California Institution for Women Medical Inspection Report Cycle 4

Robert A. Barton Office of the Inspector General Inspector General California Institution for Women Medical Inspection Results Cycle 4 September 2016 Medical Inspection Unit Page 1 Office of the Inspector General State of California Office of the Inspector General CALIFORNIA INSTITUTION FOR WOMEN Medical Inspection Results Cycle 4 Robert A. Barton Inspector General Roy W. Wesley Chief Deputy Inspector General Shaun R. Spillane Public Information Officer September 2016 TABLE OF CONTENTS Executive Summary ............................................................................................................................. i Overall Assessment: Adequate .............................................................................................. iii Clinical Case Review and OIG Clinician Inspection Results ............................................... iii Compliance Testing Results.................................................................................................. iv Population-Based Metrics ................................................................................................... viii Introduction ......................................................................................................................................... 1 About the Institution ........................................................................................................................... 1 Objectives, Scope, and Methodology.................................................................................................. 5 Case Reviews ................................................................................................................................... 6 Patient Selection for Retrospective Case Reviews .................................................................... 6 Benefits and Limitations of Targeted Subpopulation Review .................................................. 7 Case Reviews Sampled ............................................................................................................. 8 Compliance Testing ......................................................................................................................... 9 Sampling Methods for Conducting Compliance Testing .......................................................... 9 Scoring of Compliance Testing Results .................................................................................. 10 Dashboard Comparisons ......................................................................................................... 10 Overall Quality Indicator Rating for Case Reviews and Compliance Testing .............................. 11 Population-Based Metrics .............................................................................................................. 11 Medical Inspection Results ............................................................................................................... 12 Primary (Clinical) Quality Indicators of Health Care .................................................................... 12 Access to Care ......................................................................................................................... 13 Case Review Results ............................................................................................................ 13 Compliance Testing Results................................................................................................. 13 Recommendations ................................................................................................................ 14 Diagnostic Services ................................................................................................................. 15 Case Review Results ............................................................................................................ 15 Compliance Testing Results................................................................................................. 15 Recommendations ................................................................................................................ 16 Emergency Services................................................................................................................. 17 Case Review Results ............................................................................................................ 17 Recommendations ................................................................................................................ 18 Health Information Management (Medical Records) ............................................................. 19 Case Review Results ............................................................................................................ 19 Compliance Testing Results................................................................................................. 20 Recommendations ................................................................................................................ 21 Health Care Environment ....................................................................................................... 22 Compliance Testing Results................................................................................................. 22 Recommendations ................................................................................................................ 25 Inter- and Intra-System Transfers ........................................................................................... 26 Case Review Results ............................................................................................................ 26 Compliance Testing Results................................................................................................. 27 Recommendations ................................................................................................................ 28 California Institution for Women, Cycle 4 Medical Inspection Table of Contents Office of the Inspector General State of California Pharmacy and Medication Management ................................................................................ 29 Case Review Results ............................................................................................................ 29 Compliance Testing Results................................................................................................. 29 Recommendations ................................................................................................................ 33 Prenatal and Post-Delivery Services ...................................................................................... 34 Case Review Results ............................................................................................................ 34 Compliance Testing Results................................................................................................. 34 Recommendations ................................................................................................................ 35 Preventive Services ................................................................................................................. 36 Compliance Testing Results................................................................................................. 36 Recommendations ................................................................................................................ 37 Quality of Nursing Performance ............................................................................................. 38 Case Review Results ............................................................................................................ 38 Recommendations ................................................................................................................ 39 Quality of Provider Performance ............................................................................................ 40 Case Review Results ............................................................................................................ 40 Recommendations ................................................................................................................ 42 Specialized Medical Housing (OHU, CTC, SNF, Hospice) .................................................... 43 Case Review Results ............................................................................................................ 43 Compliance Testing Results................................................................................................. 43 Recommendations ................................................................................................................ 44 Specialty Services .................................................................................................................... 45 Case Review Results ............................................................................................................ 45 Compliance Testing Results................................................................................................. 46 Recommendations ................................................................................................................ 47 Secondary (Administrative) Quality Indicators of Health Care..................................................... 48 Internal Monitoring, Quality Improvement, and Administrative Operations ......................... 49 Compliance Testing Results................................................................................................. 49 Recommendations ................................................................................................................ 51 Job Performance, Training, Licensing, and Certifications ..................................................... 52 Compliance Testing Results................................................................................................. 52 Recommendations ................................................................................................................ 53 Population-Based Metrics .............................................................................................................. 54 Appendix A — Compliance Test Results ......................................................................................... 58 Appendix B — Clinical Data ............................................................................................................ 73 Appendix C — Compliance Sampling Methodology ....................................................................... 76 California Correctional Health Care Services’ Response ................................................................. 77 California Institution for Women, Cycle 4 Medical Inspection Table of Contents Office of the Inspector General State of California LIST OF TABLES AND FIGURES Health Care Quality Indicators ........................................................................................................... ii CIW Executive Summary Table ....................................................................................................... vii CIW Health Care Staffing Resources as of January 2016 ................................................................... 2 CIW Master Registry Data as of January 19, 2016 ............................................................................. 3 Commonly Used Abbreviations .......................................................................................................... 4 CIW Results Compared to State and National HEDIS Scores .......................................................... 57 California Institution for Women, Cycle 4 Medical Inspection List of Tables and Figures Office of the Inspector General State of California EXECUTIVE SUMMARY Under the authority of California Penal Code Section 6126, which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), the OIG conducts a comprehensive inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG explicitly makes no determination regarding the constitutionality of care in the prison setting. That determination is left to the Receiver and the federal court. The assessment of care by the OIG is just one factor in the court’s determination whether care in the prisons meets constitutional standards. The court may find that an institution the OIG found to be providing adequate care still did not meet constitutional standards, depending on the analysis of the underlying data provided by the OIG. Likewise, an institution that has been rated inadequate by the OIG could still be found to pass constitutional muster with the implementation of remedial measures if the underlying data were to reveal easily mitigated deficiencies. The OIG’s inspections are mandated by the Penal Code and not aimed at specifically resolving the court’s questions on constitutional care. To the degree that they provide another factor for the court to consider, the OIG is pleased to provide added value to the taxpayers of California. For this fourth cycle of inspections, the OIG added a clinical case review component and significantly enhanced the compliance portion of the inspection process from that used in prior cycles. In addition, the OIG added a population-based metric comparison of selected Healthcare Effectiveness Data Information Set (HEDIS) measures from other State and national health care organizations and compared that data to similar results for the California Institution for Women (CIW). The OIG performed its Cycle 4 medical inspection at CIW from February to March 2016. The inspection included in-depth reviews of 73 inmate-patient files conducted by clinicians, as well as reviews of documents from 491 inmate-patient files, covering 98 objectively scored tests of compliance with policies and procedures applicable to the delivery of medical care. The OIG assessed the case review and compliance results at CIW using 15 health care quality indicators applicable to the institution, made up of 13 primary clinical indicators and two secondary administrative indicators. To conduct clinical case reviews, the OIG employs a clinician team consisting of a physician and a registered nurse consultant, while compliance testing is done by a team of deputy inspectors general and registered nurses trained in monitoring medical compliance. Of the 13 primary indicators, eight were rated by both case review clinicians and compliance inspectors, three were rated by case review clinicians only, and two were rated by compliance inspectors only; both secondary indicators were rated by compliance inspectors only. See the Health Care Quality Indicators table on page ii. Based on that analysis, OIG experts made a considered and measured overall opinion that the quality of health care at CIW was adequate. California Institution for Women, Cycle 4 Medical Inspection Page i Office of the Inspector General State of California Health Care Quality Indicators All Institutions– Fourteen Primary Indicators (Clinical) CIW Applicability Applicability Both case review 1–Access to Care All institutions and compliance Both case review 2–Diagnostic Services All institutions and compliance 3–Emergency Services All institutions Case review only 4–Health Information Management Both case review All institutions (Medical Records) and compliance 5–Health Care Environment All institutions Compliance only Both case review 6–Inter- and Intra-System Transfers All institutions and compliance Both case review 7–Pharmacy and Medication Management All institutions and compliance Female institutions Both case review 8–Prenatal and Post-Delivery Services only and compliance 9–Preventive Services All institutions Compliance only 10–Quality of Nursing Performance All institutions Case review only 11–Quality of Provider Performance All institutions Case review only Institutions with 12–Reception Center Arrivals Not Applicable reception centers All institutions with 13–Specialized Medical Housing Both case review an OHU, CTC, SNF, (OHU, CTC, SNF, Hospice) and compliance or Hospice Both case review 14–Specialty Services All institutions and compliance Two Secondary Indicators All Institutions– CIW Applicability (Administrative) Applicability 15–Internal Monitoring, Quality Improvement, and Administrative All institutions Compliance only Operations 16–Job Performance, Training, Licensing, All institutions Compliance only and Certifications California Institution for Women, Cycle 4 Medical Inspection Page ii Office of the Inspector General State of California Overall Assessment: Adequate Based on the clinical case reviews and compliance testing, the OIG’s overall assessment rating for CIW was adequate. Of the Overall Assessment 13 primary (clinical) quality indicators applicable to CIW, the Rating: OIG found four proficient, eight adequate, and one inadequate. Of the two secondary (administrative) quality indicators, the OIG Adequate found both proficient. To determine the overall assessment for CIW, the OIG considered individual clinical ratings and individual compliance question scores within each of the indicator categories, putting emphasis on the primary indicators. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed at CIW. This institution performed very well, displaying few significant deficiencies in medical care. However, some of those deficiencies occurred in key indicators such as Quality of Provider Performance, Quality of Nursing Performance, and Emergency Services. The OIG rated these three indicators adequate. With these important indicators rated adequate, along with five other adequate primary indicators, the overall institutional score was adequate, not proficient. Clinical Case Review and OIG Clinician Inspection Results The clinicians’ case reviews sampled patients with high medical needs and included a review of 1,380 patient care events.1 Of the 13 primary indicators applicable to CIW, 11 were evaluated by clinician case review; three were proficient, seven were adequate, and one was inadequate. When determining the overall adequacy of care, the OIG paid particular attention to the clinical nursing and provider quality indicators, as adequate health care staff can sometimes overcome suboptimal processes and programs. However, the opposite is not true; inadequate health care staff cannot provide adequate care, even though the established processes and programs onsite may be adequate. The OIG clinicians identify inadequate medical care based on the risk of significant harm to the patient, not the actual outcome. Program Strengths — Clinical  Providers at CIW reported that medical leadership was supportive and approachable.  CIW generally provided excellent access to primary care services during the time frame reviewed.2  CIW provided exemplary management and care for patients in the inter- and intra-facility transfer processes. 1 Each OIG clinician team includes a board-certified physician and registered nurse consultant with experience in correctional and community medical settings. 2 The onsite inspection revealed a backlog of patients since the implementation of the new electronic medical record (late October 2015). California Institution for Women, Cycle 4 Medical Inspection Page iii Office of the Inspector General State of California  The daily provider morning report meetings and morning huddles in the clinics were informative, pertinent, and effective for relaying necessary information.  The population management meetings, which occurred twice monthly for each clinic, were also informative, pertinent, and effective. They fostered excellent team spirit.  Management of anticoagulation patients was a team effort effectively performed by providers and pharmacy. Program Weaknesses — Clinical  Inadequate health information processes resulted in multiple diagnostic and specialty reports not being properly signed by a primary care provider prior to being scanned into the eUHR.  CIW experienced minor delays in community ambulance response times for the past year, and continued to report these delays to CCHCS and the ambulance companies. Compliance Testing Results Of the 15 total health care indicators applicable to CIW, 12 were evaluated by compliance inspectors.3 There were 98 individual compliance questions within those 12 indicators, generating 1,442 data points, that tested CIW’s compliance with California Correctional Health Care Services (CCHCS) policies and procedures.4 Those 98 questions are detailed in Appendix A — Compliance Test Results. The institution’s inspection scores in the 12 applicable indicators ranged from 49.8 percent to 94.1 percent, with the primary (clinical) indicator Health Information Management (Medical Records) receiving the lowest score, and the secondary indicator Internal Monitoring, Quality Improvement, and Administrative Operations receiving the highest. Of the ten primary indicators applicable to compliance testing, the OIG rated four proficient, five adequate, and one inadequate. Of the two secondary indicators, which involve administrative health care functions, both were rated proficient. Program Strengths — Compliance As the CIW Executive Summary Table on page vii indicates, the institution’s compliance ratings were proficient, scoring above 85 percent, in four primary indicators: Access to Care, Diagnostic Services, Inter- and Intra-System Transfers, and Preventive Services. The institution also received proficient scores in the secondary indicators Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications. The 3 The OIG’s compliance inspectors are trained deputy inspectors general and registered nurses with expertise in CDCR policies regarding medical staff and processes. 4 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 Women, Cycle 4 Medical Inspection Page iv Office of the Inspector General State of California following are some of CIW’s strengths based on its compliance scores on individual questions in all the primary health care indicators:  Patients had a standardized process to obtain and submit request forms for health care services, and nursing staff timely reviewed patients’ requests and completed face-to-face visits with patients.  All clinical areas were appropriately disinfected, cleaned, and sanitary; in all clinics, staff properly sterilized or disinfected reusable invasive and non-invasive medical equipment.  For inmate-patients who transferred into CIW from other CDCR institutions, nurses completed their initial health screening and assessment on the day the patient arrived.  Nursing staff timely administered or delivered patients’ newly ordered medications and ensured that patients transferring from one housing unit to another received their medications without interruption.  CIW’s main pharmacy followed general security, organization, and cleanliness management protocols.  All pregnant patients sampled who arrived at the institution were appropriately assigned to a lower bunk in lower-tier housing.  For all patients sampled, the institution offered or provided timely influenza vaccinations and breast cancer screenings.  For patients assigned to the outpatient housing unit (OHU) or correctional treatment center (CTC), nurses timely completed initial patient assessments.  Patients received timely high-priority and routine specialty services, and were timely notified when provider requests for specialty services were denied. The following are some of the strengths identified within the two secondary administrative indicators:  CIW timely processed patient medical appeals and addressed all appealed issues.  The Quality Management Committee (QMC) met monthly, evaluated program performance, and took action when it identified improvement opportunities; the QMC also took adequate steps to ensure the accuracy of its Dashboard data reporting.  All providers, nursing staff, and the pharmacist in charge were current with their professional licenses; the pharmacy and authorized providers who prescribe controlled substances maintained current Drug Enforcement Agency registrations. California Institution for Women, Cycle 4 Medical Inspection Page v Office of the Inspector General State of California  All nursing staff hired within the last year received timely new employee orientation training, and nursing staff who administered medications possessed current clinical competency validations. Program Weaknesses — Compliance The institution received ratings of inadequate, scoring below 75 percent, in the primary indicator Health Information Management (Medical Records). The following are some of the weaknesses identified by CIW’s compliance scores on individual questions in all the primary health care indicators:  The institution did not always timely receive final pathology reports, and providers did not always timely communicate the results of those reports to patients.  Health records staff did not timely scan transcribed provider notes, community hospital discharge documents, and medication administration records into patients’ electronic health records; and, did not always properly label or file them.  Clinical staff did not follow universal hand hygiene precautions before or after patient encounters, or practice proper hand hygiene contamination protocols during medication preparation and administration.  In most clinics, essential equipment and supplies were missing in exam rooms and common areas, and some clinic exam rooms were too small or lacked auditory privacy for patients.  Nursing staff did not always timely deliver or administer prescribed medications for patients who suffered with chronic care conditions or for those who returned from a community hospital.  In most clinics and in the main pharmacy, staff did not follow proper protocols for storing non-narcotic medications that required refrigeration.  Pregnant patients did not always receive their ongoing obstetrician appointments within required time frames; after delivery, patients did not always receive a timely six-week postpartum appointment.  Providers did not complete timely assessments for patients admitted to the institution’s CTC and OHU. The CIW Executive Summary Table on the following page lists the quality indicators the OIG inspected and assessed during the clinical case reviews and objective compliance tests, and provides the institution’s rating in each area. The overall indicator ratings were based on a consensus decision by the OIG’s clinicians and non-clinical inspectors. California Institution for Women, Cycle 4 Medical Inspection Page vi Office of the Inspector General State of California CIW Executive Summary Table Case Compliance Overall Indicator Primary Indicators (Clinical) Review Rating Rating Rating Access to Care Proficient Proficient Proficient Diagnostic Services Proficient Proficient Proficient Emergency Services Adequate Not Applicable Adequate Health Information Management Inadequate Inadequate Inadequate (Medical Records) Health Care Environment Not Applicable Adequate Adequate Inter- and Intra-System Transfers Proficient Proficient Proficient Pharmacy and Medication Management Adequate Adequate Adequate Prenatal and Post-Delivery Services Adequate Adequate Adequate Preventive Services Not Applicable Proficient Proficient Quality of Nursing Performance Adequate Not Applicable Adequate Quality of Provider Performance Adequate Not Applicable Adequate Specialized Medical Housing Adequate Adequate Adequate (OHU, CTC, SNF, Hospice) Specialty Services Adequate Adequate Adequate Note: The Reception Center Arrivals indicator did not apply to this institution. Case Compliance Overall Indicator Secondary Indicators (Administrative) Review Rating Rating Rating Internal Monitoring, Quality Improvement, Not Applicable Proficient Proficient and Administrative Operations Job Performance, Training, Licensing, and Not Applicable Proficient Proficient Certifications Compliance results for quality indicators are proficient (greater than 85.0 percent), adequate (75.0 percent to 85.0 percent), or inadequate (below 75.0 percent). California Institution for Women, Cycle 4 Medical Inspection Page vii Office of the Inspector General State of California Population-Based Metrics In general, CIW performed well as measured by population-based metrics. In all five comprehensive diabetes care measures, the institution scored higher than or similar to other State and national organizations. This included Medi-Cal, Kaiser Permanente (typically one of the highest-scoring health organizations in California), Medicaid, Medicare, commercial entities, and the United States Department of Veterans Affairs (VA). With regard to immunization measures, CIW outperformed or closely matched other entities’ scores, except for flu shots to younger adults, for which it scored lower than the VA. With regard to cancer screening measures, the institution scored well for breast cancer screenings, but lower than most other entities for cervical cancer screenings and colorectal cancer screenings. However, with regard to all immunization and cancer screening measures, CIW routinely offered inmate-patients these preventive services, but many of them refused the offers; these refusals adversely affected the institution’s scores. The institution outperformed all other entities reporting data for initial prenatal care, and performed better than or similar to the other entities for providing patients their initial postpartum visit. Overall, CIW’s performance demonstrated by the population-based metrics comparison indicates that its comprehensive diabetes care, immunizations, and prenatal and postpartum care were above average when compared to other State and national health care organizations. With respect to cancer screenings, a heightened emphasis on educating patients about refusals could improve CIW’s scores in these measures. California Institution for Women, Cycle 4 Medical Inspection Page viii Office of the Inspector General State of California INTRODUCTION Under the authority of California Penal Code Section 6126, which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), and at the request of the federal Receiver, the OIG developed a comprehensive medical inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. For this fourth cycle of inspections, the OIG augmented the breadth and quality of its inspection program used in prior cycles, adding a clinical case review component and significantly enhancing the compliance component of the program. The California Institution for Women (CIW) was the 20th medical inspection of Cycle 4. During the inspection process, the OIG assessed the delivery of medical care to patients for 13 primary clinical health care indicators and two secondary administrative health care indicators applicable to the institution. It is important to note that while the primary quality indicators represent the clinical care being provided by the institution at the time of the inspection, the secondary quality indicators are purely administrative and are not reflective of the actual clinical care provided. The OIG is committed to reporting on each institution’s delivery of medical care to assist in identifying areas for improvement, but the federal court will ultimately determine whether any institution’s medical care meets constitutional standards. ABOUT THE INSTITUTION The California Institution for Women accommodates all custody levels of female inmates. In addition to its large general population, CIW houses inmates with special needs such as pregnancy care, psychiatric care, methadone treatment, and specialized care for medical problems such as HIV infection. CIW serves as a hub institution for the selection and physical fitness training of female firefighters for conservation camp placement. Other specialized programs specifically geared to meet the special needs of female offenders include academic and vocational programs, pre-release and substance abuse programming, pre-forestry and camp training, an arts in corrections program, and a wide variety of inmate self-help groups and community betterment projects. The institution also serves as a higher-security facility for female inmates in the administrative segregation unit. CIW runs ten medical clinics where staff members handle non-urgent requests for medical services. The institution also conducts patient screenings in its receiving and release clinical area; treats patients who require urgent or immediate care in its triage and treatment area (TTA); and treats patients who require inpatient care in its correctional treatment center (CTC). In its outpatient housing unit (OHU), CIW also treats patients who require assistance with the activities of daily living but who do not require a higher level of inpatient care. CIW is designated an “intermediate care prison”; these institutions are predominantly located in urban areas close to tertiary care centers and specialty care providers for the most cost-effective care. California Institution for Women, Cycle 4 Medical Inspection Page 1 Office of the Inspector General State of California On August 17, 2014, the institution received national accreditation from the Commission on Accreditation for Corrections. This accreditation program is a professional peer review process based on national standards set by the American Correctional Association. The chief physician and surgeon (CP&S) position was the only authorized and filled health care management position at CIW as of January 2016; the institution shared its chief executive officer (CEO), chief medical executive (CME), and chief nurse executive (CNE) positions with the California Rehabilitation Center (CRC). All three of those positions were funded by CRC. CIW’s vacancy rate among medical managers, primary care providers (PCPs), supervisors, and staff nurses was 22 percent in January 2016, with the highest vacancy percentages among both PCPs and nursing staff. Based on reported data, CIW had two vacant PCP positions and one additional PCP who was redirected in late 2015 to assist with the institutional rollout of the new Electronic Health Record System. Furthermore, CIW had 27.1 vacant nursing positions and 11 additional nursing staff members on long-term medical leave, as well as two redirected nurses. Of the 83 total nursing staff on hand, CIW employed 52 of them (63 percent) as registry nurses. The CEO also reported that in January 2016, there were four medical staff members who had recently been subject to disciplinary review. Of the four, one was on administrative leave while the remaining three continued to work in the institution’s clinical settings. CIW Health Care Staffing Resources as of January 2016 Primary Care Nursing Management Nursing Staff Totals Providers Supervisors Description Number % Number % Number % Number % Number % Authorized 1 1% 8 6% 14.5 11% 110.1 82% 133.6 100% Positions Filled Positions 1 100% 6 75% 14.5 100% 83 75% 104.5 78% Vacancies 0 0% 2 25% 0 0% 27.1 25% 29.1 22% Recent Hires (within 12 1 100% 2 33% 0 0% 28 34% 31 30% months) Staff Utilized 0 0% 0 0% 0 0% 52 63% 52 50% from Registry Redirected Staff (to Non-Patient 0 0% 1 17% 0 0% 2 2% 3 3% Care Areas) Staff on Long-Term 0 0% 0 0% 0 0% 11 13% 11 11% Medical Leave Note: CIW Health Care Staffing Resources data was not validated by the OIG. California Institution for Women, Cycle 4 Medical Inspection Page 2 Office of the Inspector General State of California As of January 19, 2016, the Master Registry for CIW showed that the institution had a total population of 1,946. Within that total population, 5.3 percent were designated as high medical risk, Priority 1 (High 1), and 13.8 percent were designated as high medical risk, Priority 2 (High 2). Patients’ assigned risk levels are based on the complexity of their required medical care related to their specific diagnoses, frequency of higher levels of care, age, and abnormal labs and procedures. High 1 has at least two high-risk conditions; High 2 has only one. Patients at high medical risk are more susceptible to poor health outcomes than those at medium or low medical risk. Patients at high medical risk also typically require more health care services than do patients with lower assigned risk levels. The chart below illustrates the breakdown of the institution’s medical risk levels at the start of the OIG medical inspection. CIW Master Registry Data as of January 19, 2016 Medical Risk Level # of Inmate-Patients Percentage High 1 103 5.3% High 2 269 13.8% Medium 852 43.8% Low 722 37.1% Total 1,946 100.0% California Institution for Women, Cycle 4 Medical Inspection Page 3 Office of the Inspector General State of California Commonly Used Abbreviations ACLS Advanced Cardiovascular Life Support HIV Human Immunodeficiency Virus AHA American Heart Association HTN Hypertension ASU Administrative Segregation Unit INH Isoniazid (anti-tuberculosis medication) BLS Basic Life Support IV Intravenous CBC Complete Blood Count KOP Keep-on-Person (in taking medications) CC Chief Complaint LPT Licensed Psychiatric Technician CCHCS California Correctional Health Care Services LVN Licensed Vocational Nurse CCP Chronic Care Program MAR Medication Administration Record California Department of Corrections and CDCR MRI Magnetic Resonance Imaging Rehabilitation CEO Chief Executive Officer MD Medical Doctor CHF Congestive Heart Failure NA Nurse Administered (in taking medications) CME Chief Medical Executive N/A Not Applicable CMP Comprehensive Metabolic (Chemistry) Panel NP Nurse Practitioner CNA Certified Nursing Assistant OB Obstetrician CNE Chief Nurse Executive OHU Outpatient Housing Unit C/O Complains of OIG Office of the Inspector General COPD Chronic Obstructive Pulmonary Disease P&P Policies and Procedures (CCHCS) CP&S Chief Physician and Surgeon PA Physician Assistant CPR Cardio-Pulmonary Resuscitation PCP Primary Care Provider CSE Chief Support Executive POC Point of Contact CT Computerized Tomography PPD Purified Protein Derivative CTC Correctional Treatment Center PRN As Needed (in taking medications) DM Diabetes Mellitus RN Registered Nurse Directly Observed Therapy (in taking DOT Rx Prescription medications) Dx Diagnosis SNF Skilled Nursing Facility Subjective, Objective, Assessment, Plan, & EKG Electrocardiogram SOAPE Education ENT Ear, Nose, and Throat SOMS Strategic Offender Management System ER Emergency Room S/P Status Post EHRS Electronic Health Record System TB Tuberculosis eUHR electronic Unit Health Record TTA Triage and Treatment Area FTF Face-to-Face UA Urinalysis History and Physical (reception center H&P UM Utilization Management examination) HIM Health Information Management California Institution for Women, Cycle 4 Medical Inspection Page 4 Office of the Inspector General State of California OBJECTIVES, SCOPE, AND METHODOLOGY In designing the medical inspection program, the OIG reviewed CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. The OIG also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the Receiver’s office, CDCR, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of the OIG’s inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates medical care delivery by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population-based metrics. To maintain a metric-oriented inspection program that evaluates medical care delivery consistently at each State prison, the OIG identified 14 primary (clinical) and two secondary (administrative) quality indicators of health care to measure. The primary quality indicators cover clinical categories directly relating to the health care provided to patients, whereas the secondary quality indicators address the administrative functions that support a health care delivery system. The 14 primary quality indicators are Access to Care, Diagnostic Services, Emergency Services, Health Information Management (Medical Records), Health Care Environment, Inter- and Intra-System Transfers, Pharmacy and Medication Management, Prenatal and Post-Delivery Services, Preventive Services, Quality of Nursing Performance, Quality of Provider Performance, Reception Center Arrivals, Specialized Medical Housing (OHU, CTC, SNF, Hospice), and Specialty Services. The two secondary quality indicators are Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications. The OIG rates each of the quality indicators applicable to the institution under inspection based on case reviews conducted by OIG clinicians and compliance tests conducted by OIG deputy inspectors general and registered nurses. The ratings may be derived from the case review results alone, the compliance test results alone, or a combination of both these information sources. For example, the ratings for the primary quality indicators Quality of Nursing Performance and Quality of Provider Performance are derived entirely from the case review results, while the ratings for the primary quality indicators Health Care Environment and Preventive Services are derived entirely from compliance test results. As another example, primary quality indicators such as Diagnostic Services and Specialty Services receive ratings derived from both sources. At CIW, 15 of the quality indicators were applicable, consisting of 13 primary clinical indicators and two secondary administrative indicators. Of the 13 primary indicators, eight were rated by both case review clinicians and compliance inspectors, three were rated by case review clinicians only, and two were rated by compliance inspectors only; both secondary indicators were rated by compliance inspectors only. California Institution for Women, Cycle 4 Medical Inspection Page 5 Office of the Inspector General State of California Consistent with the OIG’s agreement with the Receiver, this report only addresses the conditions found related to medical care criteria. The OIG does not review for efficiency and economy of operations. Moreover, if the OIG learns of an inmate-patient needing immediate care, the OIG notifies the chief executive officer of health care services and requests a status report. Additionally, if the OIG learns of significant departures from community standards, it may report such departures to the institution’s chief executive officer or to CCHCS. Because these matters involve confidential medical information protected by State and federal privacy laws, specific identifying details related to any such cases are not included in the OIG’s public report. In all areas, the OIG is alert for opportunities to make appropriate recommendations for improvement. Such opportunities may be present regardless of the score awarded to any particular quality indicator; therefore, recommendations for improvement should not necessarily be interpreted as indicative of deficient medical care delivery. CASE REVIEWS The OIG has added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders. At the conclusion of Cycle 3, the federal Receiver, the stakeholders, and the Inspector General determined that the health care provided at the institutions was not fully evaluated by the compliance tool alone, and that the compliance tool was not designed to provide comprehensive qualitative assessments. Accordingly, the OIG added case reviews in which OIG physicians and nurses evaluate selected cases in detail to determine the overall quality of health care provided to the inmate-patients. The OIG’s clinicians perform a retrospective chart review of selected patient files to evaluate the care given by an institution’s primary care providers and nurses. Retrospective chart review is a well-established review process used by health care organizations that perform peer reviews and patient death reviews. Currently, CCHCS uses retrospective chart review as part of its death review process and in its pattern-of-practice reviews. CCHCS also uses a more limited form of retrospective chart review when performing appraisals of individual primary care providers. PATIENT SELECTION FOR RETROSPECTIVE CASE REVIEWS Because retrospective chart review is time consuming and requires qualified health care professionals to perform it, OIG clinicians must carefully sample patient records. Accordingly, the group of patients the OIG targeted for chart review carried the highest clinical risk and utilized the majority of medical services. A majority of the patients selected for retrospective chart review were classified by CCHCS as high-risk patients. The reason the OIG targeted these patients for review is twofold: 1. The goal of retrospective chart review is to evaluate all aspects of the health care system. Statewide, high-risk and high-utilization patients consume medical services at a disproportionate rate; 11 percent of the total patient population are considered high-risk and California Institution for Women, Cycle 4 Medical Inspection Page 6 Office of the Inspector General State of California account for more than half of the institution’s pharmaceutical, specialty, community hospital, and emergency costs. 2. Selecting this target group for chart review provides a significantly greater opportunity to evaluate all the various aspects of the health care delivery system at an institution. Underlying the choice of high-risk patients for detailed case review, the OIG clinical experts made the following three assumptions: 1. If the institution is able to provide adequate clinical care to the most challenging patients with multiple complex and interdependent medical problems, it will be providing adequate care to patients with less complicated health care issues. Because clinical expertise is required to determine whether the institution has provided adequate clinical care, the OIG utilizes experienced correctional physicians and registered nurses to perform this analysis. 2. The health of less complex patients is more likely to be affected by processes such as timely appointment scheduling, medication management, routine health screening, and immunizations. To review these processes, the OIG simultaneously performs a broad compliance review. 3. Patient charts generated during death reviews, sentinel events (unexpected occurrences involving death or serious injury, or risk thereof), and hospitalizations are mostly of high-risk patients. BENEFITS AND LIMITATIONS OF TARGETED SUBPOPULATION REVIEW Because the selected patients utilize the broadest range of services offered by the health care system, the OIG’s retrospective chart review provides adequate data for a qualitative assessment of the most vital system processes (referred to as “primary quality indicators”). Retrospective chart review provides an accurate qualitative assessment of the relevant primary quality indicators as applied to the targeted subpopulation of high-risk and high-utilization patients. While this targeted subpopulation does not represent the prison population as a whole, the ability of the institution to provide adequate care to this subpopulation is a crucial and vital indicator of how the institution provides health care to its whole patient population. Simply put, if the institution’s medical system does not adequately care for those patients needing the most care, then it is not fulfilling its obligations, even if it takes good care of patients with less complex medical needs. Since the targeted subpopulation does not represent the institution’s general prison population, the OIG cautions against inappropriate extrapolation of conclusions from the retrospective chart reviews to the general population. For example, if the high-risk diabetic patients reviewed have poorly-controlled diabetes, one cannot conclude that the entire diabetic population is inadequately controlled. Similarly, if the high-risk diabetic patients under review have poor outcomes and require significant specialty interventions, one cannot conclude that the entire diabetic population is having similarly poor outcomes. California Institution for Women, Cycle 4 Medical Inspection Page 7 Office of the Inspector General State of California Nonetheless, the health care system’s response to this subpopulation can be accurately evaluated and yields valuable systems information. In the above example, if the health care system is providing appropriate diabetic monitoring, medication therapy, and specialty referrals for the high-risk patients reviewed, then it can be reasonably inferred that the health care system is also providing appropriate diabetic services to the entire diabetic subpopulation. However, if these same high-risk patients needing monitoring, medications, and referrals are generally not getting those services, it is likely that the health care system is not providing appropriate diabetic services to the greater diabetic subpopulation. CASE REVIEWS SAMPLED As indicated in Appendix B, Table B–1, CIW Sample Sets, the OIG clinicians evaluated medical charts for 73 unique inmate-patients. Appendix B, Table B–4, CIW Case Review Sample Summary, clarifies that both nurses and physicians reviewed charts for 12 of those patients, for 85 reviews in total. Physicians performed detailed reviews of 30 charts, and nurses performed detailed reviews of 17 charts, totaling 47 detailed reviews. For detailed case reviews, physicians or nurses looked at all encounters occurring in approximately six months of medical care. Nurses also performed a limited or focused review of medical records for an additional 38 inmate-patients. These generated 1,380 clinical events for review (Appendix B, Table B-3, CIW Event-Program). The reporting format provides details on whether the encounter was adequate or had significant deficiencies, and identifies deficiencies by programs and processes to help the institution focus on improvement areas. The OIG inspection occurred during the transition at CIW from the eUHR (electronic Unit Health Record), an electronic repository of scanned paper medical records, to the full electronic medical record, EHRS (Electronic Health Record System). The OIG clinicians reviewed two months of the EHRS records and four months of eUHR records for 16 of the 73 cases. Fifty-seven case reviews had only eUHR records reviewed. With this limited review of the EHRS, the OIG was unable to evaluate the impact of the new medical record system on the CIW health care system. While the sample method specifically pulled only six chronic care patient records, i.e., three diabetes patients and three anticoagulation patients (Appendix B, Table B–1, CIW Sample Sets), the 73 unique inmate-patients sampled included patients with 213 chronic care diagnoses, including 10 additional patients with diabetes (for a total of 13 diabetes patients) (Appendix B, Table B–2, CIW Chronic Care Diagnoses). The OIG’s sample selection tool evaluated many chronic care programs because the complex and high-risk patients selected from the different categories often had multiple medical problems. While the OIG did not evaluate every chronic disease or health care staff member, the overall operation of the institution’s system and staff were assessed for adequacy. The OIG’s case review methodology and sample size matched other qualitative research. The empirical findings, supported by expert statistical consultants, showed adequate conclusions after 10 to 15 charts had undergone full clinician review. In qualitative statistics, this phenomenon is known as “saturation.” The OIG asserts that the physician sample size of over 30 detailed reviews certainly California Institution for Women, Cycle 4 Medical Inspection Page 8 Office of the Inspector General State of California far exceeds the saturation point necessary for an adequate qualitative review. With regard to reviewing charts from different providers, the case review is not intended to be a focused search for poorly performing providers; rather, it is focused on how the system cares for those patients who need care the most. Nonetheless, while not sampling cases by each provider at the institution, the OIG inspections adequately review most providers. Providers would only escape OIG case review if institutional management successfully mitigated patient risk by having the more poorly performing providers care for the less complicated, low-utilizing, and lower-risk patients. The OIG’s clinicians concluded that the case review sample size was more than adequate to assess the quality of services provided. Based on the collective results of clinicians’ case reviews, the OIG rated each quality indicator as either proficient (excellent), adequate (passing), inadequate (failing), or not applicable. A separate confidential CIW Supplemental Medical Inspection Results: Individual Case Review Summaries report details the case reviews OIG clinicians conducted and is available to specific stakeholders. For further details regarding the sampling methodologies and counts, see Appendix B — Clinical Data, Table B–1; Table B–2; Table B–3; and Table B–4. COMPLIANCE TESTING SAMPLING METHODS FOR CONDUCTING COMPLIANCE TESTING From February to April 2016, deputy inspectors general and registered nurses attained answers to 98 objective medical inspection test (MIT) questions designed to assess the institution’s compliance with critical policies and procedures applicable to the delivery of medical care. To conduct most tests, inspectors randomly selected samples of inmate-patients for whom the testing objectives were applicable and reviewed their electronic unit health records. In some cases, inspectors used the same samples to conduct more than one test. In total, inspectors reviewed health records for 491 individual inmate-patients and analyzed specific transactions within their records for evidence that critical events occurred. Inspectors also reviewed management reports and meeting minutes to assess certain administrative operations. In addition, during the week of February 1, 2016, field inspectors conducted a detailed onsite inspection of CIW’s medical facilities and clinics; interviewed key institutional employees; and reviewed employee records, logs, medical appeals, death reports, and other documents. This generated 1,442 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 CIW’s plant infrastructure, protocols for tracking medical appeals and local operating procedures, and staffing resources. CIW transitioned to the new EHRS at the end of October 2015, which aligned with the end of the planned sampling period for most CIW compliance tests. For a few compliance tests, the planned sampling period ended in November 2015, but OIG inspectors were still learning to use the new EHRS and had difficulty retrieving some information from it. For efficiency, the OIG adjusted the California Institution for Women, Cycle 4 Medical Inspection Page 9 Office of the Inspector General State of California scope of its sampling period for some of those tests to include transactions through October 26, 2015, which were retrievable from the eUHR. However, OIG compliance inspectors did successfully use EHRS data to conduct three compliance tests in the Preventive Services indicator. As it was with case review, based on this limited testing, the OIG was unable to evaluate the impact of the new medical record system on the CIW health care system. For details of the compliance results, see Appendix A — Compliance Test Results. For details of the OIG’s compliance sampling methodology, see Appendix C — Compliance Sampling Methodology. SCORING OF COMPLIANCE TESTING RESULTS The OIG rated the institution in the following ten primary (clinical) and two secondary (administrative) quality indicators applicable to the institution for compliance testing:  Primary indicators: Access to Care, Diagnostic Services, Health Information Management (Medical Records), Health Care Environment, Inter- and Intra-System Transfers, Pharmacy and Medication Management, Prenatal and Post-Delivery Services, Preventive Services, Specialized Medical Housing (OHU, CTC, SNF, Hospice), and Specialty Services.  Secondary indicators: Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications. After compiling the answers to the 98 questions, the OIG derived a score for each primary and secondary quality indicator identified above by calculating the percentage score of all Yes answers for each of the questions applicable to a particular indicator, then averaging those scores. Based on those results, the OIG assigned a rating to each quality indicator of proficient (greater than 85 percent), adequate (between 75 percent and 85 percent), or inadequate (less than 75 percent). DASHBOARD COMPARISONS In the first ten medical inspection reports of Cycle 4, the OIG identified where similar metrics for some of the individual compliance questions were available within the CCHCS Dashboard, which is a monthly report that consolidates key health care performance measures statewide and by institution. However, there was not complete parity between the metrics due to differing time frames for data collecting and differences in sampling methods, rendering the metrics non-comparable. Some of the OIG’s stakeholders suggested removing the Dashboard comparisons from future reports to eliminate confusion. Dashboard data is available on CCHCS’s website, www.cphcs.ca.gov. California Institution for Women, Cycle 4 Medical Inspection Page 10 Office of the Inspector General State of California OVERALL QUALITY INDICATOR RATING FOR CASE REVIEWS AND COMPLIANCE TESTING The OIG derived the final rating for each quality indicator by combining the ratings from the case reviews and from the compliance testing, as applicable. When combining these ratings, the case review evaluations and the compliance testing results usually agreed, but there were instances when the rating differed for a particular quality indicator. In those instances, the inspection team assessed the quality indicator based on the collective ratings from both components. Specifically, the OIG clinicians and deputy inspectors general discussed the nature of individual exceptions found within that indicator category and considered the overall effect on the ability of patients to receive adequate medical care. To derive an overall assessment rating of the institution’s medical inspection, the OIG evaluated the various rating categories assigned to each of the quality indicators applicable to the institution, giving more weight to the rating results of the primary quality indicators, which directly relate to the health care provided to inmate-patients. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed. POPULATION-BASED METRICS The OIG identified a subset of Healthcare Effectiveness Data Information Set (HEDIS) measures applicable to the CDCR inmate-patient population. To identify outcomes for CIW, the OIG reviewed some of the compliance testing results, randomly sampled additional inmate-patients’ records, and obtained CIW 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 Women, Cycle 4 Medical Inspection Page 11 Office of the Inspector General State of California MEDICAL INSPECTION RESULTS PRIMARY (CLINICAL) QUALITY INDICATORS OF HEALTH CARE The primary quality indicators assess the clinical aspects of health care. As shown on the Health Care Quality Indicators table on page ii of this report, 13 of the OIG’s primary indicators were applicable to CIW. Of those 13 indicators, eight were rated by both the case review and compliance components of the inspection, three were rated by the case review component alone, and two were rated by the compliance component alone. The CIW Executive Summary Table on page vii shows the case review compliance ratings for each applicable indicator. Summary of Case Review Results: The clinical case review component assessed 11 of the 13 primary (clinical) indicators applicable to CIW. Of these 11 indicators, OIG clinicians rated three proficient, seven adequate, and one inadequate. The OIG physicians rated the overall adequacy of care for each of the 30 detailed case reviews they conducted. Of these 30 cases, one was proficient, 27 were adequate, and two were inadequate. In the 1,380 events reviewed, there were 337 deficiencies, of which 13 were considered to be of such magnitude that, if left unaddressed, they would likely contribute to patient harm. Adverse Events Identified During Case Review: Medical care is a complex dynamic process with many moving parts, subject to human error even within the best health care organizations. Adverse events are typically identified and tracked by all major health care organizations for the purpose of quality improvement. They are not generally representative of medical care delivered by the organization. The OIG identifies adverse events for the dual purposes of quality improvement and the illustration of problematic patterns of practice found during the inspection. There were no adverse event/events identified in the case reviews at CIW. Summary of Compliance Results: The compliance component assessed 10 of the 13 primary (clinical) indicators applicable to CIW. Of these ten indicators, OIG inspectors rated four proficient, five adequate, and one inadequate. The results of those assessments are summarized within this section of the report. The test questions used to assess compliance for each indicator are detailed in Appendix A. California Institution for Women, Cycle 4 Medical Inspection Page 12 Office of the Inspector General State of California ACCESS TO CARE This indicator evaluates the institution’s ability to provide Case Review Rating: inmate-patients with timely clinical appointments. Areas specific to Proficient inmate-patients’ access to care are reviewed, such as initial Compliance Score: assessments of newly arriving inmates, acute and chronic care Proficient follow-ups, face-to-face nurse appointments when an inmate-patient (86.9%) requests to be seen, provider referrals from nursing lines, and Overall Rating: follow-ups after hospitalization or specialty care. Compliance Proficient testing for this indicator also evaluates whether inmate-patients have Health Care Services Request forms (CDCR Form 7362) available in their housing units. Case Review Results The OIG clinicians reviewed 839 provider and nurse encounters and identified 33 minor deficiencies relating to Access to Care, none of which were significant deficiencies. CIW performed very well with regard to Access to Care, and the case review rating for this indicator was proficient. Compliance Testing Results The institution performed in the proficient range in the Access to Care indicator, with a compliance score of 86.9 percent. CIW scored in the proficient range in the following four test areas:  Inspectors sampled 30 Health Care Services Request forms (CDCR Form 7362) submitted by patients across all facility clinics. Nursing staff reviewed all the forms on the same day they were received (MIT 1.003). In addition, nursing staff completed a face-to-face encounter with 29 of the 30 patients within one business day of reviewing the service request form (97 percent). For one patient, the face-to-face encounter occurred four days late (MIT 1.004).  Of seven Health Care Services Request forms sampled on which nursing staff referred the patient for a PCP appointment, six patients (86 percent) received a timely appointment. The one exception was a patient who received his routine appointment 28 days late (MIT 1.005).  Inmates had access to Health Care Services Request forms at all six housing units inspected (MIT 1.101). The following test areas received scores in the adequate range:  Of the 29 sampled patients who had been discharged from a community hospital, 24 (83 percent) either received a timely follow-up appointment with a PCP or refused the California Institution for Women, Cycle 4 Medical Inspection Page 13 Office of the Inspector General State of California follow-up visit. Five patients received a PCP follow-up appointment from one to seven days late (MIT 1.007).  Inspectors sampled 28 patients who received a high-priority or routine specialty service; 22 of them (79 percent) received a timely follow-up appointment with a PCP. Six patients received their high-priority follow-up appointment between one and six days late (MIT 1.008).  Primary care provider visits occurred timely for 16 of the 21 sampled patients who had transferred into CIW from another institution and been referred to a PCP based on nursing staff’s initial health care screening of the patient (76 percent). For three patients, providers conducted appointments between 2 and 12 days late. For two remaining patients, follow-up visits did not occur prior to CIW’s conversion to EHRS; the provider visits were already 5 and 25 days late as of the date of conversion (MIT 1.002).  Routine appointments for 30 out of 40 sampled patients with chronic care conditions occurred timely (75 percent). Ten patients received appointments from 3 to 98 days late (MIT 1.001). Recommendations No specific recommendations. California Institution for Women, Cycle 4 Medical Inspection Page 14 Office of the Inspector General State of California DIAGNOSTIC SERVICES This indicator addresses several types of diagnostic services. Case Review Rating: Specifically, it addresses whether radiology and laboratory services Proficient were timely provided to inmate-patients, whether the primary care Compliance Score: provider (PCP) timely reviewed the results, and whether the results Proficient were communicated to the inmate-patient within the required time (85.6%) frames. In addition, for pathology services, the OIG determines Overall Rating: whether the institution received a final pathology report and Proficient whether the PCP timely reviewed and communicated the pathology results to the patient. The case reviews also factor in the appropriateness, accuracy, and quality of the diagnostic test(s) ordered and the clinical response to the results. Case Review Results The OIG clinicians reviewed 209 diagnostic events and found 33 deficiencies. The majority of these deficiencies related to health information management, e.g., labs were not available for review, a provider did not timely sign the lab report, or reports were misfiled into the wrong patients’ health record. The OIG found only two significant deficiencies, which were both a result of the quality of provider care. The Quality of Provider Performance indicator describes these two deficiencies (cases 20 and 28). CIW performed very well with regard to diagnostic services, and the case review rating was proficient. Compliance Testing Results The institution received a proficient compliance score of 85.6 percent in the Diagnostic Services indicator, which encompasses radiology, laboratory, and pathology services. For clarity, each type of diagnostic service is discussed separately below. Radiology Services The institution performed radiology services within the required time frame for nine of ten patients sampled (90 percent). For one other patient, the radiology service was provided two days late (MIT 2.001). CIW providers timely reviewed the diagnostic services reports and timely communicated the results for all ten patients (MIT 2.002, 2.003). Laboratory Services In all ten of the laboratory services sampled, the ordering provider timely reviewed the laboratory reports and communicated the results to the patient within the required time frame (MIT 2.005, 2.006). Laboratory services were performed timely for eight of the ten patients (80 percent); however, one patient received her laboratory service one day late, and another, three days late (MIT 2.004). California Institution for Women, Cycle 4 Medical Inspection Page 15 Office of the Inspector General State of California Pathology Services CIW timely received the final pathology report for only five of nine patients sampled (56 percent). Four reports were from 3 to 21 days late (MIT 2.007). Providers timely reviewed pathology results for seven of the nine patients (78 percent). One patient’s report was reviewed six days late; for another patient, there was no evidence of the provider’s review at all (MIT 2.008). Providers timely communicated the final pathology results to six of the nine patients sampled (67 percent), communicating the results to two patients three and nine days late, and entirely failing to communicate the results to a third patient (MIT 2.009). Recommendations No specific recommendations. California Institution for Women, Cycle 4 Medical Inspection Page 16 Office of the Inspector General State of California EMERGENCY SERVICES An emergency medical response system is essential to providing Case Review Rating: effective and timely emergency medical response, assessment, Adequate treatment, and transportation 24 hours per day. Provision of Compliance Score: urgent/emergent care is based on a patient’s emergency situation, Not Applicable clinical condition, and need for a higher level of care. The OIG reviews emergency response services including first aid, basic life Overall Rating: support (BLS), and advanced cardiac life support (ACLS) Adequate consistent with the American Heart Association guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care, and the provision of services by knowledgeable staff appropriate to each individual’s training, certification, and authorized scope of practice. The OIG evaluates this quality indicator entirely through clinicians’ reviews of case files and conducts no separate compliance testing element. Case Review Results The OIG clinicians reviewed 136 urgent/emergent events and found 58 deficiencies, most of which were in the area of nursing care. There were two significant deficiencies (case 9 and 11). Seven of the minor deficiencies were due to documents not being found in the health records. CIW’s performance in this indicator was adequate. Provider Performance Providers covering the TTA generally made appropriate triage decisions and sent patients to appropriate levels of care. Nursing Performance The majority of the deficiencies found in emergency services were related to inadequate nursing assessment, including monitoring, intervention, and documentation. In most cases, patients were not at increased risk of harm. The two notable exceptions were as follows:  In case 9, the patient’s oxygen saturation decreased to 71%, and the nurse applied 4 liters of oxygen via nasal cannula. Though the patient’s oxygen saturation remained low, the nurse failed to further increase the amount of oxygen delivered to the patient.  In case 11, the RN failed to promptly initiate oxygen in an unresponsive patient with agonal breathing (the gasping, ineffective breathing, indicating the last breaths before death). A review by a supervising registered nurse failed to recognize this delay in oxygen administration. California Institution for Women, Cycle 4 Medical Inspection Page 17 Office of the Inspector General State of California Emergency Medical Response Review Committee Nineteen of the deficiencies found in emergency services were related to inadequate chief medical executive (CME) and chief nurse executive (CNE) review of non-scheduled emergency transports to the local emergency room, as required by policy. Some of the events were reviewed by the CNE but not by the CME or the Emergency Response Review Committee (EMRRC). Clinician Onsite Inspection During review of EMRRC minutes, the OIG clinicians noted delays in ambulance arrivals for the transfer of patients to local emergency rooms. CIW staff confirmed the delays during the onsite visit. There had been consistent delays of five to six minutes in ambulance response times to CIW for approximately one year. Medical leadership had been notifying the statewide emergency medical services liaison and the ambulance companies of these delays. The explanation for these delays was the housing development in the nearby communities, which resulted in an increase of ambulance utilization by these communities. CIW had recently implemented a new non-scheduled emergency transportation nursing and provider review process. Cases with concerns identified by the chief nurse executive or the chief medical executive requiring training were elevated to the Emergency Medical Response Review Committee. Recommendations The OIG recommends that CIW take steps to ensure the following:  Nursing assessment, intervention, and documentation are complete.  Training is provided to ensure the CME and CNE review all non-scheduled transports according to policy. California Institution for Women, Cycle 4 Medical Inspection Page 18 Office of the Inspector General State of California HEALTH INFORMATION MANAGEMENT (MEDICAL RECORDS) Health information management is a crucial link in the delivery of Case Review Rating: medical care. Medical personnel require accurate information in Inadequate order to make sound judgments and decisions. This indicator Compliance Score: examines whether the institution adequately manages its health care Inadequate information. This includes determining whether the information is (49.8%) correctly labeled and organized and available in the electronic unit Overall Rating: health record (eUHR); whether the various medical records (internal Inadequate and external, e.g., hospital and specialty reports and progress notes) are obtained and scanned timely into the inmate-patient’s eUHR; whether records routed to clinicians include legible signatures or stamps; and whether hospital discharge reports include key elements and are timely reviewed by providers. The OIG inspection occurred as CIW transitioned from the eUHR to the full electronic medical record, EHRS (Electronic Health Record System). For case reviews, the OIG clinicians reviewed two months of the EHRS records and four months of eUHR records for 16 of the 73 cases. Fifty-seven case reviews involved only eUHR records. For compliance testing, inspectors only used the EHRS for three tests in the Preventive Services indicator. With this limited review of the EHRS, the OIG was unable to evaluate the impact of the new medical record system on the CIW health care system. Case Review Results The OIG clinicians found that 87 of 344 (total) deficiencies identified from the case reviews related to the health information management processes. While only two deficiencies were significant, the high number and patterns of deficiencies found led the OIG clinicians to rate the Health Information Management indicator inadequate. Inter-Departmental Transmission A few deficiencies were related to orders not carried through to various departments, e.g., pathology reports requested but not retrieved in a timely manner:  In case 12, the report was never retrieved.  In case 16, the report was obtained after another request three months later. Hospital Records Hospital records were generally reviewed in a timely manner. California Institution for Women, Cycle 4 Medical Inspection Page 19 Office of the Inspector General State of California Specialty Services The majority of the health information management deficiencies relating to specialty services were when specialty reports were not timely or properly signed by a primary care provider. However, as noted in the Specialty Services indicator, it was clear a provider reviewed the reports, as evidenced by documentation in progress notes and orders. A handful of deficiencies were also due to specialty reports not found in the eUHR. Diagnostic Reports Twenty-seven of the deficiencies in Health Information Management were diagnostic reports not properly and timely signed by a primary care provider, or missing from the health record altogether. The delay in providers’ signing of the reports ranged from a few days to six months. Urgent/Emergent Records There were a few missing nursing records regarding urgent/emergent events. Scanning Performance The deficiencies relating to scanning performance were due to misfiled documents, and documents missing from patient’s health records, e.g., refusal forms, procedure notes, and PCP or nursing notes (cases 10, 16, 17, 24, 25, 26, 28, and 81). Legibility Nine deficiencies were due to illegible progress notes and signatures. Of these, three were notes from specialty services consultants. Miscellaneous Three deficiencies were due to transcription errors: case 18 (one deficiency) and case 22 (two deficiencies). Compliance Testing Results CIW scored in the inadequate range in the Health Information Management (Medical Records) indicator, receiving a compliance score of 49.8 percent. CIW received inadequate scores in five areas below:  The institution scored zero in labeling and filing documents scanned into patients’ eUHR; most errors were mislabeled documents, such as the scanning and mislabeling of a Medication Reconciliation as a Physicians Order (CDCR Form 7221). Other documents were either mislabeled or missing from the eUHR altogether (MIT 4.006). California Institution for Women, Cycle 4 Medical Inspection Page 20 Office of the Inspector General State of California  Only 4 of the 20 sampled medical administration records (MARs) were timely scanned into the patients’ eUHR (20 percent); 16 MARs were scanned from 5 to 45 days late (MIT 4.005).  CIW scored 25 percent for the timely scanning of dictated or transcribed provider progress notes into patients’ eUHR files. Only 5 of 20 sampled documents were timely scanned within five calendar days; 15 documents were scanned between one and ten days late (MIT 4.002).  The institution timely scanned only 11 of 20 sampled community hospital discharge reports or treatment records into patients’ eUHRs (55 percent); nine reports were scanned from one to nine days late (MIT 4.004).  Only 20 of 32 samples of various medical documents such as hospital discharge reports, initial health screening forms, certain medication records, and specialty services reports (63 percent) showed compliance with clinical staff legibly documenting their names on the forms. Twelve of the samples did not include clinician name stamps, or the signatures were illegible (MIT 4.007). The institution performed in the adequate range in the following areas:  Institution staff timely scanned 16 of 20 sampled initial health screening forms and health care service request forms into patients’ eUHRs within three calendar days of the patient encounter (80 percent). Four documents were scanned one to five days late (MIT 4.001).  CIW staff timely scanned 16 of 20 specialty service consultant reports sampled into the patient’s eUHR file (80 percent). The other four reports were scanned one to 20 days late (MIT 4.003).  The eUHR files for 22 out of 29 patients sent or admitted to the hospital were complete and reviewed by providers within three calendar days of discharge (76 percent). For three patients, providers signed the hospital discharge report but did not provide the review date demonstrating if the review was timely; for two of these three patients, the hospital discharge report did not contain key elements. CIW providers reviewed the discharge summary reports four to nine days late for three other patients, and the hospital discharge report was not complete for another patient (MIT 4.008). Recommendations The OIG recommends that CIW management request legible or dictated reports from specialty consultants when handwritten notes are illegible. California Institution for Women, Cycle 4 Medical Inspection Page 21 Office of the Inspector General State of California HEALTH CARE ENVIRONMENT This indicator addresses the general operational aspects of the Case Review Rating: institution’s clinics, including certain elements of infection control Not Applicable and sanitation, medical supplies and equipment management, the Compliance Score: Adequate availability of both auditory and visual privacy for inmate-patient (78.3%) visits, and the sufficiency of facility infrastructure to conduct comprehensive medical examinations. Rating of this component is Overall Rating: based entirely on the compliance testing results from the visual Adequate observations inspectors make at the institution during their onsite visit. Compliance Testing Results The institution received an adequate compliance score of 78.3 percent in the Health Care Environment indicator, and scored proficient in the following six areas:  All 12 applicable clinics were appropriately disinfected, cleaned, and sanitary. Cleaning logs were available and complete, indicating cleaning crews regularly cleaned the clinics (MIT 5.101).  Clinical health care staff at all 12 applicable clinics ensured that reusable invasive and non-invasive medical equipment was properly sterilized and disinfected (MIT 5.102).  Staff at all 13 applicable clinics followed proper protocols to mitigate exposure to blood-borne pathogens and contaminated waste (MIT 5.105).  All non-clinic bulk medical supply storage areas met the supply management process and support needs of the medical health care program (MIT 5.106).  Twelve of the 13 clinics inspected had operable sinks and sufficient quantities of hand hygiene supplies in clinical areas (92 percent). In one location, the patients’ designated bathroom had been inoperative for the past five months, and an alternate bathroom located nearby had no antiseptic hand soap or disposable towels (MIT 5.103).  At nine of the ten sampled clinical locations, clinical staff inspected emergency response bags daily, inventoried them monthly, and ensured they contained all essential items (90 percent). However, one clinic’s bag did not contain the required medium-sized blood pressure cuff (MIT 5.111). California Institution for Women, Cycle 4 Medical Inspection Page 22 Office of the Inspector General State of California The following two test areas received scores in the adequate range:  Ten of the 13 clinics (77 percent) followed adequate medical supply storage and management protocols. In three clinic areas, bulk medical supplies in storage rooms were not labeled for easy identification (Figure 1). Additionally, there were personal food items and a bread toaster stored in an exam room of one of those same clinics (MIT 5.107).  While 9 of 12 clinic common areas had an environment conducive to provide medical services (75 percent), the OHU and CTC Figure 1: Unlabeled, disorganized supplies lacked adequate auditory privacy for patients during vital sign encounters. Also, the TTA’s blood draw station was within audible range of another seating area, compromising auditory privacy (MIT 5.109). CIW scored in the inadequate range in the following three test areas:  The OIG inspected various exam rooms in each of CIW’s 13 clinics, observing patient encounters and interviewing clinical staff, to determine if appropriate space, configuration, supplies, and equipment allowed clinicians to perform a proper clinical exam. Exam rooms or treatment spaces were sufficient in 9 of the 13 clinics (69 percent). Four clinics had exam areas that were unacceptable for a variety of reasons. For example, exam rooms in three clinics were too small to allow for adequate patient examinations (Figure 2), one of those same rooms contained an exam table with ripped vinyl covering that could harbor infectious agents if not adequately disinfected; an exam room in another clinic did not provide auditory privacy for patients during clinical encounters (MIT 5.110). Figure 2: Exam room too small for  Only 4 of the 13 clinics’ common areas and exam adequate examinations rooms had all essential supplies and core medical equipment available for immediate and reliable use (31 percent); the remaining nine clinics had one or more deficiencies. Exam rooms in five clinics lacked a biohazard waste receptacle or bags. Exam rooms in three clinics lacked oto-ophthalmoscopes and otoscope tips, and another clinic’s exam room had an oto-ophthalmoscope without evidence of its last calibration. PCP exam rooms in four clinics lacked items such as lubricating jelly, tongue California Institution for Women, Cycle 4 Medical Inspection Page 23 Office of the Inspector General State of California depressors, and hemoccult cards and developer; one of the provider’s rooms had an overhead light intended to aid with pelvic exams that had been inoperative for more than one month. In addition, one clinic was missing a nebulization unit, while another clinic retained an automated external defibrillator unit last calibrated in June 2014, almost two years prior to the OIG’s inspection (MIT 5.108).  OIG inspectors observed clinical encounters with patients in 11 of CIW’s clinics and found that clinicians followed good hand hygiene practices in only three clinics (27 percent). Providers and nurses in eight clinics did not properly sanitize their hands before and after an invasive procedure or a service that required physical patient contact. For those staff who utilized gloves during patient encounters, deficiencies included the failure to wash hands or use hand sanitizer between glove changes, or to immediately remove gloves following patient contact (MIT 5.104). Other Information Obtained from Non-Scored Results  The OIG gathered information to determine if CIW’s physical infrastructure was maintained in a manner that supported health care management’s ability to provide timely or adequate health care. This question was not scored. When OIG inspectors interviewed health care management, staff did not express concerns about the facility’s infrastructure or its effect on staff’s ability to provide adequate health care. However, at the time of the inspection, CIW had a master infrastructure project underway to remedy identified deficiencies in its existing health care components. The sub-projects included the addition and renovation of CIW’s general population primary care clinic, the renovation of the support care unit primary clinic, an addition to the central health services building, and disability placement program accessibility improvements. The CEO acknowledged that during construction, staff were managing well while working within temporary “swing spaces.” Management concurred that CIW continued to provide adequate health care to patients despite the distractions of construction. All projects were on track with a completion date targeted for August 2016 (MIT 5.999). California Institution for Women, Cycle 4 Medical Inspection Page 24 Office of the Inspector General State of California Recommendation for CCHCS The OIG recommends that CCHCS develop a statewide policy to identify required core equipment and supplies for each type of clinical setting, including primary care clinics, specialty clinics, TTAs, R&Rs, and inpatient units. Recommendations for CIW The OIG recommends that CIW develop local operating procedures or provide training to ensure the following:  All clinical areas maintain a full complement of core medical equipment that includes a nebulization unit; each exam room contains an oto-ophthalmoscope and otoscope tips, a biohazard waste receptacle or bags, and tongue depressors; and each provider exam room contains lubricating jelly, and hemoccult cards and developer.  Staff regularly monitor medical equipment items to ensure applicable equipment is in working order and currently calibrated, and that torn areas on vinyl-covered exam tables are repaired or the tables are replaced.  Auditory privacy is provided to patients being examined in clinicians’ exam rooms and at triage and blood draw stations in clinic common areas.  Clinicians are aware of universal hand hygiene protocols, and staff adhere to these practices before and after providing invasive and non-invasive medical procedures. California Institution for Women, Cycle 4 Medical Inspection Page 25 Office of the Inspector General State of California INTER- AND INTRA-SYSTEM TRANSFERS This indicator focuses on the management of inmate-patients’ Case Review Rating: medical needs and continuity of patient care during the inter- and Proficient intra-facility transfer process. The patients reviewed for Inter- and Compliance Score: Intra-System Transfers include inmates received from other CDCR Proficient facilities and inmates transferring out of CIW to another CDCR (89.3%) facility. The OIG review includes evaluation of the institution’s Overall Rating: ability to provide and document health screening assessments, Proficient initiation of relevant referrals based on patient needs, and the continuity of medication delivery to patients arriving from another institution. For those patients, the OIG clinicians also review the timely completion of pending health appointments, tests, and requests for specialty services. For inmate-patients who transfer out of the facility, the OIG evaluates the ability of the institution to document transfer information that includes pre-existing health conditions, pending appointments, tests and requests for specialty services, medication transfer packages, and medication administration prior to transfer. The OIG clinicians also evaluate the care provided to patients returning to the institution from an outside hospital and check to ensure appropriate implementation of the hospital assessment and treatment plans. Case Review Results The OIG clinicians reviewed 19 encounters relating to Inter- and Intra-System Transfers, including information from both the sending and receiving institutions. Clinicians also reviewed 75 hospitalization events. Twenty-seven of these events were actual hospitalizations or emergency room visits, the majority of which resulted in a transfer back to the institution (a few events resulted in transfers to other hospitals or to other institutions, or in patient deaths). The OIG identified very few deficiencies, and the Inter- and Intra-System Transfers processes at CIW were proficient. Transfers In Nurses thoroughly completed the Initial Health Screening forms (CDCR Form 7277) for patients arriving to CIW. The few deficiencies related to appointments initially scheduled at sending institutions that were not re-scheduled by CIW staff upon the patients’ arrival. Transfers Out Five cases were reviewed specifically of patients transferring out of CIW. Nursing staff properly completed the Health Care Transfer Information forms (CDCR Form 7371), including pending specialty appointments, pending diagnostic tests, and pending primary care appointments. California Institution for Women, Cycle 4 Medical Inspection Page 26 Office of the Inspector General State of California 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. At CIW, providers and nurses adequately assessed patients returning from hospitals. On a few occasions, PCP follow-up appointments did not occur in a timely manner. Compliance Testing Results The institution obtained a proficient compliance score of 89.3 percent in the Inter- and Intra-System Transfers indicator. The institution scored in the proficient range in the following three tests:  Inspectors sampled 30 patients who transferred into CIW from other institutions to ensure that each patient received a timely health screening upon arrival at the institution. For 29 of the 30 sampled patients (97 percent), nursing staff completed an Initial Health Screening form (CDCR Form 7277) on the same day the patient arrived. For one patient, nursing staff did not complete all of the applicable questions on the form (MIT 6.001).  Nursing staff properly completed the assessment and disposition section of the screening form for 28 of the 30 patients sampled (93 percent). The two exceptions were patients whom the RN did not refer to the TTA after the screening form responses identified them as having possible signs and symptoms of tuberculosis (MIT 6.002).  During the OIG’s onsite inspection, ten patients who were transferring out of the facility had their transfer packages inspected to determine whether they included required medications and supporting documentation. Nine of the ten transfer packages were compliant, and the institution received a score of 90 percent on this test. One patient did not have all of her medication in the transfer package (MIT 6.101). The institution scored within the adequate range in the following two tests:  Out of 30 inmate-patients sampled who transferred into CIW, 19 had an existing medication order upon arrival. For 16 of those 19 patients (84 percent), nurses delivered or administered the medications without interruption. Two patients received their keep-on-person (KOP) or direct observation therapy (DOT) medication one day late; another patient received two of her DOT medications one day late and did not receive another DOT medication for seven days, at which time the order was changed to a KOP medication, then delivered to the patient the following day (MIT 6.003).  Inspectors sampled 17 patients who transferred out of CIW to another CDCR institution to determine if the institution listed their scheduled specialty service appointments on the Health Care Transfer Information form (CDCR Form 7371). CIW nursing staff identified California Institution for Women, Cycle 4 Medical Inspection Page 27 Office of the Inspector General State of California the scheduled appointments on the transfer forms for 14 of the 17 patients sampled (82 percent) (MIT 6.004). Recommendations No specific recommendations. California Institution for Women, Cycle 4 Medical Inspection Page 28 Office of the Inspector General State of California PHARMACY AND MEDICATION MANAGEMENT This indicator is an evaluation of the institution’s ability to provide Case Review Rating: appropriate pharmaceutical administration and security management, Adequate encompassing the process from the written prescription to the Compliance Score: administration of the medication. By combining both a quantitative Adequate (77.9%) compliance test with case review analysis, this assessment identifies issues in various stages of the medication management process, Overall Rating: including ordering and prescribing, transcribing and verifying, Adequate dispensing and delivering, administering, and documenting and reporting. Because effective medication management is affected by numerous entities across various departments, this assessment considers internal review and approval processes, pharmacy, nursing, health information systems, custody processes, and actions taken by the PCP prescriber, staff, and patient. Case Review Results In the majority of cases, patients received their medications timely and as prescribed. There were only rare occurrences of CIW staff not administering medications timely. Some anticoagulation patients were co-managed by the primary care provider and pharmacy staff, with pharmacists noting laboratory results and making recommendations for changes in medication dosing. The pharmacy recommendations were appropriate, allowing the provider more time to attend to other medical issues. Conclusion The OIG rated the case review portion of this indicator adequate. Compliance Testing Results The institution received an adequate compliance score of 77.9 percent in the Pharmacy and Medication Management indicator. For discussion purposes below, this indicator is divided into three sub-indicators: medication administration, observed medication practices and storage controls, and pharmacy protocols. Medication Administration For this sub-indicator, the institution received an average score of 81.0 percent, scoring in the proficient range in the following areas:  Twenty-eight of the 30 patients sampled timely received their new medication orders (93 percent). One patient received her medication one day late; for a second patient, California Institution for Women, Cycle 4 Medical Inspection Page 29 Office of the Inspector General State of California inspectors could not locate the monthly medication administration record in the patient’s eUHR to verify that she received two newly ordered DOT medications (MIT 7.002).  CIW ensured that 28 of 30 patients sampled (93 percent) received their medications without interruption when they transferred from one housing unit to another. Two patients did not receive their prescribed medication at their next dosing interval following the transfer (MIT 7.005). CIW showed room for improvement in the following areas of this sub-indicator:  Nursing staff timely dispensed long-term chronic care medications to 23 of the 32 patients sampled, scoring 72 percent on this test. Inspectors found the following deficiencies (MIT 7.001): o For five patients, inspectors were unable to locate eUHR evidence that the patients received doses of their DOT medications on two or more days; for one of those patients, there was no evidence she received her medication for an entire month. o Two patients did not receive a renewal of their KOP medication for two or more weeks before the medication was discontinued. o One patient did not receive her newly ordered insulin for six days; instead, she continued to receive her previously ordered insulin medication for seven days after it was discontinued. o One patient refused her insulin doses on many days; on some of those days, she did not receive a nurse referral for provider counseling, and on other days, she received the referral but did not receive provider counseling within one calendar day.  Only 19 of 29 patients sampled who had returned from a community hospital (66 percent) timely received their hospital discharge medications. Seven patients received one or more of their medications from one to four days late; one of those patients and another patient never received one medication order at all. Of the two remaining patients, one never received one of her KOP medications and instead received a refill of the higher pre-hospitalization dosage of the medication. For the other patient, upon her discharge from the hospital, the PCP ordered three medications, which should have been administered to the patient the next day, but the patient did not receive them. Then, the PCP discontinued all the medications three days after ordering them, but the institution administered one of those discontinued medications the following day (MIT 7.003). California Institution for Women, Cycle 4 Medical Inspection Page 30 Office of the Inspector General State of California Observed Medication Practices and Storage Controls In this sub-indicator, the institution received an adequate score of 75.7 percent and performed well in the following areas:  Clinical staff employed appropriate administrative controls and followed proper protocols during medication preparation at all seven applicable medication line locations observed (MIT 7.105).  The institution employed strong medication security controls over narcotic medications in 10 of the 11 applicable clinics and medication line locations where narcotics were stored (91 percent). At one medication line location, a review of the narcotics log book showed that while physical inventories were routinely performed between nursing shifts, a second nurse did not always counter-sign the log book certifying the reconciliation of narcotics pill totals (MIT 7.101).  When observing the medication distribution process at seven pill line locations, inspectors found that six locations were compliant with appropriate administrative controls and protocols (86 percent). However, at one clinic, a medication nurse mixed Levemir (a long-acting form of insulin) with Novolog (a fast-acting form of insulin) in the same syringe prior to the patient self-injecting the medication; the same nurse did not always require patients on DOT medications to demonstrate that they swallowed their medication or verify patients’ self-injection of insulin (MIT 7.106).  CIW properly stored non-narcotic medications that did not require refrigeration at 12 of the 16 applicable clinics and medication line storage locations sampled (75 percent). At one location, inspectors discovered that staff did not follow a standard system to store non-refrigerated medication pending return to the pharmacy. Another location had a previously opened single-dose vial of sterile water that had not been discarded per the manufacturer’s guidelines. Finally, two locations had external medications that were not separately stored from internal medications (MIT 7.102). The institution received inadequate scores in the following two tests:  The institution properly stored non-narcotic medications that require refrigeration at only 5 of the 11 applicable clinics and medication line locations, receiving a score of 45 percent. Four of the locations did not have a system in place to return unused medications to the pharmacy; at four locations, refrigerators had open vials of medication that were expired or had no date; and one location did not have a temperature log or a thermometer for the freezer (MIT 7.103).  Inspectors observed the medication preparation and administration processes in seven medication line locations. Nursing staff were compliant with proper hand hygiene California Institution for Women, Cycle 4 Medical Inspection Page 31 Office of the Inspector General State of California contamination control protocols at four of them (57 percent). At three locations, the medication nurse did not re-sanitize hands after changing gloves, and at two of the three locations, the medication nurse did not sanitize hands prior to initially putting on gloves (MIT 7.104). Pharmacy Protocols In this sub-indicator, the institution received an average score of 78.0 percent, comprised of scores received at the institution’s main pharmacy. CIW received a proficient score in the following areas:  In its main pharmacy, CIW followed general security, organization, and cleanliness management protocols; properly stored non-refrigerated medications; and properly accounted for narcotic medications. As a result, the institution scored 100 percent in these areas (MIT 7.107, 7.108, 7.110).  The institution’s pharmacist in charge (PIC) followed required protocols for 27 of the 30 medication error reports and monthly statistical reports reviewed (90 percent). For two errors, the PIC did not assign a medication error severity level or identify the follow-up review date; as a result, the PIC did not timely complete the follow-up report. In addition, the PIC completed one medication error follow-up report 15 days late (MIT 7.111). The institution scored in the inadequate range on the following test:  CIW’s main pharmacy did not properly store and monitor refrigerated or frozen medications, scoring zero on this test. Specifically, the main pharmacy’s December 2015 refrigerator temperature log recorded temperatures below the approved minimum temperature limit of 36° F on five separate days (MIT 7.109). Non-Scored Tests In addition to testing reported medication errors, OIG inspectors follow up on any significant medication errors found during the case reviews or compliance testing to determine if the errors were properly identified and reported. These findings are not scored. At CIW, the OIG did not find any applicable medication errors subject to this test (MIT 7.998). The OIG tested patients in isolation units to determine if they had immediate access to their prescribed KOP asthma rescue inhalers and nitroglycerin medications. Nine of the ten applicable patients interviewed indicated they had possession of their rescue medications; one patient did not have her rescue inhaler on her person. The patient indicated she had been without her inhaler for approximately one month after giving it to a nurse who subsequently did not return the medication. Upon the OIG inspector’s notification to the institution regarding this deficiency, CIW immediately reissued the medication to the patient (MIT 7.999). California Institution for Women, Cycle 4 Medical Inspection Page 32 Office of the Inspector General State of California Recommendations The OIG recommends that CIW provide training to nursing staff in the use of proper hand hygiene protocols when preparing and administering medication. California Institution for Women, Cycle 4 Medical Inspection Page 33 Office of the Inspector General State of California PRENATAL AND POST-DELIVERY SERVICES This indicator evaluates the institution’s capacity to provide timely Case Review Rating: and appropriate prenatal, delivery, and postnatal services. This Adequate includes the ordering and monitoring of indicated screening tests, Compliance Score: follow-up visits, referrals to higher levels of care, e.g., the high-risk Adequate (80.0%) obstetrics clinic, when necessary, and postnatal follow-up. Overall Rating: Case Review Results Adequate The OIG clinicians reviewed 60 encounters related to prenatal and post-delivery services. These included provider encounters, specialty services such as the high-risk obstetrics clinic and fetal monitoring, diagnostic testing, urgent/emergent encounters, and hospitalizations for deliveries. The few minor deficiencies found did not result in increased risk of harm to the mother, fetus, or newborn. The OIG rated the case review portion of this indicator adequate. Compliance Testing Results The institution received an adequate compliance score of 80.0 percent in the Prenatal and Post-Delivery Services indicator, and scored proficient in the following three areas:  CIW provided all ten sampled pregnant patients a lower bunk and lower-tier housing (MIT 8.002).  Clinical staff documented the patient’s weight and blood pressure at every prenatal visit for all ten samples tested (MIT 8.006).  Nine of ten pregnant patients saw an obstetrician within seven business days of arrival at CIW (90 percent). The one exception was a patient who received her first obstetrician visit at CIW three days late (MIT 8.001). CIM scored in the inadequate range in the following two tests:  Only six of ten pregnant patients received all of their prenatal visits with a supervising obstetrician or obstetrics nurse practitioner at the required intervals (60 percent). Four patients received one or two appointments between one and seven days late (MIT 8.004).  CIW timely provided required six-week postpartum visits to only four of the eight patients sampled (50 percent). Four patients received appointments from one to 25 days late (MIT 8.007). California Institution for Women, Cycle 4 Medical Inspection Page 34 Office of the Inspector General State of California Recommendations No specific recommendations. California Institution for Women, Cycle 4 Medical Inspection Page 35 Office of the Inspector General State of California PREVENTIVE SERVICES This indicator assesses whether various preventive medical services Case Review Rating: are offered or provided to inmate-patients. These include cancer Not Applicable screenings, tuberculosis screenings, and influenza and chronic care Compliance Score: Proficient immunizations. This indicator also assesses whether certain (92.6%) institutions take preventive actions to relocate inmate-patients identified as being at higher risk for contracting coccidioidomycosis Overall Rating: (valley fever). Proficient The OIG rates this indicator entirely through the compliance testing component; the case review process does not include a separate qualitative analysis for this indicator. Compliance Testing Results The institution performed in the proficient range in the Preventive Services indicator, with a compliance score of 92.6 percent. Seven test areas scored in the proficient range, including three scores of 100 percent, as described below:  CIW completed the required tuberculosis monitoring assessment for all nine sampled patients who received anti-tuberculosis medications during the three-month review period (MIT 9.002).  All 30 sampled patients timely received or were offered influenza vaccinations during the most recent influenza season (MIT 9.004).  All 30 sampled patients received or were offered a mammogram within CCHCS policy guidelines (MIT 9.006).  CIW offered pap smear screenings to 28 of 30 sampled patients aged 21 through 65 (93 percent). Two patients neither received nor were offered a pap smear within the last 36 months (MIT 9.007).  The institution offered colorectal cancer screenings to 27 of 30 sampled patients (90 percent) subject to the annual screening requirement. For three patients, there was no evidence in the eUHR that health care staff offered a colorectal cancer screening within the previous 12 months, or that the patient had a normal colonoscopy within the last ten years (MIT 9.005).  CIW scored 89 percent for timely administration of anti-tuberculosis medications. Of the nine patients sampled, eight received all required doses of anti-tuberculosis medication for the three-month test period. The single exception was a patient who missed multiple California Institution for Women, Cycle 4 Medical Inspection Page 36 Office of the Inspector General State of California medication doses and did not receive counseling from a provider about the missed medication (MIT 9.001).  The OIG tested whether patients who suffered from a chronic care condition were offered vaccinations for influenza, pneumonia, and hepatitis. Among the 26 sampled patients with applicable chronic conditions, 23 patients (88 percent) were timely offered the vaccinations. For three patients, there was no record that they received or refused the pneumococcal immunization within the last five years (MIT 9.008). The institution scored within the adequate range in the following test:  Although the institution timely conducted annual tuberculosis screenings within the prior year for all 30 sampled patients, nursing staff conducted those screenings adequately for only 24 of those patients (80 percent). Nurses properly screened only 10 of the 15 patients classified as Code 22 (requiring a tuberculosis skin test in addition to a signs and symptoms check); for three patients, nursing staff did not read the test within the required 48-to-72-hour time period; for another patient, the nurse did not document the administration time of the test so the OIG could not determine if the test was read timely; for the remaining patient, the nurse did not complete the signs and symptoms section of the Tuberculin Testing/Evaluation Report (CDCR Form 7331). Nurses properly screened 14 of 15 sampled Code 34 patients (subject only to an annual signs and symptoms check); for one patient, the nurse failed to document a complete review of the patient’s signs and symptoms (MIT 9.003). Recommendations No specific recommendations. California Institution for Women, Cycle 4 Medical Inspection Page 37 Office of the Inspector General State of California QUALITY OF NURSING PERFORMANCE The Quality of Nursing Performance indicator is a qualitative Case Review Rating: evaluation of the institution’s nursing services. The evaluation is Adequate completed entirely by OIG nursing clinicians within the case Compliance Score: review process, and, therefore, does not have a score under the Not Applicable compliance testing component. The OIG nurses conduct case reviews that include reviewing face-to-face encounters related to Overall Rating: nursing sick call requests identified on the Health Care Services Adequate Request form (CDCR Form 7362), urgent walk-in visits, referrals for medical services by custody staff, RN case management, RN utilization management, clinical encounters by licensed vocational nurses (LVNs) and licensed psychiatric technicians (LPTs), and any other nursing service performed on an outpatient basis. The OIG case review also includes activities and processes performed by nursing staff that are not considered direct patient encounters, such as the initial receipt and review of CDCR Form 7362 service requests and follow-up with primary care providers and other staff on behalf of the patient. Key focus areas for evaluation of outpatient nursing care include appropriateness and timeliness of patient triage and assessment, identification and prioritization of health care needs, use of the nursing process to implement interventions including patient education and referrals, and documentation that is accurate, thorough, and legible. Nursing services provided in the outpatient housing unit (OHU), correctional treatment center (CTC), or other inpatient units are reported in the Specialized Medical Housing indicator. Nursing services provided in the triage and treatment area (TTA) or related to emergency medical responses are reported in the Emergency Services indicator. Case Review Results The Quality of Nursing Performance at CIW was adequate. The OIG clinicians reviewed 153 outpatient nursing encounters and identified 46 deficiencies related to outpatient nursing services. Outpatient nursing care at CIW was generally timely and appropriate. The majority of deficiencies noted were due to incomplete assessments and documentation. The OIG identified one significant deficiency (cases 18).  In case 15, the patient complained of constipation. The nurse failed to inspect and palpate the abdomen, and did not assess the presence or absence of bowel sounds.  In case 18, the nurse failed to review the patient screening questions, which contraindicated administration of an influenza vaccine. The influenza vaccine was given to the patient. Fortunately, no harm came to the patient.  In case 20, when the provider ordered orthostatic vital signs, the nurse documented the patient’s blood pressure but not her pulse. California Institution for Women, Cycle 4 Medical Inspection Page 38 Office of the Inspector General State of California Clinician Onsite Inspection The nursing staff worked cohesively with providers and support staff. Though the staff did report some initial frustrations with the implementation of the new electronic record, they also recognized their local leadership’s efforts to overcome these obstacles. Recommendations No specific recommendations. California Institution for Women, Cycle 4 Medical Inspection Page 39 Office of the Inspector General State of California QUALITY OF PROVIDER PERFORMANCE In this indicator, the OIG physicians provide a qualitative Case Review Rating: evaluation of the adequacy of provider care at the institution. Adequate Appropriate evaluation, diagnosis, and management plans are Compliance Score: reviewed for programs including, but not limited to, nursing sick Not Applicable call, chronic care programs, TTA, specialized medical housing, and specialty services. The assessment of provider care is Overall Rating: performed entirely by OIG physicians. There is no compliance Adequate testing component associated with this quality indicator. Case Review Results A review of 385 medical provider encounters identified 38 deficiencies related to provider performance, the majority of which did not place the patient at increased risk for harm. The care provided by CIW medical providers was appropriate overall. Of the 30 cases reviewed, one was proficient, 27 were adequate, and two were inadequate. The OIG identified six significant deficiencies (cases 18, 20, 21, 28, 29, and 39). The OIG rated the Quality of Provider Performance at CIW adequate. Assessment and Decision-Making There were nine deficiencies related to provider assessments and decision-making. These deficiencies ranged from poor supporting documentation for assessments to failure to address abnormal diagnostic test results in a timely manner. The most serious of these deficiencies were the following:  In cases 20 and 28, laboratory reports indicating possible urinary tract infections were not addressed in a timely manner.  In case 21, despite the patient’s multiple nursing visits and complaints of pain to the primary care provider, the provider failed to adequately address the patient’s pain. Review of Records Records were not adequately reviewed in six cases:  In case 18, the provider (twice) failed to note the most recent laboratory reports indicating worsening kidney function.  In cases 20 and 21, providers’ documentation of recent events were incorrect.  In cases 33 and 96, insufficient review of records resulted in incorrect or incomplete orders. California Institution for Women, Cycle 4 Medical Inspection Page 40 Office of the Inspector General State of California Emergency Care The quality of emergency care by providers was adequate. Chronic Care The quality of provider chronic care was also adequate. However, a few deficiencies were noted in the management of anticoagulation (cases 24 and 25) and diabetes (case 29). Specialty Services CIW providers usually requested specialty services appropriately. When providers saw patients for follow-up after specialty services, providers usually reviewed the reports adequately and took appropriate actions. The few exceptions were as follows:  Providers submitted inaccurate referrals in cases 13 and 39. In cases 28, 31, 33, and 39, clinical staff did not implement specialty recommendations in a timely manner. Health Information Management The quality of provider performance as it related to health information management was adequate. There were a few instances when providers planned to order certain diagnostic tests, but failed to complete the physician order form. Pharmacy and Medication Management Pharmacy and medication management by providers was generally adequate. Two deficiencies were related to incorrect dosing of medications; one deficiency was for a provider that did not submit non-formulary drug requests in a timely manner. Clinician Onsite Inspection CIW providers were generally content with their work and the ancillary services the institution provided. Ancillary services, including laboratory, pharmacy, radiology, and specialty services, functioned well. The providers felt well supported by their leadership and took pride in their work, their fellow providers, and the cohesiveness and functionality of their clinic teams. The OIG clinicians observed a providers’ morning report meeting. These occurred every weekday morning to communicate the after-hours activities of patient care by the on-call provider. Provider meetings occurred once weekly and were similar to medical authorization review committee meetings. The providers discussed challenging patients, specialty referrals, and provider or patient concerns. The OIG clinicians did not observe a provider meeting. The OIG clinicians observed the morning huddle meetings for two different yards. While the issues discussed were comprehensive and pertinent, the huddles were abbreviated due to a scheduled population management meeting for each yard. During this population management meeting, California Institution for Women, Cycle 4 Medical Inspection Page 41 Office of the Inspector General State of California certain populations of patients, such as asthmatics, were reviewed. The clinic team (PCP, RN, LVN, and OT) engaged in teambuilding activities in addition to discussing patients. While some participants were hesitant at first, the results were positive, with team members getting to know each other better. When the OIG questioned providers as to possible barriers to providing patient care, a unanimous answer was the new electronic medical record system. While the particulars of the providers’ complaints are beyond the scope of this report, it was notable that since the implementation of the new electronic medical record, provider productivity had decreased significantly. Recommendations The OIG recommends that CIW management require the following:  Providers review the CCHCS care guides for anticoagulation and diabetes management.  Providers review specialty reports and implement recommendations in a timely manner. If not implemented, the provider document why specialty recommendations are not followed. California Institution for Women, Cycle 4 Medical Inspection Page 42 Office of the Inspector General State of California SPECIALIZED MEDICAL HOUSING (OHU, CTC, SNF, HOSPICE) This indicator addresses whether the institution follows appropriate Case Review Rating: policies and procedures when admitting inmate-patients to onsite Adequate inpatient facilities, including completion of timely nursing and Compliance Score: provider assessments. The chart review assesses all aspects of Adequate medical care related to these housing units, including quality of (78.3%) provider and nursing care. CIW’s specialized medical housing units Overall Rating: are an onsite outpatient housing unit (OHU) and an onsite Adequate correctional treatment center (CTC). Case Review Results At the time of the OIG inspection, the California Institution for Women’s OHU contained seven beds for medical patients and ten temporary mental health beds. The CTC contained eight beds for medical patients and ten beds for mental health patients. The OIG clinicians reviewed 122 provider encounters and 138 nursing encounters relating to the OHU and CTC in 15 cases. These included admissions for medical and mental health conditions. Provider Performance Provider performance as it related to Specialized Medical Housing was proficient. Of the 122 provider encounters reviewed, only four deficiencies were identified. One significant deficiency was for a patient’s chronic hand and foot pain management (case 21). Nursing Performance Overall, the specialized medical housing nursing care at CIW was adequate. Nurses usually provided timely assessments. The majority of the 42 nursing deficiencies were due to incomplete documentation and assessments. Examples include failing to document onset, duration, and frequency of pain (cases 10 and 44); and failing to assess or reassess vital signs (cases 9 and 23). Clinician Summary The providers’ and nursing performance within Specialized Medical Housing was satisfactory overall despite a number of nursing deficiencies related to assessments and documentation. Fortunately, the majority of these deficiencies were unlikely to put patients at increased risk of harm. The case review portion for Specialized Medical Housing was rated adequate. Compliance Testing Results The institution received an adequate score of 78.3 percent for the Specialized Medical Housing indicator, which focused on the institution’s CTC and OHU. As detailed below, CIW received a proficient score in the following two tests: California Institution for Women, Cycle 4 Medical Inspection Page 43 Office of the Inspector General State of California  For all 20 patients sampled, nursing staff timely completed an initial assessment on the day the patient was admitted to the CTC or OHU (MIT 13.001).  For 18 of the 20 patients (90 percent), providers completed a history and physical exam within 72 hours of the patients’ admission to the CTC or OHU. For one patient, the provider completed the exam one day late; for another patient, the provider did not complete the exam at all (MIT 13.003). The institution scored in the adequate range in the following test:  Providers evaluated 17 of the 20 patients within 24 hours of their admission to the CTC or OHU (85 percent). The attending physician evaluated two patients one and three days late; for a third patient, the physician did not complete a 24-hour evaluation at all (MIT 13.002). The institution scored within the inadequate range in the following two tests:  Providers completed their subjective, objective, assessment, plan, and education (SOAPE) notes at required three-day (CTC) and 14-day (OHU) intervals for 12 of 18 applicable patients (67 percent). For six patients, providers failed either to complete SOAPE notes timely or to complete the required number of notes based on the patients’ length of stay (MIT 13.004).  Staff who regularly worked in the CTC and OHU stated that urgent or emergent access to cells was timely (from one to two minutes). Management did not identify any concerns regarding response times at any of the housing units. In the CTC, the OIG found that the call buttons in patient rooms were in good working condition. In the OHU, inspectors found a local operating procedure in place to document 30-minute patient welfare checks; however, at the time of the site visit, a review of patient logs for the most recent 30-minute rounds showed CIW staff did not complete the rounds timely. As a result, the institution received a score of 50 percent on this test (MIT 13.101). Recommendations No specific recommendations. California Institution for Women, Cycle 4 Medical Inspection Page 44 Office of the Inspector General State of California SPECIALTY SERVICES This indicator focuses on specialist care from the time a request for Case Review Rating: services or physician’s order for specialist care is completed to the Adequate time of receipt of related recommendations from specialists. This Compliance Score: indicator also evaluates the providers’ timely review of specialist Adequate records and documentation reflecting the patients’ care plans, (84.2%) including course of care when specialist recommendations were not Overall Rating: ordered, and whether the results of specialists’ reports are Adequate communicated to the patients. For specialty services denied by the institution, the OIG determines whether the denials are timely and appropriate, and whether the inmate-patient is updated on the plan of care. Case Review Results The OIG clinicians reviewed 362 events related to Specialty Services, over 200 of which were specialty consultations and procedures. Other events related to provider and nursing follow-up visits and orders after specialty consultations and procedure. There were 60 deficiencies in this category, the majority of which posed no increased risk of harm to patients. Case review rated this indicator adequate. Access to Specialty Services Urgent and routine specialty services were generally timely and adequate with only a few minor delays in specialty follow-up appointments. Nursing Performance Nursing performance in specialty services was generally adequate, though there were a few issues with assessment and documentation. Provider Performance Provider performance in specialty services was also adequate overall. The few issues included specialty recommendations not always implemented and providers not ordering referrals appropriately. Health Information Management The majority of deficiencies found in specialty services related to health information management. These deficiencies included specialty reports not properly signed by a primary care provider before being scanned into the eUHR, although the reports were usually reviewed as evidenced by documentation in progress notes and orders; some specialty reports were not in the eUHR; and two referral requests were not in the eUHR. California Institution for Women, Cycle 4 Medical Inspection Page 45 Office of the Inspector General State of California Compliance Testing Results The institution received an adequate compliance score of 84.2 percent in the Specialty Services indicator, scoring within the proficient range in four of the seven test areas, as described below:  All 15 patients sampled either received or refused their routine specialty services appointment within 90 calendar days of the provider’s order (MIT 14.003).  Denials of provider specialty services requests for all 20 patients sampled occurred within the required time frame (MIT 14.006).  For 14 of 15 patients sampled (93 percent), their high-priority specialty services appointment occurred within 14 days of the provider’s order. For one patient, the appointment occurred six days late (MIT 14.001).  For those patients sampled who received routine specialty services, providers timely received and reviewed 12 of the 14 specialists’ reports (86 percent). For the two remaining patients, the provider reviewed the specialty report one and seven days late (MIT 14.004). The institution scored in the adequate range in the test below:  Providers timely received and reviewed the specialists’ reports for 12 of the 15 sampled patients who received high-priority specialty services (80 percent). For one patient, the report was received 19 days late; for another patient, the report was not received at all; for the remaining patient, the provider reviewed the report one day late (MIT 14.002). The institution scored within the inadequate range in the following two tests:  When an institution approves or schedules a patient for specialty services appointments and then transfers the patient to another institution, policy requires that the receiving institution ensure a patent’s appointment occurs timely. At CIW, only 14 of the 20 sampled patients (70 percent) received their specialty services appointment within the required action period. One patient with two pending appointments received one appointment 12 days late and did not receive the other; three patients received their appointments between 7 and 49 days late; two other patients did not receive an appointment at all (MIT 14.005).  Providers timely informed patients of the denial status for requested specialty services for 12 of the 20 denials sampled (60 percent). Providers informed six patients of the specialty service denial between 3 and 51 days late. For two other patients, inspectors did not find any evidence that the provider ever discussed the denial with them (MIT 14.007). California Institution for Women, Cycle 4 Medical Inspection Page 46 Office of the Inspector General State of California Recommendations No specific recommendations. California Institution for Women, Cycle 4 Medical Inspection Page 47 Office of the Inspector General State of California SECONDARY (ADMINISTRATIVE) QUALITY INDICATORS OF HEALTH CARE The last two quality indicators (Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications) involve health care administrative systems and processes. Testing in these areas applies only to the compliance component of the process. Therefore, there is no case review assessment associated with either of the two indicators. As part of the compliance component of the first of these two indicators, the OIG did not score several questions. Instead, the OIG presented the findings for informational purposes only. For example, the OIG described certain local processes in place at CIW. To test both the scored and non-scored areas within these two secondary quality indicators, OIG inspectors interviewed key institutional employees and reviewed documents during their onsite visit to CIW in February 2016. They also reviewed documents obtained from the institution and from CCHCS prior to the start of the inspection. The test questions used to assess compliance for each indicator are detailed in Appendix A. For comparative purposes, the CIW Executive Summary Table on page vii of this report shows the case review and compliance ratings for each applicable indicator. California Institution for Women, Cycle 4 Medical Inspection Page 48 Office of the Inspector General State of California INTERNAL MONITORING, QUALITY IMPROVEMENT, AND ADMINISTRATIVE OPERATIONS This indicator focuses on the institution’s administrative health care Case Review Rating: oversight functions. The OIG evaluates whether the institution Not Applicable promptly processes inmate-patient medical appeals and addresses Compliance Score: all appealed issues. Inspectors also verify that the institution follows Proficient reporting requirements for adverse/sentinel events and inmate (94.1%) deaths, and whether the institution is making progress toward its Overall Rating: Performance Improvement Work Plan initiatives. In addition, the Proficient OIG verifies that the Emergency Medical Response Review Committee (EMRRC) performs required reviews and that staff perform required emergency response drills. Inspectors also assess whether the Quality Management Committee (QMC) meets regularly and adequately addresses program performance. For those institutions with licensed facilities, inspectors also verify that required committee meetings are held. Compliance Testing Results The institution received a proficient, 94.1 percent compliance score in the Internal Monitoring, Quality Improvement, and Administrative Operations indicator. CIW scored 100 percent in the following test areas:  The institution promptly processed all inmate medical appeals in each of the most recent 12 months (MIT 15.001). Based on a sample of ten second-level medical appeals, the institution’s responses addressed all of the patients’ appealed issues (MIT 15.102).  CIW’s QMC met monthly, evaluated program performance, and took action when improvement opportunities were identified (MIT 15.003). The institution also took adequate steps to ensure the accuracy of its Dashboard data reporting (MIT 15.004).  The institution’s local governing body (LGB) met at least quarterly over the last 12 months and exercised responsibility for the quality management of patient health care each quarter, as documented in the meeting minutes (MIT 15.006).  Emergency response drill packages for three medical emergency response drills conducted in the prior quarter contained all required summary reports and related documentation. All drills included participation by both health care and custody staff (MIT 15.101).  Medical staff timely submitted the Initial Inmate Death Report (CDCR Form 7229A) to CCHCS’s Death Review Unit for the seven applicable deaths that occurred at CIW in the prior 12-month period (MIT 15.103). California Institution for Women, Cycle 4 Medical Inspection Page 49 Office of the Inspector General State of California The institution performed in the adequate range in the following area:  CIW improved or reached targeted performance objectives for eight of the ten quality improvement initiatives identified in its 2015 Performance Improvement Work Plan, resulting in a score of 80 percent. The institution’s data showed that performance results declined for two of the ten initiatives (MIT 15.005). The following test area received a score in the inadequate range:  The OIG inspected documentation for 12 emergency medical response incidents reviewed by CIW’s Emergency Medical Response Review Committee (EMRRC) during the prior six-month period; 8 of the 12 incident packages (67 percent) complied with policy. For four packages, either the CEO or the warden failed to sign the corresponding meeting minutes (MIT 15.007). Other Information Obtained from Non-Scored Areas  The OIG gathered data regarding the completion of death review reports. During the OIG’s review period, the CCHCS’s Death Review Committee (DRC) was required to complete a death review summary within 30 business days of an inmate-patient’s death and to submit it to the institution’s chief executive officer for health care services (CEO) within five additional business days. The DRC completed five summary reports between 7 and 16 days late (or 42 to 47 calendar days after the death). CCHCS did not timely submit any of those reports to the institution’s CEO. For one other death, the committee timely completed the death review summary, but submitted it to the CEO 97 days late (MIT 15.996).  Inspectors met with the institution’s CEO to inquire about CIW’s protocols for tracking medical appeals. Management utilized monthly appeals summary reports to track the number of open appeals by subject type and status. Inclusive metric data also provided management the ability to identify trends, resolve issues, and plan for the improvement of future outcomes. In instances when appeals presented issues with a CIW provider, it was common for the CEO to meet with the chief medical executive and chief physician and surgeon to evaluate concerns and, if warranted, to identify resolutions. The most notable problem area, according to the CEO, was the recent integration of a new technology system for the delivery of healthcare; the October 2015 implementation of this pilot system caused appeal numbers to increase. In response to this issue, management at CIW arranged for staff training, and utilized subject matter experts to help staff transition to the new system (MIT 15.997).  The OIG gathered non-scored data regarding the institution’s practices for implementing local operating procedures (LOPs). The data indicated that the institution had an effective process in place for developing LOPs. According to the institution’s health program manager, assigned staff were responsible for reviewing changes to statewide policies and California Institution for Women, Cycle 4 Medical Inspection Page 50 Office of the Inspector General State of California procedures and determining what, if any, impact they had on CIW’s established LOPs; program subcommittees or the CEO and CME decided if newly proposed LOPs were required. The institution utilized a matrix that listed due dates for annual reviews of LOPs; when due, the LOP was sent to a Patient Care Policy Committee (PCPC), reviewed, and approved. Following approval by the PCPC, the LOP went to a quality management committee and then to the local governing body for final approval. Updates on LOPs were communicated to staff through monthly meetings and forwarded via email to appropriate staff and the law library. At the time of the OIG’s inspection, CIW had implemented 30 of the 50 applicable stakeholder-recommended LOPs (60 percent) (MIT 15.998).  The OIG discusses the institution’s health care staffing resources in the About the Institution section on page 2 (MIT 15.999). Recommendations No specific recommendations. California Institution for Women, Cycle 4 Medical Inspection Page 51 Office of the Inspector General State of California JOB PERFORMANCE, TRAINING, LICENSING, AND CERTIFICATIONS In this indicator, the OIG examines whether the institution Case Review Rating: adequately manages its health care staffing resources by evaluating Not Applicable whether job performance reviews are completed as required; Compliance Score: specified staff possess current, valid credentials and professional Proficient licenses or certifications; nursing staff receive new employee (88.7%) orientation training and annual competency testing; and clinical and Overall Rating: custody staff have current medical emergency response Proficient certifications. Compliance Testing Results The institution received a proficient compliance score of 88.7 percent in the Job Performance, Training, Licensing, and Certifications indicator. The institution scored 100 percent in six of the indicator’s eight tests, as follows:  All providers were current with their professional licenses (MIT 16.001).  Nursing staff and the pharmacist in charge were current with their professional licenses and certification requirements (MIT 16.105).  All ten of the nurses sampled who administered medications possessed current clinical competency validations (MIT 16.102).  All nursing staff hired within the last year timely received new employee orientation training (MIT 16.107).  The institution’s pharmacy and providers who prescribed controlled substances were current with their Drug Enforcement Agency registrations (MIT 16.106).  All five of the sampled nurses received periodic evaluation reviews by a supervising registered nurse (MIT 16.101). The institution scored within the inadequate range in the following two tests:  The institution performed complete structured clinical performance appraisals for only three of seven applicable primary care providers (43 percent). One provider did not have a performance appraisal completed in the last year; three providers had incomplete 360-Degree Evaluations or did not have the 360-Degree Evaluation completed by the CEO or CME (MIT 16.103).  Provider, nursing, and custody staff records were tested to determine if the institution ensured that those staff members had current emergency response certifications. The California Institution for Women, Cycle 4 Medical Inspection Page 52 Office of the Inspector General State of California institutions’ nursing and custody staff were all compliant, but one provider was not. As a result, the institution received a score of 67 percent on this test (MIT 16.104). Recommendations No specific recommendations. California Institution for Women, Cycle 4 Medical Inspection Page 53 Office of the Inspector General State of California POPULATION-BASED METRICS The compliance testing and the case reviews give an accurate assessment of how the institution’s health care systems are functioning with regard to the patients with the highest risk and utilization. This information is vital to assess the capacity of the institution to provide sustainable, adequate care. However, one significant limitation of the case review methodology is that it does not give a clear assessment of how the institution performs for the entire population. For better insight into this performance, the OIG has turned to population-based metrics. For comparative purposes, the OIG has selected several Healthcare Effectiveness Data and Information Set (HEDIS) measures for disease management to gauge the institution’s effectiveness in outpatient health care, especially chronic disease management. The Healthcare Effectiveness Data and Information Set is a set of standardized performance measures developed by the National Committee for Quality Assurance with input from over 300 organizations representing every sector of the nation’s health care industry. It is used by over 90 percent of the nation’s health plans as well as many leading employers and regulators. It was designed to ensure that the public (including employers, the Centers for Medicare and Medicaid Services, and researchers) has the information it needs to accurately compare the performance of health care plans. Healthcare Effectiveness Data and Information Set data is often used to produce health plan report cards, analyze quality improvement activities, and create performance benchmarks. Methodology For population-based metrics, the OIG used a subset of HEDIS measures applicable to the CDCR inmate-patient population. Selection of the measures was based on the availability, reliability, and feasibility of the data required for performing the measurement. The OIG collected data utilizing various information sources, including the eUHR, the Master Registry (maintained by CCHCS), as well as a random sample of patient records analyzed and abstracted by trained personnel. Data obtained from the CCHCS Master Registry and Diabetic Registry was not independently validated by the OIG and is presumed to be accurate. For some measures, the OIG used the entire population rather than statistically random samples. While the OIG is not a certified HEDIS compliance auditor, the OIG uses similar methods to ensure that measures are comparable to those published by other organizations. Comparison of Population-Based Metrics For the California Institution for Women, 13 HEDIS measures were selected and are listed in the following CIW 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 Women, Cycle 4 Medical Inspection Page 54 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. CIW outperformed all other entities in three of the five diabetic measures and scored marginally lower than one other entity in each of the two remaining measures. When compared statewide, CIW outperformed Medi-Cal in all five diabetic measures selected (diabetic monitoring, diabetics under poor control, diabetics under good control, diabetics’ blood pressure control, and dilated eye examinations for diabetics). The institution also outperformed Kaiser Permanente in four of the five measures, scoring slightly lower than Kaiser in diabetic patients’ blood pressure control. When compared nationally, CIW outperformed Medicaid, Medicare, and commercial health plans (based on data obtained from health maintenance organizations) in each of the five diabetic measures listed. The institution outperformed the U.S. Department of Veterans Affairs (VA) in all applicable measures except dilated eye exams, for which it scored 5 percentage points lower than the VA. Immunizations Comparative data for immunizations was only fully available for the VA and partially available for Kaiser, commercial entities, and Medicare. For the administration of influenza shots to younger adults, CIW closely matched Kaiser’s results and outperformed commercial entities, but scored lower than the VA; for flu shots to older adults, CIW outperformed both Medicare and the VA. With regard to pneumococcal immunizations, CIW significantly outperformed Medicare and closely matched the VA. For all three immunization measures, CIW had offered the preventive services to all of the patients sampled, but many of them refused the offers; these refusals adversely affected the institution’s scores. Cancer Screening Comparative data for cancer screening measures was fully available for Kaiser, commercial entities, and the VA; and partially available for the other entities. For breast cancer screenings, CIW scored slightly lower than both Kaiser and the VA; but scored significantly higher than Medicaid, commercial entities, and Medicare. For cervical cancer screenings, the institution scored much lower than Kaiser, commercial entities, and the VA; but scored higher than Medi-Cal and Medicaid. With regard to colorectal cancer screenings, CIW’s score matched the commercial entities’ average score, but was lower than all other entities’ scores. Similar to the results for immunizations, CIW’s cancer screening scores were largely affected by patient refusals. California Institution for Women, Cycle 4 Medical Inspection Page 55 Office of the Inspector General State of California Prenatal and Postpartum Care Comparative data for prenatal and postpartum care was only available for Medi-Cal, Kaiser, Medicaid, and commercial entities. With regard to providing pregnant patients with timely initial prenatal care visits, CIW scored 100 percent, outperforming all of those entities. For patients receiving timely initial postpartum visits, CIW’s performance was slightly lower than Kaiser’s but significantly higher than that of the other entities. Summary CIW’s population-based metrics performance reflects a well-functioning chronic care program, corroborated by its proficient ratings in the Access to Care and Preventive Services indicators, and adequate ratings in the Quality of Nursing Performance and Quality of Provider Performance indicators. The institution also performed well for two of the three immunization measures and for its initial prenatal care and postpartum visits. However, for two of the three cancer screening measures, CIW scored lower than most other entities. For all immunization and cancer screening measures, the institution has an opportunity to improve its scores by placing an emphasis on educating patients regarding their refusals of these preventive services. California Institution for Women, Cycle 4 Medical Inspection Page 56 Office of the Inspector General State of California CIW Results Compared to State and National HEDIS Scores California National Kaiser Kaiser CIW HEDIS (No.CA) (So.CA) HEDIS Clinical Measures Medi- HEDIS HEDIS HEDIS Com- HEDIS VA Cycle 4 Cal Scores Scores Medicaid mercial Medicare Average Results1 20142 20153 20153 20154 20154 20154 20145 Comprehensive Diabetes Care HbA1c Testing (Monitoring) 100% 83% 95% 94% 86% 91% 93% 99% Poor HbA1c Control (>9.0%)6,7 9% 44% 18% 24% 44% 31% 25% 19% HbA1c Control (<8.0%)6 82% 47% 70% 62% 47% 58% 65% - Blood Pressure Control (<140/90)6 82% 60% 84% 85% 62% 65% 65% 78% Eye Exams 85% 51% 69% 81% 54% 56% 69% 90% Immunizations Influenza Shots - Adults (18–64) 54% - 54% 55% - 50% - 58% Influenza Shots - Adults (65+) 79% - - - - - 72% 76% Immunizations: Pneumococcal 92% - - - - - 70% 93% Cancer Screening Breast Cancer Screening (50–74)8 85% - 87% 88% 59% 74% 72% 87% Cervical Cancer Screening 67% 64% 92% 87% 60% 76% - 93% Colorectal Cancer Screening 64% - 80% 82% - 64% 67% 82% Prenatal and Postpartum Care Prenatal Care 9 100% 81% 96% 97% 82% 88% - - Postpartum Care9 91% 57% 93% 93% 62% 77% - - 1. Unless otherwise stated, data was collected in February 2016 by reviewing medical records from a sample of CIW’s population of applicable inmate-patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. 2. HEDIS Medi-Cal data was obtained from the California Department of Health Care Services 2014 HEDIS Aggregate Report for the Medi-Cal Managed Care Program. 3. Data was obtained from Kaiser Permanente November 2015 reports for the Northern and Southern California regions. 4. National HEDIS data for Medicaid, commercial, and Medicare was obtained from the 2015 State of Health Care Quality Report, available on the NCQA website: http://www.ncqa.org. The results for commercial 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, http://www.va.gov. For the Immunizations: Pneumococcal measure and the Cervical Cancer Screening measure, the data was obtained from the VHA Facility Quality and Safety Report - Fiscal Year 2012 Data. 6. For this measure, the entire applicable CIW population was tested. 7. For this measure only, a lower score is better. For Kaiser, the OIG derived the Poor HbA1c Control indicator using the reported data for the <9.0% HbA1c control indicator. 8. The Kaiser HEDIS data age range is 52-74 and the VA is 50-69. 9. HEDIS measures whether a patient’s initial prenatal care visit occurred in the first trimester of pregnancy or within 42 days of arrival, and whether a postpartum visit occurred on or between 21 and 56 days after delivery. California Institution for Women, Cycle 4 Medical Inspection Page 57 Office of the Inspector General State of California APPENDIX A — COMPLIANCE TEST RESULTS California Institution for Women Range of Summary Scores: 49.80% - 94.07% Indicator Compliance Score (Yes %) Access to Care 86.86% Diagnostic Services 85.56% Emergency Services Not Applicable Health Information Management (Medical Records) 49.80% Health Care Environment 78.32% Inter- and Intra-System Transfers 89.31% Pharmacy and Medication Management 77.89% Prenatal and Post-Delivery Services 80.00% Preventive Services 92.59% Quality of Nursing Performance Not Applicable Quality of Provider Performance Not Applicable Reception Center Arrivals Not Applicable Specialized Medical Housing (OHU, CTC, SNF, Hospice) 78.33% Specialty Services 84.15% Internal Monitoring, Quality Improvement, and Administrative 94.07% Operations Job Performance, Training, Licensing, and Certifications 88.69% California Institution for Women, Cycle 4 Medical Inspection Page 58 Office of the Inspector General State of California Scored Answers Yes Reference + Access to Care Number Yes No No Yes % N/A 1.001 Chronic care follow-up appointments: Was the 30 10 40 75.00% 0 inmate-patient’s most recent chronic care visit within the health care guideline’s maximum allowable interval or within the ordered time frame, whichever is shorter? 1.002 For endorsed inmate-patients received from another 16 5 21 76.19% 9 CDCR institution: If the nurse referred the inmate-patient to a provider during the initial health screening, was the inmate-patient seen within the required time frame? 1.003 Clinical appointments: Did a registered nurse review the 30 0 30 100.00% 0 inmate-patient’s request for service the same day it was received? 1.004 Clinical appointments: Did the registered nurse complete a 29 1 30 96.67% 0 face-to-face visit within one business day after the CDCR Form 7362 was reviewed? 1.005 Clinical appointments: If the registered nurse determined a 6 1 7 85.71% 23 referral to a primary care provider was necessary, was the inmate-patient seen within the maximum allowable time or the ordered time frame, whichever is the shorter? 1.006 Sick call follow-up appointments: If the primary care Not Applicable 30 provider ordered a follow-up sick call appointment, did it take place within the time frame specified? 1.007 Upon the inmate-patient’s discharge from the 24 5 29 82.76% 0 community hospital: Did the inmate-patient receive a follow-up appointment within the required time frame? 1.008 Specialty service follow-up appointments: Do specialty 22 6 28 78.57% 2 service primary care physician follow-up visits occur within required time frames? 1.101 Clinical appointments: Do inmate-patients have a 6 0 6 100.00% 0 standardized process to obtain and submit health care services request forms? Overall percentage: 86.86% California Institution for Women, Cycle 4 Medical Inspection Page 59 Office of the Inspector General State of California Scored Answers Yes Reference + Diagnostic Services Number Yes No No Yes % N/A 2.001 Radiology: Was the radiology service provided within the 9 1 10 90.00% 0 time frame specified in the provider’s order? 2.002 Radiology: Did the primary care provider review and initial 10 0 10 100.00% 0 the diagnostic report within specified time frames? 2.003 Radiology: Did the primary care provider communicate the 10 0 10 100.00% 0 results of the diagnostic study to the inmate-patient within specified time frames? 2.004 Laboratory: Was the laboratory service provided within the 8 2 10 80.00% 0 time frame specified in the provider’s order? 2.005 Laboratory: Did the primary care provider review and 10 0 10 100.00% 0 initial the diagnostic report within specified time frames? 2.006 Laboratory: Did the primary care provider communicate 10 0 10 100.00% 0 the results of the diagnostic study to the inmate-patient within specified time frames? 2.007 Pathology: Did the institution receive the final diagnostic 5 4 9 55.56% 0 report within the required time frames? 2.008 Pathology: Did the primary care provider review and initial 7 2 9 77.78% 0 the diagnostic report within specified time frames? 2.009 Pathology: Did the primary care provider communicate the 6 3 9 66.67% 0 results of the diagnostic study to the inmate-patient within specified time frames? Overall percentage: 85.56% Emergency Services Scored Answers Assesses reaction times and responses to emergency situations. The OIG RN clinicians will use detailed information obtained from the institution’s Not Applicable incident packages to perform focused case reviews. California Institution for Women, Cycle 4 Medical Inspection Page 60 Office of the Inspector General State of California Scored Answers Health Information Management Yes Reference + (Medical Records) Number Yes No No Yes % N/A 4.001 Are non-dictated progress notes, initial health screening 16 4 20 80.00% 0 forms, and health care service request forms scanned into the eUHR within three calendar days of the inmate-patient encounter date? 4.002 Are dictated / transcribed documents scanned into the eUHR 5 15 20 25.00% 0 within five calendar days of the inmate-patient encounter date? 4.003 Are specialty documents scanned into the eUHR within the 16 4 20 80.00% 0 required time frame? 4.004 Are community hospital discharge documents scanned into 11 9 20 55.00% 0 the eUHR within three calendar days of the inmate-patient date of hospital discharge? 4.005 Are medication administration records (MARs) scanned into 4 16 20 20.00% 0 the eUHR within the required time frames? 4.006 During the eUHR review, did the OIG find that documents 0 12 12 0.00% 0 were correctly labeled and included in the correct inmate-patient’s file? 4.007 Did clinical staff legibly sign health care records, when 20 12 32 62.50% 0 required? 4.008 For inmate-patients discharged from a community 22 7 29 75.86% 0 hospital: Did the preliminary hospital discharge report include key elements and did a PCP review the report within three calendar days of discharge? Overall percentage: 49.80% California Institution for Women, Cycle 4 Medical Inspection Page 61 Office of the Inspector General State of California Scored Answers Yes Reference + Health Care Environment Number Yes No No Yes % N/A 5.101 Infection Control: Are clinical health care areas 12 0 12 100.00% 2 appropriately disinfected, cleaned and sanitary? 5.102 Infection control: Do clinical health care areas ensure that 12 0 12 100.00% 2 reusable invasive and non-invasive medical equipment is properly sterilized or disinfected as warranted? 5.103 Infection Control: Do clinical health care areas contain 12 1 13 92.31% 1 operable sinks and sufficient quantities of hygiene supplies? 5.104 Infection control: Does clinical health care staff adhere to 3 8 11 27.27% 3 universal hand hygiene precautions? 5.105 Infection control: Do clinical health care areas control 13 0 13 100.00% 1 exposure to blood-borne pathogens and contaminated waste? 5.106 Warehouse, Conex and other non-clinic storage areas: 1 0 1 100.00% 0 Does the medical supply management process adequately support the needs of the medical health care program? 5.107 Clinical areas: Does each clinic follow adequate protocols 10 3 13 76.92% 1 for managing and storing bulk medical supplies? 5.108 Clinical areas: Do clinic common areas and exam rooms 4 9 13 30.77% 1 have essential core medical equipment and supplies? 5.109 Clinical areas: Do clinic common areas have an adequate 9 3 12 75.00% 2 environment conducive to providing medical services? 5.110 Clinical areas: Do clinic exam rooms have an adequate 9 4 13 69.23% 1 environment conducive to providing medical services? 5.111 Emergency response bags: Are TTA and clinic emergency 9 1 10 90.00% 4 medical response bags inspected daily and inventoried monthly, and do they contain essential items? 5.999 For Information Purposes Only: Does the institution’s health care management believe that all clinical areas have Information Only physical plant infrastructures sufficient to provide adequate health care services? Overall percentage: 78.32% California Institution for Women, Cycle 4 Medical Inspection Page 62 Office of the Inspector General State of California Scored Answers Yes Reference + Inter- and Intra-System Transfers Number Yes No No Yes % N/A 6.001 For endorsed inmate-patients received from another 29 1 30 96.67% 0 CDCR institution or COCF: Did nursing staff complete the initial health screening and answer all screening questions on the same day the inmate-patient arrived at the institution? 6.002 For endorsed inmate-patients received from another 28 2 30 93.33% 0 CDCR institution or COCF: When required, did the RN complete the assessment and disposition section of the health screening form; refer the inmate-patient to the TTA, if TB signs and symptoms were present; and sign and date the form on the same day staff completed the health screening? 6.003 For endorsed inmate-patients received from another 16 3 19 84.21% 11 CDCR institution or COCF: If the inmate-patient had an existing medication order upon arrival, were medications administered or delivered without interruption? 6.004 For inmate-patients transferred out of the facility: Were 14 3 17 82.35% 0 scheduled specialty service appointments identified on the Health Care Transfer Information Form 7371? 6.101 For inmate-patients transferred out of the facility: Do 9 1 10 90.00% 0 medication transfer packages include required medications along with the corresponding Medical Administration Record (MAR) and Medication Reconciliation? Overall percentage: 89.31% California Institution for Women, Cycle 4 Medical Inspection Page 63 Office of the Inspector General State of California Scored Answers Yes Reference + Pharmacy and Medication Management Number Yes No No Yes % N/A 7.001 Did the inmate-patient receive all chronic care medications 23 9 32 71.88% 8 within the required time frames or did the institution follow departmental policy for refusals or no-shows? 7.002 Did health care staff administer or deliver new order 28 2 30 93.33% 0 prescription medications to the inmate-patient within the required time frames? 7.003 Upon the inmate-patient’s discharge from a community 19 10 29 65.52% 0 hospital: Were all medications ordered by the institution’s primary care provider administered or delivered to the inmate-patient within one calendar day of return? 7.004 For inmate-patients received from a county jail: Were all medications ordered by the institution’s reception center Not Applicable provider administered or delivered to the inmate-patient within the required time frames? 7.005 Upon the inmate-patient’s transfer from one housing unit 28 2 30 93.33% 0 to another: Were medications continued without interruption? 7.006 For inmate-patients en route who lay over at the institution: If the temporarily housed inmate-patient had an Not Applicable existing medication order, were medications administered or delivered without interruption? 7.101 All clinical and medication line storage areas for narcotic 10 1 11 90.91% 11 medications: Does the institution employ strong medication security controls over narcotic medications assigned to its clinical areas? 7.102 All clinical and medication line storage areas for 12 4 16 75.00% 6 non-narcotic medications: Does the institution properly store non-narcotic medications that do not require refrigeration in assigned clinical areas? 7.103 All clinical and medication line storage areas for 5 6 11 45.45% 11 non-narcotic medications: Does the institution properly store non-narcotic medications that require refrigeration in assigned clinical areas? California Institution for Women, Cycle 4 Medical Inspection Page 64 Office of the Inspector General State of California Scored Answers Yes Reference + Pharmacy and Medication Management Number Yes No No Yes % Yes 7.104 Medication preparation and administration areas: Do 4 3 7 57.14% 15 nursing staff employ and follow hand hygiene contamination control protocols during medication preparation and medication administration processes? 7.105 Medication preparation and administration areas: Does 7 0 7 100.00% 15 the institution employ appropriate administrative controls and protocols when preparing medications for inmate-patients? 7.106 Medication preparation and administration areas: Does 6 1 7 85.71% 15 the institution employ appropriate administrative controls and protocols when distributing medications to inmate-patients? 7.107 Pharmacy: Does the institution employ and follow general 1 0 1 100.00% 0 security, organization, and cleanliness management protocols in its main and satellite pharmacies? 7.108 Pharmacy: Does the institution’s pharmacy properly store 1 0 1 100.00% 0 non-refrigerated medications? 7.109 Pharmacy: Does the institution’s pharmacy properly store 0 1 1 0.00% 0 refrigerated or frozen medications? 7.110 Pharmacy: Does the institution’s pharmacy properly 1 0 1 100.00% 0 account for narcotic medications? 7.111 Pharmacy: Does the institution follow key medication error 27 3 30 90.00% 0 reporting protocols? 7.998 For Information Purposes Only: During eUHR compliance testing and case reviews, did the OIG find that medication Information Only errors were properly identified and reported by the institution? 7.999 For Information Purposes Only: Do inmate-patients in isolation housing units have immediate access to their KOP Information Only prescribed rescue inhalers and nitroglycerin medications? Overall percentage: 77.89% California Institution for Women, Cycle 4 Medical Inspection Page 65 Office of the Inspector General State of California Scored Answers Yes Reference + Prenatal and Post-Delivery Services Number Yes No No Yes % N/A 8.001 Was the pregnant inmate-patient seen by an obstetrical (OB) 9 1 10 90.00% 0 physician or an OB nurse practitioner within seven business days of her arrival at the institution? 8.002 Was the pregnant inmate-patient issued a Form 7410 10 0 10 100.00% 0 (Comprehensive Accommodation Chrono) for a lower bunk and lower-tier housing? 8.003 Did medical staff promptly order recommended vitamins, Not Applicable 10 extra daily nutritional supplements and food for the inmate-patient? 8.004 Did the inmate-patient visit with a supervising OB physician 6 4 10 60.00% 0 or OB nurse practitioner according to the applicable time frames? 8.005 Were the results of the inmate-patient’s prenatal screening Not Applicable 10 tests documented on the prenatal flow record within the specified time frame? 8.006 Was the inmate-patient’s weight and blood pressure 10 0 10 100.00% 0 documented at each clinic visit? 8.007 Did the inmate-patient receive her six-week postpartum 4 4 8 50.00% 2 visit? Overall percentage: 80.00% California Institution for Women, Cycle 4 Medical Inspection Page 66 Office of the Inspector General State of California Scored Answers Yes Reference + Preventive Services Number Yes No No Yes % N/A 9.001 Inmate-patients prescribed TB medications: Did the 8 1 9 88.89% 0 institution administer the medication to the inmate-patient as prescribed? 9.002 Inmate-patients prescribed TB medications: Did the 9 0 9 100.00% 0 institution monitor the inmate-patient monthly for the most recent three months he or she was on the medication? 9.003 Annual TB Screening: Was the inmate-patient screened for 24 6 30 80.00% 0 TB within the last year? 9.004 Were all inmate-patients offered an influenza vaccination for 30 0 30 100.00% 0 the most recent influenza season? 9.005 All inmate-patients from the age of 50 through the age of 27 3 30 90.00% 0 75: Was the inmate-patient offered colorectal cancer screening? 9.006 Female inmate-patients from the age of 50 through the 30 0 30 100.00% 0 age of 74: Was the inmate-patient offered a mammogram in compliance with policy? 9.007 Female inmate-patients from the age of 21 through the 28 2 30 93.33% 0 age of 65: Was the inmate-patient offered a pap smear in compliance with policy? 9.008 Are required immunizations being offered for chronic care 23 3 26 88.46% 14 inmate-patients? 9.009 Are inmate-patients at the highest risk of coccidioidomycosis (valley fever) infection transferred out Not Applicable of the facility in a timely manner? Overall percentage: 92.59% California Institution for Women, Cycle 4 Medical Inspection Page 67 Office of the Inspector General State of California Quality of Nursing Performance Scored Answers The quality of nursing performance will be assessed during case reviews, conducted by OIG clinicians, and is not applicable for the compliance portion of the medical inspection. The methodologies OIG clinicians use to Not Applicable evaluate the quality of nursing performance are presented in a separate inspection document entitled OIG MIU Retrospective Case Review Methodology. Quality of Provider Performance Scored Answers The quality of provider performance will be assessed during case reviews, conducted by OIG clinicians, and is not applicable for the compliance portion of the medical inspection. The methodologies OIG clinicians use to Not Applicable evaluate the quality of provider performance are presented in a separate inspection document entitled OIG MIU Retrospective Case Review Methodology. Reception Center Arrivals Scored Answers This indicator is not applicable to this institution. Not Applicable California Institution for Women, Cycle 4 Medical Inspection Page 68 Office of the Inspector General State of California Scored Answers Specialized Medical Housing Yes Reference + (OHU, CTC, SNF, Hospice) Number Yes No No Yes % N/A 13.001 For all higher level care facilities: Did the registered nurse 20 0 20 100.00% 0 complete an initial assessment of the inmate-patient on the day of admission, or within eight hours of admission to CMF’s Hospice? 13.002 For OHU, CTC, & SNF only: Did the primary care 17 3 20 85.00% 0 provider for OHU or attending physician for a CTC & SNF evaluate the inmate-patient within 24 hours of admission? 13.003 For OHU, CTC, & SNF only: Was a written history and 18 2 20 90.00% 0 physical examination completed within 72 hours of admission? 13.004 For all higher level care facilities: Did the primary care 12 6 18 66.67% 2 provider complete the Subjective, Objective, Assessment, Plan, and Education (SOAPE) notes on the inmate-patient at the minimum intervals required for the type of facility where the inmate-patient was treated? 13.101 For OHU and CTC Only: Do inpatient areas either have 1 1 2 50.00% 0 properly working call systems in its OHU & CTC or are 30-minute patient welfare checks performed; and do medical staff have reasonably unimpeded access to enter inmate-patient’s cells? Overall percentage: 78.33% California Institution for Women, Cycle 4 Medical Inspection Page 69 Office of the Inspector General State of California Scored Answers Yes Reference + Specialty Services Number Yes No No Yes % N/A 14.001 Did the inmate-patient receive the high-priority specialty 14 1 15 93.33% 0 service within 14 calendar days of the PCP order? 14.002 Did the PCP review the high priority specialty service 12 3 15 80.00% 0 consultant report within the required time frame? 14.003 Did the inmate-patient receive the routine specialty service 15 0 15 100.00% 0 within 90 calendar days of the PCP order? 14.004 Did the PCP review the routine specialty service consultant 12 2 14 85.71% 1 report within the required time frame? 14.005 For endorsed inmate-patients received from another 14 6 20 70.00% 0 CDCR institution: If the inmate-patient was approved for a specialty services appointment at the sending institution, was the appointment scheduled at the receiving institution within the required time frames? 14.006 Did the institution deny the primary care provider request for 20 0 20 100.00% 0 specialty services within required time frames? 14.007 Following the denial of a request for specialty services, was 12 8 20 60.00% 0 the inmate-patient informed of the denial within the required time frame? Overall percentage: 84.15% California Institution for Women, Cycle 4 Medical Inspection Page 70 Office of the Inspector General State of California Scored Answers Yes Internal Monitoring, Quality Improvement, Reference + Number and Administrative Operations Yes No No Yes % N/A 15.001 Did the institution promptly process inmate medical appeals 12 0 12 100.00% 0 during the most recent 12 months? 15.002 Does the institution follow adverse/sentinel event reporting Not Applicable requirements? 15.003 Did the institution Quality Management Committee (QMC) 6 0 6 100.00% 0 meet at least monthly to evaluate program performance, and did the QMC take action when improvement opportunities were identified? 15.004 Did the institution’s Quality Management Committee 1 0 1 100.00% 0 (QMC) or other forum take steps to ensure the accuracy of its Dashboard data reporting? 15.005 For each initiative in the Performance Improvement Work 8 2 10 80.00% 1 Plan (PIWP), has the institution performance improved or reached the targeted performance objective(s)? 15.006 For institutions with licensed care facilities: Does the 4 0 4 100.00% 0 Local Governing Body (LGB), or its equivalent, meet quarterly and exercise its overall responsibilities for the quality management of patient health care? 15.007 Does the Emergency Medical Response Review Committee 8 4 12 66.67% 0 perform timely incident package reviews that include the use of required review documents? 15.101 Did the institution complete a medical emergency response 3 0 3 100.00% 0 drill for each watch and include participation of health care and custody staff during the most recent full quarter? 15.102 Did the institution’s second level medical appeal response 10 0 10 100.00% 0 address all of the inmate-patient’s appealed issues? 15.103 Did the institution’s medical staff review and submit the 7 0 7 100.00% 0 initial inmate death report to the Death Review Unit in a timely manner? 15.996 For Information Purposes Only: Did the CCHCS Death Review Committee submit its inmate death review summary Information Only to the institution timely? 15.997 For Information Purposes Only: Identify the institution’s Information Only protocols for tracking medical appeals. 15.998 For Information Purposes Only: Identify the institution’s protocols for implementing health care local operating Information Only procedures. California Institution for Women, Cycle 4 Medical Inspection Page 71 Office of the Inspector General State of California Scored Answers Yes Internal Monitoring, Quality Improvement, Reference + Number and Administrative Operations Yes No No Yes % N/A 15.999 For Information Purposes Only: Identify the institution’s Information Only health care staffing resources. Overall percentage: 94.07% Scored Answers Job Performance, Training, Licensing, Yes Reference + and Certifications Number Yes No No Yes % N/A 16.001 Do all providers maintain a current medical license? 10 0 10 100.00% 0 16.101 Does the institution’s Supervising Registered Nurse conduct 5 0 5 100.00% 0 periodic reviews of nursing staff? 16.102 Are nursing staff who administer medications current on 10 0 10 100.00% 0 their clinical competency validation? 16.103 Are structured clinical performance appraisals completed 3 4 7 42.86% 1 timely? 16.104 Are staff current with required medical emergency response 2 1 3 66.67% 0 certifications? 16.105 Are nursing staff and the Pharmacist-in-Charge current with 5 0 5 100.00% 1 their professional licenses and certifications? 16.106 Do the institution’s pharmacy and authorized providers who 1 0 1 100.00% 0 prescribe controlled substances maintain current Drug Enforcement Agency (DEA) registrations? 16.107 Are nursing staff current with required new employee 1 0 1 100.00% 0 orientation? Overall percentage: 88.69% California Institution for Women, Cycle 4 Medical Inspection Page 72 Office of the Inspector General State of California APPENDIX B — CLINICAL DATA Table B–1, CIW Sample Sets Sample Set Total Anticoagulation 3 CTC/OHU 3 Death Review/Sentinel Events 5 Diabetes 3 Emergency Services—CPR 3 Emergency Services—Non-CPR 4 High Risk 4 Hospitalization 5 Intra-System Transfers In 3 Intra-System Transfers Out 3 Perinatal Services 3 RN Sick Call 30 Specialty Services 4 73 California Institution for Women, Cycle 4 Medical Inspection Page 73 Office of the Inspector General State of California Table B–2, CIW Chronic Care Diagnoses Diagnosis Total Anemia 9 Anticoagulation 3 Arthritis/Degenerative Joint Disease 12 Asthma 20 COPD 3 Cancer 9 Chronic Kidney Disease 6 Chronic Pain 12 Cirrhosis/End-Stage Liver Disease 5 Deep Venous Thrombosis/Pulmonary Embolism 2 Diabetes 13 Gastroesophageal Reflux Disease 18 Gastrointestinal Bleed 1 HIV 1 Hepatitis C 13 Hyperlipidemia 15 Hypertension 33 Mental Health 18 Migraine Headaches 7 Rheumatological Disease 1 Seizure Disorder 3 Sleep Apnea 1 Thyroid Disease 8 213 California Institution for Women, Cycle 4 Medical Inspection Page 74 Office of the Inspector General State of California Table B–3, CIW Event — Program Program Total Diagnostic Services 209 Emergency Care 91 Hospitalization 73 Intra-System Transfers In 14 Intra-System Transfers Out 5 Not Specified 2 Outpatient Care 432 Prenatal & Postpartum Care 42 Specialized Medical Housing 263 Specialty Services 249 1,380 Table B–4, CIW Case Review Sample Summary Total MD Reviews Detailed 30 MD Reviews Focused 0 RN Reviews Detailed 17 RN Reviews Focused 38 Total Reviews 85 Total Unique Cases 73 Overlapping Reviews (MD & RN) 12 California Institution for Women, Cycle 4 Medical Inspection Page 75 Office of the Inspector General State of California APPENDIX C — COMPLIANCE SAMPLING METHODOLOGY California Institution for Women 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 inmate-patient—any risk level) (40)  Randomize MIT 1.002 Nursing Referrals OIG Q: 6.001  See Intra-system Transfers (30) MITs 1.003-006 Nursing sick call MedSATS  Clinic (each clinic tested) (5 per clinic)  Appointment date (3–9 months) 30  Randomize MIT 1.007 Returns from OIG Q: 4.008  See Health Information Management (Medical community hospital Records) (returns from community hospital) (29) 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 request review 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) (9)  Randomize California Institution for Women, Cycle 4 Medical Inspection Page 76 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Health Information Management (Medical Records) MIT 4.001 Timely scanning OIG Qs: 1.001,  Non-dictated documents (20) 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 (20)  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: 4.008  Community hospital discharge documents (20)  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 (12) any tested inmate during OIG compliance review (12 or more = No) MIT 4.007 Legible signatures & OIG Qs: 4.008,  First 8 IPs sampled review 6.001, 6.002,  One source document per IP 7.001, 12.001, (32) 12.002 & 14.002 MIT 4.008 Returns from Inpatient claims  Date (2–8 months) community hospital data  Most recent 6 months provided (within date range)  Rx count  Discharge date  Randomize (each month individually)  First 5 inmate-patients from each of the 6 months (if not 5 in a month, supplement from another, as (29) needed) Health Care Environment MIT 5.101-111 Clinical areas OIG inspector  Identify and inspect all onsite clinical areas. (14) onsite review Inter- and Intra-System Transfers MIT 6.001-003 Intra-system transfers SOMS  Arrival date (3–9 months)  Arrived from (another CDCR facility)  Rx count (30)  Randomize MIT 6.004 Specialty services MedSATS  Date of transfer (3–9 months) send-outs  Randomize (17) MIT 6.101 Transfers out OIG inspector  R&R IP transfers with medication (10) onsite review California Institution for Women, Cycle 4 Medical Inspection Page 77 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Pharmacy and Medication Management MIT 7.001 Chronic care OIG Q: 1.001 See Access to Care medication  At least one condition per inmate-patient—any risk level (40)  Randomize MIT 7.002 New Medication Master Registry  Rx count Orders  Randomize (30)  Ensure no duplication of IPs tested in MIT 7.001 MIT 7.003 Returns from OIG Q: 4.008  See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (29) MIT 7.004 RC arrivals – OIG Q: 12.001  See Reception Center Arrivals medication orders N/A at this institution MIT 7.005 Intra-facility moves MAPIP transfer  Date of transfer (3–8 months) data  To location/from location (yard to yard and to/from ASU)  Remove any to/from MHCB  NA/DOT meds (and risk level) (30)  Randomize MIT 7.006 En Route SOMS  Date of transfer (2–8 months)  Sending institution (another CDCR facility)  Randomize (0)  NA/DOT meds MITs 7.101-103 Medication storage OIG inspector  Identify and inspect clinical & med line areas that areas onsite review store medications (22) MITs 7.104–106 Medication OIG inspector  Identify and inspect onsite clinical areas that Preparation and onsite review prepare and administer medications Administration Areas (22) 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 (30) reports MIT 7.999 Isolation unit KOP Onsite active  KOP rescue inhalers & nitroglycerin medications medications medication for IPs housed in isolation units (0) listing Prenatal and Post-Delivery Services MIT 8.001-007 Recent Deliveries OB Roster  Delivery date (5–12 months) (5)  Most recent deliveries (within date range) Pregnant Arrivals OB Roster  Arrival date (5–12 months) (5)  Earliest arrivals (within date range) California Institution for Women, Cycle 4 Medical Inspection Page 78 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Preventive Services MITs 9.001–002 TB Medications Maxor  Dispense date (past 9 months)  Time period on TB meds (3 months or 12 weeks) (9)  Randomize MIT 9.003 TB Code 22, annual SOMS  Arrival date (at least 1 year prior to inspection) TST  TB Code (22) (15)  Randomize TB Code 34, annual SOMS  Arrival date (at least 1 year prior to inspection) screening  TB Code (34) (15)  Randomize MIT 9.004 Influenza SOMS  Arrival date (at least 1 year prior to inspection) vaccinations  Randomize (30)  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) (30)  Randomize MIT 9.006 Mammogram SOMS  Arrival date (at least 2 yrs prior to inspection)  Date of birth (age 52–74) (30)  Randomize MIT 9.007 Pap smear SOMS  Arrival date (at least 3 yrs prior to inspection)  Date of birth (age 24–53) (30)  Randomize MIT 9.008 Chronic care OIG Q: 1.001  Chronic care conditions (at least 1 condition per vaccinations IP—any risk level)  Randomize (40)  Condition must require vaccination(s) MIT 9.009 Valley fever Cocci transfer  Reports from past 2–8 months (number will vary) status report  Institution  Ineligibility date (60 days prior to inspection date) N/A at this institution  All California Institution for Women, Cycle 4 Medical Inspection Page 79 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Reception Center Arrivals MITs 12.001–008 RC SOMS  Arrival date (2–8 months)  Arrived from (county jail, return from parole, etc.) N/A at this institution  Randomize Specialized Medical Housing MITs 13.001–004 OHU CADDIS  Admit date (3–8 months) (10)  Type of stay (no MH beds) CTC  Length of stay (minimum of 5 days) (10)  Randomize MIT 13.101 Call buttons OIG inspector  Review by location CTC (all) onsite review Specialty Services Access 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) (15)  Remove optometry, physical therapy or podiatry  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) (10)  Randomize IUMC/MAR  Meeting date (9 months) Meeting Minutes  Denial upheld (10)  Randomize California Institution for Women, Cycle 4 Medical Inspection Page 80 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Internal Monitoring, Quality Improvement, & 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 requiring RCAs (2–8 events events report months) N/A at this institution MITs 15.003–004 QMC Meetings Quality  Meeting minutes (12 months) Management Committee (6) meeting minutes MIT 15.005 Performance Institution PIWP  PIWP with updates (12 months) improvement work  Medical initiatives plans (PIWP) (11) MIT 15.006 LGB LGB meeting  Quarterly meeting minutes (12 months) (4) minutes MIT 15.007 EMRRC EMRRC meeting  Monthly meeting minutes (6 months) (12) 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  Initial death reports (7) 12 months MIT 15.996 Death Review OIG summary  Between 35 business days & 12 months prior Committee log - deaths  CCHCS death reviews (0) MIT 15.998 Local operating Institution LOPs  All LOPs procedures (LOPs) (all) California Institution for Women, Cycle 4 Medical Inspection Page 81 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Job Performance, Training, Licensing, and Certifications MIT 16.001 Provider licenses Current provider  Review all listing (at start of (10) inspection) MIT 16.101 RN Review Onsite  RNs who worked in clinic or emergency setting Evaluations supervisor six or more days in sampled month periodic RN  Randomize (5) reviews MIT 16.102 Nursing Staff Onsite nursing  On duty one or more years Validations education files  Nurse administers medications (10)  Randomize MIT 16.103 Provider Annual OIG Q:16.001  All required performance evaluation documents Evaluation Packets (8) MIT 16.104 Medical Emergency Onsite  All staff Response certification o Providers (ACLS) Certifications tracking logs o Nursing (BLS/CPR) (all) o Custody (CPR/BLS) MIT 16.105 Nursing staff and Onsite tracking  All required licenses and certifications Pharmacist-in-charge system, logs, or Professional employee files Licenses and Certifications (all) MIT 16.106 Pharmacy and Onsite listing of  All DEA registrations Providers’ Drug provider DEA Enforcement Agency registration #s & (DEA) Registrations pharmacy registration (all) document MIT 16.107 Nursing Staff New Nursing staff  New employees (hired within last 12 months) Employee training logs Orientations (all) California Institution for Women, Cycle 4 Medical Inspection Page 82 Office of the Inspector General State of California C C ALIFORNIA ORRECTIONAL H C S ’ EALTH ARE ERVICES R ESPONSE California Institution for Women, Cycle 4 Medical Inspection Page 83 Office of the Inspector General State of California