California Medical Facility Medical Inspection Results Cycle 2

CALIFORNIA MEDICAL FACILITY MEDICAL INSPECTION RESULTS BUREAU OF AUDITS OFFICE OF THE INSPECTOR GENERAL STATE OF CALIFORNIA March 2011 Contents Executive Summary ......................................................................................… 1 Introduction …................................................................................................… 3 Background …....................................................................................… 3 About the Institution …......................................................................… 4 Objectives, Scope, and Methodology ….............................................. 4 Medical Inspection Results ….......................................................................… 7 Appendix – Comparative Medical Inspection Scores …................................27 California Prison Health Care Receivership Corporation's Response ….............................................................................. 28 Office of the Inspector General's Comments on the Receiver's Response …........................................................................ 31 Executive Summary An April 2001 class action lawsuit filed by inmates represented by the Prison Law Office alleged that the state provided constitutionally inadequate medical care at California state prisons in violation of inmates’ constitutional rights. And, in October 2005, the U.S. Court for the Northern District of California declared that California’s delivery system for prison medical care was “broken beyond repair” and still not meeting constitutional standards. As a result, the federal court imposed a receivership to raise the delivery of medical care to constitutional standards. To evaluate and monitor the progress of medical care delivery to inmates, the receiver requested, and the Office of the Inspector General agreed, to establish an objective, clinically appropriate, and metric-oriented medical inspection program to review the delivery of medical care at each state prison. In September 2010, we inspected the California Medical Facility (CMF) for the Overall second time. Our medical inspection encompassed 18 components of medical Score delivery and comprised 125 questions. The questions are weighted based on 79.0% their importance to the delivery of medical care to inmates. CMF received 79.0 percent of the total weighted points possible. This is a 6.6 percentage point improvement over the score of 72.4 percent from our first inspection of this prison issued in January 2009. The following summary table lists the components we inspected in order of importance (highest to lowest), with the institution’s score and the definitions of each inspection component. The detailed medical inspection results, with the questions for each component, begin on page 7 of this report. While we are committed to helping each institution achieve a higher level of medical care, it is not our intent to determine the percentage score needed by an institution to meet constitutional standards—that is a legal matter for the federal court to determine. Executive Summary Table Component Weighted Score Definition Chronic Care 68.3% Examines how well the prison provided care and medication to inmates with specific chronic care conditions, which are those that affect (or have the potential to affect) an inmate's functioning and long-term prognosis for more than six months. Our inspection tests anticoagulation therapy and the following chronic care conditions: asthma, diabetes, HIV (Human Immunodeficiency Virus), and hypertension. Clinical Services 67.1% Evaluates the inmate's access to primary health care services and focuses on inmates who recently received services from any of the prison's facility or administrative segregation unit clinics. This component evaluates sick call processes (doctor or nurse line), medication management, and nursing. Health Screening 74.8% Focuses on the prison's process for screening new inmates upon arrival to the institution for health care conditions that require treatment and monitoring, as well as ensuring inmates' continuity of care. Specialty Services 75.7% Focuses on the prison's process for approving, denying, and scheduling services that are outside the specialties of the prison's medical staff. Common examples of these services include physical therapy, oncology services, podiatry consultations, and neurology services. Urgent Services 85.4% Addresses the care provided by the institution to inmates before and after they were sent to a community hospital. Emergency Services 79.5% Examines how well the prison responded to inmate medical emergencies. Bureau of Audits Page 1 Office of the Inspector General State of California Component Weighted Score Definition Prenatal N/A Focuses on the prenatal and post-delivery medical care provided to pregnant inmates. This Care/Childbirth/Post- component is not applicable at men's institutions. delivery Diagnostic Services 73.5% Addresses the timeliness of radiology (x-ray) and laboratory services and whether the prison followed up on clinically significant results. Access to Health Care 72.5% Addresses the prison's effectiveness in filing, storing, and retrieving medical records and Information medical-related information. Outpatient Housing Unit 92.3% Determines whether the prison followed department policies and procedures when placing inmates in the outpatient housing unit. This component also evaluates whether the placement provided the inmate with adequate care and whether the physician's plan addressed the placement diagnosis. Internal Reviews 85.0% Focuses on the activities of the prison's Quality Management Committee and its Emergency Medical Response Review Committee. This component also evaluates the timeliness of the inmates' medical appeals and the prison's use of inmate death reviews. Inmate Transfers N/A Focuses on inmates pending transfer to determine whether the sending institution documented medication and medical conditions to assist the receiving institution in providing continuity of care. For the CMF inspection, we identified only one inmate transfer that was available for testing during our inspection week. Therefore, we excluded the results because we do not include a score for any question or component for which only one sample item is found to apply unless we know that the sample item represents the entire population in the time period under review. Clinic Operations 100.0% Addresses the general operational aspects of the prison's facility clinics. Generally, the questions in this component relate to the overall cleanliness of the clinics, privacy afforded to inmates during nonemergency visits, use of priority ducats (slip of paper the inmate carries for scheduled medical appointments), and availability of health care request forms. Preventive Services 85.0% Focuses on inmate cancer screening, tuberculosis evaluation, and influenza immunizations. Pharmacy Services 97.6% Addresses whether the prison's pharmacy complies with various operational policies, such as conducting periodic inventory counts, maintaining the currency of medications in its crash carts and after-hours medication supplies, and having valid permits. In addition, this component also addresses whether the pharmacy has an effective process for screening medication orders for potential adverse reactions/interactions. Other Services 100.0% Examines additional areas that are not captured in the other components. The areas evaluated in this component include the prison's provision of therapeutic diets, its handling of inmates who display poor hygiene, and the availability of the current version of the department's Inmate Medical Services Policies and Procedures. Inmate Hunger Strikes 92.6% Examines medical staff's monitoring of inmates participating in hunger strikes lasting longer than three days. Chemical Agent 100.0% Addresses the prison's process of handling inmates who may be predisposed to an adverse Contraindications outcome from calculated uses of force (cell extractions) involving Oleoresin Capsicum, which is commonly referred to as "pepper spray." For example, this might occur if the inmate has asthma. Staffing Levels and 100.0% Examines the prison's medical staffing levels and training provided. Training Nursing Policy 60.0% Determines whether the prison maintains written policies and procedures for the safe and effective provision of quality nursing care. The questions in this component also determine whether nursing staff review their duty statements and whether supervisors periodically review the work of nurses to ensure they properly follow established nursing protocols. Overall Score 79.0% Bureau of Audits Page 2 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 inspection program to evaluate the delivery of medical care at each of CDCR’s 33 adult prisons. In September 2010, we inspected the California Medical Facility (CMF). Our medical inspection encompassed 18 components of medical delivery and comprised 125 questions. To help readers understand the medical risk associated with certain components of medical delivery—which pose a greater risk to an inmate-patient—we developed a weighting system and assigned points to each question. Consequently, we assigned more total points to more critical components, such as chronic care, clinical services, and health screening. We assigned fewer total points to less critical components, such as inmate hunger strikes, staffing levels and training, and chemical agent contraindications. (For a detailed description of the weighting system, see Objectives, Scope, and Methodology on the next page.) Background In April 2001, inmates represented by the Prison Law Office filed a class action lawsuit, known as Plata v. Schwarzenegger. The lawsuit alleged that the state provided constitutionally inadequate medical care at California state prisons in violation of inmates’ constitutional rights. In June 2002, the parties entered into a Stipulation for Injunctive Relief, and the state agreed to implement over several years comprehensive new medical care policies and procedures at all institutions. Nevertheless, the U.S. Court for the Northern District of California declared in October 2005 that California’s delivery system for prison medical care was “broken beyond repair” and still not meeting constitutional standards. Thus, the federal court imposed a receivership to raise the delivery of medical care to constitutional standards. In essence, the court ordered the receiver to manage the state’s delivery of medical care and restructure day-to-day operations to develop and sustain a system that provides constitutionally adequate medical care to inmates. The court stated that it would remove the receiver and return control to the state once the system is stable and provides for constitutionally adequate medical care. To evaluate and monitor the progress of medical care delivery to inmates, the receiver requested that the OIG establish an objective, clinically appropriate, and metric-oriented medical inspection program. To that end, the Inspector General agreed to inspect each state prison on a cycle basis. In June 2010, we completed the fieldwork for our first cycle of medical inspections of the state’s 33 prisons. This report presents the results of the second medical inspection conducted at this institution. The appendix to this report provides summary comparative data for the first and second cycle inspections conducted at this institution. We are committed to helping each institution achieve a higher level of medical care, but it is up to the federal court to determine the percentage score necessary for an institution to meet constitutional standards. Bureau of Audits Page 3 Office of the Inspector General State of California About the Institution CMF 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 houses a general acute care hospital, correctional treatment center, licensed elderly care unit, in-patient and out- patient psychiatric facilities, a hospice unit for terminally ill inmates, housing and treatment for inmates identified with AIDS/HIV, general population, and other special inmate housing. Along with five clinics that handle urgent and non-urgent requests for medical services, CMF has a state-licensed standby emergency room. As of March 2, 2011, CDCR reported that CMF had custody over 2,717 male inmates. According to information provided by the institution, CMF's vacancy rate among licensed medical managers, primary care providers, supervisors, and rank and file nurses is 7.1 percent. Nathaniel Elam serves as the prison's chief executive officer of health care services while Joseph Bick, M.D., serves as the chief medical executive. Objectives, Scope, and Methodology In designing the medical inspection program, we reviewed CDCR’s policies and procedures, relevant court orders, guidelines developed by the department’s Quality Medical Assurance Team, and guidance developed by the American Correctional Association. We also reviewed professional literature on correctional medical care, consulted with clinical experts, and met with stakeholders from the court, the receiver’s office, the department, and the Prison Law Office to discuss the nature and scope of the inspection program. Based on input from these stakeholders, we developed a medical inspection program that evaluates medical care delivery. Within each of 20 components, we created “yes” or “no” questions designed to gauge performance. To make the inspection results meaningful to both a medical expert and a lay reader, we worked with clinical experts to create a weighting system that factors the relative importance of each component compared to other components. Further, the program considers the relative importance of each question within a component to the other questions in that component. This weighting ensures that more critical components—such as those that pose the greatest medical risk to the inmate-patient—are given more weight compared to those considered less serious. For example, we assign a high number of possible points to the chronic care component because we consider this the most serious of all the components. We assign proportionately fewer points to all other components. Each inspection question is weighted and scored. The score is derived from the percentage of “yes” answers for each question from all items sampled. We then multiply the percentage of “yes” answers within a given question by the question’s weight to arrive at a score. The following example shows how this scoring system works. Example Question: Institution X Answers Weighting Points Yes No Yes + No Yes % Possible Received Score % N/A Unk Is the clinical history adequate? 40 10 50 80% 20 16 80.0% 0 0 Bureau of Audits Page 4 Office of the Inspector General State of California If the institution receives 40 “yes” answers and 10 “no” answers, the percentage of “yes” answers to this question equals 80 percent. We calculate the number of points the institution would receive by multiplying the “yes” percent of 80 by the number of possible points for this question, which is 20, to arrive at 16 points. To arrive at the total score, we add the points received for each question and then for each program component. Finally, we calculate the institution’s overall score by dividing the sum of the points received by the sum of the points possible. We do not include in the institution’s overall score the weight for questions that are not applicable or, in some cases, where a lack of documentation would result in numerous “no” answers for one deviation from policy (unknown). For instance, an institution may not be able to provide documentation that its Emergency Medical Response Review Committee met for a particular month. Therefore, when we evaluate whether meeting minutes document monthly meetings for a particular month, the institution would receive a “no” answer for that question. However, when we evaluate whether the meeting minutes document the warden’s attendance at the meeting, the answer would be “unknown” so that the institution’s score is not penalized twice for the same reason, not documenting the meeting. Further, we do not include a score for any question for which only one sample item is found to apply unless we know that the sample item represents the entire population related to the question in the time period under review. In these cases, the one sample item is identified as not applicable in our report and thereby not included in the inspection scores. To evaluate the institution’s delivery of medical care, we obtained various electronic data files maintained by the institution for inmate medical scheduling and tracking, pharmacy, and census data. We used these electronic data files only to identify random samples of inmates receiving or requiring specific medical services. We then reviewed the medical file for each inmate in our sample. We did not rely on the medical care information contained in these electronic data files. Our inspection program assumes that if a prison's medical staff does not document an event in an inmate's unit health record, the event in question did not happen. If an inmate's record does not show that the inmate received his medications on a specified date, for example, we assume that the inmate did not receive the medications. While it is possible that the inmate received his medications and the staff neglected to document the event, our program cannot assume that appropriate care was provided. Our medical inspection at CMF encompassed 18 of the 20 components of medical delivery. Two of the components were not applicable during the period inspected. In total, we reviewed 197 inmate medical files, which are referred to as unit health records. In addition, we reviewed staffing level reports, medical appeals summaries, nursing policies and procedures, summaries of medical drills and emergencies, minutes from Quality Management Committee and Emergency Medical Response Review Committee hearings, contents of inmate transfer envelopes, and assorted manual logs or tracking worksheets related to medical care delivery. Finally, we interviewed medical and custody staff members about the delivery of medical care to inmates, and we observed day-to-day medical delivery at the institution. We do not test the care provided in the licensed hospitals or correctional treatment centers because they are subject to inspections and oversight by other regulatory agencies. Bureau of Audits Page 5 Office of the Inspector General State of California Consistent with our agreement with the receiver, our report only addresses the conditions found related to the medical care criteria. We do not discuss the causes of noncompliance, nor do we make specific recommendations in this report. However, if we learn of an inmate-patient who needs immediate care, we notify the chief executive officer of health care services and request a status report. Moreover, if we learn of significant departures from community standards, we may report such departures to the institution’s chief executive officer or the receiver’s office. Because these matters involve confidential medical information protected by state and federal privacy laws, specific details related to these cases are not included in our report. Following completion of the first cycle of 33 prison medical inspections in June 2010, we evaluated the medical inspection program for improvement opportunities with input from the stakeholders involved with the Plata v. Schwarzenegger litigation. As a result, we made a limited number of revisions. These revisions include eliminating a medical emergency drill, adding five questions and eliminating seven others, and adjusting the weighting of certain questions. To assist the reader in comparing the results of the two inspections at this institution, taking into account the program revisions, this report includes an appendix. For ease of reference, following is a table of abbreviations used in the remainder of this report. Abbreviations used in this report CEO Chief Executive Officer CME Chief Medical Executive FTF Face-to-Face INH Isoniazid (antituberculous medication) LVN Licensed Vocational Nurse MD Medical Doctor OB Obstetrician OHU Outpatient Housing Unit OIG Office of the Inspector General PCP Primary Care Provider RN Registered Nurse TB Tuberculosis TTA Triage and Treatment Area UHR Unit Health Record Bureau of Audits Page 6 Office of the Inspector General State of California OFFICE OF THE INSPECTOR GENERAL CALIFORNIA MEDICAL FACILITY Overall Score: MEDICAL INSPECTION RESULTS 79.0% 09/27/2010 – 09/30/2010 Answers Weighting Points Questions Not Answered Component Page Yes No Yes + No Yes % Points Possible Points Received Score % Not Applicable Unknown Chronic Care 8 151 58 209 72.2% 133 90.9 68.3% 13 8 Clinical Services 9 250 101 351 71.2% 100 67.1 67.1% 30 6 Health Screening 11 96 27 123 78.0% 60 44.9 74.8% 57 0 Specialty Services 12 77 28 105 73.3% 69 52.2 75.7% 72 0 Urgent Services 13 123 19 142 86.6% 59 50.4 85.4% 8 0 Emergency Services 14 24 5 29 82.8% 44 35.0 79.5% 10 1 Diagnostic Services 15 39 15 54 72.2% 52 38.2 73.5% 9 2 Access to Health Care Information 16 5 2 7 71.4% 51 37.0 72.5% 0 0 Outpatient Housing Unit 17 66 5 71 93.0% 48 44.3 92.3% 0 5 Internal Reviews 18 32 2 34 94.1% 40 34.0 85.0% 0 0 Clinic Operations 19 19 0 19 100.0% 33 33.0 100.0% 0 0 Preventive Services 20 33 5 38 86.8% 30 25.5 85.0% 0 0 Pharmacy Services 21 26 3 29 89.7% 29 28.3 97.6% 0 0 Other Services 22 7 0 7 100.0% 17 17.0 100.0% 0 0 Inmate Hunger Strikes 23 14 1 15 93.3% 19 17.6 92.6% 0 0 Chemical Agent Contraindications 24 12 0 12 100.0% 17 17.0 100.0% 2 0 Staffing Levels and Training 25 8 0 8 100.0% 16 16.0 100.0% 1 0 Nursing Policy 26 11 4 15 73.3% 14 8.4 60.0% 0 0 Totals 993 275 1268 78.3% 831 656.8 79.0% 202 22 Bureau of Audits Page 7 Office of the Inspector General State of California Answers Weighting Points Reference Chronic Care Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 03.076 Was the inmate's most recent chronic care visit within the time frame 14 9 23 60.9% 20 12.2 60.9% 0 1 required by the degree of control of the inmate's condition based on his or her prior visit? 03.082 Did the institution document that it provided the inmate with health care 16 8 24 66.7% 6 4.0 66.7% 0 0 education? 03.175 Did the inmate receive his or her prescribed chronic care medications during 15 7 22 68.2% 16 10.9 68.2% 2 0 the most recent three-month period or did the institution follow departmental policy if the inmate refused to pick up or show up for his or her medications? 03.294 Is the follow-up interval documented at the most recent chronic care visit 22 1 23 95.7% 5 4.8 95.7% 1 0 consistent with the intervals required in the policy? 03.235 Is the clinical history adequate? 15 8 23 65.2% 18 11.7 65.2% 1 0 03.236 Is the focused clinical examination adequate? 11 9 20 55.0% 16 8.8 55.0% 4 0 03.237 Is the assessment adequate? 14 6 20 70.0% 18 12.6 70.0% 0 4 03.238 Is the plan adequate? 10 6 16 62.5% 16 10.0 62.5% 5 3 03.262 Is the inmate's Problem List complete and filed accurately in the inmate's 22 2 24 91.7% 8 7.3 91.7% 0 0 UHR? 03.293 Are immunizations current for the chronic care condition? 12 2 14 85.7% 10 8.6 85.7% 0 0 Component Subtotals: 151 58 209 72.2% 133 90.9 68.3% 13 8 Bureau of Audits Page 8 Office of the Inspector General State of California Answers Weighting Points Reference Clinical Services Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 01.024 RN FTF Documentation: Did the inmate's request for health care get 29 0 29 100.0% 6 6.0 100.0% 0 1 reviewed the same day it was received? 01.025 Did the RN complete a FTF visit within one (1) business day after the Form 29 0 29 100.0% 10 10.0 100.0% 0 1 7362 was reviewed? 01.027 If the RN determined a referral to a PCP was necessary, was the inmate seen 20 6 26 76.9% 10 7.7 76.9% 4 0 within the time lines specified by the RN during the FTF triage? 01.246 Did documentation indicate that the RN reviewed all of the inmate's 29 1 30 96.7% 4 3.9 96.7% 0 0 clinically significant complaints listed on Form 7362 (Health Care Services Request Form)? 01.157 RN FTF Documentation: Did the RN's subjective note address the nature 14 16 30 46.7% 6 2.8 46.7% 0 0 and history of the inmate's clinically significant complaint(s)? 01.159 RN FTF Documentation: Did the RN's objective note include vital signs and 11 19 30 36.7% 5 1.8 36.7% 0 0 a focused physical examination, and did it adequately address the clinically significant problems noted in the subjective note? 01.244 RN FTF Documentation: Did the RN's objective note include allergies, 12 18 30 40.0% 3 1.2 40.0% 0 0 weight, current medication, and where appropriate, medication compliance? 01.158 RN FTF Documentation: For the clinically significant complaints, did the 23 7 30 76.7% 5 3.8 76.7% 0 0 RN's assessment provide appropriate conclusions based on subjective and objective data? 01.162 RN FTF Documentation: Did the RN's plan include an adequate strategy to 21 9 30 70.0% 6 4.2 70.0% 0 0 address the clinically significant problems identified during the FTF triage? 01.163 RN FTF Documentation: Did the RN's education/instruction adequately 26 2 28 92.9% 4 3.7 92.9% 2 0 address the clinically significant problems identified during the FTF triage? 01.247 Sick Call Follow-up: If the provider ordered a follow-up sick call 14 1 15 93.3% 5 4.7 93.3% 15 0 appointment, did it take place within the time frame specified? Bureau of Audits Page 9 Office of the Inspector General State of California Answers Weighting Points Reference Clinical Services Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 01.124 Sick Call Medication: Did the institution administer or deliver prescription 14 13 27 51.9% 6 3.1 51.9% 3 0 medications (new orders) to the inmate within specified time frames? 15.234 Are clinic response bags audited daily and do they contain essential items? 1 1 2 50.0% 5 2.5 50.0% 0 0 21.278 If pre-existing medical conditions contributed to the need for the TTA visit, 7 8 15 46.7% 25 11.7 46.7% 6 4 was there adequate prior management of those conditions? Component Subtotals: 250 101 351 71.2% 100 67.1 67.1% 30 6 Bureau of Audits Page 10 Office of the Inspector General State of California Answers Weighting Points Reference Health Screening Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 02.016 Did the institution complete the initial health screening on the same day the 20 0 20 100.0% 9 9.0 100.0% 0 0 inmate arrived at the institution? 02.017 If "Yes" was answered to any of the questions on the initial health screening 18 0 18 100.0% 8 8.0 100.0% 2 0 form(s), did the RN provide an assessment and disposition on the date of arrival? 02.018 If, during the assessment, the RN referred the inmate to a clinician, was the 9 11 20 45.0% 9 4.1 45.0% 0 0 inmate seen within the time frame? 02.020 Did the LVN/RN adequately document the tuberculin test and timely 17 3 20 85.0% 6 5.1 85.0% 0 0 reading of the test results; or, if the inmate did not have a TB test because of a previous positive TB test, was a review of signs and symptoms completed? 02.015 Was a review of symptoms completed if the inmate's tuberculin test was 0 0 0 0.0% 0 0.0 0.0% 20 0 positive, and were the results reviewed by the infection control nurse or the public health nurse? 02.128 If the inmate had an existing medication order upon arrival at the institution, 9 7 16 56.3% 8 4.5 56.3% 4 0 did the inmate receive the medications by the next calendar day, or did a physician document why the medications were not to be continued? 02.007 Non-reception center: Does the health care transfer information form 16 4 20 80.0% 7 5.6 80.0% 0 0 indicate that it was reviewed and signed by licensed health care staff within one calendar day of the inmate's arrival at the institution? 02.014 Non-reception center: If the inmate was scheduled for a specialty 1 1 2 50.0% 7 3.5 50.0% 18 0 appointment at the sending institution, did the receiving institution schedule the appointment within 30 days of the original appointment date? 02.111 Non-reception center: Did the inmate receive medical accommodations 6 1 7 85.7% 6 5.1 85.7% 13 0 upon arrival, if applicable? Component Subtotals: 96 27 123 78.0% 60 44.9 74.8% 57 0 Bureau of Audits Page 11 Office of the Inspector General State of California Answers Weighting Points Reference Specialty Services Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 07.037 Did the institution approve or deny the PCP's request for specialty services 16 9 25 64.0% 8 5.1 64.0% 2 0 within the specified time frames? 07.035 Did the inmate receive the specialty service within specified time frames? 14 3 17 82.4% 9 7.4 82.4% 10 0 07.090 Physical therapy services: Did the physical therapist assess the inmate and 0 0 0 0.0% 0 0.0 0.0% 27 0 document the treatment plan and treatment provided to the inmate? 07.043 Did the PCP review the specialist's report and see the inmate for a follow-up 13 2 15 86.7% 10 8.7 86.7% 12 0 appointment within specified time lines following completion of the specialty service? 07.260 Was the institution's denial of the PCP's request for specialty services 4 0 4 100.0% 15 15.0 100.0% 6 0 consistent with the "medical necessity" requirement? 07.273 Was information provided on the request for services sufficient for the 4 6 10 40.0% 4 1.6 40.0% 0 0 medical authorization review committee to make a medical necessity determination? 07.259 Was there adequate documentation of the reason for the denial of specialty 8 2 10 80.0% 4 3.2 80.0% 0 0 services? 07.270 Did the specialty provider provide timely findings and recommendations or 16 0 16 100.0% 6 6.0 100.0% 11 0 did an RN document that he or she called the specialty provider to ascertain the findings and recommendations? 07.261 Is the institution scheduling high-priority (urgent) specialty services within 1 1 2 50.0% 9 4.5 50.0% 0 0 14 days? 07.288 At the first PCP visit following the denial, did the PCP inform the patient of 1 5 6 16.7% 4 0.7 16.7% 4 0 the denial and appropriately manage the condition that gave rise to the specialty service request? Component Subtotals: 77 28 105 73.3% 69 52.2 75.7% 72 0 Bureau of Audits Page 12 Office of the Inspector General State of California Answers Weighting Points Reference Urgent Services Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 21.248 Upon the inmate's discharge from the community hospital, did the TTA RN 23 2 25 92.0% 6 5.5 92.0% 0 0 document that he or she reviewed the inmate's discharge plan and completed a face-to-face assessment of the inmate? 21.249 Upon the inmate's discharge from the community hospital, did the inmate 24 1 25 96.0% 8 7.7 96.0% 0 0 receive a follow-up appointment with his or her PCP within five calendar days of discharge? 21.281 Upon the inmate's discharge from a community hospital, did the institution 6 11 17 35.3% 7 2.5 35.3% 8 0 administer or deliver all prescribed medications to the inmate within specified time frames? 21.275 Was the TTA nursing clinical care and documentation adequate? 22 3 25 88.0% 15 13.2 88.0% 0 0 21.276 While the patient was in the TTA, did the provider render adequate and 23 2 25 92.0% 19 17.5 92.0% 0 0 timely clinical care, and adequately document that care? 21.250 Upon the inmate's return from the community hospital, was the inmate 25 0 25 100.0% 4 4.0 100.0% 0 0 placed in housing appropriate for his or her clinical status? Component Subtotals: 123 19 142 86.6% 59 50.4 85.4% 8 0 Bureau of Audits Page 13 Office of the Inspector General State of California Answers Weighting Points Reference Emergency Services Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 08.183 Was the medical emergency responder notified of the medical emergency 5 0 5 100.0% 7 7.0 100.0% 0 0 without delay? 08.241 Did the first responder provide adequate basic life support prior to medical 4 0 4 100.0% 8 8.0 100.0% 0 1 staff arriving? 08.184 Did the medical emergency responder arrive at the location of the medical 5 0 5 100.0% 6 6.0 100.0% 0 0 emergency within eight (8) minutes of initial notification? 08.185 Did the medical emergency responder use proper equipment to address the 5 0 5 100.0% 9 9.0 100.0% 0 0 emergency and was adequate medical care provided within the scope of his or her license? 08.242 Did staff call 911 without unnecessary delay after a life-threatening 0 0 0 0.0% 0 0.0 0.0% 5 0 condition was identified by a licensed health care provider or peace officer? 08.187 Did the institution provide adequate preparation for the ambulance's arrival, 0 0 0 0.0% 0 0.0 0.0% 5 0 access to the inmate, and departure? 08.186 Were both the first responder (if peace officer or licensed health care staff) 5 0 5 100.0% 5 5.0 100.0% 0 0 and the medical emergency responder basic life support certified at the time of the incident? 08.222 Were the findings of the institution's Emergency Medical Response Review 0 5 5 0.0% 9 0.0 0.0% 0 0 Committee supported by the documentation and completed within 30 days? Component Subtotals: 24 5 29 82.8% 44 35.0 79.5% 10 1 Bureau of Audits Page 14 Office of the Inspector General State of California Answers Weighting Points Reference Diagnostic Services Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 06.049 Radiology order: Was the radiology service provided within the time frame 4 1 5 80.0% 7 5.6 80.0% 0 0 specified in the physician's order? 06.245 Radiology order: Was the diagnostic report received by the institution 5 0 5 100.0% 6 6.0 100.0% 0 0 within 14 days? 06.200 Radiology order: Did the PCP review the diagnostic report and initiate 1 4 5 20.0% 7 1.4 20.0% 0 0 written notice to the inmate within two (2) business days of the date the institution received the diagnostic reports? 06.188 All laboratory orders: Was the specimen collected within the applicable time 8 2 10 80.0% 6 4.8 80.0% 0 0 frames of the physician's order? 06.191 All diagnostic services: At the next clinic visit following report of a 10 0 10 100.0% 7 7.0 100.0% 4 1 clinically significant abnormal diagnostic test result, did the PCP document the abnormal test result in the progress note? 06.263 All diagnostic services: At the next clinic visit following the report of a 9 0 9 100.0% 12 12.0 100.0% 5 1 clinically significant abnormal diagnostic test, did the PCP adequately manage the result? 06.202 All laboratory orders: Did the PCP review the diagnostic reports and initiate 2 8 10 20.0% 7 1.4 20.0% 0 0 written notice to the inmate within two (2) business days of the date the institution received the diagnostic reports? Component Subtotals: 39 15 54 72.2% 52 38.2 73.5% 9 2 Bureau of Audits Page 15 Office of the Inspector General State of California Answers Weighting Points Reference Access to Health Care Information Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 19.150 Is the medical records office current with its loose filing? 0 1 1 0.0% 9 0.0 0.0% 0 0 19.169 Did medical records staff make UHRs available to clinic staff for the 2 0 2 100.0% 15 15.0 100.0% 0 0 inmates ducated for medical appointments the next day? 19.243 Was the institution able to account for the OIG's requested UHR files? 1 0 1 100.0% 12 12.0 100.0% 0 0 19.266 Does the institution properly file inmates' medical information? 1 0 1 100.0% 5 5.0 100.0% 0 0 19.271 While reviewing UHRs as part of the OIG's inspection, were the OIG's RN 1 0 1 100.0% 5 5.0 100.0% 0 0 and MD inspectors able to locate all relevant documentation of health care provided to inmates? 19.272 Does the institution promptly file blood pressure logs in UHRs? 0 1 1 0.0% 5 0.0 0.0% 0 0 Component Subtotals: 5 2 7 71.4% 51 37.0 72.5% 0 0 Bureau of Audits Page 16 Office of the Inspector General State of California Answers Weighting Points Reference Outpatient Housing Unit Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 04.052 Did the RN complete an initial assessment of the inmate on the day of 10 0 10 100.0% 5 5.0 100.0% 0 0 placement? 04.051 Did the PCP evaluate the inmate within one calendar day after placement? 9 1 10 90.0% 5 4.5 90.0% 0 0 04.053 While the inmate was placed in the OHU, did the PCP complete the 10 0 10 100.0% 4 4.0 100.0% 0 0 Subjective, Objective, Assessment, Plan and Education note at a minimum of every 14 days? 04.112 Was the PCP's initial evaluation adequate for the problem(s) requiring OHU 8 2 10 80.0% 7 5.6 80.0% 0 0 placement? 04.230 Was the PCP's initial assessment (or diagnoses) appropriate for the findings 8 1 9 88.9% 7 6.2 88.9% 0 1 in the initial evaluation? 04.056 Did the PCP's plan adequately address the patient's medical needs? 8 0 8 100.0% 7 7.0 100.0% 0 2 04.208 Was the level of care available in the OHU adequate for the patient's clinical 8 0 8 100.0% 7 7.0 100.0% 0 2 needs? 15.103 In the OHU, are patient call buttons operational or does medical staff make 2 1 3 66.7% 3 2.0 66.7% 0 0 rounds every 30 minutes? 15.225 Does the OHU use disinfectant daily in common patient areas? 3 0 3 100.0% 3 3.0 100.0% 0 0 Component Subtotals: 66 5 71 93.0% 48 44.3 92.3% 0 5 Bureau of Audits Page 17 Office of the Inspector General State of California Answers Weighting Points Reference Internal Reviews Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 17.221 Did the institution complete a medical emergency response drill for each 1 0 1 100.0% 5 5.0 100.0% 0 0 watch and include participation of health care and custody staff during the most recent full quarter? 17.174 Did the institution promptly process inmate medical appeals during the most 0 1 1 0.0% 5 0.0 0.0% 0 0 recent 12 months? 17.136 For each death sampled, did the institution complete the death review 4 1 5 80.0% 5 4.0 80.0% 0 0 process? 17.132 Do the Emergency Medical Response Review Committee meeting minutes 6 0 6 100.0% 5 5.0 100.0% 0 0 document monthly meetings for the last six (6) months? 17.138 Do the Emergency Medical Response Review Committee meeting minutes 6 0 6 100.0% 5 5.0 100.0% 0 0 document the warden's (or his or her designee's) attendance? 17.118 Do the Quality Management Committee meeting minutes document 6 0 6 100.0% 5 5.0 100.0% 0 0 monthly meetings for the last six (6) months? 17.119 Did the Quality Management Committee report its findings to the 6 0 6 100.0% 5 5.0 100.0% 0 0 CEO/CME each of the last six (6) meetings? 17.135 Did the last three Quality Management Committee meeting minutes reflect 3 0 3 100.0% 5 5.0 100.0% 0 0 findings and strategies for improvement? Component Subtotals: 32 2 34 94.1% 40 34.0 85.0% 0 0 Bureau of Audits Page 18 Office of the Inspector General State of California Answers Weighting Points Reference Clinic Operations Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 14.023 Does the institution make the Form 7362 (Health Care Services Request 5 0 5 100.0% 4 4.0 100.0% 0 0 Form) available to inmates? 14.164 Are areas available to ensure audio and visual privacy during RN FTF 2 0 2 100.0% 3 3.0 100.0% 0 0 assessments and doctors' examinations for non-emergencies? 14.166 Were refrigerated drugs stored without food in the refrigerator, or were the 1 0 1 100.0% 2 2.0 100.0% 0 0 drugs stored in a sealed container if food was present? 14.131 Do medication nurses understand that the licensed staff member who 1 0 1 100.0% 4 4.0 100.0% 0 0 prepares the medication, must also administer it on the same day it is prepared? 14.106 Does clinical staff wash their hands (either with soap or hand sanitizer) or 4 0 4 100.0% 6 6.0 100.0% 0 0 change gloves between patients? 14.033 Does the institution have an adequate process to ensure inmates who are 2 0 2 100.0% 4 4.0 100.0% 0 0 moved to a new cell still receive their medical ducats? 14.160 Does the institution have a process to identify, review, and address urgent 1 0 1 100.0% 4 4.0 100.0% 0 0 appointments if a doctor's line is canceled? 14.029 Does medical staff in the facility clinic know which inmates are on modified 1 0 1 100.0% 4 4.0 100.0% 0 0 program or confined to quarters and does staff have an adequate process to ensure those inmates receive their medication? 14.165 Are the clinic floors, waiting room chairs, and equipment cleaned with a 2 0 2 100.0% 2 2.0 100.0% 0 0 disinfectant daily? Component Subtotals: 19 0 19 100.0% 33 33.0 100.0% 0 0 Bureau of Audits Page 19 Office of the Inspector General State of California Answers Weighting Points Reference Preventive Services Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 10.228 Inmates prescribed INH: Did the institution properly administer the 2 2 4 50.0% 6 3.0 50.0% 0 0 medication to the inmate? 10.232 Inmates prescribed INH: Did the institution monitor the inmate monthly for 4 0 4 100.0% 6 6.0 100.0% 0 0 the most recent three months he or she was on the medication? 10.229 Annual TB Screening: Was the inmate appropriately screened for TB within 10 0 10 100.0% 7 7.0 100.0% 0 0 the last year? 10.086 All inmates age 65 and older: Did the inmate receive an influenza 10 0 10 100.0% 6 6.0 100.0% 0 0 vaccination for the most recent influenza season? 10.085 All inmates age 51 or older: Did the inmate receive a fecal occult blood test 7 3 10 70.0% 5 3.5 70.0% 0 0 within the previous 12 months? Component Subtotals: 33 5 38 86.8% 30 25.5 85.0% 0 0 Bureau of Audits Page 20 Office of the Inspector General State of California Answers Weighting Points Reference Pharmacy Services Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 13.139 Does the institution conspicuously post a valid permit in its pharmacy(ies)? 1 0 1 100.0% 2 2.0 100.0% 0 0 13.141 Does the institution properly maintain its emergency crash cart 5 3 8 62.5% 2 1.3 62.5% 0 0 medications? 13.252 Does the institution properly maintain medications in its after-hours 4 0 4 100.0% 2 2.0 100.0% 0 0 medication supply(ies)? 13.253 Does the institution conduct monthly inspections of its emergency crash cart 12 0 12 100.0% 1 1.0 100.0% 0 0 and after-hours medication supply(ies)? 13.142 Is the pharmacist-in-charge's license current? 1 0 1 100.0% 5 5.0 100.0% 0 0 13.144 Does the institution have information to ensure that medications are 1 0 1 100.0% 6 6.0 100.0% 0 0 prescribed by licensed health-care providers lawfully authorized to do so? 13.145 Does the pharmacist in charge have an effective process for screening new 1 0 1 100.0% 7 7.0 100.0% 0 0 medication orders for potential adverse reactions? 13.148 Does the pharmacist-in-charge monitor the quantity of medications on 1 0 1 100.0% 4 4.0 100.0% 0 0 hand? Component Subtotals: 26 3 29 89.7% 29 28.3 97.6% 0 0 Bureau of Audits Page 21 Office of the Inspector General State of California Answers Weighting Points Reference Other Services Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 15.059 Did the institution properly provide therapeutic diets to inmates? 1 0 1 100.0% 3 3.0 100.0% 0 0 15.134 Did the institution properly respond to all active cases of TB discovered in 1 0 1 100.0% 7 7.0 100.0% 0 0 the last six months? 15.265 Is the most current version of the Inmate Medical Services Policies and 1 0 1 100.0% 3 3.0 100.0% 0 0 Procedures available in the institution's law library? 20.092 Hygiene Intervention: Did custody staff understand the department's 4 0 4 100.0% 4 4.0 100.0% 0 0 policies and procedures for identifying and evaluating inmates displaying inappropriate hygiene management? Component Subtotals: 7 0 7 100.0% 17 17.0 100.0% 0 0 Bureau of Audits Page 22 Office of the Inspector General State of California Answers Weighting Points Reference Inmate Hunger Strikes Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 11.097 Did the RN conduct a FTF triage of the inmate within two (2) business days 5 0 5 100.0% 6 6.0 100.0% 0 0 of receipt of the Form 128-B and document the inmate's reasons for the hunger strike, most recent recorded weight, current weight, vital signs, and physical condition? 11.099 After the first 48 hours, did an RN or PCP complete daily assessments 5 0 5 100.0% 6 6.0 100.0% 0 0 documenting the inmate's weight, physical condition, emotional condition, vital signs, and hydration status? 11.100 After the first 72 hours, did a physician perform a physical examination and 4 1 5 80.0% 7 5.6 80.0% 0 0 order a metabolic panel and a urinalysis of the inmate? Component Subtotals: 14 1 15 93.3% 19 17.6 92.6% 0 0 Bureau of Audits Page 23 Office of the Inspector General State of California Answers Weighting Points Reference Chemical Agent Contraindications Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 12.062 Did the institution document that it consulted with an RN or PCP before a 5 0 5 100.0% 9 9.0 100.0% 2 0 calculated use of Oleoresin Capsicum (pepper spray)? 12.064 Did the institution record how it decontaminated the inmate and did it 7 0 7 100.0% 8 8.0 100.0% 0 0 follow the decontamination policy? Component Subtotals: 12 0 12 100.0% 17 17.0 100.0% 2 0 Bureau of Audits Page 24 Office of the Inspector General State of California Answers Weighting Points Reference Staffing Levels and Training Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 18.002 Information purposes only: Calculate the institution's average vacancy 0 0 0 0.0% 0 0.0 0.0% 1 0 percentages, the number of health care staff starting within six (6) months of the OIG visit, and the number of health care staff hired from the registry. The institution provided vacancy statistics within four licensed medical staffing groups: (1) management; (2) primary care providers; (3) supervision; and (4) rank and file nursing. Total number of filled positions: 238 Total number of vacancies: 18.2 Total number of positions: 256.2 Vacancy percentage: 7.1% Number of staff hired within last six months: 40 Total number of registry staff: 4 18.004 Did the institution have an RN available on site 24 hours a day, seven days a 1 0 1 100.0% 4 4.0 100.0% 0 0 week, for emergency care? 18.005 Did the institution have a physician on site, a physician on call, or a medical 1 0 1 100.0% 4 4.0 100.0% 0 0 officer of the day available 24 hours a day, seven days a week, for the last 30 days? 18.006 Does the institution's orientation program for all newly hired nursing staff 1 0 1 100.0% 4 4.0 100.0% 0 0 include a module for sick call protocols that require a FTF triage? 18.001 Are licensed health care staff current with their certifications and did they 5 0 5 100.0% 4 4.0 100.0% 0 0 attend required training? Component Subtotals: 8 0 8 100.0% 16 16.0 100.0% 1 0 Bureau of Audits Page 25 Office of the Inspector General State of California Answers Weighting Points Reference Nursing Policy Number Yes No Yes + No Yes % Possible Received Score % N/A Unk 16.231 Does the institution ensure that nursing staff review their duty statements? 5 0 5 100.0% 2 2.0 100.0% 0 0 16.154 Does the institution have written nursing local operating procedures that 5 0 5 100.0% 5 5.0 100.0% 0 0 adhere to the department's policies and procedures? 16.254 Does the institution's supervising registered nurse conduct periodic reviews 1 4 5 20.0% 7 1.4 20.0% 0 0 of nursing staff? Component Subtotals: 11 4 15 73.3% 14 8.4 60.0% 0 0 Bureau of Audits Page 26 Office of the Inspector General State of California APPENDIX COMPARATIVE MEDICAL INSPECTION SCORES CALIFORNIA MEDICAL FACILITY Following the completion of the first cycle of 33 prison medical inspections in June 2010, we evaluated the medical inspection program for improvement opportunities with input from the stakeholders involved with the Plata v. Schwarzenegger litigation. As a result, we made a limited number of revisions including adding, deleting, and adjusting the weights of certain questions. The following table shows the medical inspection scores earned by the California Medical Facility during the course of the Office of the Inspector General’s medical inspection program. To assist the reader in comparing the results of the two inspections at this institution, we recalculated the scores for each cycle to eliminate the questions that were not applicable in both inspections for this institution. The recalculated scores give the best information for evaluating performance by the institution regarding those questions that are applicable in both inspection cycles. However, the final cycle scores provide the most complete indication of the measure of health care provided at the institution. Cycle One Cycle Two Recalculated Recalculated for for Cycle One Cycle Two Comparison Comparison Component Final1 Final2 Only3 Only4 Chronic Care 84% 68% 83% 66% Clinical Services 87% 67% 87% 67% Health Screening 87% 75% 87% 78% Specialty Services 43% 76% 42% 82% Urgent Services 79% 85% 94% 85% Emergency Services 72% 80% 69% 80% Diagnostic Services 72% 73% 73% 73% Access to Health Care Information 59% 73% 59% 73% Outpatient Housing Unit 86% 92% 92% 92% Internal Reviews 69% 85% 69% 85% Inmate Transfers 50% N/A N/A N/A Clinic Operations 83% 100% 83% 100% Preventive Services 44% 85% 44% 85% Pharmacy Services 76% 98% 76% 98% Other Services 100% 100% 100% 100% Inmate Hunger Strikes 32% 93% 32% 93% Chemical Agent Contraindications 87% 100% 87% 100% Staffing Levels and Training 95% 100% 95% 100% Nursing Policy 36% 60% 36% 60% Overall Score 72% 79% 75% 79% 1 Cycle One Final: These are the prison’s scores from our January 2009 medical inspection report. This report is part of our first cycle of medical inspections we conducted at the state’s 33 adult prisons. 2 Cycle Two Final: These are the prison’s scores reported in the body of this report and include results from all questions applicable in cycle two. 3 Cycle One Recalculated for Comparison Only: These are the cycle one scores recalculated to exclude questions that were not applicable in both cycles. Also, in making this calculation, for each question we applied cycle two weights to cycle one results for more accurate comparability. 4 Cycle Two Recalculated for Comparison Only: These are cycle two scores recalculated to exclude questions that were not applicable in both cycles. Bureau of Audits Page 27 Office of the Inspector General State of California California Prison Health Care Receivership Corporation's Response Bureau of Audits Page 28 Office of the Inspector General State of California Office of the Inspector General’s Comments on the Receiver’s Response Preventive Services - Reference Number 10.085 The receiver’s response correctly states that the OIG reviewed 10 inmates’ unit health records and did not find documentation for fecal occult blood test (FOBT) screening for three of the 10 inmates. Subsequent to our inspection, CMF located documents that confirmed the three inmates received or signed a refusal of service for an FOBT screening as required. However, consistent with the protocols jointly established with the receiver’s office during the pilot stage of the inspection program, if supporting documentation is not contained in the inmate’s unit health record during the OIG’s review, the question being tested is answered as if the service was not provided (or offered). This protocol is consistent with department policy that all health care information, regardless of source, shall be promptly incorporated into the patient’s health record. In this case, two OIG inspectors each reviewed the unit health records for the three inmates and neither found the laboratory reports (or refusals of service) for the FOBT screening. Further, the documents provided after the inspection to the OIG are marked “extra copy” indicating that they were obtained from the laboratory files rather than the patient’s unit health record. Therefore, our answers remain unchanged. Inmate Hunger Strikes – Reference Number 11.100 The receiver’s response correctly states that the OIG reviewed five inmates’ unit health records and for one inmate did not find documentation that the physician ordered a metabolic panel and urinalysis after the first 72 hours of a hunger strike as required. The OIG also acknowledges that after the inspection, CMF later produced a document that confirmed that the inmate received the metabolic panel and urinalysis as required by policy. However, as discussed above in Preventive Services and consistent with the protocols jointly established with the receiver’s office during the pilot stage of the inspection program, if supporting documentation is not contained in the inmate’s unit health record during the OIG’s review, the question being tested is answered as if the service was not provided (or offered). In this case, two OIG inspectors each reviewed the unit health records for the inmate and did not find the metabolic panel and urinalysis. Further, the documents provided after the inspection to the OIG are marked “extra copy” indicating that they were obtained from the laboratory files rather than the patient’s unit health record. Therefore, our answer remains unchanged. Bureau of Audits Page 31 Office of the Inspector General State of California Access to Health Care Information – Reference Number 19.150 As part of our inspection, the OIG reviews blood pressure logs maintained at the clinics to determine if the logs contain information greater than 60 days old. The purpose of this question is to determine if the blood pressure logs containing older information are filed into the inmates’ unit health records within 60 days. This test was reviewed and agreed to by the receiver’s office and the plaintiff’s counsel during the development phase of this program. The receiver’s office states that CMF logs contain 90 days of values. Because CMF does not file the logs consistent with the agreed upon criteria, the answer to this question remains unchanged. Bureau of Audits Page 32 Office of the Inspector General State of California