California Men’s Colony Medical Inspection Report Cycle 5

Roy W. Wesley Office of the Inspector General Inspector General California Men’s Colony Medical Inspection Results Cycle 5 August 2018 Fairness Integrity Respect Medical Inspection Unit Page 1 Office of the Inspector General State of California Service Transparency Office of the Inspector General CALIFORNIA MEN’S COLONY Medical Inspection Results Cycle 5 Roy W. Wesley Inspector General Bryan B. Beyer Chief Deputy Inspector General Shaun R. Spillane Public Information Officer August 2018 December 2017 T C ABLE OF ONTENTS Foreword ............................................................................................................................................... i Executive Summary ............................................................................................................................ iii Overall Rating: Adequate ................................................................................................................ iii Expert Clinician Case Review Results ................................................................................... v Compliance Testing Results ................................................................................................... v Recommendations ................................................................................................................. vii Population-Based Metrics ..................................................................................................... vii Introduction .......................................................................................................................................... 1 About the Institution ......................................................................................................................... 1 Objectives, Scope, and Methodology .................................................................................................. 4 Case Reviews .................................................................................................................................... 5 Patient Selection for Retrospective Case Reviews ................................................................. 6 Benefits and Limitations of Targeted Subpopulation Review ................................................ 7 Case Review Sampling Methodology .................................................................................... 7 Breadth of Case Reviews ........................................................................................................ 8 Case Review Testing Methodology ........................................................................................ 9 Compliance Testing ........................................................................................................................ 12 Sampling Methods for Conducting Compliance Testing ..................................................... 12 Scoring of Compliance Testing Results ............................................................................... 12 Overall Quality Indicator Rating for Case Reviews and Compliance Testing ............................... 12 Population-Based Metrics............................................................................................................... 13 Medical Inspection Results ................................................................................................................ 14 Access to Care ................................................................................................................. 16 Case Review Results............................................................................................................. 16 Compliance Testing Results ................................................................................................. 19 Diagnostic Services.......................................................................................................... 21 Case Review Results............................................................................................................. 21 Compliance Testing Results ................................................................................................. 22 Emergency Services ......................................................................................................... 24 Case Review Results............................................................................................................. 24 Health Information Management..................................................................................... 27 Case Review Results............................................................................................................. 27 Compliance Testing Results ................................................................................................. 29 Health Care Environment ................................................................................................ 30 Compliance Testing Results ................................................................................................. 30 Inter- and Intra-System Transfers.................................................................................... 33 Case Review Results............................................................................................................. 33 Compliance Testing Results ................................................................................................. 35 Pharmacy and Medication Management ......................................................................... 37 Case Review Results............................................................................................................. 37 Compliance Testing Results ................................................................................................. 38 California Men’s Colony, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California Prenatal and Post-Delivery Services ............................................................................... 42 Preventive Services .......................................................................................................... 43 Compliance Testing Results ................................................................................................. 43 Quality of Nursing Performance .................................................................................. 45 Case Review Results............................................................................................................. 45 Quality of Provider Performance ................................................................................. 48 Case Review Results............................................................................................................. 48 Reception Center Arrivals ............................................................................................ 51 Specialized Medical Housing ....................................................................................... 52 Case Review Results............................................................................................................. 52 Compliance Testing Results ................................................................................................. 54 Specialty Services ......................................................................................................... 55 Case Review Results............................................................................................................. 55 Compliance Testing Results ................................................................................................. 57 Administrative Operations (Secondary) ....................................................................... 59 Compliance Testing Results ................................................................................................. 59 Recommendations .............................................................................................................................. 62 Population-Based Metrics .................................................................................................................. 63 Appendix A — Compliance Test Results .......................................................................................... 66 Appendix B — Clinical Data ............................................................................................................. 79 Appendix C — Compliance Sampling Methodology ........................................................................ 83 California Correctional Health Care Services’ Response .................................................................. 90 California Men’s Colony, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California L T F IST OF ABLES AND IGURES CMC Executive Summary Table........................................................................................................ iv CMC Health Care Staffing Resources as of September 2017 ............................................................. 2 CMC Master Registry Data as of August 28, 2017 ............................................................................. 3 Exhibit 1. Case Review Definitions .................................................................................................... 5 Chart 1. Case Review Sample Selection ............................................................................................. 8 Chart 2. Case Review Testing and Deficiencies ............................................................................... 10 Chart 3. Inspection Indicator Review Distribution............................................................................ 14 Table B-1: CMC Sample Sets ........................................................................................................... 79 Table B-2: CMC Chronic Care Diagnoses ........................................................................................ 80 Table B-3: CMC Event – Program .................................................................................................... 81 Table B-4: CMC Review Sample Summary ..................................................................................... 82 California Men’s Colony, Cycle 5 Medical Inspection List of Tables and Figures Office of the Inspector General State of California This page intentionally left blank. California Men’s Colony, Cycle 5 Medical Inspection Office of the Inspector General State of California F OREWORD Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), the OIG conducts a comprehensive inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG explicitly makes no determination regarding the constitutionality of care in the prison setting. 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 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. In Cycle 5, for the first time, the OIG will be inspecting institutions delegated back to CDCR from the Receivership. There is no difference in the standards used for assessment of a delegated institution versus an institution not yet delegated. California Men’s Colony (CMC) was delegated back to the CDCR in May 2018. At the time of the Cycle 5 inspection of CMC, the Receiver had not yet delegated this institution back to the CDCR. This fifth cycle of inspections will continue evaluating the areas addressed in Cycle 4, which included clinical case review, compliance testing, and a population-based metric comparison of selected Healthcare Effectiveness Data Information Set (HEDIS) measures. In agreement with stakeholders, the OIG made changes to both the case review and compliance components. The OIG found that in every inspection in Cycle 4, larger samples were taken than were needed to assess the adequacy of medical care provided. As a result, the OIG reduced the number of case reviews and sample sizes for compliance testing. Also, in Cycle 4, compliance testing included two secondary (administrative) indicators (Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications). For Cycle 5, these have been combined into one secondary indicator, Administrative Operations. California Men’s Colony, Cycle 5 Medical Inspection Page i Office of the Inspector General State of California This page intentionally left blank. California Men’s Colony, Cycle 5 Medical Inspection Page ii Office of the Inspector General State of California E S XECUTIVE UMMARY The OIG completed the Cycle 5 medical inspection of California Men’s Colony (CMC) in August 2018. The vast majority of our OVERALL RATING: inspection findings were based on CMC’s health care delivery between December 2016 and December 2017. Our policy Adequate compliance inspectors performed an onsite inspection in September 2017. After reviewing the institution’s health care delivery, our case review clinicians performed an onsite inspection in March 2018. Our clinician team, consisting of expert physicians and nurse consultants, reviewed cases (patient medical records) and interpreted our policy compliance results to determine the quality of health care the institution provided. Our compliance team, consisting of registered nurses, monitored the institution’s compliance with its medical policies by answering a predetermined set of policy compliance questions. Our clinician team reviewed 75 cases that contained 1,636 patient-related events. Our compliance team tested 89 policy questions by observing CMC’s processes and examining 442 patient records and 1,225 data points. We distilled the results from both the case review and compliance testing into 13 health care indicators, and have listed the individual indicators and ratings applicable for this institution in the CMC Executive Summary Table on the following page. Our experts made a considered and measured opinion that the overall quality of health care at CMC was adequate. California Men’s Colony, Cycle 5 Medical Inspection Page iii Office of the Inspector General State of California CMC Executive Summary Table Inspection Indicators Case Review Compliance Cycle 5 Cycle 4 Rating Rating Overall Overall Rating Rating 1—Access to Care Adequate Adequate Adequate Adequate 2—Diagnostic Services Proficient Inadequate Adequate Adequate 3—Emergency Services Inadequate Not Applicable Inadequate Inadequate 4—Health Information Adequate Inadequate Adequate Inadequate Management 5—Health Care Environment Not Applicable Inadequate Inadequate Adequate 6—Inter- and Intra-System Adequate Adequate Adequate Proficient Transfers 7—Pharmacy and Medication Adequate Inadequate Inadequate I Inadequate Management n a 8—Prenatal and Post-Delivery Not Applicable Not Applicable Not Applicable Not Applicable Services 9—Preventive Services Not Applicable Adequate Adequate Inadequate 10—Quality of Nursing Adequate Not Applicable Adequate Adequate Performance 11—Quality of Provider Adequate Not Applicable Adequate Adequate Performance 12—Reception Center Arrivals Not Applicable Not Applicable Not Applicable Not Applicable 13—Specialized Medical Housing Adequate Proficient Adequate Adequate 14—Specialty Services Adequate Inadequate Inadequate Adequate 15—Administrative Operations Not Applicable Proficient Proficient Adequate** (Secondary) *In Cycle 4, there were two secondary (administrative) indicators. This score reflects the average of those two scores. California Men’s Colony, Cycle 5 Medical Inspection Page iv Office of the Inspector General State of California Expert Clinician Case Review Results The clinicians’ case reviews sampled patients with high medical needs and included a review of more than 1,636 patient care events.1 The vast majority of our case review covered the period between February 2017 and December 2017. As depicted on the summary table on page iv, of the 13 indicators applicable to CMC, case reviewers evaluated 10; 1 was proficient, 8 were adequate, and 1 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 • According to CMC providers, the chief medical executive (CME) and chief physician and surgeon (CP&S) provided strong leadership and support, which fostered a friendly, close- knit, and collegial atmosphere. • CMC providers developed strong relationships with specialty consultants, which enabled excellent communication between the providers and the specialists. Program Weaknesses — Clinical • CMC providers and nurses frequently provided poor emergency care, with many errors resulting from poor cardiovascular care. • Nurses at CMC often made incomplete or poor assessments for patients returning from the hospital. Nursing plans were frequently insufficient and did not clearly describe patients’ medical conditions. Compliance Testing Results Of the 13 health care indicators applicable to CMC, compliance inspectors evaluated 10.2 Of these, two were proficient, three were adequate, and five were inadequate. The vast majority of our compliance testing was of medical care that occurred between December 2016 and August 2017. There were 89 individual compliance questions within those ten indicators, generating 1,225 data points that tested CMC’s compliance with California Correctional Health Care Services (CCHCS) 1 Each OIG clinician team includes a board-certified physician and registered nurse consultant with experience in correctional and community medical settings. 2 The OIG’s compliance inspectors are trained registered nurses with expertise in CDCR policies regarding medical staff and processes. California Men’s Colony, Cycle 5 Medical Inspection Page v Office of the Inspector General State of California policies and procedures.3 Appendix A — Compliance Test Results provides details for the 89 questions. Program Strengths — Compliance The following are some of CMC’s strengths based on its compliance scores on individual questions in the applicable health care indicators: • CMC staff excelled at completing timely nursing and provider assessments when they admitted patients to the correctional treatment center (CTC). • The institution did well offering and providing health screenings and immunizations for their patients. • CMC nursing staff completed initial health screening forms for newly transferred patients within the required time frames. • CMC nursing staff received and reviewed health care services request (sick call) forms timely and saw their patients within one business day. Also, there were adequate supplies of health care services request forms in the CMC housing units. Program Weaknesses — Compliance The following are some of the weaknesses identified by CMC’s compliance scores on individual questions in applicable health care indicators: • Clinical staff at CMC did poorly in maintaining proper hand hygiene during patient encounters. • CMC medical clinics did not properly maintain medical supplies. Medical clinics lacked the properly calibrated medical equipment needed to give standard medical care. • The institution did not provide chronic care or specialty services follow-up appointments within required time frames. • CMC providers did not sign radiology, laboratory, and pathology reports timely. Additionally, the providers did not communicate the results of these reports to the patients within required time frames. 3 The OIG used its own clinicians to provide clinical expert guidance for testing compliance in certain areas where CCHCS policies and procedures did not specifically address an issue. California Men’s Colony, Cycle 5 Medical Inspection Page vi Office of the Inspector General State of California Recommendations • The CEO should rectify the EMRRC review process because the committee failed to identify problems with the care provided by the TTA providers and nurses. The institution needs a properly functioning EMRRC to identify and correct its various lapses in emergency care. • The CEO should analyze and adjust many of the pharmacy and nursing processes because the institution demonstrated poor compliance with most measures of medication administration, observed medication practices, and storage controls. • The CEO should identify and correct several specialty services processes because of the institution’s problems with scheduling urgent specialty referrals and providing follow-up specialty appointments. • The CNE should analyze and correct the sick call processes because the CMC nurses did not see patients as promptly as medically necessary. Furthermore, when the nurses referred patients with sick calls to providers, the provider appointments sometimes occurred late or not at all. Population-Based Metrics In general, CMC performed well as measured by population-based metrics. In comprehensive diabetes care, CMC outperformed most state and national health care plans in all five diabetic measures. However, CMC scored lower than four health care plans for diabetic eye exams. With regard to immunization measures, CMC scored higher than all other health care plans for influenza immunizations for younger adults. However, for influenza immunizations for older adults, CMC scored lower than two health care plans. When administering pneumococcal immunizations to older adults, CMC scored higher than Medicare, but lower than the United States Veterans Administration. CMC’s colorectal cancer screening scores were higher than all reporting health care plans. CMC performed well as measured by population-based metrics compared to the other health care plans reviewed. CMC may improve its scores for influenza vaccinations by reducing patient refusals through educating patients on the benefits of these preventive services. California Men’s Colony, Cycle 5 Medical Inspection Page vii Office of the Inspector General State of California This page intentionally left blank. California Men’s Colony, Cycle 5 Medical Inspection Page viii Office of the Inspector General State of California I NTRODUCTION Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), and at the request of the federal Receiver, the OIG developed a comprehensive medical inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG conducted a clinical case review and a compliance inspection, ensuring a thorough, end-to-end assessment of medical care within CDCR. California Men’s Colony (CMC) was the 25th medical inspection of Cycle 5. During the inspection process, the OIG assessed the delivery of medical care to patients using the primary clinical health care indicators applicable to the institution. The Administrative Operations indicator is secondary because it does not reflect the actual clinical care provided. ABOUT THE INSTITUTION Opened in 1945, the California Men’s Colony (CMC) is located northwest of the city of San Luis Obispo, in San Luis Obispo County. The institution has two separate housing complexes, commonly referred to as “East” and “West.” At both complexes, medical staff members run multiple clinics where patients are seen for non-urgent care. The east complex houses medium security and general population patients, and is divided into four facilities, including a triage and treatment area (TTA) where medical staff members see patients requiring urgent and emergent care, and a correctional treatment center (CTC) which provides inpatient care. The west complex houses minimum-security and general population patients. CDCR has designated CMC as an intermediate care prison; these institutions are predominantly located in urban areas, close to tertiary care centers and specialty care providers for the most cost-effective care. In April of 2015, CMC received accreditation from the Commission on Accreditation for Corrections, a professional peer review process based on national standards set by the American Correctional Association. Based on staffing data the OIG obtained from the institution as identified in the CMC Health Care Staffing Resources as of September 2017 table on the following page, CMC’s vacancy rate among medical managers, primary care providers, supervisors, and rank-and-file nurses was only 3 percent overall in September 2017 with the highest vacancy percentages among nursing supervisors at 5 percent. At the time of the OIG’s inspection, one health care staff member was on extended leave. California Men’s Colony, Cycle 5 Medical Inspection Page 1 Office of the Inspector General State of California CMC Health Care Staffing Resources as of September 2017 Management Primary Care Nursing Nursing Staff Totals Providers Supervisors Description Number % Number % Number % Number % Number % Authorized 5 3% 13.5 7% 19.5 10% 161.4 81% 199.4 100% Positions Filled 5 100% 13.5 100% 18 92% 142 88% 178.5 90% Positions Vacancies 0 0% 0 0% 1.5 8% 19.4 12% 20.9 10% Recent Hires 1 20% 6 44% 3 17% 18 13% 28 16% (within 12 months) Staff Utilized 0 0% 0 0% 0 0% 4 3% 4 2% from Registry Redirected 0 0% 0 0% 0 0% 0 0% 0 0% Staff (to Non-Patient Care Areas) Staff on 0 0% 0 0% 0 0% 1 1% 1 1% Extended Leave Note: CMC Health Care Staffing Resources data was not validated by the OIG As of August 28, 2017, the Master Registry for CMC showed that the institution had a total population of 4,208. Within that total population, 5.6 percent was designated as high medical risk, Priority 1 (High 1), and 13.0 percent was 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 on the next page illustrates the breakdown of the institution’s medical risk levels at the start of the OIG medical inspection. California Men’s Colony, Cycle 5 Medical Inspection Page 2 Office of the Inspector General State of California CMC Master Registry Data as of August 28, 2017 Medical Risk Level Number of Patients Percentage High 1 237 5.6% High 2 545 13.0% Medium 1,763 41.9% Low 1,663 39.5% Total 4,208 100.0% California Men’s Colony, Cycle 5 Medical Inspection Page 3 Office of the Inspector General State of California O , S , M BJECTIVES COPE AND ETHODOLOGY In designing the medical inspection program, the OIG reviewed CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. The OIG also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the Receiver’s office, CDCR, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of the OIG’s inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates medical care delivery by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population-based metrics. To maintain a metric-oriented inspection program that evaluates medical care delivery consistently at each state prison, the OIG identified 15 indicators (14 primary (clinical) indicators and one secondary (administrative) indicator) of health care to measure. The primary quality indicators cover clinical categories directly relating to the health care provided to patients, whereas the secondary quality indicator addresses the administrative functions that support a health care delivery system. The CMC Executive Summary Table on page iv of this report identifies these 15 indicators. The OIG rates each of the quality indicators applicable to the institution under inspection based on case reviews conducted by OIG clinicians and compliance tests conducted by OIG registered nurses. The case review results alone, the compliance test results alone, or a combination of both these information sources may influence an indicator’s overall rating. For example, the OIG derives the ratings for the primary quality indicators Quality of Nursing Performance and Quality of Provider Performance entirely from the case review done by clinicians, while the ratings for the primary quality indicators Health Care Environment and Preventive Services are derived entirely from compliance testing done by registered nurse inspectors. As another example, primary quality indicators such as Diagnostic Services and Specialty Services receive ratings derived from both sources. The OIG does not inspect for efficiency or cost-effectiveness of medical operations. Consistent with the OIG’s agreement with the Receiver, this report only addresses the quality of CDCR’s medical operations and its compliance with quality-related policies. Moreover, if the OIG learns of a patient needing immediate care, the OIG notifies the chief executive officer of health care services and requests a status report. Additionally, if the OIG learns of significant departures from community standards, it may report such departures to the institution’s chief executive officer or to CCHCS. Because these matters involve confidential medical information protected by state and federal privacy laws, the OIG does not include specific identifying details related to any such cases in the public report. California Men’s Colony, Cycle 5 Medical Inspection Page 4 Office of the Inspector General State of California In all areas, the OIG is alert for opportunities to make appropriate recommendations for improvement. Such opportunities may be present regardless of the score awarded to any particular quality indicator; therefore, recommendations for improvement are not necessarily indicative of deficient medical care delivery. CASE REVIEWS The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders, which continues in the Cycle 5 medical inspections. The following exhibit provides definitions that describe this process. Exhibit 1. Case Review Definitions Case = Sample = Patient An appraisal of the medical care provided to one patient over a specific period, which can comprise detailed or focused case reviews. Detailed Case Review A review that includes all aspects of one patient’s medical care assessed over a six-month period. This review allows the OIG clinicians to examine many areas of health care delivery, such as access to care, diagnostic services, health information management, and specialty services. Focused Case Review A review that focuses on one specific aspect of medical care. This review tends to concentrate on a singular facet of patient care, such as the sick call process or the institution’s emergency medical response. Case Review Event A direct or indirect interaction between the patient and the health care system. Examples of direct interactions include provider encounters and nurse encounters. An example of an indirect interaction includes a provider reviewing a diagnostic test and placing additional orders. Case Review Deficiency A medical error in procedure or in clinical judgment. Both procedural and clinical judgment errors can result in policy non-compliance, elevated risk of patient harm, or both. Adverse Deficiency A medical error that increases the risk of, or results in, serious patient harm. Most health care organizations refer to these errors as adverse events. California Men’s Colony, Cycle 5 Medical Inspection Page 5 Office of the Inspector General State of California The OIG’s clinicians perform a retrospective case review of selected patient files to evaluate the care given by an institution’s primary care providers and nurses. Retrospective case review is a well-established review process used by health care organizations that perform peer reviews and patient death reviews. Currently, CCHCS uses retrospective case review as part of its death review process and in its pattern-of-practice reviews. CCHCS also uses a more limited form of retrospective case review when performing appraisals of individual primary care providers. Patient Selection for Retrospective Case Reviews Because retrospective case review is time consuming and requires qualified health care professionals to perform it, the OIG must carefully select a sample of patient records for clinician review. Accordingly, the group of patients the OIG targeted for case review carried the highest clinical risk and utilized the majority of medical services. The majority of patients selected for retrospective case review were high-utilizing patients with chronic care illnesses who were classified as high or medium risk. The reason the OIG targeted these patients for review is twofold: 1. The goal of retrospective case review is to evaluate all aspects of the health care system. Statewide, high-risk and high-utilization patients consume medical services at a disproportionate rate; 11 percent of the total patient population is high-risk and accounts for more than half of the institution’s pharmaceutical, specialty, community hospital, and emergency costs. 2. Selecting this target group for case review provides a significantly greater opportunity to evaluate all the various aspects of the health care delivery system at an institution. Underlying the choice of high-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 is more likely to provide adequate care to patients with less complicated health care issues. Because clinical expertise is required to determine whether the institution has provided adequate clinical care, the OIG utilizes experienced correctional physicians and registered nurses to perform this analysis. 2. The health of less complex patients is more likely to be affected by processes such as timely appointment scheduling, medication management, routine health screening, and immunizations. To review these processes, the OIG simultaneously performs a broad compliance review. 3. Patient cases generated during death reviews, sentinel events (unexpected occurrences involving death or serious injury, or risk thereof), and hospitalizations are more likely to comprise high-risk patients. California Men’s Colony, Cycle 5 Medical Inspection Page 6 Office of the Inspector General State of California Benefits and Limitations of Targeted Subpopulation Review Because the patients selected utilize the broadest range of services offered by the health care system, the OIG’s retrospective case review provides adequate data for a qualitative assessment of the most vital system processes (referred to as “primary quality indicators”). Retrospective case review provides an accurate qualitative assessment of the relevant primary quality indicators as applied to the targeted subpopulation of high-risk and high-utilization patients. While this targeted subpopulation does not represent the prison population as a whole, the institution’s ability to respond with adequate medical care to this subpopulation is a crucial and vital indicator of how the institution provides health care to its whole patient population. Simply put, if the institution’s medical system does not respond adequately for those patients needing the most care, then it is not fulfilling its obligations, even if it takes good care of patients with less complex medical needs. Since the targeted subpopulation does not represent the institution’s general prison population, the OIG cautions against inappropriate extrapolation of medical conditions or outcomes from the retrospective case reviews to the general population. For example, if the high-risk diabetic patients reviewed have poorly controlled diabetes, one cannot conclude that all the diabetics’ conditions are poorly controlled. Similarly, if the high-risk diabetic patients under review have poor outcomes, one cannot conclude that the entire diabetic population is having similarly poor outcomes. The OIG does not extrapolate conditions or outcomes, but instead extrapolates the institution’s response for those patients needing the most care because the response yields valuable system information. In the above example, if the institution responds by providing appropriate diabetic monitoring, medication therapy, and specialty referrals for the high-risk patients reviewed, then it is reasonable to infer that the institution is also responding appropriately to all the diabetics in the prison. However, if these same high-risk patients needing monitoring, medications, and referrals are not getting those needed services, it is likely that the institution is not providing appropriate diabetic services. Case Review Sampling Methodology Using a pre-defined case review sampling algorithm, OIG analysts apply various filters to each institution’s patient population. The various filters include medical risk status, number of prescriptions, number of specialty appointments, number of clinic appointments, and other health-related data. The OIG uses these filters to narrow down the population to those patients with the highest utilization of medical resources (see Chart 1, next page). To prevent selection bias, the OIG ensures that the same clinicians who perform the case reviews do not participate in the sample selection process. California Men’s Colony, Cycle 5 Medical Inspection Page 7 Office of the Inspector General State of California Chart 1. Case Review Sample Selection The OIG’s case sample sizes matched those of other qualitative research. The empirical findings, supported by expert statistical consultants, showed adequate conclusions after 10 to 15 cases had undergone comprehensive, or detailed, clinician review. In qualitative statistics, this phenomenon is known as “saturation.” The OIG found the Cycle 4 medical inspection sample size of 30 for detailed physician reviews far exceeded the saturation point necessary for an adequate qualitative review. At the end of Cycle 4 inspections, the OIG re-analyzed the case review results using half the number of cases; there were no significant differences in the ratings. To improve inspection efficiency while preserving the quality of the inspection, the OIG reduced the number of the samples for Cycle 5 medical inspections to the current levels. For most basic institutions, the OIG samples 20 cases for detailed physician review. For intermediate institutions and several basic institutions with larger high-risk populations, the OIG samples 25 cases. For California Health Care Facility, the OIG samples 30 cases for detailed physician review. Breadth of Case Reviews As indicated in Appendix B, Table B-1: CMC Sample Sets, the OIG clinicians evaluated medical records for 75 unique cases. Appendix B, Table B-4: CMC Case Review Sample Summary, clarifies that both nurses and physicians reviewed 16 of those cases, for 91 reviews in total. Physicians performed detailed reviews of 25 cases, and nurses performed detailed reviews of 18 cases, totaling 43 detailed case reviews. Nurses and physicians also performed focused reviews California Men’s Colony, Cycle 5 Medical Inspection Page 8 Office of the Inspector General State of California of an additional 48 cases. These reviews generated 1,636 case review events (Appendix B, Table B-3: CMC Event–Program). While the sample method specifically pulled only 6 chronic care cases, i.e., 3 diabetes cases and 3 anticoagulation cases (Appendix B, Table B-1: CMC Sample Sets), the 75 unique cases sampled included 281 chronic care diagnoses, including 18 additional cases with diabetes (for a total of 21)and 8 additional anticoagulation cases (for a total of 11) (Appendix B, Table B-2: CMC Chronic Care Diagnoses). The OIG’s sample selection tool allowed evaluation of many chronic care programs because the complex and high-risk patients selected from the different categories often had multiple medical problems. While the OIG did not evaluate every chronic disease or health care staff member, the OIG did assess the overall operation of the institution’s system and staff. Case Review Testing Methodology A physician, a nurse consultant, or both clinician inspectors review each case. The OIG clinician inspector can perform one of two different types of case review: detailed or focused (see Exhibit 1, page 5, and Chart 1, page 8). As the OIG clinician inspector reviews the medical record for each sample, the inspector records pertinent interactions between the patient and the health care system. These interactions are also known as case review events. When an OIG clinician inspector identifies a medical error, the inspector also records these errors as case review deficiencies. If a deficiency is of such magnitude that it caused, or had the potential to cause, serious patient harm, then the OIG clinician records it as an adverse deficiency (see Chart 2, next page). California Men’s Colony, Cycle 5 Medical Inspection Page 9 Office of the Inspector General State of California Chart 2. Case Review Testing and Deficiencies When the OIG clinician inspectors have reviewed all cases, they analyze the deficiencies. OIG inspectors search for similar types of deficiencies to determine if a repeating pattern of errors existed. When the same type of error occurs multiple times, the OIG inspectors identify those errors as findings. When the error is frequent, the likelihood is high that the error is regularly recurring at the institution. The OIG categorizes and summarizes these deficiencies in one or more health care quality indicators in this report to help the institution focus on areas for improvement. California Men’s Colony, Cycle 5 Medical Inspection Page 10 Office of the Inspector General State of California Additionally, the OIG physicians also rate each of the detailed physician cases for adequacy based on whether the institution met the patient’s medical needs and if it placed the patient at significant risk of harm. The cumulative analysis of these cases gives the OIG clinicians additional perspective to help determine whether the institution is providing adequate medical services or not.4 Based on the collective results of clinicians’ case reviews, the OIG clinicians rated each quality indicator proficient (excellent), adequate (passing), or inadequate (failing). A separate confidential CMC Supplemental Medical Inspection Results: Individual Case Review Summaries report details the case reviews the OIG clinicians conducted and is available to specific stakeholders. For further details regarding the sampling methodologies and counts, see Appendix B — Clinical Data, Table B-1; Table B-2; Table B-3; and Table B-4. 4 Regarding individual provider performance, the OIG did not design the medical inspection to be a focused search for poorly performing providers; rather, the inspection assesses each institution’s systemic health care processes. Nonetheless, while the OIG does not purposefully sample cases to review each provider at the institution, the cases usually involve most of the institutions’ providers. Providers should only escape OIG case review if institutional managers assigned poorly performing providers the care of low-utilizing and low-risk patients, or if the institution had a relatively high number of providers. California Men’s Colony, Cycle 5 Medical Inspection Page 11 Office of the Inspector General State of California COMPLIANCE TESTING Sampling Methods for Conducting Compliance Testing Our nurse inspectors attained answers to 89 objective medical inspection test (MIT) questions designed to assess the institution’s compliance with critical policies and procedures applicable to the delivery of medical care. To conduct most tests, inspectors randomly selected samples of patients for whom the testing objectives were applicable and reviewed their electronic medical records. In some cases, inspectors used the same samples to conduct more than one test. In total, inspectors reviewed health records for 442 individual patients and analyzed specific transactions within their records for evidence that critical events occurred. Inspectors also reviewed management reports and meeting minutes to assess certain administrative operations. In addition, during the week of September 11, 2017, registered nurse field inspectors conducted a detailed onsite inspection of CMC’s medical facilities and clinics; interviewed key institutional employees; and reviewed employee records, logs, medical appeals, death reports, and other documents. This generated 1,225 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 CMC’s plant infrastructure, protocols for tracking medical appeals and local operating procedures, and staffing resources. For details of the compliance results, see Appendix A — Compliance Test Results. For details of the OIG’s compliance sampling methodology, see Appendix C — Compliance Sampling Methodology. Scoring of Compliance Testing Results After compiling the answers to the 89 questions for the ten indicators for which compliance testing was applicable, the OIG compliance team derived a score for each quality indicator by calculating the percentage score of all Yes answers for each of the questions applicable to a particular indicator, then averaging those scores. Based on those results, the OIG assigned a rating to each quality indicator of proficient (greater than 85 percent), adequate (between 75 percent and 85 percent), or inadequate (less than 75 percent). 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 for this inspection when the rating differed for a particular quality indicator. In those California Men’s Colony, Cycle 5 Medical Inspection Page 12 Office of the Inspector General State of California instances, the inspection team assessed the quality indicator based on the collective ratings from both components. Specifically, the OIG clinicians and registered nurse inspectors discussed the nature of individual 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 patients. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed. POPULATION-BASED METRICS The OIG identified a subset of Healthcare Effectiveness Data Information Set (HEDIS) measures applicable to the CDCR patient population. To identify outcomes for CMC, the OIG reviewed some of the compliance testing results, randomly sampled additional patients’ records, and obtained CMC data from the CCHCS Master Registry. The OIG compared those results to HEDIS metrics reported by other statewide and national health care organizations. California Men’s Colony, Cycle 5 Medical Inspection Page 13 Office of the Inspector General State of California M I R EDICAL NSPECTION ESULTS The OIG’s case review and clinician teams use quality indicators to assess the clinical aspects of health care. The CMC Executive Summary Table on page iv of this report identifies the 13 indicators applicable to this institution. The following chart depicts their union and intersection: Chart 3. Inspection Indicator Review Distribution The Administrative Operations indicator is a secondary indicator; therefore, the OIG did not rely upon this indicator when determining the institution’s overall score. Based on the analysis and results in all the primary indicators, the OIG experts made a considered and measured opinion that the quality of health care at CMC was adequate. Summary of Case Review Results: The clinical case review component assessed 10 of the 13 primary (clinical) indicators applicable to CMC. Of these ten indicators, OIG clinicians rated one proficient, eight adequate and one inadequate. The OIG physicians rated the overall adequacy of care for each of the 25 detailed case reviews they conducted. Of these 25 cases, 2 were proficient, 21 were adequate, and 2 were inadequate. California Men’s Colony, Cycle 5 Medical Inspection Page 14 Office of the Inspector General State of California In the 1,636 events reviewed, there were 283 deficiencies, 57 of which were considered to be of such magnitude that, if left unaddressed, they would likely contribute to patient harm. Adverse Deficiencies Identified During Case Review: Adverse deficiencies are medical errors that markedly increased the risk of, or resulted in, serious patient harm. Medical care is a complex and dynamic process with many moving parts, subject to human error even within the best health care organizations. All major health care organizations typically identify and track adverse deficiencies for the purpose of quality improvement. Adverse deficiencies are not typically representative of medical care delivered by the organization. The OIG normally identifies adverse deficiencies for the dual purposes of quality improvement and the illustration of problematic patterns of practice found during the inspection. Because of the anecdotal nature of these deficiencies, the OIG cautions against drawing inappropriate conclusions regarding the institution based solely on adverse events. The OIG identified one adverse deficiency in the case reviews at CMC. • In case 11, the patient had significant cardiac disease and two recent transfers to outside emergency departments for chest pain. After the patient experienced chest pain and almost fainted, CMC staff sent him to an emergency room. When the patient returned, the provider failed to review the emergency department records sufficiently. Also, the provider overlooked findings that were worrisome for significant heart disease and placed the patient at risk for a heart attack. The provider should have ordered an urgent cardiac stress test or a cardiology consultation for the patient. This error possibly contributed to the patient’s death. The Emergency Services and Quality of Provider Performance indicators also discuss this case. Summary of Compliance Results: The compliance component assessed 10 of the 13 indicators applicable to CMC. Of these ten indicators, OIG inspectors rated two proficient, three adequate, and five inadequate. Appendix A details the test questions used to assess compliance for each indicator. California Men’s Colony, Cycle 5 Medical Inspection Page 15 Office of the Inspector General State of California ACCESS TO CARE This indicator evaluates the institution’s ability to provide patients Case Review Rating: with timely clinical appointments. Compliance and case review Adequate teams review areas specific to patients’ access to care, such as initial Compliance Score: assessments of newly arriving patients, acute and chronic care Adequate (76.4%) follow-ups, face-to-face nurse appointments when patients request to be seen, provider referrals from nursing lines, and follow-ups after Overall Rating: hospitalization or specialty care. Compliance testing for this Adequate indicator also evaluates whether patients have Health Care Services Request forms (CDCR Form 7362) available in their housing units. Case Review Results The OIG clinicians reviewed 720 provider, nurse, specialty, and hospital events that required a follow-up appointment, and identified 28 deficiencies relating to access to care, 12 of which were significant. The case review rating for this indicator was adequate. Provider-to-Provider Follow-up Appointments CMC performed well with provider-ordered follow-up appointments. There were no deficiencies in this critical area. RN Sick Call Access The institution did not consistently provide patients who submitted sick call requests with timely access to a nurse. Of the 43 sick call requests reviewed, CMC did not provide patients with prompt access to sick call nursing appointments in cases 9, 18, 19, 41, 44, and 51. The Quality of Nursing Performance indicator discusses this performance further. There were significant deficiencies in the following two cases: • In case 19, the nurse failed to see the diabetic patient with concerns of a new foot blister. For diabetic patients, nurses should evaluate blisters urgently because of the possibility of skin breakdown and infection. • In case 51, the patient was awaiting elbow surgery and was complaining of constant pain and swelling. The nurse should have performed a face-to-face evaluation to examine the patient’s condition. California Men’s Colony, Cycle 5 Medical Inspection Page 16 Office of the Inspector General State of California RN-to-Provider Referrals CMC performed poorly with providing patients timely access to a provider when a nurse referred a patient to a provider for a higher level of care. The OIG clinicians reviewed 57 nursing encounters that generated a provider follow-up referral and found provider appointments were delayed or did not occur in cases 1, 19, 46, 59, 66, and the following: • In case 47, the nurse referred the patient to a provider for hearing loss. The appointment occurred 52 days late. • In case 53, the nurse referred the patient to a provider for worsening back pain. The appointment occurred 33 days late. • In case 69, the patient complained of having a kidney stone and bloody urine. The nurse referred the patient for a routine 14-day appointment after obtaining a urine sample. Although the patient’s urine test showed evidence of infection, no provider intervened, and the provider appointment occurred 15 days late. No provider addressed the abnormal urine test until 29 days after the test. RN Follow-up Appointments Nurses performed satisfactorily with scheduling and completing registered nurse (RN) follow-up appointments that providers or nurses generated. Of the six RN follow-up appointments reviewed, there was only one occasion where the appointment did not occur: • In case 58, the patient accidentally stuck himself with a sewing needle. The nurse scheduled an RN follow-up appointment, but it did not occur. Provider Follow-up After Specialty Services CMC performed well with ensuring provider follow-up appointments occurred after specialty services. The OIG clinicians reviewed 162 specialty services requiring follow-up appointments. Instances of provider follow-up not occurring or occurring late were rare (cases 11, 21, and 28), and did not affect the quality of the care provided. Intra-System Transfers / Reception Center CMC performed well with providing patients who transferred in from another CDCR facility with timely provider and RN appointments. All patients who transferred to CMC had provider and RN appointments within 30 days. Additionally, CMC timely scheduled all patients who transferred with pending specialty referrals. California Men’s Colony, Cycle 5 Medical Inspection Page 17 Office of the Inspector General State of California Follow-up After Hospitalization CMC did well at ensuring the providers followed up with their patients after an outside hospitalization or emergency department visit. CCHCS policy requires CMC to provide a follow-up appointment with the regular provider within five days of these visits. The clinicians reviewed 43 hospitalizations and outside emergency department events. There were two significant delays in the following cases: • In case 9, the patient returned from hospitalization for abdominal pain. The on-call provider was concerned about the patient’s condition and ordered a three-day provider follow-up. The appointment did not occur, and five days later the patient’s severe abdominal pain came back, resulting in staff sending the patient back to the hospital. • In case 25, the patient returned from hospitalization for a lung procedure. The provider follow-up occurred 27 days late. Follow-up After Urgent/Emergent Care When staff evaluated patients in the TTA and sent them back to regular housing, CMC performed well with ensuring provider follow-ups. CCHCS policy requires CMC to provide follow-up with the regular provider within five days of these visits. The OIG clinicians reviewed 59 TTA events. There were only two deficiencies, in cases 38 and 66. Specialized Medical Housing CMC providers saw patients in the correctional treatment center (CTC) timely. They performed history and physical exams on all newly admitted patients promptly. There were no deficiencies related to follow-up encounters from the CTC. Specialty Access and Follow-up CMC performed well with providing specialty consultations and specialty follow-up. The Specialty Services indicator also discusses performance in this area. Diagnostic Results Follow-up The providers routinely reviewed diagnostic studies and ordered follow-up appointments when abnormal tests indicated a medical appointment was necessary. Clinician Onsite Inspection During the onsite visit, clinic nurses reported seeing five to nine patients each day in the RN clinics, while the providers were seeing about 10 to 12 patients each day. Each clinic had an office technician who attended daily clinic huddles and coordinated with the providers to schedule all the follow-up appointments. The office technician reported that there were no significant backlogs in any of the clinics. The RNs in the east clinic were tracking the 14-day California Men’s Colony, Cycle 5 Medical Inspection Page 18 Office of the Inspector General State of California provider referrals in a log but did not consistently identify the reason for delayed or missed appointments (such as the lack of provider availability). With the implementation of the electronic health record system (EHRS), the clinic RN was made responsible for ordering the provider and RN follow-ups, face-to-face sick call appointments, TTA follow-ups, and the out- to-medical returns provider follow-ups. Case Review Conclusion CMC performed well in many aspects of Access to Care, including most provider and RN follow-ups, as well as follow-ups after patients returned from offsite specialty services or hospitalizations. However, CMC was inconsistent with providing sick call access, as there were strong patterns of delays for sick call patients that needed to see a nurse as well as when a nurse referred the patient to a provider. Overall, the OIG clinicians rated the Access to Care indicator adequate. Compliance Testing Results The institution performed in the adequate range, with a score of 76.4 percent in the Access to Care indicator. The following tests earned scores in the proficient range: • OIG inspectors sampled 30 health care services request forms that patients submitted across all facility clinics and found nursing staff reviewed all forms on the same day they were received (MIT 1.003). • Patients had access to health care services request forms at all six housing units the OIG inspected (MIT 1.101). • For 27 of the 30 sampled patients who submitted health care services request forms (90.0 percent), nursing staff conducted a face-to-face encounter with the patient within one business day of reviewing the form. For one patient, the nurse conducted the encounter two days late. For two other patients, a face-to-face encounter with a nurse did not occur (MIT 1.004). Three tests received scores in the adequate range: • Of the 14 applicable health care services request forms sampled for which the nurse referred the patient to a provider appointment, 11 patients (78.6 percent) received timely appointments. Three patients received their provider appointments from one to 28 days late (MIT 1.005). • OIG inspectors tested 25 patients discharged from a community hospital to determine whether they received a provider follow-up appointment at CMC within five calendar days of their return to the institution. For 19 patients, a timely follow-up appointment occurred California Men’s Colony, Cycle 5 Medical Inspection Page 19 Office of the Inspector General State of California (76.0 percent). Six patients received their appointments from one to 27 days late (MIT 1.007). • Of the four applicable patients sampled whom nursing staff referred to a provider and for whom the provider subsequently ordered a follow-up appointment, three (75.0 percent) received their follow-up appointments timely. One patient received his appointment 12 days late (MIT 1.006). The OIG inspectors found room for improvement in the following three tests: • OIG inspectors sampled 25 patients who suffered from one or more chronic care conditions; only 11 patients timely received their provider-ordered follow-up appointments (44.0 percent). Twelve other patients received their appointments late as follows: ten patients’ appointments were from 9 to 35 days late; two patients’ appointments were from 59 to 88 days late. For two other patients, their appointments never occurred (MIT 1.001). • Only 16 of 26 applicable sampled patients who received a high-priority or routine specialty service (61.5 percent) also received a timely follow-up appointment with a provider. Of those ten patients who did not receive a timely follow-up appointment, five patients’ high-priority specialty service follow-up appointments were 2 to 35 days late, four patients’ routine specialty service follow-up appointments were 2 to 17 days late, and one patient’s appointment did not occur (MIT 1.008). • Among 24 patients sampled who transferred into CMC from other institutions and whom nurses referred to a provider based on their initial health care screening, only 15 of them (62.5 percent) were seen timely. Six patients received their provider appointments from one to 20 days late. Two other patients received their appointments from 45 to 55 days late. For one final patient, there was no evidence found the appointment occurred at all (MIT 1.002). California Men’s Colony, Cycle 5 Medical Inspection Page 20 Office of the Inspector General State of California DIAGNOSTIC SERVICES This indicator addresses several types of diagnostic services. Case Review Rating: Specifically, it addresses whether radiology and laboratory services Proficient were timely provided to patients, whether primary care providers Compliance Score: timely reviewed results, and whether providers communicated results Inadequate (62.2%) to the patient within required time frames. In addition, for pathology Overall Rating: services, the OIG determines whether the institution received a final Adequate pathology report and whether the provider 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. For this indicator, the case review and compliance review processes yielded different results, with the case review giving a proficient rating and the compliance review resulting in an inadequate score. The main reason for the inadequate compliance score was providers did not timely review radiology and laboratory reports. Also, CMC providers did not communicate laboratory and pathology results to the patient. Despite these errors, the providers usually performed a thorough review at the subsequent follow-up appointment and discussed the results with the patient, thus effectively mitigating potential harm. Nevertheless, CMC had room for improvement with its diagnostic report signature and patient notification processes. The overall rating for this indicator was adequate. Case Review Results The OIG clinicians reviewed 242 diagnostic events and identified only ten deficiencies, one of which was significant. The case review rating for this indicator was proficient. Test Completion CMC had effective laboratory and diagnostic test processes. There were no deficiencies because CMC completed all ordered laboratory and imaging tests timely. Health Information Management CMC staff retrieved and scanned laboratory and procedure reports into the electronic medical records appropriately. However, providers were not consistent in signing the reports or notifying their patients of the results, resulting in six of the ten deficiencies that occurred in this area, one of which was significant: • In case 69, the patient’s urine test showed evidence of a possible urinary tract infection. A provider did not sign or address the report. This error placed the patient at risk for complications from the infection. Fortunately, this error did not result in harm. California Men’s Colony, Cycle 5 Medical Inspection Page 21 Office of the Inspector General State of California Although the providers sometimes neglected to sign or review reports, or notify their patients of the test results, the providers usually thoroughly reviewed the results with the patient during the subsequent provider encounter. Clinician Onsite Inspection The CMC diagnostic services team recently began scheduling all the imaging studies within the institution. Mobile units came to the institution twice a month to perform specialized imaging tests, such as magnetic resonance imaging (MRI), computed tomography (CT), and ultrasound scans. The institution performed imaging studies timely, and there was no backlog of patients. CMC providers had easy access to the test results, but occasionally had trouble viewing diagnostic images through the institution’s computer system. The institution’s laboratory team had a comprehensive workflow to ensure that they completed diagnostic tests and the providers reviewed the corresponding reports. Importantly, the laboratory team had good procedures for the proper management of critically important pathology and emergent laboratory results. Case Review Conclusion CMC completed diagnostic and laboratory services promptly. Diagnostic reports were readily available in the electronic medical record; however, providers did not consistently sign the reports or notify their patients of their tests results. Nevertheless, the providers had access to the diagnostic results and implemented suitable treatment plans successfully. The OIG clinicians rated the Diagnostic Services indicator proficient. Compliance Testing Results The institution received an inadequate compliance score of 62.2 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 timely performed radiology services for all ten sampled patients (MIT 2.001). CMC providers then timely reviewed the corresponding diagnostic services reports for only four of the ten sampled patients (40.0 percent), as the patients’ designated primary care providers did not sign six of the reports (MIT 2.002). Other providers timely communicated the test results to seven of the ten sampled patients (70.0 percent). Providers communicated three patients’ results 13 to 27 days late (MIT 2.003). Laboratory Services • All ten sampled patients received their provider-ordered laboratory services timely (MIT 2.004). The patient’s designated primary care providers then signed five of the ten corresponding laboratory services reports within the required time frame (50.0 percent); five California Men’s Colony, Cycle 5 Medical Inspection Page 22 Office of the Inspector General State of California reports were signed from one to five days late (MIT 2.005). Finally, providers timely communicated results to only one of the ten sampled patients (10.0 percent). For five patients, providers communicated the results from one to 26 days late; and the providers failed to communicate four patients’ results (MIT 2.006). Pathology Services • CMC timely received final pathology reports for all ten patients sampled (MIT 2.007). Designated primary care providers then timely signed the pathology results for seven of those ten sampled patients (70.0 percent). The patients’ designated providers signed three pathology results from four to seven days late (MIT 2.008). Finally, providers timely communicated the pathology results to only two of the ten patients sampled (20.0 percent). For eight patients, results were communicated one to 27 days late (MIT 2.009). California Men’s Colony, Cycle 5 Medical Inspection Page 23 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, Inadequate 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 Overall Rating: reviews emergency response services including first aid, basic life Inadequate support (BLS), and advanced cardiac life support (ACLS) consistent with the American Heart Association guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care, and the provision of services by knowledgeable staff appropriate to each individual’s training, certification, and authorized scope of practice. The OIG evaluates this quality indicator entirely through clinicians’ reviews of case files and conducts no separate compliance testing element. Case Review Results The OIG clinicians reviewed 29 cases which yielded 61 urgent or emergent events. From these events, the OIG clinicians identified 41 deficiencies, 11 of which were significant. The case review rating for this indicator was inadequate. CPR Response The OIG clinicians reviewed eight emergency CPR cases and found the institution’s response and interventions to be appropriate. The CMC medical staff provided appropriate and timely CPR and documentation. In five cases, custody officers started CPR immediately while waiting for medical staff to arrive. In the other three cases, custody staff waited for medical staff to perform CPR. In those cases, the medical staff arrived swiftly and started CPR within acceptable time frames. Provider Performance CMC’s emergency provider performance was usually sufficient. The providers recognized patients with urgent medical conditions and triaged the patient appropriately. The providers appropriately sent sicker patients to the institution’s specialized medical housing or to a community hospital. However, providers made errors in five cases, often involving cardiac care, which is a very important aspect of emergency services. The following are examples of poor provider care: • In case 2, the diabetic patient was acutely ill with critically elevated blood sugar. The provider should have given the patient intravenous fluids but neglected to do so. California Men’s Colony, Cycle 5 Medical Inspection Page 24 Office of the Inspector General State of California • In case 11, the patient with cardiac disease developed chest pain, but the provider failed to prescribe aspirin. On three occasions, providers did not intervene timely for this patient whose worsening chest pain warranted emergent treatment. • In case 29, the provider did not perform a face-to-face evaluation of a patient with new complaints of multiple fainting episodes and instead sent the patient back to regular housing. • In case 30, the patient came to the TTA for complaints of dizziness and chest discomfort. The provider sent the patient back to regular housing once the dizziness resolved and did not address the chest discomfort. Nursing Performance Emergency nursing care provided at CMC was poor, and nursing performance accounted for 28 deficiencies, of which 8 were significant. Five of the eight significant deficiencies involved poor nursing care for patients with chest or abdominal pain. Nurses did not recognize the potential urgency of the patients’ symptoms and did not follow established nursing protocols. The cases below are examples of these deficiencies: • In case 1, the patient had chest tightness and difficulty breathing. The TTA nurse determined the patient’s breathing status was within normal limits and released him back to regular housing without addressing the patient’s chest pain. Within one hour, the patient again returned to the TTA with chest pain. The nurse failed to administer aspirin or nitroglycerin (medication to open the heart vessels) for over a half an hour after the patient arrived at the TTA, placing the patient at increased risk of developing serious cardiac complications. • In case 9, the patient with a history of intestinal blockage had abdominal pain and constipation. The TTA nurse released the patient to his housing unit without performing an acceptable abdominal examination and did not consult a provider or refer the patient for a follow-up appointment. • Also in case 9, the nurse evaluated the patient for stomach pain, diarrhea, ankle pain, and an absent pulse in his foot. The nurse did not recognize the seriousness of the patient’s condition and failed to notify a provider when the patient refused to go to the TTA. Six hours later, the patient developed severe lower leg pain and numbness in his toes. At an outside hospital, physicians diagnosed the patient with a pierced bowel. The patient died three days later. • In case 11, the patient with cardiac disease had chest pain and had already taken two doses of nitroglycerin with no improvement, before arriving in the TTA. The TTA nurse did not give the patient a third dose of nitroglycerin and did not notify the provider at the time of the initial evaluation. Instead, the nurse waited over an hour before notifying the provider. Although the patient’s electrocardiogram (EKG) revealed a concern for a possible heart attack, the nurse failed to follow chest pain protocol and did not provide continuous cardiac California Men’s Colony, Cycle 5 Medical Inspection Page 25 Office of the Inspector General State of California monitoring. The nurse also failed to monitor the patient’s consciousness or oxygen levels every five minutes as specified by the CCHCS protocol. Emergency Medical Response Review Committee Although the institution’s EMRRC conducted regular reviews of urgent and emergent medical response cases, it did not identify many lapses in emergency care. The EMRRC did not identify the deficiencies in case 9 regarding the patient with abdominal pain and case 11 for the patient with unrelieved chest pain. Additionally, the EMRRC should have reviewed the care of a patient (case 4) who was unresponsive in his cell and died. Clinician Onsite Inspection CMC has two physically separate facilities, the east complex, and the west complex. The east complex has medical clinics for four yards in addition to the CTC and the TTA. The proximity of the TTA to the clinics was advantageous as it allowed for collegiality among medical staff and providers readily discussed patient care. However, during peak clinic hours the east complex was quite congested with patients, which had the potential to lead to chaos during a medical emergency. The west complex has nursing treatment areas, sick call areas, and medical clinics for four yards. The west complex was less congested and was orderly and quiet in comparison to the east complex. CMC staff anticipated an increase in congestion at the west complex because it experienced a nearly 20 percent increase in high-risk patients since last year. The TTA had one dedicated provider along with nursing support staff. The medical staff felt the workload was reasonable and expressed a great affinity for the institution and leadership. Case Review Conclusion CMC’s CPR response was satisfactory. On the other hand, CMC providers performed sub- optimally in the emergency setting, and TTA nurses often made critical assessment errors. Many of these deficiencies were in cardiac care, which is a critical component of a viable and well- functioning emergency services system. In its reviews, the EMRRC often did not identify lapses in care. The OIG clinicians rated the Emergency Services indicator inadequate. California Men’s Colony, Cycle 5 Medical Inspection Page 26 Office of the Inspector General State of California HEALTH INFORMATION MANAGEMENT Health information management is a crucial link in the delivery of Case Review Rating: medical care. Medical personnel require accurate information in Adequate order to make sound judgments and decisions. This indicator Compliance Score: examines whether the institution adequately manages its health care Inadequate (65.7%) information. This includes determining whether the information is correctly labeled and organized and available in the electronic Overall Rating: medical record; whether the various medical records (internal and Adequate external, e.g., hospital and specialty reports and progress notes) are obtained and scanned timely into the patient’s electronic medical record; whether records routed to clinicians include legible signatures or stamps; and whether hospital discharge reports include key elements and are timely reviewed by providers. During the OIG’s testing period, CMC had converted to the new electronic health record system (EHRS) in January 2017; therefore, most testing occurred in the EHRS, with a minor portion of the testing done in the electronic unit health record (eUHR). For this indicator, the case review and compliance review processes yielded different results, with the case reviewers assigning an adequate rating and the compliance testing resulting in an inadequate score. The main reason for the inadequate score: CMC often improperly scanned, labeled, or filed documents. Also, CMC providers did not sign hospital discharge records timely. While the providers may not have signed the hospital reports within the required timeframe, they usually performed a thorough review at the subsequent follow-up appointment. Because the errors did not significantly increase the risk of harm, the overall rating for this indicator was adequate. Case Review Results The OIG clinicians reviewed 1,637 events and found only 35 deficiencies related to health information management, of which 3 were significant. CMC successfully retrieved and scanned medical documents into the electronic medical records timely. The case review rating for this indicator was adequate. Hospital Records As in Cycle 4, CMC providers occasionally did not sign specialty and hospital records. In nine cases, the provider did not sign the hospital records before they were scanned into the medical record (cases 1, 2, 3, 9, 11, 16, 21, 23, and 24). However, the providers thoroughly addressed these unsigned reports at the subsequent follow-up appointment. California Men’s Colony, Cycle 5 Medical Inspection Page 27 Office of the Inspector General State of California Specialty Services CMC scanned specialty notes into the electronic medical record without a provider review and signature. These errors might have led to missed information or lapses in care. These deficiencies occurred in cases 1, 2, 16, 29, and the following: • In case 21, the provider did not review and sign the cancer specialist’s report timely or at all on several occasions. Diagnostic Reports CMC retrieved and scanned diagnostic reports appropriately. However, providers did not consistently sign diagnostic reports and notify their patients of the results. The Diagnostic Services indicator also discusses this performance. Urgent/Emergent Records CMC performed well in this area. There were no deficiencies within this sub-indicator. Scanning Performance The OIG clinicians identified only five minor deficiencies of mislabeled or misfiled documentation. Legibility The reports were legible because providers either dictated or typed their progress notes. Clinician Onsite Inspection The institution’s medical staff maintained open communication with each other and the community at large. According to staff, the open communication fostered rare community collegiality, which also resulted in timely retrieval and scanning of medical documentation. The institution’s medical records staff had contacts within the community hospitals and with specialists that would reliably retrieve the outside medical documentation. Case Review Conclusion CMC did well with retrieving and scanning medical documents. CMC had some difficulty with their providers not reviewing and signing hospital records, specialty records, and diagnostic reports. Also, CMC providers did not reliably notify their patients of diagnostic test results. Nevertheless, CMC processes most health information sufficiently for the patient’s medical needs. The case review rating for the Health Information Management indicator was adequate. California Men’s Colony, Cycle 5 Medical Inspection Page 28 Office of the Inspector General State of California Compliance Testing Results The institution scored in the inadequate range with a score of 65.7 percent in the Health Information Management indicator. The following tests were inadequate: • CMC scored 4.2 percent in its labeling and filing of documents scanned into patients’ electronic health care records. OIG inspectors identified a total of 23 incorrectly labeled documents (MIT 4.006). • Among 25 sampled patients admitted to a community hospital who then returned to the institution, CMC providers timely reviewed 17 of the corresponding hospital discharge reports (68.0 percent) within three calendar days of the patient’s discharge date. Eight of the sampled reports were reviewed one to five days late (MIT 4.007). • Institution staff timely scanned five of seven sampled documents (71.4 percent), such as nursing initial health screening forms, and patient health care service request forms into the patient’s electronic medical record within three calendar days of the patient encounter. Two documents were scanned two and five days late (MIT 4.001). Two tests received proficient scores: • The OIG tested 20 patients’ discharge records to determine if staff timely scanned the records into the patients’ electronic medical records. Nineteen records (95.0 percent) were compliant. One record was scanned seven days late (MIT 4.004). • Institution staff timely scanned 18 of 20 specialty service consultant reports sampled (90.0 percent) into the patients’ electronic health care records. The other two specialty reports were scanned five and eight days late (MIT 4.003). California Men’s Colony, Cycle 5 Medical Inspection Page 29 Office of the Inspector General State of California HEALTH CARE ENVIRONMENT This indicator addresses the general operational aspects of the Case Review Rating: institution’s clinics, including certain elements of infection control Not Applicable and sanitation, medical supplies, and equipment management, the Compliance Score: availability of both auditory and visual privacy for patient visits, and Inadequate (67.6%) the sufficiency of facility infrastructure to conduct comprehensive medical examinations. The OIG rates this component from the visual Overall Rating: observations inspectors make at the institution during their onsite Inadequate visit. The OIG evaluates this indicator by compliance testing only. There is no case review portion. Compliance Testing Results The institution received scores in the inadequate range on the following seven tests: • Inspectors examined emergency response medical bags (EMRB) in ten applicable clinics to determine whether clinical staff inspected the bags daily and inventoried them monthly and whether the bags contained all essential items. Only three of the ten EMRBs were compliant (30.0 percent). The OIG noted one or more of the following deficiencies at the time of the inspection at seven clinic locations: crash cart was missing minimum par level of medical supplies randomly inspected; clinics were missing EMRB log entries to confirm staff had verified that the bag’s compartments were sealed Figure 1:A second instant glucose tube and intact; documentation did not indicate an was missing from the EMRB inventory of the EMRB had been completed in the previous 30 days; and clinics stored EMRB medical supplies beyond the manufacturers’ guidelines. Out of the seven clinic locations with deficiencies, the OIG found the following additional deficiencies: one clinic was missing nasal cannula and a glucose tube (Figure 1), and another clinic was missing a CPR micro-mask (MIT 5.111). California Men’s Colony, Cycle 5 Medical Inspection Page 30 Office of the Inspector General State of California • In only 6 of the 16 clinic examination rooms the OIG observed, (37.5 percent) inspectors found appropriate space, configuration, supplies, and equipment to allow clinicians to perform proper clinical examinations. In ten clinic locations, the following deficiencies were identified: patients lacked auditory privacy because they were examined in the same exam room at the same time; patients were unable to lie fully extended on the exam table due to physical obstructions; examination rooms had insufficient space (Figure 2); and confidential patient records were accessible to inmate-porters (Figure 3) (MIT 5.110). Figure 2: Insufficient patient Figure 3: Confidential patient records examination space accessible to inmate-porters • In 8 of the 16 clinics inspected, the OIG found that staff followed appropriate medical supply storage and management protocols (50.0 percent). At the remaining eight clinics, the OIG found the following deficiencies: medical supplies were not clearly identifiable; medical supplies were stored inappropriately in the same area with personal items belonging to staff; and medical supplies were stored beyond manufacturers’ guidelines (MIT 5.107). • Eight of the 16 clinic locations (50.0 percent) met compliance requirements for essential core medical equipment and supplies. The remaining eight clinics were missing one or more functional pieces of medical equipment necessary to conduct a comprehensive exam. The missing items included: a demarcation line for the Snellen eye exam chart, disposable paper for the exam table, hemoccult cards, peak flow meter, and disposable tips. Also, several oto- ophthalmoscopes were found non-operational at the time of inspection. In addition, the following equipment did not have current calibration stickers: weight scale, automated external defibrillator (AED), digital thermometer, and pulse oximeter (Figure 4) (MIT 5.108). Figure 4: Expired pulse oximeter calibration sticker California Men’s Colony, Cycle 5 Medical Inspection Page 31 Office of the Inspector General State of California • Health care staff at 9 of 16 clinics followed proper protocols to mitigate exposure to blood- borne pathogens and contaminated waste (56.3 percent). Six other clinics did not have puncture-resistant containers in exam rooms for medical staff to discard expended needles and sharps. In another clinic, personal protective equipment was not readily accessible to clinical staff (MIT 5.105). • Inspectors observed clinician encounters with patients in 16 clinics. Clinicians followed good hand hygiene practices in ten clinics (62.5 percent). At six clinic locations, clinicians failed to wash their hands before or after patient contact, or before applying gloves (MIT 5.104). • Clinic common areas at seven of ten clinics (70.0 percent) had environments conducive to providing medical services. In the remaining three clinics, the location of triage and vital signs stations compromised patients’ auditory privacy (MIT 5.109). Four tests received scores in the proficient range: • All 16 clinics were appropriately clean, disinfected, and sanitary. Also, cleaning logs were present and completed, indicating crews regularly cleaned the clinic (MIT 5.101). • The non-clinic bulk medical supply storage areas met the supply management process and supported the needs of the medical health care program, earning CMC a score of 100 percent on this test (MIT 5.106). • Clinical health care staff in 15 of the 16 applicable clinics (93.8 percent) properly sterilized or disinfected invasive and non-invasive medical equipment. One clinic did not properly process, package, or store a previously sterilized instrument (MIT 5.102). • Of the 16 clinics inspected, 15 of them had operating sinks and sufficient quantities of hand hygiene supplies in examination areas (93.8 percent). One clinic did not have sufficient quantities of hand hygiene supplies, such as disposable hand towels (MIT 5.103). Non-Scored Results The OIG gathered information to determine if the institution maintained its physical infrastructure in a manner that supported health care management’s ability to provide timely or adequate health care. The OIG does not score this question. • When OIG inspectors interviewed health care managers, they did not identify any significant concerns. At the time of the OIG’s medical inspection, CMC had several significant infrastructure projects underway, which included renovation of clinical areas, building a new pharmacy and laboratory, expanding medication distribution areas, and remodeling the TTA. These projects began in summer 2015, and the institution estimated they would complete the projects by spring 2019 (MIT 5.999). California Men’s Colony, Cycle 5 Medical Inspection Page 32 Office of the Inspector General State of California INTER- AND INTRA-SYSTEM TRANSFERS This indicator focuses on the management of patients’ medical needs Case Review Rating: and continuity of patient care during the inter- and intra-system Adequate transfer process. The patients reviewed for this indicator include Compliance Score: those received from, as well as those transferring out to, other CDCR Adequate (76.9%) institutions. The OIG review includes evaluation of the institution’s ability to provide and document health screening assessments, Overall Rating: initiation of relevant referrals based on patient needs, and the Adequate continuity of medication delivery to patients arriving from another institution. For those patients, the OIG clinicians also review the timely completion of pending health appointments, tests, and requests for specialty services. For patients who transfer out of the institution, the OIG evaluates the ability of the institution to document transfer information that includes pre-existing health conditions, pending appointments, tests and requests for specialty services, medication transfer packages, and medication administration before 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 10 patients who transferred into the institution, 3 patients who transferred out of the institution, and 18 patients that returned from a hospitalization or emergency department (ED). These reviews yielded 96 transfer events. For inter- and intra- system transfers, the OIG clinicians reviewed information from both the sending and receiving institutions. For hospital returns, the OIG clinicians reviewed the nursing assessments upon the patient’s return to CMC to determine whether the nurse notified the provider, implemented the hospital discharge recommendations, ensured medication continuity, and facilitated the plan of care. The OIG identified 34 deficiencies in the transfer events at CMC, of which four were significant. The case review rating for this indicator was adequate. Transfers In CMC performed well with patients transferring into the institution. The OIG clinicians reviewed ten patients who transferred into CMC and identified 12 deficiencies, only one of which was significant. Most deficiencies identified were minor and were related to incomplete nursing evaluations, slight lapses in medication therapy, or small delays in scheduling provider appointments for patients. These deficiencies occurred in cases 7, 8, 23, 31, and 32. In one case, there was a significant deficiency. • In case 33, the patient with chronic abdominal pain arrived at CMC complaining of ear and abdominal pain. The nurse was aware the patient had arrived with a prescription for antibiotics but failed to examine the patient’s ear and abdomen. Also, the patient answered California Men’s Colony, Cycle 5 Medical Inspection Page 33 Office of the Inspector General State of California “yes” to the tuberculosis (TB) screening risk factors of fever, night sweats, chills, and loss of appetite. However, the nurse did not address these symptoms. The transfer was suboptimal because the patient may have needed further evaluation in the triage and treatment area (TTA) after his arrival to CMC. The failure to transfer the newly-arrived patient to the TTA was a significant transfer deficiency. Transfers Out The OIG clinicians reviewed three patients who transferred out of CMC to other CDCR institutions and found nursing performance questionable. Nurses did not always perform face-to- face evaluations before patients transferred. Nurses sometimes failed to send patients to the receiving institution with their healthcare transfer information and medications, such as in the following example: • In case 34, the patient was transferred from the CMC’s correctional treatment center (CTC) to another CDCR institution, due to his worsening respiratory infection. The CMC nurse did not assess the patient prior to the transfer and did not complete the discharge summary. The nurse did not document the patient had refused his morning medications at the time of transfer or that he repeatedly refused to have his vital signs checked. The nurse also did not document that the patient had symptoms of coughing up blood and shortness of breath, and thus failed to communicate these issues to the staff at the receiving institution. Finally, the nurse failed to provide the patient with his rescue inhaler during the transport in case he developed shortness of breath. Hospitalizations Patients returning from hospitalizations are some of the highest-risk encounters due to two factors. First, these patients are usually admitted to the hospital for a severe illness or injury. Second, they are at risk due to potential lapses in care that can occur during any transfer. Out of 18 cases the OIG reviewed, there were 59 events where patients returned to CMC from an offsite hospital or emergency department (ED), and the OIG identified 21 deficiencies. Though overall performance in this area was acceptable for many of the patients, CMC had significant room for improvement for patients returning from a hospital or ED: • In cases 9 and 25, CMC did not ensure that the patient saw his provider within five days of his return from the hospital. • In cases 26 and 43, medication continuity was broken due to hospitalizations. • In cases 1, 3, 9, 11, 21, 23, and 26, providers did not sign hospital records. • In case 24, the nurse did not perform an assessment or evaluation of the patient when he returned from the hospital. California Men’s Colony, Cycle 5 Medical Inspection Page 34 Office of the Inspector General State of California • In case 26, the patient had a prolonged hospitalization for respiratory failure that included the use of a ventilator (a machine that provides mechanical breaths for the patient). After the patient returned to CMC, the TTA nurse incorrectly documented the patient had clear lungs, failed to measure the patient’s baseline airflows, and released the patient back to regular housing without informing the TTA provider. The patient developed shortness of breath two hours later and had to be transferred back to the TTA urgently. The patient was subsequently admitted to the CTC to further monitor his breathing. Clinician Onsite Inspection CMC has two receiving and release (R&R) areas, one on the west side, and the other on the east side of the institution. According to the institution’s nurses, the transfer process at CMC was challenging due to the increasing numbers of high-risk patients who were arriving with more complex conditions. The institution’s transition to the EHRS created some new challenges for nurses, which may have resulted in many of the deficiencies present in the Cycle 5 inspection. In response to the OIG questions about the deficiencies that occurred during the R&R and hospitalization return processes, the chief nursing executive (CNE) expressed a desire to improve communication between medical staff concerning patients returning from the hospital or offsite specialty care. The chief physician and surgeon (CP&S) said that the communication between the utilization management (UM) nurse and the providers was excellent; the UM nurse always kept providers abreast of their hospitalized patients and their need for further care when they returned from the hospital. Case Review Conclusion CMC’s performance for patients transferring in to the institution was acceptable but was inconsistent for patients transferring out of the institution. CMC did not always evaluate patients before they transferred out, send transfer information to the receiving institution, or provide patients with essential medications during their transfer. For patients returning from an outside hospital, nurses occasionally made errors with assessment, and providers did not consistently review and sign the discharge reports. Nevertheless, for most patients, the transfer process was acceptable, and the patients transferred without significant risk. The OIG clinicians rated the Inter- and Intra-system Transfers indicator adequate. Compliance Testing Results The institution obtained an adequate compliance score of 76.8 percent in the Inter- and Intra- System Transfers indicator, and received proficient scores on the following tests: • The OIG inspected the transfer packages of ten patients who were transferring out of the institution to determine whether the packages included required medications and support documentation. All ten transfer packages were compliant (MIT 6.101). California Men’s Colony, Cycle 5 Medical Inspection Page 35 Office of the Inspector General State of California • For 24 of 25 sampled patients who transferred into CMC (96.0 percent), nursing staff timely completed the assessment and disposition sections of the Initial Health Screening forms (CDCR Form 7277) on the same day staff performed the patients’ initial health screenings. For one patient, nursing staff failed to complete the assessment and disposition sections (MIT 6.002). CMC showed room for improvement on the following tests: • Of 25 sampled patients who transferred into CMC, 16 had an existing medication order upon arrival; 9 of those 16 patients (56.0 percent) received their medications without interruption. Six patients incurred medication interruptions of one or two dosing periods and for one patient, there was no evidence found that he received one of his ordered medications (MIT 6.003). • Among 20 sampled health care transfer forms for patients who transferred from CMC to other CDCR institutions, only 12 (60.0 percent) had all ordered specialty services appointments properly included on the form. Eight transfer forms sampled did not have all of the patients’ specialty services appointments listed (MIT 6.004). • The OIG tested 25 patients who transferred into CMC from other CDCR institutions to determine whether they received a complete initial health screening assessment from nursing staff on their day of arrival. CMC received a score of 72.0 percent for this test; nursing staff timely completed the assessment for only 18 of the sampled patients. For seven patients, nurses neglected to answer one or more of the screening form questions (MIT 6.001). California Men’s Colony, Cycle 5 Medical Inspection Page 36 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 Inadequate (62.8%) compliance test with case review analysis, this assessment identifies issues in various stages of the medication management process, Overall Rating: including ordering and prescribing, transcribing and verifying, Inadequate dispensing and delivering, administering, and documenting and reporting. Because numerous entities across various departments affect medication management, this assessment considers internal review and approval processes, pharmacy, nursing, health information systems, custody processes, and actions taken by the prescriber, staff, and patient. For this indicator, the case review and compliance review processes yielded different results, with the case review assigning an adequate rating and the compliance review resulting in an inadequate score. The main reason for the inadequate score during the compliance review was the institution’s poor performance in most areas of medication administration. CMC did not administer newly ordered medications correctly and did not maintain medication continuity for patients in the chronic care program, patients returning from the hospital, or transferring patients that had a layover at CMC on the way to another CDCR institution. The institution failed all but one test of its medication practices and storage controls. The compliance results were more representative of CMC’s performance in this indicator as the compliance tests comprised a more comprehensive approach to testing the processes involved. The overall rating for this indicator was inadequate. Case Review Results The OIG clinicians evaluated 131 events related to medications and found 16 deficiencies, 6 of which were significant. The case review rating for this indicator was adequate. Medication Continuity CMC usually ensured patients received their chronic care medications on time and without interruption. However, there was one significant deficiency which occurred when the provider reordered a medication: • In case 11, the patient experienced an unexpected break in medication continuity, which increased the patient’s risk for medical complications. Medication Administration CMC nurses were sometimes unable to administer prescribed medications timely and accurately. Nurses documented various reasons for not administering medications, such as the patient was California Men’s Colony, Cycle 5 Medical Inspection Page 37 Office of the Inspector General State of California not at the medication line to receive his monthly keep-on-person (KOP) medications, or the medications were not available upon hospital or specialty return. Nurses did not administer medications timely in cases 11, 26, 73, and in the following example: • In case 24, the patient was on anticoagulation therapy following a recent hospitalization. The provider prescribed a blood thinner for the patient. However, the patient received the blood thinner one week late, which was a significant lapse in anticoagulation therapy for this patient because he had a prosthetic aortic valve and therefore, an increased risk of developing a blood clot. Furthermore, when the patient was discharged from the CTC, he did not receive a prescribed antibiotic until two days later. Pharmacy Errors CMC had one error in the pharmacy process: • In case 21, the pharmacy ran out of immunotherapy medication for a cancer patient. The patient missed a total of nine doses before receiving the medication. Clinician Onsite Inspection During the onsite visit, the OIG clinicians met with the providers, nursing staff, and the pharmacist to discuss the case review findings. CMC staff acknowledged the deficiencies and provided information regarding the medication delays and errors. The medication nurses were knowledgeable regarding medication preparation and administration processes and procedures. Case Review Conclusion CMC performed well with chronic care medication continuity; however, the institution was inconsistent with administering medications. Nonetheless, most patients received their medications without excessive delay; thus, the indicator rating was adequate. Compliance Testing Results The institution received an inadequate compliance score of 62.3 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 In this sub-indicator, the institution received a score of 53.3 percent. The following tests were inadequate: • Clinical staff timely provided prescribed new and previously prescribed medications to only 6 of 25 sampled patients (24.0 percent) who were discharged from a community hospital and California Men’s Colony, Cycle 5 Medical Inspection Page 38 Office of the Inspector General State of California then returned to the institution. Seventeen patients’ medications were either provided or administrated later or were ordered outside of the required time frame. One other patient received one of his KOP medications from 7 to 23 days late, and there was no evidence found that he ever received his other KOP medication, a newly prescribed nitroglycerin. For one final patient, there was no evidence he ever received his ordered KOP inhaler (MIT 7.003). • Nursing staff administered medications without interruption to only three of ten patients sampled (30.0 percent) who were transported from one institution to another and had a temporary layover at CMC. For seven patients, there was no medical record evidence their medications were administered as ordered (MIT 7.006). • The institution timely administered or delivered new medication orders to 15 of the 25 patients sampled (60.0 percent). Nine patients received their nurse-administered or KOP medications from one to 30 days late. Another patient failed to report to the medication line, and nursing staff did not properly document the failure as required by CCHCS policy (MIT 7.002). • Among 22 sampled patients, 16 of them (72.7 percent) timely received their ordered chronic care medications. For two patients, there was no evidence found if patients received or refused chronic care medications. Two other patients’ refusals were not properly documented per CCHCS policy. Finally, two patients received their KOP medications 30 or more days late; one of those had multiple KOP medication supplies refilled within a shorter than normal replenishment time frame (MIT 7.001). One test earned a score in the adequate range: • Of the 25 sampled patients at CMC who transferred from one housing unit to another, 20 of them (80.0 percent) received their prescribed nurse-administered medications without interruption. Five patients did not receive their medication at the next dosing interval after the transfer occurred (MIT 7.005). Observed Medication Practices and Storage Controls The institution scored 50.3 percent in this sub-indicator, with the following tests scoring in the inadequate range: • Nursing staff at all six of the inspected medication preparation and administration areas did not demonstrate appropriate administrative controls and protocols, resulting in a score of zero on this test. One or more of the following deficiencies were identified in the six locations inspected: the medication nurse did not always ensure that patients swallowed direct observation therapy medication; and patients waiting to receive their medications did not have sufficient outdoor cover to protect them from heat or inclement weather (MIT 7.106). • The institution employed adequate security controls over narcotic medications in three of the nine applicable clinic and medication line locations where narcotics were stored California Men’s Colony, Cycle 5 Medical Inspection Page 39 Office of the Inspector General State of California (33.3 percent). At six locations, the narcotics logbook showed no evidence, for multiple dates, that two licensed nursing staff had performed a controlled substance inventory (MIT 7.101). • The OIG inspectors observed the medication preparation and administration processes at six applicable medication line locations. Nursing staff were compliant regarding proper hand hygiene and contamination control protocols at three locations (50.0 percent). At three other locations, not all nursing staff washed or sanitized their hands when required, such as before putting on gloves or before each subsequent re-gloving (MIT 7.104). • The institution properly stored non-narcotic refrigerated medications at five of the eight clinics and medication line storage locations (62.5 percent). Three locations did not have a designated area for refrigerated medications to be returned to the pharmacy (MIT 7.103). • CMC properly stored non-narcotic medications not requiring refrigeration in 8 of the 11 applicable clinic and medication line storage locations (72.7 percent). In three locations, one or more of the following deficiencies were observed: the medication area lacked a designated area for return-to-pharmacy medications; multi-use medication was not labeled with the date it was opened; and medications were stored in the same area with personal food items and staff belongings (MIT 7.102). One test received a score of adequate: • Nursing staff at five of the six inspected medication line locations (83.3 percent) employed appropriate administrative controls and followed appropriate protocols during medication preparation. At one medication line location, nursing staff did not have a system to validate if newly received medications were correct through reconciling those medications with the physician’s orders (MIT 7.105). Pharmacy Protocols CMC scored 87.2 percent in this sub-indicator, with the following tests earning proficient scores: • CMC’s main and satellite pharmacy locations followed general security, organization, and cleanliness management protocols; properly stored non-refrigerated and refrigerated medications; and maintained adequate controls over and properly accounted for narcotic medications (MIT 7.107, 7.108, 7.109, 7.110). The following tests received inadequate scores: • The institution’s pharmacist in charge (PIC) followed required protocols for 9 of the 25 medication error reports and monthly statistical reports reviewed (36.0 percent). For 11 medication error reports, the PIC completed medication error follow-up review reports from California Men’s Colony, Cycle 5 Medical Inspection Page 40 Office of the Inspector General State of California one to 24 days late. For five other reports, the PIC did not submit the monthly medication error statistical report for June 2017 (MIT 7.111). Non-Scored Tests • In addition to the OIG’s testing of reported medication errors, inspectors follow up on any significant medication errors found during compliance testing to determine whether CMC properly identified and reported errors. The OIG provides those results for information purposes only. At CMC, the OIG did not find any applicable medication errors (MIT 7.998). • The OIG interviewed patients in isolation units to determine whether they had immediate access to their prescribed KOP rescue inhalers and nitroglycerin medications. All ten of the sampled patients had access to their rescue inhalers or nitroglycerin medications (MIT 7.999). California Men’s Colony, Cycle 5 Medical Inspection Page 41 Office of the Inspector General State of California PRENATAL AND POST-DELIVERY SERVICES This indicator evaluates the institution’s capacity to provide timely Case Review Rating: and appropriate prenatal, delivery, and postnatal services to pregnant Not Applicable patients. This includes the ordering and monitoring of indicated Compliance Score: screening tests, follow-up visits, referrals to higher levels of care, Not Applicable e.g., high-risk obstetrics clinic, when necessary, and postnatal Overall Rating: follow-up. Not Applicable As CMC does not have female patients, this indicator does not apply. California Men’s Colony, Cycle 5 Medical Inspection Page 42 Office of the Inspector General State of California PREVENTIVE SERVICES This indicator assesses whether the institution offered or provided Case Review Rating: various preventive medical services to patients. These include cancer Not Applicable screenings, tuberculosis screenings, and influenza and chronic care Compliance Score: immunizations. This indicator also assesses whether certain Adequate (77.4%) institutions take preventive actions to relocate patients identified as being at higher risk for contracting coccidioidomycosis Overall Rating: (valley fever). Adequate The OIG rates this indicator entirely through the compliance testing component; the case review process does not include a separate qualitative analysis for this indicator. Compliance Testing Results The institution scored in the adequate range for this indicator at 77.4 percent. The following four tests were in the proficient range: • All 25 patients sampled timely received or were offered influenza vaccinations during the most recent influenza season (MIT 9.004). • The OIG found that 29 of the 30 patients sampled (96.7 percent) received annual tuberculosis (TB) screenings during their birth month as required by current CCHCS policy. Nursing staff did not properly complete the annual TB screening form for one patient (MIT 9.003). • CMC offered colorectal cancer screenings to 22 of the 25 sampled patients (88.0 percent) subject to the annual screening requirement. For three patients, there was no medical record evidence 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). • CMC scored 87.5 percent for the timely administration of TB medications to its patients. Of 24 sampled patients, 21 of them received their medication timely, while 3 patients missed one or more scheduled doses and did not receive provider counseling regarding their missed doses (MIT 9.001). One test received an adequate score: • The OIG tested whether CMC offered required influenza, pneumonia, and hepatitis vaccinations to patients who suffered from a chronic condition; 12 of the 16 sampled patients (75.0 percent) were timely offered the vaccinations. For the other four patients, the OIG found no evidence the patients had been offered or evidence the patients had received one or more of the required vaccinations (MIT 9.008). California Men’s Colony, Cycle 5 Medical Inspection Page 43 Office of the Inspector General State of California Two tests were inadequate: • The OIG tested 20 patients who during the testing period were medically restricted and ineligible to reside at CMC because of their elevated risk of contracting the coccidioidomycosis infection (valley fever) to determine if the patients were transferred out of the institution within 60 days from the time they were initially determined to be ineligible. The institution transferred 8 of the 20 sampled patients (40.0 percent) from the institution timely. Of the other 12 patients that were not timely transferred out of the institution, three patients were transferred between 52 and 247 days late, one patient was transferred 659 days late, one patient was transferred 1,309 days late, and seven patients were still housed at CMC at the time of the inspection (MIT 9.009). • The institution scored poorly in monitoring patients receiving TB medications. Only 12 of 22 patients sampled (54.6 percent) received monitoring at all required intervals. For ten other patients, staff either failed to complete monitoring at all required intervals or failed to timely scan monitoring forms into the patient’s medical record (MIT 9.002). California Men’s Colony, Cycle 5 Medical Inspection Page 44 Office of the Inspector General State of California QUALITY OF NURSING PERFORMANCE The Quality of Nursing Performance indicator is a qualitative Case Review Rating: evaluation of the institution’s nursing services. The evaluation is Adequate completed entirely by OIG nursing clinicians within the case review Compliance Score: process and does not have a score under the OIG compliance testing Not Applicable component. Case reviews include face-to-face encounters and Overall Rating: indirect activities performed by nursing staff on behalf of the patient. Adequate Review of nursing performance includes all nursing services performed onsite, such as outpatient, inpatient, urgent/emergent, patient transfers, care coordination, and medication management. The key focus areas for evaluation of nursing care include appropriateness and timeliness of patient triage and assessment, identification and prioritization of health care needs, use of the nursing process to implement interventions, and accurate, thorough, and legible documentation. Although the OIG reports nursing services provided in specialized medical housing units in the Specialized Medical Housing indicator, and those provided in the TTA or related to emergency medical responses in the Emergency Services indicator, this Quality of Nursing Performance indicator summarizes all areas of nursing services. Case Review Results The OIG clinicians reviewed 437 nursing encounters, 194 of which were in the outpatient setting. Most outpatient nursing encounters were for sick call requests, walk-in visits, and RN follow-up visits. In all, there were 145 deficiencies identified related to nursing performance, 21 of which were significant. The case review rating for this indicator was adequate. Nursing Assessment and Intervention Most nurses at the institution performed appropriate patient evaluations, which included both subjective and objective assessments. Nurses usually identified serious conditions and made appropriate interventions. Most deficiencies the OIG clinicians identified were minor, but the following cases are examples of significantly inadequate nursing assessment: • In case 33, the patient, who had prior bowel obstructions, complained of stomach pain. The licensed vocational nurse (LVN) failed to check the patient’s vital signs and did not ask if the patient had any associated nausea, vomiting, or diarrhea. The LVN provided the patient a note to excuse him from work or school for two days but did not inform the RN or provider of the patient’s condition. The next day, the patient had to be transferred to an outside hospital for bowel obstruction. The LVN’s failure to perform a complete assessment significantly increased the patient’s risk of developing a bowel perforation and a severe infection. California Men’s Colony, Cycle 5 Medical Inspection Page 45 Office of the Inspector General State of California • In case 43, the patient had back pain, a severe headache, and severely elevated blood pressure. The nurse mistakenly used the joint pain protocol to evaluate the patient instead of the headache treatment protocol, which would have led the nurse to evaluate the patient for signs of stroke and prompted the nurse to refer the patient to a provider urgently. Instead, the nurse failed to address the patient’s severely elevated blood pressure and headache and sent the patient back to his housing unit with instructions to follow up in two weeks. This error significantly increased the patient’s risk of developing a heart attack or a stroke. Six days later, the patient required an emergency transfer to an outside hospital. Had the nurse chosen the correct treatment protocol and notified a provider about the patient’s condition, the patient’s transfer might have been prevented. Nursing Documentation Nursing documentation was satisfactory; OIG clinicians identified only minor nursing deficiencies for incomplete documentation that were not likely to increase the risk of harm. Nursing Sick Call The OIG clinician reviewed 131 nursing sick call encounters. In most cases, CMC nurses reviewed sick call requests timely and evaluated patients the same day or the next business day. Although most of the nursing sick call encounters were satisfactory, nursing deficiencies were frequent and minor. However, the following are two significant deficiencies that may have contributed to preventable hospitalizations: • In case 23, the patient complained of pain with breathing and shortness of breath for the past two days. The nurse did not immediately examine the patient, and the next day the patient required hospitalization for pneumonia and fluid around his lung. By failing to examine the patient, the nurse increased the patient’s risk of pneumonia complications. • In case 67, the patient was coughing up green sputum and using his inhalers frequently. After reviewing the patient’s sick call slip, the nurse failed to urgently see the patient that same day and instead scheduled a follow-up appointment for the next day. Later that afternoon, the patient developed respiratory distress and required hospitalization for pneumonia. Urgent/Emergent Care When faced with a cardiac arrest, CMC staff provided adequate CPR response. However, in many other urgent situations, the TTA nurses made critical assessment errors. The Emergency Services indicator discusses this performance further. Care Management CMC had RN care managers assigned in each clinic. Their main responsibility was to ensure the high-risk and chronic care patients were receiving care promptly. The west side of the institution had four RN care managers, and the east side had two care managers. According to the nurses, California Men’s Colony, Cycle 5 Medical Inspection Page 46 Office of the Inspector General State of California their interventions and daily patient follow-ups were not always documented in the electronic medical record, which may explain why the OIG rarely observed care management during this review period. Inter- and Intra-System Transfers CMC nurses appropriately coordinated patient care during the transfer process. The TTA nurse appropriately evaluated patients after they returned from an outside hospital. The Inter- and Intra-System Transfers indicator discusses this performance further. Specialized Medical Housing While nursing performance was satisfactory in the CTC, a few nursing deficiencies occurred. The Specialized Medical Housing indicator discusses this performance in more detail. Offsite Specialty Services Returns CMC nurses provided appropriate care to patients returning from offsite specialty appointments. This is discussed more in the Specialty Services indicator. Medication Management The institution’s nurses usually provided timely administration and delivery of medications to patients; however, OIG clinicians identified some delays in several cases reviewed. These delays are discussed in more detail in the Pharmacy and Medication Management indicator. Clinician Onsite Inspection The OIG clinicians met with CMC’s CNE and RN supervisors to discuss the case reviews and onsite findings. CMC’s medical leadership were aware most case reviews were performed during the EHRS implementation and noted their nursing staff was challenged with learning this new system. Also, the OIG clinicians observed morning huddles that were organized, in which the staff made appropriate interdisciplinary care plans for their patients. The overall morale of CMC’s medical staff was good. According to clinic staff, RN supervisors were supportive and communicated with them daily. Case Review Conclusion While the OIG clinicians identified frequent deficiencies in nursing assessments and with sick call, most of the deficiencies did not severely increase the risk of patient harm, with the exception of emergency services. The institution’s nursing staff provided care that was timely and appropriate; therefore, the Quality of Nursing Performance indicator was adequate. California Men’s Colony, Cycle 5 Medical Inspection Page 47 Office of the Inspector General State of California QUALITY OF PROVIDER PERFORMANCE In this indicator, the OIG physicians provide a qualitative evaluation Case Review Rating: of the adequacy of provider care at the institution. The case review Adequate clinicians review the provider care regarding appropriate evaluation, Compliance Score: diagnosis, and management plans for programs including, but not Not Applicable limited to, nursing sick call, chronic care programs, TTA, specialized Overall Rating: medical housing, and specialty services. Adequate OIG physicians alone assess provider care. There is no compliance testing component associated with this quality indicator. Case Review Results The OIG clinicians reviewed 379 medical provider encounters and identified 58 deficiencies related to provider performance, 17 of which were significant. Of the 25 cases reviewed, 2 received proficient ratings, 21 cases received adequate ratings, and 2 cases were inadequate. CMC provider performance was adequate overall. Assessment and Decision-Making CMC providers usually made sound assessments and good decisions. Overall performance in this area helped CMC deliver quality care to its patients. However, CMC providers were not always consistent with their assessments or decisions and made these errors with high frequency. There were problems with CMC providers’ assessments or decisions in nearly all cases reviewed by OIG physicians. Nonetheless, most of the deficiencies were minor and did not significantly increase the risk of harm to the patients. The following are some rare exceptions: • In case 27, the provider did not address the new finding of the patient’s low blood pressure. The patient had been vomiting and was not eating or drinking. The patient might have been dehydrated, but the provider ignored the findings. The provider should have obtained orthostatic blood pressure checks (tests performed while the patient was lying, sitting, and standing to determine if the patient was dehydrated). The provider should have performed a physical examination to determine if the patient required intervention and should have scheduled a close follow-up. Instead, the provider did not sufficiently examine the patient and ordered a 6-month follow-up. Fortunately, these errors did not result in harm. • In case 29, the patient complained of his throat closing and choking when he ate. The provider did not examine the patient. Fortunately, another provider examined him a few days later and ensured that the patient received the care he needed. California Men’s Colony, Cycle 5 Medical Inspection Page 48 Office of the Inspector General State of California Review of Records CMC had a multitude of complex patients requiring specialty consultations and transfers to higher levels of care. The providers usually reviewed those reports thoroughly and implemented the needed care. However, providers occasionally did not review the available medical records sufficiently to implement their patient’s plan of care properly. Eight of these deficiencies occurred in cases 1, 16, 27, 30, 69, and the following: • In case 11, the patient had significant cardiac disease and two recent transfers to outside emergency departments for chest pain. After experiencing chest pain and almost fainting, the patient was sent to an emergency room. The provider failed to review the emergency department records sufficiently and overlooked findings that were worrisome for significant heart disease and placed the patient at risk for a heart attack. The provider should have ordered an urgent cardiac stress test or a cardiology consult. • In case 15, the provider did not review the patient’s consistently elevated blood sugars. This mistake contributed to the provider’s inaccurate assessment and prolonged the period of poor blood sugar control for the patient. • In case 24, the provider noted the patient was taking an important anticoagulation medication. However, the provider had not reviewed the records appropriately, as the patient’s medication had been stopped three days prior. Chronic Care CMC providers excelled in nearly all aspects of chronic care. Providers regularly monitored, assessed, and treated the medically complex patients appropriately. The providers referred their patients to specialists and transferred their patients to higher levels of care when warranted. Despite the overall good performance, CMC providers had occasional difficulty with some chronic conditions. Providers often did not request follow-up appointments at appropriate intervals for their patients with uncontrolled diabetes: • In case 15, the provider did not review the patient’s blood sugars, which indicated poorly controlled diabetes. Even after reviewing a separate laboratory report that also showed uncontrolled diabetes, the provider requested a lengthy 90-day follow-up for the patient. • In case 17, the provider ordered a lengthy 60-day follow-up for a patient with out-of-control diabetes. • In case 19, the patient was having recurrent hypoglycemic (low blood sugar) episodes while he was taking new diabetic medications. The provider ordered a follow-up with a lengthy interval, placing the patient at risk for recurrent hypoglycemia and its possible serious side effects. California Men’s Colony, Cycle 5 Medical Inspection Page 49 Office of the Inspector General State of California Specialty Services CMC specialty care was excellent. The providers requested specialty consultations appropriately and reviewed the specialty reports timely. CMC managed anticoagulation patients well; the providers monitored their patients closely to minimize the risk of adverse side effects from the blood thinner medications. Emergency Care Emergency care was satisfactory. CMC providers often made appropriate triage decisions when patients arrived emergently at the TTA. The mistakes providers did make were usually in the management of cardiovascular care. The Emergency Services indicator also discusses performance in this area. Specialized Medical Housing CMC providers excelled in specialized medical housing. There were several documentation deficiencies, most of which were minor. CMC providers saw their CTC patients daily, monitored their patients’ conditions, and formulated appropriate plans for their sicker patients. Clinician Onsite Inspection The OIG found that CMC providers were completely satisfied with their work and ancillary services. Providers felt supported by their medical leadership and described their environment as close-knit and collegial. At CMC, providers valued learning and practicing evidence-based medicine. Access to specialty care was readily available. The providers described good relationships with specialists. These relationships were built and maintained through effective communication and mutual respect. Case Review Conclusion Provider care was appropriate most of the time. Although, providers could be more consistent with their assessments and decisions, as well as ensure they review records thoroughly. For emergency services, the providers should follow standards of cardiac care closer. For chronic care, the providers should see their patients with poorly controlled diabetes more often. Nonetheless, when CMC providers made errors, they were usually minor and they usually corrected them quickly. Overall, CMC providers delivered good medical care. Considering all factors, the OIG rated the Quality of Provider Care indicator adequate. California Men’s Colony, Cycle 5 Medical Inspection Page 50 Office of the Inspector General State of California RECEPTION CENTER ARRIVALS This indicator focuses on the management of medical needs and Case Review Rating: continuity of care for patients arriving from outside the CDCR Not Applicable system. The OIG review includes evaluation of the ability of the Compliance Score: institution to provide and document initial health screenings, initial Not Applicable health assessments, continuity of medications, and completion of Overall Rating: required screening tests; address and provide significant Not Applicable accommodations for disabilities and health care appliance needs; and identify health care conditions needing treatment and monitoring. The patients reviewed for reception center cases are those received from non-CDCR facilities, such as county jails. CMC does not have a reception center; therefore, this indicator does not apply. California Men’s Colony, Cycle 5 Medical Inspection Page 51 Office of the Inspector General State of California SPECIALIZED MEDICAL HOUSING This indicator addresses whether the institution follows appropriate Case Review Rating: policies and procedures when admitting patients to onsite inpatient Adequate facilities, including completion of timely nursing and provider Compliance Score: assessments. The case review assesses all aspects of medical care Proficient (90.0%) related to these housing units, including quality of provider and nursing care. CMC’s only specialized medical housing unit is a Overall Rating: correctional treatment center (CTC). Adequate For this indicator, our case review and compliance testing yielded different results, with the case reviewers assigning an adequate rating and the compliance testing resulting in a proficient score. In this indicator, there were only four compliance tests which marginally affected the quality of patient care. Therefore, we heavily relied upon the case review rating for the overall rating of this indicator, which was adequate. Case Review Results CMC has a 37-bed CTC, of which only seven beds were occupied during the OIG onsite inspection. The OIG clinicians reviewed 269 events, including 89 provider events and 82 nursing events. There were 36 deficiencies identified, including seven minor provider deficiencies and 22 nursing deficiencies, two of which were significant. The case review rating for this indicator was adequate. Provider Performance Provider care within the CTC was excellent. The OIG clinicians reviewed 99 provider encounters in the CTC and identified only seven minor deficiencies. The providers saw their patients often and reviewed nursing notes for changes in the patient’s medical condition. The diligence of the providers ensured they delivered good care for their patients. Nursing Performance Nurses usually provided good care in the CTC. Most nursing encounters included appropriate nursing assessments, timely treatment interventions, and good documentation. Although, some nursing assessments were problematic and resulted in deficiencies in cases 24, 73, 74, and the following: • In case 26, the patient returned from a hospitalization for pneumonia. The patient fell and sustained a rib injury while in the hospital. When the patient was admitted to the CTC, the nurse did not assess the patient’s risk for falls. • Also in case 26, during a different CTC admission, the patient had a surgical wound where his chest tube was removed. Nursing staff did not evaluate this wound for nine days. Additionally, the patient had an intravenous (IV) catheter to administer medications and California Men’s Colony, Cycle 5 Medical Inspection Page 52 Office of the Inspector General State of California fluids. The CTC nurses did not change the patient’s IV site for eight days, even though the standard is to change IV sites every 72-96 hours (or sooner if signs of infection occur). Furthermore, failure to change IV sites appropriately places the patient at increased risk of developing vein inflammation or infection. The nursing care plan did not include patient- specific goals and interventions for the patient’s IV site care and compromised respiratory status. The nursing care plan is an essential tool to communicate a patient’s health care needs and to provide consistent and individualized patient care. CTC nurses frequently did well in initiating nursing care plans. However, nurses did not initiate care plans to address patients’ health care needs in cases 24, 26, 73, and 74. The OIG clinicians identified a nurse’s response to an encounter in the CTC that exemplifies good nursing performance: • In case 24, the patient returned from an 11-day hospitalization for a surgical prosthetic valve replacement. The patient had been in the CTC for one day, when he began to perspire, became cool to touch, and developed abnormally low blood pressure of 75/82 (normal 120/80). The nurse immediately contacted the provider, lowered the head of the bed which elevated the patient’s legs to increase circulation to the brain and heart, and started an intravenous line to administer fluids. The nurse performed an EKG (electrocardiogram) and the results indicated a possible a heart attack. The nurse’s prompt and efficient interventions helped transfer the patient to a community hospital immediately, where he was diagnosed with an internal bleed. Medication Management Medication management in the CTC was sufficient. Deficiencies occurred in cases 73, 74, and the following cases: • In case 24, there was a significant lapse in medication therapy. The provider ordered anticoagulation (blood thinning medication) treatment, but the patient did not receive the medication for seven days. Fortunately, the lapse in anticoagulation treatment medication did not cause a bad outcome. • In case 26, the patient did not receive his chronic care medications until two days after he was admitted to the CTC. Clinician Onsite Inspection Due to construction work on the first floor, only patients who could independently use the stairs were housed on the second floor of the CTC. The CTC had two negative pressure rooms. At the time of the OIG inspection, some CTC patients were undergoing antibiotic or cancer treatments and had various intravenous access devices. A dedicated provider cared for the CTC patients and California Men’s Colony, Cycle 5 Medical Inspection Page 53 Office of the Inspector General State of California rounded on the patients daily. There were two RNs and one charge nurse caring for seven patients in the CTC. No patients were in isolation for infection control precautions. The patients did not have complex conditions. They had pneumonia, required a special diet for wired jaws, or needed wound care. The medical staff knew their patients’ conditions well and expressed satisfaction with all aspects of the delivery of medical services to patients in the CTC. Case Review Conclusion The CMC providers and nurses performed well with respect to CTC care. Most deficiencies were minor and did not place patients at serious risk of harm. The CTC nurses could be more consistent in making careful assessments and ensuring proper medication administration. The overall medical care provided to patients in the CTC was appropriate; therefore, the case review rating for this indicator was adequate. Compliance Testing Results The institution received a score of 90.0 percent in this indicator. Three tests earned scores in the proficient range: • Nursing staff timely completed an initial health assessment for all ten patients sampled on the day the patient entered the CTC (MIT 13.001). • Providers evaluated all ten patients sampled within 24 hours of admission to the CTC and also completed the required history and physical (MIT 13.002). • When OIG inspectors observed the condition of call buttons in the CTC patient rooms, they found those that were tested all worked properly. Also, according to staff members interviewed, custody officers and clinicians could expeditiously access patients’ locked rooms when emergent events occurred (MIT 13.101). One test did indicate room for improvement: • When OIG inspectors tested whether providers had completed their Subjective, Objective, Assessment, Plan, and Education (SOAPE) notes at the required three-day intervals, they found that providers timely completed SOAPE notes for six of the ten sampled patients (60.0 percent). Provider notes were one day late for four patients (MIT 13.003). California Men’s Colony, Cycle 5 Medical Inspection Page 54 Office of the Inspector General State of California SPECIALTY SERVICES This indicator focuses on specialist care from the time a physician Case Review Rating: completes a request for services or a physician’s order for specialist Adequate care to the time of receipt of related recommendations from Compliance Score: specialists. This indicator also evaluates the providers’ timely review Inadequate (59.0%) of specialist records and documentation reflecting the patients’ care plans, including the course of care when specialist recommendations Overall Rating: were not ordered, and whether the results of specialists’ reports are Inadequate communicated to the patients. For specialty services denied by the institution, the OIG determines whether the denials are timely and appropriate and whether the provider updates the patient on the plan of care. In this indicator, the OIG case review and compliance review processes yielded different results, with the case reviewers assigning an adequate rating and the compliance testing resulting in an inadequate score. Both compliance testing and case reviewers agreed CMC performed well with routine specialty referrals. However, the reasons for the inadequate compliance score included: CMC’s inability to meet high-priority specialty referral time frames, poor compliance with the requirement to sign and review specialty reports, and CMC’s inability to provide specialty services for newly-arrived patients with preapproved specialty referrals. The case review samples had limited numbers of these important situations, with the most concerning being the delayed high- priority specialty referrals. The OIG experts relied heavily upon compliance scores for the overall rating of this indicator and rated this indicator inadequate. Case Review Results The OIG clinicians reviewed 264 events related to specialty services, the majority of which were specialty consultations and procedures. Twenty-five deficiencies occurred in this category, three of which were significant. The case review rating for this indicator was adequate. Access to Specialty Services Access to specialty services at CMC was good. Only two minor deficiencies were identified, and they did not affect the overall care of the patient or delay services provided. Nursing Performance Nursing performance in specialty services at CMC was poor. The OIG clinicians found a pattern of failures of CMC nurses to review recommendations from the specialist thoroughly or to inform the provider of these recommendations. This pattern occurred in cases 21, 27, 57, and 73. At times, the nurses failed to perform proper face-to-face evaluations when the patient returned from their offsite specialty appointments. The following are a few examples of poor nursing performance: California Men’s Colony, Cycle 5 Medical Inspection Page 55 Office of the Inspector General State of California • In case 21, the nurse did not perform a face-to-face evaluation of the patient who had returned from seeing the oncologist (a cancer doctor). Also, the nurse failed to review or process the oncologist’s recommendations to perform further imaging tests, resulting in a one-week delay before CMC staff performed the CT scan. • In case 57, the offsite oncologist recommended restarting the patient on prednisone (a steroid medication used to treat some cancers). The nurse failed to thoroughly review these recommendations and started the patient on prednisone four days later than the date requested by the oncologist, which was a significant lapse in nursing care. Provider Performance CMC providers performed well with specialty services. The providers appropriately identified medical ailments that required specialty consultation and addressed these concerns efficiently and judiciously. There were only four minor deficiencies. On several occasions, the providers did not sign the specialty reports; however, the providers reviewed the reports thoroughly and discussed the recommendations with their patients at the subsequent specialty follow-up appointment. Health Information Management CMC handled specialty reports well. The OIG found several minor deficiencies resulting from providers not always signing those reports. The two significant deficiencies that occurred did not suggest there were any problems with the specialty report handling process. CMC staff appropriately retrieved and scanned nearly all the specialty documentation into the EHRS. Clinician Onsite Inspection CMC’s specialty department was separated into three divisions: telemedicine, onsite consultation services, and offsite consultation services. The providers reported close relationships with the offsite specialists. These specialists were readily available by phone to clarify or elaborate on the patient’s medical concerns. The relationships providers had with the community specialists were collegial. Onsite specialists included one physiatrist (a specialist that treats injuries to the muscles, bones, ligaments, or nervous system). This physiatrist was a unique and highly-valued provider at CMC because this provider managed many patients with chronic pain efficiently and without the need to send the patients offsite. Medical staff and leadership were very pleased with the access and quality of specialty services. Case Review Conclusion CMC performed well with specialty access and with retrieving specialty reports. Providers ordered specialty consultations appropriately but did not always sign the specialty reports. CMC nurses often did not carefully examine their patients when they returned from the offsite consultations. The OIG clinicians rated the Specialty Services indicator adequate. California Men’s Colony, Cycle 5 Medical Inspection Page 56 Office of the Inspector General State of California Compliance Testing Results The institution received a score of 59.0 percent in this indicator, with the following five tests scoring in the inadequate range: • When patients are approved or scheduled for specialty services at one institution and then transfer to another, CCHCS policy requires that the receiving institution reschedule and provide the patient’s appointment within a required time frame. Only 2 of the 20 applicable patients sampled (10.0 percent) who transferred to CMC with approved specialty services received their appointments within the required time frame. The institution held four patients’ appointments from 10 to 44 days late, and one patient’s more than three months late. For 14 other patients, there was no evidence they ever received their appointments (MIT 14.005). • Of the 15 patients sampled, 6 of them (40.0 percent) received or refused their high-priority specialty services appointment or service within 14 calendar days of the provider’s order. Nine patients received their specialty service from 4 to 27 days late (MIT 14.001). • Providers timely received and reviewed 8 of the 15 routine specialists’ reports that inspectors sampled (53.3 percent). For three patients, providers reviewed the reports from 8 to 14 days late; for four other patients, OIG inspectors found no medical record evidence providers reviewed their reports (MIT 14.004). • Among 19 applicable patients sampled for whom CMC’s health care management denied a specialty service, only 12 of them (63.2 percent) received timely notification of the service denial, including a provider meeting with the patient within 30 days to discuss alternate treatment strategies. For three patients, the providers’ follow-up visits occurred one, three, and ten days late; three other patients’ visits occurred 25, 52, and 82 days late. For one final patient, there was no provider follow-up to discuss the denial (MIT 14.007). • Providers timely received and reviewed the specialists’ reports for 11 of the 15 patients sampled (73.3 percent). CMC retrieved one report four days late; a provider signed another report 32 days late. Two other reports were not found in the electronic medical records (MIT 14.002). One test received an adequate score: • CMC denied providers’ specialty services requests timely in 16 of 20 sampled patients (80.0 percent). The institution denied four specialty services requests between one and four days late (MIT 14.006). California Men’s Colony, Cycle 5 Medical Inspection Page 57 Office of the Inspector General State of California One test earned a proficient score: • CMC provided routine priority specialty service appointments to 14 of 15 patients sampled (93.3 percent) within the required time frame. One patient received his appointment 40 days late (MIT 14.003). California Men’s Colony, Cycle 5 Medical Inspection Page 58 Office of the Inspector General State of California ADMINISTRATIVE OPERATIONS (SECONDARY) This indicator focuses on the institution’s administrative health care Case Review Rating: oversight functions. The OIG evaluates whether the institution Not Applicable promptly processes patient medical appeals and addresses all Compliance Score: appealed issues. Inspectors also verify that the institution follows Proficient (88.5%) reporting requirements for adverse/sentinel events and patient deaths. The OIG verifies that the Emergency Medical Response Review Overall Rating: Committee (EMRRC) performs required reviews and that staff Proficient perform required emergency response drills. Inspectors also assess whether the Quality Management Committee (QMC) meets regularly and adequately addresses program performance. For those institutions with licensed facilities, inspectors also verify that required committee meetings are held. In addition, the OIG examines whether the institution adequately manages its health care staffing resources by evaluating whether job performance reviews are completed as required; specified staff possess current, valid credentials and professional licenses or certifications; nursing staff receive new employee orientation training and annual competency testing, and clinical and custody staff have current emergency medical response certifications. The Administrative Operations indicator is a secondary indicator; therefore, it was not relied on for the institution’s overall score. Compliance Testing Results The institution received a proficient score of 88.5 percent in this indicator, with multiple tests scoring in the proficient range: • The institution promptly processed all patient medical appeals in each of the most recent 12 months (MIT 15.001). • CMC’s QMC met monthly, evaluated program performance, and took action when management identified areas for improvement opportunities (MIT 15.003). • CMC took adequate steps to ensure the accuracy of its Dashboard data reporting (MIT 15.004). • The OIG inspectors reviewed the last 12 months of CMC’s local governing body (LGB) meeting minutes and determined the LGB met at least quarterly and exercised responsibility for the quality management of patient heath care each quarter, as documented in the meeting minutes (MIT 15.006). • The OIG inspectors reviewed drill packages for three emergency medical response drills conducted during the prior quarter and found they were all properly completed. Also, the drills included participation by both health care and custody staff (MIT 15.101). California Men’s Colony, Cycle 5 Medical Inspection Page 59 Office of the Inspector General State of California • Based on a sample of ten second-level medical appeals, the institution’s responses addressed all of the patients’ appealed issues (MIT 15.102). • The OIG reviewed performance evaluation packets for CMC’s 12 providers, and CMC met all performance review requirements for them (MIT 15.106). • All providers at the institution were current with their professional licenses. Similarly, all nursing staff and the pharmacist in charge were current with their professional licenses and certification requirements (MIT 15.107, 15.109). • All nurses and active-duty providers were current with their emergency response certifications (MIT 15.108). • All pharmacy staff and providers who prescribed controlled substances had current Drug Enforcement Agency registrations (MIT 15.110). • All nursing staff hired within the last year had received new employee orientation training promptly (MIT 15.111). One test earned an adequate score: • The OIG examined 12 of the institution’s Emergency Medical Response Review Committee (EMRRC) incident packages for emergency medical responses during the prior six-month period. Nine of the 12 packages (75 percent) complied with policy. Three of the packages contained incomplete checklists (MIT 15.005). Three tests earned scores in the inadequate range: • The OIG inspected records from July 2017 for five nurses to determine whether their nursing supervisors properly completed monthly performance reviews. Inspectors identified the following deficiencies for the five nurses’ monthly nursing reviews (MIT 15.104): o The supervisor’s review did not summarize aspects that were well done for five nurses; o The supervisor's review did not summarize aspects that needed improvement for two nurses. • Seven of the ten nurses sampled (70.0 percent) were current with their clinical competency validations. Three nurses did not receive a clinical competency validation within the required time frame (MIT 15.105). • Seven patient deaths occurred at CMC during the OIG’s sample test period. Medical staff reviewed and timely submitted the Initial Inmate Death Report (CDCR Form 7229A) to California Men’s Colony, Cycle 5 Medical Inspection Page 60 Office of the Inspector General State of California CCHCS’ Death Review Unit for five patient deaths, resulting in a score of 71.4 percent. For two patient deaths, the institution did not use the correct form to report the deaths, and for one of those deaths, the notification to the CCHCS’ Death Review Unit was one day late (MIT 15.103). Non-Scored Results • The OIG gathered non-scored data regarding the CCHCS Death Review Committee (DRC) completing its death review reports. Seven unexpected (Level 1) deaths occurred during the OIG’s review period. The DRC was required to complete its death review summary reports within 60 calendar days from the dates of death and submit these reports to the institution’s CEO within seven calendar days after that. None of the death review reports at CMC met CCHCS reporting guidelines. The DRC timely completed one report but submitted it to CMC’s CEO 269 days late. Three reports were completed 21, 57, and 68 days late and submitted to CMC’s CEO 43, 59, and 74 days late. For three other reports, there was no evidence found that final death review summaries had been completed at the time of the OIG’s inspection (MIT 15.998). • The OIG discusses the institution’s health care staffing resources in the About the Institution section of this report (MIT 15.999). California Men’s Colony, Cycle 5 Medical Inspection Page 61 Office of the Inspector General State of California R ECOMMENDATIONS • The CEO should rectify the EMRRC review process because the committee failed to identify problems with the care provided by the TTA providers and nurses. The institution needs a properly functioning EMRRC to identify and correct its various lapses in emergency care. • The CEO should analyze and adjust many of the pharmacy and nursing processes because the institution demonstrated poor compliance with most measures of medication administration, observed medication practices, and storage controls. • The CEO should identify and correct several specialty services processes because of the institution’s problems with scheduling urgent specialty referrals and providing follow-up specialty appointments. • The CNE should analyze and correct the sick call processes because the CMC nurses did not see patients as promptly as medically necessary. Furthermore, when the nurses referred patients with sick calls to providers, the provider appointments sometimes occurred late or not at all. California Men’s Colony, Cycle 5 Medical Inspection Page 62 Office of the Inspector General State of California P -B M OPULATION ASED ETRICS The compliance testing and the case reviews give an accurate assessment of how the institution’s health care systems are functioning with regard to the patients with the highest risk and utilization. This information is vital to assess the capacity of the institution to provide sustainable, adequate care. However, one significant limitation of the case review methodology is that it does not give a clear assessment of how the institution performs for the entire population. For better insight into this performance, the OIG has turned to population-based metrics. For comparative purposes, the OIG has selected several Healthcare Effectiveness Data and Information Set (HEDIS) measures for disease management to gauge the institution’s effectiveness in outpatient health care, especially chronic disease management. The Healthcare Effectiveness Data and Information Set is a set of standardized performance measures developed by the National Committee for Quality Assurance with input from over 300 organizations representing every sector of the nation’s health care industry. It is used by over 90 percent of the nation’s health plans as well as many leading employers and regulators. HEDIS was designed to ensure that the public (including employers, the Centers for Medicare and Medicaid Services, and researchers) has the information it needs to accurately compare the performance of health care plans. Healthcare Effectiveness Data and Information Set data is often used to produce health plan report cards, analyze quality improvement activities, and create performance benchmarks. Methodology For population-based metrics, the OIG used a subset of HEDIS measures applicable to the CDCR patient population. Selection of the measures was based on the availability, reliability, and feasibility of the data required for performing the measurement. The OIG collected data utilizing various information sources, including the electronic medical record, the Master Registry (maintained by CCHCS), as well as a random sample of patient records analyzed and abstracted by trained personnel. 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 Men’s Colony, nine HEDIS measures were selected and are listed in the following CMC 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 Men’s Colony, Cycle 5 Medical Inspection Page 63 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. CMC performed well with its management of diabetes. When compared statewide, CMC outperformed Medi-Cal in all five diabetic measures, and the institution outperformed Kaiser in four of the five diabetic measures. The institution scored lower than Kaiser (North and South) with regard to diabetic eye exams. When compared nationally, CMC outperformed Medicaid and commercial health plans in all five diabetic measures but scored lower than Medicare and the Department of Veteran’s Affairs (VA) with respect to diabetic eye exams, and lower than the VA in HbA1c testing (a blood test that determines a patient’s average blood sugar levels over the past three months). Immunizations Comparative data for immunizations was only fully available for the VA and partially available for Kaiser, commercial plans, Medicaid, and Medicare. With respect to administering influenza vaccinations to younger adults, CMC outperformed all state and national health care entities. When administering influenza vaccinations to older adults, CMC scored slightly lower than Medicare and the VA. With regard to administering pneumococcal vaccines to older adults, CMC scored higher than Medicare but slightly lower than the VA. Cancer Screening With respect to colorectal cancer screening, CMC outperformed all health care plans. Summary CMC’s population-based metrics performance indicated a higher score for most of the clinical measures tested compared to the other state and national health care entities reviewed. The institution may improve its scores for influenza vaccinations by reducing patient refusals through patient education about the benefits of these preventive services. California Men’s Colony, Cycle 5 Medical Inspection Page 64 Office of the Inspector General State of California CMC Results Compared to State and National HEDIS Scores California National HEDIS HEDIS CMC HEDIS HEDIS Kaiser Kaiser HEDIS HEDIS VA Clinical Measures Com- Medi-Cal (No. (So. Medicaid Medicare Average Cycle 5 mercial 20152 CA) CA) 20164 20164 20155 Results1 20164 20163 20163 Comprehensive Diabetes Care HbA1c Testing (Monitoring) 97% 87% 94% 94% 87% 91% 94% 99% Poor HbA1c Control (>9.0%)6, 7 12% 38% 20% 23% 43% 33% 26% 18% HbA1c Control (<8.0%)6 78% 52% 70% 63% 47% 56% 63% - Blood Pressure Control 85% 63% 83% 83% 60% 62% 64% 76% (<140/90)6 Eye Exams 67% 57% 68% 81% 55% 54% 70% 89% Immunizations Influenza Shots - Adults (18–64) 65% - 56% 57% 39% 48% - 52% Influenza Shots - Adults (65+) 68% - - - - - 71% 72% Immunizations: Pneumococcal 92% - - - - - 74% 93% Cancer Screening Colorectal Cancer Screening 83% - 79% 82% - 62% 67% 82% 1. Unless otherwise stated, data was collected in August 2017 by reviewing medical records from a sample of CMC’s population of applicable patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. 2. HEDIS Medi-Cal data was obtained from the California Department of Health Care Services 2015 HEDIS Aggregate Report for Medi-Cal Managed Care. 3. Data was obtained from Kaiser Permanente November 2016 reports for the Northern and Southern California regions. 4. National HEDIS data for Medicaid, commercial plans, and Medicare was obtained from the 2016 State of Health Care Quality Report, available on the NCQA website: www.ncqa.org. The results for commercial plans were based on data received from various health maintenance organizations. 5. The Department of Veterans Affairs (VA) data was obtained from the VA’s website, www.va.gov. For the Immunizations: Pneumococcal measure only, the data was obtained from the VHA Facility Quality and Safety Report - Fiscal Year 2012 Data. 6. For this indicator, the entire applicable CMC population was tested. 7. For this measure only, a lower score is better. For Kaiser, the OIG derived the Poor HbA1c Control indicator using the reported data for the <9.0% HbA1c control indicator. California Men’s Colony, Cycle 5 Medical Inspection Page 65 Office of the Inspector General State of California A A — C T R PPENDIX OMPLIANCE EST ESULTS California Men’s Colony Range of Summary Scores: 59.0% – 90.0% Indicator Compliance Score (Yes %) 1 – Access to Care 76.4% 2 – Diagnostic Services 62.2% 3 – Emergency Services Not Applicable 4 – Health Information Management (Medical Records) 65.7% 5 – Health Care Environment 67.6% 6 – Inter- and Intra-System Transfers 76.9% 7 – Pharmacy and Medication Management 62.8% 8 – Prenatal and Post-Delivery Services Not Applicable 9 – Preventive Services 77.4% 10 – Quality of Nursing Performance Not Applicable 11 – Quality of Provider Performance Not Applicable 12 – Reception Center Arrivals Not Applicable 13 – Specialized Medical Housing (OHU, CTC, SNF, Hospice) 90.0% 14 – Specialty Services 59.0% 15 – Administrative Operations 88.5% California Men’s Colony, Cycle 5 Medical Inspection Page 66 Office of the Inspector General State of California Scored Answers Yes Reference + 1 – Access to Care Number Yes No No Yes % N/A Chronic care follow-up appointments: Was the patient’s most recent chronic care visit within the health care guideline’s 1.001 11 14 25 44.0% 0 maximum allowable interval or within the ordered time frame, whichever is shorter? For endorsed patients received from another CDCR institution: If 1.002 the nurse referred the patient to a provider during the initial health 15 9 24 62.5% 1 screening, was the patient seen within the required time frame? Clinical appointments: Did a registered nurse review the patient’s 1.003 30 0 30 100.0% 0 request for service the same day it was received? Clinical appointments: Did the registered nurse complete a face- 1.004 to-face visit within one business day after the CDCR Form 7362 27 3 30 90.0% 0 was reviewed? Clinical appointments: If the registered nurse determined a referral to a primary care provider was necessary, was the patient 1.005 11 3 14 78.6% 16 seen within the maximum allowable time or the ordered time frame, whichever is the shorter? Sick call follow-up appointments: If the primary care provider 1.006 ordered a follow-up sick call appointment, did it take place within 3 1 4 75.0% 26 the time frame specified? Upon the patient’s discharge from the community hospital: Did 1.007 the patient receive a follow-up appointment within the required 19 6 25 76.0% 0 time frame? Specialty service follow-up appointments: Do specialty service 1.008 primary care physician follow-up visits occur within required time 16 10 26 61.5% 4 frames? Clinical appointments: Do patients have a standardized process to 1.101 6 0 6 100.0% 0 obtain and submit health care services request forms? Overall percentage: 76.4% California Men’s Colony, Cycle 5 Medical Inspection Page 67 Office of the Inspector General State of California Scored Answers Yes Reference + 2 – Diagnostic Services Number Yes No No Yes % N/A Radiology: Was the radiology service provided within the time 2.001 10 0 10 100.0% 0 frame specified in the provider’s order? Radiology: Did the primary care provider review and initial the 2.002 4 6 10 40.0% 0 diagnostic report within specified time frames? Radiology: Did the primary care provider communicate the results 2.003 7 3 10 70.0% 0 of the diagnostic study to the patient within specified time frames? Laboratory: Was the laboratory service provided within the time 2.004 10 0 10 100.0% 0 frame specified in the provider’s order? Laboratory: Did the primary care provider review and initial the 2.005 5 5 10 50.0% 0 diagnostic report within specified time frames? Laboratory: Did the primary care provider communicate the 2.006 results of the diagnostic study to the patient within specified time 1 9 10 10.0% 0 frames? Pathology: Did the institution receive the final diagnostic report 2.007 10 0 10 100.0% 0 within the required time frames? Pathology: Did the primary care provider review and initial the 2.008 7 3 10 70.0% 0 diagnostic report within specified time frames? Pathology: Did the primary care provider communicate the results 2.009 2 8 10 20.0% 0 of the diagnostic study to the patient within specified time frames? Overall percentage: 62.2% 3 – Emergency Services This indicator is evaluated only by case review clinicians. There is no compliance testing component. California Men’s Colony, Cycle 5 Medical Inspection Page 68 Office of the Inspector General State of California Scored Answers Yes Reference + 4 – Health Information Management Number Yes No No Yes % N/A Are non-dictated healthcare documents (provider progress notes) 4.001 5 2 7 71.4% 0 scanned within 3 calendar days of the patient encounter date? Are dictated/transcribed documents scanned into the patient’s 4.002 electronic health record within five calendar days of the encounter Not Applicable date? Are High-Priority specialty notes (either a Form 7243 or other 4.003 scanned consulting report) scanned within the required time 18 2 20 90.0% 0 frame? Are community hospital discharge documents scanned into the 4.004 patient’s electronic health record within three calendar days of 19 1 20 95.0% 0 hospital discharge? Are medication administration records (MARs) scanned into the 4.005 Not Applicable patient’s electronic health record within the required time frames? During the inspection, were medical records properly scanned, 4.006 1 23 24 4.2% 0 labeled, and included in the correct patients’ files? For patients discharged from a community hospital: Did the preliminary hospital discharge report include key elements and 4.007 17 8 25 68.0% 0 did a primary care provider review the report within three calendar days of discharge? Overall percentage: 65.7% California Men’s Colony, Cycle 5 Medical Inspection Page 69 Office of the Inspector General State of California Scored Answers Yes Reference + 5 – Health Care Environment Number Yes No No Yes % N/A Are clinical health care areas appropriately disinfected, cleaned 5.101 16 0 16 100.0% 0 and sanitary? Do clinical health care areas ensure that reusable invasive and 5.102 non-invasive medical equipment is properly sterilized or 15 1 16 93.8% 0 disinfected as warranted? Do clinical health care areas contain operable sinks and sufficient 5.103 15 1 16 93.8% 0 quantities of hygiene supplies? Does clinical health care staff adhere to universal hand hygiene 5.104 10 6 16 62.5% 0 precautions? Do clinical health care areas control exposure to blood-borne 5.105 9 7 16 56.3% 0 pathogens and contaminated waste? Warehouse, Conex and other non-clinic storage areas: Does the 5.106 medical supply management process adequately support the needs 1 0 1 100.0% 0 of the medical health care program? Does each clinic follow adequate protocols for managing and 5.107 8 8 16 50.0% 0 storing bulk medical supplies? Do clinic common areas and exam rooms have essential core 5.108 8 8 16 50.0% 0 medical equipment and supplies? Do clinic common areas have an adequate environment conducive 5.109 7 3 10 70.0% 6 to providing medical services? Do clinic exam rooms have an adequate environment conducive 5.110 6 10 16 37.5% 0 to providing medical services? Emergency response bags: Are TTA and clinic emergency 5.111 medical response bags inspected daily and inventoried monthly, 3 7 10 30.0% 6 and do they contain essential items? Overall percentage: 67.6% California Men’s Colony, Cycle 5 Medical Inspection Page 70 Office of the Inspector General State of California Scored Answers Yes Reference + 6 – Inter- and Intra-System Transfers Number Yes No No Yes % N/A For endorsed patients received from another CDCR institution or COCF: Did nursing staff complete the initial health screening and 6.001 18 7 25 72.0% 0 answer all screening questions on the same day the patient arrived at the institution? For endorsed patients received from another CDCR institution or COCF: When required, did the RN complete the assessment and disposition section of the health screening form; refer the patient 6.002 24 1 25 96.0% 0 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? For endorsed patients received from another CDCR institution or COCF: If the patient had an existing medication order upon 6.003 9 7 16 56.3% 9 arrival, were medications administered or delivered without interruption? For patients transferred out of the facility: Were scheduled 6.004 specialty service appointments identified on the patient’s health 12 8 20 60.0% 0 care transfer information form? For patients transferred out of the facility: Do medication transfer 6.101 packages include required medications along with the 10 0 10 100.0% 2 corresponding transfer packet required documents? Overall percentage: 76.9% California Men’s Colony, Cycle 5 Medical Inspection Page 71 Office of the Inspector General State of California Scored Answers 7 – Pharmacy and Medication Yes Reference + Management Number Yes No No Yes % N/A Did the patient receive all chronic care medications within the 7.001 required time frames or did the institution follow departmental 16 6 22 72.7% 3 policy for refusals or no-shows? Did health care staff administer, make available, or deliver new 7.002 order prescription medications to the patient within the required 15 10 25 60.0% 0 time frames? Upon the patient’s discharge from a community hospital: Were all 7.003 ordered medications administered, made available, or delivered to 6 19 25 24.0% 0 the patient within required time frames? For patients received from a county jail: Were all medications ordered by the institution’s reception center provider 7.004 Not Applicable administered, made available, or delivered to the patient within the required time frames? Upon the patient’s transfer from one housing unit to another: 7.005 20 5 25 80.0% 0 Were medications continued without interruption? For patients en route who lay over at the institution: If the 7.006 temporarily housed patient had an existing medication order, were 3 7 10 30.0% 0 medications administered or delivered without interruption? All clinical and medication line storage areas for narcotic 7.101 medications: Does the Institution employ strong medication 3 6 9 33.3% 7 security over narcotic medications assigned to its clinical areas? All clinical and medication line storage areas for non-narcotic medications: Does the Institution properly store non-narcotic 7.102 8 3 11 72.7% 5 medications that do not require refrigeration in assigned clinical areas? All clinical and medication line storage areas for non-narcotic 7.103 medications: Does the institution properly store non-narcotic 5 3 8 62.5% 8 medications that require refrigeration in assigned clinical areas? Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols 7.104 3 3 6 50.0% 10 during medication preparation and medication administration processes? Medication preparation and administration areas: Does the 7.105 institution employ appropriate administrative controls and 5 1 6 83.3% 10 protocols when preparing medications for patients? Medication preparation and administration areas: Does the 7.106 Institution employ appropriate administrative controls and 0 6 6 0.0% 10 protocols when distributing medications to patients? Pharmacy: Does the institution employ and follow general 7.107 security, organization, and cleanliness management protocols in 3 0 3 100.0% 0 its main and satellite pharmacies? California Men’s Colony, Cycle 5 Medical Inspection Page 72 Office of the Inspector General State of California Scored Answers 7 – Pharmacy and Medication Yes Reference + Management Number Yes No No Yes % N/A Pharmacy: Does the institution’s pharmacy properly store non- 7.108 3 0 3 100.0% 0 refrigerated medications? Pharmacy: Does the institution’s pharmacy properly store 7.109 3 0 3 100.0% 0 refrigerated or frozen medications? Pharmacy: Does the institution’s pharmacy properly account for 7.110 2 0 2 100.0% 1 narcotic medications? Does the institution follow key medication error reporting 7.111 9 16 25 36.0% 0 protocols? Overall percentage: 62.8% 8 – Prenatal and Post-Delivery Services The institution had no female patients, so this indicator was not applicable. California Men’s Colony, Cycle 5 Medical Inspection Page 73 Office of the Inspector General State of California Scored Answers Yes Reference + 9 – Preventive Services Number Yes No No Yes % N/A Patients prescribed TB medication: Did the institution administer 9.001 21 3 24 87.5% 0 the medication to the patient as prescribed? Patients prescribed TB medication: Did the institution monitor the 9.002 patient monthly for the most recent three months he or she was on 12 10 22 54.6% 2 the medication? Annual TB Screening: Was the patient screened for TB within the 9.003 29 1 30 96.7% 0 last year? Were all patients offered an influenza vaccination for the most 9.004 25 0 25 100.0% 0 recent influenza season? All patients from the age of 50 - 75: Was the patient offered 9.005 22 3 25 88.0% 0 colorectal cancer screening? Female patients from the age of 50 through the age of 74: Was the 9.006 Not Applicable patient offered a mammogram in compliance with policy? Female patients from the age of 21 through the age of 65: Was 9.007 Not Applicable patient offered a pap smear in compliance with policy? Are required immunizations being offered for chronic care 9.008 12 4 16 75.0% 9 patients? Are patients at the highest risk of coccidioidomycosis (valley 9.009 8 12 20 40.0% 0 fever) infection transferred out of the facility in a timely manner? Overall percentage: 77.4% 10 – Quality of Nursing Performance This indicator is evaluated only by case review clinicians. There is no compliance testing component. 11 – Quality of Provider Performance This indicator is evaluated only by case review clinicians. There is no compliance testing component. California Men’s Colony, Cycle 5 Medical Inspection Page 74 Office of the Inspector General State of California 12 – Reception Center Arrivals The institution had no reception center, so this indicator was not applicable. Scored Answers Yes Reference + 13 – Specialized Medical Housing Number Yes No No Yes % N/A For OHU, CTC, and SNF: Did the registered nurse complete an 13.001 initial assessment of the patient on the day of admission, or 10 0 10 100.0% 0 within eight hours of admission to CMF’s Hospice? For CTC and SNF only: Was a written history and physical 13.002 10 0 10 100.0% 0 examination completed within the required time frame? For OHU, CTC, SNF, and Hospice: Did the primary care provider complete the Subjective, Objective, Assessment, Plan, 13.003 and Education (SOAPE) notes on the patient at the minimum 6 4 10 60.0% 0 intervals required for the type of facility where the patient was treated? For OHU and CTC only: Do inpatient areas either have properly working call systems in its OHU & CTC or are 30- 13.101 2 0 2 100.0% 0 minute patient welfare checks performed; and do medical staff have reasonably unimpeded access to enter patient’s cells? Overall percentage: 90.0% California Men’s Colony, Cycle 5 Medical Inspection Page 75 Office of the Inspector General State of California Scored Answers Yes Reference + 14 – Specialty Services Number Yes No No Yes % N/A Did the patient receive the high priority specialty service within 14.001 14 calendar days of the primary care provider order or the 6 9 15 40.0% 0 Physician Request for Service? Did the primary care provider review the high priority specialty 14.002 11 4 15 73.3% 0 service consultant report within the required time frame? Did the patient receive the routine specialty service within 90 14.003 calendar days of the primary care provider order or Physician 14 1 15 93.3% 0 Request for Service? Did the primary care provider review the routine specialty service 14.004 8 7 15 53.3% 0 consultant report within the required time frame? For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at 14.005 2 18 20 10.0% 0 the sending institution, was the appointment scheduled at the receiving institution within the required time frames? Did the institution deny the primary care provider request for 14.006 16 4 20 80.0% 0 specialty services within required time frames? Following the denial of a request for specialty services, was the 14.007 12 7 19 63.2% 1 patient informed of the denial within the required time frame? Overall percentage: 59.0% California Men’s Colony, Cycle 5 Medical Inspection Page 76 Office of the Inspector General State of California Scored Answers Reference Yes 15 – Administrative Operations + Number Yes No No Yes % N/A Did the institution promptly process inmate medical appeals 15.001 12 0 12 100.0% 0 during the most recent 12 months? Does the institution follow adverse / sentinel event reporting 15.002 Not Applicable requirements? Did the institution Quality Management Committee (QMC) meet at least monthly to evaluate program performance, and did the 15.003 6 0 6 100.0% 0 QMC take action when improvement opportunities were identified? Did the institution’s Quality Management Committee (QMC) or 15.004 other forum take steps to ensure the accuracy of its Dashboard 1 0 1 100.0% 0 data reporting? Does the Emergency Medical Response Review Committee 15.005 perform timely incident package reviews that include the use of 9 3 12 75.0% 0 required review documents? For institutions with licensed care facilities: Does the Local Governing Body (LGB), or its equivalent, meet quarterly and 15.006 4 0 4 100.0% 0 exercise its overall responsibilities for the quality management of patient health care? Did the institution complete a medical emergency response drill 15.101 for each watch and include participation of health care and 3 0 3 100.0% 0 custody staff during the most recent full quarter? Did the institution’s second level medical appeal response address 15.102 10 0 10 100.0% 0 all of the patient’s appealed issues? Did the institution’s medical staff review and submit the initial 15.103 5 2 7 71.4% 0 inmate death report to the Death Review Unit in a timely manner? Does the institution’s Supervising Registered Nurse conduct 15.104 0 5 5 0.0% 0 periodic reviews of nursing staff? Are nursing staff who administer medications current on their 15.105 7 3 10 70.0% 0 clinical competency validation? 15.106 Are structured clinical performance appraisals completed timely? 12 0 12 100.0% 0 15.107 Do all providers maintain a current medical license? 15 0 15 100.0% 0 Are staff current with required medical emergency response 15.108 2 0 2 100.0% 1 certifications? Are nursing staff and the Pharmacist-in-Charge current with their professional licenses and certifications, and is the pharmacy 15.109 6 0 6 100.0% 1 licensed as a correctional pharmacy by the California State Board of Pharmacy? California Men’s Colony, Cycle 5 Medical Inspection Page 77 Office of the Inspector General State of California Scored Answers Reference Yes 15 – Administrative Operations + Number Yes No No Yes % N/A Do the institution’s pharmacy and authorized providers who 15.110 prescribe controlled substances maintain current Drug 2 0 2 100.0% 0 Enforcement Agency (DEA) registrations? 15.111 Are nursing staff current with required new employee orientation? 1 0 1 100.0% 0 Overall percentage: 88.5% California Men’s Colony, Cycle 5 Medical Inspection Page 78 Office of the Inspector General State of California A B — C D PPENDIX LINICAL ATA Table B-1: CMC Sample Sets Sample Set Total Anticoagulation 3 CTC/OHU 3 Death Review/Sentinel Events 3 Diabetes 3 Emergency Services - CPR 5 Emergency Services - Non-CPR 3 High Risk 5 Hospitalization 4 Intra-system Transfers-In 3 Intra-system Transfers-Out 3 RN Sick Call 36 Specialty Services 4 75 California Men’s Colony, Cycle 5 Medical Inspection Page 79 Office of the Inspector General State of California Table B-2: CMC Chronic Care Diagnoses Diagnosis Total Anemia 5 Anticoagulation 11 Arthritis/Degenerative Joint Disease 12 Asthma 14 COPD 13 Cancer 9 Cardiovascular Disease 15 Chronic Kidney Disease 8 Chronic Pain 27 Cirrhosis/End Stage Liver Disease 5 Coccidioidomycosis 3 Deep Venous Thrombosis/Pulmonary Embolism 3 Diabetes 21 Gastroesophageal Reflux Disease 16 Hepatitis C 18 Hyperlipidemia 33 Hypertension 39 Mental Health 14 Seizure Disorder 4 Sleep Apnea 6 Thyroid Disease 5 281 California Men’s Colony, Cycle 5 Medical Inspection Page 80 Office of the Inspector General State of California Table B-3: CMC Event – Program Diagnosis Total Diagnostic Services 244 Emergency Care 114 Hospitalization 57 Intra-system Transfers-In 27 Intra-system Transfers-Out 9 Not Specified 2 Outpatient Care 638 Specialized Medical Housing 263 Specialty Services 282 1,636 California Men’s Colony, Cycle 5 Medical Inspection Page 81 Office of the Inspector General State of California Table B-4: CMC Review Sample Summary Total MD Reviews Detailed 25 MD Reviews Focused 1 RN Reviews Detailed 18 RN Reviews Focused 47 Total Reviews 91 Total Unique Cases 75 Overlapping Reviews (MD & RN) 16 California Men’s Colony, Cycle 5 Medical Inspection Page 82 Office of the Inspector General State of California A C — C S M PPENDIX OMPLIANCE AMPLING ETHODOLOGY California Men’s Colony Sample Category Quality (number of Indicator samples) Data Source Filters Access to Care MIT 1.001 Chronic Care Patients Master Registry • Chronic care conditions (at least one condition per patient—any risk level) (25) • Randomize MIT 1.002 Nursing Referrals OIG Q: 6.001 • See Intra-system Transfers (25) MITs 1.003-006 Nursing Sick Call MedSATS • Clinic (each clinic tested) • Appointment date (2–9 months) (30) • Randomize MIT 1.007 Returns from OIG Q: 4.007 • See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (25) MIT 1.008 Specialty Services OIG Q: 14.001 & • See Specialty Services Follow-up 14.003 (30) MIT 1.101 Availability of Health OIG onsite • Randomly select one housing unit from each yard Care Services review Request Forms (6) Diagnostic Services MITs 2.001–003 Radiology Radiology Logs • Appointment date (90 days–9 months) • Randomize (10) • Abnormal MITs 2.004–006 Laboratory Quest • Appt. date (90 days–9 months) • Order name (CBC or CMPs only) • Randomize (10) • Abnormal MITs 2.007–009 Pathology InterQual • Appt. date (90 days–9 months) • Service (pathology related) (10) • Randomize California Men’s Colony, Cycle 5 Medical Inspection Page 83 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 (7) 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 (0) • First 20 IPs selected MIT 4.003 OIG Qs: 14.002 • Specialty documents (20) & 14.004 • First 10 IPs for each question MIT 4.004 OIG Q: 4.007 • Community hospital discharge documents (20) • First 20 IPs selected MIT 4.005 OIG Q: 7.001 • MARs (0) • First 20 IPs selected MIT 4.006 Documents for • Any misfiled or mislabeled document identified (24) any tested patient during OIG compliance review (24 or more = No) MIT 4.007 Returns From Inpatient claims • Date (2–8 months) Community Hospital data • Most recent 6 months provided (within date range) • Rx count • Discharge date • Randomize (each month individually) • First 5 patients from each of the 6 months (if not 5 in a month, supplement from another, as needed) (25) Health Care Environment MIT 5.101-105 Clinical Areas OIG inspector • Identify and inspect all onsite clinical areas. MIT 5.107–111 (16) onsite review Inter- and Intra-System Transfers MIT 6.001-003 Intra-System SOMS • Arrival date (3–9 months) Transfers • Arrived from (another CDCR facility) • Rx count • Randomize (25) MIT 6.004 Specialty Services MedSATS • Date of transfer (3–9 months) Send-Outs • Randomize (20) MIT 6.101 Transfers Out OIG inspector • R&R IP transfers with medication (12) onsite review California Men’s Colony, Cycle 5 Medical Inspection Page 84 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Pharmacy and Medication Management MIT 7.001 Chronic Care OIG Q: 1.001 See Access to Care Medication • At least one condition per patient—any risk level • Randomize (25) MIT 7.002 New Medication Master Registry • Rx count Orders • Randomize (25) • Ensure no duplication of IPs tested in MIT 7.001 MIT 7.003 Returns from OIG Q: 4.007 • See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (25) MIT 7.004 RC Arrivals – OIG Q: 12.001 • See Reception Center Arrivals Medication Orders (N/A at this institution) MIT 7.005 Intra-Facility Moves MAPIP transfer • Date of transfer (2–8 months) data • To location/from location (yard to yard and to/from ASU) • Remove any to/from MHCB • NA/DOT meds (and risk level) (25) • Randomize MIT 7.006 En Route SOMS • Date of transfer (2–8 months) • Sending institution (another CDCR facility) • Randomize (10) • NA/DOT meds MITs 7.101-103 Medication Storage OIG inspector • Identify and inspect clinical & med line areas that Areas onsite review store medications (varies by test) MITs 7.104–106 Medication OIG inspector • Identify and inspect onsite clinical areas that Preparation and onsite review prepare and administer medications Administration Areas (varies by test) MITs 7.107-110 Pharmacy OIG inspector • Identify & inspect all onsite pharmacies (3) onsite review MIT 7.111 Medication Error Monthly • All monthly statistic reports with Level 4 or higher Reporting medication error • Select a total of 5 months (25) reports MIT 7.999 Isolation Unit KOP Onsite active • KOP rescue inhalers & nitroglycerin medications Medications medication for IPs housed in isolation units (10) listing Prenatal and Post-Delivery Services MIT 8.001-007 Recent Deliveries OB Roster • Delivery date (2–12 months) (N/A at this • Most recent deliveries (within date range) institution) Pregnant Arrivals OB Roster • Arrival date (2–12 months) (N/A at this • Earliest arrivals (within date range) institution) California Men’s Colony, Cycle 5 Medical Inspection Page 85 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) (24) • Randomize MIT 9.003 TB Evaluation, SOMS • Arrival date (at least 1 year prior to inspection) Annual Screening • Birth Month (30) • Randomize MIT 9.004 Influenza SOMS • Arrival date (at least 1 year prior to inspection) Vaccinations • Randomize (25) • Filter out IPs tested in MIT 9.008 MIT 9.005 Colorectal Cancer SOMS • Arrival date (at least 1 year prior to inspection) Screening • Date of birth (51 or older) (25) • Randomize MIT 9.006 Mammogram SOMS • Arrival date (at least 2 yrs prior to inspection) (N/A at this • Date of birth (age 52–74) institution) • Randomize MIT 9.007 Pap Smear SOMS • Arrival date (at least three yrs prior to inspection) (N/A at this • Date of birth (age 24–53) institution) • Randomize MIT 9.008 Chronic Care OIG Q: 1.001 • Chronic care conditions (at least 1 condition per Vaccinations IP—any risk level) • Randomize (25) • Condition must require vaccination(s) MIT 9.009 Valley Fever Cocci transfer • Reports from past 2–8 months (number will vary) status report • Institution • Ineligibility date (60 days prior to inspection date) (20) • All California Men’s Colony, Cycle 5 Medical Inspection Page 86 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) (N/A at this • Arrived from (county jail, return from parole, etc.) institution) • Randomize Specialized Medical Housing MITs 13.001–003 CTC CADDIS • Admit date (1–6 months) • Type of stay (no MH beds) • Length of stay (minimum of 5 days) (10) • Randomize MIT 13.101 Call Buttons OIG inspector • Review by location CTC onsite review (all) Specialty Services MITs 14.001–002 High-Priority MedSATS • Approval date (3–9 months) (15) • Randomize MITs 14.003–004 Routine MedSATS • Approval date (3–9 months) • Remove optometry, physical therapy or podiatry (15) • Randomize MIT 14.005 Specialty Services MedSATS • Arrived from (other CDCR institution) Arrivals • Date of transfer (3–9 months) (20) • Randomize MIT 14.006-007 Denials InterQual • Review date (3–9 months) (20) • Randomize IUMC/MAR • Meeting date (9 months) Meeting Minutes • Denial upheld (0) • Randomize California Men’s Colony, Cycle 5 Medical Inspection Page 87 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.001 Medical Appeals Monthly medical • Medical appeals (12 months) (all) appeals reports MIT 15.002 Adverse/Sentinel Adverse/sentinel • Adverse/sentinel events (2–8 months) Events events report (0) MITs 15.003–004 QMC Meetings Quality • Meeting minutes (12 months) Management Committee (6) meeting minutes MIT 15.005 EMRRC EMRRC meeting • Monthly meeting minutes (6 months) (12) minutes MIT 15.006 LGB LGB meeting • Quarterly meeting minutes (12 months) (4) minutes MIT 15.101 Medical Emergency Onsite summary • Most recent full quarter Response Drills reports & • Each watch documentation (3) for ER drills MIT 15.102 2nd Level Medical Onsite list of • Medical appeals denied (6 months) Appeals appeals/closed (10) appeals files MIT 15.103 Death Reports Institution-list of • Most recent 10 deaths deaths in prior 12 • Initial death reports (7) months MIT 15.104 RN Review Onsite supervisor • RNs who worked in clinic or emergency setting Evaluations periodic RN six or more days in sampled month reviews • Randomize (5) MIT 15.105 Nursing Staff Onsite nursing • On duty one or more years Validations education files • Nurse administers medications (10) • Randomize MIT 15.106 Provider Annual Onsite • All required performance evaluation documents Evaluation Packets provider (12) evaluation files MIT 15.107 Provider licenses Current provider • Review all listing (at start of (15) inspection) MIT 15.108 Medical Emergency Onsite • All staff Response certification o Providers (ACLS) Certifications tracking logs o Nursing (BLS/CPR) (all) • Custody (CPR/BLS) MIT 15.109 Nursing staff and Onsite tracking • All required licenses and certifications Pharmacist in system, logs, or Charge Professional employee files Licenses and Certifications (all) California Men’s Colony, Cycle 5 Medical Inspection Page 88 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.110 Pharmacy and Onsite listing of • All DEA registrations Providers’ Drug provider DEA Enforcement Agency registration #s & (DEA) Registrations pharmacy registration (all) document MIT 15.111 Nursing Staff New Nursing staff • New employees (hired within last 12 months) Employee training logs • Orientations (all) MIT 15.998 Death Review OIG summary log • Between 35 business days & 12 months prior Committee - deaths • CCHCS death reviews (7) California Men’s Colony, Cycle 5 Medical Inspection Page 89 Office of the Inspector General State of California C C ALIFORNIA ORRECTIONAL H C S ’ EALTH ARE ERVICES R ESPONSE California Men’s Colony, Cycle 5 Medical Inspection Page 90 Office of the Inspector General State of California