California Medical Facility Medical Inspection Report Cycle 4

Robert A. Barton Office of the Inspector General Inspector General California Medical Facility Medical Inspection Results Cycle 4 September 2016 Medical Inspection Unit Page 1 Office of the Inspector General State of California Office of the Inspector General CALIFORNIA MEDICAL FACILITY Medical Inspection Results Cycle 4 Robert A. Barton Inspector General Roy W. Wesley Chief Deputy Inspector General Shaun R. Spillane Public Information Officer September 2016 TABLE OF CONTENTS Executive Summary ............................................................................................................................. i Overall Assessment: Inadequate ........................................................................................... iii Clinical Case Review and OIG Clinician Inspection Results ............................................... iii Compliance Testing Results................................................................................................... v Population-Based Metrics ..................................................................................................... ix Introduction ......................................................................................................................................... 1 About the Institution ........................................................................................................................... 1 Objectives, Scope, and Methodology.................................................................................................. 5 Case Reviews ................................................................................................................................... 6 Patient Selection for Retrospective Case Reviews .................................................................... 6 Benefits and Limitations of Targeted Subpopulation Review .................................................. 7 Case Reviews Sampled ............................................................................................................. 8 Compliance Testing ......................................................................................................................... 9 Sampling Methods for Conducting Compliance Testing .......................................................... 9 Scoring of Compliance Testing Results .................................................................................... 9 Dashboard Comparisons ......................................................................................................... 10 Overall Quality Indicator Rating for Case Reviews and Compliance Testing .............................. 10 Population-Based Metrics .............................................................................................................. 11 Medical Inspection Results ............................................................................................................... 12 Primary (Clinical) Quality Indicators of Health Care .................................................................... 12 Access to Care ......................................................................................................................... 14 Case Review Results ............................................................................................................ 14 Compliance Testing Results................................................................................................. 16 Recommendations ................................................................................................................ 18 Diagnostic Services ................................................................................................................. 19 Case Review Results ............................................................................................................ 19 Compliance Testing Results................................................................................................. 21 Recommendation for CCHCS .............................................................................................. 22 Recommendations for CMF ................................................................................................. 22 Emergency Services................................................................................................................. 23 Case Review Results ............................................................................................................ 23 Recommendation for CCHCS .............................................................................................. 26 Recommendations for CMF ................................................................................................. 27 Health Information Management (Medical Records) ............................................................. 28 Case Review Results ............................................................................................................ 28 Compliance Testing Results................................................................................................. 30 Recommendations ................................................................................................................ 31 Health Care Environment ....................................................................................................... 32 Compliance Testing Results................................................................................................. 32 Recommendations ................................................................................................................ 34 California Medical Facility, Cycle 4 Medical Inspection Table of Contents Office of the Inspector General State of California Inter- and Intra-System Transfers ........................................................................................... 35 Case Review Results ............................................................................................................ 35 Compliance Testing Results................................................................................................. 37 Recommendations ................................................................................................................ 38 Pharmacy and Medication Management ................................................................................ 39 Case Review Results ............................................................................................................ 39 Compliance Testing Results................................................................................................. 40 Recommendations ................................................................................................................ 44 Preventive Services ................................................................................................................. 45 Compliance Testing Results................................................................................................. 45 Recommendations ................................................................................................................ 46 Quality of Nursing Performance ............................................................................................. 47 Case Review Results ............................................................................................................ 47 Recommendations ................................................................................................................ 54 Quality of Provider Performance ............................................................................................ 55 Case Review Results ............................................................................................................ 55 Recommendations ................................................................................................................ 59 Specialized Medical Housing (OHU, CTC, SNF, Hospice) .................................................... 60 Case Review Results ............................................................................................................ 60 Compliance Testing Results................................................................................................. 64 Recommendations ................................................................................................................ 65 Specialty Services .................................................................................................................... 66 Case Review Results ............................................................................................................ 66 Compliance Testing Results................................................................................................. 68 Recommendations ................................................................................................................ 69 Secondary (Administrative) Quality Indicators of Health Care..................................................... 70 Internal Monitoring, Quality Improvement, and Administrative Operations ......................... 71 Compliance Testing Results................................................................................................. 71 Recommendations ................................................................................................................ 73 Job Performance, Training, Licensing, and Certifications ..................................................... 74 Compliance Testing Results................................................................................................. 74 Recommendations ................................................................................................................ 75 Population-Based Metrics .............................................................................................................. 76 Appendix A — Compliance Test Results ......................................................................................... 80 Appendix B — Clinical Data ............................................................................................................ 94 Appendix C — Compliance Sampling Methodology ....................................................................... 97 California Correctional Health Care Services’ Response ................................................................. 98 California Medical Facility, Cycle 4 Medical Inspection Table of Contents Office of the Inspector General State of California LIST OF TABLES AND FIGURES Health Care Quality Indicators ........................................................................................................... ii CMF Executive Summary Table ..................................................................................................... viii CMF Health Care Staffing Resources as of February 2016 ................................................................ 2 CMF Master Registry Data as of February 8, 2016 ............................................................................. 3 Commonly Used Abbreviations .......................................................................................................... 4 CMF Results Compared to State and National HEDIS Scores .......................................................... 79 California Medical Facility, Cycle 4 Medical Inspection List of Tables and Figures Office of the Inspector General State of California EXECUTIVE SUMMARY Under the authority of California Penal Code Section 6126, which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), the OIG conducts a comprehensive inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG explicitly makes no determination regarding the constitutionality of care in the prison setting. That determination is left to the Receiver and the federal court. The assessment of care by the OIG is just one factor in the court’s determination whether care in the prisons meets constitutional standards. The court may find that an institution the OIG found to be providing adequate care still did not meet constitutional standards, depending on the analysis of the underlying data provided by the OIG. Likewise, an institution that has been rated inadequate by the OIG could still be found to pass constitutional muster with the implementation of remedial measures if the underlying data were to reveal easily mitigated deficiencies. The OIG’s inspections are mandated by the Penal Code and not aimed at specifically resolving the court’s questions on constitutional care. To the degree that they provide another factor for the court to consider, the OIG is pleased to provide added value to the taxpayers of California. For this fourth cycle of inspections, the OIG added a clinical case review component and significantly enhanced the compliance portion of the inspection process from that used in prior cycles. In addition, the OIG added a population-based metric comparison of selected Healthcare Effectiveness Data Information Set (HEDIS) measures from other State and national health care organizations and compared that data to similar results for the California Medical Facility (CMF). The OIG performed its Cycle 4 medical inspection at CMF from February to April 2016. The inspection included in-depth reviews of 82 inmate-patient files conducted by clinicians, as well as reviews of documents from 407 inmate-patient files, covering 92 objectively scored tests of compliance with policies and procedures applicable to the delivery of medical care. The OIG assessed the case review and compliance results at CMF using 14 health care quality indicators applicable to the institution, made up of 12 primary clinical indicators and two secondary administrative indicators. To conduct clinical case reviews, the OIG employs a clinician team consisting of a physician and a registered nurse consultant, while compliance testing is done by a team of deputy inspectors general and registered nurses trained in monitoring medical compliance. Of the 12 primary indicators, seven were rated by both case review clinicians and compliance inspectors, three were rated by case review clinicians only, and two were rated by compliance inspectors only; both secondary indicators were rated by compliance inspectors only. See the Health Care Quality Indicators table on page ii. Based on that analysis, OIG experts made a considered and measured overall opinion that the quality of health care at CMF was inadequate. California Medical Facility, Cycle 4 Medical Inspection Page i Office of the Inspector General State of California Health Care Quality Indicators All Institutions– CMF Fourteen Primary Indicators (Clinical) Applicability Applicability Both case review 1–Access to Care All institutions and compliance Both case review 2–Diagnostic Services All institutions and compliance 3–Emergency Services All institutions Case review only 4–Health Information Management Both case review All institutions (Medical Records) and compliance 5–Health Care Environment All institutions Compliance only Both case review 6–Inter- and Intra-System Transfers All institutions and compliance Both case review 7–Pharmacy and Medication Management All institutions and compliance Female institutions 8–Prenatal and Post-Delivery Services Not applicable only 9–Preventive Services All institutions Compliance only 10–Quality of Nursing Performance All institutions Case review only 11–Quality of Provider Performance All institutions Case review only Institutions with 12–Reception Center Arrivals Not applicable reception centers All institutions with 13–Specialized Medical Housing Both case review an OHU, CTC, SNF, (OHU, CTC, SNF, Hospice) and compliance or hospice Both case review 14–Specialty Services All institutions and compliance Two Secondary Indicators All Institutions– CMF (Administrative) Applicability Applicability 15–Internal Monitoring, Quality Improvement, and Administrative All institutions Compliance only Operations 16–Job Performance, Training, Licensing, All institutions Compliance only and Certifications California Medical Facility, Cycle 4 Medical Inspection Page ii Office of the Inspector General State of California Overall Assessment: Inadequate Based on the clinical case reviews and compliance testing, the OIG’s overall assessment rating for CMF was inadequate. Of the Overall Assessment 12 primary (clinical) quality indicators applicable to CMF, the Rating: OIG found seven adequate and five inadequate. Of the two secondary (administrative) quality indicators, the OIG found both Inadequate inadequate. To determine the overall assessment for CMF, the OIG considered individual clinical ratings and individual compliance question scores within each of the indicator categories, putting emphasis on the primary indicators. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed at CMF. Clinical Case Review and OIG Clinician Inspection Results The clinicians’ case reviews sampled patients with high medical needs and included a review of 1,283 patient care events.1 Of the 12 primary indicators applicable to CMF, ten were evaluated by clinician case review; eight were adequate, and two were 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. The OIG clinicians identify inadequate medical care based on the risk of significant harm to the patient, not the actual outcome. While CMF providers overcame many systemic problems, they were not able to overcome poor nursing performance and an inadequate after-hours on-call coverage system. Patient care at CMF demanded frequent provider encounters and exceptional provider performance. When those conditions were met, patients received adequate care, despite widespread problems with non-existent or inadequate nursing evaluations. Most of the time, CMF providers successfully mitigated these problems, as 22 of the 30 detailed physician-reviewed cases were judged adequate or proficient. However, eight other cases had deficiencies that required a rating of inadequate. The OIG clinicians rated two indicators inadequate: Emergency Services and Quality of Nursing Performance. In each of these indicators, nurses failed to adequately perform independent or thorough nursing evaluations. Insufficient physician coverage after hours did not allow providers to mitigate nursing problems in Emergency Services. Both indicators address vital components of an adequately performing institution. 1 Each OIG clinician team includes a board-certified physician and registered nurse consultant with experience in correctional and community medical settings. California Medical Facility, Cycle 4 Medical Inspection Page iii Office of the Inspector General State of California Program Strengths — Clinical  The institution had an extremely well-run hospice program. CMF providers, nurses, and other staff provided exceptionally caring, compassionate, and high-quality care. CMF used a multidisciplinary team approach to provide patients with maximum comfort and dignity at the end of life.  Providers in the correctional treatment center (CTC) and outpatient housing unit (OHU) performed at high levels. The history and physical (H&P) examination documentation and corresponding discharge summaries demonstrated thorough review of records as well as excellent assessment and decision-making.  Physicians and pharmacists at CMF provided proficient onsite HIV, hepatitis C, and anticoagulation services.  Specialty services access at CMF was excellent, both for routine and for high-priority referrals. The specialty department also developed a secondary process whereby all specialty reports were tracked, retrieved, reviewed for recommendations, and forwarded to the PCP for additional review. While this process was not documented in the medical record, it did ensure that patients were provided with good specialty care. Program Weaknesses — Clinical  The institution often failed to give patients a follow-up appointment with their PCP after they were seen in the triage and treatment area (TTA) or when the on-call physician ordered the appointment.2  Emergency response at CMF was inadequate. There was evidence that critical emergency equipment was not readily available during a medical emergency. Case reviews identified a strong pattern of inadequate nursing evaluations and delayed physician notification. On-call providers occasionally made poor and inaccurate assessments over the telephone, which markedly increased the risk of medical harm and likely contributed to one preventable death.  Nurses at CMF demonstrated poor performance in multiple areas, including emergency services, return from hospital or specialty services, CTC, and sick call. When patients submitted requests that described their symptoms, sick call nurses regularly failed to see them. More importantly, sick call nurses frequently failed to recognize urgent symptoms and often triaged their patients inappropriately. 2 CMF has a State-licensed stand-by emergency room that functions similarly to a TTA. For consistency with the common terminology at the majority of institutions, the OIG refers to the stand-by emergency room as the TTA throughout this report. California Medical Facility, Cycle 4 Medical Inspection Page iv Office of the Inspector General State of California  Nurses in the CTC failed to meet standards of nursing practice. They did not assess their patients every shift. When CTC nurses did perform assessments, they were often inadequate. Documentation was also poor. The OIG clinicians found deficiencies regarding even basic observations, such as vital signs, patient safety during restraint, and fluid intake for patients on fluid restriction. Compliance Testing Results Of the 14 total health care indicators applicable to CMF, 11 were evaluated by compliance inspectors.3 There were 92 individual compliance questions within those 11 indicators, generating 1,412 data points, that tested CMF’s compliance with California Correctional Health Care Services (CCHCS) policies and procedures.4 Those 92 questions are detailed in Appendix A — Compliance Test Results. The institution’s inspection scores in the 11 applicable indicators ranged from 53.7 percent to 78.4 percent, with the secondary (administrative) indicator Internal Monitoring, Quality Improvement, and Administrative Operations receiving the lowest score, and the primary indicator Access to Care receiving the highest. Of the nine primary indicators applicable to compliance testing, the OIG rated zero proficient, three adequate, and six inadequate. Of the two secondary indicators, which involve administrative health care functions, both were rated inadequate. Program Strengths — Compliance As the CMF Executive Summary Table on page viii indicates, the institution did not have any primary or secondary indicator areas that received a proficient compliance rating. However, the following are some of CMF’s strengths based on its compliance scores for individual questions in all the primary health care indicators:  Nursing staff timely reviewed patient requests for medical services within the required time frame, and patients received a timely provider visit when ordered by nursing staff.  The institution provided radiology and laboratory services within required time frames.  Staff ensured that CMF clinics’ invasive and non-invasive reusable equipment was properly sterilized and disinfected, and clinics had operable sinks and sufficient quantities of hygiene supplies.  Institution staff followed proper administrative controls during medication preparation for medication pill lines. 3 The OIG’s compliance inspectors are trained deputy inspectors general and registered nurses with expertise in CDCR policies regarding medical staff and processes. 4 The OIG used its own clinicians to provide clinical expert guidance for testing compliance in certain areas where CCHCS policies and procedures did not specifically address an issue. California Medical Facility, Cycle 4 Medical Inspection Page v Office of the Inspector General State of California  The institution’s main and satellite pharmacies followed general security, organization, and cleanliness management protocols; properly stored refrigerated and frozen medications; and properly accounted for narcotic medication.  Nursing staff completed initial assessments on the same day a provider admitted a patient to the CTC, OHU, or hospice units.  Patients received their high-priority and routine specialty services within required time frames. The following are some of the strengths identified within the two secondary administrative indicators:  Emergency response drills at the institution were completed for each watch in the last quarter that inspectors tested.  Providers received performance evaluations within required time frames. Program Weaknesses — Compliance The institution received ratings of inadequate, scoring below 75 percent, in the following six primary indicators: Health Information Management (Medical Records), Health Care Environment, Inter- and Intra-System Transfers, Pharmacy and Medication Management, Preventive Services, and Specialty Services. The institution also received an inadequate score in the two secondary indicators Internal Monitoring, Quality Improvement, and Administrative Operations and Job Performance, Training, Licensing, and Certifications. The following are some of the weaknesses identified by CMF’s compliance scores for individual questions in all the primary health care indicators:  Nursing staff did not always complete SOAPE notes for sick call encounters.  Patients did not always receive a timely provider follow-up appointment upon return from a community hospital or a specialty service appointment.  Providers did not always review and communicate pathology results within the required time frames.  Providers did not timely review hospital discharge reports when patients returned to the institution for the majority of sampled patients.  Clinical staff did not always use proper hand hygiene, clinic common areas and exam rooms did not always have all essential equipment available, and some clinic exam rooms did not have an adequate environment to allow a clinician perform a comprehensive examination. California Medical Facility, Cycle 4 Medical Inspection Page vi Office of the Inspector General State of California  Patients did not always receive their chronic care medication within required time frames.  The institution did not employ strong controls at medication line locations for narcotic medications, and storage protocols were weak for both refrigerated and non-refrigerated non-narcotic medication.  Nursing staff did not always follow proper hand hygiene protocols and administrative procedures for medication distribution.  Patients at CMF did not always timely receive their tuberculosis medication, and the institution’s monthly monitoring of these patients was poor. In addition, CMF did not perform well with annual tuberculosis screenings.  Patients who arrived at CMF from another institution with pending specialty services appointments did not always receive their appointments within the required time frame. The following are some of the weaknesses identified within the two secondary administrative indicators:  Nurse supervisors did not complete proper reviews of nursing staff, and the institution did not provide new employee orientation training to all new nursing staff. The CMF Executive Summary Table on the following page lists the quality indicators the OIG inspected and assessed during the clinical case reviews and objective compliance tests, and provides the institution’s rating in each area. The overall indicator ratings were based on a consensus decision by the OIG’s clinicians and non-clinical inspectors. California Medical Facility, Cycle 4 Medical Inspection Page vii Office of the Inspector General State of California CMF Executive Summary Table Case Compliance Overall Indicator Primary Indicators (Clinical) Review Rating Rating Rating Access to Care Adequate Adequate Adequate Diagnostic Services Adequate Adequate Adequate Emergency Services Inadequate Not Applicable Inadequate Health Information Management Adequate Inadequate Adequate (Medical Records) Health Care Environment Not Applicable Inadequate Inadequate Inter- and Intra-System Transfers Adequate Inadequate Adequate Pharmacy and Medication Management Adequate Inadequate Inadequate Preventive Services Not Applicable Inadequate Inadequate Quality of Nursing Performance Inadequate Not Applicable Inadequate Quality of Provider Performance Adequate Not Applicable Adequate Specialized Medical Housing Adequate Adequate Adequate (OHU, CTC, SNF, Hospice) Specialty Services Adequate Inadequate Adequate The Prenatal and Post-Delivery Services and Reception Center Arrivals indicators did not apply to this institution. Secondary Indicators (Administrative) Internal Monitoring, Quality Improvement, Not Applicable Inadequate Inadequate and Administrative Operations Job Performance, Training, Licensing, and Not Applicable Inadequate Inadequate Certifications Compliance results for quality indicators are proficient (greater than 85.0 percent), adequate (75.0 percent to 85.0 percent), or inadequate (below 75.0 percent). California Medical Facility, Cycle 4 Medical Inspection Page viii Office of the Inspector General State of California Population-Based Metrics Overall, population-based metrics showed that CMF’s State and national comparative performance was generally adequate for diabetic and immunization measures, but has room for improvement for colorectal cancer screening. Statewide, the institution outperformed Medi-Cal in all five diabetic measures. In addition, the institution outperformed Kaiser North in four of the five diabetic measures, with Kaiser outperforming the institution in blood pressure control. However, CMF only outperformed Kaiser South in three of five diabetic measures, with Kaiser South outperforming the institution in blood pressure control and eye exams. Nationally, CMF outperformed or matched Medicaid, commercial entities (based on data obtained from health maintenance organizations), Medicare, and the United States Department of Veterans Affairs (VA) in all five applicable diabetic measures. With regard to immunization measures, CMF scores were average, outperforming all statewide and national health management organizations for administering influenza vaccinations for younger adults. The institution outperformed Medicare for administering influenza vaccinations for older adults and pneumococcal vaccinations, but underperformed compared to the VA for the same immunization measures. The institution performed more poorly for colorectal cancer screening than all statewide and national health care organizations, but a high rate of patient refusals for cancer screenings negatively affected the institution’s score. Overall, CMF’s performance demonstrated by population-based metrics indicated that the comprehensive diabetes care and immunizations were average in comparison to statewide and national health care organizations. Colorectal cancer screenings were below average; however, the institution has room for improvement by making interventions to reduce the rate of patient refusals for colorectal cancer screenings. California Medical Facility, Cycle 4 Medical Inspection Page ix Office of the Inspector General State of California INTRODUCTION Under the authority of California Penal Code Section 6126, which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), and at the request of the federal Receiver, the OIG developed a comprehensive medical inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. For this fourth cycle of inspections, the OIG augmented the breadth and quality of its inspection program used in prior cycles, adding a clinical case review component and significantly enhancing the compliance component of the program. The California Medical Facility (CMF) was the 22nd medical inspection of Cycle 4. During the inspection process, the OIG assessed the delivery of medical care to patients for 12 primary clinical health care indicators and two secondary administrative health care indicators applicable to the institution. It is important to note that while the primary quality indicators represent the clinical care being provided by the institution at the time of the inspection, the secondary quality indicators are purely administrative and are not reflective of the actual clinical care provided. The OIG is committed to reporting on each institution’s delivery of medical care to assist in identifying areas for improvement, but the federal court will ultimately determine whether any institution’s medical care meets constitutional standards. ABOUT THE INSTITUTION The California Medical Facility was established in 1955 by the Legislature to provide a centrally located medical psychiatric institution for the health care needs of the male felon population in California’s prisons. CMF is designated an “intermediate care prison”; these institutions are located in predominantly urban areas close to tertiary care centers and specialty care providers for the most cost-effective care. The facility comprises a correctional treatment center, an outpatient housing unit, a licensed elderly care unit, inpatient and outpatient psychiatric facilities, a hospice unit for terminally ill inmates, housing and treatment for inmates identified with HIV/AIDS, general population housing, and other special inmate housing. Along with multiple clinics that handle daily non-urgent requests for medical services, CMF has a treatment and triage area (TTA or standby emergency room). On August 16, 2015, the institution received national accreditation from the Commission on Accreditation for Corrections. This accreditation program is a professional peer review process based on national standards set by the American Correctional Association. California Medical Facility, Cycle 4 Medical Inspection Page 1 Office of the Inspector General State of California According to information provided by the institution (not audited by the OIG), CMF’s overall vacancy rate among medical managers, primary care providers, nursing supervisors, and non-supervisory nurses was 16 percent in February 2016. The highest number of vacancies was among nursing staff with 38.9 vacant positions, resulting in a 16 percent vacancy rate. In addition, 14 nursing staff were on long-term medical leave. As a result, CMF used eight registry nurses to compensate for nursing vacancies. Providers had three vacant positions, which resulted in a 20 percent vacancy rate, and management had one vacant position that resulted in a 25 percent vacancy rate. Lastly, the CEO reported that no medical staff at CMF was redirected as of February 2016. CMF Health Care Staffing Resources as of February 2016 Primary Care Nursing Management Nursing Staff Totals Providers Supervisors Description Number % Number % Number % Number % Number % Authorized 4 1% 15 5% 19.6 7% 244.9 87% 283.5 100% Positions Filled Positions 3 75% 12 80% 18 92% 206 84% 239 84% Vacancies 1 25% 3 20% 1.6 8% 38.9 16% 44.5 16% Recent Hires (within 12 2 67% 0 0% 1 6% 28 14% 31 13% months) Staff Utilized from 0 0% 1 8% 0 0% 8 4% 9 4% Registry Redirected Staff (to 0 0% 0 0% 0 0% 0 0% 0 0% Non-Patient- Care Areas) Staff on Long-term 0 0% 0 0% 0 0% 14 7% 14 6% Medical Leave Note: CMF Health Care Staffing Resources data was not validated by the OIG. California Medical Facility, Cycle 4 Medical Inspection Page 2 Office of the Inspector General State of California As of February 8, 2016, the Master Registry for CMF showed that the institution had a total population of 2,549. Within that total population, 20.4 percent were designated as high medical risk, Priority 1 (High 1), and 27.3 percent were designated as high medical risk, Priority 2 (High 2). Patients’ assigned risk levels are based on the complexity of their required medical care related to their specific diagnoses, frequency of higher levels of care, age, and abnormal labs and procedures. High 1 has at least two high-risk conditions; High 2 has only one. Patients at high medical risk are more susceptible to poor health outcomes than those at medium or low medical risk. Patients at high medical risk also typically require more health care services than do patients with lower assigned risk levels. The chart below illustrates the breakdown of the institution’s medical risk levels at the start of the OIG medical inspection. CMF Master Registry Data as of February 8, 2016 Medical Risk Level # of Inmate-Patients Percentage High 1 519 20.4% High 2 697 27.3% Medium 1,043 40.9% Low 290 11.4% Total 2,549 100.0% California Medical Facility, Cycle 4 Medical Inspection Page 3 Office of the Inspector General State of California Commonly Used Abbreviations ACLS Advanced Cardiovascular Life Support HIV Human Immunodeficiency Virus AHA American Heart Association HTN Hypertension ASU Administrative Segregation Unit INH Isoniazid (anti-tuberculosis medication) BLS Basic Life Support IV Intravenous CBC Complete Blood Count KOP Keep-on-Person (in taking medications) CC Chief Complaint LPT Licensed Psychiatric Technician CCHCS California Correctional Health Care Services LVN Licensed Vocational Nurse CCP Chronic Care Program MAR Medication Administration Record California Department of Corrections and CDCR MRI Magnetic Resonance Imaging Rehabilitation CEO Chief Executive Officer MD Medical Doctor CHF Congestive Heart Failure NA Nurse Administered (in taking medications) CME Chief Medical Executive N/A Not Applicable CMP Comprehensive Metabolic (Chemistry) Panel NP Nurse Practitioner CNA Certified Nursing Assistant OB0 Obstetrician CNE Chief Nurse Executive OHU Outpatient Housing Unit C/O Complains of OIG Office of the Inspector General COPD Chronic Obstructive Pulmonary Disease P&P Policies and Procedures (CCHCS) CP&S Chief Physician and Surgeon PA Physician Assistant CPR Cardio-Pulmonary Resuscitation PCP Primary Care Provider CSE Chief Support Executive POC Point of Contact CT Computerized Tomography PPD Purified Protein Derivative CTC Correctional Treatment Center PRN As Needed (in taking medications) DM Diabetes Mellitus RN Registered Nurse Directly Observed Therapy (in taking DOT Rx Prescription medications) Dx Diagnosis SNF Skilled Nursing Facility Subjective, Objective, Assessment, Plan, EKG Electrocardiogram SOAPE Education ENT Ear, Nose and Throat SOMS Strategic Offender Management System ER Emergency Room S/P Status Post eUHR electronic Unit Health Record TB Tuberculosis FTF Face-to-Face TTA Triage and Treatment Area History and Physical (reception center H&P UA Urinalysis examination) HIM Health Information Management UM Utilization Management California Medical Facility, Cycle 4 Medical Inspection Page 4 Office of the Inspector General State of California OBJECTIVES, SCOPE, AND METHODOLOGY In designing the medical inspection program, the OIG reviewed CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. The OIG also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the Receiver’s office, CDCR, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of the OIG’s inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates medical care delivery by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population-based metrics. To maintain a metric-oriented inspection program that evaluates medical care delivery consistently at each State prison, the OIG identified 14 primary (clinical) and two secondary (administrative) quality indicators of health care to measure. The primary quality indicators cover clinical categories directly relating to the health care provided to patients, whereas the secondary quality indicators address the administrative functions that support a health care delivery system. The 14 primary quality indicators are Access to Care, Diagnostic Services, Emergency Services, Health Information Management (Medical Records), Health Care Environment, Inter- and Intra-System Transfers, Pharmacy and Medication Management, Prenatal and Post-Delivery Services, Preventive Services, Quality of Nursing Performance, Quality of Provider Performance, Reception Center Arrivals, Specialized Medical Housing (OHU, CTC, SNF, Hospice), and Specialty Services. The two secondary quality indicators are Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications. The OIG rates each of the quality indicators applicable to the institution under inspection based on case reviews conducted by OIG clinicians and compliance tests conducted by OIG deputy inspectors general and registered nurses. The ratings may be derived from the case review results alone, the compliance test results alone, or a combination of both these information sources. For example, the ratings for the primary quality indicators Quality of Nursing Performance and Quality of Provider Performance are derived entirely from the case review results, while the ratings for the primary quality indicators Health Care Environment and Preventive Services are derived entirely from compliance test results. As another example, primary quality indicators such as Diagnostic Services and Specialty Services receive ratings derived from both sources. At CMF, 14 of the quality indicators were applicable, consisting of 12 primary clinical indicators and two secondary administrative indicators. Of the 12 primary indicators, seven were rated by both case review clinicians and compliance inspectors, three were rated by case review clinicians only, and two were rated by compliance inspectors only; both secondary indicators were rated by compliance inspectors only. California Medical Facility, Cycle 4 Medical Inspection Page 5 Office of the Inspector General State of California Consistent with the OIG’s agreement with the Receiver, this report only addresses the conditions found related to medical care criteria. The OIG does not review for efficiency and economy of operations. Moreover, if the OIG learns of an inmate-patient needing immediate care, the OIG notifies the chief executive officer of health care services and requests a status report. Additionally, if the OIG learns of significant departures from community standards, it may report such departures to the institution’s chief executive officer or to CCHCS. Because these matters involve confidential medical information protected by State and federal privacy laws, specific identifying details related to any such cases are not included in the OIG’s public report. In all areas, the OIG is alert for opportunities to make appropriate recommendations for improvement. Such opportunities may be present regardless of the score awarded to any particular quality indicator; therefore, recommendations for improvement should not necessarily be interpreted as indicative of deficient medical care delivery. CASE REVIEWS The OIG has added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders. At the conclusion of Cycle 3, the federal Receiver and the Inspector General determined that the health care provided at the institutions was not fully evaluated by the compliance tool alone, and that the compliance tool was not designed to provide comprehensive qualitative assessments. Accordingly, the OIG added case reviews in which OIG physicians and nurses evaluate selected cases in detail to determine the overall quality of health care provided to the inmate-patients. The OIG’s clinicians perform a retrospective chart review of selected patient files to evaluate the care given by an institution’s primary care providers and nurses. Retrospective chart review is a well-established review process used by health care organizations that perform peer reviews and patient death reviews. Currently, CCHCS uses retrospective chart review as part of its death review process and in its pattern-of-practice reviews. CCHCS also uses a more limited form of retrospective chart review when performing appraisals of individual primary care providers. PATIENT SELECTION FOR RETROSPECTIVE CASE REVIEWS Because retrospective chart review is time consuming and requires qualified health care professionals to perform it, OIG clinicians must carefully sample patient records. Accordingly, the group of patients the OIG targeted for chart review carried the highest clinical risk and utilized the majority of medical services. A majority of the patients selected for retrospective chart review were classified by CCHCS as high-risk patients. The reason the OIG targeted these patients for review is twofold: 1. The goal of retrospective chart review is to evaluate all aspects of the health care system. Statewide, high-risk and high-utilization patients consume medical services at a disproportionate rate; 11 percent of the total patient population are considered high-risk and California Medical Facility, Cycle 4 Medical Inspection Page 6 Office of the Inspector General State of California account for more than half of the institution’s pharmaceutical, specialty, community hospital, and emergency costs. 2. Selecting this target group for chart review provides a significantly greater opportunity to evaluate all the various aspects of the health care delivery system at an institution. Underlying the choice of high-risk patients for detailed case review, the OIG clinical experts made the following three assumptions: 1. If the institution is able to provide adequate clinical care to the most challenging patients with multiple complex and interdependent medical problems, it will be providing adequate care to patients with less complicated health care issues. Because clinical expertise is required to determine whether the institution has provided adequate clinical care, the OIG utilizes experienced correctional physicians and registered nurses to perform this analysis. 2. The health of less complex patients is more likely to be affected by processes such as timely appointment scheduling, medication management, routine health screening, and immunizations. To review these processes, the OIG simultaneously performs a broad compliance review. 3. Patient charts generated during death reviews, sentinel events (unexpected occurrences involving death or serious injury, or risk thereof), and hospitalizations are mostly of high-risk patients. BENEFITS AND LIMITATIONS OF TARGETED SUBPOPULATION REVIEW Because the selected patients utilize the broadest range of services offered by the health care system, the OIG’s retrospective chart review provides adequate data for a qualitative assessment of the most vital system processes (referred to as “primary quality indicators”). Retrospective chart review provides an accurate qualitative assessment of the relevant primary quality indicators as applied to the targeted subpopulation of high-risk and high-utilization patients. While this targeted subpopulation does not represent the prison population as a whole, the ability of the institution to provide adequate care to this subpopulation is a crucial and vital indicator of how the institution provides health care to its whole patient population. Simply put, if the institution’s medical system does not adequately care for those patients needing the most care, then it is not fulfilling its obligations, even if it takes good care of patients with less complex medical needs. Since the targeted subpopulation does not represent the institution’s general prison population, the OIG cautions against inappropriate extrapolation of conclusions from the retrospective chart reviews to the general population. For example, if the high-risk diabetic patients reviewed have poorly-controlled diabetes, one cannot conclude that the entire diabetic population is inadequately controlled. Similarly, if the high-risk diabetic patients under review have poor outcomes and require significant specialty interventions, one cannot conclude that the entire diabetic population is having similarly poor outcomes. California Medical Facility, Cycle 4 Medical Inspection Page 7 Office of the Inspector General State of California Nonetheless, the health care system’s response to this subpopulation can be accurately evaluated and yields valuable systems information. In the above example, if the health care system is providing appropriate diabetic monitoring, medication therapy, and specialty referrals for the high-risk patients reviewed, then it can be reasonably inferred that the health care system is also providing appropriate diabetic services to the entire diabetic subpopulation. However, if these same high-risk patients needing monitoring, medications, and referrals are generally not getting those services, it is likely that the health care system is not providing appropriate diabetic services to the greater diabetic subpopulation. CASE REVIEWS SAMPLED As indicated in Appendix B, Table B–1, CMF Sample Sets, the OIG clinicians evaluated medical charts for 82 unique inmate-patients. Appendix B, Table B–4, CMF Case Review Sample Summary, clarifies that both nurses and physicians reviewed charts for 18 of those patients, for 100 reviews in total. Physicians performed detailed reviews of 30 charts, and nurses performed detailed reviews of 19 charts, totaling 49 detailed reviews. For detailed case reviews, physicians or nurses looked at all encounters occurring in approximately six months of medical care. Nurses also performed a limited or focused review of medical records for an additional 51 inmate-patients. These generated 1,283 clinical events for review (Appendix B, Table B-3, CMF Event-Program). The reporting format provides details on whether the encounter was adequate or had significant deficiencies, and identifies deficiencies by programs and processes to help the institution focus on improvement areas. While the sample method specifically pulled only six chronic care patient records, i.e., three diabetes patients and three anticoagulation patients (Appendix B, Table B–1, CMF Sample Sets), the 82 unique inmate-patients sampled included patients with 344 chronic care diagnoses, including 25 additional patients with diabetes (for a total of 28) and one additional anticoagulation patient (for a total of four) (Appendix B, Table B–2, CMF Chronic Care Diagnoses). The OIG’s sample selection tool evaluated many chronic care programs because the complex and high-risk patients selected from the different categories often had multiple medical problems. While the OIG did not evaluate every chronic disease or health care staff member, the overall operation of the institution’s system and staff were assessed for adequacy. The OIG’s case review methodology and sample size matched other qualitative research. The empirical findings, supported by expert statistical consultants, showed adequate conclusions after 10 to 15 charts had undergone full clinician review. In qualitative statistics, this phenomenon is known as “saturation.” The OIG asserts that the physician sample size of over 30 detailed reviews certainly far exceeds the saturation point necessary for an adequate qualitative review. With regard to reviewing charts from different providers, the case review is not intended to be a focused search for poorly performing providers; rather, it is focused on how the system cares for those patients who need care the most. Nonetheless, while not sampling cases by each provider at the institution, the OIG inspections adequately review most providers. Providers would only escape OIG case review if institutional management successfully mitigated patient risk by having the more poorly performing providers care for the less California Medical Facility, Cycle 4 Medical Inspection Page 8 Office of the Inspector General State of California complicated, low-utilizing, and lower-risk patients. The OIG’s clinicians concluded that the case review sample size was more than adequate to assess the quality of services provided. Based on the collective results of clinicians’ case reviews, the OIG rated each quality indicator as either proficient (excellent), adequate (passing), inadequate (failing), or not applicable. A separate confidential CMF Supplemental Medical Inspection Results: Individual Case Review Summaries report details the case reviews OIG clinicians conducted and is available to specific stakeholders. For further details regarding the sampling methodologies and counts, see Appendix B — Clinical Data, Table B–1; Table B–2; Table B–3; and Table B–4. COMPLIANCE TESTING SAMPLING METHODS FOR CONDUCTING COMPLIANCE TESTING From February to April 2016, deputy inspectors general and registered nurses attained answers to 92 objective medical inspection test (MIT) questions designed to assess the institution’s compliance with critical policies and procedures applicable to the delivery of medical care. To conduct most tests, inspectors randomly selected samples of inmate-patients for whom the testing objectives were applicable and reviewed their electronic unit health records. In some cases, inspectors used the same samples to conduct more than one test. In total, inspectors reviewed health records for 407 individual inmate-patients and analyzed specific transactions within their records for evidence that critical events occurred. Inspectors also reviewed management reports and meeting minutes to assess certain administrative operations. In addition, during the week of February 22, 2016, field inspectors conducted a detailed onsite inspection of CMF’s medical facilities and clinics; interviewed key institutional employees; and reviewed employee records, logs, medical appeals, death reports, and other documents. This generated 1,412 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 CMF’s plant infrastructure, protocols for tracking medical appeals and local operating procedures, and staffing resources. For details of the compliance results, see Appendix A — Compliance Test Results. For details of the OIG’s compliance sampling methodology, see Appendix C — Compliance Sampling Methodology. SCORING OF COMPLIANCE TESTING RESULTS The OIG compliance team scored the institution in the following nine primary (clinical) and two secondary (administrative) quality indicators applicable to the institution:  Primary indicators: Access to Care, Diagnostic Services, Health Information Management (Medical Records), Health Care Environment, Inter- and Intra-System Transfers, Pharmacy California Medical Facility, Cycle 4 Medical Inspection Page 9 Office of the Inspector General State of California and Medication Management, Preventive Services, Specialized Medical Housing (OHU, CTC, SNF, Hospice), and Specialty Services.  Secondary indicators: Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications. After compiling the answers to the 92 questions, the OIG derived a score for each primary and secondary quality indicator identified above by calculating the percentage score of all Yes answers for each of the questions applicable to a particular indicator, then averaging those scores. Based on those results, the OIG assigned a rating to each quality indicator of proficient (greater than 85 percent), adequate (between 75 percent and 85 percent), or inadequate (less than 75 percent). DASHBOARD COMPARISONS In the first ten medical inspection reports of Cycle 4, the OIG identified where similar metrics for some of the individual compliance questions were available within the CCHCS Dashboard, which is a monthly report that consolidates key health care performance measures statewide and by institution. However, there was not complete parity between the metrics due to differing time frames for data collecting and differences in sampling methods, rendering the metrics non-comparable. Some of the OIG’s stakeholders suggested removing the Dashboard comparisons from future reports to eliminate confusion. Dashboard data is available on CCHCS’s website, www.cphcs.ca.gov. OVERALL QUALITY INDICATOR RATING FOR CASE REVIEWS AND COMPLIANCE TESTING The OIG derived the final rating for each quality indicator by combining the ratings from the case reviews and from the compliance testing, as applicable. When combining these ratings, the case review evaluations and the compliance testing results usually agreed, but there were instances when the rating differed for a particular quality indicator. In those instances, the inspection team assessed the quality indicator based on the collective ratings from both components. Specifically, the OIG clinicians and deputy inspectors general discussed the nature of individual exceptions found within that indicator category and considered the overall effect on the ability of patients to receive adequate medical care. To derive an overall assessment rating of the institution’s medical inspection, the OIG evaluated the various rating categories assigned to each of the quality indicators applicable to the institution, giving more weight to the rating results of the primary quality indicators, which directly relate to the health care provided to inmate-patients. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed. California Medical Facility, Cycle 4 Medical Inspection Page 10 Office of the Inspector General State of California POPULATION-BASED METRICS The OIG identified a subset of Healthcare Effectiveness Data Information Set (HEDIS) measures applicable to the CDCR inmate-patient population. To identify outcomes for CMF, the OIG reviewed some of the compliance testing results, randomly sampled additional inmate-patients’ records, and obtained CMF data from the CCHCS Master Registry. The OIG compared those results to HEDIS metrics reported by other statewide and national health care organizations. California Medical Facility, Cycle 4 Medical Inspection Page 11 Office of the Inspector General State of California MEDICAL INSPECTION RESULTS PRIMARY (CLINICAL) QUALITY INDICATORS OF HEALTH CARE The primary quality indicators assess the clinical aspects of health care. As shown on the Health Care Quality Indicators table on page ii of this report, 12 of the OIG’s primary indicators were applicable to CMF. Of those 12 indicators, seven were rated by both the case review and compliance components of the inspection, three were rated by the case review component alone, and two were rated by the compliance component alone. The CMF Executive Summary Table on page viii shows the case review and compliance ratings for each applicable indicator. Summary of Case Review Results: The clinical case review component assessed 10 of the 12 primary (clinical) indicators applicable to CMF. Of these ten indicators, OIG clinicians rated eight adequate and two inadequate. The OIG physicians rated the overall adequacy of care for each of the 30 detailed case reviews they conducted. Of these 30 cases, three were proficient, 19 were adequate, and eight were inadequate. In the 1,283 events reviewed, there were 590 deficiencies, of which 146 were considered to be of such magnitude that, if left unaddressed, they would likely contribute to patient harm. Adverse Events Identified During Case Review: Medical care is a complex dynamic process with many moving parts, subject to human error even within the best health care organizations. Adverse events are typically identified and tracked by all major health care organizations for the purpose of quality improvement. They are not generally representative of medical care delivered by the organization. The OIG identified adverse events for the dual purposes of quality improvement and the illustration of problematic patterns of practice found during the inspection. Because of the anecdotal description of these events, the OIG cautions against drawing inappropriate conclusions regarding the institution based solely on adverse events. For CMF, while these events were not representative of usual care delivery in the institution, they were illustrative of the serious problems that contributed to the inadequate rating for the institution. There were four unsafe conditions and sentinel events identified in the case reviews at CMF. Case 26 is also discussed in the Quality of Nursing Services indicator. Cases 9, 11, and 13 are discussed in the Emergency Services indicator.  In case 26, the sick call nurse saw the patient, who was taking warfarin (blood thinner). He fell from the top bunk, hit his head, and developed headache, dizziness, nausea, and vomiting. These symptoms indicated possible life-threatening bleeding in the brain. Despite this, the sick call nurse treated the patient for diarrhea and planned to make a routine 14-day physician referral. Fortunately, the patient’s symptoms resolved, and the patient suffered no harm. This event was classified as an unsafe condition. California Medical Facility, Cycle 4 Medical Inspection Page 12 Office of the Inspector General State of California  In case 9, the patient had end-stage liver disease and presented to the TTA with a fever of 102.4° F and low blood pressure. However, the on-call physician treated the patient for a viral syndrome and did not consider a possible life-threatening infection or order a prompt physician follow-up. Three days later, the patient was sent to the hospital, where he was diagnosed with a spinal abscess. Fortunately, the patient recovered and suffered no permanent harm from the delayed emergency response.  In case 13, the patient presented to the TTA with confusion and a severely swollen, bruised, and blistered leg that was oozing copious amounts of fluid. He had low blood pressure, low oxygen levels, and an extremely low body temperature of 92° F. The on-call physician did not order any meaningful interventions, and ordered only a routine transportation to the hospital. The patient left the facility more than two hours after the medical emergency, and subsequently died of an overwhelming infection. While the death was not preventable, the on-call physician did not recognize the gravity of the patient’s condition and was responsible for the inadequate emergency response.  In case 11, the patient had chronic lung disease and came to the TTA with increased shortness of breath. The on-call physician sent the patient back to housing after improvement with breathing treatments and a high dose of steroids to decrease lung inflammation. However, the physician did not perform a face-to-face evaluation, prescribe empiric antibiotics, obtain a chest x-ray, or arrange a prompt physician follow-up. The physician missed the diagnosis of pneumonia. Three days later, the patient had respiratory failure and, despite hospitalization, died. The death was potentially preventable had the patient received appropriate care in the TTA three days prior to him being sent to the hospital. Summary of Compliance Results: The compliance component assessed 9 of the 12 primary (clinical) indicators applicable to CMF. Of these nine indicators, OIG inspectors rated three adequate and six inadequate. The results of those assessments are summarized within this section of the report. The test questions used to assess compliance for each indicator are detailed in Appendix A. California Medical Facility, Cycle 4 Medical Inspection Page 13 Office of the Inspector General State of California ACCESS TO CARE This indicator evaluates the institution’s ability to provide Case Review Rating: inmate-patients with timely clinical appointments. Areas specific to Adequate inmate-patients’ access to care are reviewed, such as initial Compliance Score: assessments of newly arriving inmates, acute and chronic care Adequate follow-ups, face-to-face nurse appointments when an inmate-patient (78.4%) requests to be seen, provider referrals from nursing lines, and Overall Rating: follow-ups after hospitalization or specialty care. Compliance Adequate testing for this indicator also evaluates whether inmate-patients have Health Care Services Request forms (CDCR Form 7362) available in their housing units. Case Review Results The OIG clinicians reviewed 551 provider, nursing, specialty, and outside hospital encounters in which a follow-up visit needed to be scheduled, and found 38 deficiencies relating to Access to Care. Twenty-six of the 38 deficiencies were significant, and more likely than not to cause patient harm if not rectified and allowed to persist. However, due to the relatively low frequency of problems in this area (less than 5 percent), Access to Care at CMF was rated adequate. Provider-to-Provider Follow-up Appointments CMF performed well with provider-ordered follow-up appointments. These are among the most important aspects of the Access to Care indicator. Failure to accommodate provider-ordered appointments can often result in lapses in care or in patients being lost to follow-up. The problem was rare at CMF, with no pattern of problems in this area. RN Sick Call Access When nurses decided to see a patient with a sick call complaint, the patient received prompt nurse access. Unfortunately, sick call nurses often failed to perform nursing evaluations when the patients needed them. This poor sick call nursing performance is further discussed in the Quality of Nursing Performance indicator, and did not negatively affect the Access to Care indicator. RN-to-RN Follow-up Appointments CMF nurses did not refer patients for nursing follow-up appointments in any of the cases reviewed. California Medical Facility, Cycle 4 Medical Inspection Page 14 Office of the Inspector General State of California Nurse-to-Provider Referrals Any properly functioning health care system must allow nurses to refer a patient for a provider evaluation if the patient’s medical needs are beyond the nurse’s scope of practice. CMF performed well, with nearly all nurse-to-provider referrals resulting in an appointment. Provider Follow-up After Specialty Services CMF usually provided patients with provider follow-up visits after their specialty services encounters. The OIG clinicians reviewed 84 diagnostic and consultative specialty services and found only four instances in which the provider follow-up did not occur or was delayed. Intra-System Transfers The OIG clinicians reviewed five transfer-in patients and found no instances of deficient access to care in this area. Follow-up After Hospitalization CMF did well at ensuring that providers followed up with their patients after the patients’ return from an outside hospital or an emergency department. OIG clinicians reviewed 28 hospitalization and outside emergency events and found only one case in which CMF delayed a provider follow-up. Follow-up After Urgent/Emergent Care CMF had significant difficulty providing PCP follow-up appointments for patients seen in the TTA or when the on-call physician ordered a follow-up appointment. Most of these patients had a change in medical status and were at high risk for medical complications. CMF’s failure to provide PCP follow-up care in these situations placed the patient at even higher risk. Of the 70 urgent/emergent encounters reviewed, 32 required a PCP follow-up appointment. Provider follow-up appointments were delayed or did not occur in cases 8, 11, 12, 16, 24, and 29.  In case 12, medical staff saw the patient in the TTA for a decreased mental status and turning blue in the lips and the eyelids. He had very low blood pressure and low oxygen levels. The patient refused transfer to the hospital, and the TTA provider ordered a three-to-five-day follow-up with the PCP. The appointment did not occur until ten days later. Fortunately, no immediate harm resulted from this deficiency.  In case 16, the patient went to the TTA due to pelvic pain and bleeding after he felt something rupture while performing his own bladder catheterization. The TTA provider inserted a Foley catheter into the patient’s bladder, and ordered a five-to-seven-day PCP follow-up. The appointment did not occur. Fortunately, no immediate harm resulted from this deficiency. California Medical Facility, Cycle 4 Medical Inspection Page 15 Office of the Inspector General State of California Specialized Medical Housing CMF performed well with provider access during and after admission to the correctional treatment center (CTC). A provider usually visited CTC patients at appropriate intervals. The OIG clinicians reviewed 15 CTC admissions with 106 CTC provider encounters. A provider did not perform timely CTC rounds in only two instances. Specialty Access The institution generally performed well in this area, as is further discussed in the Specialty Services indicator. Diagnostic Results Follow-up CMF provided adequate follow-up after providers received abnormal diagnostic tests. After reviewing diagnostic results, a provider indicated whether the patient required a follow-up appointment on the Notification of Diagnostic Test Results (CDCR Form 7393). CMF sometimes had difficulty processing those forms, occasionally scanning them into the medical record without scheduling appointments. Clinician Onsite Inspection At the onsite inspection, the OIG clinicians tried to determine if any process problems could explain CMF’s trouble ensuring that PCPs followed up with their patients after the patients were seen in the TTA or when the on-call physician ordered a follow-up. CMF staff explained that the process was dependent on the TTA log. The process in place had remained the same for years. Every morning, the primary care team reviewed the patients listed on the TTA log and arranged a follow-up appointment. CMF could not explain the pattern of missed appointments in this area. Clinician Summary CMF demonstrated good overall ability to provide patients with adequate Access to Care. The OIG clinicians found good performance in almost all areas, with only two notable exceptions: CMF had difficulty giving patients follow-up PCP appointments after they had been seen in the TTA, and when the on-call physician ordered a follow-up appointment, it did not reliably occur. Despite those problems, the OIG clinicians rated this indicator adequate. Compliance Testing Results The institution received an adequate compliance score of 78.4 percent in the Access to Care indicator, and scored in the proficient range in the following four test areas:  Inmates had access to Health Care Services Request forms (CDCR Form 7362) at all six housing units inspected (MIT 1.101). California Medical Facility, Cycle 4 Medical Inspection Page 16 Office of the Inspector General State of California  All 24 sampled health care service requests on which nursing staff referred the patient for a PCP appointment resulted in the patient receiving a timely appointment (MIT 1.005).  Nursing staff reviewed 29 out of 30 sampled Health Care Services Request forms (CDCR Form 7362) on the same day they were received (97 percent). For one sample, no date evidence was documented to demonstrate that a nurse promptly reviewed the form after it was collected (MIT 1.003).  Primary care provider visits occurred timely for 25 of the 29 sampled patients who transferred into CMF with a pre-existing chronic care PCP visit need or who, upon arrival, received a new PCP referral from the CMF screening nurse (86 percent). Four other patients received their provider visits from six to seven days late (MIT 1.002). CMF performed in the adequate range on the following test:  Recent routine appointments were timely for 31 of the 40 sampled patients with chronic conditions (78 percent). Nine patients received their follow-up appointments from one to 189 days late (MIT 1.001). The institution scored within the inadequate range on the following four tests:  Inspectors sampled 29 Health Care Service Request forms (CDCR Form 7362) submitted by patients across all facility clinics. For 13 samples (45 percent), nursing staff completed a face-to-face encounter with the patient within one business day of reviewing the service request form. However, for 15 other samples, the nurse had a face-to-face encounter with the patient, but did not document the event with supporting SOAPE notes. For one additional sample, the RN did not document the encounter date to demonstrate the event was timely (MIT 1.004).  The OIG tested 30 patients discharged from a community hospital to determine if they received a PCP follow-up appointment at CMF within five calendar days of their return to the institution, or earlier if a TTA provider ordered the appointment to occur sooner. Only 18 of the patients (60 percent) received a timely PCP follow-up appointment. Twelve patients received their appointment from one to 50 days late (MIT 1.007).  Inspectors also sampled 30 patients who received a specialty service; only 21 of them (70 percent) received a timely follow-up appointment with a provider. Eight patients received their follow-up appointments from one to 55 days late, and two other patients never received a provider follow-up appointment (MIT 1.008).  The OIG sampled 24 patients who submitted a sick call request and were subsequently seen by a provider. Out of the 24 patient encounters, providers ordered ten of the patients to return for a second follow-up visit. Of the ten patients, only seven (70 percent) received their California Medical Facility, Cycle 4 Medical Inspection Page 17 Office of the Inspector General State of California follow-up appointments timely. One patient received his follow-up appointment two days late, and two other patients never received their follow-up appointments (MIT 1.006). Recommendations No specific recommendations. California Medical Facility, Cycle 4 Medical Inspection Page 18 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 Adequate were timely provided to inmate-patients, whether the primary care Compliance Score: provider (PCP) timely reviewed the results, and whether the results Adequate were communicated to the inmate-patient within the required time (76.3%) frames. In addition, for pathology services, the OIG determines Overall Rating: whether the institution received a final pathology report and Adequate whether the PCP timely reviewed and communicated the pathology results to the patient. The case reviews also factor in the appropriateness, accuracy, and quality of the diagnostic test(s) ordered and the clinical response to the results. Case Review Results The OIG clinicians reviewed 151 diagnostic events and found 31 deficiencies, of which 26 were related to health information management and five were related to the non-completion of ordered tests. CMF performed the majority of diagnostic services in a timely manner. However, not completing diagnostic tests is a serious system deficiency that can lead to significant delays or even lapses in care. CMF errors whereby tests were not completed within the provider’s ordered time frame were uncommon, but were more likely to occur when tests were ordered with short processing time frames.  In case 11, the patient had multiple injuries, including several facial fractures. The PCP was concerned about the possibility of rib fractures and ordered a chest x-ray and a TTA follow-up to occur the following morning. Neither of these occurred until the PCP noticed the error three days later. The subsequent x-ray did confirm rib fractures, but, fortunately, no acute intervention was required and the patient was not harmed from this lapse in care. CMF demonstrated inconsistent performance with retrieving radiology reports from the radiology information system (RIS) and scanning them into the eUHR. At the onsite inspection, CMF leadership explained that they had stopped scanning radiology reports from RIS into the primary medical record (eUHR) based on a memo from CCHCS headquarters. This new process, however, increased the risk of patient harm due to the chance of a lapse in care because of a provider being unaware of the report. Even if the ordering provider initially was notified of the report and reviewed it in the radiology information system, the report would still not be readily available to any subsequent medical staff. Any nurse or provider caring for the patient in the coming months or years would face a tremendous barrier, as the main information base used for patient care, the eUHR, would lack a scanned copy of the report. Though CMF leadership admitted that the institution had stopped scanning reports from RIS to the eUHR, case reviews demonstrated only a California Medical Facility, Cycle 4 Medical Inspection Page 19 Office of the Inspector General State of California moderate pattern of deficiencies in this area. The OIG clinicians identified deficiencies in the retrieval and scanning of radiology reports in cases 11, 13, 39, and 41. CMF clinicians did a good job ensuring that they reviewed the reports, despite the extra barrier to reviewing those results. However, in these cases, the corresponding patient notification form was not completed, and CMF did not send the patient notification of the test results. In one case (case 13), the provider did not review the report at all.  In case 13, the PCP and a cancer specialist were following the patient for liver cancer. An ultrasound showed a 3.6 cm mass, but institution staff did not scan the report into the eUHR and the provider did not review the report. Fortunately, the interventional radiology specialist monitored the patient closely, and no harm resulted from the oversight. In addition to radiology reports, CMF sometimes did not retrieve laboratory reports or scan them into the eUHR. This occurred in cases 11, 13, 29, and 41. CMF providers admitted that the use of the main medical record (eUHR) to review labs was unreliable due to a high frequency of missing lab reports. Most providers used another information system directly from the laboratory provider to review those reports. At the onsite inspection, the lab supervisor confirmed that the lab report was retrieved in case 29. The lab report and a CDCR Form 7393 (for patient notification of results) was sent to the PCP for completion. The breakdown in the lab reporting process may have been occurring after the provider was sent the lab report for review. CMF providers did not consistently review diagnostic test results in a timely manner. Delays in diagnostic test reviews occurred in cases 13, 16, 18, 20, 22, 31, and 39. Some review delays were excessive and constituted severe deficiencies:  In case 13, the institution completed the labs, but a provider did not review them for more than five weeks.  In case 16, the institution completed the labs, but a provider did not review them for more than three weeks. CMF providers did not review routine EKG tests and complete patient notification forms that relayed the results of the diagnostic test. This occurred in cases 7 and 22. On rare occasions, CMF providers did not date or initial the diagnostic test reports when they reviewed them. This occurred in cases 13, 16, and 20. Clinician Summary The institutions staff completed radiology and laboratory tests in a timely manner, with only rare occurrences of tests not being completed, usually when tests were required within very short time frames. Retrieval of diagnostic test results was sometimes problematic, with intermittent failures to scan radiology reports from RIS to the eUHR. Failure to place radiology reports into the primary medical record presented a significant and ongoing risk for lapses in care. CMF providers did not California Medical Facility, Cycle 4 Medical Inspection Page 20 Office of the Inspector General State of California consistently review diagnostic test results in a timely manner and did not always complete patient notification forms. Despite suboptimal services, diagnostic services were sufficient to provide basic medical care to CMF’s patient population, and the indicator was rated adequate. Compliance Testing Results The institution received an adequate compliance score of 76.3 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  All ten of the radiology services sampled were timely performed (MIT 2.001). In addition, CMF providers initialed and dated the radiology report, evidencing they reviewed the report within two business days of receipt, for eight of those patients (80 percent). For two patients, providers documented no evidence that the reports were timely reviewed (MIT 2.002). Lastly, provider’s timely communicated radiology results to nine of ten patients sampled (90 percent). There was no evidence the provider communicated the radiology results to one patient (MIT 2.003). Laboratory Services  CMF performed all ten laboratory services sampled within the required time frame (MIT 2.004). The institution’s providers also reviewed eight of ten laboratory reports within the required time frame (80 percent). However, a provider reviewed one laboratory report two days late, and a different provider failed to review another laboratory report at all (MIT 2.005). CMF providers timely communicated the laboratory results to nine of ten patients sampled (90 percent). For one patient, the provider communicated the laboratory results six days late (MIT 2.006). Pathology Services  The institution documented eUHR evidence that it timely received a final pathology report for eight of ten patients sampled (80 percent). For one patient, CMF received the pathology report three days late, and for another patient, the institution never received a pathology report (MIT 2.007). Further, of the nine sampled patients for whom the institution received a final report, providers evidenced their timely review of the report results for only two of them (22 percent). For the other seven sampled reports, the OIG could not find any eUHR evidence that a provider reviewed them (MIT 2.008). OIG inspectors also found that only four of the nine patients for whom the institution received a final pathology report (44 percent) had their pathology results communicated to them by a provider. Two patients received their pathology results 9 and 12 days late, while three other patients never received their results (MIT 2.009). California Medical Facility, Cycle 4 Medical Inspection Page 21 Office of the Inspector General State of California Recommendation for CCHCS The OIG recommends that, to avoid risk of patient harm, CCHCS review the current process of not scanning radiology reports into the eUHR and develop a better process for staff to access radiology reports. Recommendations for CMF No specific recommendations. California Medical Facility, Cycle 4 Medical Inspection Page 22 Office of the Inspector General State of California EMERGENCY SERVICES An emergency medical response system is essential to providing Case Review Rating: effective and timely emergency medical response, assessment, 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 reviews emergency response services including first aid, basic life Overall Rating: support (BLS), and advanced cardiac life support (ACLS) consistent Inadequate 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 70 urgent/emergent events and found 64 deficiencies. Of those, 43 were related to nursing and nine were related to provider care. With few exceptions, TTA providers made accurate assessments and triage decisions when patients were evaluated in person. However, on-call providers sometimes performed inadequate assessments by telephone, leading to poor decisions and inadequate follow-ups. A strong pattern emerged of inadequate nursing assessment and delayed physician notification. CMF also demonstrated lack of preparedness for emergency response when an automated external defibrillator (AED) was not readily available at the scene. These factors resulted in an inadequate rating for this indicator. Provider Performance On-call and TTA providers performed well in most cases. However, on-call providers sometimes made inadequate assessments, which increased the risk of poor decisions, such as in the following examples:  In case 9, the patient had end-stage liver disease and presented to the TTA with fever of 102.4° F and low blood pressure. The on-call physician treated the patient for a viral syndrome by ordering oral fluids. The physician confined the patient to quarters with a nurse follow-up in the morning. The patient was at high risk for recurrent severe infection related to his liver disease, but the on-call physician failed to evaluate the high-risk patient face to face, failed to consider possible life-threatening infection, and failed to ensure close physician monitoring. The following day, the patient developed confusion and had a persistent fever of 102.5° F. He was re-evaluated by the TTA nurse, but the nurse failed to refer the patient to the physician. On the third day, institution staff sent the patient to the California Medical Facility, Cycle 4 Medical Inspection Page 23 Office of the Inspector General State of California hospital for worsening confusion and a severe infection. The hospital determined the patient had a spinal abscess. Fortunately, the patient recovered and suffered no permanent harm from the severely delayed emergency response.  In case 11, the patient had long-standing lung disease and presented to the TTA with five days of shortness of breath, productive cough, and brownish to greenish phlegm. The nurse noted that the patient’s breathing was rapid and labored and that he was coughing and wheezing. Initially, the patient’s oxygen levels were low, even after nurses gave him supplemental oxygen. The patient also had an abnormally rapid heart rate of 126 beats per minute and a high respiratory rate of 26 breaths per minute. The on-call physician gave the patient breathing treatments and a high dose of steroids to decrease lung inflammation. The physician sent the patient back to housing after his symptoms seemed to improve in the TTA. The physician did not perform a face-to-face evaluation, prescribe empiric antibiotics, obtain a chest x-ray, or arrange close physician follow-up. The physician missed the diagnosis of pneumonia. Three days later, the patient came back to the TTA with respiratory failure and was immediately hospitalized. The patient was transferred to the intensive care unit and placed on a breathing machine, but did not survive his pneumonia that had turned into an overwhelming infection. The death was potentially preventable had the patient received appropriate care in the TTA three days prior to being sent to the hospital.  In case 13, the patient presented to the TTA with confusion and a severely swollen, bruised, and blistered leg that was oozing copious amounts of fluid. He had low blood pressure, low oxygen levels, and an extremely low body temperature of 92° F. The on-call physician did not order any meaningful interventions, such as intravenous fluids or antibiotics, and ordered only a routine transportation to the hospital. The patient did not leave the facility for more than two hours after the medical emergency, and subsequently died of an overwhelming infection. The death was not preventable because there was evidence that patient was already in septic shock by the time he arrived in the TTA. It was unlikely that earlier intervention could have prevented his death. Nevertheless, the on-call physician did not recognize the gravity of the patient’s condition and was responsible for the inadequate emergency response. The OIG clinicians classified cases 9, 11, and 13 as unsafe conditions or sentinel events. They are duplicated in the Medical Inspection Results: Adverse Events Identified During Case Review section of the report beginning on page 12. Nursing Performance The TTA nurses demonstrated significantly delayed performance in notifying the on-call physician and custody staff of patients’ medical conditions and medical emergencies: California Medical Facility, Cycle 4 Medical Inspection Page 24 Office of the Inspector General State of California  In case 4, the patient was found unresponsive in the OHU, and staff initiated CPR. The AED machine was not readily available in the unit because it was locked in the treatment room and thus was not applied until the patient arrived in the TTA.  In case 7, the patient presented to the TTA with chest pain. It took 20 minutes for the TTA nurse to contact the on-call physician. It also took nine minutes from the time of the physician contact to notify the watch commander of the emergency transport.  In case 8, there was a delay of more than 30 minutes in notifying the physician of a patient with difficulty breathing, severe pain, and abnormal vital signs.  In case 9, there was a delay of more than 45 minutes in notifying the physician of a patient with altered mental status and severe abdominal pain. On another occasion, the patient was brought to the TTA for persistent fever and altered level of consciousness. The TTA RN did not refer the patient to the physician for immediate medical evaluation.  In case 12, on two occasions, there was a delay of more than one hour notifying the physician of the patient’s altered mental status and low blood pressure.  In case 20, it took more than 30 minutes for the RN to contact the on-call physician for a patient with severe abdominal pain and fever.  In case 21, the RN took 45 minutes to contact the on-call physician for a poorly controlled diabetic patient with chest pain and high blood pressure. Additionally, the RN did not start the chest pain protocol until after contacting the physician. There was also a delay in notifying the watch commander of the medical transport.  In case 80, it took 23 minutes for the RN to call 9-1-1 for a patient with severe chest pain. The TTA nursing staff had inadequate assessment and documentation in the following cases:  In case 6, the RN did not assess the patient’s neck for any injury or address pain after a reported fall.  In cases 8, 11, and 12, after administrating breathing treatments, the RN did not assess the patients for effectiveness of the medication.  In case 21, The TTA RN did not closely monitor the patient’s vital signs. The RN did not check the patient’s vital signs for more than two hours after the initial reading and the RN took vitals only four other times during his seven-hour-plus stay in the TTA.  In case 24, after the physician evaluated the patient, the TTA RN did not continue to assess the patient’s condition and document the nursing care provided prior to the patient’s transfer to the hospital. California Medical Facility, Cycle 4 Medical Inspection Page 25 Office of the Inspector General State of California  In cases 9, 12, 20, and 24, the RN failed to document the patient’s condition, the nursing care provided while in the TTA, and the care provided prior to the patient’s transfer of care. Nurses must document all critical information chronologically during an emergency medical response. Complete documentation identifies the quality of assessment and care provided to the patient and the timeliness and coordination of emergency response. Omissions in documenting the time when custody or EMS were notified and the times when EMS arrived and left the facility were found in cases 8, 9, 11, 12, 13, 19, 20, 21, and 24. Emergency Medical Response Review Committee The EMRRC reviewed emergency medical responses on a regular basis and generally identified the deficiencies in first responder performance, documentation, and coordination of emergency medical response during its reviews. Case 12 was the only deficient instance reviewed; the committee failed to identify that there was more than a one-hour delay in notifying the physician of the patient’s condition. Clinician Onsite Inspection The CMF TTA staff was responsible for responding to all medical emergencies, but they did not have any emergency vehicles available for use. This was especially problematic when responding to medical emergencies that occurred in distant yards, such as CMF’s C and D yards. TTA nurses explained it took as long as 15 minutes for them to gather their emergency equipment and walk or run to a medical emergency. CMF physicians expressed extreme dissatisfaction with recent changes to the after-hours coverage system. The physicians claimed that in the spring of 2015, CMF changed after-hours coverage from onsite physician coverage (MOD – medical officer of the day) to offsite coverage (POC – provider on call). Because of CMF’s high-risk population, most physicians felt the change had significantly compromised patient care and that with no after-hours physician onsite to evaluate patients who required emergency assessments, the risk of inaccurate assessments over the telephone markedly increased. The institution’s chief medical executive (CME) explained that the directive to change the after-hours coverage came from CCHCS despite his objections. The CME agreed that the change in coverage had dramatically lowered physician morale and created a serious problem with retention of high-quality physicians. This problem is further discussed in the Quality of Provider Performance indicator. Recommendation for CCHCS The OIG recommends that CCHCS reinstate the onsite after-hours physician coverage for intermediate health care prisons because intermediate level medical facilities, such as CMF, house large numbers of medically complex patients who require frequent utilization of emergency resources. Telephone coverage by the on-call physician increases the risk of inaccurate physician California Medical Facility, Cycle 4 Medical Inspection Page 26 Office of the Inspector General State of California assessments, which can result in poor decisions and patient harm, as documented by the OIG’s clinical reviews. Recommendations for CMF The OIG recommends the institution do the following:  Provide vehicles for TTA staff so that they can respond promptly to medical emergencies.  Require that the EMRRC prioritize the review of critical emergency response measures, such as length of time until physician notification. In addition, ensure that the EMRRC’s review includes the quality of emergency nursing assessments. California Medical Facility, Cycle 4 Medical Inspection Page 27 Office of the Inspector General State of California HEALTH INFORMATION MANAGEMENT (MEDICAL RECORDS) Health information management is a crucial link in the delivery of Case Review Rating: medical care. Medical personnel require accurate information in Adequate order to make sound judgments and decisions. This indicator Compliance Score: examines whether the institution adequately manages its health care Inadequate information. This includes determining whether the information is (61.7%) correctly labeled and organized and available in the electronic unit Overall Rating: health record (eUHR); whether the various medical records (internal Adequate and external, e.g., hospital and specialty reports and progress notes) are obtained and scanned timely into the inmate-patient’s eUHR; whether records routed to clinicians include legible signatures or stamps; and whether hospital discharge reports include key elements and are timely reviewed by providers. In this indicator, the OIG’s case review and compliance review processes yielded different results, with the case review giving an adequate rating and the compliance testing resulting in an inadequate score. The OIG’s internal review process considered those factors that led to both results. Although the compliance review found providers did not timely review hospital discharge reports and inspectors identified miss-scanned and mislabeled documents, the case review clinicians were able to conclude that CMF provider’s review time of hospital discharge reports did not affect the quality of patient care, and mislabeled documents did not significantly hinder their reviews. As a result, the OIG’s medical inspection team concluded that the appropriate overall score for this indicator should be adequate. Case Review Results Inter-Departmental Transmission CMF performed adequately with interdepartmental transmission. Nurses properly noted and processed provider orders to the appropriate department. CMF demonstrated a moderate pattern of missing documents across various aspects of the institution. Missing documents included clinic provider notes, emergency first responder notes, TTA nursing notes, post-hospitalization nursing notes, clinic nursing notes, and CTC documentation. Missing documents were identified in cases 9, 14, 15, 19, 21, 24, 25, and 74. Hospital Records CMF did well with the retrieval of emergency department (ED) physician reports and hospital discharge summaries. The OIG clinicians reviewed 11 outside ED events and 17 community hospital events. Except in cases 6 and 21, CMF staff retrieved and scanned ED reports and hospital discharge summaries in the required time frame. However, providers failed to review and initial the ED physician report or the hospital discharge summary, and provider initials were missing on outside hospital reports in almost all cases. California Medical Facility, Cycle 4 Medical Inspection Page 28 Office of the Inspector General State of California Specialty Services Findings regarding specialty report handling are discussed in the Specialty Services indicator. Diagnostic Reports Findings regarding diagnostic report handling are discussed in the Diagnostic Services indicator. Urgent/Emergent Records CMF nurses sometimes did not properly document their urgent or emergent encounters. Cases 9, 19, and 21 were missing emergency or TTA documentation. CMF on-call providers also did not reliably document their telephone encounters. Cases 7, 9, and 16 were missing on-call provider documentation. Scanning Performance Erroneously scanned documents can create lapses in care by hindering providers’ ability to find relevant clinical information. CMF performed adequately in this area with no significant pattern of mislabeled documents. However, cases 7, 19, 25, and 38 had documents misfiled (into the wrong patient chart). Scanning times for documents were generally good. Documentation Quality and Legibility Provider documentation was often scarce. In the majority of cases, the care management was adequate, but providers often failed to document their thought processes and reasoning in their progress notes. Poor legibility greatly increases the risk for medical errors, especially in medical systems where continuity of care is poor. Fortunately, continuity of care was good in most of the reviewed cases. Nevertheless, extremely poor legibility was a significant problem across nearly all health care staff, including the majority of nurses and providers. CMF health care staff rarely utilized name stamps. CMF leadership expressed optimism that the implementation of the upcoming electronic health record system (EHRS) will solve legibility concerns. Clinician Summary CMF health care staff performed poorly with regard to documenting their review of important health care information. Providers generally did not initial or date hospital discharge summaries or specialty consult notes to indicate their review. Providers also did not reliably document their review of these reports in their progress notes. Providers often did not document their decision-making thought processes. CMF nurses and providers displayed extremely poor legibility throughout all cases reviewed. In-depth chart reviews also showed evidence that, despite insufficient documentation, CMF providers appropriately reviewed and considered the vast majority of hospital discharge summaries California Medical Facility, Cycle 4 Medical Inspection Page 29 Office of the Inspector General State of California and specialty reports. The specialty department used a locally developed tracking form to track the documents and all the specialty recommendations to ensure the provider was aware of those recommendations. The specialty department retrieved specialty reports and carefully reviewed them for any action needed. With respect to poor provider documentation and legibility, continuity of primary care providers minimized those risks. Overall, the OIG clinicians rated this indicator adequate. Compliance Testing Results The institution received an inadequate compliance score of 61.7 percent in the Health Information Management (Medical Records) indicator and scored in the inadequate range in the following three tests:  The institution scored zero in its labeling and filing of documents scanned into patients’ electronic unit health records; most documents were mislabeled, such as non-CDCR hospital admission reports that were commonly mislabeled as History and Physical forms. For this test, once the OIG identifies 12 mislabeled or misfiled documents, the maximum points are lost and the resulting score is zero. During the CMF medical inspection, inspectors identified a total of 17 documents with scanning errors, five more than the maximum allowable number (MIT 4.006).  The OIG reviewed hospital discharge reports and treatment records for 30 sampled patients whom the institution sent to the hospital for a higher level of care; providers only reviewed nine reports within the required time frame (30 percent). Providers reviewed 15 reports from one to 13 days late, and six other reports were never reviewed (MIT 4.008).  When the OIG reviewed various medical documents such as hospital discharge reports, initial health screening forms, certain medication administration records, and specialty service reports to ensure that clinical staff legibly documented their names on the forms, only 23 of 32 samples (72 percent) showed compliance. Nine of the samples tested did not have a legible signature or stamp to clearly identify the clinician (MIT 4.007). The following three tests scored in the adequate range:  Among 20 sampled miscellaneous non-dictated documents, including providers’ progress notes and patients’ initial health screening forms and requests for health care services, the institution timely scanned 16 of the documents (80 percent). Four initial health screening forms were scanned one to three days late (MIT 4.001).  CMF timely scanned community hospital discharge reports or treatment records into each patient’s eUHR for 16 of the 20 sampled reports (80 percent); four reports were scanned between one and three days late (MIT 4.004). California Medical Facility, Cycle 4 Medical Inspection Page 30 Office of the Inspector General State of California  CMF staff timely scanned medication administration records (MARs) into the patient’s eUHR for 15 of 20 samples tested (75 percent). Five MARs were scanned three to ten days late (MIT 4.005). The institution scored in the proficient range on the following test:  For 19 of 20 specialty service consultant reports sampled (95 percent), CMF staff scanned the reports into the patient’s eUHR file within five calendar days. The institution scanned one routine specialty services report a day late (MIT 4.003). Recommendations No specific recommendations. California Medical Facility, Cycle 4 Medical Inspection Page 31 Office of the Inspector General State of California HEALTH CARE ENVIRONMENT This indicator addresses the general operational aspects of the Case Review Rating: institution’s clinics, including certain elements of infection control Not Applicable and sanitation, medical supplies and equipment management, the Compliance Score: Inadequate availability of both auditory and visual privacy for inmate-patient (72.5%) visits, and the sufficiency of facility infrastructure to conduct comprehensive medical examinations. Rating of this component is Overall Rating: based entirely on the compliance testing results from the visual Inadequate observations inspectors make at the institution during their onsite visit. Compliance Testing Results The institution received an inadequate compliance score of 72.5 percent in the Health Care Environment indicator with the following three tests receiving scores in the inadequate range:  Only one of 14 clinic locations (7 percent) met compliance requirements for essential core medical equipment and supplies. The remaining 13 clinics were missing functional core equipment or supplies necessary to conduct a comprehensive exam. Various clinic locations were missing one or more of the following: Snellen eye exam chart, AED, nebulization unit, functional ophthalmoscope, functional portable light source (Figure 1), emergency medical response bag, glucometer and strips, medication refrigerator, peak flow meter and disposable tips, and Hemoccult cards and developer (MIT 5.108). Figure 1: Exam Room light fixture without a light bulb  Inspectors observed clinician’s encounters with patients in nine clinics and found only one clinic location (11 percent) followed good hand hygiene practices. Clinicians at eight clinics did not routinely sanitize their hands before or after patient contact, before putting on gloves, or after administering injections (MIT 5.104).  Inspectors examined 14 clinics to determine if appropriate space, configuration, supplies, and equipment allowed clinicians to perform a proper clinical exam. Only six clinic locations (43 percent) were in compliance. Seven clinics had Figure 2: Exam table with exam room tables with tears and cracks on the vinyl covers worn vinyl area that could (Figure 2). In addition, the R&R did not have a portable harbor infection California Medical Facility, Cycle 4 Medical Inspection Page 32 Office of the Inspector General State of California privacy screen to ensure visual privacy (Figure 3) (MIT 5.110). CMF scored in the adequate range in the following test areas:  The clinic common areas generally had an adequate environment conducive to providing medical services; however, there were Figure 3: Exam room without privacy screen, opportunities for improvement. While seven of viewable from common hallway nine clinic locations received adequate scores (78 percent), two clinic’s triage areas had a lack of auditory privacy at blood draw and vital signs stations (MIT 5.109).  Inspectors examined emergency response bags to determine if they were inspected daily and inventoried monthly and whether they contained all essential items. Emergency response bags were compliant in four of the five clinical locations where bags were stored (80 percent). In one clinic, an emergency response bag contained two emergency oxygen tanks, and neither was fully charged (MIT 5.111). The institution scored within the proficient range on the following six tests:  Health care staff properly sterilized and disinfected reusable invasive and non-invasive medical equipment in all 12 clinics locations tested (MIT 5.102).  All of CMF’s 14 clinic locations had adequate hygiene supplies available and operable sinks (MIT 5.103).  CMF’s non-clinic medical storage areas generally met the supply management process and support needs of the medical health care program (MIT 5.106).  CMF appropriately disinfected, cleaned, and sanitized 13 of 14 clinics locations tested (93 percent). At one clinic, staff did not sign inmate-porters’ cleaning logs to validate the areas were properly cleaned (MIT 5.101).  When inspecting for proper protocols to mitigate exposure to blood-borne pathogens and contaminated waste, staff members at 13 of the 14 clinic locations (93 percent) followed proper protocols, one clinic did not have a sharps container (MIT 5.105).  Inspectors found 13 of 14 clinic locations (93 percent) followed adequate medical supply storage and management protocols. The only exception was the R&R clinic, in which the exam room storage shelf was not clearly labeled for easy identification of items (MIT 5.107). California Medical Facility, Cycle 4 Medical Inspection Page 33 Office of the Inspector General State of California Other Information Obtained from Non-Scored Results The OIG gathered information to determine if the institution’s physical infrastructure was maintained in a manner that supported health care management’s ability to provide adequate health care. The OIG did not score this question. When OIG inspectors interviewed health care management, they did not identify any concerns. CMF had a number of significant infrastructure projects underway (MIT 5.999): Project A:  New 5,600-square-foot central health services specialty clinic: March 2017.  New 3,900-square-foot TTA between H and J wing buildings: March 2017.  10,000-square-foot renovation of B wing primary care, dialysis services, nurse triage, radiology, emergency treatment, pharmacy services, and medical specialty services areas: December 2017.  2,500-square-foot medical records space renovation: September 2017. Project B:  New 370-square-foot C and D dorm medication distribution room: June 2016.  New 300-square-foot U and V wing medication distribution room: November 2016. Recommendations  Conduct periodic training and refresher courses on proper hand sanitation techniques and protocols that staff should follow when applying and removing protective gloves before, during, and subsequent to patient encounters. California Medical Facility, Cycle 4 Medical Inspection Page 34 Office of the Inspector General State of California INTER- AND INTRA-SYSTEM TRANSFERS This indicator focuses on the management of inmate-patients’ Case Review Rating: medical needs and continuity of patient care during the inter- and Adequate intra-facility transfer process. The patients reviewed for Inter- and Compliance Score: Intra-System Transfers include inmates received from other CDCR Inadequate facilities and inmates transferring out of CMF to another CDCR (72.8%) facility. The OIG review includes evaluation of the institution’s Overall Rating: ability to provide and document health screening assessments, Adequate initiation of relevant referrals based on patient needs, and the continuity of medication delivery to patients arriving from another institution. For those patients, the OIG clinicians also review the timely completion of pending health appointments, tests, and requests for specialty services. For inmate-patients who transfer out of the facility, the OIG evaluates the ability of the institution to document transfer information that includes pre-existing health conditions, pending appointments, tests and requests for specialty services, medication transfer packages, and medication administration prior to transfer. The OIG clinicians also evaluate the care provided to patients returning to the institution from an outside hospital and check to ensure appropriate implementation of the hospital assessment and treatment plans. In this indicator, the OIG’s case review and compliance review processes yielded different results, with case reviews giving an adequate rating and the compliance review resulting in an inadequate score. The OIG’s internal review process considered those factors that led to both results to determine an overall rating score. The key factor in the decision was that while the compliance review process found newly arrived patients did not always receive their medications without interruption, the interruptions only caused one-day delays in patients receiving their medications, which, from a qualitative standpoint, was insignificant. As a result, the inspection team concluded that an overall rating of adequate was appropriate. Case Review Results Clinicians reviewed 38 encounters relating to Inter- and Intra-System Transfers, including information from both the sending and receiving institutions. These included 28 outside emergency room and hospitalization events, each of which resulted in a transfer back to the institution. Thirty deficiencies were identified, of which six were significant. In general, the inter- and intra-system transfer processes at CMF were adequate. Transfers In Of the five sampled cases of patients who transferred into CMF, the OIG clinicians found only one significant deficiency (case 33) that could have likely contributed to patient harm: California Medical Facility, Cycle 4 Medical Inspection Page 35 Office of the Inspector General State of California  In case 33, the patient arrived at CMF and reported feeling depressed for the last two weeks. The patient also reported hearing voices or seeing things that were not there. The receiving RN failed to refer the patient to a mental health clinician immediately. Fortunately, this did not result in any harm and a mental health clinician saw the patient after six days.  In case 34, there was no evidence that nurses checked the patient’s blood sugar or administered his insulin medication on the evening he arrived at CMF. Transfers Out OIG clinicians reviewed five cases of patients transferring out of CMF, and all five cases were adequate. The patients’ health care transfer information forms were complete. All necessary information and forms were available. Medications and health care appliances transferred with the patients. Hospitalizations Patients returning from hospitalizations are some of the highest-risk encounters due to two factors: First, these patients are generally hospitalized for a severe illness or injury. Second, they are at risk due to potential lapses in care that can occur during any transfer. OIG clinicians reviewed 28 events in which patients returned from an outside hospital or emergency department. TTA nurses processed return patients upon return to CMF. Most discharge summaries were retrieved from community hospitals and scanned into the eUHR within acceptable time frames, but discharge summaries were generally not signed or dated by a provider. Medication continuity was acceptable in the cases reviewed. There were widespread problems with respect to the quality of nursing assessment and adequate review of hospital discharge summaries by CMF nurses for patients returning from the hospital or emergency department. Nursing assessments were unfocused and were barely adequate. The following examples illustrate these concerns:  In cases 8 and 73, the institution sent the patient out for difficulty breathing. Upon the patient’s return from the hospital, the RN did not assess his lungs and respiratory status.  In case 9, the institution sent the patient out for abdominal pain. When he returned to CMF, the RN did not assess his abdomen.  In case 20, the patient returned from the emergency department, where he received treatment for abdominal pain and constipation. The RN did not assess the patient’s abdomen, address his elevated temperature, or check when he last received medication for fever. The RN should have also scheduled the patient for a RN clinic follow-up in the morning to recheck his temperature. California Medical Facility, Cycle 4 Medical Inspection Page 36 Office of the Inspector General State of California  In case 24, CMF sent the patient out for leg edema and pain and was diagnosed with lower extremity cellulitis and exacerbation of congestive heart failure. The RN did not assess the patient’s leg.  In case 80, the patient had chest pain, and the institution sent him to the hospital. When he returned, the RN did not assess him for chest pain, discomfort, or any other symptoms. In the case below, the RN failed to provide patient education or instructions on hospital recommendations.  In case 10, the RN did not adequately review the discharge medications and the discharge summary, which instructed the patient to take a higher dose of carvedilol (blood pressure medication). The lack of attention to detail resulted in the nurse missing a medication change upon the patient’s return from the hospital. Good provider performance largely mitigated the significant problems with nursing assessment after the patients’ return to the institution. The institutions staff scheduled most returning patients to see their PCPs within a few days. At those appointments, the PCPs reviewed the discharge summaries and ensured proper intervention and follow-up. Clinician Onsite Inspection During the onsite visit, the OIG clinicians observed that the transfer processes were functioning well. There was one RN assigned in the R&R each shift during weekdays. The R&R nurse was knowledgeable of the transfer process and tracked in a log newly arrived patient referrals to mental health, dental, and medical providers. The primary care team was informed of patients’ arrivals, and pending specialty appointments were forwarded to the specialty nurse. Compliance Testing Results The institution earned an inadequate compliance score of 72.8 percent in the Inter- and Intra-System Transfers indicator. CMF performed in the inadequate range on the three tests below:  The transfer packages of four patients who were transferring out of the facility were examined by OIG inspectors to determine whether they included required medications and support documentation. Only two of four transfer packages (50 percent) were compliant. Two of the patients who transferred from CMF to another institution did not have all of their required medication in their transfer packages (MIT 6.101).  Inspectors sampled 20 patients who transferred out of CMF to another CDCR institution to determine whether the institution listed their scheduled specialty service appointments on the Health Care Transfer Information form (CDCR Form 7371). CMF nursing staff only correctly listed the pending specialty service for 11 of the 20 patients sampled who transferred out of the institution (55 percent) (MIT 6.004). California Medical Facility, Cycle 4 Medical Inspection Page 37 Office of the Inspector General State of California  Among the 30 sampled patients who transferred into the institution, 16 had an existing medication order that CMF should have administered or delivered without interruption. Ten of the 16 patients (63 percent) received their medications timely. Six patients did not receive all medications during the next required dosing interval, but patients received them the next day after arrival (MIT 6.003). The institution scored within the proficient range on the following tests:  Nursing staff properly completed the Initial Health Screening form (CDCR Form 7277) on the same day the patient arrived for all 30 patients sampled who transferred into the institution (MIT 6.001).  For 29 of 30 sampled patients who transferred into the institution, RN nursing staff timely completed the assessment and disposition sections of the CDCR Form 7277 on the same day that they performed the patient’s initial health screening (97 percent). The only exception was one patient whom the RN did not refer to the TTA after showing possible signs and symptoms of tuberculosis (MIT 6.002). Recommendations No specific recommendations. California Medical Facility, Cycle 4 Medical Inspection Page 38 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 (68.8%) 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 effective medication management is affected by numerous entities across various departments, this assessment considers internal review and approval processes, pharmacy, nursing, health information systems, custody processes, and actions taken by the PCP prescriber, staff, and patient. In this indicator, the OIG’s case review and compliance review processes yielded different results, with case review yielding an adequate rating and the compliance review giving an inadequate score. The case reviews focused on qualitative measures, while the compliance review focused on quantitative ones. Because the compliance testing for this indicator has more robust sampling and testing, the compliance score outweighed the case review rating. As a result, the inspection team determined an overall rating of inadequate for this indicator. Case Review Results The OIG clinicians evaluate pharmacy and medication management as secondary processes as they relate to the quality of clinical care provided. Compliance testing is a more targeted approach and the overall rating for this indicator relies on the comprehensive compliance testing. Medication Continuity For the majority of patients reviewed, medication continuity was not a significant problem for the patients transferring into the institution, returning from a community hospital, and receiving monthly chronic care medications. The following cases are provided for quality improvement purposes.  In case 8, the patient’s theophylline (lung medication) prescription expired, but a provider did not order a renewal of the medication. The institution sent the patient to the hospital six weeks later for breathing problems. See the Quality of Provider Performance indicator for additional discussion of this case.  In case 22, the hospital prescribed several new discharge medications prior to the patient’s return to the institution. Institution staff administered the new cholesterol and asthma medications one day late. California Medical Facility, Cycle 4 Medical Inspection Page 39 Office of the Inspector General State of California  In case 34, on the evening this diabetic patient transferred into CMF, no staff at the institution checked the patient’s finger-stick glucose level or administered the patient’s dose of regular insulin. This case is also discussed in the Inter- and Intra-System Transfers indicator. Medication Administration In the majority of cases reviewed, patients received their medications timely and as prescribed, but there were a few nursing medication administration errors:  In case 11, on five occasions, the patient did not receive doses of clonidine (blood pressure medication and sedative).  In case 12, on one occasion, the medication nurse did not administer the evening glaucoma medications to the patient or document why the patient did not receive the medications.  In case 14, on one occasion, the medication nurse did not administer timolol eye drops and terazosin (prostate and blood pressure medication).  In case 38, the medication nurse did not administer dexamethasone (anti-inflammatory steroid) on two occasions, and did not administer Revlimid (cancer medication) on three occasions. Pharmacy Errors The OIG clinicians found extremely limited pharmacy documentation in the eUHR, and had difficulty discerning if any of the various medication errors could have been attributed to pharmacy services. The following error may have been a pharmacy error:  In case 20, a dentist prescribed antibiotics for the patient to start on the same day. There was no evidence that pharmacy ever received the order, and the patient never received the medications. Clinician Summary While there were a suboptimal number of medication administration and medication continuity errors identified at CMF, there was not a significant pattern of deficiencies in this area. The OIG clinicians rated this indicator adequate. Compliance Testing Results The institution received an inadequate compliance score of 68.8 percent in the Pharmacy and Medication Management indicator. This indicator is divided into three sub-indicators: Medication Administration, Observed Medication Practices and Storage Controls, and Pharmacy Protocols. California Medical Facility, Cycle 4 Medical Inspection Page 40 Office of the Inspector General State of California Medication Administration In this sub-indicator, the institution received an average score of 74.7 percent, which fell into the inadequate range. The institution scored poorly in the following area:  For 18 of 36 patients sampled, the institution timely and correctly administered all required chronic care medications and followed proper protocols when patients refused or did not show to receive their medications (50 percent) (MIT 7.001). Many notable instances led to the low score in this sub-indicator, and for some patients sampled there was more than one identified problem area. The following are examples of deficiencies: o Three patients’ keep-on-person (KOP) medication administration records (MARs) did not contain both a nurse’s signature and a date to evidence a timely and proper medication administration. o Three patients never received their monthly supply of KOP chronic care medications. o Four patients missed or refused a dose of a critical medication, and never received medication counseling. o Seven patients received their chronic care medications from 2 to 29 days late. o One patient was taking his critical HIV medication by directly observed therapy (DOT), and the provider switched the medication to KOP, but the patient never received the medication as KOP during the sample test period. o One patient missed a DOT medication four days in a row, and never received medication counseling. In addition, the patient missed two doses of insulin, but failed to receive provider medication counseling by the provider. The institution performed in the adequate range on the following three tests:  The OIG found that the institution timely administered or delivered new medication orders to 32 of the 40 patients sampled (80 percent). Three patients received their medications from one to two days late, and five patients had missing or incomplete eUHR MARs to demonstrate that they received their medications (MIT 7.002).  Eight of the ten sampled patients who were in transit to another institution and were temporarily laid over at CMF received their medications without interruption (80 percent). Two patients each missed at least one dose of their required medications (MIT 7.006).  CMF timely provided hospital discharge medications to 23 of 30 patients sampled who had returned from a community hospital (77 percent). For six patients, their discharge California Medical Facility, Cycle 4 Medical Inspection Page 41 Office of the Inspector General State of California medications were one to six days late, and one patient did not receive his discharge medication at all (MIT 7.003). CMF scored in the proficient range on the test below:  Among 30 sampled patients at CMF who had transferred from one housing unit to another, 26 received their prescribed medications without interruption (87 percent). Four patients did not receive their medication by the next dosing interval after the transfer occurred (MIT 7.005). Observed Medication Practices and Storage Controls For this sub-indicator, the institution received an average score of 46.3 percent, scoring in the inadequate range on the following five tests:  Among 11 inspected clinics and medication line storage locations, non-narcotic medications that require refrigeration were properly stored in only one (9 percent). Some inspected locations had more than one identified problem area. Deficiencies included: ten sampled locations without a designated area for return-to-pharmacy medications, two locations with expired floor stock medications, two locations with refrigerators whose temperature logs were missing entries, and one clinic with medication vials that nurses did not date when first opened. Finally, one location had a refrigeration unit that was unsanitary (Figure 4) (MIT 7.103).  The OIG interviewed nursing staff and inspected narcotics storage areas at 13 applicable locations to Figure 4: Unsanitary medication assess narcotics security controls. Overall, only three refrigerator with grime on bottom shelf area clinic locations (23 percent) had good controls. In the ten other sampled locations, nursing staff did not always complete required control log entries. More specifically, for the OIG’s limited 30-day review period, log books were missing from 2 to 18 required signature entries, generally relating to shift change narcotics count reconciliations, but also periodically relating to the destruction of a wasted medication (MIT 7.101). California Medical Facility, Cycle 4 Medical Inspection Page 42 Office of the Inspector General State of California  The OIG inspected 16 applicable clinics and medication line storage locations and found that non-narcotic medications that did not require refrigeration were properly stored at only five (31 percent). Some inspected areas had more than one identified problem area. Deficiencies included seven locations that did not have a designated area for return-to-pharmacy medications; two locations that had a stash of medications that were not properly controlled or accounted for by the pharmacy (Figure 5), and two locations with expired medications on hand. Figure 5: Stash of uncontrolled medications Finally, one location had internal and external found in the R&R clinic area medications unsafely stored together (MIT 7.102).  Nursing staff at only four of seven sampled medication preparation and administration locations followed proper hand hygiene contamination control protocols during the medication preparation and administration processes (57 percent). Nursing staff at three other locations did not always sanitize their hands prior to initially putting on protective gloves or between subsequent glove changes (MIT 7.104).  Only four of seven toured medication areas demonstrated appropriate administrative controls and protocols during medication distribution (57 percent). Nursing staff did not verify the identification of two patients prior to administering medication at two locations, and the nurse at one other location did not verify a patient’s identification and administered a liquid medication for a patient from another patient’s bottle (MIT 7.106). CMF scored in the proficient range on the following test:  Nursing staff at all seven of the inspected medication and preparation administration locations followed appropriate administrative controls and protocols during medication preparation (MIT 7.105). Pharmacy Protocols For this sub-indicator, the institution received an average score of 90.0 percent, scoring 100 percent in the following test areas:  In its main and satellite pharmacies, CMF followed general security, organization, and cleanliness management protocols; properly stored refrigerated and frozen medications; and maintained adequate controls and properly accounted for narcotic medications (MIT 7.107, 7.109, 7.110). California Medical Facility, Cycle 4 Medical Inspection Page 43 Office of the Inspector General State of California  CMF’s pharmacist in charge timely processed all 30 inspector-sampled medication error reports (MIT 7.111). The institution scored in the inadequate range on the following test:  The institution scored 50 percent for storage of non-refrigerated medication in pharmacy locations. Specifically, the main pharmacy (one of two CMF pharmacies) had medication placed in bins and stored on the floor (MIT 7.108). Non-Scored Tests  In addition to the OIG’s testing of reported medication errors, inspectors follow-up on any significant medication errors that were found during the case reviews or compliance testing to determine whether the errors were properly identified and reported. The OIG provides those results for information purposes only. At CMF, the OIG did not find any applicable medication errors (MIT 7.998).  The OIG tested patients in isolation units to determine if they had immediate access to their prescribed KOP rescue asthma inhalers and nitroglycerin medications. Inspectors identified three patients to which this test applied. Based on interviews with all three patients, all had physical possession of their rescue medication (MIT 7.999). Recommendations The OIG recommends that as part of staff’s performance evaluation, CMF management should evaluate clinicians’ compliance and understanding of good hand sanitation practices. California Medical Facility, Cycle 4 Medical Inspection Page 44 Office of the Inspector General State of California PREVENTIVE SERVICES This indicator assesses whether various preventive medical services Case Review Rating: are offered or provided to inmate-patients. These include cancer Not Applicable screenings, tuberculosis screenings, and influenza and chronic care Compliance Score: Inadequate immunizations. This indicator also assesses whether certain (65.4%) institutions take preventive actions to relocate inmate-patients identified as being at higher risk for contracting coccidioidomycosis Overall Rating: (valley fever). Inadequate x The OIG rates this indicator entirely through the compliance testing component; the case review process does not include a separate qualitative analysis for this indicator. Compliance Testing Results The institution performed in the inadequate range in the Preventive Services indicator, with a score of 65.4 percent. The institution scored in the inadequate range on the following three tests:  CMF scored 53 percent in regard to conducting annual tuberculosis screenings. Although all 30 inmate-patients sampled were screened for tuberculosis within the prior year, only 6 of the 15 patients identified as Code 22 (requiring a tuberculosis skin test in addition to screening of signs and symptoms) were properly tested. For each of the other nine Code 22 patient screenings, inspectors identified one or more of the following errors: the 48-to-72-hour window to read test results was not clear because nursing staff did not document either the administered (start) or read (end) date and time; test results were read outside of the required 72-hour time period; an LVN read the test results rather than an RN, public health nurse, or primary care provider; or nursing staff did not complete all required sections of the Tuberculin Testing/Evaluation Report (CDCR Form 7331). In addition, five of the 15 patients identified as Code 34 (requiring only a signs and symptoms screening) did not receive a proper evaluation because nursing staff did not properly complete the history section of the CDCR Form 7331 (MIT 9.003).  CMF scored 67 percent in regard to timely administration of anti-tuberculosis medications. Of 18 patients sampled, 12 received all required doses of their medication in the most recent three-month or 12-week period. Six patients did not receive all of their anti-tuberculosis medications and did not receive provider counseling regarding the missed doses (MIT 9.001). In addition, only one of 17 patients tested (6 percent) received monthly or weekly monitoring while taking anti-tuberculosis medications. Nine patients received no monitoring at all, and six patients only received monitoring sporadically while on the medication. Finally, one patient received all of the required monitoring, but the monitoring forms were not scanned into the eUHR after each monitoring visit (MIT 9.002). California Medical Facility, Cycle 4 Medical Inspection Page 45 Office of the Inspector General State of California The institution scored in the proficient range on the following tests:  The institution offered annual influenza vaccinations to 28 of 30 sampled patients subject to the annual screening requirement (93 percent). No evidence was found in the eUHR that two patients received an influenza vaccination in the most recent influenza season (MIT 9.004).  The OIG found 26 of 30 patients sampled (87 percent) either had a normal colonoscopy within the last ten years or that health care staff offered a colon cancer screening in the last year. Four patients either did not have a normal colonoscopy within ten years or were not offered a colon cancer screening in the last 12 months (MIT 9.005).  The OIG tested whether CMF offered required influenza, pneumonia, and hepatitis vaccinations to patients who suffered from a chronic condition; 26 of the 30 patients sampled (87 percent) received them; the institution did not offer four patients one or more of the vaccinations (MIT 9.008). Recommendations No specific recommendations. California Medical Facility, Cycle 4 Medical Inspection Page 46 Office of the Inspector General State of California QUALITY OF NURSING PERFORMANCE The Quality of Nursing Performance indicator is a qualitative Case Review Rating: evaluation of the institution’s nursing services. The evaluation is Inadequate completed entirely by OIG nursing clinicians within the case Compliance Score: review process, and, therefore, does not have a score under the Not Applicable compliance testing component. The OIG nurses conduct case reviews that include reviewing face-to-face encounters related to Overall Rating: nursing sick call requests identified on the Health Care Services Inadequate Request form (CDCR Form 7362), urgent walk-in visits, referrals for medical services by custody staff, RN case management, RN utilization management, clinical encounters by licensed vocational nurses (LVNs) and licensed psychiatric technicians (LPTs), and any other nursing service performed on an outpatient basis. The OIG case review also includes activities and processes performed by nursing staff that are not considered direct patient encounters, such as the initial receipt and review of CDCR Form 7362 service requests and follow-up with primary care providers and other staff on behalf of the patient. Key focus areas for evaluation of outpatient nursing care include appropriateness and timeliness of patient triage and assessment, identification and prioritization of health care needs, use of the nursing process to implement interventions including patient education and referrals, and documentation that is accurate, thorough, and legible. Nursing services provided in the outpatient housing unit (OHU), correctional treatment center (CTC), and hospice are reported in the Specialized Medical Housing indicator. Nursing services provided in the triage and treatment area (TTA) or related to emergency medical responses are reported in the Emergency Services indicator. Case Review Results The OIG clinicians reviewed 183 outpatient nursing encounters, 152 of which were for sick call requests or outpatient clinic nurse follow-up visits. There were 108 deficiencies identified related to the quality of nursing care, with 29 that were significant. The majority of these deficiencies involved failure to perform face-to-face assessments when Health Care Services Request forms (CDCR Form 7362) described clinical symptoms. Some of these deficiencies contributed to substantial lapses in care. Serious deficiencies also occurred when nurses reviewing sick call requests failed to recognize the need for a same-day RN assessment and when outpatient clinic nurses failed to refer patients to providers in a timely manner. There were serious concerns regarding the lack of and inadequate nursing assessment and timely intervention. The OIG nursing clinicians rated this indicator inadequate. Nursing Sick Call The National Commission of Correctional Health Care (NCCHC) has set a standard for nonemergency health care requests and services to ensure that patients have access to care to meet their health care needs. All patients should have the opportunity to request health care, and these requests should be reviewed for immediacy of need. When a patient submits a sick call request California Medical Facility, Cycle 4 Medical Inspection Page 47 Office of the Inspector General State of California describing clinical symptoms, a face-to-face encounter with a health care provider is required. CCHCS policy requires that an RN see these patients face to face within the prescribed time frame, adequately assess them, document the encounter, and ensure that an appropriate disposition is implemented. CMF health care staff collected and triaged Health Care Service Requests forms (CDCR 7362) in a timely manner. However, case reviews showed that the outpatient clinic nurses consistently failed to perform face-to-face assessments on patients with symptom complaints. Frequently, the outpatient clinic nurses initiated referral to the provider or added medical requests on the next provider appointment without performing a face-to-face assessment, and patients would wait several days or even weeks to see a provider. While on site reviewing sick call request forms, the OIG clinicians also noted that CMF sick call nurses failed to see patients with symptoms face to face (these patients were in addition to the case review samples). In one of the clinics, a patient submitted a sick call request because of leaking fluid from his right ear. The sick call RN did not schedule the patient for face-to-face assessment and instead added the complaint to the next provider appointment one week later. The RN stated that the patient was just seen five days before by the ear, nose, and throat specialist (ENT) provider, who noted no abnormal findings, but the leaking had started after the ENT encounter. Another patient, who submitted a sick call request with complaints of neck, back, and knee pain and high blood sugar for a month, was also referred to the provider line without an RN face-to-face assessment as required by CCHCS policy and nursing standards of practice. In fact, CMF nurses collected multiple sick call requests with symptom complaints, but CMF RN’s mostly deferred to the provider without a nursing assessment. Additionally, the outpatient clinic nurses sometimes failed to perform immediate face-to-face assessments when medically necessary, perform adequate patient assessments, or formulate an appropriate plan of care, such as a timely referral to the provider. While many of the patients ultimately received adequate care, the pattern of nursing staff’s failure to see patients face to face, to perform adequate assessments, and appropriately refer patients to a provider increased the potential for patient harm. In the following examples, RN face-to-face encounters did not occur:  In case 11, the patient had a fall and sustained multiple facial fractures, which required surgery. He also had an abscess on his leg and later developed pneumonia, which resulted in an overwhelming infection and the patient’s death. He submitted multiple sick call requests that were not addressed by the outpatient clinic nurse: o In late June, the patient submitted a sick call request for pain, but the RN did not conduct a face-to-face encounter. The RN referred him to the provider, who saw him ten days later. California Medical Facility, Cycle 4 Medical Inspection Page 48 Office of the Inspector General State of California o In mid-July, the patient submitted a sick call request for swelling, discharge, and pain in the eye. The RN did not see the patient and instead deferred evaluation to the next pending ophthalmology follow-up appointment in three months. o In late August, the patient submitted a sick call request to see the provider for an “emergency” and because he just returned from the hospital. The RN did not see the patient face-to-face, and instead noted that a provider saw the patient two days prior and scheduled the patient for routine provider appointment. The patient was seen in the TTA later in the evening for shortness of breath.  In case 16, the outpatient clinic nurses repeatedly failed to see the patient face-to-face for sick call requests with clinical symptoms: o The patient submitted a sick call request for flushing, anxiety, bronchial constriction, and tremors since his Nortriptyline medication were discontinued. The RN reviewed the sick call slip but did not see the patient. o Three days later the RN reviewed another sick call request describing the same clinical symptoms and discussed it with the provider, who ordered a new medication. The RN failed to perform a face-to-face assessment. o One month later, the patient submitted a sick call request reporting problems with his ability to self-catheterize his bladder. The RN did not see the patient face-to-face to assess the patient’s ability to perform self-catheterization and provide instruction or demonstration if necessary. o Nearly three weeks after that, the patient submitted a sick call request stating he had torn or ruptured his urethra over three weeks ago with daily blood in his urine and pain. The RN did not see the patient face-to-face, and instead added the issue to the next provider appointment. The provider saw the patient four days later. o Less than one week later, the patient submitted a sick call request for severe pain and hematuria (blood in the urine). The RN did not see the patient face-to-face.  In case 24, there were multiple sick call requests that were addressed inappropriately: o The patient submitted a sick call form requesting Lyrica for his neuropathy and complained of acid reflux and a hernia. The RN did not see the patient and instead added the request to the upcoming provider appointment. The appointment occurred ten days later. o Six weeks later, the patient submitted a sick call request to discontinue Lyrica because of side effects. He complained of high blood sugar, swelling, rash, and muscle pain. Not all of the symptoms described by the patient could be attributed to the medication, and the California Medical Facility, Cycle 4 Medical Inspection Page 49 Office of the Inspector General State of California patient may have been having symptoms for other medical reasons. The RN did not assess the patient and did not make a new referral, but instead added the new issues to an existing provider appointment. The appointment did not occur until five weeks later. By failing to address the patient’s concerns at the time of the complaint, the nurse contributed to a significant lapse in care. o Another six weeks later, the patient submitted a sick call request for one month of continued leg swelling. Despite multiple diagnostic tests and interventions provided, the RN still did not see the patient. o Five days later, the patient submitted a sick call request and wrote “emergency” and that his legs had continued to get worse. The nurse did not see the patient and instead wrote that a provider already saw the patient four days prior. The nurse should have brought the patient in for an evaluation and had the provider readdress the medical problem.  In case 45, the patient submitted a sick call request for severe leg swelling and for refill of his blood pressure medication, losartan. The RN did not see the patient face-to-face and only noted that the request was sent to the provider to reorder medication.  In case 49, the patient submitted a sick call request for severe back and leg pain. The patient also stated the he had not seen his provider since he arrived at CMF, and he requested to see the podiatrist. The RN did not see the patient face-to-face and failed to review the eUHR, which documented that the patient had multiple medical conditions, including a history of deep vein thrombosis (blood clot). The RN referred the patient for a routine provider appointment. A provider last saw the patient almost one month before. At that time, the provider ordered a three- to five-day follow-up, but this did not occur. The RN should have referred the patient to the provider sooner.  In case 51, the patient submitted multiple sick call requests to see the podiatrist because his shoes were in disrepair, causing ankle and foot pain. Each time, the RN did not see the patient for a face-to-face encounter.  In case 52, the patient submitted a sick call slip for abdominal symptoms. The RN did not see the patient face-to-face.  In case 58, the patient submitted a sick call request for severe facial pain and headaches. The RN did not perform a face-to-face assessment. Nine days later, the patient submitted another sick call request for the same symptoms. Again, the RN did not see the patient or refer him to the provider.  The outpatient clinic RN also failed to see the patient, in some instances multiple times, in cases 6, 7, 8, 12, 19, 21, 22, 43, 46, 48, 56, 59, 60, 61, 63, 64, 65, 67, 70, and 71. California Medical Facility, Cycle 4 Medical Inspection Page 50 Office of the Inspector General State of California In the following cases, the outpatient RN failed to see the patient with serious medical symptoms on the same day:  In case 16, the patient woke up with his urine bag full of blood and submitted a sick call request, but the RN did not see the patient until four days later.  In case 21, the patient submitted a sick call request for acute bleeding symptoms. He stated that he was a diabetic and on blood thinners. The RN did not see the patient on the same day.  In case 28, the patient submitted a sick call request because his pacemaker alarm continued to beep. The RN did not assess the patient on the same day. During RN face-to-face encounters with the patient, the outpatient RN failed to collect data and perform an adequate nursing assessment relevant to each patient’s health and condition. The OIG clinicians could not determine if the nurse asked important questions, examined pertinent areas of the body, or performed necessary measurements. Nurses also failed to document the presence or absence of common accompanying signs and symptoms.  In case 10, the patient submitted a sick call request for kidney pain. The RN failed to obtain a urine test and assess the patient for abdominal distention, tenderness, or pain.  In case 17, the patient saw the outpatient RN for leg pain, numbness, and swelling. In addition, the patient stated that he had not seen his provider for a follow-up for his neurology consultation. The neurologist recommended medication changes, and the RN did not adequately review the patient’s medical records and inform the provider of the specialist’s recommendation.  In case 19, the patient saw the RN for stomach pain. The RN did not obtain adequate history, such as time of symptom onset, duration and location of pain, any accompanying signs and symptoms, last meal eaten, and current medications. The RN did not examine the patient for any abnormal findings such as abdominal distention, guarding (tense abdominal muscles), or tenderness.  In case 40, the patient submitted a sick call request for numbness in the hands and fingers along with forearm cramps, swollen wrist, nerve tissue damage, and pain in the right shoulder. The nurse did not perform an adequate assessment. Additionally, the RN added the problem to an unrelated provider appointment, with no evidence that the nurse even consulted with the provider first. Because of the nurses’ actions, the provider did not receive the patients’ medical issues; therefore, the provider did not address them.  In case 46, the patient had back pain for two days. The RN did not examine the patient’s back for swelling, tenderness, or range of motion. The patient submitted another sick call California Medical Facility, Cycle 4 Medical Inspection Page 51 Office of the Inspector General State of California request for urinary problems, and swollen ankles and feet. The RN did not obtain a urine dipstick test to check for possible infection.  In case 59, the patient submitted sick call requests for burning sensation after urination and neck pain. The RN did not obtain adequate history such as onset or duration of symptoms, any accompanying symptoms such as flank or lower abdominal pain, problems with voiding such as dribbling or retention, color of urine, discharge, lesion, or bleeding in the area. The RN also did not assess the patients’ neck.  In case 61, the patient saw the RN for arm and leg pain. The RN did not assess the patient’s arms and legs for any swelling, circulation, sensation, or mobility problems.  In case 64, the patient saw the RN for pain and burning in his stomach. The RN did not examine the patient’s abdomen, ask for the onset or duration of the condition, or any accompanying signs and symptoms. The outpatient nurses failed to utilize the nursing process and determine an appropriate intervention or disposition, such as timely referral, to achieve a positive outcome.  In case 12, the LVN completed a sick call request on behalf of the patient. The patient complained of having severe nausea and vomiting. The LVN did not immediately refer the patient to the RN or provider. The patient was brought to the TTA the next morning for shortness of breath and confusion.  In case 24, the RN saw the patient for irregular bowel movements, kidney concerns, and retaining water in his hands and feet. The nurse did not create a new referral, but instead added the patient to an existing provider appointment. The next appointment did not occur until four weeks later. The nurse’s action contributed to a significant delay in care.  In case 26, the patient saw the RN because he fell off the top bunk, hit his head, and had symptoms of vomiting, dizziness, headache, and diarrhea. The RN obtained further history that the patient was taking blood thinners and referred the patient for a 14-day routine follow-up. The nurse should have performed a neurological assessment and had a same day provider consultation. The RN failed to consider an intracranial bleed in this situation, and did not refer the patient to a provider timely (this event was classified as an unsafe condition and is discussed in the Medical Inspection Results: Adverse Events Identified During Case Review section on page 12). Nursing Documentation Nursing documentation in some of the cases reviewed was incomplete or illegible with most words impossible to identify. Incomplete or illegible nursing notes may result in disruption in the California Medical Facility, Cycle 4 Medical Inspection Page 52 Office of the Inspector General State of California continuity of patient care and potentially put the patient at risk (cases 8, 9, 12, 16, 18, 20, 46, 75, and 81). Specialty Services The OIG clinicians reviewed 65 nursing encounters related to specialty services and found 44 nursing deficiencies. At CMF, patients returning from offsite specialty appointments were processed in the TTA. Nurses generally spent a minimum amount of time assessing patients, which often resulted in inadequate nursing assessment. Nurses rarely performed a thorough assessment and documentation was often incomplete or illegible. There was no education or instructions provided to the patient who underwent procedures. See the Specialty Services indicator for specific findings on nursing performance. Emergency Services The OIG clinicians reviewed 70 urgent/emergent events and found 43 deficiencies related to nursing care. The TTA nurses showed patterns of inadequate nursing assessments and delayed provider notifications. See the Emergency Services indicator for specific findings. Specialized Medical Housing Overall, the nursing care provided in the specialized medical housing facilities was adequate. See the Specialized Medical Housing indicator for specific findings. Medication Administration In the majority of cases reviewed, patients received their medications timely and as prescribed. See the Pharmacy and Medication Management indicator for specific findings. Inter- and Intra-System Transfers Inter- and intra-system transfer processes were adequate. However, the OIG clinicians found systemic concerns to the quality of nursing assessment and adequate review of hospital discharge summaries by nurses for patients returning from the hospital or emergency department. See the Inter- and Intra-System Transfers indicator for specific examples. Clinician Onsite Inspection At the time of the OIG inspection, there were six outpatient clinics at CMF located in one central area and an RN clinic at each of the C and D dorms. There were two additional exam rooms in the central area and a nursing station. The OIG clinicians visited the outpatient clinics and attended the primary care team morning huddles. Most of the huddles started and ended on time, and were attended by the providers, sick call nurses, and LVN care coordinators. Medication line nurses and custody staff only attended if there were issues to address or communicate to the team. Daily huddle reports included TTA log review for unscheduled transfers to higher level of care and patient returns, significant diagnostic and laboratory results, new arrivals and recent transfers, medication California Medical Facility, Cycle 4 Medical Inspection Page 53 Office of the Inspector General State of California issues, provider schedule, backlogs, staffing and supplies issues, and reviews of CDCR Form 7362’s received. However, there were no meaningful discussions from nursing on the sick call and case management line or other clinical nursing issues. The OIG clinicians interviewed outpatient clinic nurses and supervisors on the nursing sick call process. On average, the outpatient clinic nurses saw five patients daily for face-to-face assessments, including walk-ins. Nurses spent the rest of their time reviewing patient medical information. One of the outpatient clinics did not have any RN face-to-face appointments scheduled, but the clinic had received multiple sick call requests with symptom complaints. The nurses verbalized having no major barriers with initiating communication with their providers, supervisors, and custody staff regarding patient care needs. The nursing staff also reported that CMF has implemented the Complete Care Model policy, and the institution assigned each patient to a care team. However, the nurses did not fully understand their roles and responsibilities as a care team member. This clinic nursing supervisor was proactive in her assigned unit and regularly conducted audits of nursing sick call encounters. The OIG clinicians interviewed nursing staff from other clinical areas, including specialty services, telemedicine services, utilization management, public health, receiving and release areas, nursing education, medication management, correctional treatment centers, outpatient housing units, and hospice areas. The nursing and support staff were knowledgeable of their duties and responsibilities. However, they demonstrated inconsistencies in job satisfaction and described problems such as staffing issues, lack of communication, and clear directives from nursing management. The OIG clinicians also interviewed the nurse educators and reviewed training files of nurses assigned in different clinical areas. The nurse educators utilized a tracking log to ensure that CMF provided nurses with the required and mandatory training in a timely manner. New nurses attended ten days of classroom training prior to their orientation in the different clinical areas and nursing staff were required to attend annual trainings, policy update reviews, and skills improvement classes. The nurse educators also initiated mental health trainings recently for all nursing staff. The OIG clinicians also reviewed supervisory files and found the most recent performance evaluation in each of them. The file review did not identify any staff performance issues. Recommendations  The OIG recommends providing nurses training on the sick call process to ensure that they understand the CCHCS policy, appropriately review sick call requests, recognize cases requiring same-day assessment, and implement timely nursing intervention and referral.  The OIG recommends nursing leadership review and improve the process of evaluating nursing competency to reflect an accurate assessment of a nurse’s knowledge and skill. California Medical Facility, Cycle 4 Medical Inspection Page 54 Office of the Inspector General State of California QUALITY OF PROVIDER PERFORMANCE In this indicator, the OIG physicians provide a qualitative Case Review Rating: evaluation of the adequacy of provider care at the institution. Adequate Appropriate evaluation, diagnosis, and management plans are Compliance Score: reviewed for programs including, but not limited to, nursing sick Not Applicable call, chronic care programs, TTA, specialized medical housing, and specialty services. The assessment of provider care is Overall Rating: performed entirely by OIG physicians. There is no compliance Adequate testing component associated with this quality indicator. Case Review Results The OIG clinicians reviewed 195 medical provider encounters and identified 83 deficiencies, 32 of which were significant, related to provider performance at CMF. There was a strong pattern of deficiencies among two CMF physicians, who were responsible for the vast majority of the deficiencies identified below. The OIG clinicians rated CMF provider performance adequate. Assessment and Decision-Making In the majority of encounters, CMF providers made good assessments and sound decisions, as the following two cases demonstrate:  In case 10, the PCP proficiently managed the patient’s multiple chronic medical conditions and coordinated multiple diagnostic tests. The PCP obtained a cardiac catheterization, coronary stent placement, colonoscopy, and DEXA scan.  In case 39, the PCP expertly managed the patient’s medical care after the patient transferred into CMF with a diagnosis of brain cancer. The PCP arranged multiple MRIs and coordinated specialty care, including radiation oncology and neurosurgery consultations. Despite the good care found in the majority of cases reviewed, the OIG clinicians identified a significant pattern of problems with inadequate assessment and decision-making, as identified in cases 8, 11, 12, 16, 17, 18, 24, 28, 30, 31, 38, and 40. In-depth analysis of these errors revealed that two CMF physicians were responsible for the vast majority, as shown in the following examples:  In case 30, the patient had poorly controlled diabetes and hypertension. The provider did not review the most recent lab reports and did not order required monitoring tests. The provider ignored the patient’s elevated blood pressure. The patient required better mealtime blood sugar control, but the provider did not offer the patient appropriate diabetic medications and ordered an excessively long six-month follow-up.  In case 12, the provider saw the patient in the TTA for fever and low oxygen levels. After the patient refused hospitalization, the TTA provider treated him with antibiotics. When the California Medical Facility, Cycle 4 Medical Inspection Page 55 Office of the Inspector General State of California patient saw his PCP for follow-up three weeks later, the provider did not review the medical record showing that the TTA provider recently saw the patient for a serious illness. Review of Records In most encounters, CMF providers performed an adequate review of records when caring for their patients.  In case 6, the provider managed multiple chronic conditions, including seizures, low kidney function, and HIV. The patient with persistent seizures was also hospitalized at one time. The provider appropriately managed the patient’s medications based on various lab tests and changes in condition. The provider’s good performance would not have been possible without thorough review of multiple labs and hospital records. Despite good performance by most CMF providers, the same two CMF physicians were also responsible for the strong pattern of deficiencies where they performed a superficial and incomplete review of records. The OIG clinicians identified this deficiency in cases 6, 12, 18, 20, 21, 24, 30, 31, 38, and the following case:  In case 8, the patient’s chronic lung medication (theophylline) had expired within the past week. The PCP did not adequately review the records and failed to renew the patient’s theophylline, which likely contributed to the patient’s hospitalization six weeks later. In addition, the provider failed to recognize that the patient was seen in the TTA for a man-down event within the last week, and did not address the problem. The provider wrote that he last saw the patient more than two months prior; in fact, he had seen the patient only three weeks prior, which further suggested that the provider did not review the medical record. Failure to review records combined with inadequate assessment or decision-making ultimately resulted in medical problems that the provider did not address. Providers ignored and failed to adequately address medical conditions in cases 8, 13, 16, 18, 22, 24, 28, 30, 31, 40, and the following case:  In case 17, the patient had persistently elevated blood pressure in every clinical encounter for the past three months. The provider assessed the hypertension as labile (abruptly fluctuates), and failed to perform any intervention. The provider did not even order blood pressure monitoring or a follow-up appointment. Even when providers ignored or failed to address medical conditions, they still may have provided adequate care if the provider saw the patient frequently for follow-up and re-evaluation. The provider may have eventually realized the errors and intervened to correct them. Unfortunately, the same two physicians were also responsible for the majority of errors in this area as well. Deficiencies in which the provider did not order an appropriate follow-up interval occurred in cases 8, 16, 20, 21, 24, 28, 29, 31, and 38. California Medical Facility, Cycle 4 Medical Inspection Page 56 Office of the Inspector General State of California Emergency Care When CMF TTA providers evaluated patients in person, they generally made accurate assessments and safe triage decisions. In 2015, at the direction of CCHCS headquarters, CMF removed after-hours onsite physician coverage (MOD –medical officer of the day), and instituted after-hours coverage by telephone (POC – physician on call). This type of coverage is inherently more risky for a medically complex patient population. Good on-call coverage is dependent on meticulous, accurate, and consistent clinical assessment and judgment on the part of both nurses and providers. Telephone assessment is also prone to the limitations of audio-only communication. On-call coverage at CMF was severely problematic. These findings are further discussed in the Emergency Services indicator. Chronic Care The institution had two primary care physicians who managed HIV and hepatitis C patients. Both of these specialized physicians demonstrated exceptional attention to detail, comprehensive assessment, and sound decision-making. The pharmacy department at CMF ran the anticoagulation clinic. The pharmacist performed clinical evaluations at appropriate intervals, ordered and reviewed labs, and made warfarin medication adjustments precisely according to the CCHCS anticoagulation protocol. The pharmacy staff ran the anticoagulation clinic well, and they did not contribute to any significant deficiencies.  In cases 26 and 27, the anticoagulation clinic demonstrated close warfarin monitoring and management. The clinic pharmacist ordered and reviewed lab tests in a timely manner. The pharmacist inquired about side effects and any evidence of bruising or bleeding, made appropriate medication adjustments in response to low or high warfarin levels, and referred the patients back to the PCP when medication compliance became problematic. Despite the good performance by the anticoagulation clinic, proper patient care depended on the PCPs determining the appropriate warfarin target levels and communicating those targets to the clinic, which did not always occur.  In case 28, the patient had a mechanical mitral valve, which required a higher warfarin target level than normal. The target for this patient should have been to reach an INR (lab test for warfarin levels) between 2.5 and 3.5. However, the PCP directed the anticoagulation clinic to treat to a target level of only 2.0 to 3.0. This increased the patient’s risk of life-threatening blood clots from the mitral valve. Fortunately, no harm occurred during the review period. Diabetic management performance was inconsistent and was provider dependent. Those providers who had demonstrated poor review of records, inadequate assessment, and poor decision-making and who had ordered inappropriately long follow-up intervals also did not perform well with diabetic management. California Medical Facility, Cycle 4 Medical Inspection Page 57 Office of the Inspector General State of California  In case 31, the patient had poorly controlled diabetes throughout the review period. The PCP intermittently made efforts to control the patient’s diabetes. However, on several occasions, the PCP did not review the finger-stick sugar logs, did not recommend appropriate changes to insulin dosage, and ordered excessively long follow-up intervals. The provider also did not follow current guidelines for treating the patient with lipid-lowering medications. These provider errors increased the likelihood of the patient’s prolonged poorly controlled diabetes and its associated harms. Specialty Services CMF providers referred appropriately and diligently at all times. Furthermore, CMF providers ordered specialty services within appropriate time frames. When providers saw patients for follow-up after specialty services, they appropriately reviewed reports and took appropriate actions. Clinician Onsite Inspection The institution has had stable physician leadership for many years with the CME and CP&S. Most providers described the CP&S as supportive and fair, with good communication skills. The CP&S was easily reachable and was always willing to help. Providers described the CME as a firm, intelligent, and strong patient care advocate. Providers generally felt that they were well supervised and that their management team was a strength of CMF’s medical program. Providers universally described their own morale as poor. Providers were unhappy with the change in after-hours coverage from onsite to on-call. They described the change as detrimental to patient care; and felt frustrated about the perception that the providers were only concerned about their loss of overtime pay, instead of the quality of patient care. The providers explained that with CMF’s medically complex patient population, on-call providers were exposed to excessive medical risk compared to providers in other CDCR institutions. CMF patients frequently became ill and required multiple triage decisions on a daily basis. When performing a telephone encounter, the only way a provider could mitigate those risks was to come into the facility and perform a face-to-face evaluation. CMF providers did not consider travelling to and from the institution multiple times per on-call night as a practical long-term solution. At the time of the OIG clinicians’ onsite inspection (March 2016), six CMF providers had announced that they were leaving or had already retired or transferred to other, less risky institutions because of this problem. The CME acknowledged that CMF had a severe provider retention problem. After many years of provider stability, the sudden loss of six providers in the span of less than a year posed significant challenges for the institution to maintain adequate quality of care. The CME explained that CMF traditionally did not have a recruitment problem, and did not describe any recent problems in recruitment of new physicians. The CP&S and the CME were not aware of any quality concerns for any of their providers, and were resistant to the idea that two of their providers might be performing at a substandard level. California Medical Facility, Cycle 4 Medical Inspection Page 58 Office of the Inspector General State of California Clinician Summary Of the 30 detailed, physician-reviewed cases, three were proficient, 19 were adequate, and eight were inadequate. An in-depth analysis of the CMF provider deficiencies revealed that 55 of the 83 provider performance deficiencies (66 percent) were attributed to only two providers. Likewise, 24 of the 32 significant provider performance deficiencies (75 percent) were attributed to the same two providers. No patterns of deficiencies were found among the other 16 physicians who contributed to care in the cases reviewed. After considering all factors, the OIG rated CMF provider performance adequate. Recommendations The OIG recommends further clinical performance reviews for the two providers identified as performing at a sub-optimal level. California Medical Facility, Cycle 4 Medical Inspection Page 59 Office of the Inspector General State of California SPECIALIZED MEDICAL HOUSING (OHU, CTC, SNF, HOSPICE) This indicator addresses whether the institution follows appropriate Case Review Rating: policies and procedures when admitting inmate-patients to onsite Adequate inpatient facilities, including completion of timely nursing and Compliance Score: provider assessments. The chart review assesses all aspects of Adequate medical care related to these housing units, including quality of (76.5%) provider and nursing care. CMF’s specialized medical housing Overall Rating: units are correctional treatment centers (CTC), outpatient housing Adequate unit (OHU) and hospice unit. Case Review Results At the time of the OIG’s inspection, CMF had a 55-bed medical CTC, a 47-bed OHU, and a 17-bed hospice unit. There were designated negative pressure rooms (designed to minimize the spread of airborne infection) in the CTC and OHU. The OIG clinicians reviewed 106 provider and 210 nursing encounters and identified only two provider deficiencies but 132 nursing deficiencies. While there were significant problems identified with CTC nursing performance, excellent provider performance largely mitigated those issues. The OIG clinicians rated the case review portion of this indicator adequate. Provider Performance (CTC, OHU, Hospice) CMF provider performance in the specialized housing units was very good. CMF providers demonstrated excellent assessments and close follow-ups. Extremely detailed and thorough discharge summaries proved that CMF providers were well aware of and were thoughtfully managing their patients’ numerous medical conditions. CMF providers ensured that patients received adequate care, despite the questionable nursing performance in some of the specialized housing units.  In case 9, the patient was hospitalized for confusion caused by his liver disease and a severe infection. The patient was diagnosed with a small epidural (spinal) abscess. Upon the patient’s return to the institution, the CTC provider thoroughly reviewed the records and performed a detailed H&P. The regular CTC provider saw the patient within appropriate intervals and closely monitored the patient as he recovered. Close follow-ups by the physician mitigated several nursing errors in this case. Upon the patient’s discharge from the CTC, the provider documented an impressively detailed discharge summary.  In case 14, medical staff admitted the patient to CMF’s hospice unit with end-stage renal disease, and he refused dialysis treatment. The hospice physician documented a complete and well-thought-out plan of care in the admission H&P. Throughout the patient’s hospice course, the provider demonstrated compassionate care with an appropriate emphasis on controlling the patient’s symptoms and maintaining dignity at the end of life. California Medical Facility, Cycle 4 Medical Inspection Page 60 Office of the Inspector General State of California Correctional Treatment Center Nursing Performance CCHCS policy requires that CTC nurses perform a patient systems assessment (review of all body systems) during each shift. During the onsite visit, CMF management explained that this was also the requirement in the hospice unit. For OHU patients, the OHU nurses were only required to document all clinical interactions and changes in level of care. The OIG clinicians found that, prior to July 2015, the CTC nurses did not document a systems assessment each watch. When the CTC nurses did document them, they were generally inadequate assessments. Nursing staff often did not initiate, update, or scan into the eUHR patient care plans. When providers discharged patients from the CTC, the nurses failed to complete an RN discharge summary and provide evidence that they gave discharge instructions to the patient. Poor or missing nursing documentation was a serious concern throughout the review. The nurses failed to consistently document vital signs and complete the required fields in the admission assessment and nursing care record forms. The majority of records reviewed had illegible handwriting (notes and signatures). For these reasons, the OIG clinicians considered the CTC nursing performance substandard. Failure to Perform Systems Assessment Each Watch The CTC RN did not perform an assessment each watch in cases 12, 13, 73, 75, 77, and 78. Failure to Perform Adequate Assessment  In case 11, the patient was found lying on the floor. The RN did not completely assess the status of the patient, including his sensory function. The RN did not check for any signs of head or neck injury prior to moving the patient from the floor to the bed to determine if the patient required a neck collar or other immobilization device. When the patient reported chest pain, the RN did not utilize the nursing protocol for chest pain. In addition, the RN delayed calling the provider for 30 minutes. The RN did not document the exact location of the chest pain, did not inspect the patient’s chest for any injury from fall, and did not observe the patient for any breathing difficulty. The RN failed to assess the pain level after administration of nitroglycerin and to reassess the patient’s neurological status and vital signs for the remainder of the shift.  In case 74, medical staff placed the patient in clinical restraints. After the restraints were placed, the RN failed to assess each restraint to ensure adequate circulation, sensation, and motion to each extremity, and failed to assess the patient’s body alignment and respiratory status. Additionally, the CTC nurses did not assess the patient hourly or document the patient’s physical or mental condition.  In case 77, the patient was dizzy and fell to the floor. The RN did not assess the patient from head to toe for any injury or check for any changes in mental status. The RN did not continue to monitor the patient’s vital signs and condition. California Medical Facility, Cycle 4 Medical Inspection Page 61 Office of the Inspector General State of California Inadequate RN assessments were identified multiple times in some of the cases above and in cases 12, 25, 73, and 75. Failure to Initiate and Update Patient Care Plan  In case 25, the CTC nurse did not initiate patient care plans to address the patient’s poor nutrition and urinary problems.  In case 74, there was no evidence that the CTC nurse initiated any patient care plans when the patient was admitted to the CTC. Further, after the patient had a seizure, the patient care plan was not initiated or updated to address the patient’s seizure. There was also no patient care plan for the patient’s self-injurious behavior and application of clinical restraints. Inadequate Nursing Documentation  In cases 11, 12, 21, and 78, the RN did not complete RN discharge summaries or provide discharge instructions, education, and follow-up care to the patients upon their discharge from the CTC.  In case 9, the patient had been placed on oral fluid restriction. The CTC nurse did not document or monitor the amount of the patient’s oral fluid intake, resulting in the patient exceeding the limit ordered by the provider. Cloned documentation was identified from a previous note in this case. The RN documented the presence of a peripherally inserted central catheter (PICC) line and monitoring for signs of infection even though the PICC line had already been removed more than two weeks prior.  In case 74, the patient was placed in clinical restraints. During the first two days, the CTC nurses directly observing the patient did not properly document if the patient was in the restraints during 15-minute checks or if the restraints were removed or discontinued. The nurses did not document observation of the proper placement of the restraints, the patient’s skin integrity, circulation, or sensation, or the patient’s behavior.  In cases 9, 14, 15, 25, 73, 75, and 77, there was incomplete documentation on the Admission Assessment, Nursing Care Record, and Vital Signs Flow Sheet .  Illegible handwriting was identified in cases 9, 11, 12, 14, 21, 25, 75, and 76. California Medical Facility, Cycle 4 Medical Inspection Page 62 Office of the Inspector General State of California Outpatient Housing Unit Nursing Performance Nursing performance in the OHU was adequate. The OIG clinicians identified one case (case 81) in which nursing did not perform an adequate assessment on the patient.  In case 81, the patient completed six cycles of chemotherapy and a provider admitted him to the OHU for further care. There were several nursing encounters in which the OHU nurses did not assess the patient and document the clinical interaction or care provided. o The provider ordered an antibiotic eye ointment. There was no clinical interaction documented that the nurse assessed the patient for eye swelling. o The patient refused his offsite appointment and reported that he was sick and throwing up. The nurse did not assess the patient. o The patient had rectal lesions. The RN did not assess the patient’s wound or document the clinical interaction and care provided during wound treatment.  There were also several encounters in case 81 when nurses did not adequately assess the patient: o The patient complained of headache, cough, and a clogged nose. The RN did not assess the patient’s lungs for any abnormal sounds, examine his throat for redness or irritation, or check for swollen lymph nodes. o The patient complained of intermittent nausea, swollen hands and legs, and foot pain, and he was urinating less and stopping at midstream. The nurse did not assess the patient’s hands and legs for good sensation, range of motion, or presence of pulses, nor obtain a history and assess the patient for possible urinary retention. The nurse also did not notify the provider of the patient’s condition, particularly with the presence of a fever, which could indicate an infection. When the provider saw the patient two days later, the patient had early cellulitis (an infection of the skin and subcutaneous tissues). o The patient reported that his arm was swollen for a week and getting worse. The RN did not adequately assess the patient for this condition. The OIG clinicians identified other cases where there was incomplete OHU nursing assessment:  In case 79, the patient complained of leg pain. The RN did not assess the patient’s legs for color, warmth, tenderness, degree of swelling, or the presence of a pulse.  In case 80, the patient complained of blurry vision and pain in both eyes. The RN did not obtain adequate history, such as sensation of any foreign body in the eyes, chemical exposure, and pain level. California Medical Facility, Cycle 4 Medical Inspection Page 63 Office of the Inspector General State of California  Cases 78, 79, 81, and 83 displayed illegible OHU nursing signatures. Hospice Unit Nursing Performance There were only a few minor nursing deficiencies in the hospice unit. Most of these were incomplete documentation on Daily Flow Sheets and Nursing Care Record forms. The OIG clinicians rated hospice nursing performance generally good. Compliance Testing Results The institution received an adequate score of 76.5 percent in the Specialized Medical Housing indicator, which focused on the institution’s CTC, OHU, and hospice unit. The institution scored in the proficient range in the following test area:  For all 20 patients sampled, nursing staff timely completed an initial assessment on the day a provider admitted the patient to the CTC, OHU, or hospice (MIT 13.001). The institution scored in the adequate range in the following two test areas:  Providers evaluated 16 of 19 sampled patients within 24 hours of admission to the CTC and OHU (84 percent). Three patients did not receive a provider visit within 24 hours of admittance to the OHU; two patients received their provider visits three and five days late. For a third patient, the provider did not document the time of the post-admission evaluation. As a result, there was insufficient evidence to conclude that the evaluation occurred timely (MIT 13.002).  The OIG examined providers’ progress notes to verify that they completed subjective, objective, assessment, plan, and education (SOAPE) notes at required seven-day intervals for CTC patients and 14-day intervals for OHU and hospice patients. Information found in the eUHR demonstrated that the providers completed timely SOAPE notes for 15 of the 19 sampled patients (79 percent). A provider missed one required seven-day interval for a patient in the CTC by two days. Providers missed three OHU patients’ required 14-day interval visits by one day each (MIT 13.004). CMF scored in the inadequate range on the following two tests:  Providers ensured that an H&P exam was completed within 72 hours of CTC or OHU admission for only 10 of 19 patients (53 percent). Nine patients did not have a properly completed H&P exam. Of these nine, six patients had an H&P completed at an outside hospital, but none was completed within five days of admittance to the CTC or OHU, as required by CCHCS policy. The other three patients never had an H&P exam at all (MIT 13.003). California Medical Facility, Cycle 4 Medical Inspection Page 64 Office of the Inspector General State of California  While all three of CMF’s specialized medical housing units had properly functioning call buttons, the institution’s OHU was not performing and documenting evidence of conducting daily tests of the system. As a result, CMF scored 67 percent for its ability to maintain a properly working call button system. However, knowledgeable staff at all three housing units stated that urgent or emergent access to cells was timely at two minutes or less, and management did not identify any concerns related to this reported response time (MIT 13.101). Recommendations No specific recommendations. California Medical Facility, Cycle 4 Medical Inspection Page 65 Office of the Inspector General State of California SPECIALTY SERVICES This indicator focuses on specialist care from the time a request for Case Review Rating: services or physician’s order for specialist care is completed to the Adequate time of receipt of related recommendations from specialists. This Compliance Score: indicator also evaluates the providers’ timely review of specialist Inadequate records and documentation reflecting the patients’ care plans, (65.0%) including course of care when specialist recommendations were not Overall Rating: ordered, and whether the results of specialists’ reports are Adequate communicated to the patients. For specialty services denied by the institution, the OIG determines whether the denials are timely and appropriate, and whether the inmate-patient is updated on the plan of care. In this indicator, the OIG’s case review and compliance review processes yielded different results, with the case review giving an adequate rating and the compliance review resulting in an inadequate score. The OIG’s internal review process considered those factors that led to both results and ultimately rated this indicator adequate. The key factor warranting the higher overall rating was that the case review found a high quality of provided specialty services and that CMF had a unique specialty tracking process, which compensated for the lack of eUHR compliance evidence, which would normally indicate a timely review. Case Review Results The OIG clinicians reviewed 198 events related to Specialty Services, including 104 specialty consultations and procedures and 65 nursing encounters. Of the 92 deficiencies in this category, 44 related to specialty report handling and 46 to nursing services. Despite the large number of deficiencies in this category, only 8 of the 92 deficiencies were significant. Access to Specialty Services CMF performed well with access to specialty services. Out of 104 specialty consultations and procedures, there were only two deficiencies in this area. CMF performed equally well providing access for both routine and urgent specialty referrals.  One concern was the availability of wheelchair transportation. In case 41, the patient missed his offsite specialty appointment because the institution did not have a wheelchair transportation van available. While this deficiency only occurred once during the case reviews, it was notable because CMF had a large number of patients who utilized wheelchairs. California Medical Facility, Cycle 4 Medical Inspection Page 66 Office of the Inspector General State of California Nursing Performance Patients returning from offsite specialty appointments were seen in the TTA. There were only two cases identified in which an RN did not see the patient upon his return from a specialty appointment (cases 18 and 22). TTA nurses often did not perform nursing assessments for patients returning from specialty services, and often did not obtain orders for recommendations that the specialist suggested. These deficiencies occurred in cases 7, 8, 10, 17, 18, 20, 22, 24, and 80, and could have resulted in significant lapses in care. However, at the onsite inspection, CMF demonstrated an alternate process, whereby the specialty department reviewed the specialty recommendations and obtained appropriate orders directly from the PCP. This alternate process successfully mitigated the post-specialty TTA nursing deficiencies identified in the case reviews. Generally, the telemedicine nurse performed adequate nursing assessment and care during appointments. There were only a few cases in which the telemedicine nurse did not address the patient’s medical symptoms and refer to the provider appropriately:  In case 8, the patient was seen in the telemedicine clinic and his blood pressure was elevated at 188/107, with an elevated heart rate of 110. The nurse did not check whether the patient took his blood pressure medications or refer the patient to the provider.  In case 18, the telemedicine clinic saw the patient with a high blood pressure of 162/107. The nurse did not address the patient’s blood pressure reading or recheck it before leaving the telemedicine clinic. Provider Performance CMF providers performed proficiently concerning ordering specialty services. They made appropriate referrals for specialty services. Most providers made diagnostic and consultative requests with proper priority specified on the Physician Request for Services (CDCR Form 7243). Health Information Management There were frequent delays in the retrieval of specialty reports (cases 7, 13, 18, 38, 39, and 40). CMF also failed to retrieve specialty reports altogether in cases 13, 18, 24, and 27. Delays in retrieval or non-retrieval of specialty reports increased the risk of lapses in care. Nearly all specialty reports at CMF were scanned into the eUHR without a provider’s initials or date when it was reviewed. While some providers documented their review of the reports at the following PCP appointment, others did not. Poor provider documentation likely explained some of the low compliance scores in the compliance testing of this indicator. From a case review perspective, CMF providers nearly always reviewed the specialty reports appropriately, which was demonstrated by good clinical management, even when proper documentation was lacking. Poor provider documentation also likely explained CMF’s poor compliance scores (discussed below) in California Medical Facility, Cycle 4 Medical Inspection Page 67 Office of the Inspector General State of California relaying information when the institution denies a request for specialty service or in discussing alternative management for the denied service. While CMF providers showed marked room for documentation improvement, the overall quality of specialty services was good. The specialty department kept a tracking system to ensure that the PCP reviewed and processes all specialty recommendations. Consequently, the deficiencies identified in the case review were likely due to human oversight and had only minor effects on overall medical care. Clinician Onsite Inspection The telemedicine clinic was clean and adequate. The nurse kept an organized tracking and scheduling system for all telemedicine appointments. There was no appointment backlog reported. The nursing supervisor was working on training additional nurses to fill coverage behind the telemedicine nurse. The specialty department developed a secondary process that tracked every specialty service, retrieved the reports, reviewed them for recommendations, and emailed the reports and recommendations to the PCP. While CMF staff scanned many of the specialty reports into the medical record without provider review, this secondary process ensured that providers were aware of specialty consultant reports and recommendations. Compliance Testing Results The institution received an inadequate compliance score of 65.0 percent in the Specialty Services indicator, receiving low scores in the following specific test areas:  When CMF providers ordered high-priority specialty services for patients, the ordering provider did not always receive and review the corresponding specialists’ reports within the required time frame. CMF timely received and providers timely reviewed specialists’ reports for only 7 of 15 patients sampled (47 percent); the reports for eight other patients were either not received or not reviewed timely. Specifically, the institution received the specialist’s report three days late for two patients, the provider reviewed the specialist’s report from one to six days late for four patients, and providers never documented evidence of reviewing the specialist’s report for two patients (MIT 14.002).  When patients are approved or scheduled for specialty service appointments at one institution and then transfer to another institution, policy requires that the receiving institution reschedule or provide the patient’s appointment within the required time frame. Out of 20 sampled transfer-in patients who had previously approved specialty services, only ten received their specialty services appointments timely (50 percent). Six patients received their specialty appointments from one to 67 days late, and four patients did not receive an appointment at all (MIT 14.005).  Among 18 patients sampled who had a specialty service denied by health care management, only nine (50 percent) received timely notification of the denied service. Nine other patients California Medical Facility, Cycle 4 Medical Inspection Page 68 Office of the Inspector General State of California never received notification from a provider that the institution denied the specialty service (MIT 14.007).  For patients who had a routine specialty service ordered, providers both timely received and timely reviewed only 8 of the 15 corresponding specialists’ reports sampled (53 percent). Timely provider reviews did not occur for seven sampled specialists reports, five reports were reviewed from 4 to 56 days late, and two reports were never reviewed at all (MIT 14.004). The institution scored in the adequate range in the following test area:  The institution timely denied providers’ specialty service requests for 15 of 20 patients sampled (75 percent). Five specialty services requests were denied from two to six days late (MIT 14.006). The institution scored in the proficient range in the following two areas:  CMF provided routine specialty service appointments to 14 of 15 patients tested within the required time frame (93 percent). One patient received his specialty service 17 days late (MIT 14.003).  High-priority specialty services appointments occurred within 14 calendar days of the provider’s order for 13 of the 15 inmate-patients sampled (87 percent). One patient received his specialty service six days late, and another, eight days late (MIT 14.001). Recommendations No specific recommendations. California Medical Facility, Cycle 4 Medical Inspection Page 69 Office of the Inspector General State of California SECONDARY (ADMINISTRATIVE) QUALITY INDICATORS OF HEALTH CARE The last two quality indicators (Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications) involve health care administrative systems and processes. Testing in these areas applies only to the compliance component of the process. Therefore, there is no case review assessment associated with either of the two indicators. As part of the compliance component of the first of these two indicators, the OIG did not score several questions. Instead, the OIG presented the findings for informational purposes only. For example, the OIG described certain local processes in place at CMF. To test both the scored and non-scored areas within these two secondary quality indicators, OIG inspectors interviewed key institutional employees and reviewed documents during their onsite visit to CMF in February 2016. They also reviewed documents obtained from the institution and from CCHCS prior to the start of the inspection. Of these two secondary indicators, OIG compliance inspectors rated both inadequate. The test questions used to assess compliance for each indicator are detailed in Appendix A. For comparative purposes, the CMF Executive Summary Table on page viii of this report shows the case review and compliance ratings for each applicable indicator. California Medical Facility, Cycle 4 Medical Inspection Page 70 Office of the Inspector General State of California INTERNAL MONITORING, QUALITY IMPROVEMENT, AND ADMINISTRATIVE OPERATIONS This indicator focuses on the institution’s administrative health care Case Review Rating: oversight functions. The OIG evaluates whether the institution Not Applicable promptly processes inmate-patient medical appeals and addresses Compliance Score: all appealed issues. Inspectors also verify that the institution follows Inadequate reporting requirements for adverse/sentinel events and inmate (53.7%) deaths, and whether the institution is making progress toward its Overall Rating: Performance Improvement Work Plan initiatives. In addition, the Inadequate OIG verifies that the Emergency Medical Response Review Committee (EMRRC) performs required reviews and that staff perform required emergency response drills. Inspectors also assess whether the Quality Management Committee (QMC) meets regularly and adequately addresses program performance. For those institutions with licensed facilities, inspectors also verify that required committee meetings are held. Compliance Testing Results The institution scored within the inadequate range in the Internal Monitoring, Quality Improvement, and Administrative Operations indicator, with a compliance score of 53.7 percent. CMF received a score of zero in the following four test areas:  The institution had not taken adequate steps to ensure the accuracy of its Dashboard data reporting. Specifically, CMF’s Quality Management Committee meetings did not discuss methodologies used to conduct periodic validation and testing of Dashboard data, and the committee did not discuss methodologies used to train staff who collected Dashboard data (MIT 15.004).  CMF’s 2015 Performance Improvement Work Plan (PIWP) did not include adequate evidence demonstrating the institution’s improvement in achieving targeted performance objectives for any of its 11 quality improvement initiatives. In general, the work plan included insufficient progress information to demonstrate that, in each of its performance objectives, the institution either improved or reached the targeted level (MIT 15.005).  The institution’s local governing body (LGB) only conducted three of four quarterly meetings during the 12-month period ending December 2015. Of the three convened, the meeting minutes did not provide a detailed narrative of the LGB’s general management and planning of patient health care (MIT 15.006).  None of the 12 sampled incident packages Reviewed by the Emergency Medical Response Review Committee (EMRRC) included required documentation. Specifically, none of the packages included the use of the required Emergency Medical Response Review Event Checklist Form (MIT 15.007). California Medical Facility, Cycle 4 Medical Inspection Page 71 Office of the Inspector General State of California The institution scored in the adequate range on the following test:  Inspectors reviewed six recent months’ Quality Management Committee (QMC) meeting minutes and confirmed that the QMC met monthly in all six months reviewed. However, the QMC only adequately evaluated program performance or took action when the committee identified improvement opportunities in five of the six months. More specifically, the committee’s July 2015 meeting did not evaluate program performance. As a result, CMF scored 83 percent on this test (MIT 15.003). The institution scored in the proficient range with 100 percent scores on each of the following four tests:  CMF processed inmate medical appeals timely for all 12 of the most recent months. In addition, inspectors sampled ten second-level inmate medical appeals and found that all of the appeal responses addressed the inmate’s initial complaint (MIT 15.001, 15.102).  Inspectors reviewed drill packages for three medical emergency response drills conducted in the prior quarter, and the packages contained all required summary reports and related documentation. In addition, the drills included participation by both health care and custody staff (MIT 15.101).  Medical staff promptly submitted the Initial Inmate Death Report (CDCR Form 7229A) to the CCHCS Death Review Unit for the ten applicable deaths that occurred at CMF in the prior 12-month period (MIT 15.103). Other Information Obtained from Non-Scored Areas  The OIG gathered non-scored data regarding the completion of death review reports and found that CCHCS’s Death Review Committee did not timely complete its death review summary for any of the ten deaths that occurred during the testing period. The CCHCS Death Review Committee is required to complete a death review summary within 30 to 60 days of the death (depending on whether the death was expected or unexpected) and then expeditiously notify the institution’s CEO of the review results, so that any needed corrective action can be promptly pursued. For eight of the ten inmate deaths tested, the committee completed its summary from 9 to 40 days late (39 to 93 days after the death) and then notified the institution’s CEO of the review results from 2 to 13 days after that (MIT 15.996).  Inspectors met with the institution’s chief executive officer (CEO) to inquire about CMF’s protocols for tracking appeals. Management received from the appeals coordinator a weekly update, which identified when appeals were due, and the QMC received a monthly appeals update broken down by each appeals category (CMF used 22 different categories). Management reviewed the reports during QMC meetings to identify and track problem California Medical Facility, Cycle 4 Medical Inspection Page 72 Office of the Inspector General State of California areas, and used the data to address specific issues that may require staff training (MIT 15.997).  Non-scored data gathered regarding CMF’s practices for implementing local operating procedures (LOPs) indicated that the institution had an effective process in place for developing LOPs. The CEO stated the institution had an LOP committee that met on a monthly basis and worked to adhere as closely as possible to statewide policies. Each department supervisor was responsible for identifying and developing an LOP if it was necessary, and supervisors consulted with subject matter experts as needed. The LOP committee discussed each new LOP that department supervisors presented, and the committee approved the LOP. At the time of the OIG’s inspection, CMF had implemented all 49 applicable LOPs relating to the core topical areas recommended by the clinical experts who helped develop the OIG’s medical inspection compliance program (MIT 15.998).  The OIG discusses the institution’s health care staffing resources in the About the Institution section on page 2 of this report (MIT 15.999). Recommendations No specific recommendations. California Medical Facility, Cycle 4 Medical Inspection Page 73 Office of the Inspector General State of California JOB PERFORMANCE, TRAINING, LICENSING, AND CERTIFICATIONS In this indicator, the OIG examines whether the institution Case Review Rating: adequately manages its health care staffing resources by evaluating Not Applicable whether job performance reviews are completed as required; Compliance Score: specified staff possess current, valid credentials and professional Inadequate licenses or certifications; nursing staff receive new employee (69.9%) orientation training and annual competency testing; and clinical and Overall Rating: custody staff have current medical emergency response Inadequate certifications. Compliance Testing Results The institution received an inadequate compliance score of 69.9 percent in the Job Performance Training, Licensing, and Certifications indicator, scoring in the inadequate range on the following three tests:  Inspectors examined records to determine if nursing supervisors completed the required number of monthly performance reviews for subordinate nurses and discussed the results of those reviews. The OIG sampled reviews completed for five subordinate nurses; all of them had the required number of reviews completed by their supervisors. However, in each instance, the nursing supervisor failed to address the positive, well-performed aspects of the employee’s performance. CCHCS policy requires this task to be completed for each review (MIT 16.101).  OIG inspectors examined provider, nursing, and custody staff records to determine if the institution ensured that those staff members had current emergency response certifications. CMF’s provider and nursing staff were all compliant, but custody staff did not always have current certifications. Specifically, managerial custody officers above the rank of captain did not have current certifications. Although the California Penal Code exempts those custody managers who primarily perform managerial duties from medical emergency response certification training, CCHCS policy does not allow for such an exemption. As a result, the institution received a score of 67 percent in this inspection area (MIT 16.104).  When the institution hires new nursing staff, it is required to provide new employee orientation within 30 days of their being hired. However, CMF did not timely provide new employee orientation for six new nurses hired in the most recent 12 months. As a result, the institution scored zero in this test area (MIT 16.107). California Medical Facility, Cycle 4 Medical Inspection Page 74 Office of the Inspector General State of California While CMF scored low in the areas above, it received proficient scores in the following test areas:  All providers were current with their professional licenses, and nursing staff and the pharmacist in charge were current with their professional licenses and certification requirements (MIT 16.001, 16.105).  All ten nurses sampled were current on their clinical competency validations (MIT 16.102).  OIG inspectors found that 12 of 13 providers (92 percent) received timely clinical performance evaluations. However, one provider (the chief physician and surgeon), who periodically performed patient evaluations, did not receive a performance evaluation (MIT 16.103).  The pharmacy and providers who prescribe controlled substances had current Drug Enforcement Agency registrations (MIT 16.106). Recommendations No specific recommendations. California Medical Facility, Cycle 4 Medical Inspection Page 75 Office of the Inspector General State of California POPULATION-BASED METRICS The compliance testing and the case reviews give an accurate assessment of how the institution’s health care systems are functioning with regard to the patients with the highest risk and utilization. This information is vital to assess the capacity of the institution to provide sustainable, adequate care. However, one significant limitation of the case review methodology is that it does not give a clear assessment of how the institution performs for the entire population. For better insight into this performance, the OIG has turned to population-based metrics. For comparative purposes, the OIG has selected several Healthcare Effectiveness Data and Information Set (HEDIS) measures for disease management to gauge the institution’s effectiveness in outpatient health care, especially chronic disease management. The Healthcare Effectiveness Data and Information Set is a set of standardized performance measures developed by the National Committee for Quality Assurance with input from over 300 organizations representing every sector of the nation’s health care industry. It is used by over 90 percent of the nation’s health plans as well as many leading employers and regulators. It was designed to ensure that the public (including employers, the Centers for Medicare and Medicaid Services, and researchers) has the information it needs to accurately compare the performance of health care plans. Healthcare Effectiveness Data and Information Set data is often used to produce health plan report cards, analyze quality improvement activities, and create performance benchmarks. Methodology For population-based metrics, the OIG used a subset of HEDIS measures applicable to the CDCR inmate-patient population. Selection of the measures was based on the availability, reliability, and feasibility of the data required for performing the measurement. The OIG collected data utilizing various information sources, including the eUHR, the Master Registry (maintained by CCHCS), as well as a random sample of patient records analyzed and abstracted by trained personnel. Data obtained from the CCHCS Master Registry and Diabetic Registry was not independently validated by the OIG and is presumed to be accurate. For some measures, the OIG used the entire population rather than statistically random samples. While the OIG is not a certified HEDIS compliance auditor, the OIG uses similar methods to ensure that measures are comparable to those published by other organizations. Comparison of Population-Based Metrics For the California Medical Facility, nine HEDIS measures were selected and are listed in the following CMF 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 Medical Facility, Cycle 4 Medical Inspection Page 76 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. CMF performed well with its management of diabetes in the available HEDIS measures when compared to other reporting entities. Statewide, CMF significantly outperformed Medi-Cal in all five diabetic measures. When compared to Kaiser Permanente, CMF did better than or matched Kaiser North in four of the five diabetic measures, but performed not as well in diabetic blood pressure control by 4 percentage points. CMF only outperformed Kaiser South in three of the five diabetes measures, trailing in diabetic patient blood pressure control and conducting dilated eye exams by 5 and 7 percentage points, respectively. Nationally, CMF outperformed Medicaid, Medicare, and commercial health plans (based on data obtained from health maintenance organizations) in all five diabetic measures. When compared to the U.S. Department of Veterans Affairs (VA), CMF outperformed the VA in three of four applicable diabetic measures (diabetic monitoring, diabetics under poor control, and blood pressure control). However, CMF did not perform as well as the VA in conducting dilated eye exams, trailing by 16 percentage points. Immunizations Comparative data for immunizations was only fully available for the VA and partially available for Kaiser Permanente, Medicare, and commercial plans. With regard to administering influenza vaccinations to younger adults, CMF outperformed all State and national health plans. For older adults, CMF outperformed Medicare, but scored 2 percentage points lower than the VA. The OIG’s comparative analysis found that CMF’s low scores were adversely affected by patient refusals, a factor that prevented the institution from receiving full credit for providing a basic outpatient health care service. Had the refusals not occurred, the institution would have received a 100 percent compliance rate and the highest comparative score for the three immunization measures. Finally, with regard to pneumococcal vaccinations, CMF scored better than Medicare by 14 percentage points, but more poorly than the VA by 9 percentage points. The OIG found that CMF offered the immunization to 97 percent of patients sampled, and the institution would have had the highest comparable score had patients not refused the vaccination. California Medical Facility, Cycle 4 Medical Inspection Page 77 Office of the Inspector General State of California Cancer Screening With respect to colorectal cancer screening for older patients, CMF’s score of 52 percent was significantly lower than the only other statewide comparative figures, which were 80 percent and 82 percent for Kaiser, Northern California and Southern California, respectively. Nationally, CMF also performed worse than commercial plans, Medicare, and the VA. Again, patient refusals directly impacted the institution’s performance in this cancer screening measure. Specifically, 45 percent of CMF patients sampled refused the cancer screening. The cancer screening score for CMF would have been significantly higher if not for the high refusal rate. Summary Overall, based on the institution’s comparative HEDIS results, CMF’s performance reflected an adequate chronic care program with regard to comprehensive diabetes care and immunizations compared to statewide and national health plans. However, the institution showed room for improvement in providing colorectal cancer screenings, and could increase patient education to help reduce patient refusals. California Medical Facility, Cycle 4 Medical Inspection Page 78 Office of the Inspector General State of California CMF Results Compared to State and National HEDIS Scores California National CMF HEDIS HEDIS HEDIS HEDIS Clinical Measures Medi- Kaiser Kaiser HEDIS Com- HEDIS VA Cycle 4 Cal (No. CA) (So.CA) Medicaid mercial Medicare Average Results1 20142 20153 20153 20154 20154 20154 20145 Comprehensive Diabetes Care HbA1c Testing (Monitoring) 100% 83% 95% 94% 86% 91% 93% 99% Poor HbA1c Control (>9.0%)6,7 18% 44% 18% 24% 44% 31% 25% 19% HbA1c Control (<8.0%)6 68% 47% 70% 62% 47% 58% 65% - Blood Pressure Control (<140/90)6 80% 60% 84% 85% 62% 65% 65% 78% Eye Exams 74% 51% 69% 81% 54% 56% 69% 90% Immunizations Influenza Shots - Adults (18–64) 76% - 54% 55% - 50% - 58% Influenza Shots - Adults (65+) 74% - - - - - 72% 76% Immunizations: Pneumococcal 84% - - - - - 70% 93% Cancer Screening Colorectal Cancer Screening 52% - 80% 82% - 64% 67% 82% 1. Unless otherwise stated, data was collected in February 2016 by reviewing medical records from a sample of CMF’s population of applicable inmate-patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. 2. HEDIS Medi-Cal data was obtained from the California Department of Health Care Services 2014 HEDIS Aggregate Report for the Medi-Cal Managed Care Program. 3. Data was obtained from Kaiser Permanente November 2015 reports for the Northern and Southern California regions. 4. National HEDIS data for Medicaid, commercial, and Medicare was obtained from the 2015 State of Health Care Quality Report, available on the NCQA website: www.ncqa.org. The results for commercial were based on data received from various health maintenance organizations. 5. The Department of Veterans Affairs (VA) data was obtained from the VA’s website www.va.gov. For the Immunizations: Pneumococcal measure only, the data was obtained from the VHA Facility Quality and Safety Report-Fiscal Year 2012. 6. For this indicator, the entire applicable CMF 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 Medical Facility, Cycle 4 Medical Inspection Page 79 Office of the Inspector General State of California APPENDIX A — COMPLIANCE TEST RESULTS California Medical Facility Range of Summary Scores: 53.70% - 78.36% Indicator Compliance Score (Yes %) Access to Care 78.36% Diagnostic Services 76.30% Emergency Services Not Applicable Health Information Management (Medical Records) 61.70% Health Care Environment 72.50% Inter- and Intra-System Transfers 72.83% Pharmacy and Medication Management 68.81% Prenatal and Post-Delivery Services Not Applicable Preventive Services 65.42% Quality of Nursing Performance Not Applicable Quality of Provider Performance Not Applicable Reception Center Arrivals Not Applicable Specialized Medical Housing (OHU, CTC, SNF, Hospice) 76.49% Specialty Services 65.00% Internal Monitoring, Quality Improvement, and Administrative Operations 53.70% Job Performance, Training, Licensing, and Certifications 69.87% California Medical Facility, Cycle 4 Medical Inspection Page 80 Office of the Inspector General State of California Scored Answers Yes Reference + Access to Care Number Yes No No Yes % N/A 1.001 Chronic care follow-up appointments: Was the inmate-patient’s most 31 9 40 77.50% 0 recent chronic care visit within the health care guideline’s maximum allowable interval or within the ordered time frame, whichever is shorter? 1.002 For endorsed inmate-patients received from another CDCR 25 4 29 86.21% 1 institution: If the nurse referred the inmate-patient to a provider during the initial health screening, was the inmate-patient seen within the required time frame? 1.003 Clinical appointments: Did a registered nurse review the 29 1 30 96.67% 0 inmate-patient’s request for service the same day it was received? 1.004 Clinical appointments: Did the registered nurse complete a 13 16 29 44.83% 1 face-to-face visit within one business day after the CDCR Form 7362 was reviewed? 1.005 Clinical appointments: If the registered nurse determined a referral to 24 0 24 100.00% 6 a primary care provider was necessary, was the inmate-patient seen within the maximum allowable time or the ordered time frame, whichever is the shorter? 1.006 Sick call follow-up appointments: If the primary care provider 7 3 10 70.00% 20 ordered a follow-up sick call appointment, did it take place within the time frame specified? 1.007 Upon the inmate-patient’s discharge from the community hospital: 18 12 30 60.00% 0 Did the inmate-patient receive a follow-up appointment within the required time frame? 1.008 Specialty service follow-up appointments: Do specialty service 21 9 30 70.00% 0 primary care physician follow-up visits occur within required time frames? 1.101 Clinical appointments: Do inmate-patients have a standardized 6 0 6 100.00% 0 process to obtain and submit health care services request forms? Overall percentage: 78.36% California Medical Facility, Cycle 4 Medical Inspection Page 81 Office of the Inspector General State of California Scored Answers Yes Reference + Diagnostic Services Number Yes No No Yes % N/A 2.001 Radiology: Was the radiology service provided within the time frame 10 0 10 100.00% 0 specified in the provider’s order? 2.002 Radiology: Did the primary care provider review and initial the 8 2 10 80.00% 0 diagnostic report within specified time frames? 2.003 Radiology: Did the primary care provider communicate the results of 9 1 10 90.00% 0 the diagnostic study to the inmate-patient within specified time frames? 2.004 Laboratory: Was the laboratory service provided within the time 10 0 10 100.00% 0 frame specified in the provider’s order? 2.005 Laboratory: Did the primary care provider review and initial the 8 2 10 80.00% 0 diagnostic report within specified time frames? 2.006 Laboratory: Did the primary care provider communicate the results of 9 1 10 90.00% 0 the diagnostic study to the inmate-patient within specified time frames? 2.007 Pathology: Did the institution receive the final diagnostic report within 8 2 10 80.00% 0 the required time frames? 2.008 Pathology: Did the primary care provider review and initial the 2 7 9 22.22% 1 diagnostic report within specified time frames? 2.009 Pathology: Did the primary care provider communicate the results of 4 5 9 44.44% 1 the diagnostic study to the inmate-patient within specified time frames? Overall percentage: 76.30% Emergency Services Scored Answers Assesses reaction times and responses to emergency situations. The OIG RN clinicians will use detailed information obtained from the institution’s incident Not Applicable packages to perform focused case reviews. California Medical Facility, Cycle 4 Medical Inspection Page 82 Office of the Inspector General State of California Scored Answers Health Information Management Yes Reference + (Medical Records) Number Yes No No Yes % N/A 4.001 Are non-dictated progress notes, initial health screening forms, and 16 4 20 80.00% 0 health care service request forms scanned into the eUHR within three calendar days of the inmate-patient encounter date? 4.002 Are dictated / transcribed documents scanned into the eUHR within five Not Applicable calendar days of the inmate-patient encounter date? 4.003 Are specialty documents scanned into the eUHR within the required 19 1 20 95.00% 0 time frame? 4.004 Are community hospital discharge documents scanned into the eUHR 16 4 20 80.00% 0 within three calendar days of the inmate-patient date of hospital discharge? 4.005 Are medication administration records (MARs) scanned into the eUHR 15 5 20 75.00% 0 within the required time frames? 4.006 During the eUHR review, did the OIG find that documents were 0 12 12 0.00% 0 correctly labeled and included in the correct inmate-patient’s file? 4.007 Did clinical staff legibly sign health care records, when required? 23 9 32 71.88% 0 4.008 For inmate-patients discharged from a community hospital: Did the 9 21 30 30.00% 0 preliminary hospital discharge report include key elements and did a PCP review the report within three calendar days of discharge? Overall percentage: 61.70% California Medical Facility, Cycle 4 Medical Inspection Page 83 Office of the Inspector General State of California Scored Answers Yes Reference + Health Care Environment Number Yes No No Yes % N/A 5.101 Infection Control: Are clinical health care areas appropriately 13 1 14 92.86% 0 disinfected, cleaned and sanitary? 5.102 Infection control: Do clinical health care areas ensure that reusable 12 0 12 100.00% 2 invasive and non-invasive medical equipment is properly sterilized or disinfected as warranted? 5.103 Infection Control: Do clinical health care areas contain operable sinks 14 0 14 100.00% 0 and sufficient quantities of hygiene supplies? 5.104 Infection control: Does clinical health care staff adhere to universal 1 8 9 11.11% 5 hand hygiene precautions? 5.105 Infection control: Do clinical health care areas control exposure to 13 1 14 92.86% 0 blood-borne pathogens and contaminated waste? 5.106 Warehouse, Conex and other non-clinic storage areas: Does the 1 0 1 100.00% 0 medical supply management process adequately support the needs of the medical health care program? 5.107 Clinical areas: Does each clinic follow adequate protocols for 13 1 14 92.86% 0 managing and storing bulk medical supplies? 5.108 Clinical areas: Do clinic common areas and exam rooms have 1 13 14 7.14% 0 essential core medical equipment and supplies? 5.109 Clinical areas: Do clinic common areas have an adequate environment 7 2 9 77.78% 5 conducive to providing medical services? 5.110 Clinical areas: Do clinic exam rooms have an adequate environment 6 8 14 42.86% 0 conducive to providing medical services? 5.111 Emergency response bags: Are TTA and clinic emergency medical 4 1 5 80.00% 9 response bags inspected daily and inventoried monthly, and do they contain essential items? 5.999 For Information Purposes Only: Does the institution’s health care management believe that all clinical areas have physical plant Information Only infrastructures sufficient to provide adequate health care services? Overall percentage: 72.50% California Medical Facility, Cycle 4 Medical Inspection Page 84 Office of the Inspector General State of California Scored Answers Yes Reference + Inter- and Intra-System Transfers Number Yes No No Yes % N/A 6.001 For endorsed inmate-patients received from another CDCR 30 0 30 100.00% 0 institution or COCF: Did nursing staff complete the initial health screening and answer all screening questions on the same day the inmate-patient arrived at the institution? 6.002 For endorsed inmate-patients received from another CDCR 29 1 30 96.67% 0 institution or COCF: When required, did the RN complete the assessment and disposition section of the health screening form; refer the inmate-patient to the TTA, if TB signs and symptoms were present; and sign and date the form on the same day staff completed the health screening? 6.003 For endorsed inmate-patients received from another CDCR 10 6 16 62.50% 14 institution or COCF: If the inmate-patient had an existing medication order upon arrival, were medications administered or delivered without interruption? 6.004 For inmate-patients transferred out of the facility: Were scheduled 11 9 20 55.00% 0 specialty service appointments identified on the Health Care Transfer Information Form 7371? 6.101 For inmate-patients transferred out of the facility: Do medication 2 2 4 50.00% 2 transfer packages include required medications along with the corresponding Medical Administration Record (MAR) and Medication Reconciliation? Overall percentage: 72.83% California Medical Facility, Cycle 4 Medical Inspection Page 85 Office of the Inspector General State of California Scored Answers Yes Reference + Pharmacy and Medication Management Number Yes No No Yes % N/A 7.001 Did the inmate-patient receive all chronic care medications within the 18 18 36 50.00% 4 required time frames or did the institution follow departmental policy for refusals or no-shows? 7.002 Did health care staff administer or deliver new order prescription 32 8 40 80.00% 0 medications to the inmate-patient within the required time frames? 7.003 Upon the inmate-patient’s discharge from a community hospital: 23 7 30 76.67% 0 Were all medications ordered by the institution’s primary care provider administered or delivered to the inmate-patient within one calendar day of return? 7.004 For inmate-patients received from a county jail: Were all medications ordered by the institution’s reception center provider Not Applicable administered or delivered to the inmate-patient within the required time frames? 7.005 Upon the inmate-patient’s transfer from one housing unit to 26 4 30 86.67% 0 another: Were medications continued without interruption? 7.006 For inmate-patients en route who lay over at the institution: If the 8 2 10 80.00% 0 temporarily housed inmate-patient had an existing medication order, were medications administered or delivered without interruption? 7.101 All clinical and medication line storage areas for narcotic 3 10 13 23.08% 8 medications: Does the institution employ strong medication security controls over narcotic medications assigned to its clinical areas? 7.102 All clinical and medication line storage areas for non-narcotic 5 11 16 31.25% 5 medications: Does the institution properly store non-narcotic medications that do not require refrigeration in assigned clinical areas? 7.103 All clinical and medication line storage areas for non-narcotic 1 10 11 9.09% 10 medications: Does the institution properly store non-narcotic medications that require refrigeration in assigned clinical areas? 7.104 Medication preparation and administration areas: Do nursing staff 4 3 7 57.14% 0 employ and follow hand hygiene contamination control protocols during medication preparation and medication administration processes? 7.105 Medication preparation and administration areas: Does the 7 0 7 100.00% 0 institution employ appropriate administrative controls and protocols when preparing medications for inmate-patients? 7.106 Medication preparation and administration areas: Does the 4 3 7 57.14% 0 institution employ appropriate administrative controls and protocols when distributing medications to inmate-patients? 7.107 Pharmacy: Does the institution employ and follow general security, 2 0 2 100.00% 0 organization, and cleanliness management protocols in its main and satellite pharmacies? California Medical Facility, Cycle 4 Medical Inspection Page 86 Office of the Inspector General State of California Scored Answers Yes Reference + Pharmacy and Medication Management Number Yes No No Yes % N/A 7.108 Pharmacy: Does the institution’s pharmacy properly store 1 1 2 50.00% 0 non-refrigerated medications? 7.109 Pharmacy: Does the institution’s pharmacy properly store refrigerated 2 0 2 100.00% 0 or frozen medications? 7.110 Pharmacy: Does the institution’s pharmacy properly account for 1 0 1 100.00% 1 narcotic medications? 7.111 Pharmacy: Does the institution follow key medication error reporting 30 0 30 100.00% 0 protocols? 7.998 For Information Purposes Only: During eUHR compliance testing and case reviews, did the OIG find that medication errors were Information Only properly identified and reported by the institution? 7.999 For Information Purposes Only: Do inmate-patients in isolation housing units have immediate access to their KOP prescribed rescue Information Only inhalers and nitroglycerin medications? Overall percentage: 68.81% Prenatal and Post-Delivery Services Scored Answers This indicator is not applicable to this institution. Not Applicable California Medical Facility, Cycle 4 Medical Inspection Page 87 Office of the Inspector General State of California Scored Answers Yes Reference + Preventive Services Number Yes No No Yes % N/A 9.001 Inmate-patients prescribed TB medications: Did the institution 12 6 18 66.67% 0 administer the medication to the inmate-patient as prescribed? 9.002 Inmate-patients prescribed TB medications: Did the institution 1 16 17 5.88% 1 monitor the inmate-patient monthly for the most recent three months he or she was on the medication? 9.003 Annual TB Screening: Was the inmate-patient screened for TB within 16 14 30 53.33% 0 the last year? 9.004 Were all inmate-patients offered an influenza vaccination for the most 28 2 30 93.33% 0 recent influenza season? 9.005 All inmate-patients from the age of 50 through the age of 75: Was 26 4 30 86.67% 0 the inmate-patient offered colorectal cancer screening? 9.006 Female inmate-patients from the age of 50 through the age of 74: Was the inmate-patient offered a mammogram in compliance with Not Applicable policy? 9.007 Female inmate-patients from the age of 21 through the age of 65: Not Applicable Was the inmate-patient offered a pap smear in compliance with policy? 9.008 Are required immunizations being offered for chronic care 26 4 30 86.67% 10 inmate-patients? 9.009 Are inmate-patients at the highest risk of coccidioidomycosis (valley Not Applicable fever) infection transferred out of the facility in a timely manner? Overall percentage: 65.42% California Medical Facility, Cycle 4 Medical Inspection Page 88 Office of the Inspector General State of California Quality of Nursing Performance Scored Answers The quality of nursing performance will be assessed during case reviews, conducted by OIG clinicians, and is not applicable for the compliance portion of the medical inspection. The methodologies OIG clinicians use to evaluate the quality of nursing Not Applicable performance are presented in a separate inspection document entitled OIG MIU Retrospective Case Review Methodology. Quality of Provider Performance Scored Answers The quality of provider performance will be assessed during case reviews, conducted by OIG clinicians, and is not applicable for the compliance portion of the medical inspection. The methodologies OIG clinicians use to evaluate the quality of Not Applicable provider performance are presented in a separate inspection document entitled OIG MIU Retrospective Case Review Methodology. Reception Center Arrivals Scored Answers This indicator is not applicable to this institution. Not Applicable California Medical Facility, Cycle 4 Medical Inspection Page 89 Office of the Inspector General State of California Scored Answers Specialized Medical Housing Yes Reference + (OHU, CTC, SNF, Hospice) Number Yes No No Yes % N/A 13.001 For all higher-level care facilities: Did the registered nurse complete 20 0 20 100.00% 0 an initial assessment of the inmate-patient on the day of admission, or within eight hours of admission to CMF’s hospice? 13.002 For OHU, CTC, & SNF only: Did the primary care provider for OHU 16 3 19 84.21% 1 or attending physician for a CTC & SNF evaluate the inmate-patient within 24 hours of admission? 13.003 For OHU, CTC, & SNF only: Was a written history and physical 10 9 19 52.63% 1 examination completed within 72 hours of admission? 13.004 For all higher-level care facilities: Did the primary care provider 15 4 19 78.95% 1 complete the Subjective, Objective, Assessment, Plan, and Education (SOAPE) notes on the inmate-patient at the minimum intervals required for the type of facility where the inmate-patient was treated? 13.101 For OHU and CTC Only: Do inpatient areas either have properly 2 1 3 66.67% 0 working call systems in its OHU & CTC or are 30-minute patient welfare checks performed; and do medical staff have reasonably unimpeded access to enter inmate-patient’s cells? Overall percentage: 76.49% California Medical Facility, Cycle 4 Medical Inspection Page 90 Office of the Inspector General State of California Scored Answers Yes Reference + Specialty Services Number Yes No No Yes % N/A 14.001 Did the inmate-patient receive the high-priority specialty service within 13 2 15 86.67% 0 14 calendar days of the PCP order? 14.002 Did the PCP review the high-priority specialty service consultant report 7 8 15 46.67% 0 within the required time frame? 14.003 Did the inmate-patient receive the routine specialty service within 90 14 1 15 93.33% 0 calendar days of the PCP order? 14.004 Did the PCP review the routine specialty service consultant report 8 7 15 53.33% 0 within the required time frame? 14.005 For endorsed inmate-patients received from another CDCR 10 10 20 50.00% 0 institution: If the inmate-patient was approved for a specialty services appointment at the sending institution, was the appointment scheduled at the receiving institution within the required time frames? 14.006 Did the institution deny the primary care provider request for specialty 15 5 20 75.00% 0 services within required time frames? 14.007 Following the denial of a request for specialty services, was the 9 9 18 50.00% 2 inmate-patient informed of the denial within the required time frame? Overall percentage: 65.00% California Medical Facility, Cycle 4 Medical Inspection Page 91 Office of the Inspector General State of California Scored Answers Internal Monitoring, Quality Improvement, and Yes Reference + Administrative Operations Number Yes No No Yes % N/A 15.001 Did the institution promptly process inmate medical appeals during the 12 0 12 100.00% 0 most recent 12 months? 15.002 Does the institution follow adverse/sentinel event reporting Not Applicable requirements? 15.003 Did the institution Quality Management Committee (QMC) meet at 5 1 6 83.33% 0 least monthly to evaluate program performance, and did the QMC take action when improvement opportunities were identified? 15.004 Did the institution’s Quality Management Committee (QMC) or other 0 1 1 0.00% 0 forum take steps to ensure the accuracy of its Dashboard data reporting? 15.005 For each initiative in the Performance Improvement Work Plan 0 11 11 0.00% 1 (PIWP), has the institution performance improved or reached the targeted performance objective(s)? 15.006 For institutions with licensed care facilities: Does the Local 0 4 4 0.00% 0 Governing Body (LGB), or its equivalent, meet quarterly and exercise its overall responsibilities for the quality management of patient health care? 15.007 Does the Emergency Medical Response Review Committee perform 0 12 12 0.00% 0 timely incident package reviews that include the use of required review documents? 15.101 Did the institution complete a medical emergency response drill for 3 0 3 100.00% 0 each watch and include participation of health care and custody staff during the most recent full quarter? 15.102 Did the institution’s second level medical appeal response address all 10 0 10 100.00% 0 of the inmate-patient’s appealed issues? 15.103 Did the institution’s medical staff review and submit the initial inmate 10 0 10 100.00% 0 death report to the Death Review Unit in a timely manner? 15.996 For Information Purposes Only: Did the CCHCS Death Review Committee submit its inmate death review summary to the institution Information Only timely? 15.997 For Information Purposes Only: Identify the institution’s protocols Information Only for tracking medical appeals. 15.998 For Information Purposes Only: Identify the institution’s protocols Information Only for implementing health care local operating procedures. 15.999 For Information Purposes Only: Identify the institution’s health care Information Only staffing resources. Overall percentage: 53.70% California Medical Facility, Cycle 4 Medical Inspection Page 92 Office of the Inspector General State of California Scored Answers Job Performance, Training, Licensing, and Yes Reference + Certifications Number Yes No No Yes % N/A 16.001 Do all providers maintain a current medical license? 17 0 17 100.00% 0 16.101 Does the institution’s Supervising Registered Nurse conduct periodic 0 5 5 0.00% 0 reviews of nursing staff? 16.102 Are nursing staff who administer medications current on their clinical 10 0 10 100.00% 0 competency validation? 16.103 Are structured clinical performance appraisals completed timely? 12 1 13 92.31% 0 16.104 Are staff current with required medical emergency response 2 1 3 66.67% 0 certifications? 16.105 Are nursing staff and the pharmacist in charge current with their 5 0 5 100.00% 1 professional licenses and certifications? 16.106 Do the institution’s pharmacy and authorized providers who prescribe 2 0 2 100.00% 0 controlled substances maintain current Drug Enforcement Agency (DEA) registrations? 16.107 Are nursing staff current with required new employee orientation? 0 1 1 0.00% 0 Overall percentage: 69.87% California Medical Facility, Cycle 4 Medical Inspection Page 93 Office of the Inspector General State of California APPENDIX B — CLINICAL DATA Table B-1: CMF Sample Sets Sample Set Total Anticoagulation 3 CTC/OHU 11 Death Review/Sentinel Events 5 Diabetes 3 Emergency Services – CPR 5 Emergency Services – Non-CPR 5 High Risk 5 Hospitalization 5 Intra-System Transfers In 3 Intra-System Transfers Out 3 RN Sick Call 30 Specialty Services 4 82 California Medical Facility, Cycle 4 Medical Inspection Page 94 Office of the Inspector General State of California Table B-2: CMF Chronic Care Diagnoses Diagnosis Total Anemia 9 Anticoagulation 4 Arthritis/Degenerative Joint Disease 12 Asthma 11 COPD 24 Cancer 12 Cardiovascular Disease 19 Chronic Kidney Disease 4 Chronic Pain 27 Cirrhosis/End-Stage Liver Disease 3 Coccidioidomycosis 1 DVT/PE 3 Deep Venous Thrombosis/Pulmonary Embolism 2 Diabetes 28 Gastroesophageal Reflux Disease 20 HIV 3 Hepatitis C 34 Hyperlipidemia 29 Hypertension 58 Mental Health 17 Migraine Headaches 1 Rheumatological Disease 1 Seizure Disorder 8 Sickle Cell Anemia 1 Sleep Apnea 4 Thyroid Disease 9 344 California Medical Facility, Cycle 4 Medical Inspection Page 95 Office of the Inspector General State of California Table B-3: CMF Event - Program Program Total Diagnostic Services 151 Emergency Care 89 Hospitalization 43 Intra-System Transfers In 6 Intra-System Transfers Out 5 Not Specified 1 Outpatient Care 437 Specialized Medical Housing 353 Specialty Services 198 1,283 Table B-4: CMF Case Review Sample Summary Total MD Reviews Detailed 30 MD Reviews Focused 0 RN Reviews Detailed 19 RN Reviews Focused 51 Total Reviews 100 Total Unique Cases 82 Overlapping Reviews (MD & RN) 18 California Medical Facility, Cycle 4 Medical Inspection Page 96 Office of the Inspector General State of California APPENDIX C — COMPLIANCE SAMPLING METHODOLOGY California Medical Facility Sample Category Quality (number of Indicator samples) Data Source Filters Access to Care MIT 1.001 Chronic care patients Master Registry  Chronic care conditions (at least one condition per inmate-patient—any risk level) (40)  Randomize MIT 1.002 Nursing Referrals OIG Q: 6.001  See Intra-system Transfers (30) MITs 1.003-006 Nursing sick call MedSATS  Clinic (each clinic tested) (5 per clinic)  Appointment date (2–9 months) 30  Randomize MIT 1.007 Returns from OIG Q: 4.008  See Health Information Management (Medical community hospital Records) (returns from community hospital) (30) MIT 1.008 Specialty services OIG Q: 14.001 &  See Specialty Services follow-up 14.003 (30) MIT 1.101 Availability of health OIG onsite  Randomly select one housing unit from each yard care services request review forms (6) Diagnostic Services MITs 2.001–003 Radiology Radiology Logs  Appointment date (90 days–9 months)  Randomize (10)  Abnormal MITs 2.004–006 Laboratory Quest  Appt. date (90 days–9 months)  Order name (CBC or CMPs only)  Randomize (10)  Abnormal MITs 2.007–009 Pathology InterQual  Appt. date (90 days–9 months)  Service (pathology related) (10)  Randomize California Medical Facility, Cycle 4 Medical Inspection Page 97 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Health Information Management (Medical Records) MIT 4.001 Timely scanning OIG Qs: 1.001,  Non-dictated documents (20) 1.002, & 1.004  1st 10 IPs MIT 1.001, 1st 5 IPs MITs 1.002, 1.004 MIT 4.002 OIG Q: 1.001  Dictated documents (6)  First 20 IPs selected MIT 4.003 OIG Qs: 14.002  Specialty documents (20) & 14.004  First 10 IPs for each question MIT 4.004 OIG Q: 4.008  Community hospital discharge documents (20)  First 20 IPs selected MIT 4.005 OIG Q: 7.001  MARs (20)  First 20 IPs selected MIT 4.006 Documents for  Any misfiled or mislabeled document identified (12) any tested inmate during OIG compliance review (12 or more = No) MIT 4.007 Legible signatures & OIG Qs: 4.008,  First 8 IPs sampled review 6.001, 6.002,  One source document per IP 7.001, 12.001, (32) 12.002 & 14.002 MIT 4.008 Returns from Inpatient claims  Date (2–8 months) community hospital data  Most recent 6 months provided (within date range)  Rx count  Discharge date  Randomize (each month individually)  First 5 inmate-patients from each of the 6 months (if not 5 in a month, supplement from another, as (30) needed) Health Care Environment MIT 5.101-111 Clinical areas OIG inspector  Identify and inspect all onsite clinical areas. (14) onsite review Inter- and Intra-System Transfers MIT 6.001-003 Intra-system transfers SOMS  Arrival date (3–9 months)  Arrived from (another CDCR facility)  Rx count (30)  Randomize MIT 6.004 Specialty services MedSATS  Date of transfer (3–9 months) send-outs  Randomize (20) MIT 6.101 Transfers out OIG inspector  R&R IP transfers with medication (4) onsite review California Medical Facility, Cycle 4 Medical Inspection Page 98 Office of the Inspector General State of California Sample Category Quality (number of Indicator patients) Data Source Filters Pharmacy and Medication Management MIT 7.001 Chronic care OIG Q: 1.001 See Access to Care medication  At least one condition per inmate-patient—any risk level (40)  Randomize MIT 7.002 New Medication Master Registry  Rx count Orders  Randomize (40)  Ensure no duplication of IPs tested in MIT 7.001 MIT 7.003 Returns from OIG Q: 4.008  See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (30) 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) (30)  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 (7) MITs 7.107-110 Pharmacy OIG inspector  Identify & inspect all onsite pharmacies (2) onsite review MIT 7.111 Medication error Monthly  All monthly statistic reports with Level 4 or higher reporting medication error  Select a total of 5 months (30) reports MIT 7.999 Isolation unit KOP Onsite active  KOP rescue inhalers & nitroglycerin medications medications medication for IPs housed in isolation units (3) listing Prenatal and Post-Delivery Services MIT 8.001-007 Recent Deliveries OB Roster  Delivery date (2–12 months) N/A at this institution  Most recent deliveries (within date range) Pregnant Arrivals OB Roster  Arrival date (2–12 months) N/A at this institution  Earliest arrivals (within date range) California Medical Facility, Cycle 4 Medical Inspection Page 99 Office of the Inspector General State of California Sample Category Quality (number of Indicator patients) 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) (18)  Randomize MIT 9.003 TB Code 22, annual SOMS  Arrival date (at least 1 year prior to inspection) TST  TB Code (22) (15)  Randomize TB Code 34, annual SOMS  Arrival date (at least 1 year prior to inspection) screening  TB Code (34) (15)  Randomize MIT 9.004 Influenza SOMS  Arrival date (at least 1 year prior to inspection) vaccinations  Randomize (30)  Filter out IPs tested in MIT 9.008 MIT 9.005 Colorectal cancer SOMS  Arrival date (at least 1 year prior to inspection) screening  Date of birth (51 or older) (30)  Randomize MIT 9.006 Mammogram SOMS  Arrival date (at least 2 yrs prior to inspection)  Date of birth (age 52–74) N/A at this institution  Randomize MIT 9.007 Pap smear SOMS  Arrival date (at least three yrs prior to inspection)  Date of birth (age 24–53) N/A at this 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 (30)  Condition must require vaccination(s) MIT 9.009 Valley fever Cocci transfer  Reports from past 2–8 months (number will vary) status report  Institution  Ineligibility date (60 days prior to inspection date) N/A at this institution  All California Medical Facility, Cycle 4 Medical Inspection Page 100 Office of the Inspector General State of California Sample Category Quality (number of Indicator patients) Data Source Filters Reception Center Arrivals MITs 12.001–008 RC SOMS  Arrival date (2–8 months)  Arrived from (county jail, return from parole, etc.) N/A at this institution  Randomize Specialized Medical Housing MITs 13.001–004 CTC, OHU, Hospice CADDIS  Admit date (1–6 months)  Type of stay (no MH beds)  Length of stay (minimum of 5 days) (20)  Randomize MIT 13.101 Call buttons OIG inspector  Review by location CTC (all) onsite review Specialty Services Access MITs 14.001–002 High-priority MedSATS  Approval date (3–9 months) (15)  Randomize MITs 14.003–004 Routine MedSATS  Approval date (3–9 months) (15)  Remove optometry, physical therapy or podiatry  Randomize MIT 14.005 Specialty services MedSATS  Arrived from (other CDCR institution) arrivals  Date of transfer (3–9 months) (20)  Randomize MIT 14.006-007 Denials InterQual  Review date (3–9 months) (19)  Randomize IUMC/MAR  Meeting date (9 months) Meeting Minutes  Denial upheld (1)  Randomize California Medical Facility, Cycle 4 Medical Inspection Page 101 Office of the Inspector General State of California Sample Category Quality (number of Indicator patients) Data Source Filters Internal Monitoring, Quality Improvement, & Administrative Operations MIT 15.001 Medical appeals Monthly medical  Medical appeals (12 months) (all) appeals reports MIT 15.002 Adverse/sentinel Adverse/sentinel  Adverse/sentinel events (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 Performance Institution PIWP  PIWP with updates (12 months) improvement work  Medical initiatives plans (PIWP) (11) MIT 15.006 LGB LGB meeting  Quarterly meeting minutes (12 months) (4) minutes MIT 15.007 EMRRC EMRRC meeting  Monthly meeting minutes (6 months) (12) minutes MIT 15.101 Medical emergency Onsite summary  Most recent full quarter response drills reports &  Each watch documentation (3) for ER drills MIT 15.102 2nd level medical Onsite list of  Medical appeals denied (6 months) appeals appeals/closed (10) appeals files MIT 15.103 Death Reports Institution-list of  Most recent 10 deaths deaths in prior  Initial death reports (5) 12 months MIT 15.996 Death Review OIG summary  Between 35 business days & 12 months prior Committee log - deaths  CCHCS death reviews (10) MIT 15.998 Local operating Institution LOPs  All LOPs procedures (LOPs) (all) California Medical Facility, Cycle 4 Medical Inspection Page 102 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Job Performance, Training, Licensing, and Certifications MIT 16.001 Provider licenses Current provider  Review all listing (at start of (10) inspection) MIT 16.101 RN Review Onsite  RNs who worked in clinic or emergency setting Evaluations supervisor six or more days in sampled month periodic RN  Randomize (5) reviews MIT 16.102 Nursing Staff Onsite nursing  On duty one or more years Validations education files  Nurse administers medications (10)  Randomize MIT 16.103 Provider Annual OIG Q:16.001  All required performance evaluation documents Evaluation Packets (all) MIT 16.104 Medical Emergency Onsite  All staff Response certification o Providers (ACLS) Certifications tracking logs o Nursing (BLS/CPR) (all) o Custody (CPR/BLS) MIT 16.105 Nursing staff and Onsite tracking  All required licenses and certifications Pharmacist-in-charge system, logs, or Professional employee files Licenses and Certifications (all) MIT 16.106 Pharmacy and Onsite listing of  All DEA registrations Providers’ Drug provider DEA Enforcement Agency registration #s & (DEA) Registrations pharmacy registration (all) document MIT 16.107 Nursing Staff New Nursing staff  New employees (hired within last 12 months) Employee training logs Orientations (all) California Medical Facility, Cycle 4 Medical Inspection Page 103 Office of the Inspector General State of California C C ALIFORNIA ORRECTIONAL H C S ’ EALTH ARE ERVICES R ESPONSE California Medical Facility, Cycle 4 Medical Inspection Page 104 Office of the Inspector General State of California