance Testing Results 8 Population-Based Metrics 10 HEDIS Results 10 Recommendations 12 Indicators 15 Access to Care 15 Diagnostic Services 22 Emergency Services 26 Health Information Management 30 Health Care Environment 35 Transfers 46 Medication Management 52 Preventive Services 63 Nursing Performance 65 Provider Performance 71 Specialized Medical Housing 76 Specialty Services 80 Administrative Operations 85 Appendix A. Methodology 88 Case Reviews 89 Compliance Testing 92 Indicator Ratings and the Overall Medical Quality Rating 93 Appendix B. Case Review Data 94 Appendix C. Compliance Sampling Methodology 97 California Correctional Health Care Services’ Response 107 Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | iv Illustrations Tables 1. Centinela State Prison Summary Table 3 2. Centinela State Prison Policy Compliance Scores 4 3. Centinela State Prison Master Registry Data as of January 2021 5 4. Centinela State Prison Health Care Staffing Resources as of January 2021 6 5. Centinela State Prison Results Compared with State HEDIS Scores 11 6. Access to Care 19 7. Other Tests Related to Access to Care 20 8. Diagnostic Services 24 9. Health Information Management 33 10. Other Tests Related to Health Information Management 34 11. Health Care Environment 44 12. Transfers 50 13. Other Tests Related to Transfers 51 14. Medication Management 61 15. Other Tests Related to Medication Management 62 16. Preventive Services 64 17. Specialized Medical Housing 79 18. Specialty Services 83 19. Other Tests Related to Specialty Services 84 20. Administrative Operations 86 A–1. Case Review Definitions 89 B–1. Case Review Sample Sets 94 B–2. Case Review Chronic Care Diagnoses 95 B–3. Case Review Events by Program 96 B–4. Case Review Sample Summary 96 Figures A–1. Inspection Indicator Review Distribution 88 A–2. Case Review Testing 91 A–3. Compliance Sampling Methodology 92 Photographs 1. Indoor waiting area 36 2. Individual Modules 36 3. Exam room lacked visual privacy 37 4. Expired medical supplies dated April 2019 and March 2020 37 5. Expired medical supplies dated April 4, 2021 38 6. Staff inaccurately log the EMRB glucometer control solution range when performing the daily glucometer quality control 39 7. Masks stored in the dirty utility room 39 8. Expired medical supplies dated March 31, 2021 40 9. Expired medical supplies dated March 28, 2021 40 10. Rodent Droppings 41 11. Medical supplies with manufacturer temperature guidelines kept in nontemperature-monitored storage area 41 12. Blood-like substance found in clinic's staff restroom 42 13. Nonfunctional patient restroom sink with water leaking from the bottom of the spout 43 14. Medication stored beyond the prescription’s expiration date 56 15. Medications stored with disinfectant 57 16. Patient-specific medication with an expired pharmacy label dated May 8, 2021 57 Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | v 17. Staff’s documented and actual glucometer control solution range used to perform the test did not match 58 18. Expired and unexpired medications stored together and disorganized 59 19. Expired medication dated April 2021 59 20. Expired frozen medications dated April 2020 and November 2020 60 Cover: Rod of Asclepius courtesy of Thomas Shafee Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 1 Introduction Pursuant to California Penal Code section 6126 et seq., the Office of the Inspector General (the OIG) is responsible for periodically reviewing and reporting on the delivery of the ongoing medical care provided to incarcerated persons1 in the California Department of Corrections and Rehabilitation (the department).2 In Cycle 6, the OIG continues to apply the same assessment methodologies used in Cycle 5, including clinical case review and compliance testing. These methods provide an accurate assessment of how the institution’s health care systems function regarding patients with the highest medical risk who tend to access services at the highest rate. This information helps to assess the performance of the institution in providing sustainable, adequate care.3 We continue to review institutional care using 15 indicators, as in prior cycles. Using each of these indicators, our compliance inspectors collect data in answer to compliance- and performance-related questions as established in the medical inspection tool (MIT).4 We determine a total compliance score for each applicable indicator and consider the MIT scores in the overall conclusion of the institution’s performance. In addition, our clinicians complete document reviews of individual cases and also perform on-site inspections, which include interviews with staff. In reviewing the cases, our clinicians examine whether providers used sound medical judgment in the course of caring for a patient. In the event we find errors, we determine whether such errors were clinically significant or led to a significantly increased risk of harm to the patient.5 At the same time, our clinicians examine whether the institution’s medical system mitigated the error. The OIG rates the indicators as proficient, adequate, or inadequate. 1 In this report, we use the terms patient and patients to refer to incarcerated persons. 2 The OIG’s medical inspections are not designed to resolve questions about the constitutionality of care, and the OIG explicitly makes no determination regarding the constitutionality of care the department provides to its population. 3 In addition to our own compliance testing and case reviews, the OIG continues to offer selected Healthcare Effectiveness Data and Information Set (HEDIS) measures for comparison purposes. 4 The department regularly updates its policies. The OIG updates our policy-compliance testing to reflect the department’s updates and changes. 5 If we learn of a patient needing immediate care, we notify the institution’s chief executive officer. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 2 The OIG has adjusted Cycle 6 reporting in two ways. First, commencing with this reporting period, we interpret compliance and case review results together, providing a more holistic assessment of the care; and second, we consider whether institutional medical processes lead to identifying and correcting provider or system errors. The review assesses the institution’s medical care on both system and provider levels. As in Cycle 5, our office continues to inspect both those institutions remaining under federal receivership and those delegated back to the department. There is no difference in the standards used for assessing a delegated institution versus an institution not yet delegated. At the time of the Cycle 6 inspection of Centinela State Prison (CEN), the receiver had delegated this institution back to the department. We completed our sixth inspection of CEN, and this report presents our assessment of the health care provided at that institution during the inspection period between September 2020 and February 2021.6 The data was obtained for CEN and the on-site inspections occurred during the COVID-19 pandemic.7 Centinela State Prison, located in the city of Imperial in Imperial County, 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 incarcerated persons. The institution runs multiple medical clinics, where staff members manage nonurgent 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. 6 Samples are obtained per case review methodology shared with stakeholders in prior cycles. The case reviews include death reviews between July 2020 and January 2021, CPR reviews between May 2020 and July 2020, diabetes reviews between August 2020 and March 2021, high risk reviews between September 2020 and March 2021, hospitalization reviews between August 2020 and March 2021, transfer reviews between August 2020 and March 2021, and RN sick call reviews between September 2020 and March 2021. 7As of November 22, 2021, the department reports on its public tracker that 80% of its incarcerated population at CEN is fully vaccinated while 78% of CEN staff are fully vaccinated: www.cdcr.ca.gov/covid19/population-status-tracking/ Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 3 Summary We completed the Cycle 6 inspection of Centinela State Prison (CEN) in July 2021. OIG inspectors monitored the institution’s delivery of medical care that occurred between September 2020 and February 2021. The OIG rated the overall quality of health care at CEN as adequate. We list the individual indicators and ratings applicable for this institution in the Table 1 below. Table 1. CEN Summary Table Cycle 6 Cycle 6 Cycle 6 Change Health Care Indicators Case Review Compliance Overall Since Rating Rating Rating Cycle 5 Access to Care Adequate Inadequate Adequate Diagnostic Services Adequate Inadequate Adequate Emergency Services Adequate N/A Adequate Health Information Management Proficient Proficient Proficient Health Care Environment N/A Inadequate Inadequate Transfers Adequate Inadequate Adequate Medication Management Inadequate Inadequate Inadequate Preventive Services N/A Adequate Adequate Nursing Performance Inadequate N/A Inadequate Provider Performance Adequate N/A Adequate Specialized Medical Housing Adequate Inadequate Inadequate Specialty Services Adequate Adequate Adequate Administrative Operations† N/A Inadequate Inadequate * The symbols in this column correspond to changes that occurred in indicator ratings between the medical inspections conducted during Cycle 5 and Cycle 6. The equals sign means there was no change in the rating. The single arrow means the rating rose or fell one level, and the double arrow means the rating rose or fell two levels (green, from inadequate to proficient; pink, from proficient to inadequate). † Administrative Operations is a secondary indicator and is not considered when rating the institution’s overall medical quality. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 4 To test the institution’s policy compliance, our compliance inspectors, (a team of registered nurses) monitored the institution’s compliance with its medical policies by answering a standardized set of questions that measure specific elements of health care delivery. Our compliance inspectors examined 388 patient records and 1,117 data points and used the data to answer 90 policy questions. In addition, we observed CEN’s processes during an on-site inspection in May 2021. Table 2 below lists CEN’s average scores from Cycles 4, 5, and 6. Table 2. CEN Policy Compliance Scores Scoring Ranges 100%–85.0% 84.9%–75.0% 74.9%–0 Medical Cycle 4 Cycle 5 Cycle 6 Inspection Policy Compliance Category Average Average Average Tool (MIT) Score Score Score 1 Access to Care 80.6% 79.6% 71.6% 2 Diagnostic Services 66.7% 73.3% 59.6% 4 Health Information Management 76.0% 89.3% 88.6% 5 Health Care Environment 85.4% 74.6% 51.8% 6 Transfers 90.0% 90.0% 71.4% 7 Medication Management 78.2% 61.2% 51.5% 8 Prenatal and Postpartum Care N/A N/A N/A 9 Preventive Services 85.6% 78.8% 80.7% 12 Reception Center N/A N/A N/A 13 Specialized Medical Housing 98.0% 100% 58.0% 14 Specialty Services 85.7% 80.8% 82.9% 15 Administrative Operations 71.3% 77.6% 63.2% * In Cycle 4, there were two secondary (administrative) indicators, and this score reflects the average of those two scores. In Cycle 5 and moving forward, the two indicators were merged into one, with only one score as the result. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 5 The OIG clinicians (a team of physicians and nurse consultants) reviewed 48 cases, which contained 1017 patient-related events. After examining the medical records, our clinicians conducted a follow-up on-site inspection to verify their initial findings. The OIG physicians rated the quality of care for 20 comprehensive case reviews. Of these 20 cases, our physicians rated 15 adequate and five inadequate. Our physicians did not identify any adverse events during this inspection. The OIG then considered the results from both case review and compliance testing, and drew overall conclusions, which we report in the 13 health care indicators.8 Multiple OIG physicians and nurses performed quality control reviews; their subsequent collective deliberations ensured consistency, accuracy, and thoroughness. Our clinicians acknowledged institutional structures that catch and resolve mistakes that may occur throughout the delivery of care. As noted above, we listed the individual indicators and ratings applicable for this institution in Table 1, the CEN Summary Table. In April 2021, the Health Care Services Master Registry showed that CEN had a total population of 3,082. A breakdown of the medical risk level of the CEN population as determined by the department is set forth in Table 3 below.9 Table 3. CEN Master Registry Data as of April 2021 Medical Risk Level Number of Patients Percentage High 1 24 0.8% High 2 46 1.5% Medium 494 16.0% Low 2,518 81.7% Total 3,082 100.0% Source: Data for the population medical risk level were obtained from the CCHCS Master Registry dated 4-19-21. 8 The indicators for Reception Center and Prenatal and Postpartum Care did not apply to CEN. 9 For a definition of medical risk, see CCHCS HCDOM 1.2.14, Appendix 1.9. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 6 Based on staffing data the OIG obtained from California Correctional Health Care Services (CCHCS), as identified in Table 4 below, CEN had two vacant executive leadership positions, .5 vacant primary care provider positions, zero vacant nursing supervisor positions, and 4.7 vacant nursing staff positions. Table 4. CEN Health Care Staffing Resources as of April 2021 Executive Primary Care Nursing Nursing Positions Leadership* Providers Supervisors Staff† Total Authorized Positions 4 5.5 10.5 59.4 79.4 Filled by Civil Service 2 5 10.5 54.7 72.2 Vacant 2 .5 0 4.7 7.2 Percentage Filled by Civil Service 50% 90.9% 100% 92.1% 90.9% Filled by Telemedicine 0 0 0 0 0 Percentage Filled by Telemedicine 0 0 0 0 0 Filled by Registry 0 0 0 16 16 Percentage Filled by Registry 0 0% 0 29.0% 9.5% Total Filled Positions 2 5 10.5 70.7 88.2 Total Percentage Filled 50.0% 90.9% 100% 119.0% 111.1% Appointments in Last 12 Months 1 0 1 5 7 Redirected Staff 0 0 0 0 0 Staff on Extended Leave‡ 0 0 2 2 4 Adjusted Total: Filled Positions 2 5 8.5 68.7 84.2 Adjusted Total: Percentage Filled 50.0% 91.0% 81.0% 115.7% 106.0% * Executive Leadership includes the Chief Physician and Surgeon. † Nursing Staff includes Senior Psychiatric Technician and Psychiatric Technician. ‡ In Authorized Positions. Notes: The OIG does not independently validate staffing data received from the department. Positions are based on fractional time-base equivalents. Source: Cycle 6 medical inspection preinspection questionnaire received April 2021, from California Correctional Health Care Services. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 7 Medical Inspection Results Deficiencies Identified During Case Review Deficiencies are medical errors that increase the risk of patient harm. Deficiencies can be minor or significant, depending on the severity of the deficiency. An adverse event occurs when the deficiency caused harm to the patient. All major health care organizations identify and track adverse events. We identify deficiencies and adverse events to highlight concerns regarding the provision of care and for the benefit of the institution’s quality improvement program to provide an impetus for improvement.10 Our inspectors did not find any adverse events at CEN in the cases reviewed during the Cycle 6 inspection. Case Review Results OIG case reviewers (a team of physicians and nurse consultants) assessed 10 of the 13 indicators applicable to CEN. Of these 10 indicators, OIG clinicians rated one proficient, seven adequate, and two inadequate. The OIG physicians also rated the overall adequacy of care for each of the 20 detailed case reviews they conducted. Of these 20 cases, 15 were adequate and five were inadequate. In the 1,017 events reviewed, there were 255 deficiencies, 28 of which the OIG clinicians considered to be of such magnitude that, if left unaddressed, they would likely contribute to patient harm. Our clinicians found the following strengths at CEN: • Staff used the EHRS messaging system to communicate patient care issues quickly and to ensure timely care. On several occasions, specialty nurses messaged providers to ensure timely follow-up appointments and orders. • The institution provided excellent health information management, as most hospital discharge records, diagnostic results, and specialty reports were retrieved and scanned within the required time frames. • During CPR events, the medical staff and custody staff performed well in providing immediate resuscitation interventions and transfer to a higher level of care. 10 For a further discussion of an adverse event, see Table A-1. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 8 Our clinicians found the following weaknesses at CEN: • The institution performed poorly in medication management, particularly with reconciliation of prehospitalization and posthospitalization medications during the transition of care when patients returned from the hospital. • The institution performed poorly in nursing performance, with incomplete assessments, interventions, and documentation in the outpatient setting. • The CTC performed poorly in completing admission assessments at the time of admission. In addition, nursing staff occasionally did not update the patient care plans to reflect new conditions. Compliance Testing Results Our compliance inspectors assessed 10 of the 13 indicators applicable to CEN. Of these 10 indicators, our compliance inspectors rated one proficient, two adequate, and seven inadequate. We tested policy compliance in the Health Care Environment, Preventive Services, and Administrative Operations indicators, as these do not have a case review component. CEN demonstrated a high rate of policy compliance in the following areas: • The institution’s medical staff timely scanned into patients’ electronic medical records requests for health care services forms, and community hospital discharge reports. • The institution completed high-priority, medium-priority, and routine-priority specialty services within the required time frames. • Nursing staff at CEN reviewed health care services request forms and conducted face-to-face encounters within the required time frames. • CEN medical staff did well in providing tuberculosis (TB) medications, offering immunizations and providing preventive services for their patients, such as influenza vaccination, annual testing for TB, and colorectal cancer screenings. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 9 CEN demonstrated a low rate of policy compliance in the following areas: • Providers at CEN did not provide timely appointments for chronic care patients, patients returning from specialty services, and patients returning from hospital admission; nurse-to-provider referrals did not occur within required time frames. • Patients did not always receive their chronic care medications within the required time frame. There was poor medication continuity for patients returning from hospitalizations and for patients admitted to specialized medical housing. • The institution did not consistently provide routine laboratory services within the specified time frames. Moreover, providers often did not communicate results of diagnostic services timely. Most patient letters communicating these results were missing the date of the diagnostic service, the date of the results, and whether the results were within normal limits. • Clinical staff did not consistently follow universal hand hygiene precautions before or after patient encounters. • Nursing staff did not regular inspect emergency response bags and treatment carts. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 10 Population-Based Metrics In addition to our own compliance testing and case reviews, as noted above, the OIG presents selected measures from the Healthcare Effectiveness Data and Information Set (HEDIS) for comparison purposes. The HEDIS is a set of standardized quantitative performance measures designed by the National Committee for Quality Assurance to ensure that the public has the data it needs to compare the performance of health care plans. Because the Veterans Administration no longer publishes its individual HEDIS scores, we removed them from our comparison for Cycle 6. Likewise, Kaiser (commercial plan) no longer publishes HEDIS scores. However, through the California Department of Health Care Services’ Medi-Cal Managed Care Technical Report, the OIG obtained Kaiser Medi-Cal HEDIS scores for three of five diabetic measures to use in conducting our analysis, and we present them here for comparison. HEDIS Results We considered CEN’s performance with population-based metrics to assess the macroscopic view of the institution’s health care delivery. CEN’s results compared favorably with those found in State health plans for diabetic care measures. We list the nine HEDIS measures in Table 5. 11 Comprehensive Diabetes Care When compared with statewide Medi-Cal programs (California Medi-Cal, Kaiser Northern California (Medi-Cal), and Kaiser Southern California (Medi-Cal), CEN performed better in all three diabetic measures that have statewide comparative data: poor HbA1c control, blood pressure control, and HbA1c screening. Immunizations Statewide comparative data were not available for immunization measures; however, we include this data for informational purposes. CEN had a 67 percent influenza immunization rate for adults 18 to 64 years old and a 92 percent influenza immunization rate for adults 65 years of age and older. The pneumococcal vaccine rate was 69 percent.12 11 The HEDIS sampling methodology requires a minimum sample of 10 patients to have a reportable result. The sample for older adults did not include a full sample. 12 The pneumococcal vaccines administered are the 13 valent pneumococcal vaccine (PCV13) or 23 valent pneumococcal vaccine (PPSV23), depending on the patient’s medical conditions. For the adult population, the influenza or pneumococcal vaccine may have been administered at an institution other than the one where the patient was housed during the inspection period. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 11 Colorectal Cancer Screening Statewide comparative data were not available for colorectal cancer screening; however, we include these data for informational purposes. CEN had an 87 percent colorectal cancer screening rate. Table 5. CEN Results Compared with State HEDIS Scores California Californi CEN Kaiser a Kaiser California NorCal SoCal Cycle 6 Medi-Cal Medi-Cal Medi-Cal HEDIS Measure Results* 2018† 2018† 2018† HbA1c Screening 100% 90% 94% 96% Poor HbA1c Control (> 9.0%) ‡, § 6% 34% 25% 18% HbA1c Control (< 8.0%) ‡ 79% – – – Blood Pressure Control (< 140/90) ‡ 91% 65% 78% 84% Eye Examinations 83% – – – Influenza – Adults (18–64) 67% – – – Influenza – Adults (65+) 92% – – – Pneumococcal – Adults (65+) 69% – – – Colorectal Cancer Screening 87% – – – Notes and Sources * Unless otherwise stated, data were collected in February 2021 by reviewing medical records from a sample of CEN’s population of applicable patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. † HEDIS Medi-Cal data were obtained from the California Department of Health Care Services publication titled Medi-Cal Managed Care External Quality Review Technical Report, dated July 1, 2019–June 30, 2020 (published April 2021). www.dhcs.ca.gov/documents/MCQMD/CA2019-20-EQR-Technical-Report-Vol3-F2.pdf ‡ For this indicator, the entire applicable CEN population was tested. § For this measure only, a lower score is better. Source: Institution information provided by the California Department of Corrections and Rehabilitation. Health care plan data were obtained from the CCHCS Master Registry. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 12 Recommendations As a result of our assessment of CEN’s performance, we offer the following recommendations to the department: Access to Care • Medical leadership should ensure that clinic providers timely complete appointments for patients with chronic conditions; leadership should also ensure that nurse-to-provider follow-up appointments and provider-ordered sick call follow-up appointments occur on time. Diagnostic Services • Medical leadership should remind providers to timely retrieve the results of radiology and pathology reports and to timely communicate those results with complete patient notification letters. • Medical leadership should ascertain the causes of the untimely provision of laboratory services and should implement remedial measures as appropriate. Emergency Services • To ensure accurate documentation, nursing leadership should consider completing a thorough audit of staff documentation after an emergent event to provide training to staff regarding how to properly document the emergent event in the electronic health record system (EHRS). Health Information Management • The department should consider developing and implementing a patient results letter template that autopopulates with all elements required by CCHCS policy. Health Care Environment • Medical leadership should remind staff to follow universal hand hygiene precautions. Implementing random spot checks of staff could improve compliance. • Nursing leadership should consider performing random spot checks to ensure staff follow equipment and medical supply management protocols. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 13 • Nursing leadership should direct each clinic nurse supervisor to review the monthly emergency medical response bag (EMRB) logs to ensure the EMRBs are regularly inventoried and sealed. Transfers • Nursing leadership should consider developing and implementing an internal audit to ensure nurses document pending specialty referrals for patients transferring to other institutions. • The department should consider developing and implementing measures to ensure that receiving and release (R&R) nursing staff properly complete the initial health screening questions. Medication Management • Medical leadership should consider developing and implementing an audit to ensure medication continuity for patients discharged from a community hospital. • The institution should consider developing and implementing measures to ensure that staff timely make available and administer chronic care medications to the patients and that staff document in the medication administration record (MAR) as described by CCHCS policy. Preventive Services • Nursing leadership should consider developing and implementing measures to ensure that nursing staff is educated in accurately monitoring patients on TB medications and that they address TB signs and symptoms in their monitoring. Nursing Performance • Nursing leadership should ensure that nurses perform more detailed assessments and interventions during patient visits and should consider implementing audits. • Nursing leadership should ensure nurses triage urgent symptomatic sick calls timely. • Nursing leadership should ensure that COVID-19 registry nurses are provided adequate training in COVID-19 assessment and documentation, as well as in communicating abnormal findings to providers. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 14 Provider Performance • Medical leadership should ensure providers document patient- related calls and management plans in the electronic health record system (EHRS) for clear communication and collaboration with the patient care team and for the continuity of patient care. Specialized Medical Housing • Nursing leadership should ensure that the initial nursing admission assessments are completed within the required time frame as provided in CCHCS policy. • Nursing leadership should determine the root cause of challenges to patients receiving all ordered medications within the required time frame and should implement remedial measures as appropriate. Specialty Services • Medical leadership should consider reminding providers to follow specialists’ recommendations unless there exists a clinical rationale not to follow those recommendations, and to clearly document such a rationale in the EHRS. • Medical leadership should ascertain the challenges to the receipt of specialty reports within the required time frames and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 15 Access to Care In this indicator, OIG inspectors evaluated the institution’s ability to Overall provide patients with timely clinical appointments. Our inspectors Rating Adequate reviewed the scheduling and appointment timeliness for newly arrived patients, sick calls, and nurse follow-up appointments. We examined Case Review referrals to primary care providers, provider follow-ups, and specialists. Rating Furthermore, we evaluated the follow-up appointments for patients Adequate who received specialty care or returned from an off-site hospitalization. Compliance Score Results Overview Inadequate (71.6%) CEN delivered satisfactory access to care for patients. OIG clinicians found that most appointments and referral were completed timely, including appointments with correctional treatment center (CTC) providers, nurses, and specialists. However, the institution did not perform well in clinic provider appointments. In this indicator, the compliance testing showed a score of 71.6 percent. After reviewing all aspects, the OIG rated this indicator adequate. Case Review and Compliance Testing Results We reviewed 154 provider, nursing, specialty, and hospital events that required the institution to generate appointments. We identified five access deficiencies, none of which were significant.12 Access to Clinic Providers Access to clinic providers is an integral part of patient care in health care delivery. During the outbreaks of COVID-19 infection in late November through December 2020 at CEN, and due to the restricted patient movement directives from CDCR and CCHCS in response to the COVID-19 pandemic, medical staff continued to provide care using chart reviews, prioritizing urgent and emergent conditions with appointments to providers. Compliance testing found that 52.0 percent of chronic care follow-up appointments occurred on time (MIT 1.001), and 42.9 percent of nurse-to-provider follow-up appointments occurred as requested (MIT 1.005). Our clinicians reviewed 73 outpatient provider encounters and identified one minor deficiency:13 • In case 40, the nurse ordered a provider appointment for a patient evaluation in 14 days; however, the patient was seen 19 days later. 12 Minor deficiencies occurred in cases 7, 12, 14, 40 and 57. 13 Minor deficiency occurred in case 40. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 16 Access to Specialized Medical Housing Providers CEN performed well in access to care in the Correctional Treatment Center (CTC). When staff admitted patients to the CTC, the providers examined patients timely and documented their findings in progress notes within the appropriate time frames. Compliance testing found that 80.0 percent of the CTC admission history and physical examinations occurred within the required time frame (MIT 13.002). Our clinicians assessed 30 CTC provider encounters and did not find any deficiencies related to late or missed admission history and physical examinations or follow-up appointments. Access to Clinic Nurses CEN performed well in access to nurse sick calls and provider-to-nurse referrals. Compliance testing found that all nurse sick call requests were reviewed on the same day they were received (MIT 1.003, 96.7%), and nursing staff completed a face-to-face visit within one day after the sick call requests were reviewed (MIT 1.004, 93.3%). Our clinicians assessed 59 nursing sick call requests in 31 cases and identified two deficiencies related to clinic nurse access:14 • In case 7, the nurse triaged a symptomatic sick call request for urinary symptoms and leg pain. The patient was evaluated one day late. • In case 14, the nurse triaged a symptomatic sick call request for back pain; however, the patient was evaluated five days late. Access to Specialty Services CEN performed well in referrals to specialty services. Compliance testing found that 100.0 percent of the initial high-priority specialty appointments occurred within the required time frame (MIT 14.001); 86.7 percent of the initial medium-priority specialty appointments occurred within the required time frame (MIT 14.004); and 93.3 percent of the initial routine-priority specialty appointments occurred within the required time frame (MIT 14.007). Also, 85.7 percent of patients received the subsequent high-priority specialty appointments within the required time frame (MIT 14.003); 90.0 percent of medium-priority specialist appointments occurred within the required time frame (MIT 14.006); and 100 percent of routine specialty service appointments occurred within the required time frame (MIT 14.009). Our clinicians 14 Minor deficiencies occurred in cases 7 and 4. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 17 assessed 53 specialty services events and identified two deficiencies.15 One example follows: • In case 12, the provider ordered the telemedicine rheumatology follow-up appointment five weeks later than the recommended date. Follow-Up After Specialty Service CEN did not often provide clinician face-to-face follow-up visits within required time frames; however, many providers monitored progress through chart reviews in response to the COVID-19 movement restriction and determined whether face-to-face appointments were necessary. Compliance testing revealed that 11.6 percent of provider appointments after specialty services occurred as face-to-face visits within required time frames (MIT 1.008). Our clinicians evaluated 53 specialty appointments and did not identify any missed or delayed provider follow-up appointments after specialty services. Follow-Up After Hospitalization CEN performed well in ensuring that patients saw their providers within the required time frames after hospitalizations. Compliance testing found that 100 percent of provider appointments occurred within the required time frame (MIT 1.007). Our clinicians reviewed 30 hospital returns and did not identify missed or delayed provider appointments. Follow-Up After Urgent or Emergent Care (TTA) CEN performed adequately for patients with provider follow-up appointments after urgent or emergent care at the triage and treatment area (TTA). Our clinicians assessed nine TTA events and did not identify missed or delayed provider follow-up appointments. Follow-Up After Transferring into the Institution CEN performed adequately in providing appointments for newly arrived patients within the required time frames (MIT 1.002, 76.0%). Our clinicians assessed 15 transfer-in events in six cases and did not identify any delay in nursing appointments.16 Clinician On-Site Inspection 15 Minor deficiencies occurred in cases 12 and 47. 16 Transfer-in events occurred in cases 1, 4, 23, 24, 25 and 48. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 18 The OIG clinicians attended morning huddles, which were well attended by patient care team and ancillary staff. CEN has five main clinics, facilities A, B, C, D, and E. Two clinics have telemedicine exam rooms. In addition to main clinics, CEN operates a restricted housing clinic, a TTA, a CTC, and specialty clinics that offer audiology, physical therapy, podiatry, and colonoscopy services. The office technicians from each clinic attend the morning huddles and ensure that provider appointments are met. The office technicians reported scheduling about 12 appointments for each primary care provider per day. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 19 Compliance Testing Results Table 6. Access to Care Scored Answer Compliance Questions Yes No N/A Yes % Chronic care follow-up appointments: Was the patient’s most recent chronic care visit within the health care guideline’s maximum 13 12 0 52.0% allowable interval or within the ordered time frame, whichever is shorter? (1.001) * For endorsed patients received from another CDCR institution: Based on the patient’s clinical risk level during the initial health screening, 19 6 0 76.0% was the patient seen by the clinician within the required time frame? (1.002) * Clinical appointments: Did a registered nurse review the patient’s 29 1 0 96.7% request for service the same day it was received? (1.003) * Clinical appointments: Did the registered nurse complete a face-to- face visit within one business day after the CDCR Form 7362 was 28 2 0 93.3% reviewed? (1.004) * Clinical appointments: If the registered nurse determined a referral to a primary care provider was necessary, was the patient seen within the 3 4 23 42.9% maximum allowable time or the ordered time frame, whichever is the shorter? (1.005) * Sick call follow-up appointments: If the primary care provider ordered a follow-up sick call appointment, did it take place within the time N/A N/A 30 N/A frame specified? (1.006) * Upon the patient’s discharge from the community hospital: Did the patient receive a follow-up appointment within the required time 25 0 0 100% frame? (1.007) * Specialty service follow-up appointments: Did the clinician follow-up visits occur within required time frames? (1.008) * , † 5 38 2 11.6% Clinical appointments: Do patients have a standardized process to 6 0 0 100% obtain and submit health care services request forms? (1.101) Overall percentage (MIT 1): 71.6% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician follow-up visits following specialty services. As a result, we tested MIT 1.008 only for high- priority specialty services or when staff ordered follow-ups. The OIG continued to test the clinical appropriateness of specialty follow-ups through its case review testing. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 20 Table 7. Other Tests Related to Access to Care Scored Answer Compliance Questions Yes No N/A Yes % For patients received from a county jail: If, during the assessment, the nurse referred the patient to a provider, was the patient seen within the N/A N/A N/A N/A required time frame? (12.003) * For patients received from a county jail: Did the patient receive a history and physical by a primary care provider within seven calendar N/A N/A N/A N/A days? (12.004) * For CTC and SNF only (effective 4/2019, include OHU): Was a written history and physical examination completed within the required time 8 2 0 80.0% frame? (13.002) * For OHU, CTC, SNF, and Hospice (applicable only for samples prior to 4/2019): Did the primary care provider complete the Subjective, Objective, N/A N/A 10 N/A Assessment, and Plan notes on the patient at the minimum intervals required for the type of facility where the patient was treated? (13.003) * Did the patient receive the high-priority specialty service within? 14 calendar days of the primary care provider order or the Physician 15 0 0 100% Request for Service? (14.001) * Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care provider? 12 2 1 85.7% (14.003) * Did the patient receive the medium-priority specialty service within 15–45 calendar days of the primary care provider order or the Physician 13 2 0 86.7% Request for Service? (14.004) * Did the patient receive the subsequent follow-up to the medium- priority specialty service appointment as ordered by the primary care 9 1 5 90.0% provider? (14.006) * Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician 14 1 0 93.3% Request for Service? (14.007) * Did the patient receive the subsequent follow-up to the routine-priority specialty service appointment as ordered by the primary care provider? 9 0 6 100% (14.009) * * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † CCHCS changed its policies and removed mandatory minimum rounding intervals for patients located in specialized medical housing. After April 2, 2019, MIT 13.003 only applied to CTCs that still had State-mandated rounding intervals. OIG case reviewers continued to test the clinical appropriateness of provider follow-ups within specialized medical housing units through case reviews. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 21 Recommendations • Medical leadership should ensure that clinic providers timely complete appointments for patients with chronic conditions; leadership should also ensure that nurse-to-provider follow-up appointments and provider-ordered sick call follow-up appointments occur on time. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 22 Diagnostic Services In this indicator, OIG inspectors evaluated the institution’s ability to Overall timely complete radiology, laboratory, and pathology tests. Our Rating Adequate inspectors determined whether the institution properly retrieved the resultant reports and whether providers reviewed the results correctly. Case Review In addition, in Cycle 6, we examined the institution’s ability to timely Rating complete and review immediate (stat) laboratory tests. Adequate Compliance Results Overview Score Inadequate CEN performed satisfactorily in diagnostic services. CEN generally (59.6%) timely completed tests and retrieved results, but poorly communicated results with patients. Compliance testing in this indicator showed poor performance, with the score of 59.6 percent. However, these deficiencies did not increase significant risk of harm to the patients since providers generally reviewed test results with the patients at follow-up appointments. After reviewing all aspects of our review results, the OIG rated this indicator adequate. Case Review and Compliance Testing Results Our clinicians reviewed 265 diagnostic events and found 60 deficiencies, none of which were significant.17 The majority of these deficiencies were related to incomplete or missing test result patient letters. For health information management, we considered test reports that were never retrieved or reviewed as severe a problem as tests that were not performed. These deficiencies are discussed further in the Health Information Management indicator. Test Completion CEN had excellent performance completing radiology services within required time frames (MIT 2.001, 90.0%), but performed less well in timely completing laboratory services (MIT 2.004, 60.0%). There were no immediate (stat) laboratory tests in case reviews. Our clinicians reviewed 253 laboratory tests and identified the following one minor deficiency related to a delayed laboratory test completion: • In case 21, the provider ordered laboratory blood work to be done; however, the laboratory test samples were collected four days late. 17 Deficiencies occurred in cases 1, 2, 3, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 21, 22, 47 and 48. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 23 Health Information Management CEN health care providers reviewed and endorsed radiology reports (MIT 2.002, 100%) and laboratory reports (MIT 2.005, 100%) well within specified time frames. CEN staff retrieved pathology reports within the required time frames most of the time (MIT 2.010, 77.8%), and health care providers reviewed and endorsed them timely (MIT 2.011, 88.9%). However, the providers did not communicate pathology results with patient notification letters (MIT 2.012, zero). Our clinicians identified that 58 out of 60 deficiencies in this indicator were related to the patient notification letters, which either lacked required elements or were not created after the provider reviewed the test results.18 Two examples follow: • In case 1, the provider endorsed the laboratory results. However, the provider did not create a patient notification letter in the EHRS. • In case 2, the provider reviewed the result of the chest x-ray and created a patient notification letter. However, the letter did not include whether the results are within normal limits, as required by CCHCS policy. Clinician On-Site Inspection The diagnostic vendor, Quest Laboratory, sends all the laboratory test results directly to EHRS. Immediate (stat) laboratory test results are communicated to triage and treatment (TTA) staff by phone and fax; TTA staff then inform the provider. The laboratory staff reported that all laboratory tests are completed as ordered. 18 Deficiencies occurred in cases 1, 2, 3, 8, 10, 11, 12, 13, 14, 15, 17, 18, 21, 22 and 47. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 24 Compliance Testing Results Table 8. Diagnostic Services Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Was the radiology service provided within the time frame 9 1 0 90.0% specified in the health care provider’s order? (2.001) * Radiology: Did the ordering health care provider review and endorse 10 0 0 100% the radiology report within specified time frames? (2.002) * Radiology: Did the ordering health care provider communicate the results of the radiology study to the patient within specified time 0 10 0 0 frames? (2.003) Laboratory: Was the laboratory service provided within the time frame 6 4 0 60.0% specified in the health care provider’s order? (2.004) * Laboratory: Did the health care provider review and endorse the 10 0 0 100% laboratory report within specified time frames? (2.005) * Laboratory: Did the health care provider communicate the results of 2 8 0 20.0% the laboratory test to the patient within specified time frames? (2.006) Laboratory: Did the institution collect the STAT laboratory test and N/A N/A N/A N/A receive the results within the required time frames? (2.007) * Laboratory: Did the provider acknowledge the STAT results, OR did nursing staff notify the provider within the required time frames (2.008) N/A N/A N/A N/A * Laboratory: Did the health care provider endorse the STAT laboratory N/A N/A N/A N/A results within the required time frames? (2.009) Pathology: Did the institution receive the final pathology report within 7 2 0 77.8% the required time frames? (2.010) * Pathology: Did the health care provider review and endorse the 8 1 0 88.9% pathology report within specified time frames? (2.011) * Pathology: Did the health care provider communicate the results of the pathology study to the patient within specified time frames? 0 9 0 0 (2.012) Overall percentage (MIT 2): 59.6% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 25 Recommendations • Medical leadership should remind providers to timely retrieve the results of radiology and pathology reports and to timely communicate those results with complete patient notification letters. • Medical leadership should ascertain the causes of the untimely provision of laboratory services and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 26 Emergency Services In this indicator, OIG clinicians evaluated the quality of emergency Overall medical care. Our clinicians reviewed emergency medical services by Rating Adequate examining the timeliness and appropriateness of clinical decisions made during medical emergencies. Our evaluation included examining Case Review the emergency medical response, cardiopulmonary resuscitation (CPR) Rating quality, triage and treatment area (TTA) care, provider performance, Adequate and nursing performance. Our clinicians also evaluated the Emergency Compliance Medical Response Review Committee’s (EMRRC) ability to identify Score problems with its emergency services. The OIG assessed the (N/A) institution’s emergency services through case review only; we did not perform compliance testing for this indicator. Results Overview CEN delivered satisfactory emergency care. In Cycle 6, the clinicians evaluated more events and found fewer significant deficiencies than in the previous cycle. Providers were available for consultation in person or by phone and generally documented their communication with the nurses. Nursing staff responded promptly to emergent events. However, there are opportunities for improvement for nursing assessment, intervention, and documentation. In addition, in our clinical review of the emergent events, we found deficiencies not identified by staff at the institution. Overall, the OIG rated this indicator adequate. Case Review Results We reviewed 31 urgent and emergent events in 16 cases.19 We identified 23 emergency care deficiencies in 10 cases, three of which were significant.20 Emergency Medical Response CEN staff responded promptly to medical emergencies throughout the institution. They initiated CPR appropriately, activated emergency medical services (EMS), and notified TTA staff in a timely manner. 19 We reviewed emergency events in cases 2, 3, 4, 5, 6, 8, 10, 11, 12, 16, 17, 18, 19, 20, 21, and 22. 20 Deficiencies occurred in cases 2, 3, 6, 10, 11, 12, 16, 17, 18, and 47. Significant deficiencies occurred twice in case 10 and once in case 17. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 27 Cardiopulmonary Resuscitation Quality During the review period, we reviewed three cases during which cardiopulmonary resuscitation (CPR) was initiated.21 We found each of CPR cases were appropriately managed. Custody and medical staff were involved in providing emergency care. Staff moved the patient to the TTA for additional interventions and transferred the patient to a higher level of care. Staff activated the 911 system from the scene and EMS arrived timely. Provider Performance CEN providers performed well in urgent and emergent situations. Providers were available for consultation with the TTA nursing staff. They generally made appropriate diagnoses and documentation. Our clinicians identified five deficiencies in three cases, of which one was significant.22 This is discussed further in the Provider Performance indicator. Nursing Performance CEN nurses generally provided appropriate assessments and interventions during emergency events. However, on a few occasions, nurses did not thoroughly assess the patient or initiate appropriate interventions. Two examples follow: • In case 10, the patient had a history of COVID-19 infection. The patient reported a cough and difficulty taking deep breaths. In addition, the patient had an elevated temperature and low oxygenation. The nurses did not initiate oxygen, listen for lung sounds, or reassess vital signs. • In case 17, a medical alarm was activated for the patient with chest pain and shortness of breath. The nurses did not administer oxygen, nitroglycerin, or aspirin, nor obtain an electrocardiogram, nor reassess the chest pain severity.23 Nursing Documentation CEN nursing documentation was fair. Nurses generally documented the timelines. There were, however, timeline discrepancies related to the sequence of events. Medication administered during the events were not documented on the medication administration record consistently. 21 We reviewed CPR in cases 2, 5, and 6. 22 Deficiencies occurred twice in case 10, twice in case 18, and once in case 6. A significant deficiency occurred in case 10. 23 Nitroglycerin is a medication that increases blood flow to the heart. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 28 We found a pattern of incorrect time entries in the EHRS for emergency care after the patients had departed to the community hospital. 24 • In case 2, nursing staff provided emergency care for an unconscious patient requiring CPR; however, the nurse noted that Narcan was administered but was not documented on the medication administration record.25 • In case 10, during a COVID-19 isolation rounding, a patient was appropriately moved to the TTA for low blood pressure and decreased oxygenation. However, there were incorrect time entries in EHRS related to the sequence of events. Emergency Medical Response Review Committee (EMRRC) The EMRRC met monthly and reviewed emergency response care within the required time frames. The exception is that EMRRC meeting was not held in December 2020 due to the institution COVID-19 outbreak but was reconvened in January 2021. We found six deficiencies in the EMRRC reviews. 26 Clinician On-Site Inspection At CEN, there were three TTA bays which provided sufficient space for emergency care. Two of the bays were utilized for urgent or emergent cases and one bay was used for observation. The observation bay was generally where they cared for their potential COVID-19 or symptomatic COVID-19 patients during their COVID-19 outbreak. The TTA was usually staffed with two RNs on the day and two in the evening shift. The overnight shift was staffed with an RN and SRN. The TTA had an office technician during business hours during the day to assist with answering phone calls, updating the TTA log, scanning forms such as sick call requests, and completing meeting minutes. On occasion, an office technician was hired for the weekends to help with TTA. 24 Documentation deficiencies occurred in cases 2, 3, 10, 11, and 16. 25 Narcan is an opiate antidote medication. 26 Minor deficiencies occurred in cases 11, 12, 16, 17, and 47. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 29 Recommendations • To ensure accurate documentation, nursing leadership should consider completing a thorough audit of staff documentation after an emergent event to provide training to staff regarding how to properly document the emergent event in the electronic health record system (EHRS). Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 30 Health Information Management In this indicator, OIG inspectors evaluated the flow of health Overall information, a crucial link in high-quality medical care delivery. Our Rating inspectors examined whether the institution retrieved and scanned Proficient critical health information (progress notes, diagnostic reports, specialist reports, and hospital discharge reports) into the medical Case Review Rating record in a timely manner. Our inspectors also tested whether Proficient clinicians adequately reviewed and endorsed those reports. In addition, our inspectors checked whether staff labeled and organized documents Compliance in the medical record correctly. Score Proficient Results Overview (88.6%) The OIG found that CEN staff performed well in this indicator. The medical staff retrieved and scanned hospital discharge records, diagnostic results, and specialty reports timely. Taking into account both compliance testing and case review results, we rated this indicator proficient. Case Review and Compliance Testing Results The OIG clinicians reviewed 1017 events and found 42 deficiencies related to health information management (HIM), of which none were significant.27 The majority (34 of 42) of deficiencies related to health information management were pertaining to the patient notification letters for the diagnostic results. We also reviewed 31 urgent and emergent events and did not find any deficiencies related to health information management. Hospital Discharge Reports CEN staff timely retrieved hospital discharge records, scanned them into the EHRS, and reviewed them within the required time frames (MIT 4.003, 75.0%). The providers reviewed the hospital discharge reports timely (MIT 4.005, 88.0%). Our clinicians reviewed 31 offsite emergency department and hospital visits and identified three deficiencies.28 The following is an example: • In case 1, the hospital emergency department records were scanned into EHRS four days after the patient was discharged. 27 Deficiencies occurred in cases 1, 2, 3, 7, 10, 11, 12, 13, 17, 18, 21, and 48. 28 Deficiencies occurred in cases 1, 18, and 48. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 31 Specialty Reports CEN staff performed well retrieving and reviewing the specialty reports. Compliance testing showed that 93.3 percent of specialty reports were scanned within the required time frame (MIT 4.002). CEN providers reviewed the high-priority and routine specialty reports 73.3 percent of the time respectively (MIT 14.002 and MIT 14.008). However, they did not review all the medium-priority specialty reports timely (MIT 14.005, 66.7%). These findings are discussed in the Specialty Services indicator. Our clinicians reviewed 49 specialty reports and identified three deficiencies.29 The following case is an example: • In case 7, the specialist assessed the patient for a diabetic eye exam and recommended the patient to follow up in one year. However, the provider did not endorse the specialist’s report. Diagnostic Reports CEN staff proficiently retrieved and endorsed diagnostic reports timely. Compliance testing showed providers endorsed radiology and laboratory reports within the required time frames (MIT 2.002, 100%, and MIT 2.005, 100%). The staff also retrieved pathology reports within the required time frames (MIT 2.010, 77.8%) and providers reviewed and endorsed the pathology reports within specified time frames (MIT 2.011, 88.9%). However, the providers did not communicate the results of the laboratory test and pathology studies with all required key elements in the patient notification letter within specified time frames (MIT 2.006, 20.0%, and MIT 2.012, zero). Our clinicians identified 32 deficiencies, of which none were significant, and all were related to patient notification letters.30 The following is an example: • In case 1, the provider endorsed the test results and created a patient notification letter but did not include in the letter whether the results are within normal limits. Please refer to the Diagnostic Services indicator for further detailed discussion about diagnostics. Urgent and Emergent Records Our clinicians reviewed 31 emergency care events and found that CEN nurses and providers recorded these events well. Our clinicians did not identify any deficiencies. 29 Deficiencies occurred in cases 7, 10, and 11. 30 Deficiencies occurred in cases 1, 2, 3, 10, 12, 13, 17, 18, and 21. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 32 Scanning Performance CEN staff performed well with the scanning process. Compliance testing showed that the staff properly scanned, labeled, and named medical files (MIT 4.004, 91.7%). Our clinicians identified one deficiency with mislabeled documents: • In case 10, the nursing staff mislabeled the COVID-19 nursing notes as sick call request in the EHRS. Clinician On-Site Inspection Our clinicians discussed health information management processes with CEN office technicians, health information management supervisors, ancillary staff, diagnostic staff, nurses, and providers. The CEN medical records supervisor described the processes of retrieving documents from onsite and offsite reports and routing them to the providers for review directly through EHRS. The providers reported medical records staff obtained outside records quickly and records were routed appropriately for review. CEN designated specialty office staff to track and retrieve specialty reports. The laboratory vendor Quest Diagnostics posted laboratory reports directly into EHRS. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 33 Compliance Testing Results Table 9. Health Information Management Scored Answer Compliance Questions Yes No N/A Yes % Are health care service request forms scanned into the patient’s electronic health record within three calendar days of the encounter 19 1 10 95.0% date? (4.001) Are specialty documents scanned into the patient’s electronic health 28 2 15 93.3% record within five calendar days of the encounter date? (4.002) * Are community hospital discharge documents scanned into the patient’s electronic health record within three calendar days of 15 5 5 75.0% hospital discharge? (4.003) * During the inspection, were medical records properly scanned, 22 2 0 91.7% labeled, and included in the correct patients’ files? (4.004) * For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements 22 3 0 88.0% and did a provider review the report within five calendar days of discharge? (4.005) * Overall percentage (MIT 4): 88.6% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 34 Table 10. Other Tests Related to Health Information Management Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Did the ordering health care provider review and endorse the 10 0 0 100% radiology report within specified time frames? (2.002) * Laboratory: Did the health care provider review and endorse the 10 0 0 100% laboratory report within specified time frames? (2.005) * Laboratory: Did the provider acknowledge the STAT results, OR did N/A N/A N/A N/A nursing staff notify the provider within the required time frames? (2.008) * Pathology: Did the institution receive the final pathology report within 7 2 0 77.8% the required time frames? (2.010) * Pathology: Did the health care provider review and endorse the 8 1 0 88.9% pathology report within specified time frames? (2.011) * Pathology: Did the health care provider communicate the results of the 0 9 0 0 pathology study to the patient within specified time frames? (2.012) Did the institution receive and did the primary care provider review the high-priority specialty service consultant report within the required time 11 4 0 73.3% frame? (14.002) * Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the required 10 5 0 66.7% time frame? (14.005) * Did the institution receive and did the primary care provider review the routine-priority specialty service consultant report within the required 11 4 0 73.3% time frame? (14.008) * * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Recommendations • The department should consider developing and implementing a patient results letter template that autopopulates with all elements required by CCHCS policy. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 35 Health Care Environment In this indicator, OIG compliance inspectors tested clinics’ waiting Overall areas, infection control, sanitation procedures, medical supplies, Rating Inadequate equipment management, and examination rooms. Inspectors also tested clinics’ ability to maintain auditory and visual privacy for clinical Case Review encounters. Compliance inspectors asked the institution’s health care Rating administrators to comment on their facility’s infrastructure and its (N/A) ability to support health care operations. The OIG rated this indicator Compliance solely on the compliance score, using the same scoring thresholds as in Score the Cycle 4 and Cycle 5 medical inspections. Our case review clinicians Inadequate do not rate this indicator. (51.8%) Results Overview In this indicator, CEN’s performance declined from its performance in Cycle 5. In the present cycle, multiple aspects of CEN’s health care environment needed improvement: multiple clinics contained expired medical supplies; multiple clinics lacked medical supplies; emergency medical response bag (EMRB) logs were missing staff verification or inventory was not performed; and staff did not regularly sanitize their hands before or after examining patients. These factors resulted in an inadequate rating for this indicator. Compliance Testing Results Outdoor Waiting Areas At the time of our inspection, there were no outdoor patient waiting areas as CEN was able to accommodate patients in the indoor waiting areas. Indoor Waiting Areas We inspected indoor waiting areas (see Photo 1). Health care and custody staff reported that existing waiting areas contained sufficient seating capacity. Dependent on the population, patients were either placed in the clinic waiting area or held in individual modules (see Photo 2). During our inspection, we did not observe overcrowding or noncompliance with social distancing requirements in any of the clinics’ indoor waiting areas. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 36 Photo 1. Indoor waiting area (photographed May 12, 2021). Photo 2. Individual modules (photographed May 13, 2021). Clinic Environment All clinic environments were sufficiently conducive to medical care. They provided reasonable auditory privacy, appropriate waiting areas, wheelchair accessibility, and nonexamination room workspace (MIT 5.109, 100%). Of the ten clinics we observed, six contained appropriate space, configuration, supplies, and equipment to allow their clinicians to perform proper clinical examinations (MIT 5.110, 60.0%). The remaining four clinics had one or more of the following deficiencies: examination Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 37 rooms lacked visual privacy (see Photo 3); examination rooms lacked adequate space (less than 100 square feet); there was a torn clinician chair vinyl cover; and examination table placement prevented patients from lying down fully. Photo 3. Exam room lacked visual privacy (photographed May 11, 2021). Clinic Supplies Only one of the 10 clinics followed adequate medical supply storage and management protocols (MIT 5.107, 10.0%). We found one or more of the following deficiencies in nine clinics: expired medical supplies (see Photos 4 and 5); unidentified medical supplies; cleaning supplies stored in the same area with medical supplies; medical supplies stored directly on the floor; food stored with medical supplies in the storage room location; and compromised sterile medical supply packaging. Photo 4. Expired medical supplies dated April 2019 and March 2020 (photographed May 14, 2021). Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 38 Photo 5. Expired medical supplies dated April 4, 2021 (photographed May 13, 2021). Seven of the 10 clinics met requirements for essential core medical equipment and supplies (MIT 5.108, 70.0%). The remaining three clinics lacked medical supplies or contained nonfunctional equipment. The missing items included an exam table with disposable paper, hemoccult cards, and tongue depressors. We found a nonfunctional oto- ophthalmoscope. We also noted staff failed to log the results of the defibrillator performance test. In addition, staff did not complete the defibrillator performance test in accordance with the manufacturer’s instructions. We examined emergency medical response bags (EMRBs) to determine whether they contained all essential items. We checked whether staff inspected the bags daily and inventoried them monthly. Only two of the eight EMRBs passed our test (MIT 5.111, 25.0%). We found one or more of the following deficiencies with six EMRBs: staff failed to ensure the EMRB’s compartments were sealed and intact; staff failed to seal compartments when not in active use; staff had not inventoried the EMRBs when the seal tags were replaced or inventoried the EMRBs in the previous 30 days; staff failed to log EMRB daily glucometer quality control results; and staff inaccurately logged the EMRB glucometer control solution range when performing the daily glucometer quality control (see Photo 6). Staff in the TTA failed to ensure one treatment cart was sealed and intact when not in active use. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 39 Photo 6. Staff inaccurately log the EMRB glucometer control solution range when performing the daily glucometer quality control (photographed May 13, 2021). In addition to the above findings, our compliance inspectors observed the following findings in the clinics or examination rooms when they conducted their on-site inspection: • In one clinic, we found a box of surgical masks and a box of N- 95 masks stored in the biohazard/dirty utility room. Nursing staff reported the masks were used for patient distribution. The clinic supervisor promptly removed the boxes of masks upon notification. Photo 7. Masks stored in the dirty utility room (photographed May 13, 2021). Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 40 Medical Supply Management None of the medical supply storage areas located outside the medical clinics contained medical supplies stored adequately (MIT 5.106, zero). We found expired medical supplies (see Photos 8 and 9), medical supplies stored directly on the floor, and rodent droppings (See Photo 10). In addition, the warehouse manager did not maintain a temperature log for medical supplies with manufacturer temperature guidelines stored in the conex box (see Photo 11). Photo 8. Expired medical supplies dated March 31, 2021 (photographed May 13, 2021). Photo 9. Expired medical supplies dated March 28, 2021 (photographed May 13, 2021). Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 41 Photo 10. Rodent droppings (photographed May 13, 2021). Photo 11. Medical supplies with manufacturer temperature guidelines kept in non-temperature-monitored storage area (photographed May 13, 2021). According to the CEO, the institution did not have any concerns about the medical supplies process. Health care managers and medical Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 42 warehouse managers expressed no concerns about the medical supply chain or their communication process. Infection Control and Sanitation Staff appropriately, cleaned, sanitized, and disinfected seven of 10 clinics (MIT 5.101, 70.0%). In three clinics, we found one or more of the following deficiencies: cleaning logs were not maintained or had inaccurate dates; test strips were expired, and therefore could not show whether the cleaning solution meets the proper sanitation level; and clinic’s staff restroom was unsanitary (see Photo 12). Photo 12. Blood-like substance found in clinic's staff restroom (photographed May 14, 2021). Staff in eight of 10 clinics (MIT 5.102, 80.0%) properly sterilized or disinfected medical equipment. In two clinics, staff did not mention disinfecting the exam table as part of their daily start-up protocol. We found operating sinks and hand hygiene supplies in the examination rooms in four of 10 clinics (MIT 5.103, 40.0%). In five clinics, the patient restrooms lacked antiseptic soap and disposable hand towels or had a nonfunctional sink (see Photo 13). In another clinic, the RN exam room lacked disposable hand towels. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 43 Photo 13. Nonfunctional patient restroom sink with water leaking from the bottom of the spout (Photographed May 11, 2021). We observed patient encounters in seven clinics. In six clinics, clinicians did not wash their hands before or after examining their patients, before applying gloves, after performing blood draws, or before and after performing physical therapy services (MIT 5.104, 14.3%). Health care staff in all clinics followed proper protocols to mitigate exposure to bloodborne pathogens and contaminated waste (MIT 5.105,100%). Physical Infrastructure CEN’s health care management and plant operations manager reported that all clinical area infrastructures were in good working order and did not hinder health care services. At the time of our medical inspection, the institution reported the Health Care Facility Improvement Program (HCFIP) project was just resuming construction again on the Central Health building. The construction had slowed and halted due to the COVID-19 pandemic. The institution estimated the project would be completed by the end of 2021 (MIT 5.999). Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 44 Compliance Testing Results Table 11. Health Care Environment Scored Answer Compliance Questions Yes No N/A Yes % Infection control: Are clinical health care areas appropriately 7 3 0 70.0% disinfected, cleaned, and sanitary? (5.101) Infection control: Do clinical health care areas ensure that reusable invasive and noninvasive medical equipment is properly sterilized or 8 2 0 80.0% disinfected as warranted? (5.102) Infection control: Do clinical health care areas contain operable sinks 4 6 0 40.0% and sufficient quantities of hygiene supplies? (5.103) Infection control: Does clinical health care staff adhere to universal 1 6 3 14.3% hand hygiene precautions? (5.104) Infection control: Do clinical health care areas control exposure to 10 0 0 100% blood-borne pathogens and contaminated waste? (5.105) Warehouse, conex, and other nonclinic storage areas: Does the medical supply management process adequately support the needs 0 1 0 0 of the medical health care program? (5.106) Clinical areas: Does each clinic follow adequate protocols for 1 9 0 10.0% managing and storing bulk medical supplies? (5.107) Clinical areas: Do clinic common areas and exam rooms have 7 3 0 70.0% essential core medical equipment and supplies? (5.108) Clinical areas: Are the environments in the common clinic areas 10 0 0 100% conducive to providing medical services? (5.109) Clinical areas: Are the environments in the clinic exam rooms 6 4 0 60.0% conducive to providing medical services? (5.110) Clinical areas: Are emergency medical response bags and emergency crash carts inspected and inventoried within required time frames, 2 6 2 25.0% and do they contain essential items? (5.111) Does the institution’s health care management believe that all clinical This is a nonscored test. Please areas have physical plant infrastructures that are sufficient to provide see the indicator for discussion adequate health care services? (5.999) of this test. Overall percentage (MIT 5): 51.8% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 45 Recommendations • Medical leadership should remind staff to follow universal hand hygiene precautions. Implementing random spot checks of staff could improve compliance. • Nursing leadership should consider performing random spot checks to ensure staff follow equipment and medical supply management protocols. • Nursing leadership should direct each clinic nurse supervisor to review the monthly emergency medical response bag (EMRB) logs to ensure the EMRBs are regularly inventoried and sealed. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 46 Transfers In this indicator, OIG inspectors examined the transfer process for Overall those patients who transferred into the institution, as well as for those Rating who transferred to other institutions. For newly arrived patients, our Adequate inspectors assessed the quality of health screenings and the continuity Case Review of provider appointments, specialist referrals, diagnostic tests, and Rating medications. For patients who transferred out of the institution, Adequate inspectors checked whether staff reviewed patient medical records and determined the patient’s need for medical holds. They also assessed if Compliance Score staff transferred patients with their medical equipment and gave Inadequate correct medications before patients left. In addition, our inspectors (71.4%) evaluated the ability of staff to communicate vital health transfer information, such as preexisting health conditions, pending appointments, tests, and specialty referrals; and inspectors confirmed if staff sent complete medication transfer packages to the receiving institution. For patients who returned from off-site hospitals or emergency rooms, inspectors reviewed whether staff appropriately implemented the recommended treatment plans, administered necessary medications, and scheduled appropriate follow-up appointments. Results Overview Overall, CEN performed satisfactorily in the transfer process. Compared with Cycle 5, our case reviewers identified more deficiencies during this review period and found opportunities for improvement in the areas of nursing assessment, documentation, and medication continuity. However, compliance testing showed that CEN performed well in preapproved specialty continuity, transfer in and transfer out medication continuity, and follow-up after hospital returns. Considering both compliance and case reviews, the OIG rated this indicator adequate. Case Review and Compliance Testing Results Our clinicians reviewed 54 events in 23 cases in which patients transferred into or out of the institution or returned from an off-site hospital or emergency room.31 We identified 20 deficiencies, four of which were significant.32 31 We reviewed cases 1, 3, 4, 8, 10, 11, 12, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 47, and 48. 32 Deficiencies occurred in cases 1, 10, 11, 12, 15, 17, 18, 23, 26, 27, 28, and 48. Significant deficiencies occurred twice in case 18 and once in cases 12 and 17. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 47 Transfers In CEN’s performance for patients transferring into the institution was sufficient. Our case review team reviewed 15 events in six cases.33 However, compliance testing showed that receiving and release (R&R) nurses did not complete the initial health screening form thoroughly (MIT 6.001, zero). Analysis of the compliance data showed nurses did not perform one or more of the following tasks: they did not address the symptom of fatigue in the TB screening, complete a full set of vital signs, or obtain a fingerstick blood sugar for diabetic patients. In addition, nursing staff did not document an explanation to “Yes” answers to questions regarding medical appointments and mental health screening. However, the OIG case reviewers did not identify any deficiencies related to intake screening. CEN performed well in ensuring that appointments for patients with preapproved specialty services occurred within the required time frames. Compliance testing showed 100 percent (MIT, 14.001) of the specialty appointments occurred timely. Our case reviewers did not identify deficiencies in specialty appointments for new arrivals. The compliance team found medication continuity at the time of transfer was proficient (MIT 6.003, 100%). CEN also ensured medications were continued without interruption (MIT 7.005, 96.0%) when patients transferred from one housing unit to another. Similarly, our case reviewers found one opportunity for improvement related to medication continuity. Compliance testing showed that provider appointments for newly arrived patients generally occurred within the required time frames (MIT 1.002, 76.0%). Notably, analysis of the compliance data showed that three of the patients were not seen due to COVID-19 quarantine status. In contrast, our case reviewers did not find deficiencies related to provider appointments not being completed timely. The nurses performed well in completing the assessment and disposition section of the initial health screening form (MIT 6.002, 100%). Our case reviewers found that the R&R nurses evaluated newly arrived patients and requested provider appointments within the appropriate time frames. 33 We reviewed the following transfer-in cases: 1, 4, 23, 24, 25, and 48. A deficiency occurred in case 23. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 48 Transfers Out CEN’s transfer-out process was satisfactory. Our clinicians reviewed five transfer-out cases and found that nurses completed face-to-face evaluations prior to the patients’ transfer and ensured patients transferred with their medications and durable medical equipment. However, an opportunity for improvement was identified when the nurses did not always document the patents’ pending specialty referrals.34 Compliance testing found that patients who transferred out of the institution often had their medications and required documents (MIT 6.101, 85.7%). Our case reviewers determined similar findings. Hospitalizations Patients returning from an off-site hospitalization or emergency room are at high risk for lapses in care. These patients have typically experienced severe illnesses or injuries and require more care. Because these patients have complex medical issues, the successful transfer of health information is necessary for quality care. Any lapse in care can result in serious consequences for these patients. Our clinicians reviewed 30 events for patients returning from a hospital or emergency room evaluation in 18 cases.35 The clinicians identified 14 deficiencies, of which four were significant.36 All four significant deficiencies were related to lapses in medication continuity. Compliance testing found that CEN performed poorly in medication continuity (MIT 7.003, 62.5%). Analysis of the compliance data showed that insulin, antibiotics, rescue inhalers, and blood pressure medications were not administered timely. Our case reviewers identified similar findings in medication continuity; these are discussed further in the Medication Management indicator. CEN performed well in providing follow-up appointments within the required time frame to patients returning from the hospital and from emergency room visits (MIT 1.007, 100%). CEN performed satisfactorily in retrieving and scanning hospital records within three calendar days (MIT 4.003, 75.0%). Compliance 34 We reviewed the following transfer-out cases: 26, 27, 28, 47, and 48. Deficiencies occurred in cases 26, 27, 28, and 48; none were significant deficiencies. 35 We reviewed the following hospitalization cases: 1, 3, 4, 8, 10, 11, 12, 15, 16, 17, 18, 19, 20, 21, 22, 25, 47, and 48. 36 Deficiencies occurred in cases 1, 10, 11, 12, 15, 17, 18, 47, and 48. Significant deficiencies occurred twice in case 18 and once in cases 12 and 17. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 49 testing found providers routinely reviewed and endorsed documents timely (MIT 4.005, 88.0%). Our case reviewers did not identify any significant deficiencies related to the timely review of scanned hospital records. Clinician On-Site Inspection CEN’s R&R department was staffed with nursing on each of the three shifts, excluding weekends and holidays. The R&R supervisor reported they received the transfer list two weeks prior to patient transfer and the nurses prepare the patient’s transfer packets one week prior to patient transfer. The R&R RN, who worked the night shift, completed the transfer packets, reviewed and reconciled medications, and notified the primary care provider and specialty team when pending orders required reconciliation. The R&R nurses reported attempting to obtain missing durable medical equipment (DME) within 24 hours. When DME or medications are missing upon transfer, the nurse reported documenting the lapse and notifying the receiving institution regarding the missing items. The R&R nurses evaluated the patients on the yard 24 hours before transfer and followed current quarantine guidelines if the patient was not vaccinated. In addition, a COVID-19 test is completed within 24 hours of transfer. At the time of our on-site inspection, the nurses reported that for patients transferring into the institution, a COVID-19 test was completed within five days when a COVID-19 test was not done prior to transfer. Patients who had received their COVID-19 vaccine were no longer required to be quarantined. However, unvaccinated patients were quarantined, assessed for symptoms, and given a COVID-19 test. The nurses found their administrative staff to be supportive and reported a good rapport with custody staff. Overall, the nurses stated that morale is good at CEN. Compliance On-Site Inspection A sample of 10 patients transferring out to other department institutions were tested. CEN nurses performed face-to-face evaluations before the patients transferred out of the institution. In one applicable example, CEN nurses did not ensure medications with an active order were included in the transfer packet upon the patient’s leaving for another institution. In addition, we observed a lack of communication between medical and custody staff as patients scheduled to be transferred did not have the necessary COVID-19 Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 50 testing. The rapid COVID-19 tests were completed, but the testing resulted in a delayed departure. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 51 Compliance Testing Results Table 12. Transfers Scored Answers Compliance Questions Yes No N/A Yes % For endo rsed patients received from another CDCR institution or COCF: Did nursing staff complete the initial health screening and 0 25 0 0 answer all screening questions within the required time frame? (6.001) * For endorsed patients received from another CDCR institution or COCF: When required, did the RN complete the assessment and disposition section of the initial health screening form; refer the 25 0 0 100% patient to the TTA if TB signs and symptoms were present; and sign and date the form on the same day staff completed the health screening? (6.002) For endorsed patients received from another CDCR institution or COCF: If the patient had an existing medication order upon arrival, 4 0 21 100% were medications administered or delivered without interruption? (6.003) * For patients transferred out of the facility: Do medication transfer packages include required medications along with the corresponding 6 1 3 85.7% transfer packet required documents? (6.101) * Overall percentage (MIT 6): 71.4% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 52 Table 13. Other Tests Related to Transfers Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution: Based on the patient’s clinical risk level during the initial health screening, was the 19 6 0 76.0% patient seen by the clinician within the required time frame? (1.002) * Upon the patient’s discharge from the community hospital: Did the patient receive a follow-up appointment with a primary care provider 25 0 0 100% within the required time frame? (1.007) * Are community hospital discharge documents scanned into the patient’s electronic health record within three calendar days of hospital 15 5 5 75.0% discharge? (4.003) * For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements and did a 22 3 0 88.0% provider review the report within five calendar days of discharge? (4.005) * Upon the patient’s discharge from a community hospital: Were all ordered medications administered, made available, or delivered to the 15 9 1 62.5% patient within required time frames? (7.003) * Upon the patient’s transfer from one housing unit to another: Were 24 1 0 96.0% medications continued without interruption? (7.005) * For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications 5 1 0 83.3% administered or delivered without interruption? (7.006) * For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the 4 5 0 44.4% sending institution, was the appointment scheduled at the receiving institution within the required time frames? (14.010) * * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Recommendations • Nursing leadership should consider developing and implementing an internal audit to ensure nurses document pending specialty referrals for patients transferring to other institutions. • The department should consider developing and implementing measures to ensure that receiving and release (R&R) nursing staff properly complete the initial health screening questions. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 53 Medication Management In this indicator, OIG inspectors evaluated the institution’s ability to Overall administer prescription medications on time and without interruption. Rating The inspectors examined this process from the time a provider Inadequate prescribed medication until the nurse administered the medication to Case Review the patient. When rating this indicator, the OIG strongly considered Rating the compliance test results, which tested medication processes to a Inadequate much greater degree than case review testing. In addition to examining medication administration, our compliance inspectors also tested many Compliance Score other processes, including medication handling, storage, error Inadequate reporting, and other pharmacy processes. (51.5%) Results Overview CEN performed poorly in this indicator, similar to its performance in Cycle 5, although we reviewed more events in Cycle 6. Areas of improvement for medication continuity include new medication prescriptions, chronic care medications, hospital discharge medications, and medications provided in the Correctional Treatment Center (CTC). In addition, nurses did not always administer keep-on- person (KOP) medications timely. Both compliance testing and case review rated this indicator inadequate. Case Review and Compliance Testing Results We reviewed 134 encounters in 36 cases related to medication management and found 27 deficiencies, seven of which were significant.37 New Medication Prescriptions Compliance testing showed new medications were generally available, delivered, or administered timely (MIT 7.002, 76.0%). However, our case reviewers identified some delays in the availability, administration, and delivery of new medications within the required time frames. 38 • In case 3, the patient was evaluated for shortness of breath and prescribed a one-time breathing treatment, however the patient did not receive it. 37 Events reviewed in cases 1, 2, 3, 4, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 31, 34, 37, 39, 40, 42, 43, 44, 47, and 48. Deficiencies occurred in cases 1, 3, 10, 11, 12, 17, 18, 23, 28, 34, 47, and 48. Significant deficiencies occurred three times in case 18, two times in case 12, and one time in cases 10 and 17. 38 Newly prescribed medications not administered timely occurred in cases 3, 10, 11, 12, 18, and 34. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 54 • In case 10, the patient was on COVID-19 isolation and had a fever. The provider ordered Tylenol KOP; however, the patient did not receive this newly prescribed medication. • In case 11, a potassium-lowering medication (Lokelma) was ordered; however, the patient received this newly prescribed medication four days late. • In case 12, the provider ordered an immunosuppressant medication (azathioprine); however, this newly prescribed medication was provided one day late. Chronic Medication Continuity During this review period, CEN performed poorly in chronic medication continuity. Compliance testing found patients did not receive most of their chronic care medications within the required time frames (MIT 7.001, 16.7%). Case reviewers found in a few cases that chronic care medications were not received timely or were not received at all.39 • In case 3, the patient requested a refill of an asthma inhaler (Xopenex); however, the patient did not receive it for the months of January and February 2021. • In case 10, the patient requested a refill of a dermatitis lotion (selenium sulfide lotion). The patient received the medication 22 days later. • In case 12, the patient was evaluated by the RN during COVID- 19 isolation rounds, who reported that the patient’s KOP medications, including a rescue inhaler, did not transfer with the patient when the patient moved into an COVID-19 isolation cell. At the time of our review, there was no documentation that the patient was provided the KOP medications. • In case 18, the patient had a follow-up appointment with the provider after a recent hospitalization. However, the provider did not restart the blood pressure and allergy medications. Hospital Discharge Medications CEN performed poorly in ensuring that patients received their recommended medications when they returned from an off-site hospital or emergency room. Compliance testing found that most of the time, the patients discharged from a community hospital did not have their medications ordered, administered, available, or delivered within the 39 Chronic care medications not received timely occurred in cases 3, 10, 11, 12, and 18. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 55 required time frames (MIT 7.003, 62.5%). Our clinicians reviewed 18 hospital returns and identified four significant deficiencies:40 • In case 12, a patient returned to CEN from a community hospital. However, the recommended blood pressure, cholesterol, urinary retention, and prostate medications were not reconciled until more than six weeks later. • In case 17, a patient returned to CEN from a community hospital. The patient's prior cholesterol, diuretic, and blood pressure medications were not reconciled upon return. The patient did not have these medications during the rest of the review period. • In case 18, on two separate occasions after the patient returned from the community hospital, the patient’s blood pressure medications were not reconciled after returning to the institution. Specialized Medical Housing Medications Compliance testing found that when patients were admitted to the Correctional Treatment Center (CTC), medications were not always available or administered within the required time frames (MIT 13.004, 50.0%). The case review clinicians evaluated four cases, of which two cases had minor deficiencies:41 • In case 1, the patient received the urinary retention (Tamsulosin) medication one day late. • In case 48, the patient did not receive one dose of an acid reflux and pain medication. Transfer Medications CEN performed well for transfer medications. Compliance scores and case review showed similar findings. Compliance testing demonstrated CEN maintained continuity of medications for patients transferring into the institution (MIT 6.003, 100%) as well as for patients transferring from one housing unit to another (MIT 7.005, 96.0%). Our clinicians reviewed six cases in which patients arrived at CEN from other facilities and identified one deficiency in which the medication was not 40 Hospitalization with significant deficiencies occurred twice in case 18 and once in cases 12 and 17. 41 We reviewed CTC cases 1, 25, 47, and 48. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 56 available, and the patient received it one day late.42 CEN performed well for patients en-route who had a layover at the institution and were provided medications without interruption (MIT 7.006, 83.3%). CEN also performed well for patients who transferred out of the institution, ensuring patients had transfer packages that included required medications and documents (MIT 6.101, 85.7%). Our clinicians reviewed five cases and identified one deficiency in which the patient transferred to another institution without their medications.43 Medication Administration CEN performed well in administering TB medications (MIT, 9.001, 100%). However, nurses did not monitor patients’ prescribed TB medications (MIT 9.002, zero). Clinician On-Site Inspection During our on-site visit, we interviewed the pharmacist-in-charge (PIC) and chief nurse executive (CNE) to discuss specific medication-related deficiencies. The PIC verified that medications were promptly provided to nurses for administration, except on a few occasions when the medication was a nonformulary, which may have caused a delay. We visited medication administration areas and found nurses were knowledgeable about the medication administration process. The nurses reported that if the patient receives a keep on person (KOP) medication that includes refills or new medication, they will notify the building officer daily to have the patient come to the medication administration area to pick it up. If the patient refuses to pick up the medications after three days, the patient is required to complete a refusal form with the nurse, and the nurses will document the refusal in the medication administration record. Upon our observation of the medication administration areas, we found no backlogs of KOP medications. In addition, we observed team huddles, during which team members discussed new medications, refusals, and noncompliance related to medications. Overall, the medication nurses reported a good rapport with custody staff and support from nursing leadership and supervisors. 42 The deficiency occurred in case 23. 43 The deficiency occurred in case 28. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 57 Medication Practices and Storage Controls The institution adequately stored and secured narcotic medications in three of eight clinic and medication line locations (MIT 7.101, 37.5%). In five locations, nurses could not describe the narcotic medication discrepancy reporting process. CEN appropriately stored and secured nonnarcotic medications in seven of 10 clinic and medication line locations (MIT 7.102, 70.0%). In two locations, the refrigerated and/or nonrefrigerated medications did not have a designated area for medications to be returned to pharmacy. In another location, we found a medication stored beyond the prescription’s expiration date rather than having not been returned to the pharmacy (see Photo 14). Photo 14. Medication stored beyond the prescription’s expiration date (photographed May 13, 2021). Staff kept medications protected from physical, chemical, and temperature contamination in four of the 10 clinic and medication line locations (MIT 7.103, 40.0%). In six locations, we found one or more of the following deficiencies: staff did not consistently record the room temperatures, staff did not consistently record the refrigerator temperatures, staff did not store oral and topical medications separately, and staff did not separate medications from disinfectants (see Photo 15); we also found that staff did not store several medications within the manufacturer temperature guidelines. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 58 Photo 15. Medications stored with disinfectant (photographed May 11, 2021). Staff successfully stored valid and unexpired medications in two of the 10 applicable medication line locations (MIT 7.104, 20.0%). In eight locations, we found one or both of the following deficiencies occurred: medication nurses did not label multiuse medication as required by CCHCS policy, and a patient’s specific medication was stored with an expired pharmacy label (see Photo 16). Photo 16. Patient-specific medication with an expired pharmacy label dated May 8, 2021 (photographed May 11, 2021). Nurses exercised proper hand hygiene and contamination control protocols in three of six locations (MIT 7.105, 50.0%). Some nurses neglected to wash or sanitize their hands before each subsequent re- gloving. Staff in five of six medication preparation and administration areas demonstrated appropriate administrative controls and protocols (MIT Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 59 7.106, 83.3%). In one location, medication nurses did not maintain unissued medications in their original labeled packaging. None of the six medication areas used appropriate administrative controls and protocols when distributing medications to their patients (MIT 7.107, zero). In six locations, we found one or more of the following deficiencies: the medication cart was unsanitary; medication nurses did not administer medication as ordered by the provider; medication nurses did not reliably observe patients while they swallowed direct-observation therapy medications; and nurses did not validate the date and time of the recorded blood sugar level reading from the patient’s personal glucometer device prior to administering insulin medication. In addition to the above findings, our compliance inspectors observed the following issues with medication practices or storage during their on-site inspection: We found that in multiple medication preparation and administration areas, medication nurses documented daily glucometer quality control inaccurately. More specifically, the used test strips’ control solution range for both Level 1 and Level 2 did not match the documented solution range in the glucometer quality control logs (see Photo 17). Photo 17. Staff’s documented and actual glucometer control solution range used to perform the test did not match (photographed May 14, 2021). Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 60 Pharmacy Protocols CEN followed general security, organization, and cleanliness management protocols in its pharmacy (MIT 7.108, 100%). In its pharmacy, staff did not properly store nonrefrigerated medication. We found the following deficiencies: staff did not store expired and unexpired medications separately, unorganized medications (see Photo 18), expired medication (see Photo 19), staff’s personal food items and medication stored in the same area, and staff did not consistently record room temperatures. As a result, the institution scored zero in this test (MIT 7.109). Photo 18. Expired and unexpired medication were stored together and disorganized (photographed May 11, 2021). Photo 19. Expired medication dated April 2021 (photographed May 11, 2021). Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 61 The institution did not properly store refrigerated or frozen medications in the pharmacy. We found expired frozen medications (see Photo 20). As a result, the institution scored zero in this test (MIT 7.110). Photo 20. Expired frozen medications dated April 22, 2020, and November 18, 2020 (photographed May 11, 2021). The pharmacist-in-charge (PIC) correctly accounted for narcotic medications stored in CEN’s pharmacy (MIT 7.111, 100%). We examined 25 medication error reports. The PIC timely or correctly processed only 10 of these 25 reports (MIT 7.112, 40.0%). In six reports, the PIC did not document one or both of the following: explanation for not notifying the provider and/or patient, or recommended changes to correct the medication error. For the remaining nine reports, the PIC did not complete a Medication Error Follow-up form at the time of our inspection. Nonscored Tests In addition to testing the institution’s self-reported medication errors, our inspectors also followed up on any significant medication errors found during compliance testing. We did not score this test; we provide these results for informational purposes only. At CEN, the OIG did not find any applicable medication errors (MIT 7.998). The OIG interviewed patients in isolation units to determine whether they had immediate access to their prescribed asthma rescue inhalers or nitroglycerin medications. All of six applicable patients interviewed indicated they had access to their rescue medications (MIT 7.999) Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 62 Compliance Testing Results Table 14. Medication Management Scored Answer Compliance Questions Yes No N/A Yes % Did the patient receive all chronic care medications within the required time frames or did the institution follow departmental policy for refusals or 3 15 7 16.7% no-shows? (7.001) * Did health care staff administer, make available, or deliver new order prescription medications to the patient within the required time frames? (7.002) 19 6 0 76.0% Upon the patient’s discharge from a community hospital: Were all ordered medications administered, made available, or delivered to the patient within 15 9 1 62.5% required time frames? (7.003) * For patients received from a county jail: Were all medications ordered by the institution’s reception center provider administered, made available, or N/A N/A N/A N/A delivered to the patient within the required time frames? (7.004) * Upon the patient’s transfer from one housing unit to another: Were medications continued without interruption? (7.005) * 24 1 0 96.0% For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications administered or 5 1 0 83.3% delivered without interruption? (7.006) * All clinical and medication line storage areas for narcotic medications: Does the institution employ strong medication security controls over narcotic 3 5 2 37.5% medications assigned to its storage areas? (7.101) All clinical and medication line storage areas for nonnarcotic medications: Does the institution properly secure and store nonnarcotic medications in the 7 3 0 70.0% assigned storage areas? (7.102) All clinical and medication line storage areas for nonnarcotic medications: Does the institution keep nonnarcotic medication storage locations free of 4 6 0 40.0% contamination in the assigned storage areas? (7.103) All clinical and medication line storage areas for nonnarcotic medications: Does the institution safely store nonnarcotic medications that have yet to expire in 2 8 0 20.0% the assigned storage areas? (7.104) Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols during medication 3 3 4 50.0% preparation and medication administration processes? (7.105) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when preparing medications 5 1 4 83.3% for patients? (7.106) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when administering 0 6 4 0 medications to patients? (7.107) Pharmacy: Does the institution employ and follow general security, organization, and cleanliness management protocols in its main and remote 1 0 0 100% pharmacies? (7.108) Pharmacy: Does the institution’s pharmacy properly store nonrefrigerated medications? (7.109) 0 1 0 0 Pharmacy: Does the institution’s pharmacy properly store refrigerated or frozen medications? (7.110) 0 1 0 0 Pharmacy: Does the institution’s pharmacy properly account for narcotic medications? (7.111) 1 0 0 100% Pharmacy: Does the institution follow key medication error reporting protocols? (7.112) 10 15 0 40.0% Pharmacy: For Information Purposes Only: During compliance testing, did the This is a nonscored test. Please OIG find that medication errors were properly identified and reported by the see the indicator for discussion of institution? (7.998) this test. Pharmacy: For Information Purposes Only: Do patients in restricted This is a nonscored test. Please housing units have immediate access to their KOP prescribed rescue see the indicator for discussion of inhalers and nitroglycerin medications? (7.999) this test. Overall percentage (MIT 7): 51.5% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 63 Table 15. Other Tests Related to Medication Management Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution or COCF: If the patient had an existing medication order upon arrival, 4 0 21 100% were medications administered or delivered without interruption? (6.003) * For patients transferred out of the facility: Do medication transfer packages include required medications along with the corresponding 6 1 3 85.7% transfer-packet required documents? (6.101) * Patients prescribed TB medication: Did the institution administer the 16 0 0 100% medication to the patient as prescribed? (9.001) * Patients prescribed TB medication: Did the institution monitor the patient per policy for the most recent three months he or she was on the 0 16 0 0 medication? (9.002) * Upon the patient’s admission to specialized medical housing: Were all 5 5 0 50.0% medications ordered, made available, and administered to the patient within required time frames? (13.004) * * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Recommendations • Medical leadership should consider developing and implementing an audit to ensure medication continuity for patients discharged from a community hospital. • The institution should consider developing and implementing measures to ensure that staff timely make available and administer chronic care medications to the patients and that staff document in the medication administration record (MAR) as described by CCHCS policy. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 64 Preventive Services In this indicator, OIG compliance inspectors tested whether the Overall Rating institution offered or provided cancer screenings, tuberculosis (TB) Adequate screenings, influenza vaccines, and other immunizations. The OIG rated this indicator solely based on the compliance score, using the Case Review same scoring thresholds as in the Cycle 4 and Cycle 5 medical Rating inspections. Our case review clinicians do not rate this indicator. (N/A) Results Overview Compliance Score Adequate Compliance Testing Results (80.7%) CEN staff had generally good performance in preventive services. Staff performed well in administering TB medications as prescribed, offering patients an influenza vaccine for the most recent influenza season, offering colorectal cancer screening for all patients ages 50 through 75, and required immunizations to chronic care patients. The institution faltered in monitoring patients who were taking in prescribed TB medication. These findings are set forth in the table on the next page. We rated this indicator adequate. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 65 Compliance Testing Results Table 16. Preventive Services Scored Answer Compliance Questions Yes No N/A Yes % Patients prescribed TB medication: Did the institution administer the 16 0 0 100% medication to the patient as prescribed? (9.001) Patients prescribed TB medication: Did the institution monitor the patient per policy for the most recent three months he or she was on 0 16 0 0 the medication? (9.002) † Annual TB screening: Was the patient screened for TB within the last 23 2 0 92.0% year? (9.003) Were all patients offered an influenza vaccination for the most recent 25 0 0 100% influenza season? (9.004) All patients from the age of 50 through the age of 75: Was the 23 2 0 92.0% patient offered colorectal cancer screening? (9.005) Female patients from the age of 50 through the age of 74: Was the N/A N/A N/A N/A patient offered a mammogram in compliance with policy? (9.006) Female patients from the age of 21 through the age of 65: Was N/A N/A N/A N/A patient offered a pap smear in compliance with policy? (9.007) Are required immunizations being offered for chronic care patients? 10 0 15 100% (9.008) Are patients at the highest risk of coccidioidomycosis (valley fever) N/A N/A N/A N/A infection transferred out of the facility in a timely manner? (9.009) Overall percentage (MIT 9): 80.7% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † In April 2020, after our review but before this report was published, CCHCS reported adding the symptom of fatigue into the EHRS PowerForm for tuberculosis symptom monitoring. Source: The Office of the Inspector General medical inspection results. Recommendations • Nursing leadership should consider developing and implementing measures to ensure that nursing staff is educated in accurately monitoring patients on TB medications and that they address TB signs and symptoms in their monitoring. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 66 Nursing Performance In this indicator, the OIG clinicians evaluated the quality of care Overall delivered by the institution’s nurses, including registered nurses (RNs), Rating licensed vocational nurses (LVNs), psychiatric technicians (PTs), and Inadequate certified nursing assistants (CNAs). Our clinicians evaluated nurses’ ability to make timely and appropriate assessments and interventions. Case Review Rating We also evaluated the institution’s nurses’ documentation for accuracy Inadequate and thoroughness. Clinicians reviewed nursing performance in many clinical settings and processes, including sick call, outpatient care, care Compliance coordination and management, emergency services, specialized medical Score (N/A) housing, hospitalizations, transfers, specialty services, and medication management. The OIG assessed nursing care through case review only and performed no compliance testing for this indicator. When summarizing overall nursing performance, our clinicians understand that nurses perform numerous aspects of medical care. As such, specific nursing quality issues are discussed in other indicators, such as Emergency Services, Specialty Services, and Specialized Medical Housing. Results Overview CEN nurses delivered poor nursing care. In Cycle 5, nursing performed well for emergency care, transfers, and specialized medical housing. However, in Cycle 6, we found nurses did not adequately assess patients, intervene appropriately, or communicate abnormal clinical findings to providers. Sick call performance was poor, and the nurses did not evaluate urgent patients timely or thoroughly. While these nursing deficiencies illustrated poor performance, they can be corrected with quality improvement strategies. We considered the overall quality of nursing care and rated this indicator inadequate. Case Review Results We reviewed 286 nursing encounters in 48 cases. Of the nursing encounters we reviewed, 175 were in the outpatient setting. Of the 175 outpatient encounters, 58 events were related to COVID-19 quarantine or isolation rounding, and 59 events were related to sick calls. We identified 121 nursing performance deficiencies, 14 of which were significant.44 Of the 121 nursing performance deficiencies, 89 of the 44 Deficiencies occurred in cases 1, 2, 3, 4, 10, 11, 12, 13, 15, 16, 17, 18, 19, 20, 21, 22, 26, 27, 28, 29, 31, 32, 33, 35, 36, 37, 39, 40, 47, and 48. Cases 1, 2, 3, 10, 11, 12, and 17 had significant deficiencies. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 67 deficiencies were in the outpatient setting, of which 11 were significant.45 Nursing Assessment and Interventions Correctional nurses have a critical role in patient care. Often in correctional settings, nurses serve as the liaison between the patient, the primary care provider, and community health care services. Therefore, thorough assessments are critical to ensure patients receive necessary interventions and care. At CEN, we identified a pattern of deficiencies involving failure to address symptomatic patients, and not consulting the provider when symptoms warranted, especially in the outpatient areas. • In cases 2, 4, 10, 11, 12, 13, 15, 16, 17, 18, 19, 20, and 22, we found that the nurses did not complete COVID-19 rounding. • In case 10, the COVID-19 patient who was in isolation had an elevated temperature. However, there was no assessment or documentation from the TTA RN. In addition, during the COVID-19 isolation rounds, the LVN noted that the patient had weakness in both lower legs, severe swelling, and discoloration of both feet with numbness. The LVN did not notify the RN or PCP. • In case 12, the sick call nurse evaluated this patient for increased bladder pain, frequent urination with incontinence and decreased urine output. However, the nurse did not perform a thorough physical assessment and did not complete a urine test. • In case 32, the sick call nurse evaluated the patient for breathing symptoms and a request for a CPAP machine. However, the nurse did not auscultate lung sounds and initiate the provider follow-up as noted in the plan of care. Nursing Documentation Proper nursing documentation enables the transmission of complete and accurate information among health care staff, which prevents lapses in care. Inconsistent and incomplete nursing documentation at CEN occurred primarily during outpatient clinic visits.46 Some of the deficiencies were incomplete vital signs, absence of documented 45 Deficiencies occurred in cases 2, 3, 4, 10, 11, 12, 13, 15, 16, 17, 18, 19, 20, 21, 22, 29, 31, 32, 33, 35, 36, 37, 39, and 40. Significant cases occurred five times in case 10, three times in case 3, and one time in cases 2, 11, and 12. 46 Deficiencies occurred in cases 2, 3, 10, 11, 12, 15, 16, and 28. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 68 breathing treatment medications and blood sugar readings in the Medication Administration Record (MAR), and missing RN documentation after LVN consultations. Nursing Sick Call The nursing sick call process involves reviewing each sick call request and triaging whether the patient’s medical symptoms warrant an urgent or routine evaluation. The OIG clinicians reviewed 59 nursing sick call requests.47 Generally, nurses triaged sick call requests promptly. We found a pattern of urgent sick calls not seen timely, weights not measured, and incomplete nursing assessment. • In case 2, the nurse did not assess the patient who was housed in a COVID-19 quarantine unit the same day for a symptomatic sick call submitted for shortness of breath and headache. When the nurse evaluated the patient, the nurse did not assess the onset of symptoms of shortness of breath, auscultate the heart and lungs, and provide patient education. • In case 10, the sick call nurse triaged the sick call from the diabetic patient for complaints of gas, vomiting, and weakness. However, the nurse did not conduct a face-to-face evaluation of the patient. By coincidence, the patient was evaluated by the provider two days later for a follow-up from a specialty consult. • In case 12, the COVID-19 quarantined patient submitted a sick call request for complaints of abdominal pain, diarrhea, and sinus congestion. These symptoms were consistent with COVID-19 and warranted a same-day nurse intervention. However, the patient was not seen until the next day. Care Management/Coordinator The clinic RN saw patients for chronic care management appointments upon their transfer into the institution and for follow-up visits ordered by the provider. Care coordinators saw patients for blood pressure checks, wound care, annual TB screenings, vaccinations, and additional provider orders for the LVN follow-up. Wound Care We reviewed two cases in which wound care was provided for the patients. We identified minor 47 Sick call cases were cases 2, 3, 7, 10, 11, 12, 14, 15, 18, 19, 20, 21, 22, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, and 46. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 69 opportunities for improvement due to missing several days of wound care assessment.48 Emergency Services Nurses responded promptly to emergencies and provided urgent and emergency care. We identified 12 deficiencies, two of which were significant.49 CEN nurses generally provided appropriate assessments and interventions during emergency events. Opportunities for improvement are discussed in the Emergency Services indicator. Hospital Returns We reviewed 18 cases involving patients who returned from a community hospital or emergency room.50 CEN nurses did well in documentation and assessments. However, the case reviewers identified four significant deficiencies that were related to lapses in medication continuity. Additional information can be found in the Medication Management indicator. Transfers We reviewed 10 cases.51 Overall, CEN nurses performed well in managing patients transferring into the institution. However, for patients transferring out of the institution, nurses did not ensure documentation of pending specialty referrals. Additional information is discussed in the Transfer indicator. Specialized Medical Housing Case reviewers evaluated four Correctional Treatment Center (CTC) cases with 62 events, of which 19 where nursing events.52 Clinicians identified one significant nursing deficiency.53 CTC nurses evaluated the patient on each shift. There were opportunities for improvement related to assessment. More details are provided in the Specialized Medical Housing indicator. Specialty Services CEN nurses provided good nursing care for patients returning from offsite specialty appointments. Most nurses performed appropriate 48 Wound care included cases 11 and 15. 49 Emergency services cases 2, 3, 6, 7, 9, 10, 11, 15, 20, 21, and 22 had deficiencies. Significant deficiencies occurred twice in case 10 and once in case 17. 50 Hospital return cases were cases 1, 3, 4, 8, 10, 11, 12, 15, 16, 17, 18, 19, 20, 21, 22, 25, 47, and 48. 51 Transfer cases included cases 1, 4, 23, 24, 25, 26, 27, 28, 47, and 48. 52 CTC cases included cases 1, 25, 47, and 48. 53 A CTC significant deficiency occurred in case 1. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 70 nursing assessments, reviewed specialist recommendations properly, and communicated pertinent information to the providers. The Specialty Services indicator provides further information. Medication Management The OIG clinicians examined 134 events involving medication management and administration. Both compliance testing and case reviewers identified lapses in medication continuity. The Medication Management indicator provides further information. • In case 10, on two occasions, the patient’s blood sugar was elevated, and insulin was administered. However, the nurses did not assess for signs and symptoms of hyperglycemia and/or notify the provider. Clinician On-Site Inspection During our CEN on-site visit, we toured the primary care clinics, TTA, R&R, CTC, and medication areas. We met with medical executives, nursing supervisors, and medical staff. In addition, we met with the COVID-19 Crisis Team, who explained CEN’s operations during the institution’s outbreak. CEN’s COVID-19 surge began in late November 2020. The institution established COVID-19 isolation and quarantine areas. CEN has 22 buildings with solid cell doors, except for E yard and the Firehouse, which are both dormitory settings. Buildings in E yard were used for patients under quarantine and/or isolation. We learned that CEN is in the process of building a new medical building. During the outbreak, RNs staffed the isolation buildings 24 hours a day. These RNs had a State-issued cell phone to consult with the provider or TTA staff if needed. COVID-19 rounding for quarantine was generally conducted by LVNs or medical assistants (MAs) and isolation rounding was conducted by LVNs or RNs. Despite nursing receiving direction to only see urgent and emergent patients in their housing units, nurses evaluated patients in the housing unit for sick calls and evaluated patients the same day or the next business day. At the time of our visit, leadership reported no active COVID-19 patients. The COVID-19 crisis team described a collaborative effort among providers, nurses, custody staff, and the dental department in completing mass testing for COVID-19. The chief medical executive (CME) reported that 84 percent of the patients received the COVID-19 vaccination and attributed this to using the men’s advisory committee (MAC) to educate the patient population. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 71 We met with the chief nurse executive (CNE) to discuss general nursing operations and some of the OIG clinicians’ findings. The CNE reported that during the COVID-19 outbreak, the institution had COVID-19 nurses from registry, who were trained by the regional CCHCS nursing team. The four-hour training consisted of nursing COVID-19 charting and institution safety. Due to limited training, registry and licensed vocational nurses only performed operations related to COVID-19, such as isolation and quarantine rounds. The CNE attributed many of the identified nursing deficiencies to the COVID-19 registry nurses’ lack of training and that the CEN nursing leadership did not routinely audit COVID-19 registry nurses’ performance. However, the CNE explained that when patients required additional care, the COVID-19 registry nurses were instructed to contact the emergency response or the TTA RN for further care. Our clinicians attended two virtual morning huddles, which were attended by patient care team, including the medication administration nurses. The nurses presented pertinent information. The medication administration nurses provided the morning diabetic patients’ blood sugars and addressed any medication refusals. Clinic nurses generally saw 10 to 15 patients per day, and the nurses reported no nursing backlog. The nursing staff reported that the COVID-19 outbreak was challenging but that medical leadership and custody staff were supportive. CEN nurses expressed good morale and noted no communication barriers between disciplines, including custody. Recommendations • Nursing leadership should ensure that nurses perform more detailed assessments and interventions during patient visits and should consider implementing audits. • Nursing leadership should ensure nurses triage urgent symptomatic sick calls timely. • Nursing leadership should ensure that COVID-19 registry nurses are provided adequate training in COVID-19 assessment and documentation, as well as in communicating abnormal findings to providers. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 72 Provider Performance In this indicator, OIG case review clinicians evaluated the quality of Overall care delivered by the institution’s providers: physicians and a nurse Rating practitioner. Our clinicians assessed the institution’s providers’ ability Adequate to evaluate, diagnose, and manage their patients properly. We examined Case Review provider performance across several clinical settings and programs, Rating including sick call, emergency services, outpatient care, chronic care, Adequate specialty services, intake, transfers, hospitalizations, and specialized medical housing. We assessed provider care through case review only Compliance and performed no compliance testing for this indicator. Score (N/A) Results Overview CEN providers delivered generally acceptable care. They diagnosed medical conditions correctly, ordered appropriate tests and referred patients appropriately to specialist or higher level of care when needed. However, the providers did not always document on-call progress notes in the health records and reconcile hospital discharge medications. Overall, the OIG rated this indicator adequate. Case Review Results The OIG clinicians reviewed 105 medical provider encounters and identified 52 deficiencies related to provider performance, of which seven were significant.54 Out of seven significant deficiencies, five deficiencies were due to care provided by one provider.55 In addition, the OIG clinicians examined the care quality in 20 comprehensive case reviews. Of these 20 cases, 15 were adequate, and five were inadequate.56 Assessment and Decision-Making CEN providers generally made appropriate assessments and sound decisions for their patients. Most of the time, they took good history, formulated differential diagnosis, ordered appropriate tests, provided care with the correct diagnosis, and referred to proper specialists when needed. However, our clinicians identified three significant deficiencies related to poor assessment and decision-making: • In case 2, the nurse consulted the provider for a patient with low oxygen saturation. The provider gave phone orders for a 54 Deficiencies occurred in cases 1, 2, 3, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 21, 22, 25, 47, and 48. Cases 2, 10, 12, 17, and 18 had significant deficiencies. 55 Significant deficiencies by one provider occurred in cases 2 and 10; there were three deficiencies in case 18. 56 Inadequate cases were cases 2, 10, 12, 17, and 18. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 73 chest X-ray and medications. However, the provider did not assess the patient urgently or recommend the patient to be assessed in the Triage and Treatment Area (TTA). • In case 10, a nurse consulted the on-call provider for a patient at the TTA with a fever and generalized rash. The provider gave phone orders to give medications for the rash. However, the provider did not document the rationale and the plan of care in a progress note in the health record. • In case 18, a nursing staff ordered an appointment for the patient to see a provider for abdominal pain. However, instead of seeing the patient, the provider made a poor decision to merely review the chart instead of performing an in-person evaluation for right lower quadrant abdominal pain. Review of Records For patients returning from hospitalization, CEN providers did not always review medical records to thoroughly reconcile discharge medications for the continuity of care. Our clinicians identified following three significant deficiencies: • In case 12, a provider evaluated a patient for follow-up care after the patient returned from hospitalization for pneumonia. The provider did not thoroughly review discharge records and did not reconcile chronic medications for blood pressure, high cholesterol, acid reflux, and prostate condition to continue upon discharge from the hospital. The patient did not receive the medications until more than a month later. • In case 17, a provider evaluated a patient for follow-up care after the patient returned from hospitalization after surgery. The provider did not thoroughly review discharge records for recommendations for surgical follow-up and did not reconcile chronic medications for blood pressure and high cholesterol to continue upon discharge from the hospital. The patient did not receive these medications for the rest of the OIG review period. • In case 18, a provider evaluated a patient for follow-up care after the patient returned from hospitalization after surgery. The provider did not thoroughly review the discharge records and did not reconcile chronic medications for blood pressure, acid reflux, and allergies to continue upon discharge from the hospital. The patient did not receive these medications for the rest of the OIG review period. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 74 Emergency Care CEN providers made appropriate triage decisions when patients arrived at the TTA for emergency treatment. Although providers were available for consultations with the TTA nursing staff, they did not always document progress notes. Our clinicians identified five deficiencies related to emergency care.57 The following is an example: • In case 6, the TTA nurse consulted a provider before transferring the patient to a higher level of care at a community hospital emergency department. However, the provider did not document a consult progress note in the health record. Chronic Care In most instances, CEN providers appropriately managed their patients’ chronic health conditions, such as hypertension, diabetes, asthma, hepatitis C infection, and cardiovascular disease. However, our clinicians identified a pattern showing gaps in the continuation of chronic medications when patients return from hospital care. Medication reconciliation process were not always followed. We identified six deficiencies.58 The following is an example: • In case 47, a provider evaluated the patient after the patient’s return from hospitalization. The provider did not thoroughly review the hospital recommendations to start a heart medication and to order follow-up care with a heart specialist. Specialty Services CEN providers generally referred patients for specialty consultation when needed, reviewed specialty reports timely, and followed recommendations appropriately. However, specialist recommendations were not always followed timely. Our clinicians identified the following deficiency. • In case 9, the telemedicine diabetes specialist recommended an increase of long-acting insulin with follow up in three months to better manage diabetes. However, the provider did not follow through with recommendations until the telemedicine nurse reminded the provider three weeks later. We discussed providers’ specialty performance further in the Specialty Services indicator. 57 A minor deficiency occurred in case 6, and two deficiencies occurred in cases 10 and 18, of which one was significant in case 10. 58 Deficiencies occurred in cases 12, 17, 18, and 25. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 75 Documentation Quality CEN providers generally documented outpatient and emergency encounters on the same day of encounter. Although providers correctly documented most of the time during the encounters, providers did not always document on-call progress notes when required. Our clinicians identified eight deficiencies that included missing progress notes.59 The following are examples: • In case 10, on multiple occasions, the provider incorrectly documented the name of a blood thinner taken for lung blood clots as “apixaban,” not “rivaroxaban,” in the EHRS. • Also in case 10, the TTA nurse consulted a provider to evaluate the patient with low blood pressure. However, the provider did not document a progress note for this patient with post-COVID infection. Provider Continuity CEN staff assigned providers to specified clinics to ensure patients’ continuity of care. The OIG clinicians did not identify any deficiencies related to provider continuity. Clinician On-Site Inspection Clinic providers led the morning huddles, which were well attended in the clinics, using teleconference connections to include all the health care team members. Patient status was reported during the huddle, and pill-line nursing staff reported diabetic patients’ morning finger stick blood sugar levels to review if any adjustments in the interventions were needed. Health care team members shared reports for patients returning from the hospital, those seen in the TTA, CTC admissions, patients seen by the night physician-on-call, patients’ COVID-19 status, and any add-on cases for the day. All members were encouraged to participate. We discussed the lapses in medication continuity for patients returning from the community hospital with the chief medical executive (CME). During the onsite visit, medical leadership reported that they had initiated strategies to improve the medication reconciliation process. CEN experienced a COVID-19 outbreak in December 2020. Staff reported that all staff, including providers, shared the care burden of treating patients in the isolation and quarantine units. Staff created cubicles in the COVID-19 quarantine and isolation units for providers 59 Deficiencies with documentation occurred in cases 3, 6, 10, and 18. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 76 to examine patients. CEN leadership reported that CEN had high COVID-19 vaccination rates among staff and patients due to a collaborative effort with custody and medical staff. Recommendations • Medical leadership should ensure providers document patient- related calls and management plans in the electronic health record system (EHRS) for clear communication and collaboration with the patient care team and for the continuity of patient care. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 77 Specialized Medical Housing In this indicator, OIG inspectors evaluated the quality of care in the Overall specialized medical housing units. We evaluated the timeliness and Rating quality of provider and nursing intake assessments and care plans. We Inadequate assessed staff members performance in responding promptly when Case Review patients’ conditions deteriorated and looked for good communication Rating when staff consulted with one another while providing continuity of Adequate care. Our clinicians also interpreted relevant compliance results and incorporated them into this indicator. CEN’s specialized medical Compliance Score housing is a correctional treatment center (CTC), and we focused on Inadequate medical staff’s performance in assessing, monitoring, and intervening (58.0%) for medically complex patients requiring close medical supervision. Results Overview CEN delivered satisfactory patient care with case review. Providers saw patients in the CTC timely and provided good evaluations and decision making. However, compliance testing found that patients were not provided admission assessments and medications timely. Considering both case review and compliance results, we rated this overall indicator inadequate. Case Review and Compliance Testing Results The CTC is a 13-bed unit, with all 13 beds designated for medical patients. We reviewed four CTC cases, which included 30 provider events and 19 nursing events. Because of the care volume that occurs in specialized medical housing units, each provider and nursing event represents up to one month of provider care and up to one month of nursing care. We identified 13 deficiencies, one of which was significant.60 Provider Performance Case review clinicians examined 30 CTC provider encounters and noted one deficiency.61 Compliance testing found that admission histories and physical examinations were generally performed timely (MIT 13.002, 80.0%). Providers rounded at clinically appropriate intervals. Providers generally developed good care plans, made sound medical decisions, and documented well. 60 Deficiencies occurred in cases 1, 47, and 48. Case 1 had one significant deficiency. 61 A provider deficiency occurred in case 47. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 78 • In case 47, the provider evaluated the patient after hospital return for chest pain; however, the provider did not follow hospital recommendations to start lisinopril and follow up with a cardiologist within 14 days.62 Nursing Performance CTC nurses provided good care, with timely assessments and appropriate interventions. Our compliance testing showed CTC nurses did not complete admission assessments timely (MIT 13.001, 60.0%). In contrast, our clinicians found admission assessments were completed timely. Case review identified nine deficiencies in three cases, of which one was significant.63 The following are examples: • In case 1, the systolic blood pressure was extremely low, and the nurse did not document the diastolic blood pressure and recheck the blood pressure. On another occasion, the patient returned from the hospital with bilateral lower extremity swelling and swelling to the right hand. However, the nurses did not assess the extremity edema regularly. In addition, the patient had a peripherally inserted central catheter (PICC) and the nurses did not consistently inspect and assess the skin at the PICC site. The nurses did not initiate care plans for the PICC line care and for the swollen extremities. • In case 47, the patient had chest pain, however the nurse did not administer aspirin or reassess the chest pain severity per CCHCS nursing chest pain protocol. • In cases 47 and 48, we identified incomplete nursing care plans. At the time of our compliance onsite inspection, we found three rooms in the CTC with nonfunctioning call lights (MIT 13.101, zero). However, in the CTC, health care staff performed patient safety checks according to institution’s local operating procedure or within the required time frames (MIT 13.102, 100%). Medication Administration Compliance findings showed patients did not receive their medications within the required time frames upon their admission to the CTC (MIT 13.004, 50.0%). Analysis of the compliance data reviewed that KOP inhalers for shortness of breath were provided late for two patients and not provided for one patient. In addition, an antipsychotic and uric acid-reducing medications that was to be administered by a nurse was 62 Lisinopril is a medication used to treat heart disease. 63 Deficiencies occurred four times in case 1, three times in case 47, and twice in case 48. A significant deficiency occurred in case 1. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 79 not administered timely to two patients. Our clinicians found two cases in which the patient did not receive a total of three medications within the required time frame.64 Clinician On-Site Inspection The CTC had 13 medical beds, of which four were negative-pressure rooms for respiratory isolation. At the time of our inspection, two beds were not available to be used and were awaiting repair. The CTC has 24-hour nursing staff with RNs, LVNs, and CNAs. At the time of our onsite inspection, the supervising registered nurse (SRN) had been acting in the position for two months. The SRN noted that they assess quality of nursing care by performing monthly audits and random audits, as needed. Nursing reported that providers immediately reconciled orders upon the patients’ return from the hospital. Providers are onsite from 0800-1700. After hours, the nurses contact the provider on call who generally has a laptop to reconcile orders timely. In the CTC, staff complete weekly rounds and conduct weekly meetings to review care plans for each patient. The provider, RN, utilization management (UM) RN, and mental health attend these weekly meetings. Nursing staff reported they feel supported by nursing administration. 64 Medication deficiencies occurred in cases 1 and 48. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 80 Compliance Testing Results Table 17. Specialized Medical Housing Scored Answer Compliance Questions Yes No N/A Yes % For OHU, CTC, and SNF: Prior to 4/2019: Did the registered 6 4 0 60.0% nurse complete an initial assessment of the patient on the day of admission, or within eight hours of admission to CMF’s Hospice? Effective 4/2019: Did the registered nurse complete an initial assessment of the patient at the time of admission? (13.001) * For CTC and SNF only (effective 4/2019, include OHU): Was a written 8 2 0 80.0% history and physical examination completed within the required time frame? (13.002) * For OHU, CTC, SNF, and Hospice (applicable only for samples prior N/A N/A N/A N/A to 4/2019): Did the primary care provider complete the Subjective, Objective, Assessment, and Plan notes on the patient at the minimum intervals required for the type of facility where the patient was treated? (13.003) *, † Upon the patient’s admission to specialized medical housing: Were 5 5 0 50.0% all medications ordered, made available, and administered to the patient within required time frames? (13.004) * For OHU and CTC only: Do inpatient areas either have properly 0 1 0 0 working call systems in its OHU & CTC or are 30-minute patient welfare checks performed; and do medical staff have reasonably unimpeded access to enter patient’s cells? (13.101) * For specialized health care housing (CTC, SNF, Hospice, OHU): 1 0 0 100% Do health care staff perform patient safety checks according to institution’s local operating procedure or within the required time frames? (13.102) * Overall percentage (MIT 13): 58.0% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † CCHCS changed its policies and removed mandatory minimum rounding intervals for patients located in specialized medical housing. After April 2, 2019, MIT 13.003 only applied to CTCs that still have State-mandated rounding intervals. OIG case reviewers continued to test the clinical appropriateness of provider follow-ups within specialized medical housing units through case reviews. Source: The Office of the Inspector General medical inspection results. Recommendations • Nursing leadership should ensure that the initial nursing admission assessments are completed within the required time frame as provided in CCHCS policy. • Nursing leadership should determine the root cause of challenges to patients receiving all ordered medications within the required time frame and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 81 Specialty Services In this indicator, OIG inspectors evaluated the quality of specialty Overall Rating services. The OIG clinicians focused on the institution’s ability to Adequate provide needed specialty care. Our clinicians also examined specialty appointment scheduling, providers’ specialty referrals, and medical Case Review Rating staff’s retrieval, review, and implementation of any specialty Adequate recommendations. Compliance Results Overview Score Adequate CEN provided satisfactory specialty services for their patients. Specialty (82.9%) appointments were completed timely. Providers made appropriate referrals and follow-ups. Telemedicine specialty services were provided when available during the COVID-19 movement restriction. However, specialty reports were not always retrieved and scanned timely. Providers did not always follow specialists’ recommendations or document rationale for not doing so. Factoring compliance testing and case review finding, CEN had an adequate rating for this indicator. Case Review and Compliance Testing Results Our clinicians reviewed 72 events related to Specialty Services, which included 49 specialty consultations and procedures, and 23 nursing encounters. There were nine deficiencies in this category, of which none were considered significant.65 Access to Specialty Services Compliance testing showed that patients received specialty services timely with high-priority referrals (MIT 14.001, 100%), medium-priority referrals (MIT 14.004, 86.7%) and routine-priority referrals (MIT 14.007, 93.3%). The OIG clinicians identified two delayed specialty appointments.66 The following is an example: • In case 47, the patient was scheduled 20 days late for telemedicine neurology follow-up due to COVID-19 quarantine restrictions. However, continuity of specialty services for patients from other departmental institutions was not normally provided timely within the required time frame (MIT 14.010, 44.4%). The OIG clinicians identified missed specialty appointments. The following is an example: 65 Deficiencies occurred in cases 7, 9, 10, 11, 12, 25, and 47. 66 Deficiencies occurred in cases 12 and 47. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 82 • In case 25, the provider evaluated a newly arrived patient; but did not reconcile all outstanding specialty appointments and did not document the rationale for not providing a referral in the EHRS. Provider Performance Providers’ follow-up visits after specialty service appointments did not occur timely during the COVID-19 pandemic as most of the provider follow-up visits were performed with chart reviews instead of face-to- face visits (MIT 1.008, 11.6%). OIG clinicians identified one deficiency in a follow-up provider encounter after a specialty appointment as described below: • In case 9, the provider did not follow through with the specialist’s recommendation for the care of diabetes and did not document in the EHRS the rationale for not following the recommendation. Nursing Performance CEN nursing performance with specialty services was satisfactory. The OIG clinicians reviewed 23 nursing encounters related to specialty services and identified two deficiencies related to nursing assessment and intervention.67 An example is below. • In case 11, the nurse evaluated the patient returning from an ophthalmologist visit with an elevated blood pressure. However, the nurse did not consult the provider for the elevated blood pressure. Health Information Management CEN staff performed adequately in retrieving and reviewing the specialty reports. Compliance testing showed that the staff retrieved and scanned 93.3 percent of specialty reports within required time frames (MIT 4.002). CEN providers generally did not review the high- priority (MIT 14.002, 73.3%), medium-priority (MIT 14.005, 66.7%) and routine-priority (MIT 14.008, 73.3%) specialty reports within the required time frames. The OIG clinicians identified three deficiencies related to health information management.68 67 Two deficiencies occurred in case 11. 68 Minor deficiencies occurred in cases 7, 10, and 11. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 83 Clinician On-Site Inspection We discussed specialty referral management with nursing supervisors, providers, and specialty off-site nursing staff about. The chief physician and surgeon and the office services supervisor provided OIG clinicians with copies of memorandums regarding the COVID-19 and Seasonal Influenza: Interim Guidance for Health Care and Public Health Providers.69 CEN providers reviewed the charts for the medical necessity for face-to-face visits and specialists’ recommendations. Off- site specialty staff tracked specialty reports and would contact specialists’ office when reports were not available. 69 https://cchcs.ca.gov/covid-19-interim-guidance/. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 84 Compliance Testing Results Table 18. Specialty Services Scored Answer Compliance Questions Yes No N/A Yes % Did the patient receive the high-priority specialty service within 14 calendar days of the primary care provider order or the Physician 15 0 0 100% Request for Service? (14.001) * Did the institution receive and did the primary care provider review the high-priority specialty service consultant report within the 11 4 0 73.3% required time frame? (14.002) * Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care 12 2 1 85.7% provider? (14.003) * Did the patient receive the medium-priority specialty service within 15-45 calendar days of the primary care provider order or Physician 13 2 0 86.7% Request for Service? (14.004) * Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the 10 5 0 66.7% required time frame? (14.005) * Did the patient receive the subsequent follow-up to the medium- priority specialty service appointment as ordered by the primary care 9 1 5 90.0% provider? (14.006) * Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician 14 1 0 93.3% Request for Service? (14.007) * Did the institution receive and did the primary care provider review the routine-priority specialty service consultant report within the 11 4 0 73.3% required time frame? (14.008) * Did the patient receive the subsequent follow-up to the routine- priority specialty service appointment as ordered by the primary care 9 0 6 100% provider? (14.009) * For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the 4 5 0 44.4% sending institution, was the appointment scheduled at the receiving institution within the required time frames? (14.010) * Did the institution deny the primary care provider’s request for 11 0 0 100% specialty services within required time frames? (14.011) Following the denial of a request for specialty services, was the patient informed of the denial within the required time frame? 9 2 0 81.8% (14.012) Overall percentage (MIT 14): 82.9% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Compli Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 84 Table 19. Other Tests Related to Specialty Services Scored Answer Compliance Questions Yes No N/A Yes % Specialty service follow-up appointments: Did the clinician follow-up 5 38 2 11.6% visits occur within required time frames? (1.008) *, † Are specialty documents scanned into the patient’s electronic health 28 2 15 93.3% record within five calendar days of the encounter date? (4.002) * * The OIG clinicians considered these compliance tests along with their own case review findings when determining the quality rating for this indicator. † CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician follow-up visits following most specialty services. As a result, we test 1.008 only for high- priority specialty services or when the staff orders PCP or PC RN follow-ups. The OIG continues to test the clinical appropriateness of specialty follow-ups through its case review testing. Source: The Office of the Inspector General medical inspection results. Recommendations • Medical leadership should consider reminding providers to follow specialists’ recommendations unless there exists a clinical rationale not to follow those recommendations, and to clearly document such a rationale in the EHRS. • Medical leadership should ascertain the challenges to the receipt of specialty reports within the required time frames and should implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 85 Administrative Operations In this indicator, OIG compliance inspectors evaluated health care Overall administrative processes. Our inspectors examined the timeliness of the Rating medical grievance process and checked whether the institution Inadequate followed reporting requirements for adverse or sentinel events and patient deaths. Inspectors checked whether the Emergency Medical Case Review Response Review Committee (EMRRC) met and reviewed incident Rating packages. We reviewed and determined whether the institution (N/A) conducted the required emergency response drills. Inspectors also Compliance assessed whether the Quality Management Committee (QMC) met Score regularly and addressed program performance adequately. In addition, Inadequate the inspectors examined if the institution provided training and job (63.2%) performance reviews for its employees. They checked whether staff possessed current, valid professional licenses, certifications, and credentials. The OIG rated this indicator solely based on the compliance score, using the same scoring thresholds as in the Cycle 4 and Cycle 5 medical inspections. Our case review clinicians do not rate this indicator. Because none of the tests in this indicator affected clinical patient care directly (it is a secondary indicator), the OIG did not consider this indicator’s rating when determining the institution’s overall quality rating. Results Overview CEN had mixed performance in this indicator. The institution scored well in most applicable tests; however, a few areas had room for improvement. The EMRRC had untimely reviews and incomplete checklists. At the time of our on-site inspection, we found the nurse and physician managers did not always complete annual performance appraisals timely. We rated this indicator inadequate. Nonscored Results At CEN, the OIG did not have any applicable adverse sentinel events requiring root cause analysis during our inspection period (MIT 15.001). We obtained CCHCS Death Review Committee (DRC) reporting data. Three expected (Level 2) deaths occurred during our review period. The DRC must complete its death review summary report within 60 calendar days of the death. When the DRC completes the death review summary report, it must submit the report to the institution’s CEO Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 86 within seven calendar days after completion. In our inspection, we found the DRC did not complete any death review reports promptly. The DRC finished three reports 19 to 74 days late, and submitted them to the institution’s CEO 26 to 82 days after that (MIT 15.998). Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 87 Compliance Testing Results Table 20. Administrative Operations Scored Answer Compliance Questions Yes No N/A Yes % For health care incidents requiring root cause analysis (RCA): Did the N/A N/A N/A N/A institution meet RCA reporting requirements? (15.001) Did the institution’s Quality Management Committee (QMC) meet 5 1 0 83.3% monthly? (15.002) For Emergency Medical Response Review Committee (EMRRC) reviewed cases: Did the EMRRC review the cases timely, and did 7 5 0 58.3% the incident packages the committee reviewed include the required documents? (15.003) For institutions with licensed care facilities: Did the Local Governing Body (LGB) or its equivalent meet quarterly and discuss local 0 4 0 0 operating procedures and any applicable policies? (15.004) Did the institution conduct medical emergency response drills during each watch of the most recent quarter, and did health care and 2 1 0 66.7% custody staff participate in those drills? (15.101) Did the responses to medical grievances address all of the inmates’ 10 0 0 100% appealed issues? (15.102) Did the medical staff review and submit initial inmate death reports 6 0 0 100% to the CCHCS Death Review Unit on time? (15.103) Did nurse managers ensure the clinical competency of nurses who 1 9 0 10.0% administer medications? (15.104) Did physician managers complete provider clinical performance 1 4 0 20.0% appraisals timely? (15.105) Did the providers maintain valid state medical licenses? (15.106) 12 0 0 100% Did the staff maintain valid Cardiopulmonary Resuscitation (CPR), Basic Life Support (BLS), and Advanced Cardiac Life Support (ACLS) 2 0 1 100% certifications? (15.107) Did the nurses and the pharmacist-in-charge (PIC) maintain valid professional licenses and certifications, and did the pharmacy 5 1 1 83.3% maintain a valid correctional pharmacy license? (15.108) Did the pharmacy and the providers maintain valid Drug Enforcement 1 0 0 100% Agency (DEA) registration certificates? (15.109) Did nurse managers ensure their newly hired nurses received the 0 1 0 0 required onboarding and clinical competency training? (15.110) This is a nonscored test. Please Did the CCHCS Death Review Committee process death review refer to the discussion in this reports timely? (15.998) indicator. This is a nonscored test. Please What was the institution’s health care staffing at the time of the OIG refer to Table 4 for CCHCS- medical inspection? (15.999) provided staffing information. Overall percentage (MIT 15): 63.2% Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 88 Recommendations The OIG offers no specific recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 89 Appendix A: Methodology In designing the medical inspection program, the OIG met with stakeholders to review CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. We also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the receiver’s office, the department, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of our inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates the delivery of medical care by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population- based metrics. We rate each of the quality indicators applicable to the institution under inspection based on case reviews conducted by our clinicians or compliance tests conducted by our registered nurses. Figure A–1 below depicts the intersection of case review and compliance. Figure A–1. Inspection Indicator Review Distribution for CEN Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 90 Case Reviews The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders, which continues in the Cycle 6 medical inspections. Below, Table A–1 provides important definitions that describe this process. Table A–1. Case Review Definitions Case, Sample, The medical care provided to one patient over a specific or Patient period, which can comprise detailed or focused case reviews. A review that includes all aspects of one patient’s medical care Comprehensive assessed over a six-month period. This review allows the OIG clinicians to examine many areas of health care delivery, such as Case Review access to care, diagnostic services, health information management, and specialty services. A review that focuses on one specific aspect of medical care. Focused This review tends to concentrate on a singular facet of patient Case Review care, such as the sick call process or the institution’s emergency medical response. A direct or indirect interaction between the patient and the health care system. Examples of direct interactions include Event provider encounters and nurse encounters. An example of an indirect interaction includes a provider reviewing a diagnostic test and placing additional orders. Case Review A medical error in procedure or in clinical judgment. Both procedural and clinical judgment errors can result in policy Deficiency noncompliance, elevated risk of patient harm, or both. Adverse Event An event that caused harm to the patient. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 91 The OIG eliminates case review selection bias by sampling using a rigid methodology. No case reviewer selects the samples he or she reviews. Because the case reviewers are excluded from sample selection, there is no possibility of selection bias. Instead, nonclinical analysts use a standardized sampling methodology to select most of the case review samples. A randomizer is used when applicable. For most basic institutions, the OIG samples 20 comprehensive physician review cases. For institutions with larger high-risk populations, 25 cases are sampled. For the California Health Care Facility, 30 cases are sampled. Case Review Sampling Methodology We obtain a substantial amount of health care data from the inspected institution and from CCHCS. Our analysts then apply filters to identify clinically complex patients with the highest need for medical services. These filters include patients classified by CCHCS with high medical risk, patients requiring hospitalization or emergency medical services, patients arriving from a county jail, patients transferring to and from other departmental institutions, patients with uncontrolled diabetes or uncontrolled anticoagulation levels, patients requiring specialty services or who died or experienced a sentinel event (unexpected occurrences resulting in high risk of, or actual, death or serious injury), patients requiring specialized medical housing placement, patients requesting medical care through the sick call process, and patients requiring prenatal or postpartum care. After applying filters, analysts follow a predetermined protocol and select samples for clinicians to review. Our physician and nurse reviewers test the samples by performing comprehensive or focused case reviews. Case Review Testing Methodology An OIG physician, a nurse consultant, or both review each case. As the clinicians review medical records, they record pertinent interactions between the patient and the health care system. We refer to these interactions as case review events. Our clinicians also record medical errors, which we refer to as case review deficiencies. Deficiencies can be minor or significant, depending on the severity of the deficiency. If a deficiency caused serious patient harm, we classify the error as an adverse event. On the next page, Figure A–2 depicts the possibilities that can lead to these different events. After the clinician inspectors review all the cases, they analyze the deficiencies, then summarize their findings in one or more of the health care indicators in this report. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 92 Figure A–2. Case Review Testing Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 93 Compliance Testing Compliance Sampling Methodology Our analysts identify samples for both our case review inspectors and compliance inspectors. Analysts follow a detailed selection methodology. For most compliance questions, we use sample sizes of approximately 25 to 30. Figure A–3 below depicts the relationships and activities of this process. Figure A–3. Compliance Sampling Methodology Compliance Testing Methodology Our inspectors answer a set of predefined medical inspection tool (MIT) questions to determine the institution’s compliance with CCHCS policies and procedures. Our nurse inspectors assign a Yes or a No answer to each scored question. OIG headquarters nurse inspectors review medical records to obtain information, allowing them to answer most of the MIT questions. Our regional nurses visit and inspect each institution. They interview health care staff, observe medical processes, test the facilities and clinics, review employee records, logs, medical grievances, death reports, and other documents, and obtain information regarding plant infrastructure and local operating procedures. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 94 Scoring Methodology Our compliance team calculates the percentage of all Yes answers for each of the questions applicable to a particular indicator, then averages the scores. The OIG continues to rate these indicators based on the average compliance score using the following descriptors: proficient (85.0 percent or greater), adequate (between 84.9 percent and 75.0 percent), or inadequate (less than 75.0 percent). Indicator Ratings and the Overall Medical Quality Rating To reach an overall quality rating, our inspectors collaborate and examine all the inspection findings. We consider the case review, and the compliance testing results for each indicator. After considering all the findings, our inspectors reach consensus on an overall rating for the institution. Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 95 Appendix B: Case Review Data Table B–1. CEN Case Review Sample Sets Sample Set Total CTC/OHU 2 Death Review/Sentinel Events 2 Diabetes 4 Emergency Services –CPR 2 Emergency Services – Non-CPR 2 High Risk 4 Hospitalization 4 Intrasystem Transfers In 3 Intrasystem Transfers Out 3 RN Sick Call 18 Specialty Services 4 Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 96 Table B–2. CEN Case Review Chronic Care Diagnoses Diagnosis Total Anemia 6 Anticoagulation 1 Arthritis/Degenerative Joint Disease 2 Asthma 7 COPD 1 COVID-19 8 Cancer 2 Cardiovascular Disease 3 Chronic Kidney Disease 1 Chronic Pain 15 Cirrhosis/End-Stage Liver Disease 2 DVT/PE 1 Diabetes 11 Gastroesophageal Reflux Disease 5 Hepatitis C 12 Hyperlipidemia 13 Hypertension 16 Mental Health 6 Migraine Headaches 1 Seizure Disorder 1 Sleep Apnea 3 Substance Abuse 11 Thyroid Disease 3 Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 97 Table B–3. CEN Case Review Events by Program Diagnosis Total Diagnostic Services 283 Emergency Care 54 Hospitalization 49 Intrasystem Transfers In 13 Intrasystem Transfers Out 9 Outpatient Care 461 Specialized Medical Housing 61 Specialty Services 87 Table B–4. CEN Case Review Sample Summary MD Reviews Detailed 20 MD Reviews Focused 0 RN Reviews Detailed 12 RN Reviews Focused 27 Total Reviews 59 Total Unique Cases 48 Overlapping Reviews (MD & RN) 11 Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 98 Appendix C. Compliance Sampling Methodology Centinela State Prison Quality No. of Indicator Sample Category Samples Data Source Filters Access to Care MIT 1.001 Chronic Care 25 Master Registry • Chronic care conditions (at least Patients one condition per patient—any risk level) • Randomize MIT 1.002 Nursing Referrals 25 OIG Q: 6.001 • See Transfers MITs 1.003–006 Nursing Sick Call 30 Clinic Appointment • Clinic (each clinic tested) (6 per clinic) List • Appointment date (2–9 months) • Randomize MIT 1.007 Returns From 25 OIG Q: 4.005 • See Health Information Community Management (Medical Records) Hospital (returns from community hospital) MIT 1.008 Specialty Services 45 OIG Q: 14.001, • See Specialty Services Follow-Up 14.004 & 14.007 MIT 1.101 Availability of 6 OIG on-site review • Randomly select one housing unit Health Care from each yard Services Request Forms Diagnostic Services MITs 2.001–003 Radiology 10 Radiology Logs • Appointment date (90 days–9 months) • Randomize • Abnormal MITs 2.004–006 Laboratory 10 Quest • Appt. date (90 days–9 months) • Order name (CBC or CMPs only) • Randomize • Abnormal MITs 2.007–009 Laboratory STAT 0 Quest • Appt. date (90 days–9 months) • Order name (CBC or CMPs only) • Randomize • Abnormal MITs 2.010–012 Pathology 9 InterQual • Appt. date (90 days–9 months) • Service (pathology related) • Randomize Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 99 Quality No. of Indicator Sample Category Samples Data Source Filters Health Information Management (Medical Records) MIT 4.001 Health Care Services 30 OIG Qs: 1.004 • Nondictated documents Request Forms • First 20 IPs for MIT 1.004 MIT 4.002 Specialty Documents 45 OIG Qs: 14.002, • Specialty documents 14.005 & 14.008 • First 10 IPs for each question MIT 4.003 Hospital Discharge 25 OIG Q: 4.005 • Community hospital discharge Documents documents • First 20 IPs selected MIT 4.004 Scanning Accuracy 24 Documents for any • Any misfiled or mislabeled tested inmate document identified during OIG compliance review (24 or more = No) MIT 4.005 Returns From 25 CADDIS Off-site • Date (2–8 months) Community Hospital Admissions • Most recent 6 months provided (within date range) • Rx count • Discharge date • Randomize Health Care Environment MITs 5.101–105 Clinical Areas 10 OIG inspector • Identify and inspect all on-site MITs 5.107–111 on-site review clinical areas. Transfers MITs 6.001–003 Intrasystem Transfers 25 SOMS • Arrival date (3–9 months) • Arrived from (another departmental facility) • Rx count • Randomize MIT 6.101 Transfers Out 10 OIG inspector • R&R IP transfers with medication on-site review Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 100 Quality No. of Indicator Sample Category Samples Data Source Filters Pharmacy and Medication Management MIT 7.001 Chronic Care 25 OIG Q: 1.001 See Access to Care Medication • At least one condition per patient—any risk level • Randomize MIT 7.002 New Medication 25 Master Registry • Rx count Orders • Randomize • Ensure no duplication of IPs tested in MIT 7.001 MIT 7.003 Returns From 25 OIG Q: 4.005 • See Health Information Community Hospital Management (Medical Records) (returns from community hospital) MIT 7.004 RC Arrivals— N/A at this OIG Q: 12.001 • See Reception Center Medication Orders institution MIT 7.005 Intrafacility Moves 25 MAPIP transfer • Date of transfer (2–8 months) data • To location/from location (yard to yard and to/from ASU) • Remove any to/from MHCB • NA/DOT meds (and risk level) • Randomize MIT 7.006 En Route 6 SOMS • Date of transfer (2–8 months) • Sending institution (another departmental facility) • Randomize • NA/DOT meds MITs 7.101–103 Medication Storage Varies OIG inspector • Identify and inspect clinical Areas by test on-site review & med line areas that store medications MITs 7.104–107 Medication Varies OIG inspector • Identify and inspect on-site Preparation and by test on-site review clinical areas that prepare and Administration Areas administer medications MITs 7.108–111 Pharmacy 1 OIG inspector • Identify & inspect all on-site on-site review pharmacies MIT 7.112 Medication Error 25 Medication error • All medication error reports with Reporting reports Level 4 or higher • Select total of 25 medication error reports (recent 12 months) MIT 7.999 Restricted Unit 6 On-site active • KOP rescue inhalers & KOP Medications medication listing nitroglycerin medications for IPs housed in restricted units Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 101 Quality No. of Indicator Sample Category Samples Data Source Filters Prenatal and Postpartum Care MITs 8.001–007 Recent Deliveries N/A at this OB Roster • Delivery date (2–12 months) institution • Most recent deliveries (within date range) Pregnant Arrivals N/A at this OB Roster • Arrival date (2–12 months) institution • Earliest arrivals (within date range) Preventive Services MITs 9.001–002 TB Medications 16 Maxor • Dispense date (past 9 months) • Time period on TB meds (3 months or 12 weeks) • Randomize MIT 9.003 TB Evaluation, 25 SOMS • Arrival date (at least 1 year prior Annual Screening to inspection) • Birth month • Randomize MIT 9.004 Influenza 25 SOMS • Arrival date (at least 1 year prior Vaccinations to inspection) • Randomize • Filter out IPs tested in MIT 9.008 MIT 9.005 Colorectal Cancer 25 SOMS • Arrival date (at least 1 year prior Screening to inspection) • Date of birth (51 or older) • Randomize MIT 9.006 Mammogram N/A at this SOMS • Arrival date (at least 2 yrs. prior institution to inspection) • Date of birth (age 52–74) • Randomize MIT 9.007 Pap Smear N/A at this SOMS • Arrival date (at least three yrs. institution prior to inspection) • Date of birth (age 24–53) • Randomize MIT 9.008 Chronic Care 25 OIG Q: 1.001 • Chronic care conditions (at least Vaccinations 1 condition per IP—any risk level) • Randomize • Condition must require vaccination(s) MIT 9.009 Valley Fever 0 Cocci transfer • Reports from past 2–8 months status report • Institution • Ineligibility date (60 days prior to inspection date) • All Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 102 Quality No. of Indicator Sample Category Samples Data Source Filters Reception Center MITs 12.001–008 Reception Center N/A at this SOMS • Arrival date (2–8 months) institution • Arrived from (county jail, return from parole, etc.) • Randomize Specialized Medical Housing MITs 13.001–004 Specialized Health 10 CADDIS • Admit date (2–8 months) Care Housing Unit • Type of stay (no MH beds) • Length of stay (minimum of 5 days) • Rx count • Randomize MITs 13.101–102 Call Buttons All OIG inspector • Specialized Health Care Housing on-site review • Review by location Specialty Services MITs 14.001–003 High-Priority 15 Specialty Services • Approval date (3–9 months) Initial and Follow-Up Appointments • Remove consult to audiology, RFS chemotherapy, dietary, Hep C, HIV, orthotics, gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, physiatry, podiatry, and radiology services • Randomize MITs 14.004–006 Medium-Priority 15 Specialty Services • Approval date (3–9 months) Initial and Follow-Up Appointments • Remove consult to audiology, RFS chemotherapy, dietary, Hep C, HIV, orthotics, gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, physiatry, podiatry, and radiology services • Randomize MITs 14.007–009 Routine-Priority 15 Specialty Services • Approval date (3–9 months) Initial and Follow-Up Appointments • Remove consult to audiology, RFS chemotherapy, dietary, Hep C, HIV, orthotics, gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, physiatry, podiatry, and radiology services • Randomize Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 103 MIT 14.010 Specialty Services 9 Specialty Services • Arrived from (other departmental Arrivals Arrivals institution) • Date of transfer (3–9 months) • Randomize MITs 14.011–012 Denials 11 InterQual • Review date (3–9 months) • Randomize N/A IUMC/MAR • Meeting date (9 months) Meeting Minutes • Denial upheld • Randomize Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 104 Quality No. of Indicator Sample Category Samples Data Source Filters Administrative Operations MIT 15.001 Adverse/sentinel 0 Adverse/sentinel • Adverse/Sentinel events events (ASE) events report (2–8 months) MIT 15.002 QMC Meetings 6 Quality • Meeting minutes (12 months) Management Committee meeting minutes MIT 15.003 EMRRC 12 EMRRC meeting • Monthly meeting minutes minutes (6 months) MIT 15.004 LGB 4 LGB meeting • Quarterly meeting minutes minutes (12 months) MIT 15.101 Medical Emergency 3 On-site summary • Most recent full quarter Response Drills reports & • Each watch documentation for ER drills MIT 15.102 Institutional Level 10 On-site list of • Medical grievances closed Medical Grievances grievances/closed (6 months) grievance files MIT 15.103 Death Reports 6 Institution-list of • Most recent 10 deaths deaths in prior • Initial death reports 12 months MIT 15.104 Nursing Staff 10 On-site nursing • On duty one or more years Validations education files • Nurse administers medications • Randomize MIT 15.105 Provider Annual 5 On-site • All required performance Evaluation Packets provider evaluation documents evaluation files MIT 15.106 Provider Licenses 12 Current provider • Review all listing (at start of inspection) MIT 15.107 Medical Emergency All On-site • All staff Response certification ◦ Providers (ACLS) Certifications tracking logs ◦ Nursing (BLS/CPR) • Custody (CPR/BLS) MIT 15.108 Nursing Staff and All On-site tracking • All required licenses and Pharmacist in Charge system, logs, or certifications Professional Licenses employee files and Certifications Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 105 Quality No. of Indicator Sample Category Samples Data Source Filters Administrative Operations MIT 15.109 Pharmacy and All On-site listing • All DEA registrations Providers’ Drug of provider DEA Enforcement Agency registration #s (DEA) Registrations & pharmacy registration document MIT 15.110 Nursing Staff New All Nursing staff • New employees (hired within last Employee training logs 12 months) Orientations MIT 15.998 Death Review 3 OIG summary log: • Between 35 business days & Committee deaths 12 months prior • California Correctional Health Care Services death reviews Office of the Inspector General, State of California Inspection Period: September 2020 - February 2021 Report Issued: February 2022 Cycle 6, Centinela State Prison | 107 California Correctional Health Care Services’ Response Office of the Inspector General, State of California Inspection Period: June 2020 – November 2020 Report Issued: February 2022 Cycle 6 Medical Inspection Report for Centinela State Prison OFFICE of the INSPECTOR GENERAL Amarik K. Singh Inspector General STATE of CALIFORNIA February 2022 OIG