California Institution for Men Medical Inspection Report Cycle 4

Robert A. Barton Office of the Inspector General Inspector General California Institution for Men Medical Inspection Results Cycle 4 April 2016 Medical Inspection Unit Page 1 Office of the Inspector General State of California Office of the Inspector General CALIFORNIA INSTITUION FOR MEN Medical Inspection Results Cycle 4 Robert A. Barton Inspector General Roy W. Wesley Chief Deputy Inspector General Shaun R. Spillane Public Information Officer April 2016 TABLE OF CONTENTS Executive Summary ............................................................................................................................. i Overall Assessment: Adequate .............................................................................................. iii Clinical Case Review and OIG Clinician Inspection Results ............................................... iii Compliance Testing Results.................................................................................................. iv Population-Based Metrics ..................................................................................................... ix Introduction ......................................................................................................................................... 1 About the Institution ........................................................................................................................... 1 Objectives, Scope, and Methodology.................................................................................................. 5 Case Reviews ................................................................................................................................... 6 Patient Selection for Retrospective Case Reviews .................................................................... 6 Benefits and Limitations of Targeted Subpopulation Review .................................................. 7 Case Reviews Sampled ............................................................................................................. 8 Compliance Testing ......................................................................................................................... 9 Sampling Methods for Conducting Compliance Testing .......................................................... 9 Scoring of Compliance Testing Results .................................................................................... 9 Dashboard Comparisons ......................................................................................................... 10 Overall Quality Indicator Rating for Case Reviews and Compliance Testing .............................. 11 Population-Based Metrics .............................................................................................................. 11 Medical Inspection Results ............................................................................................................... 12 Primary (Clinical) Quality Indicators of Health Care .................................................................... 12 Access to Care ......................................................................................................................... 13 Case Review Results ............................................................................................................ 13 Compliance Testing Results................................................................................................. 13 Recommendations ................................................................................................................ 14 Diagnostic Services ................................................................................................................. 15 Case Review Results ............................................................................................................ 15 Compliance Testing Results................................................................................................. 15 Recommendations ................................................................................................................ 16 Emergency Services................................................................................................................. 17 Case Review Results ............................................................................................................ 17 Recommendations ................................................................................................................ 19 Health Information Management (Medical Records) ............................................................. 20 Case Review Results ............................................................................................................ 20 Compliance Testing Results................................................................................................. 21 Recommendations ................................................................................................................ 23 Health Care Environment ....................................................................................................... 24 Compliance Testing Results................................................................................................. 24 Recommendations ................................................................................................................ 27 Inter- and Intra-System Transfers ........................................................................................... 28 Case Review Results ............................................................................................................ 28 Compliance Testing Results................................................................................................. 29 Recommendations ................................................................................................................ 30 California Institution for Men, Cycle 4 Medical Inspection Table of Contents Office of the Inspector General State of California Pharmacy and Medication Management ................................................................................ 31 Case Review Results ............................................................................................................ 31 Compliance Testing Results................................................................................................. 32 Recommendations ................................................................................................................ 35 Preventive Services ................................................................................................................. 36 Compliance Testing Results................................................................................................. 36 Recommendations ................................................................................................................ 37 Quality of Nursing Performance ............................................................................................. 38 Case Review Results ............................................................................................................ 38 Recommendations ................................................................................................................ 39 Quality of Provider Performance ............................................................................................ 40 Case Review Results ............................................................................................................ 40 Recommendations ................................................................................................................ 42 Reception Center Arrivals ....................................................................................................... 43 Case Review Results ............................................................................................................ 43 Compliance Testing Results................................................................................................. 43 Recommendation ................................................................................................................. 44 Specialized Medical Housing (OHU, CTC, SNF, Hospice) .................................................... 45 Case Review Results ............................................................................................................ 45 Compliance Testing Results................................................................................................. 47 Recommendations ................................................................................................................ 47 Specialty Services .................................................................................................................... 48 Case Review Results ............................................................................................................ 48 Compliance Testing Results................................................................................................. 49 Recommendations ................................................................................................................ 50 Secondary (Administrative) Quality Indicators of Health Care..................................................... 51 Internal Monitoring, Quality Improvement, and Administrative Operations ......................... 52 Compliance Testing Results................................................................................................. 52 Recommendations ................................................................................................................ 54 Job Performance, Training, Licensing, and Certifications ..................................................... 55 Compliance Testing Results................................................................................................. 55 Recommendations ................................................................................................................ 56 Population-Based Metrics .............................................................................................................. 57 Appendix A — Compliance Test Results ......................................................................................... 60 Appendix B — Clinical Data ............................................................................................................ 75 Appendix C — Compliance Sampling Methodology ....................................................................... 78 California Correctional Health Care Services’ Response ................................................................. 83 California Institution for Men, Cycle 4 Medical Inspection Table of Contents Office of the Inspector General State of California LIST OF TABLES AND FIGURES Health Care Quality Indicators ........................................................................................................... ii CIM Executive Summary Table ...................................................................................................... viii CIM Health Care Staffing Resources as of November 2015 ............................................................... 2 CIM Master Registry Data as of November 2, 2015 ........................................................................... 3 Commonly Used Abbreviations .......................................................................................................... 4 CIM Results Compared to State and National HEDIS Scores .......................................................... 59 California Institution for Men, Cycle 4 Medical Inspection List of Tables and Figures Office of the Inspector General State of California EXECUTIVE SUMMARY Under the authority of California Penal Code Section 6126, which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), the OIG conducts a comprehensive inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG explicitly makes no determination regarding the constitutionality of care in the prison setting. That determination is left to the Receiver and the federal court. The assessment of care by the OIG is just one factor in the court’s determination whether care in the prisons meets constitutional standards. The court may find that an institution that the OIG found to be providing adequate care still does not meet constitutional standards, depending on the analysis of the underlying data provided by the OIG. Likewise, an institution that has been rated inadequate by the OIG could still be found to pass constitutional muster with the implementation of remedial measures if the underlying data were to reveal easily mitigated deficiencies. The OIG’s inspections are mandated by the Penal Code and not aimed at specifically resolving the court’s questions on constitutional care. To the degree that they provide another factor for the court to consider, the OIG is pleased to provide added value to the taxpayers of California. For this fourth cycle of inspections, the OIG added a clinical case review component and significantly enhanced the compliance portion of the inspection process from that used in prior cycles. In addition, the OIG added a population-based metric comparison of selected Healthcare Effectiveness Data Information Set (HEDIS) measures from other State and national health care organizations and compared that data to similar results for the California Institution for Men (CIM). The OIG performed its Cycle 4 medical inspection at CIM from November 2015 to January 2016. The inspection included in-depth reviews of 71 inmate-patient files conducted by clinicians, as well as reviews of documents from 459 inmate-patient files, covering 100 objectively scored tests of compliance with policies and procedures applicable to the delivery of medical care. The OIG assessed the case review and compliance results at CIM using 15 health care quality indicators applicable to the institution, made up of 13 primary clinical indicators and two secondary administrative indicators. To conduct clinical case reviews, the OIG employs a clinician team consisting of a physician and a registered nurse consultant, while compliance testing is done by a team of deputy inspectors general trained in monitoring medical compliance. Of the 13 primary indicators, eight were rated by both case review clinicians and compliance inspectors, three were rated by case review clinicians only, and two were rated by compliance inspectors only; both secondary indicators were rated by compliance inspectors only. See the Health Care Quality Indicators table on page ii. Based on that analysis, OIG experts made a considered and measured overall opinion that the quality of health care at CIM was adequate. California Institution for Men, Cycle 4 Medical Inspection Page i Office of the Inspector General State of California Health Care Quality Indicators All Institutions– Fourteen Primary Indicators (Clinical) CIM Applicability Applicability Both case review 1–Access to Care All institutions and compliance Both case review 2–Diagnostic Services All institutions and compliance 3–Emergency Services All institutions Case review only 4–Health Information Management Both case review All institutions (Medical Records) and compliance 5–Health Care Environment All institutions Compliance only Both case review 6–Inter- and Intra-System Transfers All institutions and compliance Both case review 7–Pharmacy and Medication Management All institutions and compliance Female institutions 8–Prenatal and Post-Delivery Services Not Applicable only 9–Preventive Services All institutions Compliance only 10–Quality of Nursing Performance All institutions Case review only 11–Quality of Provider Performance All institutions Case review only Institutions with Both case review 12–Reception Center Arrivals reception centers and compliance All institutions with 13–Specialized Medical Housing Both case review an OHU, CTC, SNF, (OHU, CTC, SNF, Hospice) and compliance or Hospice Both case review 14–Specialty Services All institutions and compliance Two Secondary Indicators All Institutions– CIM Applicability (Administrative) Applicability 15–Internal Monitoring, Quality Improvement, and Administrative All institutions Compliance only Operations 16–Job Performance, Training, Licensing, All institutions Compliance only and Certifications California Institution for Men, Cycle 4 Medical Inspection Page ii Office of the Inspector General State of California Overall Assessment: Adequate Based on the clinical case reviews and compliance testing, the OIG’s overall assessment rating for CIM was adequate. Of the Overall Assessment 13 primary (clinical) quality indicators applicable to CIM, the Rating: OIG found three proficient, nine adequate, and one inadequate. Of the two secondary (administrative) quality indicators, the OIG Adequate found both adequate. To determine the overall assessment for CIM, the OIG considered individual clinical ratings and individual compliance question scores within each of the indicator categories, putting emphasis on the primary indicators. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed at CIM. Clinical Case Review and OIG Clinician Inspection Results The clinicians’ case reviews sampled patients with high medical needs and included a review of more than 1,783 patient care events.1 Of the 13 primary indicators applicable to CIM, 11 were evaluated by clinician case review; two were proficient, and nine were adequate. When determining the overall adequacy of care, the OIG paid particular attention to the clinical nursing and provider quality indicators, as adequate health care staff can sometimes overcome suboptimal processes and programs. However, the opposite is not true; inadequate health care staff cannot provide adequate care, even though the established processes and programs onsite may be adequate. The OIG clinicians identify inadequate medical care based on the risk of significant harm to the patient, not the actual outcome. Program Strengths — Clinical  Providers at CIM reported medical leadership to be very supportive and approachable.  CIM provided excellent access to primary care services.  CIM provided excellent diagnostic services, with diagnostic tests being performed, results being reviewed by providers, and patients being notified of results in a timely manner.  The daily provider meetings, as well as the morning huddles, were informative, pertinent, and effective in relaying necessary information. 1 Each OIG clinician team includes a board-certified physician and registered nurse consultant with experience in correctional and community medical settings. California Institution for Men, Cycle 4 Medical Inspection Page iii Office of the Inspector General State of California Program Weaknesses — Clinical  Due to recent staffing model changes that removed yard nurses from certain weekend and holiday shifts, and the unique layout of CIM, the risk of inadequate treatment and triage emergency response times was increased.  Certain emergency supplies and medications were not available in every yard.  Pharmacy coverage on weekends was problematic, with delays in the administration of some hospital discharge medications upon patients’ return to CIM. Compliance Testing Results Of the 15 total health care indicators applicable to CIM, 12 were evaluated by compliance inspectors.2 There were 100 individual compliance questions within those 12 indicators, generating 1,506 data points, which tested CIM’s compliance with California Correctional Health Care Services (CCHCS) policies and procedures.3 Those 100 questions are detailed in Appendix A — Compliance Test Results. The institution’s inspection scores in the 12 applicable indicators ranged from 59.6 percent to 100 percent, with the primary (clinical) indicator Health Information Management receiving the lowest score, and the primary indicator Specialized Medical Housing (OHU, CTC, SNF, Hospice) receiving the highest. Of the ten primary indicators applicable to compliance testing, the OIG rated six proficient, three adequate, and one inadequate. Of the two secondary indicators, which involve administrative health care functions, both were rated adequate. Program Strengths — Compliance As the CIM Executive Summary Table on page viii indicates, the institution’s compliance ratings were proficient in the following six indicators: Specialized Medical Housing (OHU, CTC, SNF, Hospice) (100 percent), Inter- and Intra-System Transfers (92.0 percent), Diagnostic Services (88.9 percent), Preventive Services (88.9 percent), Specialty Services (88.9 percent), and Access to Care (87.7 percent). The following are some of CIM’s strengths based on its compliance scores on individual questions in all the primary health care indicators:  Patients had a standardized process to obtain and submit request forms for health care services, and nursing staff timely reviewed patients’ requests and timely completed face-to-face visits with patients.  Providers conducted timely follow-up appointments for chronic care patients and those who were released from a community hospital and returned to the institution. 2 The OIG’s compliance inspectors are trained deputy inspectors general with expertise in CDCR policies regarding medical staff and processes. 3 The OIG used its own clinicians to provide clinical expert guidance for testing compliance in certain areas where CCHCS policies and procedures did not specifically address an issue. California Institution for Men, Cycle 4 Medical Inspection Page iv Office of the Inspector General State of California  CIM provided patients with timely radiology and laboratory services, timely reviewed reports, and timely communicated the results to patients.  Specialty reports were timely scanned into patients medical records.  Clinical areas were appropriately disinfected, cleaned, and sanitary.  For inmate-patients newly arriving at CIM from other CDCR institutions or county jails via CIM’s reception center, nursing staff properly documented an assessment and disposition of the Initial Health Screening form (CDCR Form 7277) and signed and dated the form on the same day the inmate arrived at the institution.  Nursing staff ensured patients transferred from CIM to other institutions with complete transfer packets and all applicable medications.  Nursing staff timely administered or delivered patients’ new order medications, and ensured that patients transferring from one housing unit to another received their medications without interruption.  Nurses employed appropriate administrative controls and followed proper protocols while preparing patients’ medications.  In its clinics and main pharmacy, CIM properly stored and monitored non-refrigerated medications and properly accounted for narcotics.  CIM’s main pharmacy followed general security, organization, and cleanliness management protocols.  The institution offered or provided patients with timely preventive medical services.  Patients who arrived at the CIM reception center from non-CDCR facilities, such as county jails, received timely PCP health assessments and timely completion and communication of required intake screening tests.  For patients admitted to CIM’s onsite OHU, nursing staff and providers completed timely assessments upon admission and at required intervals thereafter.  The institution’s outpatient housing unit had properly working call buttons and medical staff had timely access to enter patient cells during emergent events.  Inmate-patients timely received their high-priority and routine specialty services. Also, the institution denied provider requests for specialty services within the required time frame. California Institution for Men, Cycle 4 Medical Inspection Page v Office of the Inspector General State of California The following are some of the strengths identified within the two secondary administrative indicators:  CIM timely processed inmate-patient medical appeals and addressed all appealed issues.  The Quality Management Committee met monthly, evaluated program performance and took action when improvement opportunities were identified, and took adequate steps to ensure the accuracy of its Dashboard data reporting.  The institution followed reporting requirements for inmate deaths that occurred in the prior 12 months.  All providers, nursing staff, and the pharmacist-in-charge were current with their professional licenses and certifications; the pharmacy and authorized providers who prescribe controlled substances maintained current Drug Enforcement Agency registrations.  All providers received complete clinical performance appraisals, and all nursing staff who administered medications possessed current clinical competency validations.  Nursing staff hired within the last year timely received new employee orientation training. Program Weaknesses — Compliance The institution received a rating of inadequate in the primary indicator Health Information Management (Medical Records) (59.6 percent). The following are some of the weaknesses identified by CIM’s compliance scores on individual questions in all the primary health care indicators:  CIM did not timely receive final pathology reports or timely communicate the results to patients.  Health records staff often failed to timely scan initial health screening forms, health service request forms, or transcribed provider notes into patients’ electronic health records, and did not always properly label or file them.  Several clinics were lacking core equipment and essential supplies in the common areas and exam rooms and they did not always have an environment conducive to providing adequate medical services.  Nursing staff did not always timely administer medications to patients who had a temporary layover at CIM while en route from one institution to another, or to patients who recently arrived at CIM from a county jail and for whom a CIM provider had ordered medication upon their arrival. California Institution for Men, Cycle 4 Medical Inspection Page vi Office of the Inspector General State of California  The main pharmacy, in addition to most clinics, did not properly store medications that required refrigeration; for example, some medications were stored at temperatures below the acceptable range.  Nursing staff did not always follow proper protocols when providing tuberculosis screenings to reception center patients or to patients requiring annual preventive measures; reception center patients did not receive timely coccidioidomycosis (valley fever) screenings.  Providers did not provide timely specialty service appointments to many sampled patients who transferred into CIM from other institutions with previously approved or scheduled appointments. The following are some of the weaknesses identified within the two secondary administrative indicators:  CIM did not ensure that emergency medical response drills in the prior quarter included all required information, or that custody managers were current with their emergency response certifications.  Nursing supervisors completed insufficient reviews of nursing staff by failing to discuss the performance results with employees. The CIM Executive Summary Table on the following page lists the quality indicators the OIG inspected and assessed during the clinical case reviews and objective compliance tests, and provides the institution’s rating in each area. The overall indicator ratings were based on a consensus decision by the OIG’s clinicians and non-clinical inspectors. California Institution for Men, Cycle 4 Medical Inspection Page vii Office of the Inspector General State of California CIM Executive Summary Table Case Compliance Overall Indicator Primary Indicators (Clinical) Review Rating Rating Rating Access to Care Proficient Proficient Proficient Diagnostic Services Proficient Proficient Proficient Emergency Services Adequate Not Applicable Adequate Health Information Management Adequate Inadequate Inadequate (Medical Records) Health Care Environment Not Applicable Adequate Adequate Inter- and Intra-System Transfers Adequate Proficient Adequate Pharmacy and Medication Management Adequate Adequate Adequate Preventive Services Not Applicable Proficient Proficient Quality of Nursing Performance Adequate Not Applicable Adequate Quality of Provider Performance Adequate Not Applicable Adequate Reception Center Arrivals Adequate Adequate Adequate Specialized Medical Housing Adequate Proficient Adequate (OHU, CTC, SNF, Hospice) Specialty Services Adequate Proficient Adequate The Prenatal and Post-Delivery Services indicator did not apply to this institution. Compliance Overall Indicator Secondary Indicators (Administrative) Rating Rating Internal Monitoring, Quality Improvement, Not Applicable Adequate Adequate and Administrative Operations Job Performance, Training, Licensing, and Not Applicable Adequate Adequate Certifications Compliance results for quality indicators are proficient (greater than 85.0 percent), adequate (75.0 percent to 85.0 percent), or inadequate (below 75.0 percent). California Institution for Men, Cycle 4 Medical Inspection Page viii Office of the Inspector General State of California Population-Based Metrics In general, CIM performed well for population-based metrics. In comprehensive diabetes care measures, CIM outperformed other State and national organizations in all diabetic measures. With regard to influenza immunizations, CIM outperformed Kaiser Permanente, commercial entities, and the US Department of Veterans Affairs (VA). For administering pneumococcal vaccinations, CIM performed better than Medicare, but not as well as the VA. For colorectal cancer screenings, CIM scored higher than commercial plans and Medicare, but lower than Kaiser and the VA. However, for both pneumococcal vaccinations and cancer screenings, patient refusals negative impacted the institution’s comparative metric score. CIM could improve its comparative score by reducing the number of patient refusals through patient education. Overall, CIM’s comparative population-based metrics indicate that its comprehensive diabetes care and preventive services programs are functioning very well in comparison to other State and national health care organizations. California Institution for Men, Cycle 4 Medical Inspection Page ix Office of the Inspector General State of California INTRODUCTION Under the authority of California Penal Code Section 6126, which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), and at the request of the federal Receiver, the OIG developed a comprehensive medical inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. For this fourth cycle of inspections, the OIG augmented the breadth and quality of its inspection program used in prior cycles, adding a clinical case review component and significantly enhancing the compliance component of the program. The California Institution for Men was the 15th medical inspection of Cycle 4. During the inspection process, the OIG assessed the delivery of medical care to patients for 13 primary clinical health care indicators and two secondary administrative health care indicators applicable to the institution. It is important to note that while the primary quality indicators represent the clinical care being provided by the institution at the time of the inspection, the secondary quality indicators are purely administrative and are not reflective of the actual clinical care provided. The OIG is committed to reporting on each institution’s delivery of medical care to assist in identifying areas for improvement, but the federal court will ultimately determine whether any institution’s medical care meets constitutional standards. ABOUT THE INSTITUTION The California Institution for Men is a large complex consisting of four separate facilities: Facility A and Facility C primarily house Level II sensitive needs yard custody inmates; Facility D houses general population inmates and is designated as a Secure Level I; Facility B houses medium and maximum custody level inmates and also serves as a reception center receiving and processing male inmates who have been newly committed to CDCR, primarily from Riverside and San Diego Counties. The Reception Center completes diagnostic tests, medical/mental health screenings, and literacy assessments for classification in order to determine the inmates’ appropriate institutional placements. Beside the Reception Center, the institution runs six medical clinics where staff handle non-urgent requests for medical services, and it treats inmates needing urgent or emergency care in the triage and treatment area (TTA). CIM also treats patients who require assistance with the activities of daily living but who do not require a higher level of inpatient care in the institution’s outpatient housing unit (OHU). CIM has been designated as an “intermediate care prison”; these institutions are predominantly located in urban areas close to tertiary care centers and specialty care providers, for the most cost-effective care. At the time of the inspection, CIM had not yet received a review from the Commission on Accreditation for Corrections, a professional peer review process based on national standards set by the American Correctional Association. The institution’s first review is planned for April 2016. California Institution for Men, Cycle 4 Medical Inspection Page 1 Office of the Inspector General State of California Based on unaudited staffing data reported by the institution, CIM’s vacancy rate among licensed medical managers, primary care providers (PCPs), supervisors, and nonsupervisory nurses was approximately 7 percent in November 2015, with the highest vacancy percentages among nursing staff at 8 percent. Based on the reported data, CIM had 12.3 vacant nursing positions and nine additional nursing staff who were on long-term medical leave, as well as one redirected nurse. However, to help offset the staffing void, the institution employed 17 registry nurses. CIM’s CEO also reported that as of November 2015, there were six medical staff members who were recently under disciplinary review. Of the six, the department dismissed two and the remaining four had their reviews completed and were working in the institution’s clinical settings. CIM Health Care Staffing Resources as of November 2015 Primary Care Nursing Management Nursing Staff Totals Providers Supervisors Description Number % Number % Number % Number % Number % Authorized 4 2% 20.5 11% 14 7% 154.5 80% 193 100% Positions Filled Positions 4 100% 20 98% 14 100% 142.2 92% 180.2 93% Vacancies 0 0% 0.5 2% 0 0% 12.3 8% 12.8 7% Recent Hires 0 0% 5 25% 1 7% 19 13% 25 14% (within 12 months) Staff Utilized from 0 0% 0 0% 0 0% 17 12% 17 9% Registry Redirected Staff (to Non-Patient 0 0% 0 0% 0 0% 1 0.7% 1 0.6% Care Areas) Staff on Long-term 0 0% 0 0% 0 0% 9 6% 9 5% Medical Leave Note: CIM’s Health Care Staffing Resources data was not validated by the OIG. California Institution for Men, Cycle 4 Medical Inspection Page 2 Office of the Inspector General State of California As of November 2, 2015, the Master Registry for CIM showed that the institution had 3,576 inmate-patients. Within that total population, 20.6 percent were designated High-Risk, Priority 1 (High 1), and 30.5 percent were designated High-Risk, Priority 2 (High 2). Patients’ assigned risk levels are based on the complexity of their required medical care related to their specific diagnoses, frequency of higher levels of care, age, and abnormal labs and procedures. High 1 has at least two high-risk conditions; High 2 has only one. High-risk patients are more susceptible to poor health outcomes than medium- or low-risk patients. High-risk patients also typically require more health care services than do patients with lower assigned risk levels. The chart below illustrates the breakdown of the institution’s medical risk levels at the start of the OIG medical inspection. CIM Master Registry Data as of November 2, 2015 Medical Risk Level # of Inmate-Patients Percentage High 1 738 20.6% High 2 1,089 30.5% Medium 1,050 29.4% Low 699 19.5% Total 3,576 100.0% California Institution for Men, Cycle 4 Medical Inspection Page 3 Office of the Inspector General State of California Commonly Used Abbreviations ACLS Advanced Cardiovascular Life Support HIV Human Immunodeficiency Virus AHA American Heart Association HTN Hypertension ASU Administrative Segregation Unit INH Isoniazid (anti-tuberculosis medication) BLS Basic Life Support IV Intravenous CBC Complete Blood Count KOP Keep-on-Person (in taking medications) CC Chief Complaint LPT Licensed Psychiatric Technician CCHCS California Correctional Health Care Services LVN Licensed Vocational Nurse CCP Chronic Care Program MAR Medication Administration Record California Department of Corrections and CDCR MRI Magnetic Resonance Imaging Rehabilitation CEO Chief Executive Officer MD Medical Doctor CHF Congestive Heart Failure NA Nurse Administered (in taking medications) CME Chief Medical Executive N/A Not Applicable CMP Comprehensive Metabolic (Chemistry) Panel NP Nurse Practitioner CNA Certified Nursing Assistant OB Obstetrician CNE Chief Nurse Executive OHU Outpatient Housing Unit C/O Complains of OIG Office of the Inspector General COPD Chronic Obstructive Pulmonary Disease P&P Policies and Procedures (CCHCS) CP&S Chief Physician and Surgeon PA Physician Assistant CPR Cardio-Pulmonary Resuscitation PCP Primary Care Provider CSE Chief Support Executive POC Point of Contact CT Computerized Tomography PPD Purified Protein Derivative CTC Correctional Treatment Center PRN As Needed (in taking medications) DM Diabetes Mellitus RN Registered Nurse Directly Observed Therapy (in taking DOT Rx Prescription medications) Dx Diagnosis SNF Skilled Nursing Facility Subjective, Objective, Assessment, Plan, EKG Electrocardiogram SOAPE Education ENT Ear, Nose and Throat SOMS Strategic Offender Management System ER Emergency Room S/P Status Post eUHR electronic Unit Health Record TB Tuberculosis FTF Face-to-Face TTA Triage and Treatment Area History and Physical (reception center H&P UA Urinalysis examination) HIM Health Information Management UM Utilization Management California Institution for Men, Cycle 4 Medical Inspection Page 4 Office of the Inspector General State of California OBJECTIVES, SCOPE, AND METHODOLOGY In designing the medical inspection program, the OIG reviewed CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. The OIG also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the Receiver’s office, CDCR, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of the OIG’s inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates medical care delivery by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population-based metrics. To maintain a metric-oriented inspection program that evaluates medical care delivery consistently at each State prison, the OIG identified 14 primary (clinical) and two secondary (administrative) quality indicators of health care to measure. The primary quality indicators cover clinical categories directly relating to the health care provided to patients, whereas the secondary quality indicators address the administrative functions that support a health care delivery system. The 14 primary quality indicators are Access to Care, Diagnostic Services, Emergency Services, Health Information Management (Medical Records), Health Care Environment, Inter- and Intra-System Transfers, Pharmacy and Medication Management, Prenatal and Post-Delivery Services, Preventive Services, Quality of Nursing Performance, Quality of Provider Performance, Reception Center Arrivals, Specialized Medical Housing (OHU, CTC, SNF, Hospice), and Specialty Services. The two secondary quality indicators are Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications. The OIG rates each of the quality indicators applicable to the institution under inspection based on case reviews conducted by OIG clinicians and compliance tests conducted by OIG deputy inspectors general. The ratings may be derived from the case review results alone, the compliance test results alone, or a combination of both these information sources. For example, the ratings for the primary quality indicators Quality of Nursing Performance and Quality of Provider Performance are derived entirely from the case review results, while the ratings for the primary quality indicators Health Care Environment and Preventive Services are derived entirely from compliance test results. As another example, primary quality indicators such as Diagnostic Services and Specialty Services receive ratings derived from both sources. At CIM, 15 of the quality indicators were applicable, consisting of 13 primary clinical indicators and two secondary administrative indicators. Of the 13 primary indicators, eight were rated by both case review clinicians and compliance inspectors, three were rated by case review clinicians only, and two were rated by compliance inspectors only; both secondary indicators were rated by compliance inspectors only. California Institution for Men, Cycle 4 Medical Inspection Page 5 Office of the Inspector General State of California Consistent with the OIG’s agreement with the Receiver, this report only addresses the conditions found related to medical care criteria. The OIG does not review for efficiency and economy of operations. Moreover, if the OIG learns of an inmate-patient needing immediate care, the OIG notifies the chief executive officer of health care services and requests a status report. Additionally, if the OIG learns of significant departures from community standards, it may report such departures to the institution’s chief executive officer or to CCHCS. Because these matters involve confidential medical information protected by State and federal privacy laws, specific identifying details related to any such cases are not included in the OIG’s public report. In all areas, the OIG is alert for opportunities to make appropriate recommendations for improvement. Such opportunities may be present regardless of the score awarded to any particular quality indicator; therefore, recommendations for improvement should not necessarily be interpreted as indicative of deficient medical care delivery. CASE REVIEWS The OIG has added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders. At the conclusion of Cycle 3, the federal Receiver and the Inspector General determined that the health care provided at the institutions was not fully evaluated by the compliance tool alone, and that the compliance tool was not designed to provide comprehensive qualitative assessments. Accordingly, the OIG added case reviews in which OIG physicians and nurses evaluate selected cases in detail to determine the overall quality of health care provided to the inmate-patients. The OIG’s clinicians perform a retrospective chart review of selected patient files to evaluate the care given by an institution’s primary care providers and nurses. Retrospective chart review is a well-established review process used by health care organizations that perform peer reviews and patient death reviews. Currently, CCHCS uses retrospective chart review as part of its death review process and in its pattern-of-practice reviews. CCHCS also uses a more limited form of retrospective chart review when performing appraisals of individual primary care providers. PATIENT SELECTION FOR RETROSPECTIVE CASE REVIEWS Because retrospective chart review is time consuming and requires qualified health care professionals to perform it, OIG clinicians must carefully sample patient records. Accordingly, the group of patients the OIG targeted for chart review carried the highest clinical risk and utilized the majority of medical services. A majority of the patients selected for retrospective chart review were classified by CCHCS as high-risk patients. The reason the OIG targeted these patients for review is twofold: 1. The goal of retrospective chart review is to evaluate all aspects of the health care system. Statewide, high-risk and high-utilization patients consume medical services at a disproportionate rate; 11 percent of the total patient population are considered high-risk and California Institution for Men, Cycle 4 Medical Inspection Page 6 Office of the Inspector General State of California account for more than half of the institution’s pharmaceutical, specialty, community hospital, and emergency costs. 2. Selecting this target group for chart review provides a significantly greater opportunity to evaluate all the various aspects of the health care delivery system at an institution. Underlying the choice of high-risk patients for detailed case review, the OIG clinical experts made the following three assumptions: 1. If the institution is able to provide adequate clinical care to the most challenging patients with multiple complex and interdependent medical problems, it will be providing adequate care to patients with less complicated health care issues. Because clinical expertise is required to determine whether the institution has provided adequate clinical care, the OIG utilizes experienced correctional physicians and registered nurses to perform this analysis. 2. The health of less complex patients is more likely to be affected by processes such as timely appointment scheduling, medication management, routine health screening, and immunizations. To review these processes, the OIG simultaneously performs a broad compliance review. 3. Patient charts generated during death reviews, sentinel events (unexpected occurrences involving death or serious injury, or risk thereof), and hospitalizations are mostly of high-risk patients. BENEFITS AND LIMITATIONS OF TARGETED SUBPOPULATION REVIEW Because the selected patients utilize the broadest range of services offered by the health care system, the OIG’s retrospective chart review provides adequate data for a qualitative assessment of the most vital system processes (referred to as “primary quality indicators”). Retrospective chart review provides an accurate qualitative assessment of the relevant primary quality indicators as applied to the targeted subpopulation of high-risk and high-utilization patients. While this targeted subpopulation does not represent the prison population as a whole, the ability of the institution to provide adequate care to this subpopulation is a crucial and vital indicator of how the institution provides health care to its whole patient population. Simply put, if the institution’s medical system does not adequately care for those patients needing the most care, then it is not fulfilling its obligations, even if it takes good care of patients with less complex medical needs. Since the targeted subpopulation does not represent the institution’s general prison population, the OIG cautions against inappropriate extrapolation of conclusions from the retrospective chart reviews to the general population. For example, if the high-risk diabetic patients reviewed have poorly-controlled diabetes, one cannot conclude that the entire diabetic population is inadequately controlled. Similarly, if the high-risk diabetic patients under review have poor outcomes and require significant specialty interventions, one cannot conclude that the entire diabetic population is having similarly poor outcomes. California Institution for Men, Cycle 4 Medical Inspection Page 7 Office of the Inspector General State of California Nonetheless, the health care system’s response to this subpopulation can be accurately evaluated and yields valuable systems information. In the above example, if the health care system is providing appropriate diabetic monitoring, medication therapy, and specialty referrals for the high-risk patients reviewed, then it can be reasonably inferred that the health care system is also providing appropriate diabetic services to the entire diabetic subpopulation. However, if these same high-risk patients needing monitoring, medications, and referrals are generally not getting those services, it is likely that the health care system is not providing appropriate diabetic services to the greater diabetic subpopulation. CASE REVIEWS SAMPLED As indicated in Appendix B, Table B–1, CIM Sample Sets, the OIG clinicians evaluated medical charts for 71 unique inmate-patients. Appendix B, Table B–4, CIM Case Review Sample Summary, clarifies that both nurses and physicians reviewed charts for 12 of those patients, for 83 reviews in total. Physicians performed detailed reviews of 30 charts, and nurses performed detailed reviews of 16 charts, totaling 46 detailed reviews. For detailed case reviews, physicians or nurses looked at all encounters occurring in approximately six months of medical care. Nurses also performed a limited or focused review of medical records for an additional 37 inmate-patients. These generated 1,783 clinical events for review (Appendix B, Table B-3, CIM Event-Program). The reporting format provides details on whether the encounter was adequate or had significant deficiencies, and identifies deficiencies by programs and processes to help the institution focus on improvement areas. While the sample method specifically pulled only six chronic care patient records, i.e., three diabetes patients and three anticoagulation patients (Appendix B, Table B–1,CIM Sample Sets), the 71 unique inmate-patients sampled included patients with 245 chronic care diagnoses, including 16 additional patients with diabetes (for a total of 19) and four anticoagulation patients (for a total of seven) (Appendix B, Table B–2, CIM Chronic Care Diagnoses). The OIG’s sample selection tool evaluated many chronic care programs because the complex and high-risk patients selected from the different categories often had multiple medical problems. While the OIG did not evaluate every chronic disease or health care staff member, the overall operation of the institution’s system and staff were assessed for adequacy. The OIG’s case review methodology and sample size matched other qualitative research. The empirical findings, supported by expert statistical consultants, showed adequate conclusions after 10 to 15 charts had undergone full clinician review. In qualitative statistics, this phenomenon is known as “saturation.” The OIG asserts that the sample size of over 30 detailed reviews certainly far exceeds the saturation point necessary for an adequate qualitative review. With regard to reviewing charts from different providers, the case review is not intended to be a focused search for poorly performing providers; rather, it is focused on how the system cares for those patients who need care the most. Nonetheless, while not sampling cases by each provider at the institution, the OIG inspections adequately review most providers. Providers would only escape OIG case review if institutional management successfully mitigated patient risk by having the more poorly performing providers care for the less complicated, low-utilizing, and California Institution for Men, Cycle 4 Medical Inspection Page 8 Office of the Inspector General State of California lower-risk patients. The OIG’s clinicians concluded the case review sample size was adequate to assess the quality of services provided. Based on the collective results of clinicians’ case reviews, the OIG rated each quality indicator as either proficient (excellent), adequate (passing), inadequate (failing), or not applicable. A separate confidential CIM Supplemental Medical Inspection Results: Individual Case Review Summaries report details the case reviews OIG clinicians conducted and is available to specific stakeholders. For further details regarding the sampling methodologies and counts, see Appendix B — Clinical Data, Table B–1; Table B–2; Table B–3; and Table B–4. COMPLIANCE TESTING SAMPLING METHODS FOR CONDUCTING COMPLIANCE TESTING From November 2015 to January 2016, deputy inspectors general attained answers to 100 objective medical inspection test (MIT) questions designed to assess the institution’s compliance with critical policies and procedures applicable to the delivery of medical care. To conduct most tests, inspectors randomly selected samples of inmate-patients for whom the testing objectives were applicable and reviewed their electronic unit health records. In some cases, inspectors used the same samples to conduct more than one test. In total, inspectors reviewed health records for 459 individual inmate-patients and analyzed specific transactions within their records for evidence that critical events occurred. Inspectors also reviewed management reports and meeting minutes to assess certain administrative operations. In addition, during the week of November 16, 2015, field inspectors conducted a detailed onsite inspection of CIM’s medical facilities and clinics; interviewed key institutional employees; and reviewed employee records, logs, medical appeals, death reports, and other documents. This generated 1,506 scored data points to assess care. In addition to the scored questions, the OIG obtained information from the institution that it did not score. This included, for example, information about CIM’s plant infrastructure, protocols for tracking medical appeals and local operating procedures, and staffing resources. For details of the compliance results, see Appendix A — Compliance Test Results. For details of the OIG’s compliance sampling methodology, see Appendix C — Compliance Sampling Methodology. SCORING OF COMPLIANCE TESTING RESULTS The OIG rated the institution in the following ten primary (clinical) and two secondary (administrative) quality indicators applicable to the institution for compliance testing:  Primary indicators: Access to Care, Diagnostic Services, Health Information Management (Medical Records), Health Care Environment, Inter- and Intra-System Transfers, Pharmacy California Institution for Men, Cycle 4 Medical Inspection Page 9 Office of the Inspector General State of California and Medication Management, Preventive Services, Reception Center Arrivals, Specialized Medical Housing (OHU, CTC, SNF, Hospice), and Specialty Services.  Secondary indicators: Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications. After compiling the answers to the 100 questions, the OIG derived a score for each primary and secondary quality indicator identified above by calculating the percentage score of all Yes answers for each of the questions applicable to a particular indicator, then averaging those scores. Based on those results, the OIG assigned a rating to each quality indicator of proficient (greater than 85 percent), adequate (between 75 percent and 85 percent), or inadequate (less than 75 percent). DASHBOARD COMPARISONS In the first ten medical inspection reports of Cycle 4, the OIG identified where similar metrics for some of the individual compliance questions were available within the CCHCS Dashboard, which is a monthly report that consolidates key health care performance measures statewide and by institution. However, there was not complete parity between the metrics due to differing time frames for data collecting and differences in sampling methods, rendering the metrics non-comparable. Some of the OIG’s stakeholders suggested removing the Dashboard comparisons from future reports to eliminate confusion. Dashboard data is available on CCHCS’s website, www.cphcs.ca.gov. California Institution for Men, Cycle 4 Medical Inspection Page 10 Office of the Inspector General State of California OVERALL QUALITY INDICATOR RATING FOR CASE REVIEWS AND COMPLIANCE TESTING The OIG derived the final rating for each quality indicator by combining the ratings from the case reviews and from the compliance testing, as applicable. When combining these ratings, the case review evaluations and the compliance testing results usually agreed, but there were instances when the rating differed for a particular quality indicator. In those instances, the inspection team assessed the quality indicator based on the collective ratings from both components. Specifically, the OIG clinicians and deputy inspectors general discussed the nature of individual exceptions found within that indicator category and considered the overall effect on the ability of patients to receive adequate medical care. To derive an overall assessment rating for the institution’s medical inspection, the OIG evaluated the various rating categories assigned to each of the quality indicators applicable to the institution, giving more weight to the rating results for the primary quality indicators, which directly relate to the health care provided to inmate-patients. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed. POPULATION-BASED METRICS The OIG identified a subset of Healthcare Effectiveness Data Information Set (HEDIS) measures applicable to the CDCR inmate-patient population. To identify outcomes for CIM, the OIG reviewed some of the compliance testing results, randomly sampled additional inmate-patients’ records, and obtained CIM data from the CCHCS Master Registry. The OIG compared those results to HEDIS metrics reported by other statewide and national health care organizations. California Institution for Men, Cycle 4 Medical Inspection Page 11 Office of the Inspector General State of California MEDICAL INSPECTION RESULTS PRIMARY (CLINICAL) QUALITY INDICATORS OF HEALTH CARE The primary quality indicators assess the clinical aspects of health care. As shown on the Health Care Quality Indicators table on page ii of this report, 13 of the OIG’s primary indicators were applicable to CIM. Of those 13 indicators, eight were rated by both the case review and compliance components of the inspection, three were rated by the case review component alone, and two were rated by the compliance component alone. The CIM Executive Summary Table on page viii shows the case review compliance ratings for each applicable indicator. Summary of Case Review Results: The clinical case review component assessed 11 of the 13 primary (clinical) indicators applicable to CIM. Of these 11 indicators, OIG clinicians rated two proficient, nine adequate, and none inadequate. The OIG physicians rated the overall adequacy of care for each of the 30 detailed case reviews they conducted. Of these 30 cases, two were proficient, 24 were adequate, and four were inadequate. In the 1,783 events reviewed, there were 456 deficiencies, of which 17 were considered to be of such magnitude that, if left unaddressed, they would likely contribute to patient harm. Adverse Events Identified During Case Review: Medical care is a complex dynamic process with many moving parts, subject to human error even within the best health care organizations. Adverse events are typically identified and tracked by all major health care organizations for the purpose of quality improvement. They are not generally representative of medical care delivered by the organization. The OIG identified adverse events for the dual purposes of quality improvement and the illustration of problematic patterns of practice found during the inspection. Because of the anecdotal description of these events, the OIG cautions against drawing inappropriate conclusions regarding the institution based solely on adverse events. There were no adverse events identified in the case reviews at CIM. Summary of Compliance Results: The compliance component assessed 10 of the 13 primary (clinical) indicators applicable to CIM. Of these ten indicators, OIG inspectors rated six proficient, three adequate, and one inadequate. The results of those assessments are summarized within this section of the report. The test questions used to assess compliance for each indicator are detailed in Appendix A. California Institution for Men, Cycle 4 Medical Inspection Page 12 Office of the Inspector General State of California ACCESS TO CARE This indicator evaluates the institution’s ability to provide Case Review Rating: inmate-patients with timely clinical appointments. Areas specific to Proficient inmate-patients’ access to care are reviewed, such as initial Compliance Score: assessments of newly arriving inmates, acute and chronic care Proficient follow-ups, face-to-face nurse appointments when an inmate-patient (87.7%) requests to be seen, provider referrals from nursing lines, and Overall Rating: follow-ups after hospitalization or specialty care. Compliance Proficient testing for this indicator also evaluates whether inmate-patients have Health Care Services Request forms (CDCR Form 7362) available in their housing units. Case Review Results The OIG clinicians reviewed 1,107 provider and nurse encounters and identified only 12 minor deficiencies relating to Access to Care. CIM performed very well with regard to Access to Care, and the indicator rating was proficient. Compliance Testing Results The institution performed in the proficient range in the Access to Care indicator, with a compliance score of 87.7 percent. CIM scored in the proficient range in the following test areas:  Inspectors sampled 30 Health Care Services Request forms (CDCR Form 7362) submitted by inmate-patients across all facility clinics. Nursing staff reviewed all the forms on the same day they were received (MIT 1.003). Also, in all sampled instances, nursing staff completed a face-to-face encounter with each inmate-patient within one business day of reviewing (or receiving) the service request form (MIT 1.004).  CIM offered all 30 sampled inmate-patients a follow-up appointment with a PCP within five days of discharge from a community hospital (MIT 1.007).  When the OIG reviewed recent appointments for 40 inmate-patients with chronic care conditions, 39 of the patients (98 percent) received timely routine appointments. One patient’s appointment occurred 49 days late (MIT 1.001).  Of seven Health Care Services Request forms (CDCR Form 7362) sampled on which nursing staff referred the inmate-patient for a PCP appointment, six patients (86 percent) received a timely appointment. The one exception was an inmate-patient who received his routine appointment two days late (MIT 1.005). California Institution for Men, Cycle 4 Medical Inspection Page 13 Office of the Inspector General State of California In the following test area, CIM scored in the adequate range:  Inmates had access to Health Care Services Request forms (CDCR Form 7362) at four of five housing units inspected (80 percent). One inspected housing unit did not have a supply of the forms available for patients’ use (MIT 1.101). The following test areas received scores in the inadequate range:  Of the 28 inmate-patients sampled who transferred into CIM from other institutions and were referred to a PCP for a routine appointment based on nursing staff’s initial health care screening, only 19 were seen timely (68 percent). For nine patients, appointments were held between one and 15 days late (MIT 1.002).  Inspectors also sampled 27 inmate-patients who received a specialty service; 19 of them (70 percent) received a timely follow-up appointment with a PCP while eight of the patients did not have a timely follow-up appointment. Specifically, five patients received an appointment that was between 7 and 31 days late; two patients were never seen for a follow-up visit; and, one patient refused his follow-up visit but, the refusal was obtained eight days after the required compliance date (MIT 1.008). Recommendations No specific recommendations. California Institution for Men, Cycle 4 Medical Inspection Page 14 Office of the Inspector General State of California DIAGNOSTIC SERVICES This indicator addresses several types of diagnostic services. Case Review Rating: Specifically, it addresses whether radiology and laboratory services Proficient were timely provided to inmate-patients, whether the primary care Compliance Score: provider (PCP) timely reviewed the results, and whether the results Proficient were communicated to the inmate-patient within the required time (88.9%) frames. In addition, for pathology services, the OIG determines Overall Rating: whether the institution received a final pathology report and Proficient whether the PCP timely reviewed and communicated the pathology results to the patient. The case reviews also factor in the appropriateness, accuracy, and quality of the diagnostic test(s) ordered and the clinical response to the results. Case Review Results The OIG clinicians reviewed 298 diagnostic events and found 31 minor deficiencies. Eleven deficiencies were due to diagnostic tests not being completed at the ordered interval (some were completed early, and some were completed late); seven were not reviewed or addressed in a timely manner; and 13 were related to health information management, e.g., labs were not available for review, or reports for other patients were found (misfiled). CIM performed very well with regard to diagnostic services, and the indicator rated proficient. Compliance Testing Results The institution received a compliance score of 88.9 percent in the Diagnostic Services indicator, which encompasses radiology, laboratory, and pathology services. For clarity, each type of diagnostic service is discussed separately below: Radiology Services In all ten of the radiology services sampled, the services were timely performed, the diagnostic report results were timely reviewed by the ordering provider, and the test results were timely communicated to the patients (MIT 2.001, 2.002, 2.003). Laboratory Services In all ten of the laboratory services sampled, the services were timely performed, the laboratory reports were timely reviewed by the ordering provider, and the test results were timely communicated to the patients (MIT 2.004, 2.005, 2.006). California Institution for Men, Cycle 4 Medical Inspection Page 15 Office of the Inspector General State of California Pathology Services CIM received the final pathology report timely for only five of ten inmate-patients sampled (50 percent). The five untimely reports were from 6 to 43 days late (MIT 2.007). With regard to providers’ review and communication of pathology results, providers timely reviewed the results for nine patients (90 percent). In the one exception, the PCP documented evidence of review one day late (MIT 2.008). Additionally, providers timely communicated the final pathology results to only six of the ten patients sampled (60 percent) and communicated the results to four patients from one to 85 days late (MIT 2.009). Recommendations No specific recommendations. California Institution for Men, Cycle 4 Medical Inspection Page 16 Office of the Inspector General State of California EMERGENCY SERVICES An emergency medical response system is essential to providing Case Review Rating: effective and timely emergency medical response, assessment, Adequate treatment, and transportation 24 hours per day. Provision of Compliance Score: urgent/emergent care is based on a patient’s emergency situation, Not Applicable clinical condition, and need for a higher level of care. The OIG reviews emergency response services including first aid, basic life Overall Rating: support (BLS), and advanced cardiac life support (ACLS) Adequate consistent with the American Heart Association guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care, and the provision of services by knowledgeable staff appropriate to each individual’s training, certification, and authorized scope of practice. The OIG evaluates this quality indicator entirely through clinicians’ reviews of case files and conducts no separate compliance testing element. Case Review Results The OIG clinicians reviewed 107 urgent/emergent events and found 51 deficiencies, mainly in the area of nursing care. The OIG clinicians learned that on yards A, B, and C, the emergency medical response RN responded to emergency care form each yard’s own medical clinic. When higher level of care was needed, ambulance personnel picked up patients from their respective medical clinics. In yard D, the triage and treatment area (TTA) RN responded to medical alarms and, when indicated, administered care in the TTA. Provider Performance Providers covering the TTA generally made appropriate triage decisions and sent patients to appropriate levels of care. OIG clinicians identified a few exceptions related to incorrect modes of transportation to the higher levels of care. In three cases (6, 7, 17) patients should have been transferred on an emergent, rather than merely urgent, basis. Nursing Performance The majority of deficiencies found in emergency services related to inadequate nursing assessment, intervention, and documentation. Fortunately, for most deficiencies, the patients were not put at increased risk of harm. In addition, the supervising registered nurses (SRN) inadequately monitored and trained staff in a few instances:  In case 6, the RN failed to promptly administer oxygen, aspirin, and nitroglycerin to this patient with chest pain. Additionally, the nurse failed to obtain intravenous access or to complete an EKG or cardiac monitoring. The patient later had another episode of chest pain. California Institution for Men, Cycle 4 Medical Inspection Page 17 Office of the Inspector General State of California In addition to the deficiencies already listed, the RN failed to promptly contact the provider, assess the chest pain after nitroglycerin was administered, or reassess the patient’s blood pressure for over 30 minutes. Failure to promptly administer nitroglycerin was also identified in case 7.  In case 11, the nurse failed to contact the provider for 50 minutes regarding a patient with severe abdominal pain. Emergency Medical Response Review Committee  Case 3 involved an unresponsive patient. When presented to the Emergency Response Review Committee (EMRRC), the committee failed to recognize the RN’s delay in assessing vital signs, administering oxygen, obtaining intravenous access, and the inconsistent documentation. The committee also failed to recognize deficiencies in cases 1, 4, and 6.  On two occasions for case 19, an SRN identified inadequate nursing assessment but failed to conduct training.  The institution’s health care management failed to review several non-scheduled emergency transfers, as required by policy. Onsite Visit During the onsite visit, the OIC clinicians were informed that emergency medications such as Narcan (treatment for narcotics overdose), epinephrine (treatment for allergic reaction), and glucagon (treatment for low blood sugar) were stored in the Omnicells (automated medication and supply cabinets). Because yard A did not have an Omnicell, these emergency medications were not readily available during emergencies. Additionally, intravenous catheters, intravenous fluids, and cardiac monitors were not available in the medical clinics. Effective January 11, 2016, a statewide directive was implemented by which emergency response RNs no longer staff medical clinics during the second watch on weekends and holidays. During these shifts, pill line LVNs are directed to serve as the medical first responders. The institution expressed concern about the TTA RN’s ability to respond timely to yards A, B, and C. While yards A and B were significantly closer to the responding TTA RN (located in yard D), CIM health care management informed OIG clinicians that the average TTA RN response time was greater than 10 minutes for these yards. CIM’s yard C, more remote than yards A and B, is 1.5 miles away from the TTA RN’s work location in yard D. The institution was unable to provide an average TTA RN response time for weekend or holiday emergent events on yard C during second watch. However, based on yard C’s remote proximity, the OIG clinical team believed the average emergency medical response time would far exceed the 10-minute response time experienced in yards A and B, causing concerns that delays in TTA RN response times would increase the risk for patient harm. California Institution for Men, Cycle 4 Medical Inspection Page 18 Office of the Inspector General State of California Conclusion While Emergency Services at CIM were generally adequate, due to the unique layout of CIM, distances between various yards and the TTA, and the recent implementation of statewide staffing changes, there was potential for inadequate emergency responses. Recommendations The OIG recommends that CIM implement the following:  Perform studies to determine the effect on timeliness of urgent/emergent care provided to patients on yards A, B, and C during weekend and holiday second watch shifts.  Review all medical emergency responses that involved delays in TTA RN arrivals on scene to assess the timeliness and quality of care provided by initial LVN responders.  Ensure that emergency supplies, including medications and intravenous catheters and fluids, are available in all clinical areas providing emergency care. California Institution for Men, Cycle 4 Medical Inspection Page 19 Office of the Inspector General State of California HEALTH INFORMATION MANAGEMENT (MEDICAL RECORDS) Health information management is a crucial link in the delivery of Case Review Rating: medical care. Medical personnel require accurate information in Adequate order to make sound judgments and decisions. This indicator Compliance Score: examines whether the institution adequately manages its health care Inadequate information. This includes determining whether the information is (59.6%) correctly labeled and organized and available in the electronic unit Overall Rating: health record (eUHR); whether the various medical records (internal Inadequate and external, e.g., hospital and specialty reports and progress notes) are obtained and scanned timely into the inmate-patient’s eUHR; whether records routed to clinicians include legible signatures or stamps; and whether hospital discharge reports include key elements and are timely reviewed by providers. In this indicator, the OIG’s case review and compliance review processes yielded different results, with the case review giving an adequate rating and the compliance testing resulting in an inadequate score—each area’s results are discussed in detail below. After considering both case review and compliance testing results, the OIG inspection team determined the final overall rating of inadequate was appropriate. The decision was primarily due to an excessive number of health care documents that CIM staff either mislabeled or misfiled in the eUHR. In addition, a large percentage of transcribed provider progress notes inspectors sampled were not scanned timely into the eUHR. Both of these conditions could result in important health care records not being identified and contribute to patient harm. These combined conditions warranted the lower overall indicator score. Case Review Results The OIG clinicians found minor deficiencies during case review of CIM’s health information management. Out of 457 (total) deficiencies identified from the case reviews, 48 related to health information management processes. Inter-Departmental Transmission There were deficiencies related to orders not carried through to various departments, including diagnostic test results not found in the eUHR, so it was unclear if they were performed. Hospital Records Hospital records were generally reviewed in a timely manner. Specialty Services The few pertinent deficiencies related to specialty services were due to reports not being available for review in a timely manner. California Institution for Men, Cycle 4 Medical Inspection Page 20 Office of the Inspector General State of California Diagnostic Reports Diagnostic reports were generally reviewed in a timely manner. Urgent/Emergent Records The few Health Information Management deficiencies relating to urgent/emergent records were due to missing nursing records. Scanning Performance There were multiple deficiencies relating to scanning performance. These included documents being mislabeled or misfiled. There were a number of instances when provider notes, nursing notes, and TTA flow sheets were not found in the eUHR. The OIG clinicians could not ascertain whether they were lost prior to scanning or never written at all. Legibility Six deficiencies were related to illegible signatures. Legacy Notes OIG clinicians identified where a particular provider used legacy notes, cloned copies of prior notes with few changes made. In many of these cases, portions of the notes were misleading or confusing, as they had not been changed from prior visits. For example, in one case, physical exam notes documented bilateral lower extremity pulses and normal gait in a patient with a below-the-knee amputation (before he received his prosthesis). The use of legacy notes can cause confusion for subsequent providers, and creates a risk for harm to patients. This issue is also discussed in the Quality of Provider Performance indicator. Compliance Testing Results CIM scored in the inadequate range in the Health Information Management (Medical Records) indicator, receiving a compliance score of 59.6 percent. Although the institution received a proficient score in two of the eight applicable indicator test areas and an adequate score in two other test areas, CIM received an inadequate score in four areas, including one test that scored zero, as discussed below:  The institution scored zero in its labeling and filing of documents scanned into inmate-patients’ electronic unit health records; most documents were mislabeled, such as a 7362 Health Care Services (HCS) Request Form (used by patients to see a nurse) that was scanned and labeled as a Form 7243 HCS Physician Request for Services (used by doctors to order specialty services). Other documents were either filed under the wrong tab, filed in the wrong patient’s file, or missing from the eUHR altogether. For this test, once the OIG identifies 12 mislabeled or misfiled documents, the maximum points are lost and the California Institution for Men, Cycle 4 Medical Inspection Page 21 Office of the Inspector General State of California resulting score is zero. During the CIM medical inspection, inspectors identified a total of 17 documents with filing errors, five more than the maximum allowable errors (MIT 4.006).  The institution scored only 10 percent in the timely scanning of dictated or transcribed provider progress notes into inmate-patients’ electronic health records. While sampled progress notes were timely scanned within five calendar days for 2 of 20 sampled documents, 18 sampled progress notes were scanned between 1 and 15 days late (MIT 4.002).  Institution staff timely scanned five of ten sampled initial health screening forms and health care service request forms into patients’ eUHR within three calendar days of the patient encounter (50 percent). Five documents were scanned late including three documents that were scanned one day late, and two documents that were scanned two days late (MIT 4.001).  CIM timely scanned community hospital discharge reports or treatment records into the patient’s eUHR for 14 of the 20 sampled reports (70 percent); inspectors found reports scanned from one to four days late (MIT 4.004). The institution performed in the adequate range in the following areas:  Inspectors reviewed eUHR files for 30 patients sent or admitted to the hospital and found hospital discharge reports or treatment records for 23 patients (77 percent) to be complete and reviewed by providers within three calendar days of discharge. For one patient, the CIM provider reviewed the hospital discharge summary report one day late. For six other patients, there was no evidence providers reviewed the discharge reports at all (MIT 4.008).  CIM timely scanned medical administration records (MARs) into the patients’ eUHRs for 17 of the 20 sampled documents (85 percent); three MARs were scanned from one to four days late (MIT 4.005). The institution scored in the proficient range in the following areas:  CIM staff timely scanned 18 of 20 specialty service consultant reports sampled into the inmate-patient’s eUHR file (90 percent). The other two documents were scanned one and 12 days late (MIT 4.003).  When the OIG reviewed various medical documents such as hospital discharge reports, initial health screening forms, certain medication records, and specialty services reports to ensure that clinical staff legibly documented their names on the forms, 38 of 40 samples (95 percent) were compliant. Two of the samples did not include clinician name stamps, and the signatures were illegible (MIT 4.007). California Institution for Men, Cycle 4 Medical Inspection Page 22 Office of the Inspector General State of California Recommendations The OIG recommends that CIM management do the following:  Prohibit the use of legacy notes.  Review the current document flow process to improve the scanning timeliness of documents entered by records management staff into patients’ charts. California Institution for Men, Cycle 4 Medical Inspection Page 23 Office of the Inspector General State of California HEALTH CARE ENVIRONMENT This indicator addresses the general operational aspects of the Case Review Rating: institution’s clinics, including certain elements of infection control Not Applicable and sanitation, medical supplies and equipment management, the Compliance Score: Adequate availability of both auditory and visual privacy for inmate-patient (80.1%) visits, and the sufficiency of facility infrastructure to conduct comprehensive medical examinations. Rating of this component is Overall Rating: based entirely on the compliance testing results from the visual Adequate observations inspectors make at the institution during their onsite visit. Compliance Testing Results The institution received an adequate compliance score of 80.1 percent in the Health Care Environment indicator, and scored proficient in the following five areas:  All nine clinics were appropriately disinfected, cleaned, and sanitary. Cleaning logs were available and complete, indicating cleaning crews regularly cleaned the clinics (MIT 5.101).  The institution’s non-clinic bulk medical supply storage areas met the supply management process and support needs of the medical health care program (MIT 5.106).  All nine clinics inspected followed adequate medical supply storage and management protocols in their clinical areas (MIT 5.107).  Clinical health care staff at seven of eight applicable clinics (88 percent) ensured that reusable invasive and non-invasive medical equipment was properly sterilized or disinfected. The only exception was one clinic in which staff did not replace the exam table paper between patient encounters (MIT 5.102).  OIG inspectors observed clinicians’ encounters with inmate-patients in eight of CIM’s clinics. Clinicians followed good hand hygiene practices in seven clinics (88 percent). In one clinic, both the physician and nurse utilized gloves during patient encounters, but they did not wash their hands or use hand sanitizer between glove changes (MIT 5.104). The following four test areas received scores in the adequate range:  Seven of the nine clinics inspected followed proper protocols to mitigate exposure to blood-borne pathogens and contaminated waste (78 percent). The receiving and release (R&R) clinic and one exam room in a second clinic did not have sharps containers (puncture resistant containers used for expended syringes) (MIT 5.105). California Institution for Men, Cycle 4 Medical Inspection Page 24 Office of the Inspector General State of California  Seven of the nine clinics inspected had operable sinks and sufficient quantities of hand hygiene supplies in clinical areas (78 percent). In one clinic location, the institution utilized a portable toilet, which had no running water available for hand washing. A second clinic restroom lacked soap or hand sanitizer (MIT 5.103).  Seven of the nine clinic areas observed (78 percent) had an environment conducive to providing medical services. In two clinic areas, auditory privacy was not available to patients due to the configuration of clinical vital sign and triage areas (Figure 1) (MIT 5.109).  Inspectors examined emergency response bags to determine if the bags were inspected daily and inventoried monthly, and whether they contained all essential items; bags were Figure 1: Lack of patient privacy at clinic vital compliant in five of the six sampled clinical sign station locations where they were stored (83 percent). While CIM medical staff did inspect and inventory all emergency response bags at required intervals, one bag did not contain the required supply of non-latex gloves (MIT 5.111). CIM showed room for improvement in two test areas, as described below:  The OIG inspected various exam rooms in each of CIM’s nine clinics, observing patient encounters and interviewing clinical staff, to determine if appropriate space, configuration, supplies, and equipment allowed clinicians to perform a proper clinical exam. The exam rooms or treatment spaces in only four of the nine clinics (44 percent) were sufficient. Five clinics had exam areas that were unacceptable for a variety of reasons. For example, exam rooms were too small to allow for adequate inmate-patient examinations; exam tables were poorly placed, not allowing the patient to lie in a fully extended position (Figure 2). Figure 2: Inadequate placement of exam table California Institution for Men, Cycle 4 Medical Inspection Page 25 Office of the Inspector General State of California Exam tables had ripped vinyl allowing for the potential to harbor infectious agents (Figure 3). An otoscope in one clinic exam room was fixed to the wall opposite from the exam table, so it was not readily accessible during examination of the patient on the table. The OIG also had concerns about inmate-patient privacy in one clinic. Specifically, in one exam room inspectors observed unsecured medical records designated for destruction (MIT 5.110).  The institution furnished only four of nine Figure 3: Worn vinyl on exam table clinics and exam rooms with essential supplies and core equipment necessary to conduct a comprehensive exam (44 percent). Examples of missing items in clinic areas included glucometers (and strips), peak flow meters, medication refrigerators, and a Snellen vision chart. In addition, one clinic had a nebulization unit without evidence of current calibration (Figure 4). Missing items in exam rooms included biohazard waste containers, hemoccult cards and developer, lubricating jelly, tongue depressors, an exam table, and, ophthalmoscope and tips (MIT 5.108). Figure 4: Nebulization unit with expired calibration Other Information Obtained from Non-Scored Results  The OIG gathered information to determine if the institution’s physical infrastructure was maintained in a manner that supported health care management’s ability to provide timely or adequate health care. This question was not scored. OIG inspectors interviewed health care management, and while staff did not have concerns about the facility’s ability to provide adequate health care, staff did express reservations about the adequacy of space in clinical areas. To address the existing space and privacy limitations at CIM, a master infrastructure project had been undertaken. The project consists of 13 separate health care improvement physical infrastructure projects, including the construction or renovation of various clinical areas in yards A, B, C, and D, pharmacy, central health services, and health care administration buildings. According to CIM management, the projects began in phases starting in June 2015 with the last project scheduled to break ground in late 2016. While some projects will be completed in late 2016, all 13 projects should be completed by the end of 2017 (MIT 5.999). California Institution for Men, Cycle 4 Medical Inspection Page 26 Office of the Inspector General State of California Recommendations The OIG recommends the institution implement the following:  Properly stock and maintain all clinic areas with a full complement of core equipment, including a glucometer (and strips), peak flow meter, nebulization unit, medication refrigerator, and Snellen eye chart with established distance marker. Also ensure that each exam room has a biohazard waste receptacle, otoscope tips, an ophthalmoscope, an exam table, a sharps container, and a supply of sterile tongue depressors. In addition, for exam rooms where providers might work, ensure they are stocked with lubricating jelly, hemoccult cards, and a developer.  Ensure that in all exam settings, the room is arranged so that a patient can lie fully extended on the exam table, and the provider and patient can move freely within the room. California Institution for Men, Cycle 4 Medical Inspection Page 27 Office of the Inspector General State of California INTER- AND INTRA-SYSTEM TRANSFERS This indicator focuses on the management of inmate-patients’ Case Review Rating: medical needs and continuity of patient care during the inter- and Adequate intra-facility transfer process. The patients reviewed for Inter- and Compliance Score: Intra-System Transfers include inmates received from other CDCR Proficient facilities and inmates transferring out of CIM to another CDCR (92.0%) facility. The OIG review includes evaluation of the institution’s Overall Rating: ability to provide and document health screening assessments, Adequate initiation of relevant referrals based on patient needs, and the continuity of medication delivery to patients arriving from another institution. For those patients, the OIG clinicians also review the timely completion of pending health appointments, tests, and requests for specialty services. For inmate-patients who transfer out of the facility, the OIG evaluates the ability of the institution to document transfer information that includes pre-existing health conditions, pending appointments, tests and requests for specialty services, medication transfer packages, and medication administration prior to transfer. The OIG clinicians also evaluate the care provided to patients returning to the institution from an outside hospital and check to ensure appropriate implementation of the hospital assessment and treatment plans. In this indicator, the OIG’s case review and compliance review processes yielded different results, with the case review giving an adequate rating and the compliance testing resulting in a proficient score. While each area’s results are discussed in detail below, the result variance is readily explained by the different testing approaches. For example, transfer documents may have been present in the medical record as required by policy, and the finding was positively reflected in the compliance rating. However, the clinical quality of those same documents may have been poor and negatively reflected in the case review rating. After considering both case review and compliance testing results, the OIG inspection team determined the final overall rating was adequate. The decision was primarily based on case review’s concerns related to hospital discharge returns, as discussed below. Since hospital discharge patients tend to be higher-risk patients, this finding does not warrant an indicator score higher than adequate. Case Review Results The OIG clinicians reviewed 84 encounters relating to Inter- and Intra-System Transfers, including information from both the sending and receiving institutions. Clinicians also reviewed 109 hospitalization-related events, including pre- and post-hospitalization events. Forty-four of these events were actual hospitalizations or emergency room visits, the majority of which resulted in a transfer back to the institution (a few events resulted in transfers to other hospitals or institutions, or patient deaths). In general, the Inter- and Intra-System Transfers processes at CIM were adequate with only a few deficiencies. California Institution for Men, Cycle 4 Medical Inspection Page 28 Office of the Inspector General State of California Transfers In The few deficiencies in this area were related to incomplete initial health screening forms for patients arriving at CIM and medications not being administered in a timely manner. Transfers Out Of the five cases reviewed specifically of patients transferring out of CIM, three included incomplete and incorrect Health Care Transfer Information forms (CDCR 7371). Missing information included pending specialty appointments, pending diagnostic tests, and pending primary care appointments. Hospitalizations Patients returning from hospitalizations are some of the highest risk encounters due to two factors. First, these patients are generally hospitalized for a severe illness or injury. Second, they are at risk due to potential lapses in care that can occur during any transfer. Generally, at CIM, providers and nurses adequately assessed patients returning from hospitals, though the OIG identified a few minor deficiencies. Two concerning issues are related to hospital discharge medications:  Hospital discharge medications were sometimes ordered one day prior to the patient actually being discharged. Unfortunately, there were last minute medication changes by the hospital on the day of discharge. This resulted in the patients receiving incorrect medications upon their arrival back at CIM. This practice of ordering medications prior to the patient’s hospital discharge was due to the lack of adequate pharmacy personnel during the weekends. This issue is further discussed in the Pharmacy and Medication Management indicator.  In a few instances, patients returned to CIM late in the evening and the provider on call was contacted. The physician orders were given for the patient to follow up in the morning with his primary care provider, who was then to order the appropriate medications. When these appointments occurred later in the morning, patients sometimes did not receive their morning medications. This issue is also discussed in the Pharmacy and Medication Management indicator. Compliance Testing Results The institution obtained a proficient compliance score of 92.0 percent in the Inter- and Intra-System Transfers indicator, scoring 100 percent in three of the five areas tested, as described below:  Inspectors sampled 30 patients who transferred into CIM from other institutions to ensure that each patient received a timely health screening upon arrival at the institution; in each case, nursing staff completed an Initial Health Screening form (CDCR Form 7277) on the same day the patient arrived (MIT 6.001). In addition, nursing staff timely completed the California Institution for Men, Cycle 4 Medical Inspection Page 29 Office of the Inspector General State of California assessment and disposition sections of the screening form for all 29 of the applicable patients sampled (MIT 6.002).  During onsite testing, transfer packages included the required medications and related documentation for all eight applicable inmate-patients who transferred out of the institution (MIT 6.101). The institution scored within the adequate range in the following tests:  Fifteen of 30 sampled inmate-patients who transferred into CIM had an existing medication order that required nursing staff to administer or deliver the medication upon the patients’ arrival. Twelve of those 15 patients (80 percent) received their medications without interruption. Two inmate-patients received their medications between one and 11 days late, and no eUHR evidence was found to demonstrate that another patient ever received or refused his medication (MIT 6.003).  The OIG tested 20 inmate-patients who transferred out of CIM to another CDCR institution to determine whether their scheduled specialty service appointments were listed on the Health Care Transfer Information form (CDCR Form 7371). Staff identified the scheduled appointments on the transfer forms of 16 of the 20 patients sampled (80 percent) (MIT 6.004). Recommendations  The OIG recommends that CIM ensure pharmacy coverage on the weekends so patients receive their appropriate medications in a timely manner.  The OIG recommends providers ensure appropriate medications are ordered in a timely manner for patients returning from the hospital.  The OIG recommends that nursing staff undergo structured training and complete competency testing prior to conducting initial R&R intake assessments.  The OIG recommends that health care management ensure that a standardized methodology and process is followed by supervising registered nurses to better assess the nursing care and completeness of R&R transfer forms. California Institution for Men, Cycle 4 Medical Inspection Page 30 Office of the Inspector General State of California PHARMACY AND MEDICATION MANAGEMENT This indicator is an evaluation of the institution’s ability to provide Case Review Rating: appropriate pharmaceutical administration and security management, Adequate encompassing the process from the written prescription to the Compliance Score: administration of the medication. By combining both a quantitative Adequate (81.4%) compliance test with case review analysis, this assessment identifies issues in various stages of the medication management process, Overall Rating: including ordering and prescribing, transcribing and verifying, Adequate dispensing and delivering, administering, and documenting and reporting. Because effective medication management is affected by numerous entities across various departments, this assessment considers internal review and approval processes, pharmacy, nursing, health information systems, custody processes, and actions taken by the PCP prescriber, staff, and patient. Case Review Results In the majority of cases, patients received their medications timely and as prescribed. There were occasional occurrences of medications not being administered timely, as well as a pattern of issues related to hospital discharge medications. There was also a potential pharmacy and medication management issue relating to emergency services. As previously discussed in the Inter-and Intra-Systems Transfer indicator, there were some deficiencies related to hospital discharge medications. Closer review of these deficiencies indicated the utilization management personnel at CIM were planning ahead for the patient’s hospital discharge. As part of the anticipated discharge, a list of hospital discharge medications was obtained and forwarded to the CIM provider for orders. Unfortunately, the hospital sometimes made last-minute medication changes on the day of discharge. This resulted in the patient receiving incorrect medications upon his arrival back to CIM. This issue was discussed with the medical leadership at CIM during the OIG clinicians’ onsite visit. Leadership explained this practice was an attempt to work around the lack of adequate pharmacy personnel during the weekends. While the use of Omnicell automated medication and supply cabinet systems had alleviated some of the issues of inadequate pharmacy personnel during the weekends, some issues still remained, including the lack of an Omnicell in yard A. Onsite Visit During the onsite visit, the OIG clinicians confirmed the presence of only one triage and treatment area (TTA) at CIM. With some of the yards being relatively remote from the TTA, there was concern regarding TTA response times for emergencies and the lack of available emergency response medications and supplies, e.g., epinephrine, nitroglycerin, glucagon, Narcan, IV fluids, etc., in some of these yards. Again, while most yards did have an Omnicell containing emergency medications, one of CIM’s yards did not. While case reviews did not reveal any significant California Institution for Men, Cycle 4 Medical Inspection Page 31 Office of the Inspector General State of California deficiencies due to this issue, the OIG is concerned with the potential for future problems. This issue is also noted in the Emergency Services indicator. Conclusion The OIG recognizes the complexities of the issues above and appreciates CIM’s ongoing continuous quality improvement initiatives. The OIG rated the case review portion of Pharmacy and Medication Management performance as adequate. Compliance Testing Results The institution received an adequate compliance score of 81.4 percent in the Pharmacy and Medication Management indicator. For discussion purposes below, this indicator is divided into three sub-indicators that consist of medication administration; observed medication practices and storage controls; and pharmacy protocols. Medication Administration In this sub-indicator, the institution received an average score of 79 percent and could improve in the following areas:  CIM timely provided hospital discharge medications to 24 of 29 patients sampled who had returned from a community hospital (83 percent). For three patients, nursing staff provided at least one of the patient’s discharge medications one to 25 days late; for two other patients, there was no evidence that one or more medications ordered by the provider were administered at all (MIT 7.003).  Inspectors reviewed files of 20 sampled inmate-patients who recently arrived at CIM from a county jail and identified 13 patients who needed to be reissued non-PRN medications upon their arrival. Of the 13 applicable patients sampled, eight patients received their medications timely (62 percent). Five patients received one or more of their medications from one to three days late (MIT 7.004).  Medical administration record (MAR) evidence showed that nursing staff administered prescribed medications to only five of the ten inmate-patients who, during the sample test period, were en route from one institution to another and who had a temporary layover at CIM (50 percent). For the remaining five patients, there was no evidence the medication was received at all (MIT 7.006). CIM performed well in the following three areas of this sub-indicator:  Thirty-nine of the 40 patients sampled (98 percent) timely received their new medication orders. One inmate-patient received his medication four days late (MIT 7.002). California Institution for Men, Cycle 4 Medical Inspection Page 32 Office of the Inspector General State of California  CIM ensured that 28 of 30 patients sampled (93 percent) received their medications without interruption when they transferred from one housing unit to another; the remaining two patients did not receive their prescribed medication at their next dosing interval following the transfer. The corresponding MARs indicated unexplained missed doses (MIT 7.005).  Nursing staff timely dispensed long-term chronic care medications to 32 of the 36 inmate-patients sampled, scoring 89 percent on this test. Three patients did not receive refills for one or more of their keep-on-person (KOP) medications; a fourth patient did not acknowledge his acceptance by signing the MAR for one medication refill (MIT 7.001). Observed Medication Practices and Storage Controls In this sub-indicator, the institution received a score of 89 percent and performed well in five areas:  The institution employed strong medication security controls over narcotic medications in nine sampled applicable clinic and medication line locations where narcotics were stored (MIT 7.101).  Clinical staff employed appropriate administrative controls and followed proper protocols during medication preparation at all seven sampled areas observed MIT 7.105).  CIM properly stored non-narcotic medications that did not require refrigeration at 12 of the 13 applicable clinics and medication line storage locations sampled (92 percent). In one clinic, the OIG’s November 2015 onsite inspection identified a stored medication that had been expired since September 2015 (MIT 7.102).  Inspectors observed the medication preparation and administration processes for seven medication line locations. Nursing staff were compliant with proper hand hygiene contamination control protocols at six of them (86 percent). In one of the medication lines, nurses failed to sanitize or wash their hands prior to initially putting on gloves (MIT 7.104).  When observing the medication distribution process at seven pill line locations, inspectors found that six (86 percent) were compliant with appropriate administrative controls and protocols. However, the administrative segregation unit pill line nurse consistently completed MARs, i.e., medication administration record, before distributing the medication to patients, instead of after the administration or service is provided (MIT 7.106). CIM has an opportunity for improvement in the following area:  The institution properly stored non-narcotic medications that require refrigeration at only 9 of the 13 applicable clinics, receiving a score of 69 percent. At one clinic location, historical refrigerator temperature logs were maintained, but the recorded temperatures were illegible; in addition, the refrigerated medication designated for pharmacy return was not stored separately from other medications. At a second location, the medication refrigerator was California Institution for Men, Cycle 4 Medical Inspection Page 33 Office of the Inspector General State of California operating outside of the approved temperature range; at two additional locations, historical temperature logs showed refrigerator temperatures to be consistently below the acceptable range (MIT 7.103). Pharmacy Protocols In this sub-indicator, the institution received an average score of 75 percent comprised of scores received at the institution’s main pharmacy. While the institution performed proficiently in three of five tests in this sub-indicator, the following two areas present opportunity for improvement:  CIM’s main pharmacy did not properly store and monitor refrigerated or frozen medications, scoring zero in this test area. Inspectors tested daily temperature logs in the pharmacy for the last 60 days and found freezer temperatures in the bulk storage area to be outside the acceptable range on multiple days. More specifically, the freezer unit had several recent recorded temperatures of 20° F, which is six degrees warmer than the approved maximum temperature limit of 14° F (MIT 7.109).  The institution’s pharmacist-in-charge (PIC) followed required protocols for 23 of the 30 medication error reports and monthly statistical reports reviewed (77 percent). For five errors tested, the PIC did not complete the required medication error follow-up reports and the related monthly medication error statistics report—a summary of errors categorized by severity level for the month in which they occur—resulting in six deficiencies. Finally, the PIC failed to complete the necessary reports (incident summary report and Sentinel Event/Adverse Event Reporting form) for an assigned Level 4 medication error that also met the criteria for a sentinel event (MIT 7.111). CIM performed well in the following three areas of this sub-indicator:  In its main pharmacy, the institution followed general security, organization, and cleanliness management protocols; properly stored non-refrigerated medications; and properly accounted for narcotic medications (MIT 7.107, 7.108, 7.110). Other Information Obtained from Non-Scored Results In addition to testing reported medication errors, OIG inspectors follow up on any significant medication errors found during the case reviews or compliance testing to determine whether the errors were properly identified and reported. These findings are not scored. At CIM, the OIG did not find any applicable medication errors subject to this test (MIT 7.998) The OIG also tests inmate-patients housed in isolation units to determine if they had immediate access to their prescribed KOP rescue inhalers and nitroglycerin medications. Inspectors interviewed one applicable inmate, who had possession of his prescribed rescue medication (MIT 7.999). California Institution for Men, Cycle 4 Medical Inspection Page 34 Office of the Inspector General State of California Recommendations The OIG makes several recommendations related to pharmacy and medication management in the Inter-and Intra-Systems Transfers indicator. See the Recommendations section on page 30. In addition, the OIG recommends CIM implement the following:  Equip all yards with an Omnicell automated medication and supply cabinet system. California Institution for Men, Cycle 4 Medical Inspection Page 35 Office of the Inspector General State of California PREVENTIVE SERVICES This indicator assesses whether various preventive medical services Case Review Rating: are offered or provided to inmate-patients. These include cancer Not Applicable screenings, tuberculosis screenings, and influenza and chronic care Compliance Score: Proficient immunizations. This indicator also assesses whether certain (88.9%) institutions take preventive actions to relocate inmate-patients identified as being at higher risk for contracting coccidioidomycosis Overall Rating: (valley fever). Proficient Compliance Testing Results The institution performed in the proficient range in the Preventive Services indicator, with a compliance score of 88.9 percent. Further, out of four test areas that scored in the proficient range, three received scores of 100 percent. They are detailed below:  All 30 patients sampled timely received or were offered influenza vaccinations during the most recent influenza season (MIT 9.004).  CIM timely administered anti-tuberculosis medications (INH) to patients. All 30 sampled patients received their required doses of INH in the most recent three-month period (MIT 9.001).  The OIG tested whether inmate-patients who suffered from a chronic care condition were offered vaccinations for influenza, pneumonia, and hepatitis. At CIM, all 25 patients sampled received all recommended vaccinations at the required interval (MIT 9.008).  CIM offered colorectal cancer screenings to 29 of 30 sampled inmate-patients subject to the annual screening requirement (97 percent). For one patient, there was no eUHR evidence that health care staff either offered a colorectal cancer screening within the previous 12 months or that the patient had a normal colonoscopy within the last ten years (MIT 9.005). The institution scored within the adequate range in the following test:  When the OIG reviewed CIM’s monthly monitoring of 30 sampled patients who received anti-tuberculosis medications, CIM was in compliance for 23 of those patients (77 percent). For six patients, CIM completed the required monthly tuberculosis monitoring, but failed to individually scan each month’s monitoring results into the patients’ health records. For another patient, there was no eUHR evidence that health care staff completed the required tuberculosis monitoring assessment during any of the three month sampled test period (MIT 9.002). California Institution for Men, Cycle 4 Medical Inspection Page 36 Office of the Inspector General State of California There is room for improvement in the following area:  OIG inspectors sampled 30 inmate-patients to determine whether they received a tuberculosis screening within the last year. Fifteen of the sampled patients were classified as Code 34 (subject only to an annual signs and symptoms check), and 15 sampled patients were classified as a Code 22 (requiring a tuberculosis skin test in addition to a signs and symptoms check). Although the institution timely screened all 30 sampled patients for tuberculosis within the prior year, CIM clinicians only properly screened 60 percent of those patients. Specifically, while all 15 sampled Code 34 patients were properly screened, only 3 of the 15 patients classified as Code 22 were properly screened. More specifically, 12 of the sampled Code 22 patients received improper screenings that included various combinations of the following deficiencies: nine instances in which an LVN or LPT, rather than an RN, public health nurse, or primary care provider, read the skin test results; and eight instances in which nursing staff did not document either the specific administered (start) or read (end) date and time to evidence the TB test was completed within the required 48-to-72-hour time frame (MIT 9.003). Recommendations No specific recommendations. California Institution for Men, Cycle 4 Medical Inspection Page 37 Office of the Inspector General State of California QUALITY OF NURSING PERFORMANCE The Quality of Nursing Performance indicator is a qualitative Case Review Rating: evaluation of the institution’s nursing services. The evaluation is Adequate completed entirely by OIG nursing clinicians within the case Compliance Score: review process, and, therefore, does not have a score under the Not Applicable compliance testing component. The OIG nurses conduct case reviews that include reviewing face-to-face encounters related to Overall Rating: nursing sick call requests identified on the Health Care Services Adequate Request form (CDCR Form 7362), urgent walk-in visits, referrals for medical services by custody staff, registered nurse (RN) case management, RN utilization management, clinical encounters by licensed vocational nurses (LVNs) and licensed psychiatric technicians (LPTs), and any other nursing service performed on an outpatient basis. The OIG case review also includes activities and processes performed by nursing staff that are not considered direct patient encounters, such as the initial receipt and review of CDCR Form 7362 service requests and follow-up with primary care providers and other staff on behalf of the patient. Key focus areas for evaluation of outpatient nursing care include appropriateness and timeliness of patient triage and assessment, identification and prioritization of health care needs, use of the nursing process to implement interventions including patient education and referrals, and documentation that is accurate, thorough, and legible. Nursing services provided in the outpatient housing unit (OHU) are reported under the Specialized Medical Housing indicator. Nursing services provided in the triage and treatment area (TTA) or related to emergency medical responses are reported under the Emergency Services indicator. Case Review Results The OIG nursing clinicians rated the Quality of Nursing Performance at CIM adequate. The OIG clinicians reviewed 114 outpatient nursing encounters; and identified 35 minor deficiencies related to outpatient nursing services. Outpatient nursing care at CIM was generally timely and appropriate. However, a few cases revealed incomplete assessments and interventions, as illustrated in the examples below: Nursing Assessment/Documentation  In case 15, a diabetic patient with a foot wound required wound care for over one month. The nurses failed to perform dressing changes for eight days. During this time, wound assessments were rarely documented.  In case 24, a patient with a history of cardiovascular disease, chronic obstructive pulmonary disease, and chronic kidney disease was discharged from a community hospital after being treated for pneumonia. When this patient was evaluated for bilateral lower extremity edema, pain, and a five-pound weight gain in one week, the nurse failed to listen to lung and heart sounds and did not make an urgent provider referral. California Institution for Men, Cycle 4 Medical Inspection Page 38 Office of the Inspector General State of California  Incomplete nursing assessments were also identified in cases 11, 19, 42, and 44. Onsite Visit The morning huddle was interdisciplinary, comprehensive, organized, and interactive. In addition, supervising registered nurses (SRNs) were knowledgeable and active in their clinics. They interacted well with staff and displayed ownership of clinic operations. The SRNs’ offices were physically located in the medical clinics, likely improving their knowledge and involvement in daily operations. This should be considered a best practice. Recommendations No specific recommendations. California Institution for Men, Cycle 4 Medical Inspection Page 39 Office of the Inspector General State of California QUALITY OF PROVIDER PERFORMANCE In this indicator, the OIG physicians provide a qualitative Case Review Rating: evaluation of the adequacy of provider care at the institution. Adequate Appropriate evaluation, diagnosis, and management plans are Compliance Score: reviewed for programs including, but not limited to, nursing sick Not Applicable call, chronic care programs, TTA, specialized medical housing, and specialty services. The assessment of provider care is Overall Rating: performed entirely by OIG physicians. There is no compliance Adequate testing component associated with this quality indicator. Case Review Results The OIG clinicians reviewed 434 medical provider encounters and identified 89 deficiencies related to provider performance, the majority of which did not place the patient at increased risk for harm. The care provided by CIM medical providers was appropriate overall. Of the 30 cases reviewed, two were proficient, 24 were adequate, and four cases (12, 14, 26, 29) were inadequate. As a whole, the OIG rated the Quality of Provider Performance at CIM as adequate. Assessment and Decision-Making Twenty-five deficiencies related to provider assessments and decision-making. These deficiencies ranged from incomplete documentation to assessments and plans being inappropriate. The most serious of these deficiencies were the following:  In cases 6 and 10, elevated blood pressures were not addressed.  In case 12, physical exams were not consistently performed and documented on this patient with liver cirrhosis.  In cases 12, 14, and 19, there were inappropriate delays in the management of abnormal labs.  In case 26, the provider failed to address a laboratory report showing anemia (low blood count) for a patient on anticoagulation medication. Review of Records Twenty-one deficiencies related to records not being adequately reviewed:  In case 10, providers failed to address issues for which the patient had been referred by nursing.  In case 12, due to the provider failing to adequately review records, a chronic care visit was inappropriately delayed and a medication was not renewed timely. California Institution for Men, Cycle 4 Medical Inspection Page 40 Office of the Inspector General State of California  In cases 13, 14, 23, and 26, the provider failed to adequately review the labs.  In case 15, the provider failed to review some blood sugar levels. Emergency Care The quality of provider emergency care was generally adequate. However, there were a few deficiencies:  Several cases revealed either inadequate assessments (case 14) or inappropriate methods of transfer to higher levels of care (cases 6, 7, 14), e.g., state vehicle instead of urgent ambulance or emergent ambulance. These deficiencies are also discussed in the Emergency Services indicator. Chronic Care The quality of chronic care by providers was also generally adequate. However, inadequate care resulted from deficiencies in the management of anticoagulation, and diabetes (cases 23, 27, 29). Specialty Services CIM providers generally requested specialty services appropriately. When providers saw patients for follow-up after specialty services, providers usually reviewed the reports adequately and took appropriate actions. The few exceptions were as follows:  In case 21, several specialty recommendations were not implemented, and the reasons were not documented.  In cases 7, 12, 21, follow-up appointments with specialists occasionally did not occur as requested by either the specialist (cases 12 and 21) or hospital discharge recommendations (case 7). Health Information Management As noted in the Health Information Management indicator, there was evidence of legacy or cloned notes by a particular CIM provider. This was the main issue found with the quality of provider performance as it related to health information management. A few other deficiencies were due to provider progress notes not being found in the eUHR, and orders not being found despite their being mentioned in progress notes. Onsite Inspection CIM providers were generally content with their work and the ancillary services the institution provided. Though their patient population consisted of many high-risk (complex) patients, they felt their workload was appropriate and manageable. Ancillary services, including laboratory, California Institution for Men, Cycle 4 Medical Inspection Page 41 Office of the Inspector General State of California pharmacy, radiology, and specialty services, functioned well. The providers felt well supported by their leadership. The OIG clinicians observed a provider meeting. Provider meetings, held every weekday morning, addressed patient issues, including transfers in and out and weekend or overnight patient concerns. During this time, providers reviewed labs and specialty reports, discussed challenging patients, and gave pertinent education. The OIG observed the morning huddle in yard D. The huddle issues discussed were comprehensive and pertinent. They included patients addressed by the on-call provider, patients seen in the TTA, patients transferred in or out, patients in the hospital, significant diagnostic reports, medication issues, complex patients undergoing work-ups, provider and nursing schedules for the day and week, clinic efficiency, staffing, medical holds, registries, custody concerns, resource concerns, daily clinic duties, and reviews of patients’ requests for services. CIM was utilizing both its own Daily Huddle Activity Sheet and a newly released statewide Daily Huddle Report. The institution used both because CIM’s activity sheet contained information not included in the statewide form. The OIG considered this particular huddle as a “best practice,” and other facilities could benefit from modeling their morning huddles to yard D’s format. Pharmacy and Medication Management Pharmacy and medication management by providers was generally adequate. Two deficiencies were related to incorrect doses of medications. Other deficiencies relating to hospital discharge medications are discussed in the Intra- and Inter- System Transfers indicator. Conclusion After taking all factors into consideration, the OIG rated CIM provider performance as adequate. Recommendations  The OIG recommends that CIM management prohibit the use of legacy notes and monitor for compliance.  The OIG recommends that CIM institute provider training on the proper modes of transportation when patients require higher levels of care.  The OIG recommends that providers review the CCHCS care guides for anticoagulation and diabetes management.  The OIG recommends that the institution consider modeling all of its yard morning clinical huddles after the practices and protocols utilized by the yard D clinical team. California Institution for Men, Cycle 4 Medical Inspection Page 42 Office of the Inspector General State of California RECEPTION CENTER ARRIVALS This indicator focuses on the management of medical needs and Case Review Rating: continuity of care for patients arriving from outside the CDCR Adequate system. The OIG review includes evaluation of the ability of the Compliance Score: institution to provide and document initial health screenings, initial Adequate (80.5%) health assessments, continuity of medications, and completion of required screening tests; address and provide significant Overall Rating: accommodations for disabilities and health care appliance needs; Adequate and identify health care conditions needing treatment and monitoring. The patients reviewed for reception center cases are those received from non-CDCR facilities, such as county jails. Case Review Results The OIG clinicians reviewed five reception center arrivals and rated the care adequate. There were few minor deficiencies:  In case 64, the patient did not receive his blood-thinner for two days. A delay in medication administration was also identified in case 65.  In cases 60, 64, and 66, nurses failed to assess asthma inhaler use and to examine the chests of these asthma patients at their initial health screening. Compliance Testing Results The institution performed in the adequate range in the Reception Center Arrivals indicator, with a compliance score of 80.5 percent. CIM scored in the proficient range in the following test areas:  Of the 20 sampled patients who arrived at the CIM reception center, 18 patients’ screenings required that an RN complete an assessment and disposition of the results on the same day staff completed the health screening. Of the 18 applicable samples, nursing staff properly documented and timely completed 17 of the screenings (94 percent). For one sample, nursing staff failed to indicate whether the patient required a PCP referral (MIT 12.002). In addition, based on the dispositions, intake nurses referred 14 of the 20 sampled patients to see a provider, and all of the patients received their provider appointments timely (MIT 12.003).  Providers timely completed a written history and physical examination for all 20 sampled reception center inmate-patients within seven calendar days of their arrival at CIM (MIT 12.004). California Institution for Men, Cycle 4 Medical Inspection Page 43 Office of the Inspector General State of California  Inspectors sampled 20 reception center patients to verify they received required intake tests; 19 of them (95 percent) timely received all applicable intake tests. For one patient, the PCP did not order the required varicella (chickenpox) intake test (MIT 12.005).  Providers timely reviewed and communicated intake test results for 17 of the 18 reception center inmate-patients who arrived at CIM during the sample period (94 percent). For one patient, the provider reviewed the test results one day late, then communicated them 14 days late (MIT 12.006). In the following test area, CIM scored in the adequate range:  Inspectors sampled 20 reception center patients to ensure that each patient received a timely health screening upon his arrival at the institution. Nursing staff conducted timely and complete screenings for 17 of those patients (85 percent). In three of the patient screenings, nurses did not answer all of the required screening questions. The unanswered questions related to tuberculosis signs and symptoms, dental problems, or requests for specialty provider visits (MIT 12.001). The following test areas received scores in the inadequate range:  The institution timely administered a coccidioidomycosis (valley fever) skin test to only 13 of the 20 sampled reception center inmate-patients (65 percent). One patient was administered the test 36 days late; one more patient consented to the test but did not receive it; and for five additional patients, inspectors found no evidence CIM ever offered or administered the test at all (MIT 12.008).  Although all of the 20 sampled patients received a timely tuberculosis test upon arrival at CIM’s reception center, only two patients’ skin test results were properly conducted (10 percent). More specifically, inspectors identified one or more of the following exceptions for those patients who did not receive a proper skin test: nursing staff did not document either the specific administered (start) or read (end) date and time to evidence the test was completed within the required 48-to-72-hour time period; test results were read outside of the required 48-to-72-hour time period; or an LVN or LPT, rather than an RN, public health nurse, or primary care provider, read the test results (MIT 12.007). Recommendation  The OIG recommends that nursing staff undergo structured training and complete competency testing prior to conducting initial R&R intake assessments. California Institution for Men, Cycle 4 Medical Inspection Page 44 Office of the Inspector General State of California SPECIALIZED MEDICAL HOUSING (OHU, CTC, SNF, HOSPICE) This indicator addresses whether the institution follows appropriate Case Review Rating: policies and procedures when admitting inmate-patients to onsite Adequate inpatient facilities, including completion of timely nursing and Compliance Score: provider assessments. The chart review assesses all aspects of Proficient medical care related to these housing units, including quality of (100%) provider and nursing care. CIM’s only specialized medical housing Overall Rating: unit is an onsite outpatient housing unit (OHU). Adequate In this indicator, the OIG’s case review and compliance review processes yielded different results, with the case review giving an adequate rating and the compliance testing resulting in a proficient score. While each area’s results are discussed in detail below, the result variance is readily explained by the different testing approaches. For example, OHU documents may have been present in the medical record as required by policy, and the finding was positively reflected in the compliance score. However, the clinical quality of those same documents may have been poor and negatively reflected in the case review rating. After considering both case review and compliance testing results, the OIG inspection team determined the final overall rating was adequate. The key factors were that the case review had a larger sample size, and the case review focused on the quality of care provided. As a result, the case review testing results were deemed a more accurate reflection of the appropriate overall indicator rating. Case Review Results At the time of the OIG inspection, the California Institution for Men’s OHU contained 44 beds for medical patients. There were also 34 mental health crisis beds. The OIG clinicians reviewed 159 provider encounters and 368 nursing encounters relating to the OHU in 16 cases. These included admissions to the medical OHU for medical conditions and admissions for patients requiring assistance with their activities of daily living. Provider Performance In general, the OHU provider performance was adequate. Of the 159 OHU provider encounters reviewed, 28 deficiencies were identified, two of which were considered serious enough to place the patient at increased risk for harm:  In case 13, there was concern about a possible blood clot in the patient’s leg. Diagnostic testing should have occurred immediately rather than three days later.  In case 16, a long-term antibiotic was mistakenly prescribed at half the recommended dose, a mistake not rectified until three months later. California Institution for Men, Cycle 4 Medical Inspection Page 45 Office of the Inspector General State of California  A particular provider used legacy (cloned) notes in cases 13, 21, 25, and 26. Cloned notes are also discussed in the Health Information Management and Quality of Provider Performance indicators. Nursing Performance While the majority of the 160 nursing deficiencies in the OHU were unlikely to contribute to patient harm, the number of these deficiencies was concerning. There were patterns of incomplete assessment and documentation. Examples of the more serious deficiencies are as follows:  In case 12, the patient had multiple chronic care diagnoses, including end-stage liver disease. He was admitted to the OHU because of fluid retention. A nursing assessment was conducted every 24 hours but lacked useful information, such as abdominal girth or the presence of edema (swelling). Additionally, the nurses failed to consistently obtain the ordered daily weights.  In case 13, the patient complained of severe leg pain and swelling. The nurse documented a temperature of 100.3° F, noted edema, and administered pain medications. The nurse failed to note increased warmth or document the amount of edema and perform a reassessment. Four hours later, the patient again complained of severe leg pain. His exam showed a temperature to 102.6° F, and a very fast heart rate of 144 beats per minute. It was not until 30 minutes later that the provider was contacted. The patient required transfer to a community hospital.  In case 57, this patient had multiple chronic diagnoses, including diabetes, hypertension, and peripheral vascular disease. He was admitted to the OHU for wound care while awaiting toe amputation. The nurses did not perform a thorough initial wound assessment, and the wound care was completed without corresponding assessment documentation. No one assessed leg circulation and sensation, and no one reassessed significantly elevated blood pressures or communicated them to a provider. Onsite Visit During the OIG clinician’s onsite visit, it was learned that effective January 11, 2016, CIM implemented a new OHU staffing model. Instead of the OHU being staffed with four RNs each shift, the OHU had one “lead” RN on each shift and two RNs during the second shift. Because the change was recent and in transition at the time of the visit, the OIG clinicians were unable to determine or assess the impact of the staffing change on the quality of medical care provided in the OHU. California Institution for Men, Cycle 4 Medical Inspection Page 46 Office of the Inspector General State of California Clinician Summary The quality of provider and nursing performance within Specialized Medical Housing was generally satisfactory. There was, however, a high number of nursing deficiencies related to assessments, interventions, and documentation. Fortunately, the majority of these deficiencies were minor and not likely to put patients at increased risk of harm. The case review portion for Specialized Medical Housing was rated adequate. Compliance Testing Results The institution received a proficient compliance score of 100 percent in the Specialized Medical Housing indicator, which focused on the institution’s outpatient housing unit (OHU). As detailed below, all five of the indicator’s test areas received a perfect 100 percent score:  When the OIG observed the working order of a sample of call buttons in OHU patient rooms, all inspected call buttons were working properly. In addition, according to staff interviews, custody officers and clinicians were able to efficiently respond and access inmate-patients’ rooms in about 30 seconds when an emergent event occurred (MIT 13.101).  For all ten inmate-patients sampled, nursing staff timely completed an initial assessment on the day the patient was admitted to the OHU (MIT 13.001).  Providers evaluated all ten inmate-patients within 24 hours of admission and completed a history and physical within 72 hours of admission. Providers also completed their subjective, objective, assessment, plan, and education (SOAPE) notes at required 14-day intervals for each of the seven patients who had a long enough stay to require one (MIT 13.002, 13.003, 13.004). Recommendations  The OIG recommends the institution implement a process to evaluate the CTC’s nursing assessment, intervention, and documentation. This quality improvement initiative should be ongoing, measurable, and reported in a manner that CIM leadership can effectively monitor.  Due to the recent changes in staffing reduction, the OIG recommends closely monitoring access to care for OHU patients. California Institution for Men, Cycle 4 Medical Inspection Page 47 Office of the Inspector General State of California SPECIALTY SERVICES This indicator focuses on specialist care from the time a request for Case Review Rating: services or physician’s order for specialist care is completed to the Adequate time of receipt of related recommendations from specialists. This Compliance Score: indicator also evaluates the providers’ timely review of specialist Proficient records and documentation reflecting the patients’ care plans, (88.9%) including course of care when specialist recommendations were not Overall Rating: ordered, and whether the results of specialists’ reports are Adequate communicated to the patients. For specialty services denied by the institution, the OIG determines whether the denials are timely and appropriate, and whether the inmate-patient is updated on the plan of care. In this indicator, the OIG’s case review and compliance review processes yielded different results, with the case review giving an adequate rating and the compliance review resulting in a proficient score. The OIG’s internal review process considered those factors that led to both results and ultimately rated this indicator adequate. The key factor that warranted the lower rating was the compliance testing result that showed newly arrived transfer patients did not always receive timely specialty appointments authorized by sending institutions. Case Review Results The OIG clinicians reviewed 281 events related to Specialty Services, the majority of which were specialty consultations and procedures. There were 28 minor deficiencies in this category, subcategorized below. Case review rated this indicator adequate. Access to Specialty Services Urgent and routine specialty services were generally timely and adequate, though there were occasional minor delays in specialty follow-up appointments. Nursing Performance Nursing performance as it related to Specialty Services was generally adequate, though there were a few issues with assessment and documentation. Provider Performance The provider performance, as it related to Specialty Services, was also overall adequate. Some of the issues seen included specialty recommendations not always being implemented, and providers not ordering referrals appropriately. California Institution for Men, Cycle 4 Medical Inspection Page 48 Office of the Inspector General State of California Health Information Management The few deficiencies found in the this indicator related to health information management documents (e.g. diagnostic reports, medication administration records, etc.) not being available to specialists and primary care providers. Onsite Inspection The onsite visit and discussion with CIM personnel confirmed the adequacy of specialty services found during case review. Specialty reports were provided to the primary care providers daily in their morning provider meetings; and providers reported good communication with the specialty services nursing staff. Compliance Testing Results The institution received a proficient compliance score of 88.9 percent in the Specialty Services indicator, scoring within the proficient range in five of the seven test areas:  The OIG tested the timeliness of CIM’s denials of provider specialty services requests for 20 patients; all of the denials occurred within the required time frame (MIT 14.006).  For 14 of the 15 inmate-patients sampled (93 percent), the high-priority specialty services appointment occurred within 14 calendar days of the provider’s order. One patient refused his service appointment; however, the refusal occurred one day late. In addition, following patients’ appointments, providers also timely received and reviewed the specialists’ reports for 13 of the 14 sampled appointments (93 percent). However, one instance occurred in which the provider’s review was delayed because the institution received the specialist’s report six days late (MIT 14.001, 14.002).  For 14 of the 15 of the inmate-patients sampled (93 percent), the routine specialty service appointment occurred within 90 calendar days of the provider’s order. One patient received his routine service 20 days late. In addition, following patients’ services appointments, providers timely reviewed the specialists’ reports for 13 of the 14 applicable reports (93 percent). The provider reviewed one report eight days late (MIT 14.003, 14.004). In the following test area, CIM scored in the adequate range:  Providers timely informed inmate-patients of the denial status for requested specialty services for 17 of the 20 denials sampled (85 percent). The provider informed one patient of the denial two days late. For two other patients, inspectors did not find any evidence that the provider ever discussed the denial with the patient (MIT 14.007). California Institution for Men, Cycle 4 Medical Inspection Page 49 Office of the Inspector General State of California The institution has opportunity for improvement in the following area:  When an institution approves or schedules a patient for specialty services appointments and then transfers the patient to another institution, policy requires that the receiving institution ensure a patient’s appointment occurs timely. At CIM, only 13 of the 20 sampled patients (65 percent) received their specialty services appointment within the required action period. Three patients received their appointments between one and 14 days late, two patients received appointments 37 and 68 days late, and two patients did not receive an appointment at all (MIT 14.005). Recommendations No specific recommendations. California Institution for Men, Cycle 4 Medical Inspection Page 50 Office of the Inspector General State of California SECONDARY (ADMINISTRATIVE) QUALITY INDICATORS OF HEALTH CARE The last two quality indicators (Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications) involve health care administrative systems and processes. Testing in these areas applies only to the compliance component of the process. Therefore, there is no case review assessment associated with either of the two indicators. As part of the compliance component for the first of these two indicators, the OIG did not score several questions. Instead, the OIG presented the findings for informational purposes only. For example, the OIG described certain local processes in place at CIM. To test both the scored and non-scored areas within these two secondary quality indicators, OIG inspectors interviewed key institutional employees and reviewed documents during their onsite visit to CIM in November 2015. They also reviewed documents obtained from the institution and from CCHCS prior to the start of the inspection. The test questions used to assess compliance for each indicator are detailed in Appendix A. For comparative purposes, the CIM Executive Summary Table on page viii of this report shows the case review and compliance ratings for each applicable indicator. California Institution for Men, Cycle 4 Medical Inspection Page 51 Office of the Inspector General State of California INTERNAL MONITORING, QUALITY IMPROVEMENT, AND ADMINISTRATIVE OPERATIONS This indicator focuses on the institution’s administrative health care Case Review Rating: oversight functions. The OIG evaluates whether the institution Not Applicable promptly processes inmate-patient medical appeals and addresses Compliance Score: all appealed issues. Inspectors also verify that the institution follows Adequate reporting requirements for adverse/sentinel events and inmate (80.1%) deaths, and whether the institution is making progress toward its Overall Rating: Performance Improvement Work Plan (PIWP) initiatives. In Adequate addition, the OIG verifies that the Emergency Medical Response Review Committee (EMRRC) performs required reviews and that staff perform required emergency response drills. Inspectors also assess whether the Quality Management Committee (QMC) meets regularly and adequately addresses program performance. For those institutions with licensed facilities, inspectors also verify that required committee meetings are held. Compliance Testing Results The institution received an adequate score of 80.1 percent in the Internal Monitoring, Quality Improvement, and Administrative Operations indicator. CIM scored 100 percent in the following test areas:  The institution promptly processed all inmate medical appeals in each of the most recent 12 months (MIT 15.001). In addition, based on a sample of ten second-level medical appeals, the institution’s responses addressed all of the patients’ appealed issues (MIT 15.102).  CIM’s QMC met monthly, evaluated program performance, and took action when improvement opportunities were identified (MIT 15.003). Additionally, the institution scored 100 percent for taking adequate steps to ensure the accuracy of its Dashboard data reporting (MIT 15.004).  Medical staff promptly submitted the Initial Inmate Death Report (CDCR Form 7229A) to CCHCS’s Death Review Unit for the ten applicable deaths that occurred at CIM in the prior 12-month period (MIT 15.103). The institution performed in the adequate range for one test area:  The OIG inspected documentation for 12 emergency medical response incidents reviewed by CIM’s Emergency Medical Response Review Committee (EMRRC) during the prior six-month period, and found that 10 of 12 sampled incident packages (83 percent) complied with policy. For two packages, the warden failed to sign the corresponding meeting minutes (MIT 15.007). California Institution for Men, Cycle 4 Medical Inspection Page 52 Office of the Inspector General State of California The following test areas received scores in the inadequate range:  CIM improved or reached targeted performance objectives for four of the seven quality improvement initiatives identified in its 2014 Performance Improvement Work Plan, resulting in a score of 57 percent. For three of the seven initiatives, CIM provided insufficient data to assess whether the institution made program improvement (MIT 15.005).  Inspectors reviewed the summary reports and related documentation for three medical emergency response drills conducted in the prior quarter. Documentation provided from the first, second, and third watches’ response drills lacked the inclusion of required forms. Therefore, the institution received a score of zero on this test (MIT 15.101). Other Information Obtained from Non-Scored Areas  The OIG gathered non-scored data regarding the completion of death review reports. During the time frame of the OIG’s review, the CCHCS’s Death Review Committee (DRC) was required to complete a death review summary within 30 business days of an inmate’s death and to further communicate the results to the institution’s CEO within five additional business days. The DRC both timely completed its reports and timely notified the CEO for only two of the ten sampled death reviews (20 percent). For six of the CIM inmate deaths OIG inspectors reviewed, the DRC completed its death review summary between 2 and 40 days late (or 45 to 80 calendar days after the death). In addition, the institution’s CEO was not timely notified of the summary results for those aforementioned six deaths nor for an additional two (for a total of eight). The CEO was notified of the results from 6 to 49 days late (or 55 to 96 days after death). Consequently, the DRC did not provide timely results to the CEO (MIT 15.996).  Inspectors met with the institution’s CEO to inquire about CIM’s protocols for tracking appeals. According to the CEO, the health care appeals coordinator reports monthly to the local Patient Safety Program Committee on pending appeals by department and appeal type. Management staff uses the report data to identify trends, track potential problems within various departments, and monitor delays in the appeal process. When problem areas are identified, management works with appropriate health care staff as well as stakeholders to remedy the issue(s). The OIG does not score this area or validate staff’s assertions (MIT 15.997).  Non-scored data gathered regarding the institution’s practices for implementing local operating procedures (LOPs) indicated that the institution had a good process in place for developing LOPs. The institution’s health program specialist monitored new and revised CCHCS policies and procedures. Also, she annually distributed existing LOPs to a local committee for analysis and review. The committee determined if an LOP required modification or if a new LOP was necessary. When modifications were needed, the warden and medical management staff reviewed and approved the LOP, and it was then distributed California Institution for Men, Cycle 4 Medical Inspection Page 53 Office of the Inspector General State of California to departments throughout the institution. CIM’s medical management staff and the in-service training coordinator then incorporated the LOP into training curriculum. At the time of the OIG’s inspection, CIM had implemented 43 of the 50 applicable LOPs that related to the core topical areas recommended by the clinical experts who helped develop the OIG’s medical inspection compliance program (86 percent) (MIT 15.998).  The OIG discusses the institution’s health care staffing resources in the About the Institution section on page 2 (MIT 15.999). Recommendations No specific recommendations. California Institution for Men, Cycle 4 Medical Inspection Page 54 Office of the Inspector General State of California JOB PERFORMANCE, TRAINING, LICENSING, AND CERTIFICATIONS In this indicator, the OIG examines whether the institution Case Review Rating: adequately manages its health care staffing resources by evaluating Not Applicable whether job performance reviews are completed as required; Compliance Score: specified staff possess current, valid credentials and professional Adequate licenses or certifications; nursing staff receive new employee (83.3%) orientation training and annual competency testing; and clinical and Overall Rating: custody staff have current medical emergency response Adequate certifications. Compliance Testing Results The institution received an adequate compliance score of 83.3 percent in the Job Performance Training, Licensing, and Certifications indicator. The institution scored 100 percent in six of the indicator’s eight tests, as follows:  All providers were current with their professional licenses, and nursing staff and the pharmacist-in-charge were current with their professional licenses and certification requirements (MIT 16.001, 16.105).  All of the ten nurses sampled who administered medications possessed current clinical competency validations, and all nursing staff hired within the last year timely received new employee orientation training (MIT 16.102, 16.107).  The OIG reviewed performance evaluation packets for CIM’s 21 providers; the institution met all performance review requirements for its providers (MIT 16.103).  The institution’s pharmacy and providers who prescribed controlled substances were current with their Drug Enforcement Agency registrations (MIT 16.106). The institution scored in the inadequate range in the following areas:  The OIG tested provider, nursing, and custody staff records to determine if the institution ensures that those staff members have current emergency response certifications. The institution’s provider and nursing staff were all compliant, but custody managers were not. While the California Penal Code exempts custody managers who primarily perform managerial duties from medical emergency response certification training, CCHCS policy does not allow for such an exemption. As a result, the institution received a score of 67 percent on this test (MIT 16.104). California Institution for Men, Cycle 4 Medical Inspection Page 55 Office of the Inspector General State of California  Inspectors examined records to determine if supervising nurses completed evaluation reviews of nursing staff. None of the five sampled nurses had received sufficiently completed reviews. The nursing supervisor who performed the review failed to discuss the performance results with all five nurses (MIT 16.101). Recommendations No specific recommendations. California Institution for Men, Cycle 4 Medical Inspection Page 56 Office of the Inspector General State of California POPULATION-BASED METRICS The compliance testing and the case reviews give an accurate assessment of how the institution’s health care systems are functioning with regard to the patients with the highest risk and utilization. This information is vital to assess the capacity of the institution to provide sustainable, adequate care. However, one significant limitation of the case review methodology is that it does not give a clear assessment of how the institution performs for the entire population. For better insight into this performance, the OIG has turned to population-based metrics. For comparative purposes, the OIG has selected several Healthcare Effectiveness Data and Information Set (HEDIS) measures for disease management to gauge the institution’s effectiveness in outpatient health care, especially chronic disease management. The Healthcare Effectiveness Data and Information Set is a set of standardized performance measures developed by the National Committee for Quality Assurance with input from over 300 organizations representing every sector of the nation’s health care industry. It is used by over 90 percent of the nation’s health plans as well as many leading employers and regulators. It was designed to ensure that the public (including employers, the Centers for Medicare and Medicaid Services, and researchers) has the information it needs to accurately compare the performance of health care plans. Healthcare Effectiveness Data and Information Set data is often used to produce health plan report cards, analyze quality improvement activities, and create performance benchmarks. Methodology For population-based metrics, the OIG used a subset of HEDIS measures applicable to the CDCR inmate-patient population. Selection of the measures was based on the availability, reliability, and feasibility of the data required for performing the measurement. The OIG collected data utilizing various information sources, including the eUHR, the Master Registry (maintained by CCHCS), as well as a random sample of patient records analyzed and abstracted by trained personnel. Data obtained from the CCHCS Master Registry and Diabetic Registry was not independently validated by the OIG and is presumed to be accurate. For some measures, the OIG used the entire population rather than statistically random samples. While the OIG is not a certified HEDIS compliance auditor, the OIG uses similar methods to ensure that measures are comparable to those published by other organizations. Comparison of Population-Based Metrics For the California Institution for Men, nine HEDIS measures were selected and are listed in the following CIM Results Compared to State and National HEDIS Scores table. Multiple health plans publish their HEDIS performance measures at the State and national levels. The OIG has provided selected results for several health plans in both categories for comparative purposes. California Institution for Men, Cycle 4 Medical Inspection Page 57 Office of the Inspector General State of California Results of Population-Based Metric Comparison Comprehensive Diabetes Care For chronic care management, the OIG chose measures related to the management of diabetes. Diabetes is the most complex common chronic disease requiring a high level of intervention on the part of the health care system in order to produce optimal results. CIM performed very well with its management of diabetes. When compared statewide, CIM’s scores significantly exceeded the scores of both Medi-Cal and Kaiser Permanente, North and South regions, in all five diabetic measures selected. When compared nationally, CIM outperformed Medicaid, Medicare, and commercial health plans (based on data obtained from health maintenance organizations) in all five of the diabetic measures listed. CIM also outperformed the U.S. Department of Veterans Affairs (VA) for diabetic monitoring in all four applicable measures. Immunizations Comparative data for immunizations was only fully available for the VA (national) and partially available for Kaiser Permanente (statewide), Medicare (national), and commercial plans (national). For influenza shots administered to all adults, CIM scored higher than all the plans where comparative data was available. With respect to pneumococcal vaccinations for older adults, CIM scored 90 percent, which was 20 percentage points higher than Medicare but fell 3 percentage points short of the VA’s score. While 40 of the 41 patients tested either received or were offered the pneumococcal vaccination while at CIM, three of those patients (8 percent) refused it. The refusals caused CIM to fall short of the VA’s comparative score. Cancer Screening For colorectal cancer screening, CIM achieved scores 7 and 4 percentage points higher than commercial plans and Medicare, respectively, but averaged 10 percentage points lower than the VA and Kaiser North and South. While 40 of the 41 patients sampled were offered the screening timely, 11 of them (28 percent) had subsequently refused the test. Again, the high level of refusals caused CIM to have a significantly lower comparative score than would have been otherwise achieved. Summary Overall, CIM’s HEDIS performance reflects a high-performing chronic care program, further corroborated by the institution’s proficient scores in the Access to Care and Preventive Services indicators. However, to improve its overall comparative scores in all categories, CIM should make interventions, such as an emphasis on patient education to lower refusal rates, especially in the area of colorectal cancer screenings. California Institution for Men, Cycle 4 Medical Inspection Page 58 Office of the Inspector General State of California CIM Results Compared to State and National HEDIS Scores California National CIM HEDIS HEDIS HEDIS HEDIS Clinical Measures Medi - Kaiser Kaiser HEDIS Com - HEDIS VA Cycle 4 Cal (No.CA) (So.CA) Medicaid mercial Medicare Average Results 2014 2014 2014 2015 2015 2015 2012 1 2 3 3 4 4 4 5 Comprehensive Diabetes Care HbA1c Testing (Monitoring) 100% 83% 95% 94% 86% 91% 93% 99% Poor HbA1c Control (>9.0%) 6,7 8% 44% 18% 24% 44% 31% 25% 19% HbA1c Control (<8.0%) 6 84% 47% 70% 62% 47% 58% 65% - Blood Pressure Control (<140/90) 95% 60% 84% 85% 62% 65% 65% 80% Eye Exams 93% 51% 69% 81% 54% 56% 69% 90% Immunizations Influenza Shots - Adults (18–64) 8 72% - 54% 55% - 50% - 65% Influenza Shots - Adults (65+) 90% - - - - - 72% 76% Immunizations: Pneumococcal 90% - - - - - 70% 93% Cancer Screening Colorectal Cancer Screening 71% - 80% 82% - 64% 67% 82% 1. Unless otherwise stated, data was collected in November 2015 by reviewing medical records from a sample of CIM’s population of applicable inmate-patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. 2. HEDIS Medi-Cal data was obtained from the California Department of Health Care Services 2014 HEDIS Aggregate Report for the Medi-Cal Managed Care Program. 3. Data was obtained from Kaiser Permanente November 2015 reports for the Northern and Southern California regions. 4. National HEDIS data for Medicaid, commercial plans, and Medicare was obtained from the 2015 State of Health Care Quality Report, available on the NCQA website: www.ncqa.org. The results for commercial plans were based on data received from various health maintenance organizations. 5. The Department of Veterans Affairs (VA) data was obtained from the VHA Facility Quality and Safety Report - Fiscal Year 2012 Data. 6. For this indicator, the entire applicable CIM population was tested. 7. For this measure only, a lower score is better. For Kaiser, the OIG derived the Poor HbA1c Control indicator using the reported data for the <9.0% HbA1c control indicator. 8. The VA data is for the age range 50–64. California Institution for Men, Cycle 4 Medical Inspection Page 59 Office of the Inspector General State of California APPENDIX A — COMPLIANCE TEST RESULTS California Institution for Men Range of Summary Scores: 59.58% – 100.00% Indicator Compliance Score (%Yes) Access to Care 87.68% Diagnostic Services 88.89% Emergency Services Not Applicable Health Information Management (Medical Records) 59.58% Health Care Environment 80.05% Inter- and Intra-System Transfers 92.00% Pharmacy and Medication Management 81.39% Prenatal and Post-Delivery Services Not Applicable Preventive Services 88.89% Quality of Nursing Performance Not Applicable Quality of Provider Performance Not Applicable Reception Center Arrivals 80.49% Specialized Medical Housing (OHU, CTC, SNF, Hospice) 100.00% Specialty Services 88.91% Internal Monitoring, Quality Improvement, and Administrative 80.06% Operations Job Performance, Training, Licensing, and Certifications 83.33% California Institution for Men, Cycle 4 Medical Inspection Page 60 Office of the Inspector General State of California Scored Answers Yes Reference + Access to Care Number Yes No No Yes % N/A 1.001 Chronic care follow-up appointments: Was the inmate-patient’s 39 1 40 97.50% 0 most recent chronic care visit within the health care guideline’s maximum allowable interval or within the ordered time frame, whichever is shorter? 1.002 For endorsed inmate-patients received from another CDCR 19 9 28 67.86% 2 institution: If the nurse referred the inmate-patient to a provider during the initial health screening, was the inmate-patient seen within the required time frame? 1.003 Clinical appointments: Did a registered nurse review the 30 0 30 100.00% 0 inmate-patient’s request for service the same day it was received? 1.004 Clinical appointments: Did the registered nurse complete a 30 0 30 100.00% 0 face-to-face visit within one business day after the CDCR Form 7362 was reviewed? 1.005 Clinical appointments: If the registered nurse determined a referral to 6 1 7 85.71% 23 a primary care provider was necessary, was the inmate-patient seen within the maximum allowable time or the ordered time frame, whichever is the shorter? 1.006 Sick call follow-up appointments: If the primary care provider ordered a follow-up sick call appointment, did it take place within the Not Applicable 30 time frame specified? 1.007 Upon the inmate-patient’s discharge from the community hospital: 30 0 30 100.00% 0 Did the inmate-patient receive a follow-up appointment within the required time frame? 1.008 Specialty service follow-up appointments: Do specialty service 19 8 27 70.37% 3 primary care physician follow-up visits occur within required time frames? 1.101 Clinical appointments: Do inmate-patients have a standardized 4 1 5 80.00% 0 process to obtain and submit health care services request forms? Overall percentage: 87.68% California Institution for Men, Cycle 4 Medical Inspection Page 61 Office of the Inspector General State of California Scored Answers Yes Reference + Diagnostic Services Number Yes No No Yes % N/A 2.001 Radiology: Was the radiology service provided within the time frame 10 0 10 100.00% 0 specified in the provider’s order? 2.002 Radiology: Did the primary care provider review and initial the 10 0 10 100.00% 0 diagnostic report within specified time frames? 2.003 Radiology: Did the primary care provider communicate the results of 10 0 10 100.00% 0 the diagnostic study to the inmate-patient within specified time frames? 2.004 Laboratory: Was the laboratory service provided within the time 10 0 10 100.00% 0 frame specified in the provider’s order? 2.005 Laboratory: Did the primary care provider review and initial the 10 0 10 100.00% 0 diagnostic report within specified time frames? 2.006 Laboratory: Did the primary care provider communicate the results of 10 0 10 100.00% 0 the diagnostic study to the inmate-patient within specified time frames? 2.007 Pathology: Did the institution receive the final diagnostic report within 5 5 10 50.00% 0 the required time frames? 2.008 Pathology: Did the primary care provider review and initial the 9 1 10 90.00% 0 diagnostic report within specified time frames? 2.009 Pathology: Did the primary care provider communicate the results of 6 4 10 60.00% 0 the diagnostic study to the inmate-patient within specified time frames? Overall percentage: 88.89% California Institution for Men, Cycle 4 Medical Inspection Page 62 Office of the Inspector General State of California Emergency Services Scored Answers Assesses reaction times and responses to emergency situations. The OIG RN clinicians will use detailed information obtained from the institution’s incident Not Applicable packages to perform focused case reviews. Scored Answers Health Information Management Yes Reference + (Medical Records) Number Yes No No Yes % N/A 4.001 Are non-dictated progress notes, initial health screening forms, and 5 5 10 50.00% 0 health care service request forms scanned into the eUHR within three calendar days of the inmate-patient encounter date? 4.002 Are dictated / transcribed documents scanned into the eUHR within five 2 18 20 10.00% 0 calendar days of the inmate-patient encounter date? 4.003 Are specialty documents scanned into the eUHR within the required 18 2 20 90.00% 0 time frame? 4.004 Are community hospital discharge documents scanned into the eUHR 14 6 20 70.00% 0 within three calendar days of the inmate-patient date of hospital discharge? 4.005 Are medication administration records (MARs) scanned into the eUHR 17 3 20 85.00% 0 within the required time frames? 4.006 During the eUHR review, did the OIG find that documents were 0 12 12 0.00% 0 correctly labeled and included in the correct inmate-patient’s file? 4.007 Did clinical staff legibly sign health care records, when required? 38 2 40 95.00% 0 4.008 For inmate-patients discharged from a community hospital: Did the 23 7 30 76.67% 0 preliminary hospital discharge report include key elements and did a PCP review the report within three calendar days of discharge? Overall percentage: 59.58% California Institution for Men, Cycle 4 Medical Inspection Page 63 Office of the Inspector General State of California Scored Answers Yes Reference + Health Care Environment Number Yes No No Yes % N/A 5.101 Infection Control: Are clinical health care areas appropriately 9 0 9 100.00% 0 disinfected, cleaned and sanitary? 5.102 Infection control: Do clinical health care areas ensure that 7 1 8 87.50% 1 reusable invasive and non-invasive medical equipment is properly sterilized or disinfected as warranted? 5.103 Infection Control: Do clinical health care areas contain operable 7 2 9 77.78% 0 sinks and sufficient quantities of hygiene supplies? 5.104 Infection control: Does clinical health care staff adhere to 7 1 8 87.50% 1 universal hand hygiene precautions? 5.105 Infection control: Do clinical health care areas control exposure 7 2 9 77.78% 0 to blood-borne pathogens and contaminated waste? 5.106 Warehouse, Conex and other non-clinic storage areas: Does 1 0 1 100.00% 0 the medical supply management process adequately support the needs of the medical health care program? 5.107 Clinical areas: Does each clinic follow adequate protocols for 9 0 9 100.00% 0 managing and storing bulk medical supplies? 5.108 Clinical areas: Do clinic common areas and exam rooms have 4 5 9 44.44% 0 essential core medical equipment and supplies? 5.109 Clinical areas: Do clinic common areas have an adequate 7 2 9 77.78% 0 environment conducive to providing medical services? 5.110 Clinical areas: Do clinic exam rooms have an adequate 4 5 9 44.44% 0 environment conducive to providing medical services? 5.111 Emergency response bags: Are TTA and clinic emergency 5 1 6 83.33% 3 medical response bags inspected daily and inventoried monthly, and do they contain essential items? 5.999 For Information Purposes Only: Does the institution’s health care management believe that all clinical areas have physical Information Only plant infrastructures sufficient to provide adequate health care services? Overall percentage: 80.05% California Institution for Men, Cycle 4 Medical Inspection Page 64 Office of the Inspector General State of California Scored Answers Yes Reference + Inter- and Intra-System Transfers Number Yes No No Yes % N/A 6.001 For endorsed inmate-patients received from another CDCR 30 0 30 100.00% 0 institution or COCF: Did nursing staff complete the initial health screening and answer all screening questions on the same day the inmate-patient arrived at the institution? 6.002 For endorsed inmate-patients received from another CDCR 29 0 29 100.00% 1 institution or COCF: When required, did the RN complete the assessment and disposition section of the health screening form; refer the inmate-patient to the TTA, if TB signs and symptoms were present; and sign and date the form on the same day staff completed the health screening? 6.003 For endorsed inmate-patients received from another CDCR 12 3 15 80.00% 15 institution or COCF: If the inmate-patient had an existing medication order upon arrival, were medications administered or delivered without interruption? 6.004 For inmate-patients transferred out of the facility: Were scheduled 16 4 20 80.00% 0 specialty service appointments identified on the Health Care Transfer Information Form 7371? 6.101 For inmate-patients transferred out of the facility: Do medication 8 0 8 100.00% 2 transfer packages include required medications along with the corresponding Medical Administration Record (MAR) and Medication Reconciliation? Overall percentage: 92.00% California Institution for Men, Cycle 4 Medical Inspection Page 65 Office of the Inspector General State of California Scored Answers Yes Reference + Pharmacy and Medication Management Number Yes No No Yes % N/A 7.001 Did the inmate-patient receive all chronic care medications within the 32 4 36 88.89% 4 required time frames or did the institution follow departmental policy for refusals or no-shows? 7.002 Did health care staff administer or deliver new order prescription 39 1 40 97.50% 0 medications to the inmate-patients within the required time frames? 7.003 Upon the inmate-patient’s discharge from a community hospital: 24 5 29 82.76% 1 Were all medications ordered by the institution’s primary care provider administered or delivered to the inmate-patient within one calendar day of return? 7.004 For inmate-patients received from a county jail: Were all 8 5 13 61.54% 7 medications ordered by the institution’s reception center provider administered or delivered to the inmate-patient within the required time frames? 7.005 Upon the inmate-patient’s transfer from one housing unit to 28 2 30 93.33% 0 another: Were medications continued without interruption? 7.006 For inmate-patients en route who lay over at the institution: If the 5 5 10 50.00% 0 temporarily housed inmate-patient had an existing medication order, were medications administered or delivered without interruption? 7.101 All clinical and medication line storage areas for narcotic 9 0 9 100.00% 7 medications: Does the institution employ strong medication security controls over narcotic medications assigned to its clinical areas? 7.102 All clinical and medication line storage areas for non-narcotic 12 1 13 92.31% 3 medications: Does the institution properly store non-narcotic medications that do not require refrigeration in assigned clinical areas? 7.103 All clinical and medication line storage areas for non-narcotic 9 4 13 69.23% 3 medications: Does the institution properly store non-narcotic medications that require refrigeration in assigned clinical areas? 7.104 Medication preparation and administration areas: Do nursing staff 6 1 7 85.71% 9 employ and follow hand hygiene contamination control protocols during medication preparation and medication administration processes? 7.105 Medication preparation and administration areas: Does the 7 0 7 100.00% 9 institution employ appropriate administrative controls and protocols when preparing medications for inmate-patients? 7.106 Medication preparation and administration areas: Does the 6 1 7 85.71% 9 institution employ appropriate administrative controls and protocols when distributing medications to inmate-patients? 7.107 Pharmacy: Does the institution employ and follow general security, 1 0 1 100.00% 0 organization, and cleanliness management protocols in its main and satellite pharmacies? California Institution for Men, Cycle 4 Medical Inspection Page 66 Office of the Inspector General State of California Scored Answers Yes Reference + Pharmacy and Medication Management Number Yes No No Yes % N/A 7.108 Pharmacy: Does the institution’s pharmacy properly store 1 0 1 100.00% 0 non-refrigerated medications? 7.109 Pharmacy: Does the institution’s pharmacy properly store refrigerated 0 1 1 0.00% 0 or frozen medications? 7.110 Pharmacy: Does the institution’s pharmacy properly account for 1 0 1 100.00% 0 narcotic medications? 7.111 Pharmacy: Does the institution follow key medication error reporting 23 7 30 76.67% 0 protocols? 7.998 For Information Purposes Only: During eUHR compliance testing and case reviews, did the OIG find that medication errors were Information Only properly identified and reported by the institution? 7.999 For Information Purposes Only: Do inmate-patients in isolation housing units have immediate access to their KOP prescribed rescue Information Only inhalers and nitroglycerin medications? Overall percentage: 81.39% Prenatal and Post-Delivery Services Scored Answers This indicator is not applicable to this institution. Not Applicable California Institution for Men, Cycle 4 Medical Inspection Page 67 Office of the Inspector General State of California Scored Answers Yes Reference + Preventive Services Number Yes No No Yes % N/A 9.001 Inmate-patients prescribed INH: Did the institution administer the 30 0 30 100.00% 0 medication to the inmate-patient as prescribed? 9.002 Inmate-patients prescribed INH: Did the institution monitor the 23 7 30 76.67% 0 inmate-patient monthly for the most recent three months he or she was on the medication? 9.003 Annual TB Screening: Was the inmate-patient screened for TB within 18 12 30 60.00% 0 the last year? 9.004 Were all inmate-patients offered an influenza vaccination for the most 30 0 30 100.00% 0 recent influenza season? 9.005 All inmate-patients from the age 50 through the age of 75: Was the 29 1 30 96.67% 0 inmate-patient offered colorectal cancer screening? 9.006 Female inmate-patients from the age of 50 through the age of 74: Was the inmate-patient offered a mammogram in compliance with Not Applicable policy? 9.007 Female inmate-patients from the age of 21 through the age of 65: Not Applicable Was the inmate-patient offered a pap smear in compliance with policy? 9.008 Are required immunizations being offered for chronic care 25 0 25 100.00% 15 inmate-patients? 9.009 Are inmate-patients at the highest risk of coccidioidomycosis (valley Not Applicable fever) infection transferred out of the facility in a timely manner? Overall percentage: 88.89% California Institution for Men, Cycle 4 Medical Inspection Page 68 Office of the Inspector General State of California Quality of Nursing Performance Scored Answers The quality of nursing performance will be assessed during case reviews, conducted by OIG clinicians, and is not applicable for the compliance portion of the medical inspection. The methodologies OIG clinicians use to evaluate the quality of nursing Not Applicable performance are presented in a separate inspection document entitled OIG MIU Retrospective Case Review Methodology. Quality of Provider Performance Scored Answers The quality of provider performance will be assessed during case reviews, conducted by OIG clinicians, and is not applicable for the compliance portion of the medical inspection. The methodologies OIG clinicians use to evaluate the quality of Not Applicable provider performance are presented in a separate inspection document entitled OIG MIU Retrospective Case Review Methodology. California Institution for Men, Cycle 4 Medical Inspection Page 69 Office of the Inspector General State of California Scored Answers Yes Reference + Reception Center Arrivals Number Yes No No Yes % N/A 12.001 For inmate-patients received from a county jail: Did nursing staff 17 3 20 85.00% 0 complete the initial health screening and answer all screening questions on the same day the inmate-patient arrived at the institution? 12.002 For inmate-patients received from a county jail: When required, did 17 1 18 94.40% 2 the RN complete the assessment and disposition section of the health screening form, and sign and date the form on the same day staff completed the health screening? 12.003 For inmate-patients received from a county jail: If, during the 14 0 14 100.00% 6 assessment, the nurse referred the inmate-patient to a provider, was the inmate-patient seen within the required time frame? 12.004 For inmate-patients received from a county jail: Did the 20 0 20 100.00% 0 inmate-patient receive a history and physical by a primary care provider within seven calendar days? 12.005 For inmate-patients received from a county jail: Were all required 19 1 20 95.00% 0 intake tests completed within specified timelines? 12.006 For inmate-patients received from a county jail: Did the primary 17 1 18 94.44% 2 care provider review and communicate the intake test results to the inmate-patient within specified timelines? 12.007 For inmate-patients received from a county jail: Was a tuberculin 2 18 20 10.00% 0 test both administered and read timely? 12.008 For inmate-patients received from a county jail: Was a 13 7 20 65.00% 0 Coccidioidomycosis (Valley Fever) skin test offered, administered, and read timely? Overall percentage: 80.49% California Institution for Men, Cycle 4 Medical Inspection Page 70 Office of the Inspector General State of California Scored Answers Specialized Medical Housing Yes Reference + (OHU, CTC, SNF, Hospice) Number Yes No No Yes % N/A 13.001 For all higher level care facilities: Did the registered nurse complete 10 0 10 100.00% 0 an initial assessment of the inmate-patient on the day of admission, or within eight hours of admission to CMF’s Hospice? 13.002 For OHU, CTC, & SNF only: Did the primary care provider for 10 0 10 100.00% 0 OHU or attending physician for a CTC & SNF evaluate the inmate-patient within 24 hours of admission? 13.003 For OHU, CTC, & SNF only: Was a written history and physical 10 0 10 100.00% 0 examination completed within 72 hours of admission? 13.004 For all higher level care facilities: Did the primary care provider 7 0 7 100.00% 3 complete the Subjective, Objective, Assessment, Plan, and Education (SOAPE) notes on the inmate-patient at the minimum intervals required for the type of facility where the inmate-patient was treated? 13.101 For OHU and CTC Only: Do inpatient areas either have properly 1 0 1 100.00% 0 working call systems in its OHU & CTC or are 30-minute patient welfare checks performed; and do medical staff have reasonably unimpeded access to enter inmate-patient’s cells? Overall percentage: 100.00% California Institution for Men, Cycle 4 Medical Inspection Page 71 Office of the Inspector General State of California Scored Answers Yes Reference + Specialty Services Number Yes No No Yes % N/A 14.001 Did the inmate-patient receive the high-priority specialty service within 14 1 15 93.33% 0 14 calendar days of the PCP order? 14.002 Did the PCP review the high priority specialty service consultant report 13 1 14 92.86% 1 within the required time frame? 14.003 Did the inmate-patient receive the routine specialty service within 90 14 1 15 93.33% 0 calendar days of the PCP order? 14.004 Did the PCP review the routine specialty service consultant report 13 1 14 92.86% 1 within the required time frame? 14.005 For endorsed inmate-patients received from another CDCR 13 7 20 65.00% 0 institution: If the inmate-patient was approved for a specialty services appointment at the sending institution, was the appointment scheduled at the receiving institution within the required time frames? 14.006 Did the institution deny the primary care provider request for specialty 20 0 20 100.00% 0 services within required time frames? 14.007 Following the denial of a request for specialty services, was the 17 3 20 85.00% 0 inmate-patient informed of the denial within the required time frame? Overall percentage: 88.91% California Institution for Men, Cycle 4 Medical Inspection Page 72 Office of the Inspector General State of California Scored Answers Internal Monitoring, Quality Improvement, Yes Reference + and Administrative Operations Number Yes No No Yes % N/A 15.001 Did the institution promptly process inmate medical appeals during 12 0 12 100.00% 0 the most recent 12 months? 15.002 Does the institution follow adverse/sentinel event reporting Not Applicable requirements? 15.003 Did the institution Quality Management Committee (QMC) meet at 6 0 6 100.00% 0 least monthly to evaluate program performance, and did the QMC take action when improvement opportunities were identified? 15.004 Did the institution’s Quality Management Committee (QMC) or 1 0 1 100.00% 0 other forum take steps to ensure the accuracy of its Dashboard data reporting? 15.005 For each initiative in the Performance Improvement Work Plan 4 3 7 57.14% 0 (PIWP), has the institution performance improved or reached the targeted performance objective(s)? 15.006 For institutions with licensed care facilities: Does the local governing body (LGB), or its equivalent, meet quarterly and exercise Not Applicable its overall responsibilities for the quality management of patient health care? 15.007 Does the Emergency Medical Response Review Committee perform 10 2 12 83.33% 0 timely incident package reviews that include the use of required review documents? 15.101 Did the institution complete a medical emergency response drill for 0 3 3 0.00% 0 each watch and include participation of health care and custody staff during the most recent full quarter? 15.102 Did the institution’s second level medical appeal response address all 10 0 10 100.00% 0 of the inmate-patient’s appealed issues? 15.103 Did the institution’s medical staff review and submit the initial 10 0 10 100.00% 0 inmate death report to the Death Review Unit in a timely manner? 15.996 For Information Purposes Only: Did the CCHCS Death Review Committee submit its inmate death review summary to the institution Information Only timely? 15.997 For Information Purposes Only: Identify the institution’s protocols Information Only for tracking medical appeals. 15.998 For Information Purposes Only: Identify the institution’s protocols Information Only for implementing health care local operating procedures. 15.999 For Information Purposes Only: Identify the institution’s health Information Only care staffing resources. Overall percentage: 80.06% California Institution for Men, Cycle 4 Medical Inspection Page 73 Office of the Inspector General State of California Scored Answers Job Performance, Training, Licensing, and Yes Reference + Certifications Number Yes No No Yes % N/A 16.001 Do all providers maintain a current medical license? 23 0 23 100.00% 0 16.101 Does the institution’s Supervising Registered Nurse conduct periodic 0 5 5 0.00% 0 reviews of nursing staff? 16.102 Are nursing staff who administer medications current on their clinical 10 0 10 100.00% 0 competency validation? 16.103 Are structured clinical performance appraisals completed timely? 21 0 21 100.00% 0 16.104 Are staff current with required medical emergency response 2 1 3 66.67% 0 certifications? 16.105 Are nursing staff and the Pharmacist-in-Charge current with their 5 0 5 100.00% 1 professional licenses and certifications? 16.106 Do the institution’s pharmacy and authorized providers who prescribe 1 0 1 100.00% 0 controlled substances maintain current Drug Enforcement Agency (DEA) registrations? 16.107 Are nursing staff current with required new employee orientation? 1 0 1 100.00% 0 Overall percentage: 83.33% California Institution for Men, Cycle 4 Medical Inspection Page 74 Office of the Inspector General State of California APPENDIX B — CLINICAL DATA Table B-1: CIM Sample Sets Sample Set Total Anticoagulation 3 Death Review/Sentinel Events 5 Diabetes 3 Emergency Services – CPR 5 Emergency Services – Non-CPR 5 High Risk 5 Hospitalization 5 Intra-System Transfers in 3 Intra-System Transfers out 3 RN Sick Call 25 Reception Center Transfers 5 Specialty Services 4 71 California Institution for Men, Cycle 4 Medical Inspection Page 75 Office of the Inspector General State of California Table B-2 CIM Chronic Care Diagnoses Diagnosis Total Anemia 8 Anticoagulation 7 Arthritis/Degenerative Joint Disease 5 Asthma 12 COPD 6 Cancer 11 Cardiovascular Disease 14 Chronic Kidney Disease 9 Chronic Pain 8 Cirrhosis/End Stage Liver Disease 10 Coccidioidomycosis 4 DVT/PE 1 Diabetes 19 Gastroesophageal Reflux Disease 15 Gastrointestinal Bleed 2 HIV 5 Hepatitis C 23 Hyperlipidemia 21 Hypertension 40 Mental Health 16 Rheumatological Disease 2 Seizure Disorder 4 Sleep Apnea 2 Thyroid Disease 1 245 California Institution for Men, Cycle 4 Medical Inspection Page 76 Office of the Inspector General State of California Table B-3 CIM Event - Program Program Total Diagnostic Services 298 Emergency Care 70 Hospitalization 107 Intra-System Transfers in 23 Intra-System Transfers out 7 Not Specified 3 Outpatient Care 446 Reception Center Care 20 Specialized Medical Housing 577 Specialty Services 232 1783 Table B-4 CIM Case Review Sample Summary Total MD Reviews Detailed 30 MD Reviews Focused 0 RN Reviews Detailed 16 RN Reviews Focused 37 Total Reviews 83 Total Unique Cases 71 Overlapping Reviews (MD & RN) 12 California Institution for Men, Cycle 4 Medical Inspection Page 77 Office of the Inspector General State of California APPENDIX C — COMPLIANCE SAMPLING METHODOLOGY California Institution for Men Sample Category Quality (number of Indicator patients) Data Source Filters Access to Care Chronic Care Master Registry  Chronic care conditions (at least one condition per inmate-patient—any risk level) (40)  Randomize Nursing Sick Call MedSATS  Clinic (each clinic tested) (6 per clinic)  Appt. date (2–9 months) (30)  Randomize Returns from Inpatient Claims  See Health Information Management (Medical Community Hospital Data Records) (returns from community hospital) (30) Diagnostic Radiology Radiology Logs  Appt. Date (90 days–9 months) Services  Randomize (10)  Abnormal Laboratory Quest  Appt. date (90 days–9 months)  Order name (CBC or CMPs only)  Randomize (10)  Abnormal Pathology InterQual  Appt. date (90 days–9 months)  Service (pathology related) (10)  Randomize Health Timely Scanning OIG Qs: 1.001,  Non-dictated documents Information 1.002, & 1.004  First 5 inmate-patients selected for each question Management (10) (Medical OIG Q: 1.001  Dictated documents Records) (20)  First 20 inmate-patients selected OIG Qs: 14.002  Specialty documents (20) & 14.004  First 10 inmate-patients selected for each question OIG Q: 4.008  Community hospital discharge documents (20)  First 20 inmate-patients selected for the question OIG Q: 7.001  MARs (20)  First 20 inmate-patients selected Legible Signatures OIG Qs: 4.008,  First 8 inmates sampled (each test) total 40 and Review 6.001/6.002,  One source document per inmate-patient 7.001, 12.001/12.002, & (40) 14.002 Complete and Documents for  Any incorrectly scanned eUHR document Accurate Scanning any tested inmate identified during OIG eUHR file review, e.g., (all) mislabeled, misfiled, illegibly scanned, or missing Returns from Inpatient Claims  Date (2–8 months) Community Hospital Data  Most recent 6 months provided (within date range)  Rx count  Discharge date  Randomize (each month individually)  First 5 inmate-patients from each of the 6 months (if not 5 in a month, supplement from another, as (30) needed) California Institution for Men, Cycle 4 Medical Inspection Page 78 Office of the Inspector General State of California Sample Category Quality (number of Indicator patients) Data Source Filters Health Care Clinical Areas OIG Inspector  Identify and inspect all onsite clinical areas. Environment (9) Onsite Review Inter- and Intra-System SOMS  Arrival date (3–9 months) Intra-System transfers  Arrived from (another CDCR facility) Transfers  Rx count (30)  Randomize Specialty Service MedSATS  Date of Transfer (3–9 months) Send-outs  Randomize (20) Pharmacy and Chronic Care OIG Q: 1.001 See Access to Care Medication Medication  (At least one condition per inmate-patient—any Management risk level) (40)  Randomize New Medication Master Registry  Rx Count Orders  Randomize  Ensure no duplication of inmate-patients tested in (40) chronic care medications Intra-Facility moves MAPIP Transfer  Date of transfer (2–8 months) Data  To location/from location (yard to yard and to/from ASU)  Remove any to/from MHCB  NA/DOT meds (high–low)–inmate-patient must have NA/DOT meds to qualify for testing (30)  Randomize En Route SOMS  Date of transfer (2–8 months)  Sending institution (another CDCR facility)  Randomize  Length of stay (minimum of 2 days) (10)  NA/DOT meds Returns from Inpatient Claims  See Health Information Management (Medical Community Hospital Data Records) (returns from community hospital) (30) Medication OIG Inspector  Identify and inspect onsite clinical areas that Preparation and Onsite Review prepare and administer medications Administration Areas (7) Pharmacy OIG Inspector  Identify and inspect onsite pharmacies (1) Onsite Review Medication Error OIG Inspector  Any medication error identified during OIG eUHR Reporting Review (7.998) file review, e.g., case reviews and/or compliance (0) testing Prenatal and Recent Deliveries OB Roster  Delivery date (2–12 months) Post-Delivery N/A at this institution  Most recent deliveries (within date range) Services Pregnant Arrivals OB Roster  Arrival date (2–12 months) N/A at this institution  Earliest arrivals (within date range) California Institution for Men, Cycle 4 Medical Inspection Page 79 Office of the Inspector General State of California Sample Category Quality (number of Indicator patients) Data Source Filters Preventive Chronic Care OIG Q: 1.001  Chronic care conditions (at least 1 condition per Services Vaccinations inmate-patient—any risk level)  Randomize (25)  Condition must require vaccination(s) INH Maxor  Dispense date (past 9 months)  Time period on INH (at least a full 3 months) (30)  Randomize Colorectal Screening SOMS  Arrival date (at least 1 year prior to inspection)  Date of birth (51 or older) (30)  Randomize Influenza SOMS  Arrival date (at least 1 year prior to inspection) Vaccinations  Randomize  Filter out inmate-patients tested in chronic care (30) vaccination sample TB Code 22, annual SOMS  Arrival date (at least 1 year prior to inspection) TST  TB Code (22) (15)  Randomize TB Code 34, annual SOMS  Arrival date (at least 1 year prior to inspection) screening  TB Code (34) (15)  Randomize Mammogram SOMS  Arrival date (at least 2 years prior to inspection)  Date of birth (age 52–74) N/A at this institution  Randomize Pap Smear SOMS  Arrival date (at least three years prior to inspection)  Date of birth (age 24–53) N/A at this institution  Randomize Valley Fever Cocci Transfer  Reports from past 2–8 months Status Report  Institution  Ineligibility date (60 days prior to inspection date) N/A at this institution  All Reception RC SOMS  Arrival date (2–8 months) Center Arrivals  Arrived from (county jail, return from parole, etc.) (20)  Randomize Specialized OHU CADDIS  Admit date (1–6 months) Medical  Type of stay (no MH beds) Housing  Length of stay (minimum of 5 days) (10)  Randomize California Institution for Men, Cycle 4 Medical Inspection Page 80 Office of the Inspector General State of California Sample Category Quality (number of Indicator patients) Data Source Filters Specialty High-Priority MedSATS  Approval date (3–9 months) Services Access (15)  Randomize Routine MedSATS  Approval date (3–9 months)  Remove optometry, physical therapy or podiatry (15)  Randomize Specialty Service MedSATS  Arrived from (other CDCR institution) Arrivals  Date of transfer (3–9 months) (20)  Randomize Denials InterQual  Review date (3–9 months)  Randomize (1) IUMC/MAR  Meeting date (9 months) Meeting Minutes  Denial upheld (19)  Randomize Internal Medical Appeals Monthly Medical  Medical appeals (12 months) Monitoring, (all) Appeals Reports Quality Adverse/Sentinel Adverse/Sentinel  Adverse/sentinel events (2–8 months) Improvement, Events Events Report and (0) Administrative QMC Meetings Quality  Meeting minutes (6 months) Operations Management Committee (6) Meeting Minutes Performance Performance  Performance Improvement Work Plan with Improvement Plans Improvement updates (Most recent completed calendar year) (7) Work Plan Local Governing Local Governing  Meeting minutes (12 months) Body Body Meeting (0) Minutes EMRRC EMRRC  Meeting minutes (12 months) (6) Meeting Minutes Medical Emergency OIG Inspector  Most recent full quarter Response Drills Onsite Review  Each watch (3) 2nd Level Medical OIG Inspector  Medical appeals denied (6 months) Appeals Onsite Review (10) Death Reports OIG Inspector  Death reports (12 months) (10) Onsite Review Local Operating OIG Inspector  Review all Procedures Onsite Review (all) California Institution for Men, Cycle 4 Medical Inspection Page 81 Office of the Inspector General State of California Sample Category Quality (number of Indicator patients) Data Source Filters Job Performance RN Review OIG Inspector  Current Supervising RN reviews and Training, Evaluations Onsite Review Licensing, and (5) Certifications Nursing Staff OIG Inspector  Review annual competency validations Validations Onsite Review  Randomize (10) Provider Annual OIG Inspector  All required performance evaluation documents Evaluation Packets Onsite Review (all) Medical Emergency OIG Inspector  All staff Response Onsite Review o Providers (ACLS) Certifications o Nursing (BLS/CPR) (all) o Custody (CPR/BLS) Nursing staff and OIG Inspector  All licenses and certifications Pharmacist-in-charge Onsite Review Professional Licenses and Certifications (all) Pharmacy and OIG Inspector  All current DEA registrations Providers’ Drug Onsite Review Enforcement Agency (DEA) Registrations (all) Nursing Staff New OIG Inspector  New employees (within the last 12 months) Employee Onsite Review Orientations (all) California Institution for Men, Cycle 4 Medical Inspection Page 82 Office of the Inspector General State of California C C ALIFORNIA ORRECTIONAL H C S ’ EALTH ARE ERVICES R ESPONSE California Institution for Men, Cycle 4 Medical Inspection Page 83 Office of the Inspector General State of California