California Institution for Men Medical Inspection Report Cycle 5

Roy W. Wesley Office of the Inspector General Inspector General California Institution for Men Medical Inspection Results Cycle 5 January 2019 Fairness Integrity Respect Medical Inspection Unit Page 1 Office of the Inspe ctSor Geenerral vice TransparenStatce ofy Cal ifornia Office of the Inspector General CALIFORNIA INSTITUTION FOR MEN Medical Inspection Results Cycle 5 Roy W. Wesley Inspector General Bryan B. Beyer Chief Deputy Inspector General Shaun R. Spillane Public Information Officer January 2019 T C ABLE OF ONTENTS Foreword ........................................................................................................................................ i Executive Summary ...................................................................................................................... iii Overall Rating: Inadequate ........................................................................................................ iii Expert Clinician Case Review Results .................................................................................. v Compliance Testing Results................................................................................................. vi Recommendations .............................................................................................................. vii Population-Based Metrics .................................................................................................. viii Introduction ................................................................................................................................... 1 About the Institution ................................................................................................................... 1 Objectives, Scope, and Methodology.............................................................................................. 4 Case Reviews ............................................................................................................................. 5 Patient Selection for Retrospective Case Reviews ................................................................. 6 Benefits and Limitations of Targeted Subpopulation Review ................................................ 7 Case Review Sampling Methodology ................................................................................... 8 Breadth of Case Reviews ...................................................................................................... 9 Case Review Testing Methodology ..................................................................................... 10 Compliance Testing .................................................................................................................. 12 Sampling Methods for Conducting Compliance Testing ...................................................... 12 Scoring of Compliance Testing Results ............................................................................... 13 Overall Quality Indicator Rating for Case Reviews and Compliance Testing ............................. 13 Population-Based Metrics ......................................................................................................... 13 Medical Inspection Results .......................................................................................................... 14 Access to Care ............................................................................................................ 17 Case Review Results .......................................................................................................... 17 Compliance Testing Results................................................................................................ 19 Diagnostic Services .................................................................................................... 21 Case Review Results .......................................................................................................... 21 Compliance Testing Results................................................................................................ 22 Emergency Services .................................................................................................... 23 Case Review Results .......................................................................................................... 23 Health Information Management ................................................................................ 26 Case Review Results .......................................................................................................... 26 Compliance Testing Results................................................................................................ 28 Health Care Environment ........................................................................................... 30 Compliance Testing Results................................................................................................ 30 Inter- and Intra-System Transfers ............................................................................... 34 Case Review Results .......................................................................................................... 34 Compliance Testing Results................................................................................................ 37 Pharmacy and Medication Management ..................................................................... 38 Case Review Results .......................................................................................................... 38 Compliance Testing Results................................................................................................ 39 Prenatal and Post-Delivery Services ........................................................................... 44 California Institution for Men, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California Preventive Services ..................................................................................................... 45 Compliance Testing Results................................................................................................ 45 Quality of Nursing Performance................................................................................ 47 Case Review Results .......................................................................................................... 47 Quality of Provider Performance .............................................................................. 51 Case Review Results .......................................................................................................... 51 Reception Center Arrivals ......................................................................................... 56 Case Review Results .......................................................................................................... 56 Compliance Testing Results................................................................................................ 57 Specialized Medical Housing .................................................................................... 59 Case Review Results .......................................................................................................... 59 Compliance Testing Results................................................................................................ 61 Specialty Services ..................................................................................................... 63 Compliance Testing Results................................................................................................ 66 Administrative Operations (Secondary) ..................................................................... 68 Compliance Testing Results................................................................................................ 68 Recommendations ........................................................................................................................ 71 Population-Based Metrics ............................................................................................................ 72 Appendix A — Compliance Test Results ..................................................................................... 75 Appendix B — Clinical Data ....................................................................................................... 90 Appendix C — Compliance Sampling Methodology .................................................................... 94 California Correctional Health Care Services’ Response ............................................................ 101 California Institution for Men, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California L T F IST OF ABLES AND IGURES CIM Executive Summary Table ..................................................................................................... iv CIM Health Care Staffing Resources as of November 2017 ............................................................ 2 CIM Filled Positions ...................................................................................................................... 2 CIM Master Registry Data as of November 13, 2017 ...................................................................... 3 Exhibit 1. Case Review Definitions ................................................................................................ 5 Chart 1. Case Review Sample Selection .......................................................................................... 9 Chart 2. Case Review Testing and Deficiencies ............................................................................ 11 Chart 3. Inspection Indicator Review Distribution ......................................................................... 14 CIM Results Compared to State and National HEDIS Scores ........................................................ 74 Table B-1: CIM Sample Sets ........................................................................................................ 90 Table B-2: CIM Chronic Care Diagnoses ...................................................................................... 91 Table B-3: CIM Event – Program ................................................................................................. 92 Table B-4: CIM Review Sample Summary ................................................................................... 93 California Institution for Men, Cycle 5 Medical Inspection List of Tables and Figures Office of the Inspector General State of California This page intentionally left blank. California Institution for Men, Cycle 5 Medical Inspection Office of the Inspector General State of California F OREWORD Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), the OIG conducts a comprehensive inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG explicitly makes no determination regarding the constitutionality of care in the prison setting. We leave that determination 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 Penal Code mandates the OIG’s inspections, and they are not aimed at specifically resolving the court’s questions on constitutional care. To the degree that they provide another factor for the court to consider, the OIG is pleased to provide added value to the taxpayers of California. In Cycle 5, the OIG inspects institutions delegated back to CDCR from the Receivership. There is no difference in the standards used for assessment of a delegated institution versus those for an institution not yet delegated. At the time of the Cycle 5 inspection of California Institution for Men, the Receiver had delegated this institution back to CDCR (on October 7, 2016). This fifth cycle of inspections continues evaluating the areas addressed in Cycle 4, which included clinical case review, compliance testing, and a population-based metric comparison of selected Healthcare Effectiveness Data Information Set (HEDIS) measures. In agreement with stakeholders, the OIG made changes to both the case review and compliance components. The OIG found that in every inspection in Cycle 4, we took larger samples than we needed to assess the adequacy of medical care provided. As a result, the OIG reduced the number of case reviews and sample sizes for compliance testing. Also, in Cycle 4, compliance testing included two secondary (administrative) indicators (Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications). For Cycle 5, we have combined these into one secondary indicator, Administrative Operations. California Institution for Men, Cycle 5 Medical Inspection Page i Office of the Inspector General State of California This page intentionally left blank. California Institution for Men, Cycle 5 Medical Inspection Page ii Office of the Inspector General State of California E S XECUTIVE UMMARY The OIG completed the Cycle 5 medical inspection of California Institution for Men (CIM) in August 2018. The vast majority of our OVERALL RATING: inspection findings were based on CIM’s health care delivery between February 2017 and February 2018. Our policy compliance Inadequate inspectors performed an onsite inspection in November 2017. After reviewing the institution’s health care delivery, our case review clinicians performed an onsite inspection in June 2018 to follow up on their findings. Our clinician team, consisting of expert physicians and nurse consultants, reviewed cases (patient medical records) and interpreted our policy compliance results to determine the quality of health care the institution provided. Our compliance team, consisting of registered nurses, monitored the institution’s compliance with its medical policies by answering a predetermined set of policy compliance questions. Our clinician team reviewed 58 cases, which contained 1,028 patient-related events. Our compliance team tested 95 policy questions by observing CIM’s processes and examining 443 patient records and 1,366 data points. We distilled the results from both the case review and compliance testing into 14 health care indicators and have listed the individual indicators and ratings applicable for this institution in the CIM Executive Summary Table on the following page. Our experts made a considered and measured opinion that the overall quality of health care at CIM was inadequate. California Institution for Men, Cycle 5 Medical Inspection Page iii Office of the Inspector General State of California CIM Executive Summary Table Cycle 5 Cycle 4 Case Review Compliance Inspection Indicators Overall Overall Rating Rating Rating Rating 1—Access to Care Adequate Proficient Adequate Proficient 2—Diagnostic Services Proficient Proficient Proficient Proficient 3—Emergency Services Adequate Not Applicable Adequate Adequate 4—Health Information Adequate Adequate Adequate Inadequate Management 5—Health Care Environment Not Applicable Inadequate Inadequate Adequate 6—Inter- and Intra-System Inadequate Inadequate Inadequate Adequate Transfers 7—Pharmacy and Medication I Adequate Inadequate Inadequate n Adequate Management a 8—Prenatal and Post-Delivery Not Applicable Not Applicable Not Applicable Not Applicable Services 9—Preventive Services Not Applicable Adequate Adequate Proficient 10—Quality of Nursing Adequate Not Applicable Adequate Adequate Performance 11—Quality of Provider Inadequate Not Applicable Inadequate Adequate Performance 12—Reception Center Arrivals Adequate Proficient Adequate Adequate 13—Specialized Medical Housing Inadequate Proficient Inadequate Adequate 14—Specialty Services Inadequate Proficient Inadequate Adequate 15—Administrative Operations Not Applicable Proficient Proficient Adequate * (Secondary) *In Cycle 4, there were two secondary (administrative) indicators. This score reflects the average of those two scores. California Institution for Men, Cycle 5 Medical Inspection Page iv Office of the Inspector General State of California Expert Clinician Case Review Results Our expert clinicians reviewed cases of patients with many medical needs and included a review of 1,028 patient care events.1 The vast majority of our case review covered the period between August 2017 and February 2018. As depicted on the executive summary table on page iv, we rated 11 of the 14 indicators applicable to CIM. Of those 11 applicable indicators, we rated 1 proficient, 6 adequate, and 4 inadequate. When determining the overall adequacy of care, we paid particular attention to the clinical nursing and provider quality indicators, as adequate health care staff can sometimes overcome suboptimal compliance (i.e., performance with processes and programs). However, the opposite is not true; inadequate health care staff cannot provide adequate care, even though the established processes and programs may be adequate. We identified inadequate medical care based on the risk of significant harm to the patient, not the actual outcome. Program Strengths — Clinical • CIM performed well with most aspects of access to care, as most provider and nursing appointments occurred timely. • CIM performed well with diagnostic services, as the institution timely completed diagnostic tests, retrieved the results, and scanned them into the medical record. Program Weaknesses — Clinical • CIM providers performed poorly in multiple aspects of patient care, including chronic care, hospital returns, and specialty services. Providers repeatedly made errors managing diabetes and hypertension. They often failed to review and address hospital discharge and specialist recommendations. • CIM performed poorly in the outpatient housing unit (OHU). The providers demonstrated poor medical judgment and cursory reviews of specialty and hospital records. • CIM’s hospital return processes were deficient. We found many medication errors and ineffective nursing assessments for patients returning from hospitalizations. • CIM’s specialty services were unsatisfactory. CIM providers often failed to carefully review or implement specialists’ recommendations, and the institution missed several important specialty appointments. 1 Each OIG clinician team consists of a board-certified physician and a registered nurse consultant with experience in correctional and community medical settings. California Institution for Men, Cycle 5 Medical Inspection Page v Office of the Inspector General State of California Compliance Testing Results Of the 14 health care indicators applicable to CIM, compliance inspectors evaluated 11; 6 were proficient, 2 were adequate, and 3 were inadequate.2 The vast majority of our compliance testing was of medical care that occurred between February 2017 and November 2017. There were 95 individual compliance questions within those 11 indicators, generating 1,366 data points, that tested CIM’s compliance with California Correctional Health Care Services (CCHCS) policies and procedures.3 Appendix A — Compliance Test Results provides details regarding the 95 questions. Program Strengths — Compliance • CIM nursing staff and providers did an excellent job completing nursing and provider assessments of patients admitted to the OHU within the required time frame. • CIM providers timely completed history and physical examinations for patients who arrived through the institution’s reception center. In addition, nursing staff timely administered, read, and documented the results of tuberculosis (TB) skin tests for newly arrived patients. • Patients at CIM received their diagnostic services timely. Providers also did a good job reviewing diagnostic services results within the required time frame. • CIM nursing staff received and reviewed their patients’ Health Care Service Request forms (CDCR Form 7362) within CCHCS policy guidelines. • CIM scheduled timely provider follow-up appointments for chronic care patients and for those who returned from a community hospitalization. Program Weaknesses — Compliance • CIM medical clinics lacked properly calibrated medical equipment and medical supplies needed to provide standard medical care. • Nursing staff did not always timely administer medications to patients who had a temporary layover at CIM or who recently arrived at CIM from a county jail with ordered medications. • Medication lines at CIM did not follow proper security controls over narcotic medications and did not properly store non-narcotic refrigerated and non-refrigerated medications. 2 The OIG’s compliance inspectors are trained registered nurses with expertise in CDCR policies regarding medical staff and processes. 3 The OIG used its own clinicians to provide clinical expert guidance for testing compliance in certain areas where CCHCS policies and procedures did not specifically address an issue. California Institution for Men, Cycle 5 Medical Inspection Page vi Office of the Inspector General State of California • CIM performed poorly in listing approved specialty service appointments on health care transfer information forms. Recommendations The OIG recommends the following: • The chief medical executive (CME) should audit the records of patients returning from the hospital, an emergency department, or specialty consultations to ensure the providers are addressing all their patients’ diagnoses, medications, and recommendations. The CME should also consider designating the chief physician and surgeon (CP&S) or another provider to review each of these records to ensure that the institution implements any urgent recommendations. We found serious lapses in care due to poor provider performance in this area. • The CME should revamp the methods the institution uses to appraise provider performance. Although we found serious provider quality problems during this inspection, the CME was unaware of any provider performance issues. • The chief nursing executive (CNE) should also inspect the records of patients returning from a hospital or emergency department to ensure the nurses thoroughly review the discharge summaries, perform complete assessments, and implement essential recommendations. • The CNE and the pharmacist in charge should launch a quality improvement program to increase medication continuity for patients who return from an outside emergency room or hospital. We found serious problems with medication continuity for these patients during our inspection. • The CME should instruct the providers to specify the appropriate clinical time frames for specialty services within EHRS orders. The CNE should instruct the specialty department to schedule services according to those time frames. These changes should help ensure that the institution schedules specialty appointments within clinically appropriate time frames. • CCHCS should modify the specialty access policy and eliminate both “routine” and “urgent” priority time frames. Instead, CCHCS should monitor specialty access by measuring the ability of each institution to provide specialty services within the time frame specified in each EHRS order. California Institution for Men, Cycle 5 Medical Inspection Page vii Office of the Inspector General State of California Population-Based Metrics In general, CIM performed comparably to other health plans as measured by population-based metrics. In comprehensive diabetes care, CIM outperformed Medi-Cal in all five diabetic measures, and the institution outperformed Kaiser in four of the five diabetic measures. CIM scored slightly lower in diabetic blood pressure control than Kaiser, North and South regions. When compared nationally, the institution outperformed Medicaid, commercial plans, and Medicare in all five diabetic measures. The institution also outperformed the United States Department of Veterans Affairs (VA) in two of the four applicable measures, scoring slightly lower in diabetic blood pressure control and diabetic eye exams. CIM also outperformed all reporting health care plans for administering influenza vaccinations to younger and older adults, but the results were mixed regarding administering pneumococcal vaccines to older adults. With respect to colorectal cancer screening, CIM scored higher than commercial plans and Medicare, but lower than Kaiser (North and South) and the VA. California Institution for Men, Cycle 5 Medical Inspection Page viii Office of the Inspector General State of California I NTRODUCTION Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), and at the request of the federal Receiver, the OIG developed a comprehensive medical inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG conducted a clinical case review and a compliance inspection, ensuring a thorough, end-to-end assessment of medical care within CDCR. California Institution for Men (CIM) was the 33rd medical inspection of Cycle 5. During the inspection process, the OIG assessed the delivery of medical care to patients using the primary clinical health care indicators applicable to the institution. The Administrative Operations indicator is secondary because it does not reflect the actual clinical care provided. ABOUT THE INSTITUTION Opened in 1941, the California Institution for Men (CIM) is located in San Bernardino County. The institution’s primary mission is to provide housing and programming for the general population and sensitive needs (Level II) patients. The California Institution for Men is a large complex consisting of four separate facilities: Facilities A and C primarily house Level II sensitive needs yard custody patients; Facility D houses general population patients and is designated as a Secure Level I; Facility B houses medium- and maximum-custody-level patients and also serves as a reception center, receiving and processing male patients who have been newly committed to CDCR, primarily from Riverside and San Diego Counties. The institution operates ten medical clinics where health care staff members handle routine requests for medical services. In addition, CIM operates a triage and treatment area (TTA) for urgent and emergent patient care, a receiving and release (R&R) clinic for assessment of arriving and departing patients, and its licensed correctional treatment center (CTC) for patients requiring inpatient care. In its outpatient housing unit (OHU), CIM also treats patients requiring assistance with the activities of daily living but who do not require a higher level of inpatient care. CCHCS has designated CIM as an “intermediate” health care institution. These institutions are predominantly located in or near urban areas, close to tertiary care centers and specialty care providers for the most cost-effective care. The institution first received national accreditation from the Commission on Accreditation for Corrections in August 2016. This accreditation program is a professional peer review process based on national standards set by the American Correctional Association. California Institution for Men, Cycle 5 Medical Inspection Page 1 Office of the Inspector General State of California Based on staffing data the OIG obtained from CCHCS as identified in the following CIM Health Care Staffing Resources as of November 2017 table, CIM’s vacancy rate among nursing staff was 14.73 positions in November 2017. At the time of the OIG’s inspection, CIM had three nursing staff on extended leave. CIM Health Care Staffing Resources as of November 2017 Primary Executive Care Nursing Nursing Leadership* Providers Supervisors Staff** Total Authorized Positions 6.00 18.00 16.88 185.53 226.41 Filled by Civil Service 6.00 18.00 17.00 170.80 211.80 Vacant 0.00 0.00 (0.12) 14.73 14.61 Percent Filled by Civil Service 100.00% 100.00% 100.71% 92.06% 93.55% Filled by Telemed N/A 0.00 N/A N/A 0.00 Percent Filled by Telemed N/A 0.00% N/A N/A 0.00% Filled by Registry 0.00 0.00 0.00 28.28 28.28 Percent Filled by Registry 0.00% 0.00% 0.00% 15.24% 12.49% Total Filled Positions 6.00 18.00 17.00 199.08 240.08 Total Percentage Filled 100.00% 100.00% 100.71% 107.30% 106.04% Appointments in last 12 Months 1.00 1.00 6.00 25.00 33.00 Redirected Staff 0.00 0.00 0.00 1.00 1.00 Staff on Extended Leave^ 0.00 0.00 0.00 3.00 3.00 Adjusted Total: Filled Positions 6.00 18.00 17.00 195.08 236.08 Adjusted Total: Percentage Filled 100.00% 100.00% 100.71% 105.15% 104.27% *Executive Leadership includes Chief Physician & Surgeon **Nursing Staff includes Sr Psych Tech/Psych Tech ^In Authorized Positions Note: The OIG did not validate the CIM Health Care Staffing Resources and Filled Positions data. California Institution for Men, Cycle 5 Medical Inspection Page 2 Office of the Inspector General State of California As of November 13, 2017, the Master Registry for CIM showed that the institution had a total population of 3,610. Within that total population, CDCR designated 16.4 percent as high medical risk, Priority 1 (High 1), and 30.4 percent as high medical risk, Priority 2 (High 2). Patients’ assigned risk levels are based on the complexity of their required medical care related to their specific diagnoses, frequency of higher levels of care, age, and abnormal laboratory results and procedures. High 1 has at least two high-risk conditions; High 2 has only one. Patients at high medical risk are more susceptible to poor health outcomes than those at medium or low medical risk. Patients at high medical risk also typically require more health care services than do patients with lower assigned risk levels. The following table 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 13, 2017 Medical Risk Level Number of Patients Percentage High 1 592 16.4% High 2 1,099 30.4% Medium 974 27.0% Low 945 26.2% Total 3.610 100% California Institution for Men, Cycle 5 Medical Inspection Page 3 Office of the Inspector General State of California O , S , M BJECTIVES COPE AND ETHODOLOGY In designing the medical inspection program, the OIG reviewed CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. The OIG also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the Receiver’s office, CDCR, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of the OIG’s inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates medical care delivery by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population-based metrics. To maintain a metric-oriented inspection program that evaluates medical care delivery consistently at each state prison, the OIG identified 15 indicators (14 primary (clinical) indicators and one secondary (administrative) indicator) of health care to measure. The primary quality indicators cover clinical categories directly relating to the health care provided to patients, whereas the secondary quality indicator addresses the administrative functions that support a health care delivery system. The CIM Executive Summary Table on page iv of this report identifies these 15 indicators. The OIG rates each of the quality indicators applicable to the institution under inspection based on case reviews conducted by OIG clinicians and compliance tests conducted by OIG registered nurses. The case review results alone, the compliance test results alone, or a combination of both these information sources may determine or influence an indicator’s overall rating. For example, the OIG derives the ratings for the primary quality indicators Quality of Nursing Performance and Quality of Provider Performance entirely from the case review done by clinicians, while we derive the ratings for the primary quality indicators Health Care Environment and Preventive Services entirely from compliance testing done by registered nurse inspectors. As another example, primary quality indicators such as Diagnostic Services and Specialty Services receive ratings derived from both sources. The OIG does not inspect for efficiency or cost-effectiveness of medical operations. Consistent with the OIG’s agreement with the Receiver, this report only addresses the quality of CDCR’s medical operations and its compliance with quality-related policies. Moreover, if the OIG learns of a patient needing immediate care, the OIG notifies the chief executive officer of health care services and requests a status report. Additionally, if the OIG learns of significant departures from community standards, it may report such departures to the institution’s chief executive officer or to CCHCS. Because these matters involve confidential medical information protected by state and federal privacy laws, the OIG does not include specific identifying details related to any such cases in the public report. California Institution for Men, Cycle 5 Medical Inspection Page 4 Office of the Inspector General State of California 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 are not necessarily indicative of deficient medical care delivery. CASE REVIEWS The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders, which continue in the Cycle 5 medical inspections. The following exhibit provides definitions that describe this process. Exhibit 1. Case Review Definitions Case = Sample = Patient An appraisal of the medical care provided to one patient over a specific period, which can comprise detailed or focused case reviews. Detailed Case Review A review that includes all aspects of one patient’s medical care assessed over a six-month period. This review allows the OIG clinicians to examine many areas of health care delivery, such as access to care, diagnostic services, health information management, and specialty services. Focused Case Review A review that focuses on one specific aspect of medical care. This review tends to concentrate on a singular facet of patient care, such as the sick call process or the institution’s emergency medical response. Case Review Event A direct or indirect interaction between the patient and the health care system. Examples of direct interactions include provider encounters and nurse encounters. An example of an indirect interaction includes a provider reviewing a diagnostic test and placing additional orders. Case Review Deficiency A medical error in procedure or in clinical judgment. Both procedural and clinical judgment errors can result in policy non-compliance, elevated risk of patient harm, or both. Adverse Deficiency A medical error that increases the risk of, or results in, serious patient harm. Most health care organizations refer to these errors as adverse events. California Institution for Men, Cycle 5 Medical Inspection Page 5 Office of the Inspector General State of California The OIG’s clinicians perform a retrospective case review of selected patient files to evaluate the care given by an institution’s primary care providers and nurses. Retrospective case review is a well-established review process used by health care organizations that perform peer reviews and patient death reviews. Currently, CCHCS uses retrospective case review as part of its death review process and in its pattern-of-practice reviews. CCHCS also uses a more limited form of retrospective case review when performing appraisals of individual primary care providers. Patient Selection for Retrospective Case Reviews Because retrospective case review is time consuming and requires qualified health care professionals to perform it, the OIG must carefully select a sample of patient records for clinician review. Accordingly, the group of patients the OIG targeted for case review carried the highest clinical risk and utilized the majority of medical services. The majority of patients selected for retrospective case review were high-utilizing patients with chronic care illnesses who were classified as high or medium risk. The reason the OIG targeted these patients for review is twofold: 1. The goal of retrospective case review is to evaluate all aspects of the health care system. Statewide, high-utilization patients consume medical services at a disproportionate rate. Between October 2011 and March 2012, 9 percent of the total statewide adult patient population was classified as high-risk and accounted for more than half of CCHCS’s pharmaceutical, specialty, community hospital, and emergency costs.4 This disproportionate utilization of health care resources was consistent with that observed in the general U.S. population. Based on the 2010 Medical Expenditure Panel Survey data, 5 percent of the U.S. population accounted for 50 percent of health care costs.5 By May 2018, the proportion of high-risk patients increased to 13.6 percent of the statewide adult patient population.6 2. Selecting this target group for case 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- and medium-risk patients for detailed case review, the OIG clinical experts made the following three assumptions: 4 California Correctional Health Care Services (CCHCS) Quality Management Section, High-Risk Patient Performance Report – Appropriate Placement in the CCHCS Primary Care Environment, August 2012; https://cchcs.ca.gov/wp-content/uploads/sites/60/2017/08/T21_20120915_Appendix6.pdf (accessed 9-10-18). 5 S.B. Cohen, The Concentration and Persistence in the Level of Health Expenditures Over Time: Estimates for the U.S. Population, 2009–2010 (Rockville, MD: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, 2012); https://meps.ahrq.gov/data_files/publications/st392/stat392.shtml (accessed 9-10-18). 6 CCHCS Public Dashboard, Statewide, May 2018; https://cchcs.ca.gov/wp-content/uploads/sites/60/2018/08/ Public-Dashboard-2018-05.pdf (accessed 9-10-18). California Institution for Men, Cycle 5 Medical Inspection Page 6 Office of the Inspector General State of California 1. If the institution is able to provide adequate clinical care to the most challenging patients with multiple complex and interdependent medical problems, it is more likely to provide 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 cases generated during death reviews, sentinel events (unexpected occurrences involving death or serious injury, or risk thereof), and hospitalizations are more likely to comprise high-risk patients. Benefits and Limitations of Targeted Subpopulation Review Because the patients selected utilize the broadest range of services offered by the health care system, the OIG’s retrospective case review provides adequate data for a qualitative assessment of the most vital system processes (referred to as “primary quality indicators”). Retrospective case 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 institution’s ability to respond with adequate medical 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 respond adequately 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 medical conditions or outcomes from the retrospective case reviews to the general population. For example, if the high-risk diabetic patients reviewed have poorly controlled diabetes, one cannot conclude that all the diabetics’ conditions are poorly controlled. Similarly, if the high-risk diabetic patients under review have poor outcomes, one cannot conclude that the entire diabetic population is having similarly poor outcomes. The OIG does not extrapolate conditions or outcomes, but instead extrapolates the institution’s response for those patients needing the most care because the response yields valuable system information. California Institution for Men, Cycle 5 Medical Inspection Page 7 Office of the Inspector General State of California In the above example, if the institution responds by providing appropriate diabetic monitoring, medication therapy, and specialty referrals for the high-risk patients reviewed, then it is reasonable to infer that the institution is also responding appropriately to all the diabetics in the prison. However, if these same high-risk patients needing monitoring, medications, and referrals are not getting those needed services, it is likely that the institution is not providing appropriate diabetic services. Case Review Sampling Methodology Using a pre-defined case review sampling algorithm, OIG analysts apply various filters to each institution’s patient population. The various filters include medical risk status, number of prescriptions, number of specialty appointments, number of clinic appointments, and other health-related data. The OIG uses these filters to narrow down the population to those patients with the highest utilization of medical resources (see Chart 1, next page). To prevent selection bias, the OIG ensures that the same clinicians who perform the case reviews do not participate in the sample selection process. California Institution for Men, Cycle 5 Medical Inspection Page 8 Office of the Inspector General State of California Chart 1. Case Review Sample Selection Sample Selection Analysts apply filters to the population to obtain samples (S) with high utilization. Six permutations, Population or arrangements, of case review types are possible for each sample. S S MD RN MD RN MD RN S S S S D F D D F D Case = Sample = Patient MD RN RN D D F MD = Provider RN = Registered Nurse D = Detailed Review F = Focused Review The OIG’s case sample sizes matched those of other qualitative research. The empirical findings, supported by expert statistical consultants, showed adequate conclusions after 10 to 15 cases had undergone comprehensive, or detailed, clinician review. In qualitative statistics, this phenomenon is known as “saturation.” The OIG found the Cycle 4 medical inspection sample size of 30 for detailed physician reviews far exceeded the saturation point necessary for an adequate qualitative review. At the end of Cycle 4 inspections, the OIG re-analyzed the case review results using half the number of cases; there were no significant differences in the ratings. To improve inspection efficiency while preserving the quality of the inspection, the OIG reduced the number of the samples for Cycle 5 medical inspections to the current levels. For most basic institutions, the OIG samples 20 cases for detailed physician review. For intermediate institutions and several basic institutions with larger high-risk populations, the OIG samples 25 cases. For California Health Care Facility, the OIG samples 30 cases for detailed physician review. Breadth of Case Reviews As indicated in Appendix B, Table B-1: CIM Sample Sets, the OIG clinicians evaluated medical records for 58 unique cases. Appendix B, Table B-4: CIM Case Review Sample Summary clarifies that both nurses and physicians reviewed 16 of those cases, for 74 case reviews in total. Physicians performed detailed reviews of 27 cases, and nurses performed detailed reviews of 14 cases, totaling 41 detailed case reviews. Nurses also performed a focused review of an additional 33 cases. These reviews generated 1,028 case review events (Appendix B, Table B-3: CIM Event – Program). California Institution for Men, Cycle 5 Medical Inspection Page 9 Office of the Inspector General State of California While the sample method specifically pulled only 6 chronic care cases, i.e., 3 diabetes cases and 3 anticoagulation cases (Appendix B, Table B-1: CIM Sample Sets), the 58 unique cases sampled included 231 chronic care diagnoses, including 16 additional cases with diabetes (for a total of 19) and 1 additional anticoagulation case (for a total of 4) (Appendix B, Table B-2: CIM Chronic Care Diagnoses). The OIG’s sample selection tool allowed evaluation of many chronic care programs because the complex and high-risk patients selected from the different categories often had multiple medical problems. While the OIG did not evaluate every chronic disease or health care staff member, the OIG did assess for adequacy the overall operation of the institution’s system and staff. Case Review Testing Methodology A physician, a nurse consultant, or both clinician inspectors review each case. The OIG clinician inspector can perform one of two different types of case review: detailed or focused (see Exhibit 1, page 5, and Chart 1, previous page). As the OIG clinician inspector reviews the medical record for each case, the inspector records pertinent interactions between the patient and the health care system. These interactions are also known as case review events. When an OIG clinician inspector identifies a medical error, the inspector also records these errors as case review deficiencies. If a deficiency is of such magnitude that it caused or had the potential to cause serious patient harm, then the OIG clinician records it as an adverse deficiency (see Chart 2, next page). California Institution for Men, Cycle 5 Medical Inspection Page 10 Office of the Inspector General State of California Chart 2. Case Review Testing and Deficiencies Case Review Testing The OIG clinicians examine the chosen samples, performing a detailed case review or a focused case review, to determine the events that occurred. Sample = Patient = Case No Deficiency Sample Events Deficiency A sample leading to events Deficiencies Not all events lead to deficiencies (medical errors); however, if there are errors, then the OIG clinicians determine whether any are adverse. Sample Events Deficiency* A sample leading to events with deficiencies observed Adverse * If a deficiency is serious Deficiency enough, the OIG clinician labels it adverse. When the OIG clinician inspectors have reviewed all cases, they analyze the deficiencies. OIG inspectors search for similar types of deficiencies to determine if a repeating pattern of errors exists. When the same type of error occurs multiple times, the OIG inspectors identify those errors as findings. When the error is frequent, the likelihood is high that the error is regularly occurring at the institution. The OIG categorizes and summarizes these deficiencies in one or more health care quality indicators in this report to help the institution focus on areas for improvement. California Institution for Men, Cycle 5 Medical Inspection Page 11 Office of the Inspector General State of California Additionally, the OIG physicians also rate each of the detailed physician cases for adequacy based on whether the institution met the patient’s medical needs and if it placed the patient at significant risk of harm. The cumulative analysis of these cases gives the OIG clinicians additional perspective to help determine whether the institution is providing adequate medical services or not.7 Based on the collective results of clinicians’ case reviews, the OIG clinicians rated each quality indicator proficient (excellent), adequate (passing), or inadequate (failing). A separate confidential CIM Supplemental Medical Inspection Results: Individual Case Review Summaries report details the case reviews the 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 Our registered nurse inspectors attained answers to 95 objective medical inspection test (MIT) questions designed to assess the institution’s compliance with critical policies and procedures applicable to the delivery of medical care. To conduct most tests, inspectors randomly selected samples of patients for whom the testing objectives were applicable and reviewed their electronic health records. In some cases, inspectors used the same samples to conduct more than one test. In total, inspectors reviewed health records for 447 individual patients and analyzed specific transactions within their records for evidence that critical events occurred. Inspectors also reviewed management reports and meeting minutes to assess certain administrative operations. In addition, during the week of November 27, 2017, field registered nurse 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 1,366 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 infrastructure, protocols for tracking medical appeals and local operating procedures, and staffing resources. 7 Regarding individual provider performance, the OIG did not design the medical inspection to be a focused search for poorly performing providers; rather, the inspection assesses each institution’s systemic health care processes. Nonetheless, while the OIG does not purposefully sample cases to review each provider at the institution, the cases usually involve most of the institutions’ providers. Providers should only escape OIG case review if institutional managers assigned poorly performing providers the care of low-utilizing and low-risk patients, or if the institution had a relatively high number of providers. California Institution for Men, Cycle 5 Medical Inspection Page 12 Office of the Inspector General State of California 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 After compiling the answers to the 95 questions for the 11 applicable indicators, the OIG derived a score for each quality indicator by calculating the percentage score of all Yes answers for each of the questions applicable to a particular indicator, then averaging those scores. Based on those results, the OIG assigned a rating to each quality indicator of proficient (greater than 85.0 percent), adequate (between 75.0 percent and 85.0 percent), or inadequate (less than 75.0 percent). OVERALL QUALITY INDICATOR RATING FOR CASE REVIEWS AND COMPLIANCE TESTING The OIG derived the final rating for each quality indicator by considering the ratings from the case reviews and from the compliance testing, as applicable. The case review evaluations and the compliance testing results usually agreed, but there were instances for this inspection when the rating differed for particular quality indicators. In those instances, the inspection team assessed the quality indicator based on the collective ratings from both components. Specifically, the OIG clinicians and registered nurse inspectors discussed the nature of individual deficiencies found within that indicator category and considered the overall effect on the ability of patients to receive adequate medical care. To derive an overall assessment rating of the institution’s medical inspection, the OIG evaluated the various ratings assigned to each of the quality indicators applicable to the institution, giving more weight to those indicators that directly relate to the health care provided to patients. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed. POPULATION-BASED METRICS The OIG identified a subset of Healthcare Effectiveness Data Information Set (HEDIS) measures applicable to the CDCR patient population. To identify outcomes for CIM, the OIG reviewed some of the compliance testing results, randomly sampled additional 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 5 Medical Inspection Page 13 Office of the Inspector General State of California M I R EDICAL NSPECTION ESULTS The OIG’s case review and clinician teams use quality indicators to assess the clinical aspects of health care. The CIM Executive Summary Table on page iv of this report identifies the 14 indicators applicable to this institution. The following chart depicts their union and intersection: Chart 3. Inspection Indicator Review Distribution The Administrative Operations indicator is a secondary indicator; therefore, the OIG did not rely upon this indicator when determining the institution’s overall score. Based on the analysis and results in all the primary indicators, the OIG experts made a considered and measured opinion that the quality of health care at CIM was inadequate. Summary of Case Review Results: The clinical case review component assessed 11 of the 14 indicators applicable to CIM. Of these 11 indicators, OIG clinicians rated 1 proficient, 6 adequate, and 4 inadequate. The OIG physicians rated the overall adequacy of care for each of the 27 detailed case reviews they conducted. Of these 27 cases, 1 was proficient, 14 were adequate, and 12 were inadequate. In the 1,028 events reviewed, there were 220 deficiencies, 60 of which were considered to be of such magnitude that, if left unaddressed, they would likely contribute to patient harm. Adverse Deficiencies Identified During Case Review: Adverse deficiencies are medical errors that markedly increased the risk of or resulted in serious patient harm. Medical care is a complex and dynamic process with many moving parts, subject to human error even within the best health care organizations. Major health care organizations typically identify and track adverse deficiencies for the purpose of quality improvement. Adverse deficiencies are not typically representative of California Institution for Men, Cycle 5 Medical Inspection Page 14 Office of the Inspector General State of California medical care delivered by the organization. We normally identify adverse deficiencies for the dual purposes of quality improvement and the illustration of problematic patterns of practice found during the inspection. Because of the anecdotal nature of these deficiencies, we caution against drawing inappropriate conclusions regarding the institution based solely on adverse deficiencies. We identified six adverse deficiencies in the case reviews at CIM: • In case 6, the patient had aortic stenosis (narrowing of the aorta), which had progressed from mild to moderate severity and required monitoring. The provider did not address the aortic stenosis during any of the patient’s chronic care or follow-up visits. The provider also did not realize that the patient’s cardiology follow-up appointment did not occur. After more than a year of lapsed care, the patient developed chest pain and shortness of breath with exertion, as well as dizziness. The provider failed to consider that the patient’s symptoms may have been due to his worsening aortic stenosis. Subsequently, the patient lost consciousness and required CPR. Unfortunately, the resuscitation was unsuccessful, and the patient died. The inappropriate management of the patient’s aortic stenosis placed the patient at risk of harm and may have contributed to his death. We also discuss this case in the Quality of Provider Performance indicator. • In case 18, the patient had no previous tuberculosis (TB) infection and no prior abnormal TB tests. A provider reviewed a newly positive TB blood test that suggested the patient had developed latent or active TB infection. Active pulmonary TB would require staff to place the patient in respiratory isolation to prevent the spread of the disease to other inmates and prison staff. Nonetheless, on subsequent visits, the provider did not address the positive test and did not obtain a chest X-ray to assess for possible active TB infection. The institution did not address the abnormal TB test until the OIG notified CCHCS about this lapse in care. Fortunately, subsequent tests showed no evidence of active TB. We also discuss this case in the Quality of Provider Performance indicator. • In case 24, the elderly patient with previous gastrointestinal bleeding had two consecutive laboratory tests that showed significantly worsening anemia. Also, the patient had signs and symptoms of anemia, including fatigue, dizziness, and an abnormally rapid heart rate. Furthermore, the patient had dark stool, which was even more suggestive of gastrointestinal bleeding. The provider should have transferred the patient to a community hospital for further evaluation but did not. This error placed the patient at risk of life-threatening complications of anemia and bleeding. We also discuss this case in the Quality of Provider Performance indicator. • Also in case 24, the patient returned from hospitalization with the diagnosis of a left kidney mass suspicious for cancer. The hospital physician recommended the patient see a urologist to follow up on the mass. The provider did not properly review the hospital records and failed to address the left kidney mass. The provider’s error placed the patient at risk for delayed or untreated kidney cancer. We also discuss this case in the Quality of Provider California Institution for Men, Cycle 5 Medical Inspection Page 15 Office of the Inspector General State of California Performance and Specialized Medical Housing indicators. • In case 27, the patient had an abnormal test showing blood in the stool. Some conditions that can cause blood in the stool include intestinal bleeding and intestinal cancer. Although the provider signed the test result, the provider did not address the abnormal test. This oversight placed the patient at risk of serious complications from possible intestinal bleeding or cancer. We also discuss this case in the Quality of Provider Performance indicator. • In case 29, the patient was diagnosed at his previous CDCR institution with lung cancer. The cancer was invading the patient’s right main bronchus. The patient was symptomatic and was coughing up blood. The sending institution transferred the patient to CIM promptly for urgent treatment because there were no oncology services available near the sending institution. When the patient arrived at CIM, the provider failed to request an urgent oncology consultation. Instead, the provider ordered a routine (90-day) referral, which contributed to a three- and half-month delay in the patient’s cancer treatment. We also discuss this case in the Quality of Provider Performance indicator. Summary of Compliance Results: The compliance component assessed 11 of the 14 indicators applicable to CIM. Of these 11 indicators, OIG inspectors rated 6 proficient, 2 adequate, and 3 inadequate. Each section of this report summarizes the results of those assessments, and Appendix A provides the details of the test questions used to assess compliance for each indicator. California Institution for Men, Cycle 5 Medical Inspection Page 16 Office of the Inspector General State of California ACCESS TO CARE This indicator evaluates the institution’s ability to provide patients Case Review Rating: with timely clinical appointments. Compliance and case review Adequate teams review areas specific to patients’ access to care, such as initial Compliance Score: Proficient assessments of newly arriving patients, acute and chronic care (86.2%) follow-ups, face-to-face nurse appointments when patients request to be seen, provider referrals from nursing lines, and follow-ups after Overall Rating: hospitalization or specialty care. Compliance testing for this Adequate indicator also evaluates whether patients have Health Care Services Request forms (CDCR Form 7362) available in their housing units. For this indicator, the case review and compliance review processes yielded different results, with the case reviewers assigning an adequate rating and the compliance testing resulting in a proficient score. Case review testing found issues with wound care appointments, nurse follow-ups, and provider follow-ups after specialty services. Because the institution had room to improve in those areas, we determined that the overall rating for this indicator was adequate. Case Review Results We reviewed 653 provider, nurse, specialty, and hospital events that required follow-up appointments. We identified seven deficiencies relating to access to care, five of which were significant. Although the total number of deficiencies was low, the pattern and severity of those deficiencies suggested that the institution had room for improvement with registered nurse (RN) follow-ups, specialty access, and primary care provider follow-ups after specialty services. The case review rating for the Access to Care indicator was adequate. Provider-to-Provider Follow-up Appointments Provider-ordered follow-up appointments are essential elements of access to care. CIM performed well with these appointments. We reviewed 48 provider-initiated follow-ups, and all the appointments occurred timely. Provider-to-Nurse Appointments The OIG clinicians reviewed five providers’ requests for nursing follow-ups and identified two deficiencies. RN Sick Call Access CIM performed well with sick call access. We reviewed 47 sick call face-to-face events, and CIM scheduled sick call appointments timely. California Institution for Men, Cycle 5 Medical Inspection Page 17 Office of the Inspector General State of California Nurse-to-Provider Referrals Sick call nurses assess patients and make referrals to a provider if indicated. The OIG clinicians reviewed 15 nurse-initiated provider referrals, and CIM performed well as there were no deficiencies. Nurse Follow-up Appointments CIM had difficulty ensuring nurse follow-up appointments. The OIG clinicians reviewed nine cases requiring a nurse follow-up and identified missed appointments in the following cases: • In cases 17 and 58, the nurses did not perform wound care as requested. • In case 31, the appointment with the RN care management did not occur. Intra-System Transfers CIM performed well ensuring timely provider and RN appointments for patients who transferred in from other CDCR facilities, and all pending specialty appointments occurred timely. Follow-up After Hospitalization CDCR providers should see patients returning from a hospitalization within a time frame that ensures patient safety and optimal clinical outcomes, but in no case later than five days after the discharge date. CIM performed very well with these appointments. We reviewed 33 hospital return events, and all provider follow-ups occurred timely. Specialized Medical Housing CIM providers timely completed history and physical examinations for all newly admitted outpatient housing unit (OHU) patients and saw the patients regularly. We found no deficiencies in this category. Access to Specialty Services CIM did not consistently provide access to specialty appointments. We identified three significant deficiencies with follow-up specialty appointments, which we discuss in the Specialty Services indicator. California Institution for Men, Cycle 5 Medical Inspection Page 18 Office of the Inspector General State of California Provider Follow-up After Specialty Service Visits CIM did not consistently provide follow-ups for patients returning from specialty appointments. In 25 cases in which the patient received a specialty service, two contained significant deficiencies: • In case 19, the patient saw a specialist who recommended a computed tomography (CT) scan to follow up on the patient’s lung cancer. When the patient returned from the specialist, the provider follow-up appointment after the specialty consult did not occur. Without a scheduled follow-up, the patient was at risk for a lapse in care. • In case 21, the patient saw a specialist who recommended a needle biopsy of the patient’s lymph nodes. The required 14-day provider follow-up appointment did not occur. Without a scheduled follow-up, the patient was at risk for a lapse in care. Follow-up After Urgent/Emergent Care CIM performed well scheduling provider follow-up after staff discharged patients from the triage and treatment area (TTA). All provider appointments occurred within the appropriate time frame. Clinician Onsite Inspection During the onsite visit, clinic nurses reported seeing an average of 10 patients each day in the RN clinics. Providers reported seeing an average of 8 to 12 patients each day. Each of the five clinics had a designated office technician (OT) who attended daily clinic huddles and coordinated with the providers to ensure that they scheduled all important follow-up appointments. The OTs reported that there were no provider or nursing appointment backlogs. Case Review Conclusion CIM performed well in most aspects of the Access to Care indicator, as the OTs usually ensured that most provider, nursing, and specialty appointments occurred timely. However, the institution should provide improved nurse access to wound care and nurse follow-ups. The institution should ensure timely follow-up specialty appointments, as well as more reliable access to providers after the patients return from a specialty appointment. The OIG clinicians rated this indicator adequate. Compliance Testing Results The institution performed in the proficient range with a compliance score of 86.2 percent in the Access to Care indicator. The following tests earned scores in the proficient range: • We sampled 25 patients who suffered from one or more chronic care conditions; 22 patients (88.0 percent) timely received their provider-ordered follow-up appointments. Two patients received chronic care appointments from 1 to 35 days late; and for the remaining patient, California Institution for Men, Cycle 5 Medical Inspection Page 19 Office of the Inspector General State of California chronic care follow-up did not occur at all (MIT 1.001). • We sampled 30 Health Care Services Request forms (CDCR Forms 7362) submitted by patients across all facility clinics. Nursing staff reviewed all service request forms the same day they collected them (MIT 1.003). • Nursing staff completed timely face-to-face triage encounters for 29 of 30 sampled patients (96.7 percent). For one patient, the nurse conducted the visit one day late (MIT 1.004). • Providers conducted timely follow-up appointments for all 25 sampled patients who were discharged from a community hospital (MIT 1.007). Three tests received scores in the adequate range: • Among 25 patients sampled who transferred into CIM from other institutions and whom nursing staff referred to a provider based on the initial health care screening, providers timely saw 20 (80.0 percent). Five patients received provider appointments between 1 and 26 days late (MIT 1.002). • We sampled 28 patients who received high-priority or routine specialty services; 21 of them (75.0 percent) received a timely follow-up appointment. Three patients’ high-priority specialty service follow-up appointments were 1 to 25 days late. Two patients’ routine specialty service follow-up appointments were 7 and 13 days late. For one patient, the provider failed to discuss the routine specialty service result during a follow-up visit, and for the remaining one patient, the routine specialty service follow-up appointment did not occur at all (MIT 1.008). • Patients had access to health care services request forms at five of six housing units (83.3 percent). One inspected housing unit did not have a system in place for reordering health care request forms (CDCR Form 7362) and did not have a secured lockable box for patients to submit their requests confidentially (MIT 1.101). The OIG inspectors found room for improvement in the following area: • We sampled three health care services request forms on which the nurse referred the patient for a provider appointment. Two patients (66.7 percent) received a timely appointment. One patient did not receive a provider visit at all (MIT 1.005). California Institution for Men, Cycle 5 Medical Inspection Page 20 Office of the Inspector General State of California DIAGNOSTIC SERVICES This indicator addresses several types of diagnostic services. Case Review Rating: Specifically, it addresses whether radiology and laboratory services Proficient were timely provided to patients, whether primary care providers Compliance Score: Proficient timely reviewed results, and whether providers communicated results (87.8%) to the patient within required time frames. In addition, for pathology services, the OIG determines whether the institution received a final Overall Rating: pathology report and whether the provider timely reviewed and Proficient 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 We reviewed 154 diagnostic services and found only four deficiencies, two of which were significant. CIM performed very well in this indicator. The case review rating for this indicator was proficient. Test Completion CIM demonstrated an effective laboratory process, as the institution completed nearly all laboratory tests, X-rays, onsite ultrasounds, computerized tomography (CT) scans, and magnetic resonance imaging (MRI) scans promptly. We found only two tests that were not completed: • In case 20, the patient agreed to undergo colon cancer screening. The nurse dispensed the fecal occult blood test (FOBT) cards; however, staff never collected and processed the cards and never performed the test. • In case 24, a provider ordered a blood test, but the staff did not perform the test. Health Information Management CIM retrieved and scanned laboratory reports, diagnostic procedure reports, and pathology reports into the medical records timely, and the providers reviewed the diagnostic reports promptly. Clinician Onsite Inspection CIM had an effective tracking process to ensure that staff completed diagnostic procedures timely. The phlebotomists went to each yard to draw blood tests, except in D yard where the patients went directly to the laboratory for blood tests. When patients needed urgent laboratory tests, an RN obtained the sample and arranged the expedited handling and processing of the tests. When California Institution for Men, Cycle 5 Medical Inspection Page 21 Office of the Inspector General State of California the TTA RN received a laboratory test result with critically abnormal values, the RN promptly notified a provider to ensure proper care. Case Review Conclusion CIM performed well in this indicator. Deficiencies were rare, and the OIG clinicians identified no patterns of problems. We rated the Diagnostic Services indicator at CIM proficient. Compliance Testing Results The institution received a proficient compliance score of 87.8 percent in the Diagnostic Services indicator, which encompasses radiology, laboratory, and pathology services. For clarity, we discuss each type of diagnostic service separately below: Radiology Services • All of the radiology services sampled were timely performed, and the test results were timely communicated to the patients (MIT 2.001, 2.002). While the provider reviewed the reports timely for nine of the ten samples (90.0 percent), one sample was reviewed four days late (MIT 2.003). Laboratory Services • Eight of ten sampled patients (80.0 percent) received their provider-ordered laboratory services timely. For two patients, the institution provided laboratory services one and two days late (MIT 2.004). CIM providers then reviewed eight of ten resulting laboratory services reports within the required time frame (80.0 percent). Two reports were reviewed three days late (MIT 2.005). Lastly, providers timely communicated corresponding laboratory reports to six of ten patients (60.0 percent). Three patients received their results three days late. For the remaining patient, the written communication received from the provider did not identify the specific laboratory test referenced (MIT 2.006). Pathology Services • CIM received final pathology reports timely for all ten patients sampled (MIT 2.007). In addition, providers properly evidenced their review of pathology results for nine of ten sampled patients (90.0 percent). Staff reviewed one report one day late (MIT 2.008). Finally, providers timely communicated the pathology results to nine of the ten patients (90.0 percent). Staff communicated one report seven days late (MIT 2.009). California Institution for Men, Cycle 5 Medical Inspection Page 22 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 the need for a higher level of care. The OIG Overall Rating: reviews emergency response services including first aid, basic life Adequate support (BLS), and advanced cardiac life support (ACLS) consistent with the American Heart Association guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care, and the provision of services by knowledgeable staff appropriate to each individual’s training, certification, and authorized scope of practice. The OIG evaluates this quality indicator entirely through clinicians’ reviews of case files and conducts no separate compliance testing element. Case Review Results We reviewed 27 urgent/emergent events and found 23 deficiencies within various aspects of emergency care. The OIG clinicians considered 2 of the 23 deficiencies significant, both of which occurred in case 8. The case review rating for this indicator was adequate. CPR Response CIM demonstrated good CPR response. In the reviewed cases, either custody or health care staff appropriately initiated CPR. First medical responders arrived promptly and provided necessary care. We found no delays in CPR response. However, we could not reliably determine if there were delays in other, non-CPR emergency responses because CIM nurses often failed to record accurate timelines. Provider Performance The providers made appropriate triage decisions when patients presented emergently to the TTA and medical clinics. The providers were frequently available for immediate consultation. We identified no provider deficiencies. California Institution for Men, Cycle 5 Medical Inspection Page 23 Office of the Inspector General State of California Nursing Performance CIM nurses usually provided appropriate assessments and interventions. However, we found two worrisome nursing deficiencies, both of which occurred in the same case: • In case 8, the patient had a severely low blood count suggestive of critical anemia. The provider asked the TTA RN to evaluate the patient for anemia symptoms. If the patient was symptomatic, the nurse was to contact the provider for further instructions. The nurse found that the patient indeed had symptoms of severe anemia, but the RN inappropriately released the patient back to his housing without notifying the provider. The nurse’s error placed the patient at significant risk of harm due to the possibility of complications from the untreated anemia. • Also in case 8, on a separate occasion, the patient developed a high fever of 102.3 degrees Fahrenheit. The TTA RN gave the patient a medication to relieve the fever, but the medication did not work. Even though the patient had a persistent fever, the TTA RN did not notify a provider. Instead, the nurse inappropriately released the patient back to general housing. Nursing Documentation The TTA nurses recorded incomplete chronological information during medical emergencies. The first medical responders and the TTA nurses neglected to record the times of requested emergent medical response or the times of medical response staff arrival. These documentation deficiencies resulted in our inability to assess emergent response timelines in some of these cases accurately. If not corrected, the poor nursing documentation can result in the failure of the Emergency Medical Response Review Committee (EMRRC) to identify and correct delays in emergent care. Emergency Medical Response Review Committee CIM nursing and physician leadership conducted a clinical and timeline review of all patients transferred to a higher level of care. The EMRRC generally reviewed these emergency cases satisfactorily. However, on four occasions, their reviews did not capture the nursing deficiencies identified by the OIG clinicians. Clinician Onsite Inspection The TTA was located in the D yard and had four beds. Two nurses staffed the TTA for each of three daily shifts. On weekday evening shifts, a third nurse assisted with patients returning from offsite specialty consultations. The TTA RN was also responsible for assessing any patient who returned from a community hospital. Providers were readily available for consultation, even after hours. There was an onsite provider scheduled weekdays until 11:00pm. California Institution for Men, Cycle 5 Medical Inspection Page 24 Office of the Inspector General State of California During day and evening weekday shifts, an RN first medical responder (FMR) provided emergent responses. When the RN FMR was not available, the licensed vocational nurse (LVN) FMR would respond instead and would request assistance from the TTA RN when needed. Because of the distance between the yards and the TTA, the emergency medical services (EMS) ambulance frequently responded directly to the medical clinics in the prison yards instead of to the TTA to minimize their response times. Each of CIM’s four yards contained an after-hours medication cabinet (Omnicell) where nurses could obtain medications during urgent events. However, cardiac monitoring equipment and intravenous supplies, including intravenous fluids, were only available in the TTA located in D yard. Case Review Conclusion Despite CIM’s unique challenge of extreme distance between the various yards and the TTA, the institution generally provided timely emergency responses. The providers made appropriate clinical decisions, and the nurses usually provided acceptable care. The OIG clinicians rated the Emergency Services indicator adequate. California Institution for Men, Cycle 5 Medical Inspection Page 25 Office of the Inspector General State of California HEALTH INFORMATION MANAGEMENT Health information management is a crucial link in the delivery of Case Review Rating: medical care. Medical personnel require accurate information in Adequate order to make sound judgments and decisions. This indicator Compliance Score: Adequate examines whether the institution adequately manages its health care (75.5%) information. This includes determining whether the information is correctly labeled and organized and available in the electronic Overall Rating: medical record; whether the various medical records (internal and Adequate external, e.g., hospital and specialty reports and progress notes) are obtained and scanned timely into the patient’s electronic medical record; whether records routed to clinicians include legible signatures or stamps; and whether hospital discharge reports include key elements and are timely reviewed by providers. CIM converted to the new electronic health record system (EHRS) in August 2017; therefore, most testing occurred in the EHRS, with a minor portion of the testing done in the electronic unit health record (eUHR). Case Review Results We reviewed 1,028 medical events and identified 18 health information management deficiencies, 5 of which were significant. Despite the low frequency of errors, we found a significant problem with CIM’s handling of specialty reports. We rated the Health Information Management indicator adequate. Interdepartmental Transmission We found no problems in this area, as we did not identify any deficiencies in communication between the departments within the institution. Hospital Records CIM timely retrieved, reviewed, and scanned most hospital records into the medical record. We reviewed 36 community hospital events, including emergency department visits. We found only one significant deficiency: • In case 19, during hospitalization, the patient had a CT scan that identified a new pulmonary nodule and a left kidney mass. The institution did not scan the CT scan report into the patient’s medical record. California Institution for Men, Cycle 5 Medical Inspection Page 26 Office of the Inspector General State of California Missing Documents (Progress Notes and Forms) CIM performed well ensuring that staff scanned most records, other than specialty reports, into the electronic medical record. Additionally, with the implementation of the EHRS, most nurses and providers directly recorded their encounters into the electronic system, eliminating one step during which records could have been lost or misfiled. Laboratory, Diagnostic, and Pathology Reports Staff at CIM properly retrieved and scanned into the medical records laboratory, diagnostic procedure, and pathology reports. We found no significant deficiencies in this area. Specialty Services Reports CIM staff usually timely retrieved and scanned specialty service reports into the medical record. However, we found a pattern in which the institution did not always process specialty reports correctly. We identified two missing specialty reports: • In case 19, a positron emission tomography/computed tomography (PET/CT) scan report was missing from the medical record. • In case 23, an angiogram report was missing from the medical record. CIM usually retrieved specialty reports timely; however, one report was received late: • In case 19, a telemedicine oncology consultation was not received until 14 days after the consultation. Legibility Providers and nurses typed or dictated their progress notes, and there were no legibility problems. Scanning Performance CIM staff scanned most documents accurately and timely. There were only four minor deficiencies related to scanning performance, including the following: • In case 21, a gastroenterology (GI) specialty report was incorrectly labeled as an ear, nose, and throat (ENT) consult. California Institution for Men, Cycle 5 Medical Inspection Page 27 Office of the Inspector General State of California Clinician Onsite Inspection When we interviewed specialty service staff, we confirmed that CIM experienced delays in obtaining telemedicine specialty reports. The institution claimed that certain specialty reports were at times difficult to obtain. The OIG maintains that CIM has room for improvement in its specialty report handling. Case Review Conclusion Compared to the Cycle 4 inspection, CIM showed improvement. We no longer found inappropriately cloned documents, and legibility was no longer an issue. CIM’s management of health information was good in most areas. However, the institution could improve with its handling of specialty reports. We rated CIM’s Health Information Management indicator adequate. Compliance Testing Results The institution scored in the adequate range with a score of 75.5 percent in the Health Information Management indicator. The following tests earned scores of proficient: • CIM staff scanned 19 of 20 specialty service consultant reports sampled into the patients’ electronic medical records within five calendar days (95.0 percent). However, staff scanned one high-priority specialty service report two days late (MIT 4.003). • Staff scanned 24 of 25 sampled community hospital discharge reports into patients’ electronic medical records within five calendar days (96.0 percent); staff scanned one report one day late (MIT 4.004). • CIM medical records staff timely scanned 19 of 20 medication administration records (MARs) into patients’ electronic medical records (95.0 percent). Staff scanned one MAR one day late (MIT 4.005). • We reviewed electronic medical record files for 25 patients who returned to the institution after a community hospitalization; providers timely reviewed all hospital discharge reports within three calendar days of discharge (MIT 4.007). Three tests received inadequate scores: • CIM timely scanned 8 of 11 sampled non-dictated health care documents into patients’ electronic medical records (72.7 percent). Staff scanned three non-dictated health care documents one to two days late (MIT 4.001). California Institution for Men, Cycle 5 Medical Inspection Page 28 Office of the Inspector General State of California • The institution scored 70.0 percent for timely scanning of dictated health care documents into patients’ electronic medical records. Staff timely scanned seven of ten dictated health care documents within five calendar days of the patient encounter, but staff scanned three other sampled patients’ documents from three to four days late (MIT 4.002). • The institution scored zero for the labeling and filing of electronic medical record documents. For this test, the OIG bases its score on an allowable maximum of 24 mislabeled or misfiled documents. For the CIM medical inspection, there were more than 24 mislabeled or misfiled documents (MIT 4.006). California Institution for Men, Cycle 5 Medical Inspection Page 29 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: Inadequate availability of both auditory and visual privacy for patient visits, and (55.0%) the sufficiency of facility infrastructure to conduct comprehensive medical examinations. The OIG rates this component entirely on the Overall Rating: compliance testing results from the visual observations inspectors Inadequate make at the institution during their onsite visit. There is no case review portion. Compliance Testing Results CIM earned an inadequate compliance score of 55.0 percent in the Health Care Environment indicator. The institution received scores in the inadequate range on the following seven tests: • Health care staff at 10 of 14 clinics followed proper protocols to mitigate exposure to blood-borne pathogens and contaminated waste (71.4 percent). Four other clinics did not have puncture-resistant containers in examination rooms for medical staff to discard expended needles and sharps. In addition, one of the four clinics did not have personal protective equipment readily accessible to clinical staff (MIT 5.105). • The non-clinic bulk medical supply storage areas were not in compliance with the supply management protocols and did not support the needs of the health care program, resulting in a score of zero on this test. Staff stored medical supplies beyond manufacturers’ guidelines, in a location subjected to excessive heat, and directly on the floor (MIT 5.106). • Only 5 of the 14 clinics inspected followed adequate medical supply storage and management protocols (35.7 percent). Nine clinics had one or more of the following deficiencies: clinics stored medical supplies beyond manufacturers’ guidelines (Figure 1); disinfectant agents were in the same area with medical supplies; medical storage areas were disorganized; staff stored personal food items in the bulk medical supply storage area; and medical supplies were not Figure 1: Expired medical supplies clearly identifiable (MIT 5.107). California Institution for Men, Cycle 5 Medical Inspection Page 30 Office of the Inspector General State of California • Only 7 of 14 clinic locations (50.0 percent) met compliance requirements for essential core medical equipment and supplies. The remaining seven clinics were missing one or more functional pieces of properly calibrated core equipment or other medical supplies necessary to conduct a comprehensive exam. The missing items included a nebulization unit, an examination table, an oto-ophthalmoscope, tips for the otoscope, tongue depressors, a Snellen eye chart, a biohazard receptacle or plastic bags, an automated external defibrillator (AED), and an emergency medical response bag (EMRB). In addition, an ophthalmoscope was non-operational (MIT 5.108). • Clinic common areas at 5 of the 11 applicable clinics had an environment conducive to providing medical services (45.5 percent). The location of triage and blood draw stations in five clinics compromised patients’ auditory privacy. One other clinic lacked wheelchair mobility access (MIT 5.109). • We inspected 13 clinic examination rooms, and 5 of them (38.5 percent) were conducive to appropriate clinical care. In eight clinics, one or more of the following deficiencies were identified: confidential records were clearly visible and easily accessible; there was insufficient space in the examination rooms to perform a patient examination (Figure 2); staff stored personal belongings in the same area as examination room supplies; multiple patients were examined in the same examination room, which compromised their auditory privacy (Figure 3); and the examination room configuration did not provide visual privacy during patient encounters (MIT 5.110). Figure 2: Examination room with Figure 3: Multi-patient examination room insufficient space and compromised privacy with compromised privacy California Institution for Men, Cycle 5 Medical Inspection Page 31 Office of the Inspector General State of California • We examined EMRBs in seven applicable clinics to determine whether clinical staff inspected the bags daily and inventoried them monthly and whether the bags contained all essential items. Only two of the seven EMRBs were compliant (28.6 percent). One or more of the following deficiencies emerged at five locations: staff failed to verify that the bag’s compartments were sealed and intact; staff had failed to inventory the EMRB within the last 30 days; and clinics stored EMRB medical supplies beyond the manufacturers’ guidelines (MIT 5.111). Two tests received scores in the adequate range: • Of the 14 clinic locations inspected, 11 (78.6 percent) had operable sinks and sufficient quantities of hand hygiene supplies in the examination areas. In two clinics, patient restrooms did not have sufficient quantities of hygiene supplies such as antiseptic soap and disposable hand towels. In addition, one of the two clinics did not have an operational sink (Figure 4). In another clinic, the clinicians had no access to an operational sink within Figure 4: Patient restroom with no operational sink reasonable proximity (MIT 5.103). • We observed that health care staff in 11 of 14 clinics adhered to universal hand hygiene precautions (78.6 percent). At three clinic locations, staff failed to wash or sanitize their hands before or after patient contact or before applying gloves (MIT 5.104). Two tests received scores in the proficient range: • Of the 14 clinics examined, 12 (85.7 percent) were appropriately disinfected, cleaned, and sanitized. At one clinic, floors were visibly dirty. Another clinic had dust build-up in the corners and under the sink (MIT 5.101). • Clinical health care staff at 13 of the 14 applicable clinics (92.9 percent) ensured that reusable invasive and non-invasive medical equipment was properly sterilized or disinfected. One clinic did not properly process previously sterilized instruments (MIT 5.102). California Institution for Men, Cycle 5 Medical Inspection Page 32 Office of the Inspector General State of California Non-Scored Results The OIG gathered information to determine if the institution maintained its physical infrastructure in a manner that supported health care management’s ability to provide timely or adequate health care. The OIG does not score this question. • When OIG inspectors interviewed health care managers, they did not identify any significant concerns. At the time of the OIG’s medical inspection, CIM had several significant infrastructure projects underway, which included increasing clinic space at four yards. There were new clinic construction plans for A yard, Facility B-Reception Center Health Care Processing, two clinics on D yard, and a new health care administration building. Additional construction would reconfigure and renovate clinic spaces on B and C yards, central health services, and the infirmary. Most of these projects started in summer 2015 with the exception of the infirmary, which started in fall 2017. There was one clinic estimated to break ground in spring 2018, and some clinic projects that were pending due to construction changes or dependence on the completion of other in-progress construction work. The managers estimated that these projects would be completed from early 2018 to late 2020 (MIT 5.999). California Institution for Men, Cycle 5 Medical Inspection Page 33 Office of the Inspector General State of California INTER- AND INTRA-SYSTEM TRANSFERS This indicator focuses on the management of patients’ medical needs Case Review Rating: and continuity of patient care during the inter- and intra-system Inadequate transfer process. The patients reviewed for this indicator include Compliance Score: Inadequate those received from, as well as those transferring out to, other CDCR (74.3%) institutions. The OIG review includes evaluation of the institution’s ability to provide and document health screening assessments, Overall Rating: initiation of relevant referrals based on patient needs, and the Inadequate continuity of medication delivery to patients arriving from another institution. For those patients, the OIG clinicians also review the timely completion of pending health appointments, tests, and requests for specialty services. For patients who transfer out of the institution, the OIG evaluates the ability of the institution to document transfer information that includes pre-existing health conditions, pending appointments, tests and requests for specialty services, medication transfer packages, and medication administration prior to transfer. The OIG clinicians also evaluate the care provided to patients returning to the institution from an outside hospital and check to ensure appropriate implementation of the hospital assessment and treatment plans. Case Review Results We reviewed 33 events in which patients returned from a community hospital or emergency department, 5 cases in which patients transferred into CIM from other CDCR institutions, and 4 cases in which patients transferred out to other CDCR institutions. In total, we reviewed 94 inter- and intra-system transfer events. There were 29 deficiencies, 8 of which were significant. We found significant deficiencies in cases 19, 23, 24, 34, 55, and 60. The case review rating for the Inter- and Intra-System Transfers indicator was inadequate. Transfers In The OIG clinicians reviewed five transfer-in cases, which yielded 14 related events. CIM nurses timely evaluated these patients, performed adequate assessments and interventions, and appropriately initiated provider appointments. The following is one example: • In case 34, the patient arrived without his prescribed medications, including nitroglycerin for chest pain and a rescue inhaler for asthma. The provider re-prescribed these medications and ordered them filled immediately. However, the nurse did not administer these essential medications until the following day. California Institution for Men, Cycle 5 Medical Inspection Page 34 Office of the Inspector General State of California Transfers Out CIM nurses did not consistently list essential care items on the transfer form before patients transferred to other facilities. We reviewed four cases in which patients transferred out of CIM. Although the nurses ensured that medications were with the patients, the CIM nurses did not thoroughly complete the Health Care Transfer Information forms (CDCR Form 7371) in two of the four cases: • In case 59, the RN failed to identify a pending ophthalmology follow-up. • In case 60, the RN failed to identify the patient’s peripherally inserted central catheter (catheter inserted into a blood vessel next to the heart), a pending telemedicine appointment, and a prescribed nutritional supplement. 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. CIM had difficulty ensuring continuity of care for patients who returned from an outside hospital. We reviewed 33 events in which a patient returned to CIM from a hospitalization or emergency department and identified 21 deficiencies. Six were significant, occurring in cases 19, 23, 24, and 55. CIM TTA nurses made incomplete assessments in cases 1, 7, 22, 23, 24, and 39. We also found problems with post-hospital medication continuity in cases 8, 23, 24, and 55. The following examples illustrate these problems: • In case 8, the patient returned from the hospital but did not receive his blood pressure medication until three days later. • In case 23, the patient returned from the hospital with an abdominal surgical incision and complained of post-operative pain. The nurse did not assess the patient’s pain so did not provide appropriate pain control. Additionally, the nurse did not assess when that patient last had a bowel movement, an essential part of the nurse assessment because post-operative patients are at risk for constipation and potentially serious complications. • In case 55, the patient returned from the hospital, and a provider prescribed an increased dose of a blood pressure medication; however, the patient received both the increased dose and the dose from before his hospitalization. This error increased the risk of hypotension (low blood pressure) and unnecessary medication adverse side effects. California Institution for Men, Cycle 5 Medical Inspection Page 35 Office of the Inspector General State of California CIM generally obtained pertinent hospital records and ensured the providers reviewed these records; however, in case 39, staff failed to retrieve the patient’s X-ray and procedure reports from the hospital. We found one significant deficiency related to a missing hospital summary: • In case 19, during the hospitalization, the patient had a CT scan showing new findings of a lung nodule. CIM did not retrieve or scan the CT report into the medical record. CIM providers performed poorly addressing new diagnoses and recommendations when patients returned from hospitalization. The following examples demonstrated poor provider assessment after hospitalization: • In case 21, the patient had a stricture of his upper digestive tract and required a gastric tube to bypass the stricture for feeding. The patient returned from an emergency department with the diagnosis of gastric-tube malfunction. The emergency room physician recommended to follow up with a general surgeon in one week to replace the tube; however, the CIM provider ordered a routine priority general surgery appointment. The gastric-tube was not replaced until more than one month later. • In case 23, the patient returned from the hospital after an aortic aneurysm repair and was discharged with a potentially toxic anti-arrhythmic medication. The hospital physician recommended the patient follow up with cardiology within two weeks. Instead, the CIM provider ordered a routine cardiology appointment within 90 days, and that appointment did not occur. • In case 24, the hospital physician diagnosed the patient with a kidney mass that may have been cancer and recommended the patient follow up with the kidney specialist; however, the CIM provider did not review the hospital record. CIM did not address the kidney mass until nine months later when the OIG alerted CCHCS of this oversight during our review of this case. Case Review Conclusion CIM nurses generally performed well with patients transferring into CIM from other CDCR institutions. However, they often did not identify essential care items for patients transferring to different institutions. CIM did poorly maintaining sufficient care for patients returning from an outside hospital or emergency room. CIM had difficulty maintaining medication continuity for these patients. CIM nurses made poor assessments for these patients while providers often failed to review hospital discharge summaries and did not implement hospital-recommended interventions. Because of the problems we identified, we rated CIM’s Inter- and Intra-System Transfers indicator inadequate. California Institution for Men, Cycle 5 Medical Inspection Page 36 Office of the Inspector General State of California Compliance Testing Results The institution performed in the inadequate range in this indicator, with a compliance score of 74.3 percent. CIM earned inadequate scores on the following tests: • For 16 of 25 sampled patients who transferred into CIM from other CDCR institutions, nursing staff completed an Initial Health Screening (CDCR Form 7277) on the same day the patient arrived (64.0 percent). For nine patients, nursing staff neglected to record an answer to one of the screening form questions (MIT 6.001). • Among 20 sampled patients who transferred out of CIM to other CDCR institutions, only 9 (45.0 percent) had their scheduled specialty service appointments properly included on the health care transfer form. For 11 patients, CIM failed to document specialty service appointments on the transfer forms (MIT 6.004). • CIM scored 62.5 percent when we inspected the transfer packages of eight sampled patients who transferred out of CIM during the onsite inspection to determine whether the patients’ transfer packages included required medications and related documentation. Two transfer packages were missing medications. One patient’s transfer package contained a medication that was not listed on his active medication order list (MIT 6.101). Two tests received scores in the proficient range: • Nursing staff timely completed the assessment and disposition sections of the screening form for all 25 sampled patients (MIT 6.002). • Of the 25 sampled patients who transferred into CIM, 16 had an existing medication order that required nursing staff to issue or administer medications upon arrival. All 16 patients received their medications timely (MIT 6.003). California Institution for Men, Cycle 5 Medical Inspection Page 37 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: Inadequate administration of the medication. By combining both a quantitative (63.2%) 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, Inadequate dispensing and delivering, administering, and documenting and reporting. Because numerous entities across various departments affect medication management, this assessment considers internal review and approval processes, pharmacy, nursing, health information systems, custody processes, and actions taken by the prescriber, staff, and patient. For this indicator, the case review and compliance review processes yielded different results, with the case reviewers assigning an adequate rating and the compliance testing resulting in an inadequate score. Compliance testing showed poor medication continuity for patients who returned from an outside hospital and for newly arrived patients from a county jail. In addition, CIM demonstrated extremely poor medication practices and storage controls, which included improper nurse administration of medications and unsafe storage of narcotic and non-narcotic medications. We determined that the overall rating for this indicator was inadequate. Case Review Results We evaluated 70 events related to medications and found 14 deficiencies, 2 of which were significant. The case review rating of the Pharmacy and Medication Management indicator was adequate. Medication Continuity and Administration CIM performed well with chronic care medication continuity, as the patients received their medications timely and as prescribed. Intra-System and Intra-Facility Medication Continuity CIM usually did well maintaining medication continuity for newly arrived patients from other CDCR facilities. However, the institution had difficulty maintaining medication continuity for patients returning from an outside hospital. We discuss these findings in the Inter- and Intra-System Transfers indicator. California Institution for Men, Cycle 5 Medical Inspection Page 38 Office of the Inspector General State of California Specialized Medical Housing Medication Continuity The OHU patients generally received medications timely and as prescribed; however, there were three deficiencies related to medication management. We discuss the following example also in the Specialized Medical Housing indicator: • In case 22, the patient with hypertension did not receive his blood pressure medications on two occasions. Clinician Onsite Inspection CIM’s main pharmacy was in D yard and supplied medications to the other four yards. The distance between the main pharmacy and the yards is significant. For instance, C yard is about one and a half miles from the main pharmacy. There were 14 medication administration areas, including one in the OHU. The pharmacist in charge assigned a pharmacy technician to each yard to ensure that they delivered medications to all the yards. Each of the five yards had an Omnicell (automated medication storage cabinet) stocked with medications. During the onsite visit, the patient care teams discussed medication issues in the morning huddles. The providers were informed of expiring medications and renewed those prescriptions promptly. Case Review Conclusion CIM’s patients often had multiple medical problems and often required numerous medications. The medication administration areas were far away from the main pharmacy. Despite these challenges, CIM staff usually performed sufficiently administering most needed medications, except for those patients returning from an outside emergency room or hospital. The case review clinicians rated the Pharmacy and Medication Management indicator adequate. Compliance Testing Results The institution scored 63.2 percent in the Pharmacy and Medication Management indicator, an inadequate rating. For discussion purposes below, we divide this indicator into three sub-indicators: medication administration, observed medication practices and storage controls, and pharmacy protocols. California Institution for Men, Cycle 5 Medical Inspection Page 39 Office of the Inspector General State of California Medication Administration In this sub-indicator, the institution received an inadequate score of 73.0 percent. The following four tests scored in the inadequate range: • Among 23 applicable patients, 15 (65.2 percent) timely received their ordered chronic care medications. Eight patients did not receive their keep-on-person (KOP) medications per CCHCS policy requirements (MIT 7.001). • Clinical staff timely provided new and previously prescribed medications to 14 of 25 patients sampled who transferred from a community hospital and returned to the institution (56.0 percent). For seven patients, providers did not order new medications by the required time after patients’ arrival from community hospitals. The remaining four patients received their medications from one to three days late (MIT 7.003). • We reviewed electronic medical records of 20 sampled patients who recently arrived at CIM from a county jail and identified 11 patients who needed to be reissued medications upon their arrival. Of the 11 applicable patients sampled, 6 received their medications timely (54.6 percent). Five patients received their medications from one to two days late (MIT 7.004). • Nursing staff administered medications without interruption to seven of ten patients who were en route from one institution to another with a temporary layover at CIM (70.0 percent). For three patients, the institution did not document if staff administered or delivered the medications by the next dosing interval (MIT 7.006). Two tests earned scores in the proficient range: • Among 25 patients sampled, 24 (96.0 percent) timely received their newly ordered medication. One patient received his directly observed therapy (DOT) medication one day late (MIT 7.002). • CIM ensured that 24 of 25 sampled patients who transferred from one housing unit to another (96.0 percent) received their prescribed medications without interruption. One patient did not receive one or more doses of his medication at the next dosing interval after the transfer occurred (MIT 7.005). California Institution for Men, Cycle 5 Medical Inspection Page 40 Office of the Inspector General State of California Observed Medication Practices and Storage Controls The institution scored 39.0 percent in this sub-indicator, with the following five tests scoring in the inadequate range: • We interviewed nursing staff and inspected narcotics storage areas at applicable clinics and pill line locations to assess narcotics security controls. Nursing staff implemented strong medication security controls over narcotic medications in one of ten locations (10.0 percent). In nine clinics, one or more of the following deficiencies occurred: narcotic medications did not remain under double lock control; staff did not describe the appropriate narcotics discrepancy reporting process; medication nurses removed stock from the narcotics locker in a manner that did not allow a spontaneous count; and the narcotics logbook showed that on multiple occasions a controlled substance inventory was not performed by two licensed nursing staff (MIT 7.101). • CIM safely stored non-refrigerated, non-narcotic medications in 2 of the 14 applicable clinic and medication line storage locations (14.3 percent). In 12 locations, we identified one or more of the following deficiencies: the medication area lacked a designated area for return-to-pharmacy medications; personal food items were stored in the medication room; medication storage areas were unlocked; multi-use medication was not labeled with the date it was opened; oral and topical medications were not properly separated when stored; and medications were stored outside the required temperature range (MIT 7.102). • CIM safely stored refrigerated, non-narcotic medications in three of eight applicable clinic and medication line storage locations (37.5 percent). In five locations, one or more of the following deficiencies were observed: a medication refrigerator was unlocked; staff stored food items in the medication refrigerator; clinics stored medications beyond the manufacturers’ guidelines; staff did not maintain historical daily temperature logs for the month of October 2017; and the temperature logbook showed that on multiple occasions the refrigerator temperatures were not within the acceptable range (MIT 7.103). • Inspectors observed the medication preparation and administration processes at eight applicable medication line locations. Nursing staff were compliant regarding proper hand hygiene and contamination control protocols at five locations (62.5 percent). At three locations, not all nursing staff washed or sanitized their hands when required, such as prior to putting on gloves or before re-gloving (MIT 7.104). • Staff at only three of eight inspected medication preparation and administration areas demonstrated appropriate administrative controls and protocols (37.5 percent). At five locations, one or more of the following deficiencies were observed: medication nurses did not always ensure patients swallowed DOT medications; medication nurses did not always verify the patient’s identity via picture identification prior to administering medications; California Institution for Men, Cycle 5 Medical Inspection Page 41 Office of the Inspector General State of California medication nurses did not distribute medications to the patients within the required time frame; and patients waiting to receive their medications did not have sufficient outdoor cover to protect them from heat or inclement weather. We also observed CIM medication nurses not following manufacturers’ guidelines related to proper administration of insulin to diabetic patients. Those guidelines require medication nurses to use a new glucose test strip for re-testing the blood sugar levels and to disinfect previously opened multi-use insulin vials before withdrawing and administering medication (MIT 7.106). One test received an adequate score: • CIM nursing staff at six of eight sampled locations employed appropriate administrative controls and protocols when preparing patients’ medications (75.0 percent). At two medication line locations, medications were not in their original packaging (MIT 7.105). Pharmacy Protocols CIM scored an adequate 80.0 percent in this sub-indicator, with the following tests earning proficient scores: • In its main pharmacy, the institution followed general security, organization, and cleanliness management protocols; properly stored and monitored non-narcotic medications that required refrigeration and those that did not; and maintained adequate controls over and properly accounted for narcotic medications (MIT 7.107, 7.108, 7.109, 7.110). The following test earned an inadequate score: • We examined 25 medication error follow-up reports and 5 statistical medication error reports generated by the institution’s pharmacist in charge (PIC). All 25 of the PIC’s reports were either not timely or incorrectly processed. As a result, CIM scored zero on this test. We found the following errors: the PIC did not complete medication error follow-up reports for any of the 25 reports. The PIC also did not submit the statistical report of medication errors in March 2017. Furthermore, the PIC did not share 2 of the 25 follow-up reports with the local pharmacy and therapeutics or other improvement committees (MIT 7.111). Non-Scored Tests • In addition to the OIG’s testing of reported medication errors, inspectors follow up on any significant medication errors found during the case reviews or compliance testing to determine whether the institution properly identified and reported the errors. The OIG provides those results for information purposes only. At CIM, the OIG did not find any applicable medication errors (MIT 7.998). California Institution for Men, Cycle 5 Medical Inspection Page 42 Office of the Inspector General State of California • The OIG interviewed patients in isolation units to determine if they had immediate access to their prescribed KOP rescue inhalers and nitroglycerin medications. All six of the applicable patients had access to their rescue medications (MIT 7.999). California Institution for Men, Cycle 5 Medical Inspection Page 43 Office of the Inspector General State of California PRENATAL AND POST-DELIVERY SERVICES This indicator evaluates the institution’s capacity to provide timely Case Review Rating: and appropriate prenatal, delivery, and postnatal services to pregnant Not Applicable patients. This includes the ordering and monitoring of indicated Compliance Score: screening tests, follow-up visits, referrals to higher levels of care, Not Applicable e.g., high-risk obstetrics clinic, when necessary, and postnatal Overall Rating: follow-up. Not Applicable As CIM does not have female patients, this indicator does not apply. California Institution for Men, Cycle 5 Medical Inspection Page 44 Office of the Inspector General State of California PREVENTIVE SERVICES This indicator assesses whether the institution offered or provided Case Review Rating: various preventive medical services to patients. These include cancer Not Applicable screenings, tuberculosis screenings, and influenza and chronic care Compliance Score: Adequate immunizations. This indicator also assesses whether certain (78.0%) institutions take preventive actions to relocate patients identified as being at higher risk for contracting coccidioidomycosis Overall Rating: (valley fever). Adequate The OIG rates this indicator entirely through the compliance testing component; the case review process does not include a separate qualitative analysis for this indicator. Compliance Testing Results The institution scored in the adequate range in this indicator with a compliance score of 78.0 percent. The following two tests earned scores in the proficient range: • CIM timely administered or offered influenza vaccinations during the most recent influenza season to all 25 patients sampled (MIT 9.004). • CIM offered colorectal cancer screenings to 24 of 25 sampled patients subject to the annual screening requirement (96.0 percent). For one patient, health care staff did not offer a colorectal cancer screening within the previous 12 months, and the patient did not have a normal colonoscopy within the last ten years (MIT 9.005). One test received an adequate score: • We sampled 30 patients to determine if the institution provided the annual TB screenings within the last year and during their birth month as CCHCS policy required. Out of the 30 patients sampled, 25 (83.3 percent) timely received their screening. For five patients, the TB screening did not occur in the patient’s birth month as required (MIT 9.008). Three tests scored in the inadequate range: • CIM scored 71.4 percent for administering timely TB medications to patients with TB. Out of 21 patients, 15 received their medications timely. The institution failed to document if three patients received the required counseling for missed doses; and nursing staff failed to document if three patients either received or refused TB medications (MIT 9.001). California Institution for Men, Cycle 5 Medical Inspection Page 45 Office of the Inspector General State of California • The institution scored poorly for monitoring of patients on TB medications. For 9 of 21 patients, the institution failed to complete monitoring at all required intervals (57.1 percent) (MIT 9.002). • We tested whether CIM offered vaccinations for influenza, pneumonia, and hepatitis to patients who suffered from chronic conditions. Six of ten applicable patients sampled (60.0 percent) received all recommended vaccinations at required intervals. For three patients, there was no evidence that CIM administered hepatitis A and B vaccinations or that there was a documented immunity. There was no evidence the remaining one patient received or refused a pneumococcal immunization within the last five years (MIT 9.008). California Institution for Men, Cycle 5 Medical Inspection Page 46 Office of the Inspector General State of California QUALITY OF NURSING PERFORMANCE The Quality of Nursing Performance indicator is a qualitative Case Review Rating: evaluation of the institution’s nursing services. The evaluation is Adequate completed entirely by OIG nursing clinicians within the case review Compliance Score: process and does not have a score under the OIG compliance testing Not Applicable component. Case reviews include face-to-face encounters and Overall Rating: indirect activities performed by nursing staff on behalf of the patient. Adequate Review of nursing performance includes all nursing services performed onsite, such as outpatient, inpatient, urgent/emergent, patient transfers, care coordination, and medication management. The key focus areas for evaluation of nursing care include appropriateness and timeliness of patient triage and assessment, identification and prioritization of health care needs, use of the nursing process to implement interventions, and accurate, thorough, and legible documentation. Although the OIG reports nursing services provided in specialized medical housing units in the Specialized Medical Housing indicator, and those provided in the TTA or related to emergency medical responses in the Emergency Services indicator, this Quality of Nursing Performance indicator summarizes all areas of nursing services. Case Review Results We reviewed 236 nursing encounters, 97 of which were in the outpatient setting. Most outpatient nursing encounters were for sick call requests, walk-in visits, and RN follow-up visits. In all, there were 123 deficiencies identified related to nursing care performance, 8 of which were significant. We rated this indicator adequate overall. Nursing Sick Call We reviewed 47 sick call nursing encounters. Nurses timely reviewed sick call requests and usually assessed patients on the next business day. When a patient requested to be seen for a potentially urgent condition, the nurses successfully arranged a same-day assessment. However, the sick call nurse assessments were frequently incomplete. Of the 47 sick call events reviewed, we found 27 minor deficiencies in which nurses made incomplete assessments. Although none of these deficiencies was significant, they did represent a target for quality improvement. Nursing Assessment A major component of high-quality nursing care is assessment, which consists of essential subjective and objective evaluations needed to establish and plan nursing interventions. CIM nurses did perform their assessments timely. However, in the outpatient nursing setting, many of the nurses made incomplete assessments, which increased the risk of medical errors. California Institution for Men, Cycle 5 Medical Inspection Page 47 Office of the Inspector General State of California • In case 1, the diabetic patient complained of sharp, severe foot pain. Diabetes can damage the nerves and impair the circulation in the extremities, often resulting in delayed wound healing. The clinic RN did not inspect the foot for wounds and did not assess the patient for adequate circulation and sensation. • In case 24, the patient complained of abdominal and throat pains, hiccups, and a productive cough. Although the clinic nurse obtained vital signs and referred the patient to a provider, the nurse failed to perform basic subjective and objective assessments. The nurse did not ask when the patient’s symptoms began, did not inspect the throat, and did not listen to the lungs. • In case 54, the diabetic patient complained of right foot pain, numbness, and swelling. The RN noted the foot was swollen but did not assess the foot’s range of motion and did not check for adequate blood flow. Nursing Intervention Planning and implementation are basic components of the nursing process. After the nurse assesses and establishes the nursing diagnoses, the nurse decides which actions or interventions the patient needs and performs those interventions based on the assessment findings. Although the nurses did not always make complete assessments, their plans were clinically appropriate and usually resolved their patients’ complaints. Nonetheless, on a few occasions, the patient’s symptoms warranted prompt reassessment or immediate contact with a provider, but the nurse failed to arrange these. Additionally, at times the nurses’ assessments and planned interventions did not correlate. The following are examples of these deficiencies: • In case 3, the patient had dizziness and a low heart rate. The patient’s dizziness improved. However, the clinic nurse did not reassess the patient’s low heart rate. Furthermore, the clinic nurse advised the patient to increase oral hydration because the nurse thought the patient was dehydrated. However, a dehydrated person would normally have an elevated heart rate, not a low heart rate. The nurse did not assess for signs of dehydration, and the nurse’s findings did not support the nurse’s rationale for advising the patient to increase fluid consumption. • In cases 26 and 44, the clinic nurses did not reassess their patients’ elevated blood pressures and did not assess their patients’ compliance with blood pressure medications. California Institution for Men, Cycle 5 Medical Inspection Page 48 Office of the Inspector General State of California Nursing Documentation Complete and accurate nursing documentation is essential for good medical care. Health care staff use documentation to communicate a patient’s past and current medical conditions and to identify changes in their patients’ conditions. CIM nurses usually recorded their care satisfactorily, an improved performance since the implementation of the EHRS. In outpatient nursing, we found only minor documentation deficiencies. Most of the deficiencies were related to wound care. In cases 16, 17, 21 and 58, the nurses did not always document the appearance of their patients’ wounds. We also discuss nursing documentation deficiencies in the Emergency Services and Specialized Medical Housing indicators. Urgent/Emergent Care The emergency nursing care provided at CIM was usually sufficient. However, we found two serious nursing errors in emergency care. The Emergency Services indicator discusses these further. Care Management The role of a chronic care manager includes assessing patients, initiating appropriate interventions to support patients’ treatment plans, and monitoring patients with chronic conditions to intervene for those at increased risk for developing serious health complications. In our case reviews, we found scant evidence of RN care management visits. Even in the rare case in which there was a care management appointment, the RN did not perform well. • In case 26, the provider referred the patient with uncontrolled high blood pressure for an RN care management visit. During the visit, the RN found the patient had elevated blood pressure. The RN did not check whether the patient was taking his prescribed blood pressure medications and did not recheck the patient’s high blood pressure. The RN did not educate the patient and did not ensure the patient followed up with the provider. Intra-System Transfers and Reception Center Arrivals CIM nurses provided sufficient care for patients arriving at the institution, whether the patients arrived from a county jail or another CDCR institution. However, CIM nurses often failed to list essential care items on the transfer form before their patients transferred to another facility. The Inter-and Intra-System Transfers and the Reception Center indicators discuss these in more detail. Post-Hospital Returns The TTA nurses evaluated patients returning from an outside hospital or emergency department. We identified nine nursing deficiencies in the areas of assessment, documentation, and record review. Although we rated the nurses’ performance in this area acceptable, CIM nurses can improve their California Institution for Men, Cycle 5 Medical Inspection Page 49 Office of the Inspector General State of California performance in this area by ensuring medication continuity and making complete assessments. We further describe the nursing performance in the Inter- and Intra-Systems Transfer indicator. Specialized Medical Housing CIM nurses gave satisfactory care in the OHU. Most of the issues we identified were minor. We discuss nursing performance in this area further in the Specialized Medical Housing indicator. Specialty Services CIM TTA nurses provided appropriate care for patients who returned from their offsite specialist visits. We found one significant deficiency in which the telemedicine nurse ignored a severely elevated blood pressure. The Specialty Services indicator also discusses this issue. Clinician Onsite Inspection The institution’s four separate facilities are spread out over an expansive campus. Each of the four facilities utilized medical providers, RNs, LVNs, mental health, and dental providers. Also, facility B contained a receiving and release area (R&R) as well as administrative segregation units. Facility D had two separate medical clinics, a TTA and an OHU. The pharmacy was also located on facility D. CIM had recently moved the health care leadership team to a new building located outside of facility D. We attended morning huddles in facilities B and D. The interdisciplinary huddles were informative and organized. CIM followed the statewide template, which addressed new arrivals, patients returning from specialist appointments, and community hospital admissions. The institution was also implementing new nursing workflows within each of its primary care clinics. The medical team expected the LVN provider assistant to obtain specialist records for the providers’ review. Although CIM nursing leadership had not fully implemented this process, they recognized the importance of ensuring specialist records were available during a patient’s provider appointment. Case Review Conclusion In general, CIM nurses provided timely evaluation, sufficient assessment, and appropriate interventions. Nonetheless, CIM nursing care in the outpatient areas showed significant room for improvement. In this inspection, outpatient nurses demonstrated patterns of incomplete assessment, intervention errors, and the absence of meaningful chronic care management. Fortunately, most of the deficiencies we found were minor and did not place patients at significant risk of harm. We rated CIM’s Quality of Nursing Performance indicator adequate. California Institution for Men, Cycle 5 Medical Inspection Page 50 Office of the Inspector General State of California QUALITY OF PROVIDER PERFORMANCE In this indicator, the OIG physicians provide a qualitative evaluation Case Review Rating: of the adequacy of provider care at the institution. The case review Inadequate clinicians review the provider care regarding appropriate evaluation, Compliance Score: diagnosis, and management plans for programs including, but not Not Applicable limited to, nursing sick call, chronic care programs, TTA, specialized Overall Rating: medical housing, and specialty services. Inadequate OIG physicians alone assess provider care. There is no compliance testing component associated with this quality indicator. Case Review Results We reviewed 265 medical provider encounters and identified 55 deficiencies related to provider performance, of which 38 were significant. Of the 27 cases reviewed, we rated 1 proficient, 14 adequate, and 12 inadequate. We rated this indicator inadequate overall. Assessment and Decision-Making CIM providers made numerous errors and demonstrated unsatisfactory assessment and poor decision-making. These deficiencies frequently occurred, as they were present in 14 of the 27 detailed physician case reviews (cases 6, 12, 13, 15, 17, 18, 19, 21, 23, 24, 25, 26, 27, and 29). The following examples demonstrated poor provider assessment: • In case 21, the patient had oral cancer, and the specialist recommended obtaining a needle biopsy of the lymph nodes to assess for cancer recurrence. The provider failed to order the biopsy. Subsequently, the specialist evaluated the patient without the needed diagnostic test, resulting in a delay in care. We also discuss this case in the Specialty Services indicator. • In case 24, the patient returned from hospitalization with the diagnosis of a left kidney mass suspicious for cancer. The hospital physician recommended the patient see a urologist to follow up on the mass. The provider did not properly review the hospital records and failed to address the left kidney mass. The provider’s error placed the patient at risk for delayed or untreated kidney cancer. We also discuss this case in the Specialized Medical Housing indicator. • In case 29, the patient was diagnosed at his previous CDCR institution with lung cancer. The patient was symptomatic and was coughing up blood. The sending institution transferred the patient to CIM promptly for urgent treatment because there were no oncology services available near the sending institution. When the patient arrived at CIM, the provider failed to request an urgent oncology consultation. Instead, the provider ordered a routine (90-day) California Institution for Men, Cycle 5 Medical Inspection Page 51 Office of the Inspector General State of California referral, which delayed the patient’s cancer treatment. CIM providers often did not recognize potential adverse medication side-effects or drug interactions. The following examples demonstrated poor decision-making when providers prescribed medications: • In case 15, the patient had chronic kidney disease, and a provider prescribed long-term use of a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs are toxic to the kidneys and are not recommended for patients with kidney disease. This error placed the patient at risk of worsening kidney failure. • In case 23, a provider prescribed a potentially dangerous anti-arrhythmic medication (used for treating abnormal heart rhythms). Because of the medication’s toxicity, providers are required to order multiple baseline and follow-up monitoring tests. The provider failed to order baseline thyroid function, pulmonary function, and eye examination tests. Also, the provider failed to monitor the patient’s thyroid function tests while the patient received the medication. Abnormal Diagnostic Tests CIM providers performed poorly addressing abnormal diagnostic tests such as X-ray and laboratory results. The following examples demonstrated poor provider performance when presented with abnormal diagnostic tests: • In case 12, the patient had testicular cancer that had spread to his spine. His X-ray showed a new spinal body compression, which may have represented cancer recurrence. Providers need to act on these results immediately because cancer-related spinal compressions can lead to permanent paralysis if not treated promptly. However, after the provider reviewed the X-ray report, the provider did not see the patient until 14 days later. This delay placed the patient at increased risk of complications from cancer recurrence. • In case 18, the patient had no previous TB infection and no prior abnormal TB tests. A provider reviewed a newly positive TB blood test that suggested the patient had developed latent or active TB infection. Active pulmonary TB would require staff to place the patient in respiratory isolation to prevent the spread of the disease to other inmates and prison staff. Nonetheless, on subsequent visits, the provider did not address the positive test and did not obtain a chest X-ray to assess for possible active TB infection. The institution did not address the abnormal TB test until the OIG notified CCHCS about this lapse in care. Fortunately, subsequent tests showed no evidence of active TB. • In case 24, the elderly patient with previous gastrointestinal bleeding had two consecutive laboratory tests that showed significantly worsening anemia. Also, the patient had signs and California Institution for Men, Cycle 5 Medical Inspection Page 52 Office of the Inspector General State of California symptoms of anemia, including fatigue, dizziness, and an abnormally rapid heart rate. Furthermore, the patient had dark stool, which was even more suggestive of gastrointestinal bleeding. The provider should have transferred the patient to a community hospital for further evaluation but did not. This error placed the patient at risk of life-threatening complications of anemia and bleeding. • In case 25, the patient with liver cancer had an elevated tumor marker level suggestive for cancer recurrence. The provider reviewed the abnormal laboratory result but did not schedule a timely follow-up appointment to address the abnormal test result. This delay placed the patient at risk of cancer complications. • In case 27, the patient had an abnormal test showing blood in the stool. Some conditions that can cause blood in the stool include intestinal bleeding or intestinal cancer. Although the provider signed the test result, the provider did not address the abnormal test. This oversight placed the patient at risk of serious complications from possible diagnoses such as intestinal bleeding or cancer. Hospital Return Care CIM providers performed poorly and often failed to address new diagnoses and recommendations when their patients returned from hospitalization. We discuss this performance further in the Inter- and Intra-System Transfers indicator. Emergency Care CIM providers were readily available for consultation with the TTA nursing staff when patients presented emergently to the TTA. The providers did well and made appropriate triage decisions. We found no provider deficiencies related to emergency care. Chronic Care CIM providers performed poorly in managing chronic medical conditions. Chronic care errors occurred in cases 6, 13, 15, 17, 18, 19, 20, 23, 24, 26, and 27. The following examples demonstrated poor diabetic care: • In case 13, the patient had out-of-control diabetes during the review period, and the provider made only two insulin adjustments over seven months. Current medical standards recommend that providers adjust insulin weekly. The delayed treatment of poorly controlled diabetes placed the patient at risk for diabetic complications. • In case 15, the patient had three consecutive blood tests that showed worsening diabetic control during the review period. Although the provider evaluated the patient six times, the California Institution for Men, Cycle 5 Medical Inspection Page 53 Office of the Inspector General State of California provider only made four insulin adjustments. For one of the insulin adjustments, the provider inappropriately decreased the insulin dose, leading to further worsened diabetic control. • In case 17, the patient had poorly controlled diabetes requiring insulin adjustment. The provider ordered an eight-week follow-up. The provider should have had the patient follow up weekly to reassess the patient’s glycemic control and to adjust insulin as indicated. Glycemic control for insulin-dependent diabetic patients requires close monitoring and timely insulin titration. CIM providers performed poorly managing hypertension. The following examples demonstrated poor hypertension management: • In case 15, the patient had chronic kidney disease with excessive protein in the urine, and he required optimal blood pressure control. On multiple encounters, the provider did not address the elevated blood pressure levels that suggested poorly controlled hypertension. The provider’s oversight placed the patient at risk of cardiovascular events and kidney failure. • In case 26, the patient had elevated blood pressure readings during all eight provider encounters in the review period. The provider made only three medication adjustments. During one occasion, the patient had severely elevated blood pressure, which could have led to a stroke. The provider should have ordered intensive blood pressure monitoring, reviewed those results during the morning huddles, and scheduled a close follow-up to reassess the patient’s blood pressure control and to adjust his medications further. The following example also demonstrated poor chronic care management: • In case 6, the patient had aortic stenosis (narrowing of the aorta) which had progressed from mild to moderate severity and required monitoring. The provider did not address the aortic stenosis during any of the patient’s chronic care or follow-up visits. The provider also did not realize that the patient’s cardiology follow-up appointment did not occur. After more than a year of lapsed care, the patient developed chest pain and shortness of breath with exertion, as well as dizziness. The provider failed to consider that the patient’s symptoms may have been due to the patient’s worsening aortic stenosis. Subsequently, the patient lost consciousness and required CPR. Unfortunately, the resuscitation was unsuccessful, and the patient died. The inappropriate management of the patient’s aortic stenosis placed the patient at risk of harm and may have contributed to his death. Specialty Services CIM providers often did not properly address specialists’ diagnoses and recommendations. California Institution for Men, Cycle 5 Medical Inspection Page 54 Office of the Inspector General State of California We discuss examples of these errors in the Specialty Services indicator. Specialized Medical Housing CIM providers often had problems with diagnosing and treating OHU patients correctly. We discuss this poor provider performance in the Specialized Medical Housing indicator. Health Information Management The providers documented their outpatient, TTA, and specialty housing encounters timely. The progress notes were either dictated or typed and were legible. CIM providers generally performed well in this area. Clinician Onsite Inspection At the time of the OIG clinician onsite visit, there were no provider vacancies. The chief medical executive (CME) affirmed that all annual provider evaluations were current. The CME was unaware of any poorly performing providers. CIM usually assigned each provider to one designated clinic to enhance continuity of care. Each provider usually saw 8 to 12 patients per day. The providers were generally satisfied with the institution’s nursing, diagnostic, and specialty services. The providers attended a daily morning report meeting, during which they discussed patients in the hospital or returning from the hospital. In addition to the morning report, the providers led the clinic morning huddles, which were productive. The huddles were also attended by nurses, care coordinators, custody staff, mental health staff, and office technicians. The clinic team discussed any significant TTA encounters or hospital returns from the previous day. Case Review Conclusion CIM providers performed poorly in multiple aspects of patient care. CIM providers often made poor assessments and decisions. They prescribed medications inappropriately and failed to follow up on abnormal diagnostic test results. They often failed to review and implement hospital and specialist recommendations properly. Furthermore, they had significant difficulty delivering appropriate chronic care. We identified one significantly underperforming physician and referred that provider to CCHCS for further review. Overall, the CIM providers’ combined performance was poor and resulted in inadequate ratings for 12 of the 27 detailed cases our physicians reviewed. We rated CIM’s Quality of Provider Performance indicator inadequate. California Institution for Men, Cycle 5 Medical Inspection Page 55 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 Proficient health assessments, continuity of medications, and completion of (88.1%) required screening tests; address and provide significant Overall Rating: accommodations for disabilities and health care appliance needs; and Adequate identify health care conditions needing treatment and monitoring. The patients reviewed for reception center cases are those received from non-CDCR facilities, such as county jails. For this indicator, the case review and compliance review processes yielded different results, with the case reviewers assigning an adequate rating and the compliance testing resulting in a proficient score. Our analysis determined that applicable compliance results in the Pharmacy and Medication Management indicator showed the institution had marked difficulty issuing reception center patients their regular medications within appropriate time frames. Because of the clinical importance of medication continuity for these patients, a proficient rating was not warranted, and we rated this indicator adequate overall. Case Review Results We reviewed 23 related events in five cases in which the patient arrived through the reception center, and we found five minor deficiencies. The case review rating of CIM’s Reception Center Arrivals indicator was adequate. Access to Care CIM’s receiving and release (R&R) nurses evaluated new patient arrivals and ordered provider appointments within appropriate time frames. Patients received the required screening tests, and CIM providers performed thorough intake assessments and addressed pending specialty appointments. Medication Continuity CIM R&R nurses and providers usually reconciled medications promptly in the cases we reviewed. We found one medication deficiency: • In case 38, the R&R RN did not issue a rescue inhaler to an asthmatic patient to keep with him for urgent self-administration as needed. California Institution for Men, Cycle 5 Medical Inspection Page 56 Office of the Inspector General State of California Onsite Inspection CIM’s R&R is located in facility B and is used to manage both inter-system and reception center arrivals. CIM staffed the area with RNs on the day and evening shifts. In addition to processing patients who arrived from county jails, these nurses also evaluated patients arriving from and transferring out to other CDCR institutions. Case Review Conclusion CIM generally performed sufficiently for newly arrived patients who transferred from a county jail. CIM had difficulty with medication continuity for these patients. The case review rating of CIM’s Reception Center Arrivals indicator was adequate. Compliance Testing Results The institution scored in the proficient range in this indicator with a compliance score of 88.1 percent. The following five tests scored in the proficient range: • Reception center nursing staff timely completed, signed, and dated the assessment and disposition section of the initial health screening form for all 20 patients sampled (MIT 12.002). • Nurses referred 20 patients who arrived at CIM from county jails to see a provider. Providers saw 19 of the 20 referred patients timely (95.0 percent). A provider saw one patient 63 days late (MIT 12.003). • Providers timely completed reception center history and physical examinations within seven calendar days of the patient’s arrival for 19 of 20 sampled patients (95.0 percent). For one patient, the provider completed the history and physical 53 days late (MIT 12.004). • We sampled 20 reception center patients to test for required intake tests; all 20 timely received the applicable intake tests (MIT 12.005). • We sampled 20 reception center arrivals to ensure that each patient had a timely completed and properly documented TB skin test. All 20 patients had their TB tests timely administered, read, and documented (MIT 12.007). California Institution for Men, Cycle 5 Medical Inspection Page 57 Office of the Inspector General State of California One test received an adequate score: • We sampled 20 reception center patients to ensure that they received a timely health screening upon arrival at the institution. Nursing staff conducted timely and complete screenings for 16 of those patients sampled (80.0 percent). For four patients, nurses did not complete all of the required screening questions (MIT 12.001). Two tests indicated room for improvement with inadequate scores: • After ordering intake tests for reception center arrivals, providers timely reviewed and communicated the test results to 13 of 20 patients sampled (65.0 percent). For seven patients, providers either reviewed the test results late or communicated the patient’s results from 1 to 50 days late (MIT 12.006). • The institution timely administered the coccidioidomycosis (valley fever) skin test to 14 of the 20 sampled reception center patients (70.0 percent). Staff did not timely offer the test to four patients, and staff did not obtain the other two patients’ refusals within the required time frame (MIT 12.008). California Institution for Men, Cycle 5 Medical Inspection Page 58 Office of the Inspector General State of California SPECIALIZED MEDICAL HOUSING This indicator addresses whether the institution follows appropriate Case Review Rating: policies and procedures when admitting patients to onsite inpatient Inadequate facilities, including completion of timely nursing and provider Compliance Score: Proficient assessments. The case review assesses all aspects of medical care (100.0%) related to these housing units, including quality of provider and nursing care. CIM’s specialized medical housing unit is the Overall Rating: outpatient housing unit (OHU). Inadequate For this indicator, the case review and compliance review processes yielded different results, with the case reviewers assigning an inadequate rating and the compliance testing resulting in an proficient score. Because the compliance tests in this indicator do not accurately reflect the quality of patient care, we rely on the case review rating for the overall rating of this indicator. Thus, we rated this indicator inadequate overall. Case Review Results We reviewed 12 patient admissions to the OHU, which included 32 provider and 28 nursing encounters. We found 28 deficiencies, 4 of which were significant (in cases 12, 21, 23, and 24). The case review rating for this indicator was inadequate. Provider Performance The OHU provider performed poorly in the OHU, as they made poor medical assessments and decisions. The following examples demonstrated poor provider assessment: • In case 12, the patient had cancer that had spread to the spine and was residing in the OHU for enhanced nursing care. A spine X-ray demonstrated a new vertebral body compression fracture suggestive of cancer progression. The OHU provider reviewed the X-ray report but did not evaluate the patient until 14 days later, placing the patient at risk of delayed cancer diagnosis and treatment. We also discuss this case in the Quality of Provider Performance indicator. • In case 35, the patient had heart disease, and the provider prescribed nitroglycerin medication to treat episodes of chest pain. However, the provider prescribed the nitroglycerin via nurse administration rather than allowing the patient to keep it with him to use immediately when needed. This error placed the patient at risk of delayed treatment of chest pain or heart disease. The OHU provider performed poorly addressing recommendations made by the hospital physicians after the patient returned from the hospital. The following examples demonstrated poor provider California Institution for Men, Cycle 5 Medical Inspection Page 59 Office of the Inspector General State of California assessment after hospitalization: • In case 23, the patient returned from hospitalization with a repaired aortic aneurysm and a prescription for a potentially dangerous anti-arrhythmic heart medication. The hospital physician recommended a follow-up appointment with a cardiologist two weeks after discharge. However, the OHU provider did not request the cardiology follow-up within the recommended time frame, which demonstrated the provider’s poor assessment and understanding of the patient’s condition. We also discuss this case in the Quality of Provider Performance indicator. • In case 24, the patient returned from hospitalization with the diagnosis of a left kidney mass suspicious for cancer. The hospital physician recommended the patient see a urologist to follow up on the mass. The provider did not properly review the hospital records and failed to address the left kidney mass. The provider’s error placed the patient at risk for delayed or untreated kidney cancer. Nursing Performance We identified nine nursing deficiencies in the OHU, one of which was significant. The RNs performed timely admission assessments and usually contacted the providers when warranted. However, at times nurses performed incomplete assessments, and their documentation lacked pertinent information, such as wound appearance. Also, there were instances in which the nurses did not document their communications with the providers for clinical issues. Among the 12 OHU cases reviewed, we identified nursing assessment deficiencies in cases 23, 24, 35, and 38. Most nursing deficiencies were minor and related to incomplete assessments or documentation. While OHU nursing performance was generally sufficient, we provide the following examples for quality improvement purposes: • In case 21, the patient with oral cancer requiring a feeding tube for nutritional intake had refused the liquid nutritional supplement and complained of difficulty swallowing. The patient’s heart rate increased, which should have suggested possible dehydration since the patient had not been taking fluids. However, the RN did not consider this possibility and did not contact a provider to report these findings before releasing the patient to the general population. • In case 24, the patient had a history of diabetes, and CIM staff admitted him to the OHU for weakness after he returned from a hospitalization. The OHU admitting nurse did not assess the patient’s blood glucose levels. • In case 38, the asthmatic patient arrived from a county jail and was admitted to the OHU for assistance with daily living activities. The OHU nurse did not assess the frequency of the California Institution for Men, Cycle 5 Medical Inspection Page 60 Office of the Inspector General State of California patient’s rescue inhaler use and did not ensure that the patient had a rescue inhaler to keep on his person for emergency use. Additionally, the patient informed the nurse that he had a seizure earlier that day, but the nurse did not recognize the patient’s history of previous seizures or inform the provider. Medication Management The OHU patients generally received medications timely and as prescribed; however, there were three deficiencies related to medication management. The following example identified a lapse in OHU medication management: • In case 22, the patient did not receive two blood pressure medications on two separate occasions. Clinician Onsite Inspection CIM had 44 medical OHU beds and 34 mental health beds. There were two negative-pressure rooms, which are designed to prevent the spread of airborne infections. There were two providers assigned to the OHU. An RN was present during the day shift, while LVNs staffed the evening and night shifts. The TTA RN and nursing supervisor were available to assist the LVNs during those shifts. Case Review Conclusion Patients residing in the OHU are medically complex and need close monitoring. OHU patients returning from a hospitalization also require a thorough review of hospital records to address all new diagnoses and recommendations. CIM’s OHU provider showed poor medical judgment and inadequate review of hospital records, thereby placing OHU patients at risk of harm. We rated the CIM Specialized Medical Housing indicator inadequate. Compliance Testing Results The institution received a proficient compliance score of 100.0 percent in this indicator. All three applicable tests earned scores of 100.0 percent: • For all ten patients sampled, nursing staff timely completed an initial health assessment on the day medical staff admitted the patient to the OHU (MIT 13.001). • CIM providers timely completed subjective, objective, assessment, plan, and education (SOAPE) notes at required three-day intervals for all seven applicable OHU patients sampled (MIT 13.003). • We observed the working order of sampled call buttons in OHU patient rooms and found all California Institution for Men, Cycle 5 Medical Inspection Page 61 Office of the Inspector General State of California working properly. In addition, according to staff members interviewed, custody officers and clinicians were able to expeditiously access patients’ locked rooms when emergent events occurred (MIT 13.101). California Institution for Men, Cycle 5 Medical Inspection Page 62 Office of the Inspector General State of California SPECIALTY SERVICES This indicator focuses on specialist care from the time a physician Case Review Rating: completes a request for services or a physician’s order for specialist Inadequate care to the time of receipt of related recommendations from Compliance Score: Proficient specialists. This indicator also evaluates the providers’ timely review (86.2%) of specialist records and documentation reflecting the patients’ care plans, including the course of care when specialist recommendations Overall Rating: were not ordered, and whether the results of specialists’ reports are Inadequate communicated to the patients. For specialty services denied by the institution, the OIG determines whether the denials are timely and appropriate, and whether the provider updates the patient on the plan of care. For this indicator, the case review and compliance review processes yielded different results, with the case reviewers assigning an inadequate rating and the compliance testing resulting in a proficient score. We determined that while the institution performed well with scheduling initial specialty appointments, it did not always schedule specialty follow-ups reliably. Moreover, CIM providers often failed to review specialty recommendations appropriately, resulting in lapses in care. Because of the clinical importance of providers reviewing and implementing specialists’ recommendations, we rated this indicator inadequate overall. Case Review Results We reviewed 186 events related to the Specialty Services indicator, which included 143 specialty consultations and procedures and 43 nursing encounters. There were 23 deficiencies, 11 of which were significant. The case review rating for this indicator was inadequate. Access to Specialty Services CIM usually scheduled specialty services within clinically appropriate time frames. However, we identified two significant deficiencies that suggested that CIM did not reliably schedule specialty follow-up appointments: • In case 23, the patient had a recently repaired aortic aneurysm and was taking an anti-arrhythmic medication. The provider requested a cardiology follow-up, but the appointment did not occur. • In case 25, the patient had prior liver cancer, and a provider requested an oncology follow-up in 55 days; however, a scheduling error occurred when the patient went to the oncologist’s office six weeks early. The specialist noted the appointment was too soon and asked CIM to reschedule the patient. Unfortunately, CIM’s specialty scheduler did not reschedule the appointment correctly, and the appointment occurred eight weeks late. California Institution for Men, Cycle 5 Medical Inspection Page 63 Office of the Inspector General State of California Nursing Performance The TTA nurses evaluated patients after they returned from offsite specialty appointments. A different nurse facilitated the telemedicine specialty appointments. We reviewed 43 specialty nursing events and identified eight deficiencies. Most of the deficiencies were related to documentation and assessment deficits, except for one significant lapse in case 26. Overall, CIM specialty nursing care was adequate. • In case 26, the telemedicine specialty nurse found a severely elevated blood pressure reading but did not reassess the blood pressure or notify the primary care provider of the patient’s condition. Provider Performance Providers did not properly review or implement specialists’ recommendations in cases 18, 19, 21, 23, 25, and 29. There were ten of these deficiencies, six of which were significant. Some examples of poor provider performance in relation to specialty services are as follows: • In case 18, the patient with hepatitis C infection was receiving long-term immune suppression therapy. The specialist repeatedly recommended treating the hepatitis C infection because the immune suppression medications could increase the risk of hepatitis C progression and other complications. However, the provider ignored the specialist’s recommendation and placed the patient at risk of worsening hepatitis C infection and its related complications. • In case 19, the specialist found the patient had an enlarging lung nodule suggestive of lung cancer. The specialist recommended an urgent surgical evaluation to remove the nodule. However, the provider did not implement the urgent recommendation promptly, contributing to one of the many delays we found in this case. • Also in case 19, the surgeon believed the lung nodule was suspicious for cancer and recommended obtaining an imaging test prior to possible surgical removal. The provider should have requested the imaging study with an “urgent” instead of “routine” priority. This delay placed the patient at risk of cancer complications. • In case 21, the patient had oral cancer, and the specialist recommended obtaining a needle biopsy of the lymph nodes to assess for cancer recurrence. The provider failed to order the biopsy. Subsequently, the specialist evaluated the patient without the needed diagnostic test, resulting in a delay in care. • In case 29, the patient was diagnosed at his previous CDCR institution with lung cancer. The patient was symptomatic and was coughing up blood. The sending institution transferred the California Institution for Men, Cycle 5 Medical Inspection Page 64 Office of the Inspector General State of California patient to CIM promptly for urgent treatment because there were no oncology services available near the sending institution. When the patient arrived at CIM, the provider failed to request an urgent oncology consultation. Instead, the provider ordered a routine (90-day) referral, which delayed the patient’s cancer treatment. We also discuss this case in the Quality of Provider Performance indicator. Health Information Management Medical records and specialty services staff performed well. CIM retrieved and promptly scanned into the medical record most specialty reports. However, there were two missing specialty reports: • In case 19, the PET/CT scan report was missing from the medical record. • In case 23, staff failed to retrieve the coronary angiogram results and to scan them into the medical record. Onsite Inspection At the time of our inspection, there were nursing and clerical staff assigned to offsite, onsite, and telemedicine specialty service areas. They scheduled specialty appointments, prepared medical records for specialists to review, and obtained specialists’ reports. We asked specialty staff why specialty appointments did not occur within clinically appropriate time frames. The specialty nursing supervisor and staff explained that while the providers often wanted specialty appointments to occur within four to six weeks, the specialty request forms (CDCR Form 7243) had only three priority options for providers to choose: emergent (now), urgent (within 14 days), or routine (within 90 days). CIM managers encouraged the providers to select the 90-day option for all specialty services that were not urgent, even if the patient needed the appointment earlier. CIM staff explained that they, along with other CDCR facilities, encouraged the 90-day option to score higher on the CCHCS Health Care Dashboard. The OIG does not agree with CIM’s practice of encouraging providers to order all non-urgent specialty services with routine priority. When a provider orders a specialty service, the provider should consider the patient’s clinical condition and should specify the appropriate period in which the specialty service should occur. The provider should not arbitrarily specify a 90-day window for any non-urgent service. Providers now can specify exact time frames for these services within the EHRS, and CCHCS should change its specialty access policies and monitor each institution’s ability to provide specialty access based on the provider’s order, rather than on “routine” or “urgent” time frames that may not be clinically relevant. California Institution for Men, Cycle 5 Medical Inspection Page 65 Office of the Inspector General State of California Case Review Conclusion CIM had numerous significant deficiencies related to specialty services. Specialty staff failed to schedule several critical specialty appointments, and providers often failed to review and implement important specialty recommendations. The case review rating of the Specialty Services indicator at CIM was inadequate. Compliance Testing Results The institution received a proficient compliance score of 86.0 percent in this indicator, with the following six tests scoring in the proficient range: • For all 15 patients sampled, high-priority specialty services appointments occurred within 14 calendar days of the provider’s order (MIT 14.001). • Providers timely received and reviewed high-priority specialists’ reports for 14 of the 15 patients sampled (93.3 percent). For one patient, the provider reviewed the report seven days late (MIT 14.002). • CIM provided routine specialty service appointments to 14 of 15 sampled patients within the required time frame (93.3 percent). One patient received the specialty service ten days late (MIT 14.003). • CIM providers timely reviewed specialists’ reports following routine specialty service appointments for 13 of the 14 applicable patients (92.9 percent). The provider reviewed one report one day late (MIT 14.004). • The institution timely denied providers’ specialty services requests for 18 of 20 patients sampled (90.0 percent). For two patients, CIM management denied two specialty services but failed to document the denial date (MIT 14.006). • For 18 patients sampled who had a specialty service denied by CIM’s health care management, 16 (88.9 percent) received timely notification of the denied service, including the provider meeting with the patient within 30 days to discuss alternate treatment strategies. For two sampled patients, providers communicated the denials three and nine days late (MIT 14.007). California Institution for Men, Cycle 5 Medical Inspection Page 66 Office of the Inspector General State of California One test received an inadequate score: • Among 20 patients sampled who transferred into CIM with an approved specialty service, 9 patients (45.0 percent) received it within the required time frame. Six patients received their specialty services from 5 to 58 days late. Five other patients never received their services at all (MIT 14.005). California Institution for Men, Cycle 5 Medical Inspection Page 67 Office of the Inspector General State of California ADMINISTRATIVE OPERATIONS (SECONDARY) This indicator focuses on the institution’s administrative health care Case Review Rating: oversight functions. The OIG evaluates whether the institution Not Applicable promptly processes patient medical appeals and addresses all Compliance Score: Proficient appealed issues. Inspectors also verify that the institution follows (85.9%) reporting requirements for adverse/sentinel events and patient deaths. The OIG verifies that the Emergency Medical Response Review Overall Rating: Committee (EMRRC) performs required reviews and that staff Proficient perform required emergency response drills. Inspectors also assess whether the Quality Management Committee (QMC) meets regularly and adequately addresses program performance. For those institutions with licensed facilities, inspectors also verify that required committee meetings are held. In addition, the OIG examines whether the institution adequately manages its health care staffing resources by evaluating whether job performance reviews are completed as required; specified staff possess current, valid credentials and professional licenses or certifications; nursing staff receive new employee orientation training and annual competency testing; and clinical and custody staff have current emergency medical response certifications. The Administrative Operations indicator is a secondary indicator; therefore, it was not relied on for the institution’s overall score. Compliance Testing Results The institution received a proficient compliance score of 85.9 percent in this indicator, with 11 tests scoring in the proficient range: • The institution promptly processed all 12 patient medical appeals in each of the most recent 12 months (MIT 15.001). • CIM’s QMC met monthly, evaluated program performance, and took action when management identified areas for improvement opportunities (MIT 15.003). • CIM took adequate steps to ensure the accuracy of its Dashboard data reporting (MIT 15.004). • Based on a sample of ten second-level medical appeals, the institution’s responses addressed all of the patients’ appealed issues (MIT 15.102). • Medical staff promptly submitted the initial Inmate Death Report (CDCR Form 7229A or 7229B) to CCHCS’s Death Review Unit for all nine applicable deaths that occurred at CIM in the prior 12-month period (MIT 15.103). California Institution for Men, Cycle 5 Medical Inspection Page 68 Office of the Inspector General State of California • All ten nurses sampled were current with their clinical competency validations (MIT 15.105). • All providers at the institution were current with their professional licenses. Similarly, all nursing staff and the pharmacist in charge were current with their professional licenses and certification requirements (MIT 15.107, 15.109). • All active duty providers and nurses were current with their emergency response certifications (MIT 15.108). • All pharmacy staff and providers who prescribed controlled substances had current Drug Enforcement Agency registrations (MIT 15.110). • All nursing staff hired within the last year timely received new employee orientation training (MIT 15.111). Three tests showed room for improvement with inadequate scores: • Of the 12 sampled incident packages for emergency medical responses reviewed by the institution’s Emergency Medical Response Review Committee (EMRRC) during the prior 12-month period, five (41.7 percent) complied with policy. The institution’s EMRRC failed to provide complete documentation of the EMRRC checklist for seven incident packages (MIT 15.005). • We reviewed the summary reports and related documentation for three medical emergency response drills conducted in the prior quarter. CIM did not conduct a comprehensive response drill for all three watches. More specifically, there was incomplete documentation on the required Triage and Treatment Services Flow Sheet (CDCR Form 7464), and necessary elements in an emergency response drill lacked completion and consistency. As a result, the institution scored zero on this test (MIT 15.101). • Supervisors completed a proper clinical performance appraisal for 11 of 18 CIM providers (61.1 percent). Seven other providers did not have either timely or properly completed appraisals, including one or more of the following deficiencies: the supervising physician did not sign the provider’s individual development plan; the Unit Health Record Clinical Appraisal (UCA) had incomplete documentation; the UCA did not meet the required number of clinical reviews; and the supervising physician did not discuss the results of the UCA review with the provider (MIT 15.106). California Institution for Men, Cycle 5 Medical Inspection Page 69 Office of the Inspector General State of California Non-Scored Results • The OIG gathered non-scored data regarding the completion of death review reports by CCHCS’s Death Review Committee (DRC). Eight deaths occurred during the OIG’s review period; three were unexpected (Level 1) deaths and five were expected (Level 2) deaths. None of the eight death reviews were completed or communicated to CIM’s CEO within the required time frame (MIT 15.998). • The OIG discusses the institution’s health care staffing resources in the About the Institution section of this report (MIT 15.999). California Institution for Men, Cycle 5 Medical Inspection Page 70 Office of the Inspector General State of California R ECOMMENDATIONS The OIG recommends the following: • The chief medical executive (CME) should audit the records of patients returning from the hospital, an emergency department, or from specialty consultations to ensure the providers are addressing all their patients’ diagnoses, medications, and recommendations. The CME should also consider designating the chief physician and surgeon (CP&S) or another provider to review each of these records to ensure that the institution implements any urgent recommendations. We found serious lapses in care due to poor provider performance in this area. • The CME should revamp the methods the institution uses to appraise provider performance. Although we found serious provider quality problems during this inspection, the CME was unaware of any provider performance issues. • The chief nursing executive (CNE) should also inspect the records of patients returning from a hospital or emergency department to ensure the nurses thoroughly review the discharge summaries, perform complete assessments, and implement essential recommendations. • The CNE and the pharmacist in charge should launch a quality improvement program to increase medication continuity for patients who return from an outside emergency room or hospital. We found serious problems with medication continuity for these patients during our inspection. • The CME should instruct the providers to specify the appropriate clinical time frames for specialty services within EHRS orders. The CNE should instruct the specialty department to schedule services according to those time frames. These changes should help ensure that the institution schedules specialty appointments within clinically appropriate time frames. • CCHCS should modify the specialty access policy and eliminate both “routine” and “urgent” priority time frames. Instead, CCHCS should monitor specialty access by measuring the ability of each institution to provide specialty services within the time frame specified in each EHRS order. California Institution for Men, Cycle 5 Medical Inspection Page 71 Office of the Inspector General State of California P -B M OPULATION ASED ETRICS The compliance testing and the case reviews give an accurate assessment of how the institution’s health care systems are functioning with regard to the patients with the highest risk and utilization. This information is vital to assess the capacity of the institution to provide sustainable, adequate care. However, one significant limitation of the case review methodology is that it does not give a clear assessment of how the institution performs for the entire population. For better insight into this performance, the OIG has turned to population-based metrics. For comparative purposes, the OIG has selected several Healthcare Effectiveness Data and Information Set (HEDIS) measures for disease management to gauge the institution’s effectiveness in outpatient health care, especially chronic disease management. The Healthcare Effectiveness Data and Information Set is a set of standardized performance measures developed by the National Committee for Quality Assurance with input from over 300 organizations representing every sector of the nation’s health care industry. It is used by over 90 percent of the nation’s health plans as well as many leading employers and regulators. HEDIS 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, we used a subset of HEDIS measures applicable to the CDCR patient population. Selection of the measures was based on the availability, reliability, and feasibility of the data required for performing the measurement. We collected data utilizing various information sources, including the electronic medical record, the Master Registry (maintained by CCHCS), as well as a random sample of patient records analyzed and abstracted by trained personnel. We did not independently validate the data obtained from the CCHCS Master Registry and Diabetic Registry and we presume it to be accurate. For some measures, we used the entire population rather than statistically random samples. While the OIG is not a certified HEDIS compliance auditor, we use 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 (CIM), 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 5 Medical Inspection Page 72 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 compared to other entities. When compared statewide, CIM outperformed Medi-Cal in all five diabetic measures, and the institution outperformed Kaiser in four of the five diabetic measures. CIM scored slightly lower in diabetic blood pressure control than Kaiser, North and South regions. When compared nationally, the institution outperformed Medicaid, commercial plans, and Medicare in all five diabetic measures. The institution also outperformed the United States Department of Veterans Affairs (VA) in two of the four applicable measures, with CIM scoring slightly lower in diabetic blood pressure control and diabetic eye exams. Immunizations Comparative data for immunizations was only fully available for the VA and partially available for Kaiser, commercial plans, and Medicare. With respect to administering influenza vaccinations to younger and older adults, CIM outperformed all health care plans. With regard to administering pneumococcal vaccines to older adults, CIM scored higher than Medicare but slightly lower than the VA. Cancer Screening With respect to colorectal cancer screening, CIM scored higher than commercial plans and Medicare. However, the institution scored lower than Kaiser (North and South) and the VA. The 26 percent refusal rate for colorectal cancer screening at the institution negatively affected the score for this measure. Summary CIM’s population-based metrics performance reflected a well-functioning chronic care program in comparison to the other health care plans reviewed. CIM may improve its scores in colorectal screenings by reducing patient refusals through educating patients on the benefits of these preventive services. California Institution for Men, Cycle 5 Medical Inspection Page 73 Office of the Inspector General State of California CIM Results Compared to State and National HEDIS Scores California National HEDIS HEDIS CIM HEDIS HEDIS Kaiser Kaiser HEDIS HEDIS VA Clinical Measures Com- Medi-Cal (No. (So. Medicaid Medicare Average Cycle 5 mercial 20162 CA) CA) 20164 20164 20165 Results1 20164 20163 20163 Comprehensive Diabetes Care HbA1c Testing (Monitoring) 100% 86% 94% 94% 86% 90% 93% 98% Poor HbA1c Control (>9.0%)6, 7 3% 39% 20% 23% 45% 34% 27% 19% HbA1c Control (<8.0%)6 89% 49% 70% 63% 46% 55% 63% - Blood Pressure Control 73% 63% 83% 83% 59% 60% 62% 74% (<140/90)6 Eye Exams 85% 53% 68% 81% 53% 54% 69% 89% Immunizations Influenza Shots - Adults (18–64) 72% - 56% 57% 39% 48% - 55% Influenza Shots - Adults (65+) 81% - - - - - 72% 76% Immunizations: Pneumococcal 90% - - - - - 71% 93% Cancer Screening Colorectal Cancer Screening 74% - 79% 82% - 63% 67% 82% 1. Unless otherwise stated, data was collected in November 2017 by reviewing medical records from a sample of CIM’s population of applicable patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. 2. HEDIS Medi-Cal data was obtained from the California Department of Health Care Services 2015 HEDIS Aggregate Report for Medi-Cal Managed Care. 3. Data was obtained from Kaiser Permanente November 2016 reports for the Northern and Southern California regions. 4. National HEDIS data for Medicaid, commercial plans, and Medicare was obtained from the 2016 State of Health Care Quality Report, available on the NCQA website: www.ncqa.org. The results for commercial plans were based on data received from various health maintenance organizations. 5. The Department of Veterans Affairs (VA) data was obtained from the VA’s website, www.va.gov. For the Immunizations: Pneumococcal measure only, the data was obtained from the VHA Facility Quality and Safety Report - Fiscal Year 2012 Data. 6. For this indicator, the entire applicable 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. California Institution for Men, Cycle 5 Medical Inspection Page 74 Office of the Inspector General State of California A A — C T R PPENDIX OMPLIANCE EST ESULTS California Institution for Men Range of Summary Scores: 55.0% – 100.0% Indicator Compliance Score (Yes %) 1–Access to Care 86.2% 2–Diagnostic Services 87.8% 3–Emergency Services Not Applicable 4–Health Information Management (Medical Records) 75.5% 5–Health Care Environment 55.0% 6–Inter- and Intra-System Transfers 74.3% 7–Pharmacy and Medication Management 63.2% 8–Prenatal and Post-Delivery Services Not Applicable 9–Preventive Services 78.0% 10–Quality of Nursing Performance Not Applicable 11–Quality of Provider Performance Not Applicable 12–Reception Center Arrivals 88.1% 13–Specialized Medical Housing (OHU, CTC, SNF, Hospice) 100.0% 14–Specialty Services 86.2% 15–Administrative Operations 85.9% California Institution for Men, Cycle 5 Medical Inspection Page 75 Office of the Inspector General State of California Scored Answers Yes Reference + 1–Access to Care Number Yes No No Yes % N/A Chronic care follow-up appointments: Was the patient’s most recent chronic care visit within the health care guideline’s maximum 1.001 22 3 25 88.0% 0 allowable interval or within the ordered time frame, whichever is shorter? For endorsed patients received from another CDCR institution: If the 1.002 nurse referred the patient to a provider during the initial health 20 5 25 80.0% 0 screening, was the patient seen within the required time frame? Clinical appointments: Did a registered nurse review the patient’s 1.003 30 0 30 100.0% 0 request for service the same day it was received? Clinical appointments: Did the registered nurse complete a 1.004 face-to-face visit within one business day after the CDCR Form 7362 29 1 30 96.7% 0 was reviewed? Clinical appointments: If the registered nurse determined a referral to a primary care provider was necessary, was the patient seen within 1.005 2 1 3 66.7% 27 the maximum allowable time or the ordered time frame, whichever is the shorter? Sick call follow-up appointments: If the primary care provider 1.006 ordered a follow-up sick call appointment, did it take place within the Not Applicable time frame specified? Upon the patient's discharge from the community hospital: Did the 1.007 patient receive a follow-up appointment within the required time 25 0 25 100.0% 0 frame? Specialty service follow-up appointments: Do specialty service 1.008 primary care physician follow-up visits occur within required time 21 7 28 75.0% 2 frames? Clinical appointments: Do patients have a standardized process to 1.101 5 1 6 83.3% 0 obtain and submit health care services request forms? Overall percentage: 86.2% California Institution for Men, Cycle 5 Medical Inspection Page 76 Office of the Inspector General State of California Scored Answers Yes Reference + 2–Diagnostic Services Number Yes No No Yes % N/A Radiology: Was the radiology service provided within the time frame 2.001 10 0 10 100.0% 0 specified in the provider's order? Radiology: Did the primary care provider review and initial the 2.002 9 1 10 90.0% 0 diagnostic report within specified time frames? Radiology: Did the primary care provider communicate the results of 2.003 10 0 10 100.0% 0 the diagnostic study to the patient within specified time frames? Laboratory: Was the laboratory service provided within the time 2.004 8 2 10 80.0% 0 frame specified in the provider's order? Laboratory: Did the primary care provider review and initial the 2.005 8 2 10 80.0% 0 diagnostic report within specified time frames? Laboratory: Did the primary care provider communicate the results 2.006 6 4 10 60.0% 0 of the diagnostic study to the patient within specified time frames? Pathology: Did the institution receive the final diagnostic report 2.007 10 0 10 100.0% 0 within the required time frames? Pathology: Did the primary care provider review and initial the 2.008 9 1 10 90.0% 0 diagnostic report within specified time frames? Pathology: Did the primary care provider communicate the results of 2.009 9 1 10 90.0% 0 the diagnostic study to the patient within specified time frames? Overall percentage: 87.8% 3–Emergency Services This indicator is evaluated only by case review clinicians. There is no compliance testing component. California Institution for Men, Cycle 5 Medical Inspection Page 77 Office of the Inspector General State of California Scored Answers Yes Reference + 4–Health Information Management Number Yes No No Yes % N/A Are non-dictated health care documents (provider progress notes) 4.001 8 3 11 72.7% 0 scanned within 3 calendar days of the patient encounter date? Are dictated/transcribed documents scanned into the patient’s 4.002 electronic health record within five calendar days of the encounter 7 3 10 70.0% 0 date? Are High-Priority specialty notes (either a Form 7243 or other scanned 4.003 19 1 20 95.0% 0 consulting report) scanned within the required time frame? Are community hospital discharge documents scanned into the 4.004 patient’s electronic health record within three calendar days of hospital 24 1 25 96.0% 0 discharge? Are medication administration records (MARs) scanned into the 4.005 19 1 20 95.0% 0 patient’s electronic health record within the required time frames? During the inspection, were medical records properly scanned, labeled, 4.006 0 27 27 0.0% 0 and included in the correct patients’ files? For patients discharged from a community hospital: Did the preliminary hospital discharge report include key elements and did a 4.007 25 0 25 100.0% 0 primary care provider review the report within three calendar days of discharge? Overall percentage: 75.5% California Institution for Men, Cycle 5 Medical Inspection Page 78 Office of the Inspector General State of California Scored Answers Yes Reference + 5–Health Care Environment Number Yes No No Yes % N/A Are clinical health care areas appropriately disinfected, cleaned and 5.101 12 2 14 85.7% 0 sanitary? Do clinical health care areas ensure that reusable invasive and 5.102 non-invasive medical equipment is properly sterilized or disinfected as 13 1 14 92.9% 0 warranted? Do clinical health care areas contain operable sinks and sufficient 5.103 11 3 14 78.6% 0 quantities of hygiene supplies? Does clinical health care staff adhere to universal hand hygiene 5.104 11 3 14 78.6% 0 precautions? Do clinical health care areas control exposure to blood-borne 5.105 10 4 14 71.4% 0 pathogens and contaminated waste? Warehouse, Conex and other non-clinic storage areas: Does the 5.106 medical supply management process adequately support the needs of 0 1 1 0.0% 0 the medical health care program? Does each clinic follow adequate protocols for managing and storing 5.107 5 9 14 35.7% 0 bulk medical supplies? Do clinic common areas and exam rooms have essential core medical 5.108 7 7 14 50.0% 0 equipment and supplies? Do clinic common areas have an adequate environment conducive to 5.109 5 6 11 45.5% 3 providing medical services? Do clinic exam rooms have an adequate environment conducive to 5.110 5 8 13 38.5% 1 providing medical services? Emergency response bags: Are TTA and clinic emergency medical 5.111 response bags inspected daily and inventoried monthly, and do they 2 5 7 28.6% 7 contain essential items? Overall percentage: 55.0% California Institution for Men, Cycle 5 Medical Inspection Page 79 Office of the Inspector General State of California Scored Answers Yes Reference + 6–Inter- and Intra-System Transfers Number Yes No No Yes % N/A For endorsed patients received from another CDCR institution or COCF: Did nursing staff complete the initial health screening and 6.001 16 9 25 64.0% 0 answer all screening questions on the same day the patient arrived at the institution? For endorsed patients received from another CDCR institution or COCF: When required, did the RN complete the assessment and 6.002 disposition section of the health screening form; refer the patient to the 25 0 25 100.0% 0 TTA, if TB signs and symptoms were present; and sign and date the form on the same day staff completed the health screening? For endorsed patients received from another CDCR institution or 6.003 COCF: If the patient had an existing medication order upon arrival, 16 0 16 100.0% 9 were medications administered or delivered without interruption? For patients transferred out of the facility: Were scheduled specialty 6.004 service appointments identified on the patient’s health care transfer 9 11 20 45.0% 0 information form? For patients transferred out of the facility: Do medication transfer 6.101 packages include required medications along with the corresponding 5 3 8 62.5% 0 transfer packet required documents? Overall percentage: 74.3% California Institution for Men, Cycle 5 Medical Inspection Page 80 Office of the Inspector General State of California Scored Answers Yes Reference + 7–Pharmacy and Medication Management Number Yes No No Yes % N/A Did the patient receive all chronic care medications within the required 7.001 time frames or did the institution follow departmental policy for 15 8 23 65.2% 2 refusals or no-shows? Did health care staff administer, make available, or deliver new order 7.002 prescription medications to the patient within the required time 24 1 25 96.0% 0 frames? Upon the patient’s discharge from a community hospital: Were all 7.003 ordered medications administered, made available, or delivered to the 14 11 25 56.0% 0 patient within required time frames? For patients received from a county jail: Were all medications ordered 7.004 by the institution’s reception center provider administered, made 6 5 11 54.6% 9 available, or delivered to the patient within the required time frames? Upon the patient’s transfer from one housing unit to another: Were 7.005 24 1 25 96.0% 0 medications continued without interruption? For patients en route who lay over at the institution: If the temporarily 7.006 housed patient had an existing medication order, were medications 7 3 10 70.0% 0 administered or delivered without interruption? All clinical and medication line storage areas for narcotic medications: 7.101 Does the Institution employ strong medication security over narcotic 1 9 10 10.0% 4 medications assigned to its clinical areas? All clinical and medication line storage areas for non-narcotic 7.102 medications: Does the Institution properly store non-narcotic 2 12 14 14.3% 0 medications that do not require refrigeration in assigned clinical areas? All clinical and medication line storage areas for non-narcotic 7.103 medications: Does the institution properly store non-narcotic 3 5 8 37.5% 6 medications that require refrigeration in assigned clinical areas? Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols 7.104 5 3 8 62.5% 6 during medication preparation and medication administration processes? Medication preparation and administration areas: Does the institution 7.105 employ appropriate administrative controls and protocols when 6 2 8 75.0% 6 preparing medications for patients? Medication preparation and administration areas: Does the Institution 7.106 employ appropriate administrative controls and protocols when 3 5 8 37.5% 6 distributing medications to patients? California Institution for Men, Cycle 5 Medical Inspection Page 81 Office of the Inspector General State of California Scored Answers Yes Reference + 7–Pharmacy and Medication Management Number Yes No No Yes % N/A Pharmacy: Does the institution employ and follow general security, 7.107 organization, and cleanliness management protocols in its main and 1 0 1 100.0% 0 satellite pharmacies? Pharmacy: Does the institution’s pharmacy properly store 7.108 1 0 1 100.0% 0 non-refrigerated medications? Pharmacy: Does the institution’s pharmacy properly store refrigerated 7.109 1 0 1 100.0% 0 or frozen medications? Pharmacy: Does the institution’s pharmacy properly account for 7.110 1 0 1 100.0% 0 narcotic medications? 7.111 Does the institution follow key medication error reporting protocols? 0 25 25 0.0% 0 Overall percentage: 63.2% 8–Prenatal and Post-Delivery Services The institution has no female patients, so this indicator is not applicable. California Institution for Men, Cycle 5 Medical Inspection Page 82 Office of the Inspector General State of California Scored Answers Yes Reference + 9–Preventive Services Number Yes No No Yes % N/A Patients prescribed TB medication: Did the institution administer the 9.001 15 6 21 71.4% 0 medication to the patient as prescribed? Patients prescribed TB medication: Did the institution monitor the 9.002 patient monthly for the most recent three months he or she was on the 12 9 21 57.1% 0 medication? Annual TB Screening: Was the patient screened for TB within the last 9.003 25 5 30 83.3% 0 year? Were all patients offered an influenza vaccination for the most recent 9.004 25 0 25 100.0% 0 influenza season? All patients from the age of 50 - 75: Was the patient offered colorectal 9.005 24 1 25 96.0% 0 cancer screening? Female patients from the age of 50 through the age of 74: Was the 9.006 Not Applicable patient offered a mammogram in compliance with policy? Female patients from the age of 21 through the age of 65: Was patient 9.007 Not Applicable offered a pap smear in compliance with policy? 9.008 Are required immunizations being offered for chronic care patients? 6 4 10 60.0% 15 Are patients at the highest risk of coccidioidomycosis (valley fever) 9.009 Not Applicable infection transferred out of the facility in a timely manner? Overall percentage: 78.0% 10–Quality of Nursing Performance This indicator is evaluated only by case review clinicians. There is no compliance testing component. California Institution for Men, Cycle 5 Medical Inspection Page 83 Office of the Inspector General State of California 11–Quality of Provider Performance This indicator is evaluated only by case review clinicians. There is no compliance testing component. California Institution for Men, Cycle 5 Medical Inspection Page 84 Office of the Inspector General State of California Scored Answers Yes Reference + 12–Health Information Management Number Yes No No Yes % N/A For patients received from a county jail: Did nursing staff complete the initial health screening and answer all screening 12.001 16 4 20 80.0% 0 questions on the same day the patient arrived at the institution? For patients received from a county jail: When required, did the RN complete the assessment and disposition section of the health 12.002 20 0 20 100.0% 0 screening form, and sign and date the form on the same day staff completed the health screening? For patients received from a county jail: If, during the assessment, 12.003 the nurse referred the patient to a provider, was the patient seen 19 1 20 95.0% 0 within the required time frame? For patients received from a county jail: Did the patient receive a 12.004 history and physical by a primary care provider within seven 19 1 20 95.0% 0 calendar days? For patients received from a county jail: Were all required intake 12.005 20 0 20 100.0% 0 tests completed within specified timelines? For patients received from a county jail: Did the primary care 12.006 provider review and communicate the intake test results to the 13 7 20 65.0% 0 patient within specified timelines? For patients received from a county jail: Was a tuberculin test 12.007 20 0 20 100.0% 0 both administered and read timely? For patients received from a county jail: Was a 12.008 Coccidioidomycosis (Valley Fever) skin test offered, 14 6 20 70.0% 0 administered, read, or refused timely? Overall percentage: 88.1% California Institution for Men, Cycle 5 Medical Inspection Page 85 Office of the Inspector General State of California Scored Answers Yes Reference + 13–Specialized Medical Housing Number Yes No No Yes % N/A For OHU, CTC, and SNF: Did the registered nurse complete an 13.001 initial assessment of the patient on the day of admission, or within 10 0 10 100.0% eight hours of admission to CMF’s Hospice? For CTC and SNF only: Was a written history and physical 13.002 Not Applicable examination completed within the required time frame? For OHU, CTC, SNF, and Hospice: Did the primary care provider complete the Subjective, Objective, Assessment, Plan, and 13.003 7 0 7 100.0% 3 Education (SOAPE) notes on the patient at the minimum intervals required for the type of facility where the patient was treated? For OHU and CTC Only: Do inpatient areas either have properly working call systems in its OHU & CTC or are 30-minute patient 13.101 1 0 1 100.0% 0 welfare checks performed; and do medical staff have reasonably unimpeded access to enter patient’s cells? Overall percentage: 100.0% California Institution for Men, Cycle 5 Medical Inspection Page 86 Office of the Inspector General State of California Scored Answers Yes Reference + 14–Specialty Services Number Yes No No Yes % N/A Did the patient receive the high priority specialty service within 14.001 14 calendar days of the primary care provider order or the 15 0 15 100.0% 0 Physician Request for Service? Did the primary care provider review the high priority specialty 14.002 14 1 15 93.3% 0 service consultant report within the required time frame? Did the patient receive the routine specialty service within 90 14.003 calendar days of the primary care provider order or Physician 14 1 15 93.3% 0 Request for Service? Did the primary care provider review the routine specialty service 14.004 13 1 14 92.9% 1 consultant report within the required time frame? For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at 14.005 9 11 20 45.0% 0 the sending institution, was the appointment scheduled at the receiving institution within the required time frames? Did the institution deny the primary care provider request for 14.006 18 2 20 90.0% 0 specialty services within required time frames? Following the denial of a request for specialty services, was the 14.007 16 2 18 88.9% 2 patient informed of the denial within the required time frame? Overall percentage: 86.2% California Institution for Men, Cycle 5 Medical Inspection Page 87 Office of the Inspector General State of California Scored Answers Yes Reference 15–Administrative Operations + Number Yes No No Yes % N/A Did the institution promptly process inmate medical appeals 15.001 12 0 12 100.0% 0 during the most recent 12 months? Does the institution follow adverse / sentinel event reporting 15.002 Not Applicable requirements? Did the institution Quality Management Committee (QMC) meet at least monthly to evaluate program performance, and did the 15.003 6 0 6 100.0% 0 QMC take action when improvement opportunities were identified? Did the institution’s Quality Management Committee (QMC) or 15.004 other forum take steps to ensure the accuracy of its Dashboard 1 0 1 100.0% 0 data reporting? Does the Emergency Medical Response Review Committee 15.005 perform timely incident package reviews that include the use of 5 7 12 41.7% 0 required review documents? For institutions with licensed care facilities: Does the Local Governing Body (LGB), or its equivalent, meet quarterly and 15.006 Not Applicable exercise its overall responsibilities for the quality management of patient health care? Did the institution complete a medical emergency response drill 15.101 for each watch and include participation of health care and 0 3 3 0.0% 0 custody staff during the most recent full quarter? Did the institution’s second level medical appeal response address 15.102 10 0 10 100.0% 0 all of the patient's appealed issues? Did the institution's medical staff review and submit the initial 15.103 9 0 9 100.0% 0 inmate death report to the Death Review Unit in a timely manner? Does the institution's Supervising Registered Nurse conduct 15.104 Not Applicable periodic reviews of nursing staff? Are nursing staff who administer medications current on their 15.105 10 0 10 100.0% 0 clinical competency validation? 15.106 Are structured clinical performance appraisals completed timely? 11 7 18 61.1% 0 15.107 Do all providers maintain a current medical license? 20 0 20 100.0% 0 Are staff current with required medical emergency response 15.108 2 0 2 100.0% 1 certifications? Are nursing staff and the Pharmacist-in-Charge current with their professional licenses and certifications, and is the pharmacy 15.109 licensed as a correctional pharmacy by the California State Board 6 0 6 100.0% 1 of Pharmacy? California Institution for Men, Cycle 5 Medical Inspection Page 88 Office of the Inspector General State of California Scored Answers Yes Reference 15–Administrative Operations + Number Yes No No Yes % N/A Do the institution’s pharmacy and authorized providers who 15.110 prescribe controlled substances maintain current Drug 1 0 1 100.0% 0 Enforcement Agency (DEA) registrations? 15.111 Are nursing staff current with required new employee orientation? 1 0 1 100.0% 0 Overall percentage: 85.9% California Institution for Men, Cycle 5 Medical Inspection Page 89 Office of the Inspector General State of California A B — C D PPENDIX LINICAL ATA Table B-1: CIM Sample Sets Sample Set Total Anticoagulation 3 Death Review/Sentinel Events 3 Diabetes 3 Emergency Services - CPR 3 Emergency Services - Non-CPR 3 High Risk 5 Hospitalization 4 Intra-system Transfers-In 3 Intra-system Transfers-Out 3 RN Sick Call 20 Reception Center Transfers 4 Specialty Services 4 58 California Institution for Men, Cycle 5 Medical Inspection Page 90 Office of the Inspector General State of California Table B-2: CIM Chronic Care Diagnoses Diagnosis Total Anemia 7 Anticoagulation 4 Arthritis/Degenerative Joint Disease 7 Asthma 9 COPD 10 Cancer 14 Cardiovascular Disease 7 Chronic Kidney Disease 7 Chronic Pain 15 Cirrhosis/End Stage Liver Disease 6 Deep Venous Thrombosis/Pulmonary Embolism 3 Diabetes 19 Gastroesophageal Reflux Disease 14 Gastrointestinal Bleed 1 HIV 3 Hepatitis C 16 Hyperlipidemia 28 Hypertension 39 Mental Health 7 Seizure Disorder 3 Sleep Apnea 7 Thyroid Disease 5 231 California Institution for Men, Cycle 5 Medical Inspection Page 91 Office of the Inspector General State of California Table B-3: CIM Event – Program Diagnosis Total Diagnostic Services 166 Emergency Care 42 Hospitalization 73 Intra-system Transfers-In 15 Intra-system Transfers-Out 7 Outpatient Care 380 Reception Center Care 23 Specialized Medical Housing 91 Specialty Services 231 1,028 California Institution for Men, Cycle 5 Medical Inspection Page 92 Office of the Inspector General State of California Table B-4: CIM Review Sample Summary Total MD Reviews Detailed 27 MD Reviews Focused 0 RN Reviews Detailed 14 RN Reviews Focused 33 Total Reviews 74 Total Unique Cases 58 Overlapping Reviews (MD & RN) 16 California Institution for Men, Cycle 5 Medical Inspection Page 93 Office of the Inspector General State of California A C — C S M PPENDIX OMPLIANCE AMPLING ETHODOLOGY California Institution for Men (CIM) Sample Category Quality (number of Indicator samples) Data Source Filters Access to Care MIT 1.001 Chronic Care Patients Master Registry • Chronic care conditions (at least one condition per patient—any risk level) (25) • Randomize MIT 1.002 Nursing Referrals OIG Q: 6.001 • See Intra-system Transfers (25) MITs 1.003-006 Nursing Sick Call MedSATS • Clinic (each clinic tested) (5 per clinic) • Appointment date (2–9 months) (30) • Randomize MIT 1.007 Returns from OIG Q: 4.007 • See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (25) MIT 1.008 Specialty Services OIG Q: 14.001 & • See Specialty Services Follow-up 14.003 (30) MIT 1.101 Availability of Health OIG onsite • Randomly select one housing unit from each yard Care Services review Request Forms (6) Diagnostic Services MITs 2.001–003 Radiology Radiology Logs • Appointment date (90 days–9 months) • Randomize (10) • Abnormal MITs 2.004–006 Laboratory Quest • Appt. date (90 days–9 months) • Order name (CBC or CMPs only) • Randomize (10) • Abnormal MITs 2.007–009 Pathology InterQual • Appt. date (90 days–9 months) • Service (pathology related) (10) • Randomize California Institution for Men, Cycle 5 Medical Inspection Page 94 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Health Information Management (Medical Records) MIT 4.001 Timely Scanning OIG Qs: 1.001, • Non-dictated documents (11) 1.002, & 1.004 • 1st 10 IPs MIT 1.001, 1st 5 IPs MITs 1.002, 1.004 MIT 4.002 OIG Q: 1.001 • Dictated documents (10) • First 20 IPs selected MIT 4.003 OIG Qs: 14.002 • Specialty documents (20) & 14.004 • First 10 IPs for each question MIT 4.004 OIG Q: 4.007 • Community hospital discharge documents (25) • First 20 IPs selected MIT 4.005 OIG Q: 7.001 • MARs (20) • First 20 IPs selected MIT 4.006 Documents for • Any misfiled or mislabeled document identified (27) any tested inmate during OIG compliance review (24 or more = No) MIT 4.007 Returns From Inpatient claims • Date (2–8 months) Community Hospital data • Most recent 6 months provided (within date range) • Rx count • Discharge date • Randomize (each month individually) • First 5 patients from each of the 6 months (if not 5 in a month, supplement from another, as needed) (25) Health Care Environment MIT 5.101-105 Clinical Areas OIG inspector • Identify and inspect all onsite clinical areas. MIT 5.107–111 (14) onsite review Inter- and Intra-System Transfers MIT 6.001-003 Intra-System SOMS • Arrival date (3–9 months) Transfers • Arrived from (another CDCR facility) • Rx count • Randomize (25) MIT 6.004 Specialty Services MedSATS • Date of transfer (3–9 months) Send-Outs • Randomize (20) MIT 6.101 Transfers Out OIG inspector • R&R IP transfers with medication (8) onsite review California Institution for Men, Cycle 5 Medical Inspection Page 95 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Pharmacy and Medication Management MIT 7.001 Chronic Care OIG Q: 1.001 See Access to Care Medication • At least one condition per patient—any risk level • Randomize (25) MIT 7.002 New Medication Master Registry • Rx count Orders • Randomize (25) • Ensure no duplication of IPs tested in MIT 7.001 MIT 7.003 Returns from OIG Q: 4.007 • See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (25) MIT 7.004 RC Arrivals – OIG Q: 12.001 • See Reception Center Arrivals Medication Orders (20) MIT 7.005 Intra-Facility Moves MAPIP transfer • Date of transfer (2–8 months) data • To location/from location (yard to yard and to/from ASU) • Remove any to/from MHCB • NA/DOT meds (and risk level) (25) • Randomize MIT 7.006 En Route SOMS • Date of transfer (2–8 months) • Sending institution (another CDCR facility) • Randomize (10) • NA/DOT meds MITs 7.101-103 Medication Storage OIG inspector • Identify and inspect clinical & med line areas that Areas onsite review store medications (varies by test) MITs 7.104–106 Medication OIG inspector • Identify and inspect onsite clinical areas that Preparation and onsite review prepare and administer medications Administration Areas (varies by test) MITs 7.107-110 Pharmacy OIG inspector • Identify & inspect all onsite pharmacies (1) onsite review MIT 7.111 Medication Error Monthly • All monthly statistic reports with Level 4 or higher Reporting medication error • Select a total of 5 months (25) reports MIT 7.999 Isolation Unit KOP Onsite active • KOP rescue inhalers & nitroglycerin medications Medications medication for IPs housed in isolation units (6) listing Prenatal and Post-Delivery Services MIT 8.001-007 Recent Deliveries OB Roster • Delivery date (2–12 months) (N/A at this • Most recent deliveries (within date range) institution) Pregnant Arrivals OB Roster • Arrival date (2–12 months) (N/A at this • Earliest arrivals (within date range) institution) Sample Category California Institution for Men, Cycle 5 Medical Inspection Page 96 Office of the Inspector General State of California Quality (number of Data Source Filters Indicator samples) Preventive Services MITs 9.001–002 TB Medications Maxor • Dispense date (past 9 months) • Time period on TB meds (3 months or 12 weeks) (21) • Randomize MIT 9.003 TB Evaluation, SOMS • Arrival date (at least 1 year prior to inspection) Annual Screening • Birth Month (30) • Randomize MIT 9.004 Influenza SOMS • Arrival date (at least 1 year prior to inspection) Vaccinations • Randomize (25) • Filter out IPs tested in MIT 9.008 MIT 9.005 Colorectal Cancer SOMS • Arrival date (at least 1 year prior to inspection) Screening • Date of birth (51 or older) (25) • Randomize MIT 9.006 Mammogram SOMS • Arrival date (at least 2 yrs prior to inspection) (N/A at this • Date of birth (age 52–74) institution) • Randomize MIT 9.007 Pap Smear SOMS • Arrival date (at least three yrs prior to inspection) (N/A at this • Date of birth (age 24–53) institution) • Randomize MIT 9.008 Chronic Care OIG Q: 1.001 • Chronic care conditions (at least 1 condition per Vaccinations IP—any risk level) • Randomize (25) • Condition must require vaccination(s) MIT 9.009 Valley Fever Cocci transfer • Reports from past 2–8 months (number will vary) status report • Institution (N/A at this • Ineligibility date (60 days prior to inspection date) institution) • All California Institution for Men, Cycle 5 Medical Inspection Page 97 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Reception Center Arrivals MITs 12.001–008 RC SOMS • Arrival date (2–8 months) • Arrived from (county jail, return from parole, etc.) (20) • Randomize Specialized Medical Housing MITs 13.001–003 OHU CADDIS • Admit date (1–6 months) • Type of stay (no MH beds) • Length of stay (minimum of 5 days) (10) • Randomize MIT 13.101 Call Buttons OIG inspector • Review by location OHU onsite review (all) Specialty Services MITs 14.001–002 High-Priority MedSATS • Approval date (3–9 months) (15) • Randomize MITs 14.003–004 Routine MedSATS • Approval date (3–9 months) • Remove optometry, physical therapy or podiatry (15) • Randomize MIT 14.005 Specialty Services MedSATS • Arrived from (other CDCR institution) Arrivals • Date of transfer (3–9 months) (20) • Randomize MIT 14.006-007 Denials InterQual • Review date (3–9 months) (12) • Randomize IUMC/MAR • Meeting date (9 months) Meeting Minutes • Denial upheld (8) • Randomize California Institution for Men, Cycle 5 Medical Inspection Page 98 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.001 Medical Appeals Monthly medical • Medical appeals (12 months) (all) appeals reports MIT 15.002 Adverse/Sentinel Adverse/sentinel • Adverse/sentinel events (2–8 months) Events events report (0) MITs 15.003–004 QMC Meetings Quality • Meeting minutes (12 months) Management Committee (6) meeting minutes MIT 15.005 EMRRC EMRRC meeting • Monthly meeting minutes (6 months) (12) minutes MIT 15.006 LGB LGB meeting • Quarterly meeting minutes (12 months) (0) minutes MIT 15.101 Medical Emergency Onsite summary • Most recent full quarter Response Drills reports & • Each watch documentation (3) for ER drills MIT 15.102 2nd Level Medical Onsite list of • Medical appeals denied (6 months) Appeals appeals/closed (10) appeals files MIT 15.103 Death Reports Institution-list of • Most recent 10 deaths deaths in prior 12 • Initial death reports (9) months MIT 15.104 RN Review Onsite supervisor • RNs who worked in clinic or emergency setting Evaluations periodic RN six or more days in sampled month reviews • Randomize (0) MIT 15.105 Nursing Staff Onsite nursing • On duty one or more years Validations education files • Nurse administers medications (10) • Randomize MIT 15.106 Provider Annual Onsite • All required performance evaluation documents Evaluation Packets provider (18) evaluation files MIT 15.107 Provider licenses Current provider • Review all listing (at start of (20) inspection) MIT 15.108 Medical Emergency Onsite • All staff Response certification o Providers (ACLS) Certifications tracking logs o Nursing (BLS/CPR) (all) • Custody (CPR/BLS) MIT 15.109 Nursing staff and Onsite tracking • All required licenses and certifications Pharmacist in system, logs, or Charge Professional employee files Licenses and Certifications (all) California Institution for Men, Cycle 5 Medical Inspection Page 99 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.110 Pharmacy and Onsite listing of • All DEA registrations Providers’ Drug provider DEA Enforcement Agency registration #s & (DEA) Registrations pharmacy registration (all) document MIT 15.111 Nursing Staff New Nursing staff • New employees (hired within last 12 months) Employee training logs • Orientations (all) MIT 15.998 Death Review OIG summary • Between 35 business days & 12 months prior Committee log - deaths • CCHCS death reviews (8) California Institution for Men, Cycle 5 Medical Inspection Page 100 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 5 Medical Inspection Page 101 Office of the Inspector General State of California