California Institution for Men Cycle 6 Medical Inspection Report

Amarik K. Singh, Inspector General Neil Robertson, Chief Deputy Inspector General OFFICE of the OIG INSPECTOR GENERAL Independent Prison Oversight May 2023 Cycle 6 Medical Inspection Report California Institution for Men 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 916-288-4233. Cycle 6, California Institution for Men | 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 7 Population-Based Metrics 9 HEDIS Results 9 Recommendations 11 Indicators 13 Access to Care 13 Diagnostic Services 20 Emergency Services 24 Health Information Management 27 Health Care Environment 32 Transfers 43 Medication Management 49 Preventive Services 56 Nursing Performance 59 Provider Performance 64 Specialized Medical Housing 69 Specialty Services 73 Administrative Operations 78 Appendix A: Methodology 81 Case Reviews 82 Compliance Testing 85 Indicator Ratings and the Overall Medical Quality Rating 86 Appendix B. Case Review Data 87 Appendix C. Compliance Sampling Methodology 90 California Correctional Health Care Services’ Response 99 Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | iv Illustrations Tables 1. CIM Summary Table 3 2. CIM Policy Compliance Scores 4 3. CIM Master Registry Data as of April 2022 5 4. CIM Health Care Staffing Resources as of April 2022 6 5. CIM Results Compared with State HEDIS Scores 10 6. Access to Care 17 7. Other Tests Related to Access to Care 18 8. Diagnostic Services 22 9. Health Information Management 29 10. Other Tests Related to Health Information Management 30 11. Health Care Environment 41 12. Transfers 46 13. Other Tests Related to Transfers 47 14. Medication Management 53 15. Other Tests Related to Medication Management 54 16. Preventive Services 57 17. Specialized Medical Housing 71 18. Specialty Services 75 19. Other Tests Related to Specialty Services 76 20. Administrative Operations 79 A–1. Case Review Definitions 82 B–1. CIM Case Review Sample Sets 87 B–2. CIM Case Review Chronic Care Diagnoses 88 B–3. CIM Case Review Events by Program 89 B–4. CIM Case Review Sample Summary 89 Figures A–1. Inspection Indicator Review Distribution for CIM 81 A–2. Case Review Testing 84 A–3. Compliance Sampling Methodology 85 Photographs 1. Outdoor Patient Waiting Area 32 2. Indoor Waiting Area 33 3. Individual Patient Waiting Modules 33 4. Examination Room Did Not Provide Visual Privacy During Patient Examinations 34 5. Examination Table Had a Torn Vinyl Cover 34 6. Madrone Medication Room Staff Reported Water Leaks When it Rains 35 7. Instructions Provided to Madrone Medication Room Staff 35 8. Expired Medical Supplies Dated June and November 2021 36 9. Disorganized Medical Supply Cabinet With Staff Member’s Personal Items and Food 36 10. EMRB Glucometer Daily QC Logs Were Inaccurate 37 11. Expired Medical Supplies Dated December 15, 2021 38 12. Dead Cockroaches Found in the Examination Room 39 13. Dead Cockroach in the Medication Room 40 Cover: Rod of Asclepius courtesy of Thomas Shafee Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 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 people1 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) available on the OIG’s website.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 people. 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. We update 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: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 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 we did during Cycle 5, our office is continuing 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 California Institution for Men, the institution had been delegated back to the department by the receiver. We completed our sixth inspection of California Institution for Men (CIM), and this report presents our assessment of the health care provided at this institution during the inspection period from October 2021 to March 2022.6 The data obtained for CIM and the on-site inspections occurred during the COVID-19 pandemic.7 Opened in 1941, California Institution for Men (CIM) is located in San Bernardino County. The institution’s primary mission is to provide housing and programming for the general population and sensitive needs (Level II) patients. California Institution for Men is a large complex consisting of four separate facilities: Facilities A and C primarily house Level II sensitive-needs-yard custody patients; Facility D houses general population patients and is designated as a Secure Level I; Facility B houses medium- and maximum-custody-level patients and also serves as a reception center, where it receives and processes male patients who have been newly committed to CDCR, primarily from Riverside and San Diego Counties. The institution operates 10 medical clinics in which health care staff handle routine requests for medical services. CIM operates a triage and treatment area (TTA) for urgent and emergent patient care, a receiving and release (R&R) clinic for the assessment of arriving and departing patients, and an outpatient housing unit (OHU). In its OHU, staff treat patients requiring assistance with the activities of daily living but who do not require a higher level of inpatient care. CCHCS has designated CIM as an intermediate health care prison. These institutions are predominantly located in or near urban areas and are close to tertiary care centers and specialty care providers to enable the provision of the most cost-effective care. 6 Samples are obtained per case review methodology shared with stakeholders in prior cycles. The case reviews include emergency cardiopulmonary (CPR) reviews between May 2021 and November 2021, death reviews between October 2020 and July 2021, anticoagulation reviews between October 2021 and March 2022, diabetes reviews between September 2021 and March 2022, transfer reviews between August 2021 and January 2022, and RN sick call reviews between September 2021 and March 2022. 7 As of December 28, 2022 the department reports on its public tracker that 82% of its incarcerated population at CIM is fully vaccinated while 75% of CIM staff are fully vaccinated: http://www.cdcr.ca.gov/covid19/population-status-tracking/. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 3 Summary We completed the Cycle 6 inspection of CIM in August 2022. OIG inspectors monitored the institution’s delivery of medical care that occurred between October 2021 to March 2022. The OIG rated the overall quality of health care at CIM as adequate. We list the individual indicators and ratings applicable for this institution in Table 1 below. Table 1. CIM 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 Proficient Proficient Diagnostic Services Adequate Inadequate Inadequate Emergency Services Adequate N/A Adequate Health Information Management Proficient Proficient Proficient Health Care Environment N/A Inadequate Inadequate Transfers Inadequate Adequate Inadequate Medication Management Adequate Inadequate Inadequate Prenatal and Postpartum Care N/A N/A N/A N/A Preventive Services N/A Adequate Adequate Nursing Performance Adequate N/A Adequate Provider Performance Adequate N/A Adequate Reception Center N/A N/A N/A N/A Specialized Medical Housing Adequate Inadequate Adequate Specialty Services Adequate Adequate Adequate Administrative Operations† N/A Adequate Adequate * 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. † 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: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 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 405 patient records and 1,213 data points and used the data to answer 91 policy questions. In addition, we observed CIM processes during an on-site inspection in May 2022. Table 2 below lists CIM average scores from Cycles 4, 5, and 6. Scoring Ranges Table 2. CIM Policy Compliance Scores 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 87.7% 86.2% 88.8% 2 Diagnostic Services 88.9% 87.8% 70.0% 4 Health Information Management 59.6% 75.5% 93.7% 5 Health Care Environment 80.1% 55.0% 41.8% 6 Transfers 92.0% 74.3% 77.3% 7 Medication Management 81.4% 63.2% 57.5% 8 Prenatal and Postpartum Care N/A N/A N/A 9 Preventive Services 88.9% 78.0% 81.0% 12 Reception Center 80.5% 88.1% N/A 13 Specialized Medical Housing 100% 100% 72.5% 14 Specialty Services 88.9% 86.2% 77.0% 15 Administrative Operations * 81.7% 85.9% 80.6% * 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: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 5 The OIG clinicians (a team of physicians and nurse consultants) reviewed 56 cases, which contained 1,044 patient-related events. After examining the medical records, our clinicians conducted a follow-up on-site inspection in August 2022 to verify their initial findings. The OIG physicians rated the quality of care for 25 comprehensive case reviews. Of these 25 cases, our physicians rated 23 adequate and two inadequate. Our physicians found no adverse deficiencies 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 OIG 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 CIM Summary Table. In April 2022, the Health Care Services Master Registry showed that CIM had a total population of 2,645. A breakdown of the medical risk level of the CIM population as determined by the department is set forth in Table 3 below.9 Table 3. CIM Master Registry Data as of April 2022 Medical Risk Level Number of Patients Percentage* High 1 450 17.0% High 2 699 26.4% Med 893 33.8% Low 603 22.8% Total 2,645 100.0% * Percentages may not total 100 percent due to rounding. Source: Data for the population medical risk level were obtained from the CCHCS Master Registry dated 4-15-22. 8 The indicators for Reception Center and Prenatal and Postpartum Care did not apply to CIM. 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: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 6 Based on staffing data the OIG obtained from California Correctional Health Care Services (CCHCS), as identified in Table 4 below, CIM had no vacant executive leadership positions, no primary care provider vacancies, 2.0 nursing supervisor vacancies, and 17.0 nursing staff vacancies. Table 4. CIM Health Care Staffing Resources as of April 2022 Executive Primary Care Nursing Nursing Positions Leadership* Providers Supervisors Staff† Total Authorized Positions 6.0 17.0 14.0 133.0 170.0 Filled by Civil Service 6.0 17.0 12.0 116.0 151.0 Vacant 0.0 0.0 2.0 17.0 19.0 Percentage Filled by Civil Service 100.0% 100.0% 85.7% 87.2% 88.8% Filled by Telemedicine 0 0 0 0 0 Percentage Filled by Telemedicine 0% 0% 0% 0% 0% Filled by Registry 0 0 0 26.0 26.0 Percentage Filled by Registry 0% 0% 0% 14.4% 10.3% Total Filled Positions 6.0 17.0 14.0 133.0 170.0 Total Percentage Filled 100.0% 100.0% 100.0% 100.0% 100.0% Appointments in Last 12 Months 0.0 0.0 2.0 18.0 20.0 Redirected Staff 0.0 0.0 0.0 0.0 0.0 Staff on Extended Leave‡ 0.0 0.0 0.0 3.0 3.0 Adjusted Total: Filled Positions 6.0 17.0 14.0 130.0 167.0 Adjusted Total: Percentage Filled 100.0% 100.0% 100.0% 97.7% 98.2% * 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 updated on January 3, 2023, from California Correctional Health Care Services. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 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 The OIG did not find any adverse events at CIM 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 CIM. Of these 10 indicators, OIG clinicians rated one proficient, eight adequate, and one inadequate. The OIG physicians also rated the overall adequacy of care for 25 detailed case reviews. In the 1,044 events reviewed, there were 154 deficiencies, 43 of which the OIG clinicians considered to be of such magnitude that, if left unaddressed, would likely contribute to patient harm. Our clinicians found the following strengths at CIM: • Most requested appointments occurred timely. • Staff performed well timely retrieving and scanning reports. • Providers performed well in most areas of care, specifically outpatient and emergency care. • Nurses performed good nursing assessments and interventions in transfers-in, hospitalizations, and specialty processes. Our clinicians found the following weaknesses at CIM: • Providers did not always document co-consultations with nurses. • Patients did not always receive their new or chronic medications timely. • Nurses conducted poor transfer-out nursing assessments and screenings. Compliance Testing Results Our compliance inspectors assessed 10 of the 13 indicators applicable to CIM. Of these 10 indicators, our compliance inspectors rated two proficient, four adequate, 10 For a further discussion of an adverse event, see Table A–1. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 8 and four inadequate. We tested policy compliance in Health Care Environment, Preventive Services, and Administrative Operations, as these indicators do not have a case review component. CIM demonstrated a high rate of policy compliance in the following areas: • Staff performed well in scanning initial health care screening forms, community hospital discharge reports, and requests for health care services into patients’ electronic medical records within required time frames. • Patients with chronic care conditions and those returning from outside community hospitals saw their primary care providers within the specified time frames. • Nursing staff at CIM reviewed health care services request forms and conducted face-to-face encounters within required time frames. CIM demonstrated a low rate of policy compliance in the following areas: • CIM’s medical warehouse and clinics contained multiple medical supplies that were expired. • Health care staff did not consistently follow universal hand hygiene precautions during patient encounters. • Nursing staff did not regularly inspect emergency medical response bags. • Patients did not always receive their chronic care medications within the required time frames. There was poor medication continuity for patients returning from hospitalizations, for patients admitted to specialized medical housing, and for patients transferring into and laying over at CIM. • The institution did not consistently provide routine and STAT (immediate) laboratory services within the specified time frames. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 9 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 California Medi-Cal and Kaiser Medi-Cal HEDIS scores for one diabetic measure to use in conducting our analysis, and we present that here for comparison. HEDIS Results We considered CIM’s performance with population-based metrics to assess the macroscopic view of the institution’s health care delivery. We list the applicable HEDIS measures in Table 5. Comprehensive Diabetes Care When compared with statewide Medi-Cal programs—California Medi-Cal, Kaiser Northern California (Medi-Cal), and Kaiser Southern California (Medi-Cal)—CIM performed better in the one diabetic measure that has statewide comparative data: poor HbA1c control. Immunizations Statewide comparative data were also not available for immunization measures; however, we include these data for informational purposes. CIM had an 83 percent influenza immunization rate for adults 18 to 64 years old and a 93 percent influenza immunization rate for adults 65 years of age and older.11 The pneumococcal vaccine rate was 98 percent.12 Cancer Screening Statewide comparative data were not available for colorectal cancer screening; however, we include these data for informational purposes. CIM had a 91 percent colorectal cancer screening rate. 11 The HEDIS sampling methodology requires a minimum sample of 10 patients to have a reportable result. 12 The pneumococcal vaccines administered are the 13, 15, and 20 valent pneumococcal vaccines (PCV13, PCV 15, and PCV 20), 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 a different institution other than the one in which the patient was housed during the inspection period. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 10 Table 5. CIM Results Compared with State HEDIS Scores CIM Kaiser Kaiser California NorCal SoCal Cycle 6 Medi-Cal Medi-Cal Medi-Cal HEDIS Measure Results* 2018† 2018† 2018† HbA1c Screening 100% – – – Poor HbA1c Control (> 9.0%) ‡, § 6% 42% 34% 23% HbA1c Control (< 8.0%) ‡ 84% – – – Blood Pressure Control (< 140/90) ‡ 93% – – – Eye Examinations 41% – – – Influenza – Adults (18–64) 83% – – – Influenza – Adults (65+) 93% – – – Pneumococcal – Adults (65+) 98% – – – Colorectal Cancer Screening 91% – – – Notes and Sources * Unless otherwise stated, data were collected in May 2022 by reviewing medical records from a sample of CIM’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, 2020–June 30, 2021 (published April 2022). https://www.dhcs.ca.gov/dataandstats/reports/Documents/EQRTechRpt-Vol1.pdf. ‡ For this indicator, the entire applicable CIM population was tested. § For this measure only, a lower score is better. Source: Institutional 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: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 11 Recommendations As a result of our assessment of CIM’s performance, we offer the following recommendations to the department: Diagnostic Services • The department should consider developing an electronic solution to ensure that providers create patient letters at the time of endorsement and the patient results letter automatically populates accurately with all required elements per CCHCS policy. • Medical leadership should ascertain causes related to the untimely provision of laboratory services and implement remedial measures as appropriate. • Medical leadership should consider reminding its staff on departmental policy requirements for provider acknowledgement and nursing staff’s notification of STAT (immediate) laboratory results. Health Care Environment • Medical leadership should remind staff to follow universal hand hygiene precautions. Implementing random spot checks could improve compliance. • Executive leadership should consider performing random spot checks to ensure that medical supply storage areas located outside the clinics store medical supplies adequately. • Executive leadership should consider performing random spot checks to ensure that clinics, medical storage rooms, and restrooms are cleaned. • Nursing leadership should direct each clinic nurse supervisor to review the monthly emergency medical response bag (EMRB) logs to ensure that the EMRBs are regularly inventoried and sealed. Transfers • Health care leadership should identify challenges to medication continuity for patients transferring into the institution and returning from hospitalizations or emergency rooms. • Nursing leadership and custody staff should work collaboratively to ensure that all patients are evaluated and screened by a nurse before the transfer. • Nursing leadership should educate nursing staff to completely answer and address required initial health screening questions. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 12 Medication Management • Nursing leadership should consider reminding nursing staff to document patient refusals in the medication administration record, as described in CCHCS policy and procedures. • The institution should consider developing and implementing measures to ensure that staff timely make available and administer medications to patients and that staff document the administration of medications in the electronic health record system (EHRS) as described in CCHCS policy and procedures. Preventive Services • Nursing leadership should consider developing strategies to ensure that nursing staff accurately monitor patients who are taking tuberculosis (TB) medications. Provider Performance • Medical leadership should remind providers of the necessary components of the patient notification letter. • Medical leadership should remind providers to fully document their co- consultations with nurses in the EHRS. Specialized Medical Housing • The institution should ascertain the causes related to the untimely availability and administration of medications to specialized medical housing patients and implement remedial measures as appropriate. • Nursing leadership should consider educating nursing staff about the elements required for medication documentation as described in CCHCS policy and procedures. Specialty Services • Medical leadership should ascertain causes related to the untimely provision or scheduling of patients’ specialty service appointments and implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 13 Access to Care In this indicator, OIG inspectors evaluated the institution’s performance in providing patients with timely clinical appointments. Our inspectors reviewed scheduling and Overall appointment timeliness for newly arrived patients, sick calls, and nurse follow-up Rating appointments. We examined referrals to primary care providers, provider follow- Proficient ups, and specialists. Furthermore, we evaluated follow-up appointments for patients who received specialty care or returned from an off-site hospitalization. Case Review Rating Results Overview Adequate Compliance Compared with Cycle 5, CIM improved with access to care. The compliance scores Score were proficient while the case review rating was adequate. Overall, the providers Proficient and nurses saw the patient when appointments were requested. There were a few (88.8%) cases in which patients did not receive their specialty appointments. After reviewing the details, we ultimately rated this indicator proficient. Case Review and Compliance Testing Results OIG clinicians reviewed 385 provider, nursing, urgent or emergent care (TTA), specialty, and hospital events that required the institution to schedule appointments. We identified 11 deficiencies relating to Access to Care, 10 of which were significant.13 Access to Care Providers Access to clinic providers is a critical part of patient care in a health care system. CIM performed very well with access to providers. In light of movement restrictions related to the COVID-19 pandemic, OIG case reviewers considered providers’ chart reviews of nonurgent, low- or medium-risk chronic care appointments as generally acceptable alternatives to face-to-face or telephonic visits, if clinically appropriate. Compliance testing found chronic care face-to-face follow-up appointments occurred 96.0 percent of the time (MIT 1.001) and nursing-to-primary-care and provider- sick-call referrals occurred 100 percent of the time (MIT 1.005). Case reviewers also found very good access; however, we found some deficiencies: • In cases 51 and 57, the nurses did not order the planned provider follow-up appointments. • In case 20, the provider completed an encounter without seeing the patient. Access to Specialized Medical Housing Providers and Nurses CIM provided excellent access to specialized medical housing providers. The clinicians did not identify any deficiencies in access to outpatient housing unit 13 Access to care deficiencies occurred in cases 3, 20, 21, 24, 25, 29, 30, 45, 51, and 57. Significant deficiencies occurred in cases 3, 20, 24, 25, 29, 30, 45, 51, and 57. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 14 (OHU) providers. We identified two instances in which EHRS weekly nurse compression dressing change orders were completed, but we were unable to find evidence in the EHRS that the nurses saw the patients. • In case 25, a patient was scheduled for two follow-up RN appointments for dressing changes to the leg. In the EHRS, these appointment orders were closed as completed even though there was no nursing documentation indicating that the appointments for the compression dressing had occurred. Access to Clinic Nurses CIM performed well in providing access to nurse sick calls and provider-to-nurse referrals. Compliance testing found that nurses triaged sick call requests the same day they received them (MIT 1.003, 96.7%), and performed face-to-face appointments timely (MIT 1.004, 86.7%). Our clinicians assessed 50 nursing sick call requests and found no deficiencies with access to sick call nurses. We identified one access deficiency. • In case 3, a medical assistant closed vaccine orders due to a patient being transferred to another yard; as a result, the patient did not see the nurse to receive the vaccines. Access to Specialty Services CIM performed satisfactorily in providing referrals to specialty services. Compliance testing determined there was a good completion rate of high-priority (MIT 14.001, 93.3%), medium-priority (MIT 14.004, 73.3%) and routine-priority (MIT 14.007, 80.0%) appointments. We assessed 56 scheduled specialty and specialty follow-up appointments, which occurred timely. Case review clinicians found that most specialty appointments took place within the requested time frames; we identified three deficiencies: • In case 21, an ear, nose, and throat (ENT) specialist appointment did not occur within the requested time frame. On site, the institution stated that the delay was caused by the department schedulers’ backlog in scheduling telemedicine specialists. • In case 29, a provider requested a medium-priority six-minute-walk test, but this was scheduled three months late.14 Also in the same case, the provider requested a medium-priority pulmonology consultation that was scheduled one month late. Follow-Up After Specialty Services CIM performed well in providing follow-ups after specialty services. Compliance testing revealed that 80.5 percent of provider appointments after specialty services 14 The six-minute-walk test is a specialty test to assess aerobic capacity and endurance. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 15 occurred within the required time frame (MIT 1.008). Although policy does not require follow-up provider appointments after all specialty referrals, CIM was unique in that it ordered follow-up provider appointments for all priority specialty referrals and allowed the provider to decide whether the patient needed to be seen in person or whether chart review was adequate. In instances where in-person appointments were performed, the provider completed the order; conversely, if providers only performed chart review, they canceled the order. We identified one deficiency in which it was difficult to ascertain whether the provider saw the patient after the specialist consultation. • In case 20, a provider appeared to perform a chart review for the 14- day follow-up with the urologist and completed the encounter without seeing the patient. Follow-Up After Hospitalization CIM performed well in providing follow-up after hospitalizations. The OIG clinicians reviewed 13 hospitalizations during the review period and did not identify any access deficiencies. Follow-Up After Urgent or Emergent Care (TTA) In case review, providers always saw their patients after a triage and treatment area (TTA) event. OIG clinicians assessed 16 TTA events and identified no delays in provider follow-up appointments after TTA events. Follow-Up After Transferring Into the Institution Access to care for patients who had recently transferred into the institution was excellent. Compliance testing showed good access to intake appointments for newly arrived patients (MIT 1.002, 84.0%). Case reviewers reviewed seven transfer-in cases and did not find any deficiencies in this area. Clinician On-Site Inspection Our case review clinicians spoke with CIM executive leadership, medical and nursing leadership, and schedulers regarding the institution’s access to care. CIM’s review period took place during the COVID-19 pandemic. CIM leadership described four distinct outbreaks in the institution. During the height of the outbreaks, provider, nursing, and specialty appointment backlogs occurred. Leadership and supervisors worked with nurses and providers to reduce the backlogs by assessing whether patients needed to be added into the schedules or whether patients could be seen later. They added that a backlog of scheduling for telemedicine specialists had been an issue. At the time of the on-site inspection, leadership described no backlogs with on-site appointments. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 16 Compliance On-Site Inspection Patients had access to health care services request forms at four of six housing units inspected (MIT 1.101, 66.7%). Two inspected housing units did not have a system in place for reordering Health Care Request for Services forms (CDCR form 7362). The custody officers reported reliance on medical staff to replenish the CDCR form 7362 in the housing units. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 17 Compliance Testing Results Table 6. Access to Care 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 24 1 N/A 96.0% 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 21 4 N/A 84.0% screening, 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 N/A 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 26 4 N/A 86.7% reviewed? (1.004) * Clinical appointments: If the registered nurse determined a referral to a primary care provider was necessary, was the patient seen within 5 0 25 100% the 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 0 0 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 N/A 100% frame? (1.007) * Specialty service follow-up appointments: Did the clinician follow-up visits occur within required time frames? (1.008) *,† 33 8 4 80.5% Clinical appointments: Do patients have a standardized process to 4 2 0 66.7% obtain and submit health care services request forms? (1.101) Overall percentage (MIT 1): 88.8% * 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: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 18 TTaabbllee 77.. OOtthheerr TTeessttss RReellaatteedd ttoo AAcccceessss t oto C Caarere 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 N/A 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 14 1 N/A 93.3% 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? 10 2 3 83.3% (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 11 4 N/A 73.3% 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 1 2 12 33.3% provider? (14.006) * Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician 12 3 N/A 80.0% 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? 4 2 9 66.7% (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: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 19 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 20 Diagnostic Services In this indicator, OIG inspectors evaluated the institution’s performance in timely completing radiology, laboratory, and pathology tests. Our inspectors determined Overall whether the institution properly retrieved the resultant reports and whether Rating providers reviewed the results correctly. In addition, in Cycle 6, we examined the Inadequate institution’s performance in timely completing and reviewing immediate (STAT) laboratory tests. Case Review Rating Results Overview Adequate Compliance CIM provided inadequate diagnostic services. In this indicator, compliance testing Score showed an inadequate rating while case review analysis resulted in an adequate Inadequate rating. The factors that negatively affected the compliance score were poor (70.0%) performances when completing routine and STAT laboratory tests, as well as poorly communicating laboratory, radiology, and pathology results to the patient. After reviewing all aspects, we rated this indicator inadequate. Case Review and Compliance Testing Results We reviewed 356 diagnostic events and found 35 deficiencies, two of which were significant.15 Of these 35 deficiencies, we found 34 related to health information management and one related to completion of the test. Most of the deficiencies involved required elements missing from the patient notification letters. Although there were a high number of these deficiencies, the clinicians determined that they did not significantly increase the risk of harm to the patients. Test Completion CIM’s test completion performance was mixed. Compliance testing showed good completion of radiologic studies (MIT 2.001, 90.0%), but poor test completion of laboratory tests (MIT 2.004, 40.0%) and STAT laboratory tests (MIT 2.007, 60.0%). Case review clinicians found excellent test completion. We only found one delay in completion of an ultrasound study due to the technician imaging the wrong extremity. Health Information Management CIM’s performance in managing diagnostic results was also mixed. Compliance testing showed that providers reviewed radiology studies, laboratory tests, and STAT laboratory tests perfectly (MIT 2.002, MIT 2.005, and MIT 2.009, all 100%); however, nurses did not always notify providers of STAT laboratory tests within the required time frame (MIT 2.008, 70.0%). Pathology retrieval (MIT 2.010, 90.0%) 15 Diagnostic deficiencies occurred in cases 2, 3, 5, 6, 7, 10, 18–21, and 23–27. Significant deficiencies occurred in cases 24 and 26. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 21 and provider endorsement of pathology reports (MIT 2.011, 100%) were very good, but communication of the results was poor (MIT 2.012, 40.0%). Staff retrieved laboratory and diagnostic results promptly and sent them to providers for review. Case review identified five deficiencies in which providers did not endorse reports timely, another five deficiencies in which providers did not produce patient notification letters, and 23 deficiencies in which patient notification letters were incomplete.16 The incomplete letters were missing one or more of the following required elements: date of the study, whether the study was normal or abnormal, whether the patient required a follow-up appointment, and the name of the reviewing provider. We also identified one STAT laboratory test in which the nurse received a call from the third-party laboratory but did not communicate the results to the provider. Clinician On-Site Inspection We met with the diagnostics supervisor to discuss the normal workflow of diagnostic results. We also discussed the deficiencies we had identified in our reviews with the supervisor and providers. In one deficiency, the supervisor indicated that the radiology technician had performed the study on the wrong extremity. When the provider realized the error, the provider contacted the technician and had the study performed on the correct extremity; unfortunately, this occurred several weeks later. In another deficiency, the provider also discussed that although the nurse had been contacted about the STAT laboratory test, the nurse did not document relaying the information to the provider. Further training will be provided to the nurse to ensure proper documentation. 16 Providers delayed diagnostic endorsements in cases 2, 5, 6, 23, and 24. Providers did not send patient notification letters in cases 3, 7, 19, 20, and 23. Patient notification letters did not include all required elements in cases 7, 10, 18, 19, 21, and 23–27. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 22 Compliance Testing Results TTaabbllee 88.. DDiiaaggnnoossttiicc SSeerrvviicceess Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Was the radiology service provided within the time frame 9 1 N/A 90.0% specified in the health care provider’s order? (2.001) * Radiology: Did the ordering health care provider review and endorse 10 0 N/A 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 5 5 N/A 50.0% frames? (2.003) Laboratory: Was the laboratory service provided within the time 4 6 N/A 40.0% frame specified in the health care provider’s order? (2.004) * Laboratory: Did the health care provider review and endorse the 10 0 N/A 100% laboratory report within specified time frames? (2.005) * Laboratory: Did the health care provider communicate the results of the laboratory test to the patient within specified time frames? 0 10 N/A 0 (2.006) Laboratory: Did the institution collect the STAT laboratory test and 6 4 N/A 60.0% 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? 7 3 N/A 70.0% (2.008) * Laboratory: Did the health care provider endorse the STAT laboratory 10 0 N/A 100% results within the required time frames? (2.009) Pathology: Did the institution receive the final pathology report 9 1 N/A 90.0% within the required time frames? (2.010) * Pathology: Did the health care provider review and endorse the 10 0 N/A 100% 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? 4 6 N/A 40.0% (2.012) Overall percentage (MIT 2): 70.0% * 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: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 23 Recommendations • The department should consider developing an electronic solution to ensure that providers create patient letters at the time of endorsement and that the patient results letter automatically populates accurately with all elements required per CCHCS policy. • Medical leadership should ascertain causes related to the untimely provision of laboratory services and implement remedial measures as appropriate. • Medical leadership should consider reminding its staff on departmental policy requirements for provider acknowledgement and nursing staff’s notification of STAT laboratory results. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 24 Emergency Services In this indicator, OIG clinicians evaluated the quality of emergency medical care. Our clinicians reviewed emergency medical services by examining the timeliness and Overall appropriateness of clinical decisions made during medical emergencies. Our Rating evaluation included examining the emergency medical response, cardiopulmonary resuscitation (CPR) quality, triage and treatment area (TTA) care, provider Adequate performance, and nursing performance. Our clinicians also evaluated the Emergency Case Review Medical Response Review Committee’s (EMRRC) performance in identifying Rating problems with its emergency services. The OIG assessed the institution’s emergency Adequate services mainly through case review. Compliance Results Overview Score (N/A) CIM's performance in emergency services was acceptable, which was comparable to its performance in Cycle 5. Providers delivered good care. Nursing staff performed appropriate assessments and interventions. Moreover, the nursing documentation was acceptable. Overall, we rated this indicator adequate. Case Review Results We reviewed 17 urgent and emergent events and found 12 emergency care deficiencies. Of these 12 deficiencies, two were significant. 17 Emergency Medical Response Staff responded promptly to emergencies throughout the institution. They activated emergency medical services (EMS), notified TTA staff, and initiated cardiopulmonary resuscitation (CPR) timely except for in one case. • In case 1, custody staff found a patient who was unresponsive without a pulse or respirations. However, custody staff did not initiate CPR until three minutes later. Provider Performance Providers performed well in urgent and emergent situations. Providers made good clinical decisions for patients and documented all events. On-call providers were available for consultation with the nursing staff. The case reviewers did not identify any deficiencies. 17 Deficiencies occurred in cases 1, 2, 11, 13, 15, and 23–25. Significant deficiencies occurred in cases 1 and 13. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 25 Nursing Performance Nurses generally provided appropriate nursing assessments and interventions. Nurses recognized opioid overdose and implemented the nursing overdose protocol. However, the following cases showed room for improvement: • In case 11, a patient complained of severe abdominal pain with nausea and vomiting. The patient also had an elevated pulse. The nurse did not reassess the patient until an hour later. In addition, the nurse did not reassess the patient’s pain or abdominal area. • In case 13, the nurse initiated CPR but delayed in applying the automated external defibrillator (AED). Nursing Documentation Nursing documentation was acceptable. Most nurses documented accurate timelines and assessments. However, we did identify a pattern of deficiencies related to nursing staff not documenting the times they had notified the providers. Emergency Medical Response Review Committee Our clinicians found that all patients who had transferred to a higher level of care were reviewed by the committee. The committee self-identified most of the nurses’ deficiencies. Compliance testing showed that the EMRRC checklists were not completed thoroughly (MIT 15.003, 50.0%). This is discussed further in the Administrative Operations indicator. Clinician On-Site Inspection The institution’s TTA had four examination rooms and was staffed daily with two registered nurses and a provider. The patient care area had sufficient space to provide emergency care. Nursing staff reported that they had a good rapport with their supervisors and with custody staff. We discussed some of our case review findings with the nursing leadership, who explained additional training would be provided for quality improvement. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 26 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 27 Health Information Management In this indicator, OIG inspectors evaluated the flow of health information, a crucial link in high-quality medical care delivery. Our inspectors examined whether the Overall institution retrieved and scanned critical health information (progress notes, Rating diagnostic reports, specialist reports, and hospital discharge reports) into the Proficient medical record in a timely manner. Our inspectors also tested whether clinicians adequately reviewed and endorsed those reports. In addition, our inspectors Case Review checked whether staff labeled and organized documents in the medical record Rating correctly. Proficient Compliance Results Overview Score Proficient CIM performed very well in managing health information. We found that hospital (93.7%) discharge records, diagnostic results, and specialty reports were retrieved and scanned timely. We identified a pattern in which patient notification letters did not always contain all four elements required per CCHCS policy; however, this did not significantly impact the patients’ care. After careful consideration, we rated this indicator proficient. Case Review and Compliance Results We reviewed 1,037 events and found 38 deficiencies related to health information management. Of these 38 deficiencies, one was significant.18 Hospital Discharge Reports CIM superbly managed hospital discharge reports in both compliance and case review. Compliance testing also supports this conclusion with the retrieval and scanning of hospital discharge records (MIT 4.003, 95.0%) and staff ensured that the discharge report included the discharge summary and that providers endorsed the reports in a timely manner (MIT 4.005, 96.0%). Case reviewers did not find deficiencies in hospital discharge reports. We reviewed 13 off-site emergency- discharge department visits and hospital visits. CIM staff timely retrieved hospital records, scanned them into the medical record, and reviewed them properly. Specialty Reports CIM performed well with specialty reports. Case review clinicians identified four deficiencies with specialty reports.19 One of the deficiencies was due to delayed retrieval, the second deficiency was due to incomplete retrieval, the third deficiency was due to a delay in scanning a report into the chart, and the last deficiency was a delayed provider endorsement. 18 Health information management deficiencies occurred in cases 2, 3, 5, 6, 7, 10, 11, 18, 19–21, and 23– 28. A significant deficiency occurred in case 26. 19 Health information management deficiencies in specialty reports occurred in cases 7, 11, and 28. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 28 Compliance testing showed very good performance with the retrieval of specialty reports (MIT 4.002, 90.0%) and the signing of medium- and routine-priority reports (MIT 14.005, 85.7% and MIT 14.008, 100%). However, we found the signing of high- priority reports (MIT 14.002, 73.3%) to be subpar. Diagnostic Reports CIM performed acceptably in managing diagnostic reports. Most of the diagnostic health information management deficiencies were due to incomplete patient notification letters. The institution retrieved all the diagnostic reports timely and routed them to the provider for review. There was a slight pattern of late provider endorsements. There was a major pattern in which patient notification letters did not contain all the elements required per CCHCS policy. Compliance testing scores corroborated the same pattern of incomplete communication of results. For example, there was poor notification of STAT laboratory tests (MIT 2.008, 70.0%). Compliance scores for pathology also mirrored the above. Communication of pathology results was poor (MIT 2.012, 40.0%); however, review of pathology results was always timely (MIT 2.011, 100%). Urgent and Emergent Records CIM performed well in managing urgent and emergent records. OIG clinicians reviewed 16 emergency care events and found that nurses and providers recorded these events well. However, two events were mislabeled or mis-scanned. Refer to the Emergency Services indicator for additional information regarding emergency care documentation. Scanning Performance CIM performed well with the scanning process. The compliance testing score was 87.5 percent (MIT 4.004). The OIG clinicians reviewed 1,044 encounters and identified that one was mislabeled, one was mis-scanned, two retrievals were late, and one report was scanned late. These deficiencies were not clinically significant. Clinician On-Site Inspection We discussed health information management processes with CIM health information management supervisors, ancillary staff, diagnostic staff, nurses, and providers. The medical records supervisor described the process of retrieving on- site and off-site documents. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 29 Compliance Testing Results TTaabbllee 99.. HHeeaalltthh IInnffoorrmmaattiioonn MMaannaaggeemmeenntt 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 20 0 10 100% date? (4.001) Are specialty documents scanned into the patient’s electronic health 27 3 15 90.0% 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 19 1 5 95.0% hospital discharge? (4.003) * During the inspection, were medical records properly scanned, 21 3 N/A 87.5% 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 24 1 N/A 96.0% and did a provider review the report within five calendar days of discharge? (4.005) * Overall percentage (MIT 4): 93.7% * 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: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 30 Table 10. Other Tests Related to Health Information Management 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 10 0 N/A 100% the radiology report within specified time frames? (2.002) * Laboratory: Did the health care provider review and endorse the 10 0 N/A 100% laboratory report within specified time frames? (2.005) * Laboratory: Did the provider acknowledge the STAT results, OR did nursing staff notify the provider within the required time frame? 7 3 N/A 70.0% (2.008) * Pathology: Did the institution receive the final pathology report within 9 1 N/A 90.0% the required time frames? (2.010) * Pathology: Did the health care provider review and endorse the 10 0 N/A 100% pathology report within specified time frames? (2.011) * Pathology: Did the health care provider communicate the results of the 4 6 N/A 40.0% 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 N/A 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 12 2 1 85.7% 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 15 0 N/A 100% 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. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 31 Recommendations • The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 32 Health Care Environment In this indicator, OIG compliance inspectors tested clinics’ waiting areas, infection control, sanitation procedures, medical supplies, equipment management, and Overall examination rooms. Inspectors also tested clinics’ performance in maintaining Rating auditory and visual privacy for clinical encounters. Compliance inspectors asked the Inadequate institution’s health care administrators to comment on their facility’s infrastructure and its ability to support health care operations. The OIG rated this indicator solely Case Review on the compliance score, using the same scoring thresholds as in the Cycle 4 and Rating Cycle 5 medical inspections. Our case review clinicians do not rate this indicator. (N/A) Compliance Results Overview Score Inadequate In this cycle, multiple aspects of CIM’s health care environment needed (41.8%) improvement: medical supply storage areas in and outside of the clinics contained expired 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 examining patients. These factors resulted in an inadequate rating for this indicator. Compliance Testing Results Outdoor Waiting Areas We examined outdoor patient waiting areas (see Photo 1). Health care and custody staff reported existing waiting areas had sufficient seating capacity. The staff reported the outdoor waiting area was only utilized when the indoor waiting area was at capacity. Indoor Waiting Areas We inspected CIM’s indoor waiting areas. Patients had enough seating capacity while waiting for their appointments (see Photo 2, next page). Depending on the population, patients were either placed in a cohesive holding module or held in individual modules awaiting their medical appointments (see Photo 3, next page). Custody staff also reported they bring in a few patients at a time to prevent overcrowding the indoor waiting areas and to maintain safe social distancing. During our inspection, we did not observe overcrowding in Photo 1. Outdoor patient waiting area (photographed on 5-12-22). the clinics’ waiting areas. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 33 Photo 2. Indoor waiting area (photographed on 5-11-22). Photo 3. Individual patient waiting modules (photographed on 5-11-22). Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 34 Clinic Environment Nine of 10 clinic environments were sufficiently conducive for medical care. They provided reasonable auditory privacy, appropriate waiting areas, wheelchair accessibility, and nonexamination room workspace (MIT 5.109, 90.0%). In one clinic, we observed laboratory staff provided services to multiple patients at the same time in the blood draw stations, which prohibited auditory privacy. Of the 10 clinics we observed, three contained appropriate space, configuration, supplies, and equipment to allow their clinicians to perform proper clinical examinations (MIT 5.110, 30.0%). The remaining seven clinics had one or more of the following deficiencies: the examination room lacked visual privacy for conducting clinical examinations (see Photo 4). Photo 4. Examination room did not provide visual privacy during patient examinations (photographed on 5-12-22). In addition, the examination table and patient chair had a torn vinyl cover (see Photo 5), the examination room storage area was disorganized, the examination table placement prevented patients from lying down fully, or the examination room contained unsecured confidential medical records. Photo 5. Examination table had a torn vinyl cover (photographed on 5-10-22) Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 35 In addition to the above findings, our compliance inspectors observed the following notable findings in the clinic during their on-site inspection: • In the Madrone medication room, staff reported that water leaks from the air conditioning unit when it rains (see Photo 6). Staff verbalized that they reported the issue to the clinic supervisor and were instructed to cover the electronics (see Photo 7), while the work order was being submitted. Once we shared the information with the executives, they promptly inspected the medication room and addressed the issue. Photo 6. Staff for Madrone medication room reported water leaking from the air conditioning unit when it rains (photographed on 5-11-22). Photo 7. Instructions provided to Madrone medication room staff were written on the whiteboard (photographed on 5-11-22). Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 36 Clinic Supplies None of the 10 clinics followed adequate medical supply storage and management protocols (MIT 5.107, zero). We found one or more of the following deficiencies in all 10 clinics: expired medical supplies (see Photo 8), unidentified or inaccurately labeled medical supplies, compromised original medical supply packaging, disorganized medical supply cabinets or drawers, staff members’ personal items and food stored with medical supplies (see Photo 9), and cleaning materials stored with medical supplies. Photo 8. Expired medical supplies dated June and November 2021 (photographed on 5-11-22). Photo 9. Disorganized medical supply cabinet with staff member’s personal items and food (photographed on 5-10-22). Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 37 Four of the 10 clinics met the requirements for essential core medical equipment and supplies (MIT 5.108, 40.0%). We found one or more of the following deficiencies in six clinics: the examination room lacked examination table paper; staff failed to log the results of the automated external defibrillator (AED) performance test; staff failed to log the daily performed glucometer quality control results; and staff did not document the daily glucometer quality-control performed. 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. None of the nine EMRBs passed our test (MIT 5.111, zero). We found one or more of the following deficiencies within all clinics: staff failed to ensure that the EMRB’s compartments were sealed and intact; staff had not inventoried the EMRBs when the seal tags were replaced or inventoried the EMRBs in the previous 30 days; EMRBs contained items that were not kept in the original packaging; staff failed to log EMRB daily glucometer quality-control results; and staff inaccurately logged the EMRB glucometer control solution range when performing daily glucometer quality control (see Photo 10). Photo 10. EMRB glucometer daily QC logs were inaccurate (photographed on 5-12-22). Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 38 Medical Supply Management None of the medical supply storage areas located outside the medical clinics stored medical supplies adequately (MIT 5.106, zero). We found expired medical supplies (see Photo 11). Photo 11. Expired medical supplies dated December 15, 2021 (photographed on 5-11-22). According to the chief executive officer, the institution did not have any concerns about the medical supplies process. Health care managers and medical warehouse managers expressed no concerns about the medical supply chain or their communication process with the existing system. Infection Control and Sanitation Staff appropriately, cleaned, sanitized, and disinfected four of 10 clinics (MIT 5.101, 40.0%). In six clinics, we found one or more of the following deficiencies: cleaning logs were not maintained; the examination room, staff restroom, medication room, and medical storage room had cockroaches (see photos 12 and 13, next two pages); biohazard waste had not been emptied after each clinic day; the examination room floor contained an iodine-like stain at the time of our inspection; and we found an unsanitary examination table. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 39 Photo 12. Dead cockroaches found in the examination room (photographed on 5-10-22). Staff in seven of nine clinics (MIT 5.102, 77.8%) properly sterilized or disinfected medical equipment. In one clinic, we observed the clinician utilize the examination table without disposable paper during a patient encounter, and staff did not routinely log, date stamp, and write initials when processing reusable medical equipment for sterilization. In another clinic, staff did not remove and replace the examination table disposable paper between patient encounters. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 40 We found operating sinks and hand hygiene supplies in the examination rooms in seven of 10 clinics (MIT 5.103, 70.0%). In three clinics, the patient restrooms lacked antiseptic soap and disposable hand towels. In one of the three clinics, the blood draw station had a nonfunctional soap dispenser. We observed patient encounters in eight clinics. In seven clinics, staff did not wash their hands before examining their patients and before regloving (MIT 5.104, 12.5%). Health care staff in all clinics followed proper protocols to mitigate exposure to bloodborne pathogens and contaminated waste (MIT 5.105, 100%). Physical Infrastructure At the time of our medical inspection, the institution’s administrative team reported no ongoing Health Care Facility Improvement Program construction projects. The institution’s health care management and plant operations manager reported that all clinical area infrastructures were in working order (MIT 5.999). Photo 13. Dead cockroach in the medication room (photographed on 5-11-22). Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 41 Compliance Testing Results Table 11. Health Care Environment Table 11. Health Care Environment Scored Answer Compliance Questions Yes No N/A Yes % Infection control: Are clinical health care areas appropriately 4 6 1 40.0% 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 7 2 2 77.8% disinfected as warranted? (5.102) Infection control: Do clinical health care areas contain operable sinks 7 3 1 70.0% and sufficient quantities of hygiene supplies? (5.103) Infection control: Does clinical health care staff adhere to universal 1 7 3 12.5% hand hygiene precautions? (5.104) Infection control: Do clinical health care areas control exposure to 10 0 1 100% 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 0 10 1 0 managing and storing bulk medical supplies? (5.107) Clinical areas: Do clinic common areas and exam rooms have 4 6 1 40.0% essential core medical equipment and supplies? (5.108) Clinical areas: Are the environments in the common clinic areas 9 1 1 90.0% conducive to providing medical services? (5.109) Clinical areas: Are the environments in the clinic exam rooms 3 7 1 30.0% 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, 0 9 2 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 of adequate health care services? (5.999) this test. Overall percentage (MIT 5): 41.8% * 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: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 42 Recommendations • Medical leadership should remind staff to follow universal hand hygiene precautions. Implementing random spot checks could improve compliance. • Executive leadership should consider performing random spot checks to ensure that medical supply storage areas located outside the clinics store medical supplies adequately. • Executive leadership should consider performing random spot checks to ensure that clinics, medical storage rooms, and restrooms are cleaned. • Nursing leadership should direct each clinic nurse supervisor to review the monthly emergency medical response bag (EMRB) logs to ensure that the EMRBs are regularly inventoried and sealed. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 43 Transfers In this indicator, OIG inspectors examined the transfer process for those patients who transferred into the institution as well as those who transferred to other Overall institutions. For newly arrived patients, our inspectors assessed the quality of health Rating screenings and the continuity of provider appointments, specialist referrals, Inadequate diagnostic tests, and medications. For patients who transferred out of the institution, inspectors checked whether staff reviewed patient medical records and determined Case Review the patient’s need for medical holds. They also assessed whether staff transferred Rating patients with their medical equipment and gave correct medications before patients Inadequate left. In addition, our inspectors evaluated the performance of staff in communicating vital health transfer information, such as preexisting health conditions, pending Compliance appointments, tests, and specialty referrals; and inspectors confirmed whether staff Score sent complete medication transfer packages to the receiving institution. For patients Adequate who returned from off-site hospitals or emergency rooms, inspectors reviewed (77.3%) whether staff appropriately implemented the recommended treatment plans, administered necessary medications, and scheduled appropriate follow-up appointments. Results Overview CIM’s performance was mixed in this indicator. When patients transferred in and returned from the hospital, nurses performed good nursing assessments, and provider follow-up appointments occurred within the required time frames. In contrast, we identified lapses in medication continuity for patients transferring into the institution and returning from the hospital. In addition, when patients transferred into the institution with pending specialty referrals, their appointments did not occur timely. Furthermore, when patients transferred out of the institution, they were not properly evaluated or screened. After reviewing all aspects of the Transfers indicator, we rated this indicator inadequate. Case Review and Compliance Testing Results OIG clinicians reviewed 38 events in 16 cases in which patients transferred into or out of the institution or returned from an off-site hospital or emergency room. We identified four deficiencies, three of which were significant.20 Transfers In We found CIM’s transfer-in process problematic. Compliance testing found that nurses did not complete the initial health screening form thoroughly and timely (MIT 6.001, 48.0%). Analysis of the compliance data showed that nurses did not always follow up with additional questions when patients responded “yes” to a screening question. In contrast, our clinicians found that the nurses evaluated the 20 Deficiencies occurred in cases 26, 34, 35, and 36. Significant deficiencies occurred in cases 26, 35, and 36. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 44 patients appropriately and requested provider appointments with appropriate time frames in all cases reviewed. CIM provided good access to primary care providers for patients who transferred into the institutions. The OIG clinicians found that all patients were seen on time. Compliance testing showed that most appointments occurred within the required time frame (MIT 1.002, 84.0%). Compliance testing found that transfer-in patients did not receive their medications timely (MIT 6.003, 61.1%). Our clinicians did not identify any deficiencies. When patients transferred into CIM with preapproved specialty services, compliance testing found that only 40.0 percent occurred timely (MIT 14.010). Our clinicians did not review any applicable cases. Transfers Out CIM’s transfer out process needs improvement. Compliance on-site testing found only one sample in which CIM had excellent performance providing complete transfer packets (MIT 6.101, 100%). In contrast, our clinicians found that patients were not properly evaluated before transferring out of the institution. The following are examples: • In case 35, the patient transferred out to another institution without first being screened by a nurse. As a result, pertinent information was not reviewed and documented on the transfer powerform such as the patient’s medical clearance, medical history, physical examination, patient summary, and pending orthopedic surgery referral. • In case 36, a patient transferred out to another institution. The nurse who had completed the preboarding screening had not obtained the patient’s blood pressure, pulse, respiration, and oxygen level. In addition, pertinent information had not been reviewed and documented on the transfer powerform such as the patient’s medical clearance, medical history, physical examination, patient summary, and pending specialty referral. The nurse documented that the patient had transferred before this information could be completed. Hospitalizations Patients returning from an off-site hospitalization or emergency room are at a high risk for lapses in care quality. These patients typically experienced severe illness or injury. They require more care and place a strain on the institution’s resources. In addition, because these patients have complex medical issues, the successful transfer of health information is necessary for good quality care. Any transfer lapse could result in serious consequences for these patients. CIM’s hospital return process was sufficient. Our clinicians found that nurses performed good nursing assessments when patients returned from the hospital and notified the providers of pertinent information. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 45 Our clinicians found that all discharge documents were scanned and reviewed in a timely manner. Compliance testing found similar results (MIT 4.003, 95.0% and MIT 4.005, 96.0%). Both compliance inspectors and clinicians found that CIM performed very well in providing follow-up appointments within the required time frame for patients returning from a hospital and emergency room. In compliance testing, CIM scored 100 percent (MIT 1.007). Compliance testing found that CIM did not ensure medication continuity for its patients (MIT 7.003, 54.2%). In contrast, our clinicians found that all patients received their medications timely except for in one case. Clinician On-Site Inspection The transfer nurse and supervisor were knowledgeable about the transfer process. Although CIM is not a reception center, the transfer nurse and supervisor reported that CIM averaged 40 transfers per day and that those patients were seen in a designated clinic to provide continuity of care. We discussed some of our case review findings and the transfer supervisor reported that training would be provided. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 46 Compliance Testing Results TTaabbllee 1122.. TTrraannssffeerrss Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution or COCF: Did nursing staff complete the initial health screening and 12 13 N/A 48.0% 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 N/A 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, 11 7 7 61.1% 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 1 0 0 100% transfer packet required documents? (6.101) * Overall percentage (MIT 6): 77.3% * 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: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 47 TTaabbllee 1133.. OOtthheerr TTeessttss R Reelalatetedd t oto T rTarnasnfsefresrs 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 21 4 N/A 84.0% 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 N/A 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 19 1 5 95.0% discharge? (4.003) * For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements and did a 24 1 N/A 96.0% 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 13 11 1 54.2% patient within required time frames? (7.003) * Upon the patient’s transfer from one housing unit to another: Were 20 5 N/A 80.0% 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 2 6 N/A 25.0% 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 8 12 N/A 40.0% 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. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 48 Recommendations • Health care leadership should identify challenges to medication continuity for patients transferring into the institution and returning from hospitalizations or emergency rooms. • Nursing leadership and custody staff should work collaboratively to ensure that all patients are evaluated and screened by a nurse before the transfer. • Nursing leadership should educate nursing staff to completely answer and address required initial health screening questions. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 49 Medication Management In this indicator, OIG inspectors evaluated the institution’s performance in administering prescription medications on time and without interruption. The Overall inspectors examined this process from the time a provider prescribed medication Rating until the nurse administered the medication to the patient. When rating this Inadequate indicator, the OIG strongly considered the compliance test results, which tested medication processes to a much greater degree than case review testing. In addition Case Review to examining medication administration, our compliance inspectors also tested Rating many other processes, including medication handling, storage, error reporting, and Adequate other pharmacy processes. Compliance Score Results Overview Inadequate (57.5%) CIM had a mixed performance in this indicator. Prison staff performed well in ensuring medication continuity for patients transferring from one housing unit to another as well as with the process of administering TB medication. In contrast, CIM showed room for improvement in the following medication processes: new medications, continuity of chronic care medications, hospital return medications, and specialized medical housing medications. After careful consideration of all factors, we rated this indicator inadequate. Case Review and Compliance Testing Results Our clinicians reviewed 147 events related to medication management and found 24 deficiencies, 16 which were significant.21 New Medication Prescriptions Compliance testing showed patients did not always receive their newly prescribed medications timely (MIT 7.002, 68.0%). Our clinicians found three significant deficiencies related to newly prescribed medications. The following two deficiencies occurred in case 23. • In case 23, a patient had a history of chronic obstructive pulmonary disease. The provider prescribed two maintenance inhalers (Dulera and Spiriva). The patient did not receive Dulera during the review period and he received Spiriva two days late. Two months later, the patient requested Dulera and did not receive it. This placed the patient at risk for possible respiratory complications. 21 Deficiencies occurred in cases 1, 2, 5, 6, 7, 8, 9, 11, 19, 23, 25, 26, 28, and 30. Significant deficiencies occurred in cases 2, 5, 6, 8, 11, 23, 25, 26, and 30. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 50 Chronic Medication Continuity Compliance testing found that patients did not receive their chronic care medications timely (MIT 7.001, 8.3%). Our clinicians also found a pattern of deficiencies relating to lapses in medication continuity. The following are examples: • In case 2, a patient did not receive his aspirin for one month. • In case 8, a patient did not receive his aspirin and diuretic medication for one month. • In case 23, a patient received his aspirin two months late and his maintenance inhaler 12 days late. Hospital Discharge Medications Compliance testing found that patients returning from off-site hospitals or emergency rooms did not receive their medication within the required time frames (MIT 7.003, 54.2%). In contrast, our clinicians found that all patients received their medications timely except for in one case. Transfer Medications Compliance testing found that transfer-in patients did not always receive their medications timely (MIT 6.003, 61.1%). Our clinicians found that patients transferring in and out of the institution received their medications timely. Compliance testing showed that patients transferring from one housing unit to another received their medications timely (MIT 7.005, 80.0%). Specialized Medical Housing Medications CIM performed poorly in medication management. Compliance testing showed only 30.0 percent of newly admitted patients received their medications within the required time frames (MIT 13.004). Our clinicians identified six deficiencies related to medication management, four of which were significant. The following are examples: • In case 11, a patient had a kidney transplant. The provider increased the patient’s immunosuppressive medication, which was to be given in the morning and evening. The patient did not receive his evening medication for one day. • In case 25, a patient received a duplicate 30-day supply of cholesterol medication. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 51 Medication Administration Compliance testing found that nurses very often administered TB medications as prescribed (MIT 9.001, 92.0%). Our clinicians found that most nurses administered medications properly. Clinician On-Site Inspection Our clinicians interviewed medication nurses and found them to be knowledgeable about the medication process. These nurses attended the clinic huddles and notified providers of expiring medications. We also met with a pharmacist and with nurse managers to discuss some of our findings. In response, they reported that they plan to provide training. Compliance Testing Results Medication Practices and Storage Controls The institution adequately stored and secured narcotic medications in seven of eight clinic and medication line locations (MIT 7.101, 87.5%). In one location, the supervising nurse failed to describe the appropriate narcotic medication discrepancy reporting process. CIM appropriately stored and secured nonnarcotic medications in four of 10 clinic and medication line locations (MIT 7.102, 40.0%). In seven locations, we observed one or more of the following deficiencies: the medication storage cabinet was disorganized; we found medications not securely stored in the medication storage cabinets or carts; and the medication area lacked a clearly labeled designated area for either medications with expired pharmacy labels, nonrefrigerated medications, and refrigerated medications that were to be returned to the pharmacy. Staff kept medications protected from physical, chemical, and temperature contamination in two of the nine clinic and medication line locations (MIT 7.103, 22.2%). In seven locations, we found one or more of the following deficiencies: staff did not consistently record the room temperatures; staff did not store oral and topical medications separately; and the medication refrigerator was unsanitary. Staff successfully stored valid, unexpired medications in seven of the 10 applicable medication line locations (MIT 7.104, 70.0%). In two locations, nurses did not label the multiuse medication as per CCHCS policy. In another location, we found expired medication. Nurses exercised proper hand hygiene and contamination control protocols in two of six locations (MIT 7.105, 33.3%). In four locations, some nurses neglected to wash or sanitize their hands before each subsequent regloving. In five of seven medication preparation and administration areas, staff demonstrated appropriate administrative controls and protocols (MIT 7.106, 71.4%). In two locations, nurses did not maintain unissued medication in its original labeled packaging. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 52 Staff in one of six medication areas used appropriate administrative controls and protocols when distributing medications to their patients (MIT 7.107, 16.7%). In five locations, we observed one or more of the following deficiencies: medication nurses did not distribute medications to patients within the time frame of one hour before or one hour after the normal distribution time; medication nurses did not reliably observe patients while they swallowed direct observation therapy medications; medication nurses did not consistently verify secondary identification prior to administering medications; medication nurses did not follow the CCHCS care guide when administering Suboxone medication; and nurses did not follow insulin protocols properly. During insulin administration, we observed some medication nurses did not properly disinfect the vial’s port before withdrawing medication. Pharmacy Protocols CIM followed general security, organization, and cleanliness management protocols for nonrefrigerated and refrigerated medications stored in its pharmacy (MIT 7.108, 7.109, and 7.110, 100%). The pharmacist-in-charge (PIC) did not adequately manage narcotic medications stored in CIM’s pharmacy. The PIC did not complete a monthly physical inventory of controlled substances in B Facility for the month of April 2022. Furthermore, the PIC did not correctly review monthly inventories of controlled substances in the institution’s clinic and medication storage locations. Specifically, the PIC and clinic staff did not correctly complete several medication area inspection checklists (CDCR form 7477). These errors resulted in a score of zero for this test (MIT 7.111). We examined 25 medication error reports. The PIC timely and correctly processed all reports (MIT 7.112, 100%). 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 CIM, the OIG did not find any applicable medication errors (MIT 7.998). The OIG interviewed patients in restricted housing units to determine whether they had immediate access to their prescribed asthma rescue inhalers or nitroglycerin medications. Nine of 10 applicable patients interviewed indicated they had access to their rescue medications. One patient reported his prescribed rescue inhaler had been taken away and placed in his property when he had transferred to the restricted housing unit. We promptly notified the CEO of this concern, and health care management immediately issued a replacement rescue inhaler to the patient (MIT 7.999). Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 53 Compliance Testing Results Table 14. Medication Management 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 2 22 1 8.3% no-shows? (7.001) * Did health care staff administer, make available, or deliver new order 17 8 N/A 68.0% prescription medications to the patient within the required time frames? (7.002) Upon the patient’s discharge from a community hospital: Were all ordered medications administered, made available, or delivered to the patient within 13 11 1 54.2% 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 20 5 N/A 80.0% 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 administered or 2 6 N/A 25.0% 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 7 1 3 87.5% 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 4 6 1 40.0% 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 2 7 2 22.2% 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 7 3 1 70.0% the assigned storage areas? (7.104) Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols during medication 2 4 5 33.3% 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 2 4 71.4% for patients? (7.106) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when administering 1 5 5 16.7% 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 1 0 0 100% medications? (7.109) Pharmacy: Does the institution’s pharmacy properly store refrigerated or frozen 1 0 0 100% medications? (7.110) Pharmacy: Does the institution’s pharmacy properly account for narcotic 0 1 0 0 medications? (7.111) Pharmacy: Does the institution follow key medication error reporting 25 0 0 100% protocols? (7.112) 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 housing This is a nonscored test. Please units have immediate access to their KOP prescribed rescue inhalers and see the indicator for discussion of nitroglycerin medications? (7.999) this test. Overall percentage (MIT 7): 57.5% * 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: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 54 Table 15. Other Tests Related to Medication Management 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, 11 7 7 61.1% 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 1 0 0 100% transfer-packet required documents? (6.101) * Patients prescribed TB medication: Did the institution administer the 23 2 N/A 92.0% 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 5 19 1 20.8% the medication? (9.002) * Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient 3 7 N/A 30.0% 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. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 55 Recommendations • Nursing leadership should consider reminding nursing staff to document patient refusals in medication administration records, as described in CCHCS policy and procedures. • The institution should consider developing and implementing measures to ensure that staff timely make available and administer medications to patients, and that staff document the administration of medications in the EHRS as described in CCHCS policy and procedures. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 56 Preventive Services In this indicator, OIG compliance inspectors tested whether the institution offered or provided cancer screenings, tuberculosis (TB) screenings, influenza vaccines, and Overall other immunizations. If the department designated the institution as high risk for Rating coccidioidomycosis (valley fever), we tested the institution’s performance in Adequate transferring patients out quickly. The OIG rated this indicator solely according to the compliance score, using the same scoring thresholds as in the Cycle 4 and Cycle 5 Case Review medical inspections. Our case review clinicians do not rate this indicator. Rating (N/A) Results Overview Compliance CIM had a mixed performance in preventive services. Staff performed well in Score screening patients annually for TB, administering TB medications as prescribed, Adequate offering patients an influenza vaccine for the most recent influenza season, offering (81.0%) colorectal cancer screening for all patients ages 45 through 75, and offering required immunizations to chronic care patients. The institution faltered in monitoring patients who were taking prescribed TB medications. These findings are set forth in the table on the next page. Overall, we rated this indicator adequate. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 57 Compliance Testing Results TTaabblele 1 166. .P Prreevveennttivivee SSeerrvviicceess Scored Answer Compliance Questions Yes No N/A Yes % Patients prescribed TB medication: Did the institution administer the 23 2 N/A 92.0% 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 5 19 1 20.8% the medication? (9.002) † Annual TB screening: Was the patient screened for TB within the last 25 0 N/A 100% year? (9.003) Were all patients offered an influenza vaccination for the most recent 23 2 N/A 92.0% influenza season? (9.004) All patients from the age of 45 through the age of 75: Was the 23 2 N/A 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? 8 1 16 88.9% (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): 81.0% * 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 electronic health record system (EHRS) PowerForm for tuberculosis (TB)-symptom monitoring. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 58 Recommendations • Nursing leadership should consider developing strategies to ensure that nursing staff accurately monitor patients who are taking TB medications. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 59 Nursing Performance In this indicator, the OIG clinicians evaluated the quality of care delivered by the institution’s nurses, including registered nurses (RNs), licensed vocational nurses Overall (LVNs), psychiatric technicians (PTs), and certified nursing assistants (CNAs). Our Rating clinicians evaluated nurses’ performance in making timely and appropriate Adequate assessments and interventions. We also evaluated the institution’s nurses’ documentation for accuracy and thoroughness. Clinicians reviewed nursing Case Review performance in many clinical settings and processes, including sick call, outpatient Rating care, care coordination and management, emergency services, specialized medical housing, hospitalizations, transfers, specialty services, and medication management. Adequate The OIG assessed nursing care through case review only and performed no compliance testing for this indicator. Compliance Score When summarizing overall nursing performance, our clinicians understand that (N/A) nurses perform numerous aspects of medical care. Specific nursing quality issues are discussed in other indicators, such as Emergency Services, Specialty Services, and Specialized Medical Housing. Results Overview CIM nurses provided appropriate nursing care, which improved compared with Cycle 5. We identified fewer deficiencies in this cycle. Overall, nurses performed good nursing assessments and interventions for patients in the following areas: transfer-in, hospitalization, and specialty. However, the transfer-out nursing assessment and screening process needed improvement. Considering all these factors, we rated this indicator adequate. Case Review Results We reviewed 201 nursing encounters. Of the nursing encounters we reviewed, 103 were in the outpatient setting. We identified 59 nursing performance deficiencies, eight of which were significant. 22 Nursing Assessment and Interventions A critical component of nursing care is the quality of nursing assessment, which includes both subjective (patient interviews) and objective (observation and examination) elements. Nurses generally provided appropriate nursing assessments and interventions. 22 Deficiencies occurred in cases 1, 2, 7, 11, 13, 15, 18, 20, 22–26, 34, 36, 39, 42, 45, 51, 54, and 55. Significant deficiencies occurred in cases 2, 13, 20, 24–26, and 36. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 60 Nursing Documentation Complete and accurate nursing documentation is an essential component of patient care. Without proper documentation, health care staff can overlook changes in patients’ conditions. Nurses generally documented care appropriately. However, we found room for improvement in the outpatient area. The following are examples: • In case 22, the nurse wrote that the patient’s vital signs were stable but did not document the actual readings. • In case 23, a patient complained of heartburn. The nurse wrote that a thorough assessment was completed, and heartburn medication was issued per nursing protocol. However, the nurse did not document the details of the assessment. Therefore, we could not determine whether the nurse performed an appropriate assessment or whether the nurse’s intervention or action was appropriate because the details of the assessment were missing. • In case 51, a patient complained of ongoing left ear pain. The nurse wrote that the patient’s eardrum was red but did not document whether the eardrum was intact. • In case 54, a patient complained of foot pain when he walked. The nurse did not document the steadiness of the patient’s gait. Nursing Sick Call Our clinicians reviewed 50 sick call requests. Generally, nurses triaged patient sick call requests appropriately and performed appropriate assessments and interventions for patients with symptoms. However, the following cases demonstrated room for improvement: • In case 2, a patient complained of shortness of breath and feeling tired when he walked to the pill line. The nurse wrote that the patient had activity intolerance due to heart failure and requested that a provider follow-up in 14 days. The nurse should have notified the provider the same day. • In case 20, a patient complained of ringing in his ear. The nurse labeled the sick call request as asymptomatic. Subsequently, the symptomatic patient was not seen within one day. The patient was evaluated eight days late. • In case 25, a patient complained that he was having trouble breathing. The nurse requested a refill for the patient’s inhaler and requested a next-day appointment. The nurse should have evaluated the patient the same day. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 61 Emergency Services We reviewed 13 urgent or emergent cases. Nurses responded promptly to emergent events and generally performed appropriate assessment and interventions, which we detail further in the Emergency Services indicator. Hospital Returns We reviewed seven cases that involved returns from off-site hospitals or emergency rooms. The nurses performed good nursing assessments, which we detailed further in the Transfers indicator. Transfers We reviewed eight cases that involved the transfer-in and transfer-out process. When patients transferred into CIM, the nurses performed well. The nurses evaluated patients appropriately and initiated provider appointments within the required time frames. In contrast, when patients transferred out of CIM, the nurses did not evaluate patients appropriately and did not document pertinent information. Please refer to the Transfers indicator for further details. Specialized Medical Housing We reviewed five OHU cases. Generally, the nurses performed sufficient assessments. For more specific details, please refer to the Specialized Medical Housing indicator. Specialty Services We reviewed seven cases in which patients returned from off-site specialty appointments. The nurses performed good assessments, reviewed the specialists’ findings and recommendations, and communicated results to the providers. Medication Management We reviewed 28 events involving medication management and found that most nurses administered patients’ medications as prescribed. Please refer to the Medication Management indicator for additional details. Clinician On-Site Inspection Our clinicians spoke with nurses and nurse managers in the TTA, OHU, R&R, specialty clinics, outpatient clinics, and medication areas. Overall, nursing staff reported that morale was generally good. Clinic nurses reported they saw 18 to 20 patients a day and clinic staff reported no appointment backlog. We attended organized clinic huddles and the COVID-19 meeting. Some topics of discussion included access to care and issues that significantly impacted operations Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 62 such as patients refusing to quarantine by refusing movement to another dorm. This issue necessitated additional nursing resources for nursing rounds and pill lines. Nurses reported that nursing leadership was hands-on and very supportive. We discussed some of our case review findings with nursing leadership. These leaders informed us that they had already self-identified areas that needed improvement and implemented quality-improvement training and audits in various areas. We were presented with numerous documents and information regarding the quality improvement projects and audits. For example, leadership conducted training and audits for the sick call process, RN protocols, and RN referrals, and provided education on how to identify patients at risk for skin breakdowns. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 63 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 64 Provider Performance Overall In this indicator, OIG case review clinicians evaluated the quality of care delivered by Rating the institution’s providers: physicians, physician assistants, and nurse practitioners. Adequate Our clinicians assessed the institution’s providers’ performance in evaluating, diagnosing, and managing their patients properly. We examined provider Case Review performance across several clinical settings and programs, including sick call, Rating emergency services, outpatient care, chronic care, specialty services, intake, Adequate transfers, hospitalizations, and specialized medical housing. We assessed provider care through case review only and performed no compliance testing for this Compliance indicator. Score (N/A) Results Overview CIM providers delivered good care. This was an improvement from Cycle 5 when they performed poorly. Providers excelled in decision-making, assessments, review of records, emergency care, and specialty follow-up. However, providers had opportunities for improvement in following through with their treatment plans and documentation. We identified a pattern of deficiencies in which providers did not always document their co-consultations with nurses and, in a few of the deficiencies, the patient did not receive the proper follow-up care as a result. However, these deficiencies did not significantly increase the risk of harm to the patient and therefore, we rated this indicator adequate. Case Review Results OIG clinicians reviewed 137 medical provider encounters and identified 19 deficiencies, 8 of which were significant.23 In addition, our clinicians examined the quality of care in 25 comprehensive case reviews. Of these 25 cases, we found 23 adequate and two inadequate. Decision-Making In general, providers made appropriate assessments and sound decisions for their patients. Most of the time, they took good histories, formulated differential diagnoses, ordered appropriate tests, provided care with the correct diagnosis, and referred patients to the proper specialists when needed. However, our clinicians identified a few deficiencies related to poor assessments and decision-making. On several occasions, the provider did not perform the necessary assessments on issues that were found by other providers. • In case 5, a provider evaluated a patient, who has a history of heart failure and an abnormal heart rhythm (atrial fibrillation), after a cardiology consultation. The patient complained of dizziness to the cardiologist. The provider did not obtain a patient history or develop a differential diagnosis for the dizziness. At a later appointment, the cardiologist observed swelling in the patient’s lower 23 Provider deficiencies occurred in cases 2, 5, 7, 11, 18, 22, 24, 28, 29, 30, 54, and 55. Significant provider deficiencies occurred in cases 5, 18, 22, and 24. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 65 extremities. This could be a sign of worsening heart failure or worsening heart- rhythm control. The provider did not perform a focused history or even acknowledge the swelling. • In case 24, a provider saw a patient for a chronic care appointment and documented that the patient’s skin examination revealed no lesions or eruptions, even though multiple nurses had documented that the patient had wound necrotic tissue and serous drainage. Review of Records Providers generally reviewed medical records carefully; however, we found a few errors. In one instance, the provider refused to review and sign a telecardiology consultation report. In another instance, the provider documented that the patient was on a different dosage of a medication than what he was actually taking. • In case 29, a provider reviewed that a patient had been taking aspirin and advised that the patient continue taking the medication. However, at that time, the patient had not been on aspirin for four months. Emergency Care Providers appropriately managed patients in the TTA with urgent or emergent conditions. The providers took pertinent histories, performed pertinent physical examinations, developed reasonable differential diagnoses, and sent patients out to the hospital when medically indicated. Specialty Services Providers appropriately referred patients for specialty consultation when needed. When specialists made recommendations, the providers adequately followed the recommendations. However, out of 51 specialty events, we found two deficiencies in which the provider did not review and endorse the specialty report within policy guidelines. These deficiencies were not clinically significant. Follow-Through Usually, providers followed through with their documented plans. However, providers did not always follow-through with plans during nurse co-consultations. The following are examples of incomplete follow-through: • In case 18, a provider told a nurse that the provider would order physical therapy for a patient complaining of sciatic pain.24 However, the provider did not order the physical therapy. 24 Sciatic pain is pain that radiates from the lower back though the hip into the leg and is caused by compression of the sciatic nerve. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 66 • In case 22, a provider documented ordering a methylmalonic acid laboratory test, but did not do so.25 Documentation Quality This was an area with opportunities for improvement. Providers did not always provide accurate documentation, they occasionally cloned parts of previous notes, and they did not always document co-consults with nurses. On-site, the medical leadership reiterated that providers were expected to document all co-consults. The cloned notes are discussed in more detail in the Specialized Medical Housing indicator. • In case 7, a nurse reported to a provider that a patient had blood in his urine. The provider gave a verbal order for a urine test and to report the results back when available. However, the provider did not document an on-call progress note or arrange follow-up for the patient. • In case 18, a nurse co-consulted with a provider for sciatic pain and obtained recommendations for physical therapy. The provider did not write a progress note. • In case 24, a patient had swelling, redness, and pain in the left leg. The provider ordered intramuscular and oral antibiotics but did not examine the patient, arrange follow-up, or document a note. The provider placed a note in the chart as a late entry after we asked about this event at our on-site inspection. Moreover, the provider was contacted because the leg was not healing. The provider did not see the patient and did not document the contact. • In case 28, an outpatient housing unit provider cloned previous progress notes and documented that a patient had “repeat US pending” for a liver ultrasound that had occurred weeks before. • In case 54, a provider was notified by a nurse about an open wound. The provider ordered antibiotics but did not document a note. • In case 55, a nurse notified a provider about a possible insect bite. The provider ordered antibiotics but did not document a note. Provider Continuity CIM offered good provider continuity of care. OIG clinicians did not identify any deficiencies related to provider continuity during the review period. Clinician On-Site Inspection We attended daily provider meetings and team huddles while on-site. One of the chief physician and surgeons was out due to illness. We discussed with medical 25 A methylmalonic acid laboratory test is used to check for vitamin B12 deficiency. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 67 leadership the questions we had for the providers and the expectations for providers. Medical leadership verbalized that all providers had to document each instance they were contacted by nurses. The institution did not have trouble recruiting or retaining providers. Staff schedule an appointment with the provider after each return from a higher level of care. If the provider sees a patient, he or she completes the order. If the provider does not see the patient, he or she cancels the order. This was local policy to ensure that patients’ issues were not overlooked. Medical leadership also developed a local operating procedure through which rescue inhalers were made automatic refill instead of request refill to ensure that patients had rescue inhalers when they needed them. The providers who we spoke with expressed confidence in their medical leadership and a good working environment. They did not have any issues with nursing or custody staff. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 68 Recommendations • Medical leadership should remind providers of the necessary components of the patient notification letter. • Medical leadership should remind providers to fully document their co- consultations with nurses in the EHRS. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 69 Specialized Medical Housing Overall Rating In this indicator, OIG inspectors evaluated the quality of care in the specialized Adequate medical housing units. We evaluated the performance of the medical staff in assessing, monitoring, and intervening for medically complex patients requiring Case Review close medical supervision. Our inspectors also evaluated the timeliness and quality Rating of provider and nursing intake assessments and care plans. We assessed staff Adequate members’ performance in responding promptly when patients’ conditions deteriorated and looked for good communication when staff consulted with one Compliance another while providing continuity of care. Our clinicians also interpreted relevant Score compliance results and incorporated them into this indicator. At the time of our Inadequate inspection, CIM’s specialized medical housing consisted of an outpatient housing (72.5%) unit (OHU). Results Overview CIM performed sufficiently in this indicator. Compared with Cycle 5, providers improved by providing quality care, and nurses provided acceptable care. Both the providers and nurses assessed patients timely. However, their management of medication was subpar. Considering all factors, we rated this indicator adequate. Case Review and Compliance Testing Results We reviewed five OHU cases, which included 47 provider events and 37 nursing events. Due to the frequency of nursing and provider contacts in specialized medical housing, we bundle up to two weeks of patient care into a single event. We identified 22 deficiencies, five of which were significant. 26 Provider Performance Providers delivered good care. Compliance testing showed that providers completed most admission history and physical examinations timely (MIT 13.002, 80.0%). Our clinicians found that providers performed good assessments, made sound clinical decisions, and reviewed test results and consultations within the required time frame. However, we identified occasional deficiencies related to inaccurate documentation and an instance in which a provider did not write a progress note. Nursing Performance Compliance testing showed nurses completed most admission assessments in a timely manner (MIT 13.001, 80.0%). Our clinicians found that nursing care was acceptable. However, we identified a pattern of deficiencies related to incomplete nursing assessments. The following are examples: 26 Deficiencies occurred in cases 7, 11, 25, 28, and 30. Significant deficiencies occurred in cases 11, 25, and 30. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 70 • In case 11, a patient had an abdominal drainage tube. He complained of severe abdominal pain with movement and nausea. The nurse did not inquire about the type of pain, assess bowel sounds, and palpate the abdomen for tenderness. • In case 25, a patient had a history of obesity and congested heart failure. The patient complained of bilateral lower extremity swelling and “the inability to apply pressure to his knees and ankles.” The nurse did not assess the patient’s lower extremities for strength, tone, and sensation. In addition, the nurse did not assess range of motion of the knees and ankles. Furthermore, the nurse did not weigh the patient. The provider ordered the nurse to wrap the patient’s legs with compression bandages. However, the nurse did not assess the patient’s legs for circulation after applying the compression wrap. Medication Administration CIM performed poorly with medication management. Compliance testing showed only 30.0 percent of newly admitted patients received their medications within the required time frames (MIT 13.004). Our clinicians identified six deficiencies related to medication management, four of which were significant. We discuss these further in the Medication Management indicator. Clinician On-Site Inspection The institution’s outpatient housing unit (OHU) had 44 medical beds. At the time of our visit, all medical beds were occupied. The OHU was staffed with two providers, registered nurses, and licensed vocational nurses. We attended a well-organized huddle led by the lead registered nurse. We met with nursing leadership to discuss some of our findings, and the leadership reported that training would be provided. Compliance testing showed that CIM’s call light system was functional (MIT 13.101, 100%). Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 71 Compliance Testing Results TTaabbllee 1177.. SSppeecciiaalliizzeedd MMeeddiiccaall HHoouussiinngg Scored Answer Compliance Questions Yes No N/A Yes % For OHU, CTC, and SNF: Prior to 4/2019: Did the registered nurse complete an initial assessment of the patient on the day of admission, or within eight hours of admission to CMF’s Hospice? 8 2 N/A 80.0% 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 history and physical examination completed within the required time 8 2 N/A 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, Assessment, and Plan notes on the patient at the N/A N/A 10 N/A 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 all medications ordered, made available, and administered to the 3 7 N/A 30.0% patient within required time frames? (13.004) * For OHU and CTC only: Do inpatient areas either have properly working call systems in its OHU & CTC or are 30-minute patient 1 0 0 100% 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): Do health care staff perform patient safety checks according to 0 0 1 N/A institution’s local operating procedure or within the required time frames? (13.102) * Overall percentage (MIT 13): 72.5% * 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. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 72 Recommendations • The institution should ascertain the causes related to the untimely availability and administration of medications to specialized medical housing patients and implement remedial measures as appropriate. • Nursing leadership should consider educating nursing staff about the elements required for medication documentation as described in CCHCS policy and procedures. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 73 Specialty Services In this indicator, OIG inspectors evaluated the quality of specialty services. The OIG clinicians focused on the institution’s performance in providing needed specialty Overall care. Our clinicians also examined specialty appointment scheduling, providers’ Rating specialty referrals, and medical staff’s retrieval, review, and implementation of any Adequate specialty recommendations. Case Review Results Overview Rating Adequate CIM provided good specialty services for its patients. During the review period, Compliance providers requested specialty services when patients needed them. Although the Score COVID-19 pandemic limited some access to specialists, during our review period, Adequate this did not significantly impact patients’ access to specialists. With both case review (77.0%) and compliance showing similar results, we rated this indicator adequate. Case Review and Compliance Testing Results We reviewed 115 events related to specialty services; 61 were specialty consultations and procedures. We found 11 deficiencies in this category, four of which were significant.27 Access to Specialty Services CIM provided acceptable access to specialists. Compliance test scores ran the gamut from poor to excellent: poor continuity of newly transferred patient specialty services access (MIT 14.010, 40.0%), subpar medium-priority access (MIT 14.004, 73.3%), good routine-priority access (MIT 14.007, 80.0%), and excellent high- priority access (MIT 14.001, 93.3%). OIG clinicians only found three deficiencies with access to the specialist out of the 61 specialty consultations. The following deficiencies occurred: • In case 21, an ear, nose, and throat (ENT) specialty follow-up appointment did not occur during the review period. • In case 29, a medium-priority pulmonology consultation occurred one month late. • In case 29, the six-minute-walk test did not get scheduled within the requested time frame; it was scheduled almost three months late.28 27 Specialty deficiencies occurred in cases 2, 7, 11, 20, 21, 28, 29, and 30. Significant specialty deficiencies occurred in cases 20, 29, and 30. 28 The six-minute-walk test is a specialty test to assess aerobic capacity and endurance. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 74 Provider Performance In general, providers ordered specialty consults when appropriate and followed recommendations. However, we found two deficiencies in which providers did not endorse specialty reports in a timely manner and one deficiency in which the provider requested a medium-priority EEG but set the compliance date as routine.29 Nursing Performance Nursing performance in specialty services was excellent. Nurses evaluated all patients returning from off-site appointments and performed pertinent assessments and necessary interventions when needed. They communicated findings to the primary care team and ensured that the team had the information it needed to make appropriate decisions for the patient. Health Information Management Compliance testing showed that providers generally reviewed specialty reports in a timely manner (MIT 14.008, 100%-routine priority), (MIT 14.005, 85.7%-medium priority), (MIT 14.002, 73.3%-high priority) and CIM scanned specialty reports into the EHRS in a timely manner (MIT 4.002, 90.0%). Case review did not find any deficiency patterns in specialty health information management. There were five health information management deficiencies of different types: one delayed scan, one late retrieval, one incomplete report, and two late provider endorsements. Clinician On-Site Inspection We discussed health information management processes related to specialty services with CIM specialty supervisors. They expressed that there was difficulty obtaining off-site specialty appointments during the COVID-19 pandemic. However, at the time of the on-site inspection, CIM relayed that this difficulty had mostly been resolved. Staff indicated that the telemedicine specialty schedulers at the department have had backlogs for quite some time. 29 An EEG is an electroencephalogram used to monitor electrical activity in the brain to help diagnose seizures. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 75 Compliance Testing Results TTaabblele 1 188. .S Sppeecciaialtltyy S Seerrvviciceess 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 14 1 N/A 93.3% 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 N/A 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 10 2 3 83.3% 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 11 4 N/A 73.3% 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 12 2 1 85.7% 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 1 2 12 33.3% provider? (14.006) * Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician 12 3 N/A 80.0% 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 15 0 N/A 100% 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 4 2 9 66.7% provider? (14.009) * For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the 8 12 N/A 40.0% 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 20 0 N/A 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? 18 1 1 94.7% (14.012) Overall percentage (MIT 14): 77.0% * 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: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 76 Table 19. Other Tests Related to Specialty Services 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 33 8 4 80.5% visits occur within required time frames? (1.008) *, † Are specialty documents scanned into the patient’s electronic health 27 3 15 90.0% 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. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 77 Recommendations • Medical leadership should ascertain causes related to the untimely provision or scheduling of patients’ specialty service appointments and implement remedial measures as appropriate. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 78 Administrative Operations In this indicator, OIG compliance inspectors evaluated health care administrative processes. Our inspectors examined the timeliness of the medical grievance process Overall and checked whether the institution followed reporting requirements for adverse or Rating sentinel events and patient deaths. Inspectors checked whether the Emergency Adequate Medical Response Review Committee (EMRRC) met and reviewed incident packages. We investigated and determined whether the institution conducted the required Case Review emergency response drills. Inspectors also assessed whether the Quality Rating Management Committee (QMC) met regularly and addressed program performance (N/A) adequately. In addition, our inspectors determined whether the institution provided training and job performance reviews for its employees. We checked whether staff Compliance possessed current, valid professional licenses, certifications, and credentials. The Score OIG rated this indicator solely based on the compliance score, using the same Adequate scoring thresholds as in the Cycle 4 and Cycle 5 medical inspections. Our case review (80.6%) 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 CIM’s performance was mixed in this indicator. The institution scored well in some applicable tests. However, it needed improvement in several areas. The Emergency Medical Response Review Committee (EMRRC) did not always complete the required checklists. The committee conducted medical emergency response drills with incomplete documentation. Physician managers did not always complete probationary and annual performance appraisals in a timely manner. These findings are set forth in the table below. We rated this indicator adequate. Nonscored Results At CIM, 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 unexpected (Level 1) and seven expected (Level 2) deaths occurred during our review period. In our inspection, we found the DRC did not complete any death reviews promptly. The DRC finished two reports (Level 2) 16 and 25 days late and submitted them to the institution’s CEO 11 and 20 days late. The remaining eight reports (three Level 1 unexpected deaths and five Level 2 expected deaths) were overdue at the time of OIG’s inspection (MIT 15.998). Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 79 Compliance Testing Results TTaabbllee 2200.. AAddmmiinniissttrraattiivvee OOppeerraattiioonnss 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 N/A 83.3% monthly? (15.002) For Emergency Medical Response Review Committee (EMRRC) reviewed cases: Did the EMRRC review the cases timely, and did 6 6 N/A 50.0% 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 N/A N/A N/A N/A 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 0 3 0 0 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 9 1 0 90.0% to the CCHCS Death Review Unit on time? (15.103) Did nurse managers ensure the clinical competency of nurses who 10 0 0 100% administer medications? (15.104) Did physician managers complete provider clinical performance 7 9 1 43.8% appraisals timely? (15.105) Did the providers maintain valid state medical licenses? (15.106) 20 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 6 0 1 100% 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 1 0 0 100% 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): 80.6% * Effective March 2021, this test was for informational purposes only. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 80 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 81 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 CIM Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 82 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 Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 83 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: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 84 Figure A–2. Case Review Testing Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 85 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: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 86 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: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 87 Appendix B. Case Review Data Table B–1. CIM Case Review Sample Sets Sample Set Total Anticoagulation 3 Death Review / Sentinel Events 3 Diabetes 3 Emergency Services – CPR 5 Emergency Services – Non-CPR 3 High Risk 5 Hospitalization 4 Intrasystem Transfers In 3 Intrasystem Transfers Out 3 RN Sick Call 20 Specialty Services 4 56 Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 88 Table B–2. CIM Case Review Chronic Care Diagnoses Diagnosis Total Anemia 8 Anticoagulation 3 Arthritis/Degenerative Joint Disease 8 Asthma 3 COPD 6 COVID-19 10 Cancer 13 Cardiovascular Disease 13 Chronic Kidney Disease 4 Chronic Pain 3 Cirrhosis/End-Stage Liver Disease 4 Deep Venous Thrombosis/Pulmonary Embolism 2 Diabetes 11 Gastroesophageal Reflux Disease 12 Gastrointestinal Bleed 1 HIV 4 Hepatitis C 19 Hyperlipidemia 33 Hypertension 29 Mental Health 20 Migraine Headaches 1 Seizure Disorder 2 Sleep Apnea 7 Substance Abuse 21 Thyroid Disease 3 240 Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 89 Table B–3. CIM Case Review Events by Program Diagnosis Total Diagnostic Services 366 Emergency Care 37 Hospitalization 25 Intrasystem Transfers In 9 Intrasystem Transfers Out 4 Outpatient Care 368 Specialized Medical Housing 121 Specialty Services 114 1,044 Table B–4. CIM Case Review Sample Summary Total MD Reviews Detailed 25 MD Reviews Focused 0 RN Reviews Detailed 12 RN Reviews Focused 31 Total Reviews 68 Total Unique Cases 56 Overlapping Reviews (MD & RN) 12 Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 90 Appendix C. Compliance Sampling Methodology California Institution for Men 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 10 Quest • Appt. date (90 days–9 months) • Order name (CBC or CMPs only) • Randomize • Abnormal MITs 2.010–012 Pathology 10 InterQual • Appt. date (90 days–9 months) • Service (pathology related) • Randomize Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 91 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 11 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 1 OIG inspector • R&R IP transfers with medication on-site review Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 92 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 8 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 10 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: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 93 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 25 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 (45 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 N/A at this Cocci transfer • Reports from past 2–8 months institution status report • Institution • Ineligibility date (60 days prior to inspection date) • All Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 94 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: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 95 MIT 14.010 Specialty Services 20 Specialty Services • Arrived from (other departmental Arrivals Arrivals institution) • Date of transfer (3–9 months) • Randomize MITs 14.011–012 Denials 20 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: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 96 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 N/A at this LGB meeting • Quarterly meeting minutes institution 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 10 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 17 On-site • All required performance Evaluation Packets provider evaluation documents evaluation files MIT 15.106 Provider Licenses 20 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: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 97 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 10 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: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 98 This page left blank for reproduction purposes. Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6, California Institution for Men | 99 California Correctional Health Care Services’ Response  
 

        April 19, 2023 Amarik Singh, Inspector General Office of the Inspector General 10111 Old Placerville Road, Suite 110 Sacramento, CA 95827 Dear Ms. Singh: The Office of the Receiver has reviewed the draft Medical Inspection Report for California Institution for Men (CIM) conducted by the Office of the Inspector General (OIG) from September 2021 to February 2022. California Correctional Health Care Services (CCHCS) acknowledges the OIG findings. Thank you for preparing the report. Your efforts have advanced our mutual objective of ensuring transparency and accountability in CCHCS operations. If you have any questions or concerns, please contact me at (916) 896-6780. Sincerely, DeAnna Gouldy Deputy Director Policy and Risk Management Services California Correctional Health Care Services cc: Clark Kelso, Receiver Diana Toche, D.D.S., Undersecretary, Health Care Services, CDCR Directors, CCHCS Roscoe Barrow, Chief Counsel, CCHCS Office of Legal Affairs Renee Kanan, M.D., Deputy Director, Medical Services, CCHCS Barbara Barney-Knox, R.N., Deputy Director, Nursing Services, CCHCS Annette Lambert, Deputy Director, Quality Management, CCHCS Robin Hart, Associate Director, Risk Management Branch, CCHCS Regional Executives, Region IV, CCHCS Chief Executive Officer, CIM Katherine Tebrock, Chief Assistant Inspector General, OIG Doreen Pagaran, R.N., Nurse Consultant Program Review, OIG Misty Polasik, Staff Services Manager I, OIG P.O. Box 588500 Elk Grove, CA 95758 Office of the Inspector General, State of California Inspection Period: October 2021 – March 2022 Report Issued: May 2023 Cycle 6 Medical Inspection Report for The California Institution for Men OFFICE of the INSPECTOR GENERAL Amarik K. Singh Inspector General Neil Robertson Chief Deputy Inspector General STATE of CALIFORNIA May 2023 OIG