California State Prison, Corcoran Medical Inspection Report Cycle 5

Roy W. Wesley Office of the Inspector General Inspector General (Acting) California State Prison, Corcoran Medical Inspection Results Cycle 5 September 2017 Medical Inspection Unit Page 1 Office of the Inspector General State of California Office of the Inspector General CALIFORNIA STATE PRISON, CORCORAN Medical Inspection Results Cycle 5 Roy W. Wesley Inspector General (Acting) Shaun R. Spillane Public Information Officer September 2017 T C ABLE OF ONTENTS Executive Summary ............................................................................................................................. i Overall Rating: Adequate ........................................................................................................ i Clinical Case Review and OIG Clinician Inspection Results ............................................... iii Compliance Testing Results.................................................................................................. iv Recommendations ............................................................................................................................ v Population-Based Metrics ................................................................................................................ v Introduction ......................................................................................................................................... 1 About the Institution ........................................................................................................................ 1 Objectives, Scope, and Methodology.................................................................................................. 4 Case Reviews ................................................................................................................................... 5 Patient Selection for Retrospective Case Reviews ................................................................. 5 Benefits and Limitations of Targeted Subpopulation Review ............................................... 6 Case Reviews Sampled .......................................................................................................... 6 Compliance Testing ......................................................................................................................... 8 Sampling Methods for Conducting Compliance Testing ....................................................... 8 Scoring of Compliance Testing Results ................................................................................. 9 Overall Quality Indicator Rating for Case Reviews and Compliance Testing ................................ 9 Population-Based Metrics ................................................................................................................ 9 Medical Inspection Results ............................................................................................................... 10 1 — Access to Care ................................................................................................................. 12 Case Review Results ............................................................................................................ 12 Compliance Testing Results................................................................................................. 13 2 — Diagnostic Services ......................................................................................................... 15 Case Review Results ............................................................................................................ 15 Compliance Testing Results................................................................................................. 16 3 — Emergency Services ........................................................................................................ 17 Case Review Results ............................................................................................................ 17 4 — Health Information Management .................................................................................... 20 Case Review Results ............................................................................................................ 20 Compliance Testing Results................................................................................................. 22 5 — Health Care Environment ............................................................................................... 24 Compliance Testing Results................................................................................................. 24 6 — Inter- and Intra-System Transfers ................................................................................... 27 Case Review Results ............................................................................................................ 27 Compliance Testing Results................................................................................................. 28 7 — Pharmacy and Medication Management ........................................................................ 30 Case Review Results ............................................................................................................ 30 Compliance Testing Results................................................................................................. 32 8 — Prenatal and Post-Delivery Services .............................................................................. 36 9 — Preventive Services ......................................................................................................... 37 Compliance Testing Results................................................................................................. 37 California State Prison, Corcoran, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California 10 — Quality of Nursing Performance ................................................................................... 39 Case Review Results ............................................................................................................ 39 11 — Quality of Provider Performance .................................................................................. 42 Case Review Results ............................................................................................................ 42 12 — Reception Center Arrivals ............................................................................................. 45 13 — Specialized Medical Housing ........................................................................................ 46 Case Review Results ............................................................................................................ 46 Compliance Testing Results................................................................................................. 47 14 — Specialty Services .......................................................................................................... 49 Case Review Results ............................................................................................................ 49 Compliance Testing Results................................................................................................. 50 15 — Administrative Operations (Secondary) ........................................................................ 52 Compliance Testing Results................................................................................................. 52 Recommendations ............................................................................................................................. 55 Population-Based Metrics ................................................................................................................. 56 Appendix A — Compliance Test Results ......................................................................................... 59 Appendix B — Clinical Data ............................................................................................................ 72 Appendix C — Compliance Sampling Methodology ....................................................................... 76 California Correctional Health Care Services’ Response ................................................................. 83 California State Prison, Corcoran, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California L T F IST OF ABLES AND IGURES COR Executive Summary Table ........................................................................................................ ii COR Health Care Staffing Resources as of March 2017 ..................................................................... 2 COR Master Registry Data as of March 6, 2017 ................................................................................. 3 COR Results Compared to State and National HEDIS Scores .......................................................... 58 Table B-1: COR Sample Sets ............................................................................................................ 72 Table B-2: COR Chronic Care Diagnoses ......................................................................................... 73 Table B-3: COR Event – Program ..................................................................................................... 74 Table B-4: COR Review Sample Summary ...................................................................................... 75 California State Prison, Corcoran, Cycle 5 Medical Inspection List of Tables and Figures Office of the Inspector General State of California E S XECUTIVE UMMARY Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), the OIG conducts a comprehensive inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG explicitly makes no determination regarding the constitutionality of care in the prison setting. That determination is left to the Receiver and the federal court. The assessment of care by the OIG is just one factor in the court’s determination whether care in the prisons meets constitutional standards. In Cycle 5, for the first time, the OIG will be inspecting institutions that have been delegated back to CDCR from the Receivership. There will be no difference in the standards used for assessment of a delegated institution versus those for an institution not yet delegated. 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. This fifth cycle of inspections will continue evaluating the areas addressed in Cycle 4, which included clinical case review, compliance testing, and a population-based metric comparison of selected Healthcare Effectiveness Data Information Set (HEDIS) measures. In agreement with stakeholders, the OIG made changes to both the case review and compliance components. The OIG found that in every inspection in Cycle 4, larger samples were taken than were needed to assess the adequacy of medical care provided. As a result, the OIG reduced the number of case reviews and sample sizes for compliance testing. Also, in Cycle 4, compliance testing included two secondary (administrative) indicators (Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications). For Cycle 5, these have been combined into one secondary indicator, Administrative Operations. Overall Rating: Adequate The OIG performed its Cycle 5 medical inspection at California State Prison, Corcoran (COR) from March to May 2017. The inspection included in-depth reviews of 56 patient files conducted by clinicians, as well as reviews of documents from 428 patient files covering 91 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 COR using 13 health care quality indicators applicable to the institution. 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 registered nurses trained in monitoring medical policy compliance. Of the indicators, seven were rated by both case review clinicians and compliance inspectors, three were rated by case review clinicians only, and three were rated by compliance inspectors only. The COR Executive Summary Table on the following page identifies the applicable individual indicators and scores for this institution. California State Prison, Corcoran, Cycle 5 Medical Inspection Page i Office of the Inspector General State of California COR Executive Summary Table Cycle 5 Cycle 4 Case Review Compliance Inspection Indicators Overall Overall Rating Rating Rating Rating 1—Access to Care Adequate Adequate Adequate Inadequate 2—Diagnostic Services Adequate Inadequate Adequate Adequate 3—Emergency Services Adequate Not Applicable Adequate Adequate 4—Health Information Adequate Inadequate Inadequate Inadequate Management 5—Health Care Environment Not Applicable Inadequate Inadequate Inadequate 6—Inter- and Intra-System Adequate Inadequate Inadequate Inadequate Transfers 7—Pharmacy and Medication Adequate Inadequate Inadequate Inadequate Management 8—Prenatal and Post-Delivery Not Applicable Not Applicable Not Applicable Not Applicable Services 9—Preventive Services Not Applicable Proficient Proficient Inadequate 10—Quality of Nursing Adequate Not Applicable Adequate Adequate Performance 11—Quality of Provider Adequate Not Applicable Adequate Inadequate Performance 12—Reception Center Arrivals Not Applicable Not Applicable Not Applicable Not Applicable 13—Specialized Medical Housing Adequate Adequate Adequate Inadequate 14—Specialty Services Proficient Adequate Adequate Inadequate 15—Administrative Operations Not Applicable Inadequate Inadequate Inadequate* (Secondary) *In Cycle 4, there were two secondary (administrative) indicators. This score reflects the average of those two scores. California State Prison, Corcoran, Cycle 5 Medical Inspection Page ii Office of the Inspector General State of California Clinical Case Review and OIG Clinician Inspection Results The clinicians’ case reviews sampled patients with high medical needs and included a review of 1,103 patient care events.1 Of the 13 indicators applicable to COR, 10 were evaluated by clinician case review; one was proficient, and nine were adequate. When determining the overall adequacy of care, the OIG paid particular attention to the clinical nursing and provider quality indicators, as adequate health care staff can sometimes overcome suboptimal processes and programs. However, the opposite is not true; inadequate health care staff cannot provide adequate care, even though the established processes and programs onsite may be adequate. The OIG clinicians identify inadequate medical care based on the risk of significant harm to the patient, not the actual outcome. Program Strengths — Clinical  The COR leadership implemented successful training in chronic care for providers, correcting a prior weakness identified by the OIG in its Cycle 4 medical inspection.  The COR leadership implemented successful improvement processes to remove a recent access to care backlog for provider appointments. The chief physician and surgeon (CP&S) recruited additional provider resources from other institutions to achieve this, along with scheduling additional medical clinics on the weekend.  The specialty services nurse and supervisor implemented successful improvement processes to correct the weak areas contributing to the inadequate performance in the Specialty Services indicator in Cycle 4.  Despite the lack of a chief medical executive (CME) for years, the strong leadership of the CP&S helped improve processes in provider chronic care training and in access to care.  The new nursing leadership contributed to improved morale among nursing staff. The nursing leadership recognized and appreciated nurses’ efforts with events to improve morale among the nursing ranks at the institution.  The chief nurse executive (CNE) improved communications by providing cell phones to the supervisors and hand radios to the second and third watch, which improved emergency response. Program Weaknesses — Clinical  Patients often did not receive important medications timely.  Often, there was a delay in transferring patients to the TTA due to yard gate malfunctions. 1 Each OIG clinician team includes a board-certified physician and registered nurse consultant with experience in correctional and community medical settings. California State Prison, Corcoran, Cycle 5 Medical Inspection Page iii Office of the Inspector General State of California Compliance Testing Results Of the 13 health care indicators applicable to COR, 10 were evaluated by compliance inspectors; one was proficient, three were adequate, and six were inadequate.2 There were 91 individual compliance questions within those 10 indicators, generating 1,227 data points, that tested COR’s compliance with California Correctional Health Care Services (CCHCS) policies and procedures.3 Those 91 questions are detailed in Appendix A — Compliance Test Results. Program Strengths — Compliance The following are some of COR’s strengths based on its compliance scores on individual questions in all the health care indicators:  Patients’ access to medical care, including nurse sick call assessments, and provider follow-up appointments after nurse sick call assessments, community hospital returns, and returns from specialty services were done well by the institution’s health care staff.  The institution performed well in providing timely laboratory services to patients, and providers reviewed and communicated laboratory results to patients within required time frames.  COR did an excellent job of offering and providing preventive services to its patients, including vaccination administration and colorectal cancer screening, as well as the treatment and monitoring of patients taking tuberculosis medications.  The institution did a good job of ensuring that appropriate policies and procedures were followed when patients were admitted to onsite inpatient facilities, including completion of timely nursing and provider assessments.  The institution provided pending specialty service appointments to patients who transferred in from other CDCR institutions within required time frames. Program Weaknesses — Compliance The following are some of the weaknesses identified by COR’s compliance scores on individual questions in all the health care indicators:  Several clinic locations at COR did not have essential core medical equipment and supplies; clinic locations had equipment that was not properly calibrated, and several locations did not have the necessary supplies available to staff. 2 The OIG’s compliance inspectors are trained registered nurses with expertise in CDCR policies regarding medical staff and processes. 3 The OIG used its own clinicians to provide clinical expert guidance for testing compliance in certain areas where CCHCS policies and procedures did not specifically address an issue. California State Prison, Corcoran, Cycle 5 Medical Inspection Page iv Office of the Inspector General State of California  COR did a poor job of managing patients’ medical needs and providing continuity of patient care during the inter- and intra-facility transfer process. This included problems with the initial health screening process and delivery of patients’ previously existing medication orders from the previous institution.  The institution had significant issues with the timely distribution and administration of medications for patients with chronic care conditions as well as patients receiving new medication orders. Also, the main pharmacy at COR did not properly store narcotic medications and non-narcotic medication that did not require refrigeration.  The administrative health care oversight functions of the institution were inadequate; this included the failure to timely address patient appeals as well as deficiencies with the performance of COR’s Quality Management and Emergency Medical Response Review Committees. RECOMMENDATIONS No specific recommendations. POPULATION-BASED METRICS In general, COR performed well as measured by population-based metrics. In comprehensive diabetes care, COR performed comparably to other state and national entities, outscoring in some measures and scoring less well than other plans in some measures. The diabetic eye exam score was negatively affected by patient refusals. With regard to immunization measures, COR’s rates were also mixed, and COR’s rates for colorectal cancer screening were poorer than other entities’, but, again, patient refusals had a severely negative affect on influenza immunization for younger adults and colorectal cancer screenings. Overall, COR’s performance demonstrated by the population-based metrics indicated that the chronic care program was functioning properly in comparison to other health care entities reviewed, and the institution has opportunities to improve its comparable scores by educating patients on the benefits of influenza immunizations and preventive screenings for colorectal cancer. California State Prison, Corcoran, Cycle 5 Medical Inspection Page v Office of the Inspector General State of California I NTRODUCTION Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), and at the request of the federal Receiver, the OIG developed a comprehensive medical inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG conducts a clinical case review and a compliance inspection, ensuring a thorough, end-to-end assessment of medical care within CDCR. California State Prison, Corcoran (COR), was the seventh medical inspection of Cycle 5. During the inspection process, the OIG assessed the delivery of medical care to patients using the primary clinical health care indicators applicable to the institution. The Administrative Operations indicator is purely administrative and is not reflective of the actual clinical care provided. ABOUT THE INSTITUTION Located in the City of Corcoran in Kings County, COR is a complex, multi-mission institution comprised of multiple facilities. COR was the first California prison with a separate facility built exclusively to house security housing unit (SHU) inmates. The institution houses over 3,400 inmates and is comprised of the following facilities: a Minimum Support Facility (MSF), a Level III facility for Sensitive Needs Yard (SNY) inmates, a Level IV yard that houses high security inmates, and the SHU, which houses maximum security inmates, the majority of whom have committed serious rules violations and cannot be housed in a general population setting. COR operates multiple facility clinics and one specialty clinic where staff members handle non-urgent requests for medical services. The institution also conducts screenings in its receiving and release clinical area (R&R); treats patients requiring urgent or emergency care in its triage and treatment area (TTA); houses patients requiring inpatient health services in the correctional treatment centers (CTC); and treats patients who require assistance with activities of daily living, but who do not require a higher level of inpatient care, in its outpatient housing unit (OHU). California Correctional Health Care Services (CCHCS) has designated COR a “basic” care institution. Basic institutions are located in rural areas away from tertiary care centers and specialty care providers whose services would likely be used frequently by higher-risk patients. Basic institutions have the capability to provide limited specialty medical services and consultation for a generally healthy patient population. 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 State Prison, Corcoran, Cycle 5 Medical Inspection Page 1 Office of the Inspector General State of California Based on staffing data the OIG obtained from the institution, COR’s vacancy rate among medical managers, primary care providers, supervisors, and rank-and-file nurses was 10 percent in February 2017, with the highest vacancy percentage among management with a 60 percent vacancy rate, which equated to three out of five authorized positions. Lastly, the CEO reported that as of March 2017, there were three medical staff members currently working at COR who were under CDCR disciplinary review. COR Health Care Staffing Resources as of March 2017 Primary Care Nursing Management Nursing Staff Totals Providers Supervisors Description Number % Number % Number % Number % Number % Authorized 5 3% 10 6% 20.8 11% 146 80% 181.8 100% Positions Filled Positions 2 40% 7 70% 18 87% 137.5 94% 164.5 90% Vacancies 3 60% 3 30% 2.8 13% 8.5 6% 17.3 10% Recent Hires (within 12 0 0% 2 29% 8 44% 8 6% 18 11% months) Staff Utilized 0 0% 2.5 36% 0 0% 0 0% 2.5 2% from Registry Redirected Staff (to Non-Patient 0 0% 0 0% 0 0% 0 0% 0 0% Care Areas) Staff on Long-term 0 0% 0 0% 2 11% 3 2% 5 3% Medical Leave Note: COR Health Care Staffing Resources data was not validated by the OIG. California State Prison, Corcoran, Cycle 5 Medical Inspection Page 2 Office of the Inspector General State of California As of March 6, 2017, the Master Registry for COR showed that the institution had a total population of 3,444. Within that total population, 2.7 percent were designated as high medical risk, Priority 1 (High 1), and 5.3 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 laboratory results and procedures. High 1 has at least two high-risk conditions; High 2 has only one. Patients at high medical risk are more susceptible to poor health outcomes than those at medium or low medical risk. Patients at high medical risk also typically require more health care services than do patients with lower assigned risk levels. The chart below illustrates the breakdown of the institution’s medical risk levels at the start of the OIG medical inspection. COR Master Registry Data as of March 6, 2017 Medical Risk Level # of Patients Percentage High 1 94 2.7% High 2 182 5.3% Medium 1,772 51.5% Low 1,396 40.5% Total 3,444 100.0% California State Prison, Corcoran, Cycle 5 Medical Inspection Page 3 Office of the Inspector General State of California O , S , M BJECTIVES COPE AND ETHODOLOGY In designing the medical inspection program, the OIG reviewed CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. The OIG also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the Receiver’s office, CDCR, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of the OIG’s inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates medical care delivery by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population-based metrics. To maintain a metric-oriented inspection program that evaluates medical care delivery consistently at each State prison, the OIG identified 15 indicators (14 primary (clinical) indicators and one secondary (administrative) indicator) of health care to measure. The primary quality indicators cover clinical categories directly relating to the health care provided to patients, whereas the secondary quality indicator address the administrative functions that support a health care delivery system. These 15 indicators are identified in the COR Executive Summary Table on page ii in the Executive Summary of this report. The OIG rates each of the quality indicators applicable to the institution under inspection based on case reviews conducted by OIG clinicians and compliance tests conducted by OIG registered nurses. The 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 done by clinicians, while the ratings for the primary quality indicators Health Care Environment and Preventive Services are derived entirely from compliance testing done by registered nurse inspectors. As another example, primary quality indicators such as Diagnostic Services and Specialty Services receive ratings derived from both sources. 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 a patient needing immediate care, the OIG notifies the chief executive officer of health care services and requests a status report. Additionally, if the OIG learns of significant departures from community standards, it may report such departures to the institution’s chief executive officer or to CCHCS. Because these matters involve confidential medical information protected by State and federal privacy laws, 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 California State Prison, Corcoran, Cycle 5 Medical Inspection Page 4 Office of the Inspector General State of California quality indicator; therefore, recommendations for improvement should not necessarily be interpreted as indicative of deficient medical care delivery. CASE REVIEWS The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders, which continues in Cycle 5 medical inspections. 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 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 California State Prison, Corcoran, Cycle 5 Medical Inspection Page 5 Office of the Inspector General State of California 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. 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: COR Sample Sets, the OIG clinicians evaluated medical charts for 56 unique patients. Appendix B, Table B–4: COR Case Review Sample Summary clarifies that both nurses and physicians reviewed charts for 18 of those patients, for 74 reviews in total. Physicians performed detailed reviews of 25 charts, and nurses performed detailed reviews of 17 California State Prison, Corcoran, Cycle 5 Medical Inspection Page 6 Office of the Inspector General State of California charts, totaling 42 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 30 patients. These generated 1,103 clinical events for review (Appendix B, Table B–3: COR Event–Program). The inspection tool 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: COR Sample Sets), the 56 unique patients sampled included patients with 174 chronic care diagnoses, including 10 additional patients with diabetes (for a total of 13) (Appendix B, Table B–2: COR Chronic Care Diagnoses). The OIG’s sample selection tool allowed evaluation of many chronic care programs because the complex and high-risk patients selected from the different categories often had multiple medical problems. While the OIG did not evaluate every chronic disease or health care staff member, the 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 found the Cycle 4 medical inspection physician sample size of 30 detailed reviews far exceeded the saturation point necessary for an adequate qualitative review. At the end of Cycle 4 inspections, the case review results were re-analyzed using 50 percent of the cases, finding no significant differences in the ratings. To improve inspection efficiency, while preserving the quality of the inspection, the samples for Cycle 5 medical inspections were reduced in number of cases. For Cycle 5 inspections, basic institutions, with low high-risk populations, case review will use 67 percent (20 detailed physician reviews) of the case review samples used in Cycle 4 inspection, for both physician and nurse reviewed cases. For intermediate institutions, or basic institutions housing many high-risk patients, the case review samples will use 83 percent (25 detailed physician reviews). Finally, the most medically complex institution, CHCF, has retained the full 100 percent samples of Cycle 4 inspections. For COR, the OIG used a case review sample size of 83 percent compared to Cycle 4 because the institution had a large number of high-risk patients. With regard to reviewing charts from different providers, the case review is not intended to be a focused search for poorly performing providers; rather, it is focused on how the system cares for those patients who need care the most. Nonetheless, while not sampling cases by each provider at the institution, the OIG inspections adequately review most providers. Providers would only escape OIG case review if institutional management successfully mitigated patient risk by having the more poorly performing providers care for the less complicated, low-utilizing, and lower-risk patients. The OIG’s clinicians concluded that the case review sample size was more than adequate to assess the quality of services provided. California State Prison, Corcoran, Cycle 5 Medical Inspection Page 7 Office of the Inspector General State of California 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 COR 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 March to May 2017, registered nurse inspectors attained answers to 91 objective medical inspection test (MIT) questions designed to assess the institution’s compliance with critical policies and procedures applicable to the delivery of medical care. To conduct most tests, inspectors randomly selected samples of patients for whom the testing objectives were applicable and reviewed their electronic unit health records. In some cases, inspectors used the same samples to conduct more than one test. In total, inspectors reviewed health records for 428 individual patients and analyzed specific transactions within their records for evidence that critical events occurred. Inspectors also reviewed management reports and meeting minutes to assess certain administrative operations. In addition, during the week of March 20, 2017, field registered nurse inspectors conducted a detailed onsite inspection of COR’s medical facilities and clinics; interviewed key institutional employees; and reviewed employee records, logs, medical appeals, death reports, and other documents. This generated 1,227 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 COR’s plant infrastructure, protocols for tracking medical appeals and local operating procedures, and staffing resources. For Cycle 5, the OIG reduced the number of compliance samples tested for 18 indicator tests from a sample of 30 patients to a sample of 25 patients. The OIG also removed some inspection tests upon stakeholder agreement that either were duplicated in the case reviews or had limited value. Lastly, for Cycle 4 medical inspections, the OIG tested two secondary (administrative) indicators; Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications, and have combined these tests into one Administrative Operations indicator for Cycle 5 inspections. 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. California State Prison, Corcoran, Cycle 5 Medical Inspection Page 8 Office of the Inspector General State of California Scoring of Compliance Testing Results After compiling the answers to the 91 questions for the 10 applicable indicators, the OIG derived a score for each quality indicator by calculating the percentage score of all Yes answers for each of the questions applicable to a particular indicator, then averaging those scores. Based on those results, the OIG assigned a rating to each quality indicator of proficient (greater than 85 percent), adequate (between 75 percent and 85 percent), or inadequate (less than 75 percent). OVERALL QUALITY INDICATOR RATING FOR CASE REVIEWS AND COMPLIANCE TESTING The OIG derived the final rating for each quality indicator by combining the ratings from the case reviews and from the compliance testing, as applicable. When combining these ratings, the case review evaluations and the compliance testing results usually agreed, but there were instances 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 registered nurse inspectors discussed the nature of individual exceptions found within that indicator category and considered the overall effect on the ability of patients to receive adequate medical care. To derive an overall assessment rating of the institution’s medical inspection, the OIG evaluated the various rating categories assigned to each of the quality indicators applicable to the institution, giving more weight to the rating results of the primary quality indicators, which directly relate to the health care provided to patients. Based on that analysis, OIG experts made a considered and measured overall opinion about the quality of health care observed. POPULATION-BASED METRICS The OIG identified a subset of Healthcare Effectiveness Data Information Set (HEDIS) measures applicable to the CDCR patient population. To identify outcomes for COR, the OIG reviewed some of the compliance testing results, randomly sampled additional patients’ records, and obtained COR data from the CCHCS Master Registry. The OIG compared those results to HEDIS metrics reported by other statewide and national health care organizations. California State Prison, Corcoran, Cycle 5 Medical Inspection Page 9 Office of the Inspector General State of California M I R EDICAL NSPECTION ESULTS The quality indicators assess the clinical aspects of health care. As shown on the COR Executive Summary Table on page ii of this report, 13 of the OIG’s indicators were applicable to COR; 7 were rated by both the case review and compliance components of the inspection, 3 were rated by the case review component alone, and 3 were rated by the compliance component alone. The Administrative Operations indicator is a secondary indicator, and, therefore, was not relied upon for the overall score for the institution. Based on the analysis and results in the primary indicators, the OIG experts made a considered and measured opinion that the quality of health care at COR was adequate. Summary of Case Review Results The clinical case review component assessed 10 of the indicators applicable to COR. Of these 10 indicators, OIG clinicians rated one proficient, nine adequate, and none inadequate. The OIG physicians rated the overall adequacy of care for each of the 25 detailed case reviews they conducted. Of these 25 cases, 2 were proficient, 21 were adequate, and 2 were inadequate. In the 1,103 events reviewed, there were 330 deficiencies, of which 20 were considered to be of such magnitude that, if left unaddressed, they would likely contribute to patient harm. Adverse Events Identified During Case Review Adverse events are medical errors that are more likely than not to cause grave patient harm. 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. There were two adverse events at COR during the OIG’s case review:  In case 5, the patient was discharged after hospital care for a gastrointestinal hemorrhage. An acid-blocking medication was advised by the hospital physicians to prevent future bleeding. This information was available on the day of discharge, and written on the hospital instruction sheet. However, health information management at COR failed to share this with the provider, and this medication was never started. Six days later, the patient died of a recurrent gastrointestinal bleed. California State Prison, Corcoran, Cycle 5 Medical Inspection Page 10 Office of the Inspector General State of California  In case 33, the patient had uncontrolled inflammatory bowel disease, and was experiencing abdominal pain and blood in his stool. On two occasions, the delivery of a steroid medication to reduce the inflammation was delayed, once for 7 days and once for 11 days, before the patient received the medication. Summary of Compliance Results The compliance component assessed 10 of the 13 indicators applicable to COR. Of these ten indicators, OIG compliance inspectors rated one proficient, 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 State Prison, Corcoran, Cycle 5 Medical Inspection Page 11 Office of the Inspector General State of California 1 — ACCESS TO CARE This indicator evaluates the institution’s ability to provide patients Case Review Rating: with timely clinical appointments. Areas specific to patients’ access Adequate to care are reviewed, such as initial assessments of newly arriving Compliance Score: patients, acute and chronic care follow-ups, face-to-face nurse Adequate appointments when an patient requests to be seen, provider referrals (81.1%) from nursing lines, and follow-ups after hospitalization or specialty Overall Rating: care. Compliance testing for this indicator also evaluates whether Adequate patients have Health Care Services Request forms (CDCR Form 7362) available in their housing units. Case Review Results The OIG clinicians reviewed 264 provider, nurse, specialty, and hospital events that required a follow-up appointment and identified 22 deficiencies relating to Access to Care¸ of which four were significant (more likely than not to cause patient harm if not rectified). Significant deficiencies were identified in cases 1 (twice), 2, and 33. The OIG clinicians rated the Access to Care indicator at COR adequate. Sick Call Access COR did well in scheduling and completing most nursing sick call appointments. There was only one minor deficiency. Follow-up Appointments Access to follow-up care was excellent at COR. The institution performed well with provider-to-provider follow-up care, with only two minor deficiencies whereby the follow-up care was one or two days late. COR also did well with scheduling and completing nursing appointments that were generated by a provider or nurse. The OIG reviewed 23 provider follow-up appointments after a specialty service, 26 provider appointments scheduled after a patient returned from an offsite hospital or emergency department, and 28 provider appointments scheduled after a patient was treated in the TTA, all of which were free of deficiencies. COR did well with diagnostic services access, with no deficiencies in scheduling and completing provider follow-up appointments in response to review of diagnostic tests. Nurse-to-Provider Referrals COR did well in scheduling and completing most nurse-requested provider appointments. There were three deficiencies, one of which was significant:  In case 33, the nurse referred the patient to a provider for management of abdominal pain and rectal bleeding. The scheduler incorrectly recorded the provider appointment was California State Prison, Corcoran, Cycle 5 Medical Inspection Page 12 Office of the Inspector General State of California completed when, in fact, the patient had refused the provider visit. Fortunately, the provider had provided appropriate treatment during the initial nurse visit and telephone consultation. Intra-System Transfers and Reception Center Among the four reviewed provider appointments scheduled after a patient transferred into COR, no deficiencies were found. Specialized Medical Housing There were three significant deficiencies (two in case 1 and one in case 21). These are also discussed in the Specialized Medical Housing indicator. Specialty Access COR did well with specialty service access. The three minor deficiencies are discussed in the Specialty Services indicator. Clinician Onsite Inspection The OIG met with the correctional health services administrator during the onsite inspection. There had been improvement processes over the last year to address a backlog in areas such as provider appointments. The schedulers were guided to improve appointment efficiency with bundling appointments and removing duplicate ones. The CP&S had implemented additional clinics on Saturdays and used providers from other institutions to improve access to care. The improvement plan included monthly meetings with the office technicians and an audit tool to ensure the backlog elimination would continue. Some major problems in specialty appointments identified in the OIG’s Cycle 4 inspection report were also corrected, and this is further discussed in the Specialty Services indicator. Case Review Conclusion COR demonstrated sufficient ability to provide access to care in all areas. The OIG clinicians rated this indicator adequate. Compliance Testing Results The institution received an adequate compliance score of 81.1 percent in the Access to Care indicator, with scores in the proficient range in the following five areas:  Of the five applicable patients sampled who were referred to and seen by a provider and for whom the provider subsequently ordered a follow-up appointment, all five received their follow-up appointments timely (MIT 1.006).  Patients had access to Health Care Services Request forms (CDCR Form 7362) at all six housing units the OIG inspected (MIT 1.101). California State Prison, Corcoran, Cycle 5 Medical Inspection Page 13 Office of the Inspector General State of California  Inspectors sampled 40 health services requests submitted by patients across all facility clinics. Nursing staff completed a timely face-to-face encounter for 37 patients (93 percent). For one patient, the nurse conducted the visit one day late. For two others, there was no medical record evidence that a face-to-face encounter occurred (MIT 1.004).  Among 25 sampled patients who were discharged from a community hospital, 22 (88 percent) received a timely provider follow-up appointment upon their return to COR. Two patients received their appointments one and 13 days late, and, for one other patient, there was no medical record evidence found of a follow-up appointment (MIT 1.007).  Of the 22 applicable patients sampled who received a high-priority or routine specialty service, 19 (86 percent) received a timely follow-up appointment with a provider. Two patients received follow-up appointments 4 and 14 days late, and one did not receive an appointment at all (MIT 1.008). One test in this indicator earned COR an adequate score:  Inspectors sampled 40 health care services request forms and found that nursing staff reviewed 33 of them on the same day they were received (83 percent). Nursing staff reviewed five of the forms one day late. Two sampled forms were not properly completed (MIT 1.003). COR showed room for improvement in the following areas:  Among 25 patients sampled who transferred into COR from other institutions and were referred to a provider based on nursing staff’s initial health care screening, only 14 (56 percent) were seen timely. Seven patients received their provider appointment from one day to over four months late, while four other patients did not receive a primary care provider appointment (MIT 1.002).  Inspectors sampled 25 patients who suffered from one or more chronic care conditions; only 15 patients timely received their ordered follow-up appointments (60 percent). Six patients’ follow-up appointments occurred from 2 to 10 days late; three patients’ appointments were from 20 to 41 days late; and there was no evidence found that one patient was seen (MIT 1.001).  Among the 14 applicable health care service requests sampled on which the nursing staff referred the patient for a provider appointment, 9 of the patients (64 percent) received a timely appointment. For one patient, the follow-up appointment occurred one day late. For four other patients, there was no medical record evidence found that the appointments occurred (MIT 1.005). California State Prison, Corcoran, Cycle 5 Medical Inspection Page 14 Office of the Inspector General State of California 2 — 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 patients, whether the primary care provider Compliance Score: timely reviewed the results, and whether the results were Inadequate communicated to the patient within the required time frames. In (74.8%) addition, for pathology services, the OIG determines whether the Overall Rating: institution received a final pathology report and whether the provider Adequate 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. In this indicator, the OIG’s case review and compliance review process 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 scores and ultimately rated this indicator adequate. The compliance score was nearly adequate, and the areas of deficiency did not negatively affect patient care. Case Review Results The OIG clinicians reviewed 109 diagnostic events and found 36 deficiencies, two of which were significant (both in case 11). Of the 36 deficiencies, 23 related to health information management. Test Completion With respect to test completion, COR’s performance was excellent. All laboratory and radiology orders were completed. Health Information Management In general, COR was able to retrieve and timely scan most documents. Most minor deficiencies were due to a slight delay in scanning the reports. Among the 23 deficiencies, one was significant:  In case 11, the patient had worsening control of his diabetes. Medical records staff failed to retrieve, to have the provider review and sign, and to scan the laboratory report into the electronic medical record. Provider Performance The providers performed well with diagnostics services. There was one significant deficiency in case 11, which is discussed in Quality of Provider Performance indicator. California State Prison, Corcoran, Cycle 5 Medical Inspection Page 15 Office of the Inspector General State of California Case Review Conclusion Diagnostic services at COR were performed well, and this indicator was rated adequate. Compliance Testing Results The institution received an inadequate compliance score of 74.8 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  Radiology services were timely performed for the nine applicable patients sampled (MIT 2.001); however, providers evidenced timely review of the corresponding diagnostic services reports for only two of the ten patients (20 percent). For eight patients, the OIG did not find evidence in the medical record that the providers reviewed the diagnostic services reports by initialing and dating the report per CCHCS policy (MIT 2.002). Providers timely communicated the test results to all ten patients sampled (MIT 2.003). Laboratory Services  Nine of ten sampled patients (90 percent) received their provider-ordered laboratory services timely; one patient received his service 12 days late (MIT 2.004). For all ten of those services, the provider timely reviewed the diagnostic report and timely reported the results to the patient (MIT 2.005, 2.006). Pathology Services  Clinicians at COR timely received the final pathology report for seven of ten patients sampled (70 percent). One of the remaining reports was received 13 days late, and for the remaining two, there was no evidence found in the electronic medical record that the final reports were received (MIT 2.007). Providers timely reviewed the pathology results for only four of eight applicable patients sampled (50 percent). Two reports were reviewed one and two days late; and two reports did not show evidence of clinician review (MIT 2.008). Providers timely communicated the final pathology results to three of the seven applicable patients sampled (43 percent). Results were communicated to three patients from one to 19 days late. For one additional patient, inspectors did not find evidence in the electronic medical record that the patient received notification of the test results (MIT 2.009). California State Prison, Corcoran, Cycle 5 Medical Inspection Page 16 Office of the Inspector General State of California 3 — EMERGENCY SERVICES An emergency medical response system is essential to providing Case Review Rating: effective and timely emergency medical response, assessment, Adequate treatment, and transportation 24 hours per day. Provision of Compliance Score: urgent/emergent care is based on a patient’s emergency situation, Not Applicable clinical condition, and need for a higher level of care. The OIG Overall Rating: reviews emergency response services including first aid, basic life Adequate support (BLS), and advanced cardiac life support (ACLS) consistent with the American Heart Association guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care, and the provision of services by knowledgeable staff appropriate to each individual’s training, certification, and authorized scope of practice. The OIG evaluates this quality indicator entirely through clinicians’ reviews of case files and conducts no separate compliance testing element. Case Review Results The OIG clinicians reviewed 80 urgent or emergent events and found 37 deficiencies. All of the deficiencies were in nursing care and were minor and did not significantly affect patient care. COR performed well in initiating BLS care and with 9-1-1 activation during emergency medical responses. In general, patients requiring urgent or emergent services received timely and sufficient care. Provider Performance Provider performance in emergency services at COR was excellent. There was only one minor deficiency with electronic medical record documentation. Nursing Performance The nursing deficiencies identified in emergency medical services were in nursing assessment, delays in emergency medical response, and transfers of patients to a higher level of care. Documentation by some TTA nurses was incomplete and disorganized. The OIG clinicians identified 22 minor nursing deficiencies. The following cases are examples for quality improvement strategies:  In case 7, the patient was in an altercation and fractured his hand. The patient was assessed in the TTA, but the nursing staff did not provide basic nursing measures, such as elevating the hand and applying ice to reduce swelling. California State Prison, Corcoran, Cycle 5 Medical Inspection Page 17 Office of the Inspector General State of California  In case 15, the patient was sent to the TTA for nausea, dizziness, and headaches. The nurse did not assess the patient for signs of dehydration or contact the provider before sending the patient back to his housing unit.  Also in case 15, there were two events with 20-minute delays in emergency response and transfer to the TTA. The first was after a seizure, and the second was after a fall when the patient required intravenous fluids and was transferred to a higher level of care.  In case 41, the patient was in an altercation and had lost consciousness and suffered a facial laceration requiring transfer to a higher level of care. The first emergency medical responder who arrived on scene did not document a description of the injuries. CPR Response The first responders to medical emergencies were licensed vocational nurses (LVNs), psychiatric technicians (PTs), and custody staff. In the majority of the cases reviewed, medical responders and custody staff promptly and appropriately initiated BLS measures. In general, nurses at COR provided good care during emergency medical response incidents. The nursing deficiencies were not significant and did not affect patients’ outcomes. Patient Care Environment This following case involved the emergency response of the custody staff, and included one minor deficiency, as follows:  In case 4, the patient was found hanging in the cell. The custody staff were unable to cut down the ligature from the neck with the available scissors, which were faulty. This caused a delay in rescue measures. The officer manually removed the ligature to start CPR. Fortunately, the patient survived and was transferred to a mental health institution. Emergency Medical Response Review Committee The committee generally reviewed all emergency medical response incidents and took necessary actions to improve the institution’s emergency medical response. Review of the EMRRC minutes indicated that the incorrect practice of TTA staff completing first responder forms had been identified, and training of the first responders to complete the form themselves had been implemented. The nursing administrative staff was responsive to the deficiencies that were presented with the exception of the following case:  In case 15, the EMRRC committee failed to identify errors in event time documentation. California State Prison, Corcoran, Cycle 5 Medical Inspection Page 18 Office of the Inspector General State of California Clinician Onsite Inspection The TTA had ample space for patient evaluation and working areas for both nurses and providers. The TTA had 24-hour registered nursing coverage. First responders on the yard were custody staff and clinic yard nurses. The new nursing administrator informed the OIG clinicians that previously, nursing staff on second and third watch did not have hand radios for communication with custody regarding emergencies. The administrator was able to acquire hand radios. The CNE also obtained cell phones for supervisors to further improve communications. The CNE informed the OIG clinicians that the TTA staff had received training and education on urgent/emergent protocols. There was a new third watch TTA supervisor to assist staff during this watch. The CEO had recently trained staff on the time frames for emergent transfers, including activation of 9-1-1.The OIG clinicians asked the TTA staff if there were barriers to patient transfer to the TTA from the yard. Their response was that there were occasional gate malfunctions or delays for safety concerns from custody. The TTA staff stated that otherwise, their expected response time to the yard was two to three minutes. A review of 11 nursing files revealed that two of the nurses had current ACLS certification, and all of the nurses had current BLS certification, with the exception of one nurse with an expired card on file. Clinic yard staff stated that they recently received education and training on a new policy for administration of naloxone (narcotic overdose antidote) spray, and the medication was available on the yard, when needed. Case Review Conclusion COR generally provided prompt and appropriate basic life support care during medical emergencies, and this indicator was rated adequate. California State Prison, Corcoran, Cycle 5 Medical Inspection Page 19 Office of the Inspector General State of California 4 — HEALTH INFORMATION MANAGEMENT Health information management is a crucial link in the delivery of Case Review Rating: medical care. Medical personnel require accurate information in Adequate order to make sound judgments and decisions. This indicator Compliance Score: examines whether the institution adequately manages its health care Inadequate information. This includes determining whether the information is (67.2%) correctly labeled and organized and available in the electronic health Overall Rating: record; whether the various medical records (internal and external, Inadequate e.g., hospital and specialty reports and progress notes) are obtained and scanned timely into the patient’s electronic health record; whether records routed to clinicians include legible signatures or stamps; and whether hospital discharge reports include key elements and are timely reviewed by providers. 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—each area’s results are discussed in detail below. After considering both case review and compliance testing results, the OIG inspection team determined the final overall rating of inadequate was appropriate. This decision was due to the following two factors: an excessive number of health care documents that COR staff either mislabeled or misfiled in the electronic medical records and untimely provider review of hospital discharge reports. These deficiencies could result in important health care records not being identified and contribute to patient harm and delays in the delivery of patient care, warranting the lower overall indicator score. During the OIG’s testing period, COR had not converted to the new Electronic Health Record System (EHRS); therefore, all testing occurred in the electronic Unit Health Record (eUHR) system. Case Review Results The OIG clinicians reviewed 1,103 events and found 63 deficiencies related to health information management, two of which were significant (cases 5 and 11). The OIG rated this indicator adequate. Patient Death  In case 5, the patient returned from being hospitalized for gastrointestinal bleeding. The discharge summary was not available to the provider for the follow-up visit. The provider was not given the information on the discharge summary, and did not see the recommendation from the hospital to start a medication to reduce the risk of future bleeding. The patient died six days later from recurrent bleeding. California State Prison, Corcoran, Cycle 5 Medical Inspection Page 20 Office of the Inspector General State of California Hospital Records The OIG reviewed 25 outside emergency department (ED) and community hospital events. COR did well in retrieving and scanning hospital discharge summaries and ED reports. The OIG identified 15 deficiencies, one of which was significant (case 5, discussed above). Of the 14 minor deficiencies, 11 were for health information management issues, which included five hospital discharge reports being scanned into the electronic medical records without a provider signature. The one significant deficiency in case 5 (discussed above) also involved a health information management issue. Specialty Services COR did well with retrieving and scanning specialty services reports. There were seven minor deficiencies. These are discussed further in the Specialty Services indicator. Diagnostic Reports Among the health information management deficiencies, 23 involved diagnostic services, one of which was significant:  In case 11, medical records staff failed to retrieve and scan a report showing that the patient’s diabetes was worsening. Urgent/Emergent Records There were eight minor deficiencies in the TTA provider and nurse documentation as well as on-call provider documentation. These are discussed in the Emergency Services indicator. Scanning Performance While COR displayed only two significant deficiencies in health information management, patterns of minor deficiencies showed opportunities for improvement. Missing documents were identified in cases 5, 7, 11, 21, 25, 28, and 55, and twice in case 2. Scanning occurred prior to provider signature in cases 1, 7, 21, 25, and 52, and three times in case 5. There were minor delays in scanning in cases 5, 7, 9, and 20, four times in case 15, and seven times in case 10. Scanned documents were incorrectly labelled in cases 7, 10, 19, and 43; twice each in cases 8, 9, 15, 20, and 23; and four times each in cases 1 and 2. The patient was not notified of the laboratory results in cases 9 and 10. Clinician Onsite Inspection The OIG met with the medical records supervisors. They discussed their quality improvements efforts to reduce scanning delays. The specialty services supervisor also discussed recent improvements in obtaining reports. While deficiencies were still identified, the OIG noted fewer significant deficiencies in Cycle 5 than in Cycle 4. California State Prison, Corcoran, Cycle 5 Medical Inspection Page 21 Office of the Inspector General State of California Case Review Conclusion COR did well with the retrieval of outside ED reports and hospital discharge summaries. Scanning time frames were acceptable, but improvement was needed in scanning accuracy. Missing, misfiled, or mislabeled documents were common throughout the case reviews. The OIG clinicians rated this indicator adequate. Compliance Testing Results The institution received an inadequate compliance score of 67.2 percent in the Health Information Management indicator. The following tests showed areas for needed improvement:  The institution scored zero in its labeling and filing of documents scanned into patients’ electronic medical records. Most errors included mislabeled and incorrect patient documents. For this test, once the OIG identifies 24 mislabeled or incorrect patient documents, the maximum points are lost and the resulting score is zero (MIT 4.006).  Among 25 sampled patients admitted to a community hospital and then returned to the institution, COR’s providers timely reviewed only 12 patients’ corresponding hospital discharge reports within three calendar days of the patient’s discharge (48 percent). For the other 13 patients, providers did not timely review the discharge reports; one was reviewed one day late, and 12 reports had no evidence of review (MIT 4.007).  For 12 of 18 specialty service consultant reports sampled (67 percent), COR staff scanned the reports into the patient’s electronic medical record within five calendar days. However, three documents were scanned from one to four days late, and for another three, there was no evidence that the specialty reports were scanned into the medical record (MIT 4.003). The following tests earned proficient scores:  The institution timely scanned 19 of 20 sampled non-dictated progress notes, patients’ initial health screening forms, and requests for health care services into the electronic medical records (95 percent). One initial health screening form was scanned one day late (MIT 4.001).  COR scored 91 percent for the timely scanning of dictated or transcribed provider progress notes into patients’ electronic medical record files. Timely scanning occurred within five days of the provider visit with the patient for 10 of the 11 sampled documents; the one exception was scanned four days late (MIT 4.002).  Institution staff timely scanned 18 of 20 sampled specialty service consultant reports into the patients’ electronic health care records (88 percent). The other two specialty reports were scanned one day late (MIT 4.004). California State Prison, Corcoran, Cycle 5 Medical Inspection Page 22 Office of the Inspector General State of California  COR medical records staff timely scanned medication administration records (MARs) into 12 of 15 sampled patients’ electronic medical records (80 percent). Three MARs were scanned from two to three days late (MIT 4.005). California State Prison, Corcoran, Cycle 5 Medical Inspection Page 23 Office of the Inspector General State of California 5 — HEALTH CARE ENVIRONMENT This indicator addresses the general operational aspects of the Case Review Rating: institution’s clinics, including certain elements of infection control Not Applicable and sanitation, medical supplies and equipment management, the Compliance Score: availability of both auditory and visual privacy for patient visits, and Inadequate (70.7%) the sufficiency of facility infrastructure to conduct comprehensive medical examinations. Rating of this component is based entirely on Overall Rating: the compliance testing results from the visual observations inspectors Inadequate make at the institution during their onsite visit. This indicator is evaluated entirely by compliance testing. The OIG conducts no case review component. Compliance Testing Results The institution received an inadequate compliance score of 70.7 percent in the Health Care Environment indicator, showing room for improvement in the following areas:  The non-clinic bulk medical supply storage areas did not meet the supply management process and support the needs of the medical health care program. Several expired medical supplies were found stored beyond the manufacturing guidelines, earning the institution a score of zero (MIT 5.106).  Only 4 of the 14 clinic locations (29 percent) met compliance requirements for essential core medical equipment and supplies. The remaining ten clinics were missing one or more functional pieces of properly calibrated core equipment or other medical supplies necessary to conduct a comprehensive exam. The missing items included a demarcation line for the Snellen eye exam chart, a nebulization unit, an oto-ophthalmoscope and tips, tongue depressors, and a biohazard receptacle or labeled bags. In addition, an automatic external defibrillator, oto-ophthalmoscope, nebulization unit, and weight scale were missing calibration stickers (MIT 5.108).  Of 14 clinic exam rooms observed, 9 (64 percent) had appropriate space, configuration, supplies, and equipment to allow clinicians to perform a proper clinical examination. In five clinics, the following deficiencies were identified: torn vinyl cover on the exam table (Figure 1), exam room supplies that were not clearly identifiable, and confidential Figure 1: Exam table with torn vinyl records that were not shredded on a daily basis. In California State Prison, Corcoran, Cycle 5 Medical Inspection Page 24 Office of the Inspector General State of California addition, in the receiving and release clinic, the exam room did not have adequate space to provide medical services (MIT 5.110).  The institution scored 70 percent when inspectors examined emergency response bags in ten applicable clinics to determine if clinical staff inspected the bags daily and inventoried them monthly, and whether the bags contained all essential items. At three clinics, the following deficiencies were identified: staff on each watch did not always conduct daily inspections of the bags; the emergency medical response bags were missing non-latex gloves; and the crash cart in the TTA had expired medical supplies (MIT 5.111). One test scored in the adequate range:  Clinicians whom inspectors observed in 11 of 14 clinics adhered to universal hand hygiene precautions; however, in three clinics, providers did not sanitize or wash their hands prior to putting on gloves and after physically assessing patients (79 percent) (MIT 5.104). The following tests earned proficient scores:  All fourteen clinics had environments adequately conducive to providing medical services; they provided reasonable auditory privacy, appropriate waiting areas, wheelchair accessibility, and sufficient non-exam-room workspace (MIT 5.109).  Clinical health care staff at 13 of the 14 applicable clinics (93 percent) ensured that reusable invasive and non-invasive medical equipment was properly sterilized or disinfected. One clinic had previously sterilized medical equipment that was missing a date stamp on its packaging (MIT 5.102).  Of the 14 clinics examined, 12 (86 percent) were appropriately disinfected, cleaned, and sanitized. In two clinics, cleaning logs were not maintained (MIT 5.101); 12 of the 14 (86 percent) also had operable sinks and sufficient quantities of hand hygiene supplies in the exam areas. However, two clinics’ patient restrooms did not have soap or disposable hand towels available (MIT 5.103).  Regarding proper protocols to mitigate exposure to blood-borne pathogens and contaminated waste, 12 of the 14 clinics (86 percent) were compliant. In two clinics, the exam rooms did not have puncture-resistant containers available to medical staff for expended needles and sharps; and one of those two clinics was also missing personal protective equipment (MIT 5.105).  Inspectors found that 12 of the 14 clinics (86 percent) followed adequate medical supply storage and management protocols. Two clinics’ storage rooms for bulk medical supplies were not clearly identifiable, and medical supplies were found stored in the same area with cleaning products (MIT 5.107). California State Prison, Corcoran, Cycle 5 Medical Inspection Page 25 Office of the Inspector General State of California Non-Scored Areas  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 timely or adequate health care. The OIG did not score this question. When OIG inspectors interviewed health care managers, they did not identify any significant concerns. At the time of the OIG’s medical inspection, COR had several significant infrastructure projects underway, which included increasing clinic space at seven yards and renovating the central health services building. These projects started in the fall of 2014, and the institution estimated that these projects would be completed by the end of spring 2018 (MIT 5.999). California State Prison, Corcoran, Cycle 5 Medical Inspection Page 26 Office of the Inspector General State of California 6 — INTER- AND INTRA-SYSTEM TRANSFERS This indicator focuses on the management of patients’ medical needs Case Review Rating: and continuity of patient care during the inter- and intra-facility Adequate transfer process. The patients reviewed for Inter- and Intra-System Compliance Score: Transfers include patients received from other CDCR facilities and Inadequate (43.0%) patients transferring out of COR to another CDCR facility. The OIG review includes evaluation of the institution’s ability to provide and Overall Rating: document health screening assessments, initiation of relevant Inadequate 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 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 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 scores and ultimately rated this indicator inadequate. The deficiency of transfer packets for patients transferring to other institutions from COR was a key factor; specifically, regional inspectors found that all transfer packets examined were missing required medical records. There were also issues noted with the timeliness and completion of the Initial Health Screening form (CDCR Form 7277) by registered nurses as well as with the receipt of previously ordered medication for patients transferring into COR from other institutions. The seriousness of these errors rendered the compliance score of inadequate the more appropriate overall rating. Case Review Results Clinicians reviewed encounters relating to inter- and intra-system transfers, including information from both the sending and receiving institutions. These included 64 events, of which 55 were hospital related. There were 23 hospitalizations, all of which resulted in a transfer back to COR. The cases reviewed displayed only minor deficiencies. Transfers In and Out Three events relating to transfers out were reviewed, and there was only one minor deficiency. The OIG clinicians reviewed six events regarding patients transferring into COR, and deficiencies were identified in one case, as follows: California State Prison, Corcoran, Cycle 5 Medical Inspection Page 27 Office of the Inspector General State of California  In case 28, the nurse made health care referrals without indicating the time frame and did not document the patient’s need for a Spanish-speaking interpreter. The provider evaluated the patient seven days later and needed to reschedule the appointment with an interpreter to complete an in-depth assessment. Hospitalizations Patients returning from hospitalizations or from outside emergency departments 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, e.g., from the hospital to the institution. At COR, 15 hospital transfer deficiencies were identified, one of which was significant, primarily related to health information management. These are further discussed in the Health Information Management indictor. Case Review Conclusion The OIG rated the case review portion of the Inter- and Intra-System Transfers indicator adequate. Compliance Testing Results The institution obtained an inadequate score of 43.0 percent in the Inter- and Intra-System Transfers indicator, with five of the six tests earning inadequate scores, as follows:  COR scored zero when the OIG tested seven patients who transferred out of COR during the onsite inspection to determine whether the patients’ transfer packages included required medications and related documentation. Seven patients’ transfer packets were missing MARs (MIT 6.101).  The OIG tested 25 patients who transferred into COR from other CDCR institutions to determine whether they received a complete initial health screening assessment from nursing staff on their day of arrival. COR received a score of 28 percent on this test because nursing staff timely completed the Initial Health Screening forms (CDCR Form 7277) for only 7 of the 25 sampled patients. For 18 patients, nurses neglected to answer one or more of the screening form questions (MIT 6.001).  The OIG reviewed the initial health screening forms for 25 patients who transferred into COR from other CDCR institutions to determine if nursing staff completed the assessment and disposition sections of the form on the same day staff completed an initial screening of the patient. Nursing staff properly completed the documents for 13 of the patients sampled (52 percent). For 11 patients, nursing staff signed the RN assessment and disposition sections of the form from one to three days late. For one sampled patient, the RN failed to date the screening form (MIT 6.002). California State Prison, Corcoran, Cycle 5 Medical Inspection Page 28 Office of the Inspector General State of California  Of the 25 sampled patients who transferred into COR, 20 had an existing medication order that required nursing staff to issue or administer medications upon arrival; 12 of the applicable 20 patients (60 percent) received their medications timely. Three patients received their direct observation therapy (DOT) medication from one to 21 days late. For five patients, there was no evidence that they received their medication (MIT 6.003). The institution scored within the adequate range in the following test:  Inspectors sampled 20 patients who transferred out of COR to another CDCR institution to determine whether COR identified scheduled specialty service appointments on the patients’ health care transfer forms. Nursing staff correctly listed the pending specialty service appointments for 15 of 20 patients (75 percent). Staff failed to list pending specialty services appointments for five patients (MIT 6.004). California State Prison, Corcoran, Cycle 5 Medical Inspection Page 29 Office of the Inspector General State of California 7 — PHARMACY AND MEDICATION MANAGEMENT This indicator is an evaluation of the institution’s ability to provide Case Review Rating: appropriate pharmaceutical administration and security Adequate management, encompassing the process from the written Compliance Score: prescription to the administration of the medication. By combining Inadequate (56.1%) both a quantitative compliance test with case review analysis, this assessment identifies issues in various stages of the medication Overall Rating: management process, including ordering and prescribing, Inadequate transcribing and verifying, 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 prescriber, staff, and patient. 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 scores and ultimately rated this indicator inadequate. While case review focused on medication administration, the compliance testing was a more robust assessment of medication administration and pharmacy protocols combined with onsite observations of medication and pharmacy operations. As a result, the compliance score was deemed appropriate for the overall indicator rating. Case Review Results The OIG clinicians evaluated 100 events and found 19 deficiencies regarding pharmacy and medication management. Significant deficiencies were identified in cases 2, 9 (twice), 18 (twice), and 33. Medication Process and Continuity Patients at COR generally received their medications as prescribed and as scheduled. However, four cases had significant medication management deficiencies whereby the patient did not receive the medication as ordered:  In case 2, the patient returned from the hospital after having a seizure. When the patient returned to the institution, the seizure medication was delayed two days while the pharmacist waited for a clarification on the medication dosage. Also in case 2, the patient had another delay when a different seizure medication dosage was changed.  In case 18, the physician ordered a medication to reduce heartburn, but the patient did not receive the medication until it was reordered the following month. Also in case 18, on two California State Prison, Corcoran, Cycle 5 Medical Inspection Page 30 Office of the Inspector General State of California different occasions, the provider ordered an antibiotic solution for the patient’s eye infection to be started the same day it was ordered, which did not occur on either occasion.  In case 23, the provider changed the patient’s blood pressure medication dosage but did not specify how the medication was to be administered. Because of the absence of this information, the pharmacy delayed the order. This was a minor deficiency.  In case 33, the patient had inflammatory bowel disease and was actively bleeding. A provider ordered a steroid to reduce intestinal inflammation. The patient did not receive the medication until another order was written 17 days later. Medication Administration (Nursing) Nursing staff performed adequately regarding accurate and timely administration of keep-on-person (KOP) and nurse-administered medications. Although the overall performance was adequate, there were deficiencies in the medication administration at COR:  In case 2, the nurse did not inform the provider of the patient’s refusal of a seizure medication.  In case 35, there were multiple refusals of the patient’s seizure medications, but the nurse did not document the reason for the refusals. Clinician Onsite Inspection The sick call nurses’ work area did not provide privacy for confidential assessments of patients. The windows surrounding the room were uncovered, so the area was visible to everyone outside the room. The medication nurses worked in a very small area in the program office, and the patients walked up to the medication cart without a medication window. The LVNs and PTs responsible for medications were knowledgeable about their patients, medication preparation and administration safety, and operational processes on their assigned yards. They were located in close proximity to the clinic primary care nurses and provider. These LVNs and PTs described an appropriate process at COR for verifying new medication orders and reconciling continuing medication orders. Nurses notified providers about patient medication issues during the morning huddles. The LVNs and PTs were an integral part of the primary care team, and they also served as first medical responders for medical emergencies during hours of clinic operations. Case Review Conclusion The OIG clinicians rated the Pharmacy and Medication Management indicator adequate. California State Prison, Corcoran, Cycle 5 Medical Inspection Page 31 Office of the Inspector General State of California Compliance Testing Results The institution received an inadequate compliance score of 56.1 percent in the Pharmacy and Medication Management indicator. For discussion purposes below, this indicator is divided into three sub-indicators: medication administration, observed medication practices and storage controls, and pharmacy protocols. Medication Administration In this sub-indicator, the institution received an inadequate score of 57.9 percent, with poor scores in the following tests:  Nursing staff administered medications without interruption to only two of ten patients who were en route from one institution to another with a temporary layover at COR (20 percent). For eight patients, there was no medical record evidence that medications were administered as ordered (MIT 7.006).  COR timely provided hospital discharge medications to only 12 of 25 patients sampled (48 percent). Nursing staff provided discharge medications from one to three days late for ten patients; for three other patients, no evidence was found in the medical record that DOT or KOP medications were provided (MIT 7.003).  Among 15 applicable patients, 8 (53 percent) timely received chronic care medications. One patient did not receive provider counseling, two did not receive their medications, and four received their DOT and KOP medications from two to four days late (MIT 7.001).  COR ensured that 17 of 25 patients sampled (68 percent) received their medications without interruption when they transferred from one housing unit to another. Nursing staff did not properly document refusals in the MAR for seven patients, and for the remaining patient, there was no evidence the patient received his medication (MIT 7.005). One test in this sub-indicator earned a proficient score:  Inspectors found that all 25 patients sampled received their newly ordered medication in a timely manner (MIT 7.002). Observed Medication Practices and Storage Controls The compliance score for this sub-indicator was an inadequate 68.0 percent. The following tests revealed room for improvement:  The institution employed adequate security controls over narcotic medications in 4 of the 12 applicable clinic and medication line locations where narcotics were stored (33 percent). At six clinics, the narcotics log book lacked evidence on multiple dates over a one-month period that a controlled substance inventory was performed by two licensed nursing staff. At California State Prison, Corcoran, Cycle 5 Medical Inspection Page 32 Office of the Inspector General State of California two other locations, the narcotics were stored under one lock control only, and the medication nurse did not immediately update the narcotics logbook after administering narcotics (MIT 7.101).  Only four of seven inspected medication preparation and administration areas demonstrated appropriate administrative controls and protocols (57 percent). At two different locations, the following deficiencies were identified: the medication nurse did not always ensure the patient swallowed DOT medications; the medication nurse did not consistently verify patients’ identification by using picture identification; and the medication nurse did not appropriately administer medication by crushing and floating as ordered by the primary care provider. At a third medication line location, patients waiting to receive their medications did not have sufficient outdoor cover to protect them from heat or inclement weather (MIT 7.106).  COR properly stored non-narcotic medications not requiring refrigeration in 8 of the 13 applicable clinic and medication line storage locations (62 percent). In five locations, one or more of the following deficiencies were observed: the medication area lacked a designated area for return-to-pharmacy medications; a multi-use medication was not labeled with the date it was opened; and the crash cart monthly inventory was not available for review (MIT 7.102).  Inspectors observed the medication preparation and administration processes at seven applicable medication line locations. Nursing staff were compliant regarding proper hand hygiene and contamination control protocols at five locations (71 percent). At two locations, not all nursing staff washed or sanitized their hands when required, such as prior to putting on gloves (MIT 7.104). One test in this sub-indicator received an adequate score:  Non-narcotic refrigerated medications were properly stored in 11 of 13 clinics and medication line storage locations (85 percent). One location did not have designated area for return-to-pharmacy refrigerated medications, and at another location, the medication refrigerator was found unlocked at the time of inspection (MIT 7.103). The following test earned COR a proficient score:  Nursing staff at all seven inspected medication line locations employed appropriate administrative controls and followed appropriate protocols during medication preparation (MIT 7.105). California State Prison, Corcoran, Cycle 5 Medical Inspection Page 33 Office of the Inspector General State of California Pharmacy Protocols In this sub-indicator, the institution received an inadequate average score of 40.0 percent, comprised of scores received at the institution’s main pharmacy. Three tests showed areas for improvement:  In its main pharmacy, the institution did not follow general security, organization, and cleanliness management protocols. The narcotics storage area was found unlocked at the time of inspection. Medication preparation areas were also found cluttered and disorganized (MIT 7.107).  In its main pharmacy, COR did not properly store non-refrigerated medication. Inspectors found medication boxes stored on the floor of the pharmacy (MIT 7.108).  OIG inspectors examined 25 medication error follow-up reports and five monthly medication error statistics reports generated by the institution’s pharmacist in charge (PIC). All 25 reports were untimely or incorrectly processed. The following deficiencies were identified (MIT 7.111): o The PIC was unable to confirm whether the monthly medication error statistics were reported to the chief of pharmacy services in a timely manner. o Among the 25 medication error follow-up reports provided for inspectors’ review, two were completed by the institution’s PIC between one and 25 days late. The following two tests earned proficient scores of 100 percent:  The main pharmacy properly stored refrigerated and frozen medications (MIT 7.109).  The institution’s PIC properly accounted for narcotic medications stored in COR’s pharmacy and reviewed monthly inventories of controlled substances in the institution’s clinical and medication line storage locations (MIT 7.110). Non-Scored Tests  In addition to testing reported medication errors, OIG inspectors follow up on any significant medication errors found during compliance testing to determine whether the errors were properly identified and reported. The OIG provides those results for information purposes only; however, at COR, none of the medication errors identified during testing were deemed to be at or above the necessary severity level, so there were no applicable errors for this test (MIT 7.998). California State Prison, Corcoran, Cycle 5 Medical Inspection Page 34 Office of the Inspector General State of California  The OIG interviewed patients in isolation units to determine if they had immediate access to their prescribed KOP rescue inhalers and nitroglycerin medications. All 20 of the sampled patients had access to their asthma inhalers or nitroglycerin medications (MIT 7.999). California State Prison, Corcoran, Cycle 5 Medical Inspection Page 35 Office of the Inspector General State of California 8 — PRENATAL AND POST-DELIVERY SERVICES This indicator evaluates the institution’s capacity to provide timely Case Review Rating: and appropriate prenatal, delivery, and postnatal services to pregnant Not Applicable patients. This includes the ordering and monitoring of indicated Compliance Score: screening tests, follow-up visits, referrals to higher levels of care, Not Applicable e.g., high-risk obstetrics clinic, when necessary, and postnatal Overall Rating: follow-up. Not Applicable Because COR was an all-male institution, this indicator did not apply. California State Prison, Corcoran, Cycle 5 Medical Inspection Page 36 Office of the Inspector General State of California 9 — PREVENTIVE SERVICES This indicator assesses whether various preventive medical Case Review Rating: services are offered or provided to patients. These include cancer Not Applicable screenings, tuberculosis screenings, and influenza and chronic Compliance Score: care immunizations. This indicator also assesses whether certain Proficient institutions take preventive actions to relocate patients identified (87.0%) as being at higher risk for contracting coccidioidomycosis Overall Rating: (valley fever). Proficient The OIG rates this indicator entirely through the compliance testing component; the case review process does not include a separate qualitative analysis for this indicator. Compliance Testing Results The institution performed in the proficient range in the Preventive Services indicator, with a compliance score of 87.0 percent. Five tests in this indicator received proficient scores, including four scores of 100 percent, as follows:  COR timely administered tuberculosis (TB) medications to patients. All eight sampled patients received their required doses of TB medications in the most recent three-month period reviewed (MIT 9.001).  OIG found that all eight sampled patients received monthly or weekly monitoring while taking TB medications (MIT 9.002).  All 25 patients sampled timely received or were offered influenza vaccinations during the most recent influenza season (MIT 9.004).  The OIG tested whether patients who suffered from certain chronic care conditions were offered vaccinations for influenza, pneumonia, and hepatitis. All 24 applicable patients sampled were timely offered the vaccinations (MIT 9.008).  COR offered colorectal cancer screenings to 23 of the 25 sampled patients subject to the annual screening requirement (92 percent). For two patients, there was no medical record evidence either that health care staff offered a colorectal cancer screening within the previous 12 months or that the patient had a normal colonoscopy within the last ten years (MIT 9.005). Two tests in this indicator revealed areas for improvement at COR:  The OIG sampled 17 patients at high risk for contracting the coccidioidomycosis infection (valley fever), who were medically restricted and ineligible to reside at COR, to determine if California State Prison, Corcoran, Cycle 5 Medical Inspection Page 37 Office of the Inspector General State of California the patients were transferred out of the institution within 60 days from the time they were initially determined ineligible. The institution was compliant for 12 of the 17 patients sampled (71 percent). Of the five for whom COR was not compliant, one was transferred out 58 days late; as of May 23, 2017, the four remaining patients exceeded their eligibility dates at COR by 58 days to nearly two years (MIT 9.009).  OIG inspectors sampled 30 patients to determine whether they received a TB screening within the last year; 15 of the sampled patients were classified as a Code 22 (requiring a TB skin test in addition to a signs and symptoms check), and 15 sampled patients were classified as Code 34 (subject only to an annual signs and symptoms check). Of the 30 sample patients, nursing staff timely and appropriately conducted those screenings for only 14 (47 percent). More specifically, nurses properly screened seven of the Code 22 patients and seven of the Code 34 patients. Inspectors identified the following deficiencies (MIT 9.003): o For seven of the Code 22 patients, an LVN or PT read the test results rather than an RN, public health nurse, or primary care provider as required by the CCHCS policy in place at the time of the OIG’s review; for one other Code 22 patient, nursing staff did not complete the Tuberculin Testing/Evaluation Report (CDCR Form 7331). o For eight Code 34 patients, nursing staff did not complete the TB testing and evaluation report. California State Prison, Corcoran, Cycle 5 Medical Inspection Page 38 Office of the Inspector General State of California 10 — QUALITY OF NURSING PERFORMANCE The Quality of Nursing Performance indicator is a qualitative CCaassee RReevviieeww RRaattiinngg:: evaluation of the institution’s nursing services. The evaluation is AAddeeqquuaattee completed entirely by OIG nursing clinicians within the case CCoommpplliiaannccee SSccoorree:: review process, and does not have a score under the OIG NNoott AApppplliiccaabbllee compliance testing component. Case reviews include face-to-face encounters and indirect activities performed by nursing staff on OOvveerraallll RRaattiinngg:: behalf of the patient. Review of nursing performance includes all AAddeeqquuaattee nursing services performed on site, such as outpatient, inpatient, urgent or emergent, patient transfers, care coordination, and medication management. The key focus areas for evaluation of nursing care include appropriateness and timeliness of patient triage and assessment, identification and prioritization of health care needs, use of the nursing process to implement interventions, and accurate, thorough, and legible documentation. Although nursing services provided in the CTC or OHU are reported in the Specialized Medical Housing indicator, and nursing services provided in the TTA or related to emergency medical responses are reported in the Emergency Services indicator, all areas of nursing services are summarized in this Quality of Nursing Performance indicator. Case Review Results The overall quality of nursing performance at COR was adequate. The OIG clinicians reviewed 269 nursing encounters, of which 120 were outpatient nursing encounters. Most outpatient nursing encounters were for sick call requests, walk-in visits, and RN care manager follow-up visits. In all, there were 161 deficiencies related to nursing care performance, of which two (cases 37 and 45) were significant. Sick Call A major part of adequate nursing care is the quality of nursing assessments, which include both the subjective (patient interview) and the objective (evaluation and observation) portions. The majority of nurses at COR included both subjective and objective nursing assessments when assessing patients. Most nurses utilized the CCHCS nursing protocols and encounter forms, and their assessments were usually complete and adequate. There were two cases displaying significant deficiencies:  In case 37, the patient presented with an irregular heartbeat. The sick call nurse did not examine the patient’s heart or consult with a provider. Instead, the nurse referred the patient for a routine (14-day) appointment with a provider. The provider saw the patient 14 days later and ordered an urgent cardiology consult. The nurse should have consulted with the provider the same day of the face-to-face nursing assessment. California State Prison, Corcoran, Cycle 5 Medical Inspection Page 39 Office of the Inspector General State of California  In case 45, the patient complained that his head felt like it was swollen, his jaw was tightening, and he had a burning sensation in his head, spine, and face. The sick call nurse did not assess the patient face to face and documented on the sick call request form that the primary care provider would follow up with the patient in the TTA. An evaluation by a provider did not occur that day. Instead, the patient was evaluated by a provider six days later. The nursing process involves reviewing each sick call request, describing symptoms, and determining whether the patient requires urgent or routine nursing assessment. However, at COR, some nurses did not recognize that a patient’s symptoms were potentially urgent. Although not considered a significant deficiency, case 16 demonstrated an example of delayed access to care due to nurse not recognizing the potential need for urgent care:  In case 16, the patient submitted two sick call requests, one stating that he had issues (not described in the request) and the other, almost 20 days later, requesting to have fluid drained from his genitals following recent hernia surgery. The nurse did not assess the patient, and documented that the patient would be seen the same day by the provider. The provider did not see the patient. Specialized Medical Housing Nurses generally provided good nursing care services in the CTC and OHU, as is further described in the Specialized Medical Housing indicator. Care Management The care coordinator role at COR was assigned to an LVN in each clinic. The primary function of the LVN care coordinator was providing education to patients with specific conditions, coordinating and facilitating the delivery of durable medical equipment and supplies, and collaborating with health care team members to minimize care fragmentation. The LVN care coordinators performed appropriately in their roles had a clinic RN available for consultation. Medication Administration System processes in place at COR generally supported nursing and pharmacy staff in providing timely medication administration to patients, as is further discussed in the Pharmacy and Medication Management indicator. Urgent/Emergent The emergency medical response at COR was efficient. However, two areas were identified as needing process improvement interventions: documentation by first medical responders, and evaluation of potential delays in emergency medical responders. These are further discussed in the Emergency Services indicator. California State Prison, Corcoran, Cycle 5 Medical Inspection Page 40 Office of the Inspector General State of California Inter- and Intra-System Transfers Nurses in the receiving and release center generally provided good nursing care and documentation. Patients returning to COR after a hospital discharge were assessed by a TTA nurse and received appropriate nursing assessment and appropriate follow-up referrals. The TTA nurses reconciled discharge recommendations from the hospital with the provider, and most patients received medications and treatments as recommended, as discussed in the Inter- and Intra-System Transfers indicator. Clinician Onsite Inspection The OIG clinicians visited the nursing and medication staff on all yards. The clinical staff on two of the three yards continued to operate out of the program office due to construction, as documented in the Cycle 4 inspection report. Although this confined space did not adequately allow for confidential nursing interviews or assessments, nurses stated they were able to make the appropriate accommodations when necessary. Morning huddles were organized and well attended by clinic staff. The primary care RNs did not have patient backlogs. The clinic care coordinators did not have a designated space, and continued to work through inadequate workspace barriers by coordinating with other clinic staff. Nursing staff meetings were organized by the supervisors and usually occurred monthly. The majority of the staff stated that the morale at COR had improved greatly since the arrival of the newly appointed CNE. The supervisors stated that there was good teamwork. The staff appreciated the recognition they were given by their leadership during National Nurse’s week. Case Review Conclusion The OIG rated the Quality of Nursing Performance indicator adequate. California State Prison, Corcoran, Cycle 5 Medical Inspection Page 41 Office of the Inspector General State of California 11 — QUALITY OF PROVIDER PERFORMANCE In this indicator, the OIG physicians provide a qualitative evaluation Case Review Rating: of the adequacy of provider care at the institution. Appropriate Adequate evaluation, diagnosis, and management plans are reviewed for Compliance Score: programs including, but not limited to, nursing sick call, chronic Not Applicable care programs, TTA, specialized medical housing, and specialty Overall Rating: services. The assessment of provider care is performed entirely by Adequate OIG physicians. There is no compliance testing component associated with this quality indicator. Case Review Results The OIG clinicians reviewed 253 medical provider encounters and identified 46 deficiencies identified related to provider performance, four of which were significant (cases 1, 9, and 11 (twice)). The OIG performed 25 detailed physician case reviews and found 2 proficient, 21 adequate, and 2 inadequate. Assessment and Decision-Making At COR, the providers performed adequately without patterns of deficiencies identified. One case review showed proficient provider care:  In case 26, the physician provided excellent care over six months. Multiple chronic care illnesses were thoroughly documented and well managed, with each illness being addressed at each visit. In addition, the patient’s complex eye condition required frequent and timely specialty care consultations, which were accommodated without deficiency. There were occasional minor deficiencies identified which would not pose a risk of serious harm to the patient. The following are examples of some minor deficiencies:  In case 20, the patient had end-stage liver disease, and was, therefore, at risk for confusion as his liver failed to remove metabolic toxins. However, the provider failed to order a medication, lactulose, to reduce the toxin levels.  In case 23, the patient had a known malignant tumor. While the provider noted a 15-pound weight loss over the prior two months, the provider failed to address it in the assessment or management plan.  Also in case 23, the provider increased the dose of gabapentin (seizure medication used for chronic pain) to a maximum level, and prescribed a high dose of codeine (narcotic pain medication). However, the provider failed to document a progress note as to why the changes were made. California State Prison, Corcoran, Cycle 5 Medical Inspection Page 42 Office of the Inspector General State of California  Also in case 23, the provider failed to address the patient’s elevated blood pressure. Review of Records In general, providers at COR reviewed medical records well. There were four minor deficiencies noted when providers failed to adequately review past records. The OIG identified one significant deficiency:  In case 11, the provider reviewed the patient’s laboratory results showing worsening control of diabetes (rising HbA1c to 8.5). The provider failed to order an earlier chronic care appointment, and the patient was not seen until three months later. Chronic Care COR provided adequate outpatient medical care, especially in chronic care. While the OIG noted 33 deficiencies in provider performance, only two were significant:  In case 9, the primary care provider failed to resume warfarin (blood thinner) after the patient agreed to take it to prevent blood clots. There was a 13-day delay before another provider noted the order was not written.  In case 11, the provider noted a laboratory result showing poor control of diabetes (HemA1C 9.9). The provider, however, failed to adjust any medications, and also failed to note the average glucose level also was rising. Urgent/Emergent Care The OIG noted one minor deficiency in provider emergency care. This is discussed in the Emergency Services indicator. Specialty Services The providers performed well in referring to appropriate specialists when necessary and ordering within appropriate time frames. The providers timely reviewed the specialty reports after patients returned from specialists. The OIG found no deficiencies. Specialized Medical Housing COR showed much improvement in provider performance since the Cycle 4 inspection. There were fewer deficiencies and only one significant deficiency, which is also discussed in the Specialized Medical Housing indicator:  In case 1, the patient had an unwitnessed fall. The on-call provider ordered the CTC provider to evaluate the patient that morning. Despite the nurse reminding the CTC provider to see the patient, the patient was not seen. Fortunately, there were no significant injuries to the patient. California State Prison, Corcoran, Cycle 5 Medical Inspection Page 43 Office of the Inspector General State of California Provider Continuity COR had good provider continuity of care. In addition, despite the fact that it was a large CTC, one provider was primarily responsible for the day-to-day care of CTC patients. Documentation Quality Most providers demonstrated good documentation quality. Clinician Onsite Inspection The OIG interviewed the CP&S, who had provided medical leadership without a CME for several years. CCHCS had occasionally rotated in other executive medical staff to help. A major focus for COR had been to correct an access to care backlog over the last year for provider appointments. This was corrected by filling provider vacancies and conducting additional weekend medical clinics to catch up. Providers from other institutions assisted in the weekend clinics. They developed new processes to ensure sustained compliance performance, such as monitoring patients who were close to the compliance scheduling deadlines. In addition, communication with custody was improved to help improve patient attendance in the clinics. The morale of the providers was good, especially after adequate staffing was reached. The providers felt supported by their CP&S, and reported that he was an excellent leader. The CP&S also highlighted working to improve the weak provider areas identified in the OIG’s Cycle 4 inspection. COR had the providers work on chronic care training, CCHCS guidelines review, and patient registry review for their quality improvement measures. Case Review Conclusion The OIG noted substantial improvement in the provider performance since the Cycle 4 inspection. The previously weak areas, such as chronic care and specialized medical housing, had marked improvement. With these findings, the OIG rated the Quality of Provider Performance indicator adequate. California State Prison, Corcoran, Cycle 5 Medical Inspection Page 44 Office of the Inspector General State of California 12 — RECEPTION CENTER ARRIVALS This indicator focuses on the management of medical needs and Case Review Rating: continuity of care for patients arriving from outside the CDCR Not Applicable system. The OIG review includes evaluation of the ability of the Compliance Score: institution to provide and document initial health screenings, Not Applicable initial health assessments, continuity of medications, and Overall Rating: completion of required screening tests; address and provide Not Applicable significant accommodations for disabilities and health care appliance needs; and identify health care conditions needing treatment and monitoring. The patients reviewed for reception center cases are those received from non-CDCR facilities, such as county jails. Because COR did not have a reception center, this indicator did not apply. California State Prison, Corcoran, Cycle 5 Medical Inspection Page 45 Office of the Inspector General State of California 13 — SPECIALIZED MEDICAL HOUSING This indicator addresses whether the institution follows appropriate Case Review Rating: policies and procedures when admitting patients to onsite inpatient Adequate facilities, including completion of timely nursing and provider Compliance Score: assessments. The chart review assesses all aspects of medical care Adequate related to these housing units, including quality of provider and (76.7%) nursing care. COR’s specialized medical housing units consisted of Overall Rating: a CTC and an OHU. Adequate Case Review Results The specialized medical housing at COR consisted of a 50-bed CTC and a 14-bed OHU. There were 25 CTC beds assigned to mental health patients. The OIG clinicians reviewed 256 specialized medical housing events, which included 72 provider and 37 nursing encounters, some of which included several consecutive days of inpatient care. There were a total of 107 deficiencies, of which four were significant. Three of the significant deficiencies were delays in appointments and scheduling for provider evaluation, and one was in provider performance. There were no significant deficiencies found in nursing care in the cases reviewed, and the OIG clinicians rated this indicator adequate. Provider Performance In general, the providers at COR gave good care to patients in the CTC and OHU. The OIG reviewed 72 provider events in specialized medical housing. There were five deficiencies, one of which was significant, also discussed in the Quality of Provider Performance indicator:  In case 1, the patient had an unwitnessed fall. The on-call provider ordered the CTC provider to evaluate the patient that morning. Despite the nurse reminding the CTC provider to see the patient, the patient was not seen. Fortunately, there were no significant injuries to the patient. Nursing Performance The nursing staff at COR provided good care to patients in the CTC and OHU. There were six admissions to either the CTC or the OHU. The nurses conducted physical examinations upon admission, patient assessments that included the general status regarding activities of daily living, and re-assessment after providing interventions such as pain medication. Nursing documentation was fairly thorough. However, improvements could be made in documenting ongoing assessment of peripherally inserted central catheter (PICC) intravenous lines (case 1), potential for falls (case 2), fluid retention status (case 5), and wound condition (case 21). California State Prison, Corcoran, Cycle 5 Medical Inspection Page 46 Office of the Inspector General State of California Access to Care At COR, the OIG reviewed the care in specialized medical housing for four admissions and 71 follow-up visits. There were three significant missed or late follow-up visits:  In case 1, the provider follow-up visit was one month overdue for this patient receiving care for his stroke and other medical problems.  Also in case 1, another provider follow-up visit was one month overdue.  In case 21, a patient was seen seven days late after returning from an outside emergency department for seizure management. Clinician Onsite Inspection During the onsite visit, the OIG clinicians found the CTC to be well staffed with experienced nurses, providers, and sufficient custody staff to support the timely provision of needed care to patients. There was one physician assigned full time to the CTC, with other providers assisting as needed. This provided excellent continuity of patient care in this CTC with 25 medical beds. There was also 24-hour RN coverage. Patients were only admitted with a physician’s order. The staff was familiar with the patients’ right to refuse and generally contacted the physician if the patient refused care. In the Cycle 4 inspection, COR was found deficient for the lack of nursing care plans. However, nursing care plans were documented in all CTC admissions reviewed in Cycle 5. Case Review Conclusion The OIG clinicians found improved care in specialized medical housing since Cycle 4, and rated this indicator adequate. Compliance Testing Results The institution received and adequate compliance score of 76.7 percent in the Specialized Medical Housing indicator, with proficient scores in two tests, as follows:  Nursing staff completed an initial assessment for fifteen of sixteen sampled patients on the day the patient was admitted to the specialized medical housing (94 percent). For one OHU admission, there was no RN initial assessment found in the electronic medical record (MIT 13.001).  Among ten sampled patients admitted to the CTC, nine (90 percent) were provided timely, complete history and physical examinations by a provider within 24 hours of admission. One patient’s examination was completed one day late (MIT 13.002). California State Prison, Corcoran, Cycle 5 Medical Inspection Page 47 Office of the Inspector General State of California COR showed room for improvement in two areas:  When the OIG tested whether providers completed Subjective, Objective, Assessment, Plan, and Education (SOAPE) notes for patients at required intervals, providers were compliant for only 9 of 16 sampled patients (56 percent). Two patients had provider notes that were 14 days late, and providers did not complete SOAPE notes for five sampled patients (MIT 13.003).  When inspectors observed the working order of call buttons in patient rooms in the CTC and the OHU, inspectors found all working properly. In addition, according to staff members interviewed, custody officers and clinicians were able to expeditiously access patients’ locked rooms when emergent events occurred. However in the OHU, staff did not maintain a call system log to confirm if daily tests were performed and logged, resulting in a score of 67 percent on this test (MIT 13.101). California State Prison, Corcoran, Cycle 5 Medical Inspection Page 48 Office of the Inspector General State of California 14 — 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 Proficient time of receipt of related recommendations from specialists. This Compliance Score: indicator also evaluates the providers’ timely review of specialist Adequate records and documentation reflecting the patients’ care plans, (77.3%) 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 patient is updated on the plan of care. For this indicator, the OIG’s case review and compliance review process yielded different results, with the case review giving a proficient rating and the compliance review resulting in an adequate score. The OIG’s internal review process considered those factors that led to both scores and ultimately rated this indicator adequate. The main factors preventing the proficient overall rating was the compliance results found some poor reviews of routine specialty reports and late denials of specialty services. Case Review Results The OIG clinicians reviewed 113 events related to specialty services, which included 66 specialty consultations and procedures, 27 provider encounters, and 20 nursing encounters. Twelve minor deficiencies were found in this category. The OIG rated the Specialty Services indicator at COR proficient. Access to Specialty Services COR did well providing access to specialty care. There were two minor deficiencies:  In case 21, the patient had an offsite surgical procedure to remove an implanted heart monitor. There was no provider follow-up visit to check on the patient until 11 days later. During that encounter, the provider failed to address the procedure.  In case 36, the patient with chronic pain refused an offsite neurology appointment. The provider was not notified of the patient’s refusal. Nursing Performance Nursing did well with supporting specialty services. There were two minor deficiencies: California State Prison, Corcoran, Cycle 5 Medical Inspection Page 49 Office of the Inspector General State of California  In case 33, the telemedicine nurse failed to notify the provider about the gastroenterologist’s medication recommendations. This resulted in a 13-day delay for medications needed by the patient with inflammatory bowel disease.  In case 45, the patient had rectal bleeding and an imaging procedure was scheduled, but the patient refused the procedure. Nursing completed the refusal form five days after the refusal. Provider Performance Providers did very well with specialty services. No deficiencies were found. Health Information Management There were eight minor deficiencies regarding health information management in specialty services. Two were when documents were scanned without a provider signature. The others were minor delays in scanning or mislabeling of electronic files. Only one of these errors delayed care, but not significantly:  In case 33, the gastroenterology consultation report was received 12 days late. This contributed to a delay in starting medications for a patient with inflammatory bowel disease. Clinician Onsite Inspection The OIG met with the utilization management RN tasked with specialty services at COR. This person had started in this position approximately eight months earlier. This nurse identified a high workload, which prevented effective care in this area. The nurse requested and obtained an office technician to assist with the workload. In addition, moving a previously relocated fax machine back to the specialty services area greatly improved operational efficiency. During the next eight months, the two problem areas that led to the poor rating of this indicator in Cycle 4, delay of specialty appointments and missing reports, were corrected. Case Review Conclusion The OIG rated the Specialty Services indicator at COR proficient. Compliance Testing Results The institution received an adequate compliance score of 77.3 percent in the Specialty Services indicator, with proficient scores in the following three areas:  COR provided routine specialty service appointments to 14 of 15 patients tested within the required time frame (93 percent). For one patient, there was no evidence found that the patient received the specialty service (MIT 14.003). California State Prison, Corcoran, Cycle 5 Medical Inspection Page 50 Office of the Inspector General State of California  Providers timely received and reviewed the specialists’ reports for 12 of the 13 applicable patients sampled (92 percent). For one patient, the provider received and reviewed the report 14 days late (MIT 14.002).  When patients are approved or scheduled for specialty services appointments at one institution and then transfer to another institution, policy requires that the receiving institution ensure that the patient’s appointment is timely rescheduled or scheduled, and held. Eighteen of the 20 patients sampled (90 percent) received their specialty services appointment timely. Two patients received their specialty appointment 56 and 65 days late (MIT 14.005). Two tests received adequate scores in this indicator:  Twelve of the 15 patients sampled (80 percent) received or refused their high priority specialty services appointment or service within 14 calendar days of the provider’s order. Three patients received their specialty service from one to six days late (MIT 14.001).  For 18 applicable patients sampled who had a specialty service denied by COR’s health care management, 14 patients (78 percent) received timely notification of the denied service, including a provider meeting with the patient within 30 days to discuss alternate treatment strategies. For two sampled patients, the specialty service denial notification occurred 21 and 26 days late. For the remaining two sampled patients, there was no evidence of provider follow-up to discuss the denial (MIT 14.007). The following tests received inadequate scores and showed areas for improvement:  Providers timely received and reviewed 3 of the 8 applicable routine specialists’ reports that inspectors sampled (38 percent). For five patients, providers reviewed the reports from one to ten days late (MIT 14.004).  The institution' administration timely denied providers’ specialty service requests for 14 of 20 patients sampled (70 percent). Four of the specialty service request denials were between one and 6 days late. Two other denials were issued 15 and 25 days late (MIT 14.006). California State Prison, Corcoran, Cycle 5 Medical Inspection Page 51 Office of the Inspector General State of California 15 — ADMINISTRATIVE OPERATIONS(SECONDARY) This indicator focuses on the institution’s administrative health care Case Review Rating: oversight functions. The OIG evaluates whether the institution Not Applicable promptly processes patient medical appeals and addresses all Compliance Score: appealed issues. Inspectors also verify that the institution follows Inadequate reporting requirements for adverse/sentinel events and patient (65.2%) deaths. The OIG verifies that the Emergency Medical Response Overall Rating: Review Committee (EMRRC) performs required reviews and that Inadequate 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. In addition, OIG examines whether the institution adequately manages its health care staffing resources by evaluating whether job performance reviews are completed as required; specified staff possess current, valid credentials and professional licenses or certifications; nursing staff receive new employee orientation training and annual competency testing; and clinical and custody staff have current medical emergency response certifications. The Administrative Operations indicator is a secondary indicator, and, therefore, was not relied on for the overall score for the institution. Compliance Testing Results The institution received an inadequate compliance score of 65.2 percent in the Administrative Operations indicator, showing room for improvement in the following areas:  The pharmacist in charge (PIC) at COR was not able to describe the Drug Enforcement Agency (DEA) registration process for COR providers, and the PIC only provided an outdated DEA registration list. The PIC relied on the CEO’s assistant to monitor DEA registration compliance. As a result, COR received a zero on this test (MIT 15.110).  COR’s two nurses hired within the most recent 12 months did not receive timely new employee orientation trainings. They each received their orientation ten days late, for a score of zero (MIT 15.111).  The OIG reviewed data received from the institution to determine if COR timely processed at least 95 percent of its monthly patient medical appeals during the most recent 12 month period. COR timely processed only one of the 12 months’ appeals reviewed (8 percent). Of the 11 months with more than 5 percent of medical appeals in overdue status, the percentages late ranged from 4 to 100 percent (MIT 15.001).  The OIG reviewed documentation for 12 emergency medical response incidents addressed by the institution’s EMRRC during the prior six-month period; only three (25 percent) were California State Prison, Corcoran, Cycle 5 Medical Inspection Page 52 Office of the Inspector General State of California compliant because the required EMRRC Event Checklist forms were not fully completed (MIT 15.005).  COR’s local governing body met quarterly during the four-quarter period ending January 2017, but only one of the quarter’s corresponding meeting minutes were sufficiently detailed and timely approved (25 percent). Three of the four quarterly meeting minutes were not approved timely by either the CEO or the warden (MIT 15.006).  Inspectors reviewed six recent months’ QMC meeting minutes and confirmed that the QMC evaluated program performance and took action when the committee identified improvement opportunities. Four of the six meetings (67 percent) were held properly; in the other two meetings, subcommittee reports were not submitted and no scorecard performance data was provided (MIT 15.003).  COR had three patient deaths occur during the OIG’s sample test period; for one of the deaths, the institution did not timely notify the CCHCS Death Review Unit. The notification was required to be made by noon on the business day following the date of death. As a result, the institution received a score of 67 percent on this test (MIT 15.103).  Five of seven COR providers had a proper clinical performance appraisal completed by their supervisor (71 percent). Two other providers did not have either timely or properly completed appraisals, including the following (MIT 15.106): o One provider’s evaluation was overdue by 48 calendar days. o Another provider’s evaluation had not been completed since the provider passed probation. In addition, the provider’s review packet did not include a recent Unit Health Clinic Appraisal, a core competency-based evaluation, or a 360 Degree evaluation. One test in this indicator scored in the adequate range:  When inspectors examined records to determine if nursing supervisors were completing the required number of monthly case reviews on subordinate nurses as well as discussing the results of those reviews, four of five sampled nurse supervisors properly completed their reviews. As a result, COR scored 80 percent on this test. One nursing supervisor did not complete the required number of nursing reviews for the month of January 2017 (MIT 15.104). The institution received proficient scores of 100 percent on seven tests in this indicator, as follows:  COR took adequate steps to ensure the accuracy of its Dashboard data reporting (MIT 15.004). California State Prison, Corcoran, Cycle 5 Medical Inspection Page 53 Office of the Inspector General State of California  Inspectors reviewed drill packages for three medical emergency response drills conducted in the prior quarter, and all contained required summary reports and related documentation. In addition, the drills included participation by both health care and custody staff (MIT 15.101).  Based on a sample of ten second-level medical appeals, the institution’s responses addressed all of the patients’ appealed issues (MIT 15.102).  All ten nurses’ records sampled were current with their clinical competency validations (MIT 15.105).  All providers at the institution were current with their professional licenses. Similarly, all nursing staff and the PIC were current with their professional licenses and certification requirements (MIT 15.107, 15.109).  All active duty providers, nurses, and custody staff were current with their emergency response certifications (MIT 15.108). Non-Scored Results  The OIG gathered non-scored data regarding the completion of death review reports by CCHCS’s Death Review Committee (DRC). Three deaths occurred during the OIG’s review period, two unexpected (Level 1) deaths and one expected (Level 2) death. The DRC was required to complete its death review summary report within 60 days from the date of death for the Level 1 death and within 30 days from the date of death for the Level 2 deaths; the reports should then have been submitted to the institution’s chief executive officer (CEO) within seven calendar days thereafter. However, for the two Level 1 deaths, the DRC completed its reports 46 and 74 days late (106 and 134 days after death) and submitted them to COR’s CEO 2 and 13 days late; for the one Level 2 death, the DRC completed its report 52 days late (82 days after death) and submitted it to the CEO 12 days late (MIT 15.998).  The OIG discusses COR’s health care staffing resources in the About the Institution section on page 2 (MIT 15.999). California State Prison, Corcoran, Cycle 5 Medical Inspection Page 54 Office of the Inspector General State of California R ECOMMENDATIONS No specific recommendations. California State Prison, Corcoran, Cycle 5 Medical Inspection Page 55 Office of the Inspector General State of California P -B M OPULATION ASED ETRICS The compliance testing and the case reviews give an accurate assessment of how the institution’s health care systems are functioning with regard to the patients with the highest risk and utilization. This information is vital to assess the capacity of the institution to provide sustainable, adequate care. However, one significant limitation of the case review methodology is that it does not give a clear assessment of how the institution performs for the entire population. For better insight into this performance, the OIG has turned to population-based metrics. For comparative purposes, the OIG has selected several Healthcare Effectiveness Data and Information Set (HEDIS) measures for disease management to gauge the institution’s effectiveness in outpatient health care, especially chronic disease management. The Healthcare Effectiveness Data and Information Set is a set of standardized performance measures developed by the National Committee for Quality Assurance with input from over 300 organizations representing every sector of the nation’s health care industry. It is used by over 90 percent of the nation’s health plans as well as many leading employers and regulators. 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 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 State Prison, Corcoran, nine HEDIS measures were selected and are listed in the following COR 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 State Prison, Corcoran, Cycle 5 Medical Inspection Page 56 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. COR outperformed two entities in the diabetic measures selected, but scored lower than some of the other entities in diabetic monitoring, blood pressure control, and conducting required dilated eye exams for diabetic patients. When compared statewide, COR outperformed Med-Cal in all five diabetic measures. The institution also outperformed Kaiser Permanente in three of the five measures, scoring lower than Kaiser, both North and South regions, in diabetic blood pressure control, and lower than Kaiser, South, in diabetic eye exams. When compared nationally, COR outperformed Medicaid, Medicare, and commercial health plans in all five diabetic measures. COR outperformed or closely matched the U.S Department of Veterans Affairs (VA) in all applicable measures except diabetic eye exams, in which it scored 20 percentage points lower than the VA. However, inspectors noted that 20 percent of COR’s sampled patients were offered the eye exams but refused; these refusals adversely affected the institution’s score in this measure. Immunizations Comparative data for immunizations was only fully available for the VA and partially available for Kaiser, commercial plans, Medicaid, and Medicare. With respect to administering influenza vaccinations to younger adults, COR outperformed Medicaid. However, COR scored lower than Kaiser, both North and South, commercial health plans, and the VA. The 55 percent patient refusal rate negatively affected the institution’s score in this measure. However, COR outperformed both Medicare and the VA in influenza vaccinations for older adults. With regard to administering pneumococcal vaccines to older adults, COR scored higher than Medicare but slightly lower than the VA. Cancer Screening With respect to colorectal cancer screening, COR scored lower than all reporting entities except commercial health plans. Similar to the immunization measures, patient refusals (28 percent) negatively affected the institution’s score. Summary The population-based metrics performance of COR reflected an adequate chronic care program in comparison to the other statewide and national health care plans. The institution has an opportunity to improve its scores for immunizations and colorectal cancer screening through patient education about the benefits of these preventive services. California State Prison, Corcoran, Cycle 5 Medical Inspection Page 57 Office of the Inspector General State of California COR Results Compared to State and National HEDIS Scores California National HEDIS Clinical Measures COR Kaiser HEDIS HEDIS HEDIS (No. Kaiser HEDIS Com- HEDIS VA Cycle 5 Medi-Cal CA) (So.CA) Medicaid mercial Medicare Average Results1 20152 20163 20163 20164 20164 20164 20155 Comprehensive Diabetes Care HbA1c Testing (Monitoring) 97% 86% 94% 94% 86% 90% 93% 98% Poor HbA1c Control (>9.0%)6, 7 10% 39% 20% 23% 45% 34% 27% 19% HbA1c Control (<8.0%)6 80% 49% 70% 63% 46% 55% 63% - Blood Pressure Control (<140/90)6 78% 63% 83% 83% 59% 60% 62% 74% Eye Exams 69% 53% 68% 81% 53% 54% 69% 89% Immunizations Influenza Shots - Adults (18–64) 45% - 56% 57% 39% 48% - 55% Influenza Shots - Adults (65+) 77% - - - - - 72% 76% Immunizations: Pneumococcal 87% - - - - - 71% 93% Cancer Screening Colorectal Cancer Screening 65% - 79% 82% - 63% 67% 82% 1. Unless otherwise stated, data was collected in Month 2017 by reviewing medical records from a sample of COR’s population of applicable patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. 2. HEDIS Medi-Cal data was obtained from the California Department of Health Care Services 2015 HEDIS Aggregate Report for Medi-Cal Managed Care. 3. Data was obtained from Kaiser Permanente November 2016 reports for the Northern and Southern California regions. 4. National HEDIS data for Medicaid, commercial plans, and Medicare was obtained from the 2015 State of Health Care Quality Report, available on the NCQA website: www.ncqa.org. The results for commercial plans were based on data received from various health maintenance organizations. 5. The Department of Veterans Affairs (VA) data was obtained from the VA’s website, www.va.gov. For the Immunizations: Pneumococcal measure only, the data was obtained from the VHA Facility Quality and Safety Report - Fiscal Year 2012 Data. 6. For this indicator, the entire applicable COR 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 State Prison, Corcoran, Cycle 5 Medical Inspection Page 58 Office of the Inspector General State of California A A — C T R PPENDIX OMPLIANCE EST ESULTS California State Prison, Corcoran (COR) Range of Summary Scores: 43.00% - 87.04% Indicator Compliance Score (Yes %) 1–Access to Care 81.07% 2–Diagnostic Services 74.76% 3–Emergency Services Not Applicable 4–Health Information Management (Medical Records) 67.23% 5–Health Care Environment 70.65% 6–Inter- and Intra-System Transfers 43.00% 7–Pharmacy and Medication Management 56.09% 8–Prenatal and Post-Delivery Services Not Applicable 9–Preventive Services 87.04% 10–Quality of Nursing Performance Not Applicable 11–Quality of Provider Performance Not Applicable 12–Reception Center Arrivals Not Applicable 13–Specialized Medical Housing (OHU, CTC, SNF, Hospice) 76.67% 14–Specialty Services 77.27% 15–Administrative Operations 65.19% California State Prison, Corcoran, Cycle 5 Medical Inspection Page 59 Office of the Inspector General State of California Scored Answers Yes Reference + 1–Access to Care Number Yes No No Yes % N/A Chronic care follow-up appointments: Was the patient’s most recent chronic care visit within the health care guideline’s 1.001 15 10 25 60.00% 0 maximum allowable interval or within the ordered time frame, whichever is shorter? For endorsed patients received from another CDCR institution: If 1.002 the nurse referred the patient to a provider during the initial health 14 11 25 56.00% 0 screening, was the patient seen within the required time frame? Clinical appointments: Did a registered nurse review the patient’s 1.003 33 7 40 82.50% 0 request for service the same day it was received? Clinical appointments: Did the registered nurse complete a 1.004 face-to-face visit within one business day after the CDCR Form 37 3 40 92.50% 0 7362 was reviewed? Clinical appointments: If the registered nurse determined a referral to a primary care provider was necessary, was the patient 1.005 9 5 14 64.29% 26 seen within the maximum allowable time or the ordered time frame, whichever is the shorter? Sick call follow-up appointments: If the primary care provider 1.006 ordered a follow-up sick call appointment, did it take place within 5 0 5 100% 35 the time frame specified? Upon the patient's discharge from the community hospital: Did 1.007 the patient receive a follow-up appointment within the required 22 3 25 88.00% 0 time frame? Specialty service follow-up appointments: Do specialty service 1.008 primary care physician follow-up visits occur within required time 19 3 22 86.36% 8 frames? Clinical appointments: Do patients have a standardized process to 1.101 6 0 6 100% 0 obtain and submit health care services request forms? Overall percentage: 81.07% California State Prison, Corcoran, Cycle 5 Medical Inspection Page 60 Office of the Inspector General State of California Scored Answers Yes Reference + 2–Diagnostic Services Number Yes No No Yes % N/A Radiology: Was the radiology service provided within the time 2.001 9 0 9 100% 1 frame specified in the provider's order? Radiology: Did the primary care provider review and initial the 2.002 2 8 10 20.00% 0 diagnostic report within specified time frames? Radiology: Did the primary care provider communicate the results 2.003 10 0 10 100% 0 of the diagnostic study to the patient within specified time frames? Laboratory: Was the laboratory service provided within the time 2.004 9 1 10 100% 0 frame specified in the provider's order? Laboratory: Did the primary care provider review and initial the 2.005 10 0 10 100% 0 diagnostic report within specified time frames? Laboratory: Did the primary care provider communicate the 2.006 results of the diagnostic study to the patient within specified time 10 0 10 100% 0 frames? Pathology: Did the institution receive the final diagnostic report 2.007 7 3 10 70.00% 0 within the required time frames? Pathology: Did the primary care provider review and initial the 2.008 4 4 8 50.00% 2 diagnostic report within specified time frames? Pathology: Did the primary care provider communicate the results 2.009 3 4 7 42.86% 3 of the diagnostic study to the patient within specified time frames? Overall percentage: 74.76% 3–Emergency Services This indicator is evaluated only by case review clinicians. There is no compliance testing component. California State Prison, Corcoran, Cycle 5 Medical Inspection Page 61 Office of the Inspector General State of California Scored Answers Yes Reference + 4–Health Information Management Number Yes No No Yes % N/A Are non-dictated healthcare documents (provider progress notes) 4.001 19 1 20 95.00% 0 scanned within 3 calendar days of the patient encounter date? Are dictated/transcribed documents scanned into the patient’s 4.002 electronic health record within five calendar days of the encounter 10 1 11 90.91% 0 date? Are High-Priority specialty notes (either a Form 7243 or other 4.003 scanned consulting report) scanned within the required time 12 6 18 66.67% 0 frame? Are community hospital discharge documents scanned into the 4.004 patient’s electronic health record within three calendar days of 18 2 20 90.00% 0 hospital discharge? Are medication administration records (MARs) scanned into the 4.005 12 3 15 80.00% 0 patient’s electronic health record within the required time frames? During the inspection, were medical records properly scanned, 4.006 0 24 24 0.00% 0 labeled, and included in the correct patients’ files? For patients discharged from a community hospital: Did the preliminary hospital discharge report include key elements and 4.007 12 13 25 48.00% 0 did a primary care provider review the report within three calendar days of discharge? Overall percentage: 67.23% California State Prison, Corcoran, Cycle 5 Medical Inspection Page 62 Office of the Inspector General State of California Scored Answers Yes Reference + 5–Health Care Environment Number Yes No No Yes % N/A Are clinical health care areas appropriately disinfected, cleaned 5.101 12 2 14 85.71% 0 and sanitary? Do clinical health care areas ensure that reusable invasive and 5.102 non-invasive medical equipment is properly sterilized or 13 1 14 92.86% 0 disinfected as warranted? Do clinical health care areas contain operable sinks and sufficient 5.103 12 2 14 85.71% 0 quantities of hygiene supplies? Does clinical health care staff adhere to universal hand hygiene 5.104 11 3 14 78.57% 0 precautions? Do clinical health care areas control exposure to blood-borne 5.105 12 2 14 85.71% 0 pathogens and contaminated waste? Warehouse, Conex and other non-clinic storage areas: Does the 5.106 medical supply management process adequately support the needs 0 1 1 0.00% 0 of the medical health care program? Does each clinic follow adequate protocols for managing and 5.107 12 2 14 85.71% 0 storing bulk medical supplies? Do clinic common areas and exam rooms have essential core 5.108 4 10 14 28.57% 0 medical equipment and supplies? Do clinic common areas have an adequate environment conducive 5.109 14 0 14 100% 0 to providing medical services? Do clinic exam rooms have an adequate environment conducive 5.110 9 5 14 64.29% 0 to providing medical services? Emergency response bags: Are TTA and clinic emergency 5.111 medical response bags inspected daily and inventoried monthly, 7 3 10 70.00% 4 and do they contain essential items? Overall percentage: 70.65% California State Prison, Corcoran, Cycle 5 Medical Inspection Page 63 Office of the Inspector General State of California Scored Answers Yes Reference + 6–Inter- and Intra-System Transfers Number Yes No No Yes % N/A For endorsed patients received from another CDCR institution or COCF: Did nursing staff complete the initial health screening and 6.001 7 18 25 28.00% 0 answer all screening questions on the same day the patient arrived at the institution? For endorsed patients received from another CDCR institution or COCF: When required, did the RN complete the assessment and disposition section of the health screening form; refer the patient 6.002 13 12 25 52.00% 0 to the TTA, if TB signs and symptoms were present; and sign and date the form on the same day staff completed the health screening? For endorsed patients received from another CDCR institution or COCF: If the patient had an existing medication order upon 6.003 12 8 20 60.00% 5 arrival, were medications administered or delivered without interruption? For patients transferred out of the facility: Were scheduled 6.004 specialty service appointments identified on the patient’s health 15 5 20 75.00% 0 care transfer information form? For patients transferred out of the facility: Do medication transfer 6.101 packages include required medications along with the 0 7 7 0.00% 0 corresponding transfer packet required documents? Overall percentage: 43.00% California State Prison, Corcoran, Cycle 5 Medical Inspection Page 64 Office of the Inspector General State of California Scored Answers 7–Pharmacy and Medication Yes Reference + Management Number Yes No No Yes % N/A Did the patient receive all chronic care medications within the 7.001 required time frames or did the institution follow departmental 8 7 15 53.33% 10 policy for refusals or no-shows? Did health care staff administer, make available, or deliver new 7.002 order prescription medications to the patient within the required 25 0 25 100% 0 time frames? Upon the patient’s discharge from a community hospital: Were all 7.003 ordered medications administered, made available, or delivered to 12 13 25 48.00% 0 the patient within required time frames? For patients received from a county jail: Were all medications ordered by the institution’s reception center provider 7.004 Not Applicable administered, made available, or delivered to the patient within the required time frames? Upon the patient’s transfer from one housing unit to another: 7.005 17 8 25 68.00% 0 Were medications continued without interruption? For patients en route who lay over at the institution: If the 7.006 temporarily housed patient had an existing medication order, were 2 8 10 20.00% 0 medications administered or delivered without interruption? All clinical and medication line storage areas for narcotic 7.101 medications: Does the Institution employ strong medication 4 8 12 33.33% 2 security over narcotic medications assigned to its clinical areas? All clinical and medication line storage areas for non-narcotic medications: Does the Institution properly store non-narcotic 7.102 8 5 13 61.54% 1 medications that do not require refrigeration in assigned clinical areas? All clinical and medication line storage areas for non-narcotic 7.103 medications: Does the institution properly store non-narcotic 11 2 13 84.62% 1 medications that require refrigeration in assigned clinical areas? Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols 7.104 5 2 7 71.43% 7 during medication preparation and medication administration processes? Medication preparation and administration areas: Does the 7.105 institution employ appropriate administrative controls and 7 0 7 100% 7 protocols when preparing medications for patients? Medication preparation and administration areas: Does the 7.106 Institution employ appropriate administrative controls and 4 3 7 57.14% 7 protocols when distributing medications to patients? Pharmacy: Does the institution employ and follow general 7.107 security, organization, and cleanliness management protocols in 0 1 1 0.00% 0 its main and satellite pharmacies? California State Prison, Corcoran, Cycle 5 Medical Inspection Page 65 Office of the Inspector General State of California Scored Answers 7–Pharmacy and Medication Yes Reference + Management Number Yes No No Yes % N/A Pharmacy: Does the institution’s pharmacy properly store 7.108 0 1 1 0.00% 0 non-refrigerated medications? Pharmacy: Does the institution’s pharmacy properly store 7.109 1 0 1 100% 0 refrigerated or frozen medications? Pharmacy: Does the institution’s pharmacy properly account for 7.110 1 0 1 100% 0 narcotic medications? Does the institution follow key medication error reporting 7.111 0 25 25 0.00% 0 protocols? Overall percentage: 56.09% 8–Prenatal and Post-Delivery Services The institution has no female patients, so this indicator is not applicable. California State Prison, Corcoran, Cycle 5 Medical Inspection Page 66 Office of the Inspector General State of California Scored Answers Yes Reference + 9–Preventive Services Number Yes No No Yes % N/A Patients prescribed TB medication: Did the institution administer 9.001 8 0 8 100% 0 the medication to the patient as prescribed? Patients prescribed TB medication: Did the institution monitor the 9.002 patient monthly for the most recent three months he or she was on 8 0 8 100% 0 the medication? Annual TB Screening: Was the patient screened for TB within the 9.003 14 16 30 46.67% 0 last year? Were all patients offered an influenza vaccination for the most 9.004 25 0 25 100% 0 recent influenza season? All patients from the age of 50 - 75: Was the patient offered 9.005 23 2 25 92.00% 0 colorectal cancer screening? Female patients from the age of 50 through the age of 74: Was the 9.006 Not Applicable patient offered a mammogram in compliance with policy? Female patients from the age of 21 through the age of 65: Was 9.007 Not Applicable patient offered a pap smear in compliance with policy? Are required immunizations being offered for chronic care 9.008 24 0 24 100% 1 patients? Are patients at the highest risk of coccidioidomycosis (valley 9.009 12 5 17 70.59% 0 fever) infection transferred out of the facility in a timely manner? Overall percentage: 87.04% 10–Quality of Nursing Performance This indicator is evaluated only by case review clinicians. There is no compliance testing component. 11–Quality of Provider Performance This indicator is evaluated only by case review clinicians. There is no compliance testing component. California State Prison, Corcoran, Cycle 5 Medical Inspection Page 67 Office of the Inspector General State of California 12–Reception Center Arrivals The institution has no reception center, so this indicator is not applicable. Scored Answers Yes Reference + 13–Specialized Medical Housing Number Yes No No Yes % N/A For OHU, CTC, and SNF: Did the registered nurse complete an 13.001 initial assessment of the patient on the day of admission, or within 15 1 16 93.75% 0 eight hours of admission to CMF’s Hospice? For CTC and SNF only: Was a written history and physical 13.002 9 1 10 90.00% 6 examination completed within the required time frame? For OHU, CTC, SNF, and Hospice: Did the primary care provider complete the Subjective, Objective, Assessment, Plan, and 13.003 9 7 16 56.25% 0 Education (SOAPE) notes on the patient at the minimum intervals required for the type of facility where the patient was treated? For OHU and CTC Only: Do inpatient areas either have properly working call systems in its OHU & CTC or are 30-minute patient 13.101 2 1 3 66.67% 0 welfare checks performed; and do medical staff have reasonably unimpeded access to enter patient’s cells? Overall percentage: 76.67% California State Prison, Corcoran, Cycle 5 Medical Inspection Page 68 Office of the Inspector General State of California Scored Answers Yes Reference + 14–Specialty Services Number Yes No No Yes % N/A Did the patient receive the high-priority specialty service within 14.001 14 calendar days of the primary care provider order or the 12 3 15 80.00% 0 Physician Request for Service? Did the primary care provider review the high-priority specialty 14.002 12 1 13 92.31% 2 service consultant report within the required time frame? Did the patient receive the routine specialty service within 90 14.003 calendar days of the primary care provider order or Physician 14 1 15 93.33% 0 Request for Service? Did the primary care provider review the routine specialty service 14.004 3 5 8 37.50% 7 consultant report within the required time frame? For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at 14.005 18 2 20 90.00% 0 the sending institution, was the appointment scheduled at the receiving institution within the required time frames? Did the institution deny the primary care provider request for 14.006 14 6 20 70.00% 0 specialty services within required time frames? Following the denial of a request for specialty services, was the 14.007 14 4 18 77.78% 2 patient informed of the denial within the required time frame? Overall percentage: 77.27% California State Prison, Corcoran, Cycle 5 Medical Inspection Page 69 Office of the Inspector General State of California Scored Answers Yes Reference 15–Administrative Operations + Number Yes No No Yes % N/A Did the institution promptly process inmate medical appeals 15.001 1 11 12 8.33% 0 during the most recent 12 months? Does the institution follow adverse / sentinel event reporting 15.002 Not Applicable requirements? Did the institution Quality Management Committee (QMC) meet at least monthly to evaluate program performance, and did the 15.003 4 2 6 66.67% 0 QMC take action when improvement opportunities were identified? Did the institution’s Quality Management Committee (QMC) or 15.004 other forum take steps to ensure the accuracy of its Dashboard 1 0 1 100% 0 data reporting? Does the Emergency Medical Response Review Committee 15.005 perform timely incident package reviews that include the use of 3 9 12 25.00% 0 required review documents? For institutions with licensed care facilities: Does the Local Governing Body (LGB), or its equivalent, meet quarterly and 15.006 1 3 4 25.00% 0 exercise its overall responsibilities for the quality management of patient health care? Did the institution complete a medical emergency response drill 15.101 for each watch and include participation of health care and 3 0 3 100% 0 custody staff during the most recent full quarter? Did the institution’s second level medical appeal response address 15.102 10 0 10 100% 0 all of the patient's appealed issues? Did the institution's medical staff review and submit the initial 15.103 2 1 3 66.67% 0 inmate death report to the Death Review Unit in a timely manner? Does the institution's Supervising Registered Nurse conduct 15.104 4 1 5 80.00% 0 periodic reviews of nursing staff? Are nursing staff who administer medications current on their 15.105 10 0 10 100% 0 clinical competency validation? 15.106 Are structured clinical performance appraisals completed timely? 5 2 7 71.43% 0 15.107 Do all providers maintain a current medical license? 8 0 8 100% 0 Are staff current with required medical emergency response 15.108 2 0 2 100% 1 certifications? Are nursing staff and the Pharmacist-in-Charge current with their professional licenses and certifications, and is the pharmacy licensed as a correctional pharmacy by the California State Board 15.109 6 0 6 100% 0 of Pharmacy? California State Prison, Corcoran, Cycle 5 Medical Inspection Page 70 Office of the Inspector General State of California Scored Answers Yes Reference 15–Administrative Operations + Number Yes No No Yes % N/A Do the institution’s pharmacy and authorized providers who 15.110 prescribe controlled substances maintain current Drug 0 1 1 0.00% 0 Enforcement Agency (DEA) registrations? 15.111 Are nursing staff current with required new employee orientation? 0 3 3 0.00% 0 Overall percentage: 65.19% California State Prison, Corcoran, Cycle 5 Medical Inspection Page 71 Office of the Inspector General State of California A B — C D PPENDIX LINICAL ATA Table B-1: COR Sample Sets Sample Set Total Anticoagulation 3 Death Review/Sentinel Events 3 Diabetes 3 Emergency Services – CPR 1 Emergency Services – Non-CPR 3 High Risk 5 Hospitalization 4 Intra-System Transfers In 3 Intra-System Transfers Out 3 RN Sick Call 24 Specialty Services 4 56 California State Prison, Corcoran, Cycle 5 Medical Inspection Page 72 Office of the Inspector General State of California Table B-2: COR Chronic Care Diagnoses Diagnosis Total Anemia 4 Anticoagulation 3 Arthritis/Degenerative Joint Disease 3 Asthma 14 COPD 6 Cancer 3 Cardiovascular Disease 5 Chronic Kidney Disease 1 Chronic Pain 14 Cirrhosis/End Stage Liver Disease 7 Diabetes 13 Gastroesophageal Reflux Disease 9 Hepatitis C 27 Hyperlipidemia 17 Hypertension 25 Mental Health 11 Seizure Disorder 6 Sickle Cell Anemia 1 Sleep Apnea 1 Thyroid Disease 4 174 California State Prison, Corcoran, Cycle 5 Medical Inspection Page 73 Office of the Inspector General State of California Table B-3: COR Event – Program Program Total Diagnostic Services 115 Emergency Care 80 Hospitalization 53 Intra-System Transfers In 6 Intra-System Transfers Out 3 Not Specified 4 Outpatient Care 458 Specialized Medical Housing 252 Specialty Services 132 1,103 California State Prison, Corcoran, Cycle 5 Medical Inspection Page 74 Office of the Inspector General State of California Table B-4: COR Review Sample Summary Total MD Reviews Detailed 25 MD Reviews Focused 2 RN Reviews Detailed 17 RN Reviews Focused 30 Total Reviews 74 Total Unique Cases 56 Overlapping Reviews (MD & RN) 18 California State Prison, Corcoran, Cycle 5 Medical Inspection Page 75 Office of the Inspector General State of California A C — C S M PPENDIX OMPLIANCE AMPLING ETHODOLOGY California State Prison, Corcoran (COR) Sample Category Quality (number of Indicator samples) Data Source Filters Access to Care MIT 1.001 Chronic Care Patients Master Registry  Chronic care conditions (at least one condition per patient—any risk level) (25)  Randomize MIT 1.002 Nursing Referrals OIG Q: 6.001  See Intra-system Transfers (25) MITs 1.003-006 Nursing Sick Call MedSATS  Clinic (each clinic tested) (5 per clinic)  Appointment date (2–9 months) 40  Randomize MIT 1.007 Returns from OIG Q: 4.007  See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (25) MIT 1.008 Specialty Services OIG Q: 14.001 &  See Specialty Services Follow-up 14.003 (30) MIT 1.101 Availability of Health OIG onsite  Randomly select one housing unit from each yard Care Services review Request Forms (6) Diagnostic Services MITs 2.001–003 Radiology Radiology Logs  Appointment date (90 days–9 months)  Randomize (10)  Abnormal MITs 2.004–006 Laboratory Quest  Appt. date (90 days–9 months)  Order name (CBC or CMPs only)  Randomize (10)  Abnormal MITs 2.007–009 Pathology InterQual  Appt. date (90 days–9 months)  Service (pathology related) (10)  Randomize California State Prison, Corcoran, Cycle 5 Medical Inspection Page 76 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Health Information Management (Medical Records) MIT 4.001 Timely Scanning OIG Qs: 1.001,  Non-dictated documents (20) 1.002, & 1.004  1st 10 IPs MIT 1.001, 1st 5 IPs MITs 1.002, 1.004 MIT 4.002 OIG Q: 1.001  Dictated documents (11)  First 20 IPs selected MIT 4.003 OIG Qs: 14.002  Specialty documents (18) & 14.004  First 10 IPs for each question MIT 4.004 OIG Q: 4.007  Community hospital discharge documents (20)  First 20 IPs selected MIT 4.005 OIG Q: 7.001  MARs (15)  First 20 IPs selected MIT 4.006 Documents for  Any misfiled or mislabeled document identified (24) any tested inmate during OIG compliance review (12 or more = No) MIT 4.007 Returns From Inpatient claims  Date (2–8 months) Community Hospital data  Most recent 6 months provided (within date range)  Rx count  Discharge date  Randomize (each month individually)  First 5 patients from each of the 6 months (if not 5 in a month, supplement from another, as needed) (25) Health Care Environment MIT 5.101-105 Clinical Areas OIG inspector  Identify and inspect all onsite clinical areas. MIT 5.107–111 (14) onsite review Inter- and Intra-System Transfers MIT 6.001-003 Intra-System SOMS  Arrival date (3–9 months) Transfers  Arrived from (another CDCR facility)  Rx count  Randomize (25) MIT 6.004 Specialty Services MedSATS  Date of transfer (3–9 months) Send-Outs  Randomize (20) MIT 6.101 Transfers Out OIG inspector  R&R IP transfers with medication (9) onsite review California State Prison, Corcoran, Cycle 5 Medical Inspection Page 77 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Pharmacy and Medication Management MIT 7.001 Chronic Care OIG Q: 1.001 See Access to Care Medication  At least one condition per patient—any risk level  Randomize (25) MIT 7.002 New Medication Master Registry  Rx count Orders  Randomize (25)  Ensure no duplication of IPs tested in MIT 7.001 MIT 7.003 Returns from OIG Q: 4.007  See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (25) MIT 7.004 RC Arrivals – OIG Q: 12.001  See Reception Center Arrivals Medication Orders N/A at this institution MIT 7.005 Intra-Facility Moves MAPIP transfer  Date of transfer (2–8 months) data  To location/from location (yard to yard and to/from ASU)  Remove any to/from MHCB  NA/DOT meds (and risk level) (25)  Randomize MIT 7.006 En Route SOMS  Date of transfer (2–8 months)  Sending institution (another CDCR facility)  Randomize (10)  NA/DOT meds MITs 7.101-103 Medication Storage OIG inspector  Identify and inspect clinical & med line areas that Areas onsite review store medications (varies by test) MITs 7.104–106 Medication OIG inspector  Identify and inspect onsite clinical areas that Preparation and onsite review prepare and administer medications Administration Areas (varies by test) MITs 7.107-110 Pharmacy OIG inspector  Identify & inspect all onsite pharmacies (1) onsite review MIT 7.111 Medication Error Monthly  All monthly statistic reports with Level 4 or higher Reporting medication error  Select a total of 5 months (25) reports MIT 7.999 Isolation Unit KOP Onsite active  KOP rescue inhalers & nitroglycerin medications Medications medication for IPs housed in isolation units (20) 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 State Prison, Corcoran, Cycle 5 Medical Inspection Page 78 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Preventive Services MITs 9.001–002 TB Medications Maxor  Dispense date (past 9 months)  Time period on TB meds (3 months or 12 weeks) (8)  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 (25)  Filter out IPs tested in MIT 9.008 MIT 9.005 Colorectal Cancer SOMS  Arrival date (at least 1 year prior to inspection) Screening  Date of birth (51 or older) (25)  Randomize MIT 9.006 Mammogram SOMS  Arrival date (at least 2 yrs prior to inspection)  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 (25)  Condition must require vaccination(s) MIT 9.009 Valley Fever Cocci transfer  Reports from past 2–8 months status report  Institution  Ineligibility date (60 days prior to inspection date) (number will vary)  All California State Prison, Corcoran, Cycle 5 Medical Inspection Page 79 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Reception Center Arrivals MITs 12.001–008 RC SOMS  Arrival date (2–8 months)  Arrived from (county jail, return from parole, etc.) N/A at this institution  Randomize Specialized Medical Housing MITs 13.001–004 CTC & OHU CADDIS  Admit date (1–6 months)  Type of stay (no MH beds)  Length of stay (minimum of 5 days) (16)  Randomize MIT 13.101 Call Buttons OIG inspector  Review by location CTC & OHU (all) onsite review Specialty Services MITs 14.001–002 High-Priority MedSATS  Approval date (3–9 months) (15)  Randomize MITs 14.003–004 Routine MedSATS  Approval date (3–9 months)  Remove optometry, physical therapy or podiatry (15)  Randomize MIT 14.005 Specialty Services MedSATS  Arrived from (other CDCR institution) Arrivals  Date of transfer (3–9 months) (20)  Randomize MIT 14.006-007 Denials InterQual  Review date (3–9 months) (20)  Randomize IUMC/MAR  Meeting date (9 months) Meeting Minutes  Denial upheld (0)  Randomize California State Prison, Corcoran, Cycle 5 Medical Inspection Page 80 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.001 Medical Appeals Monthly medical  Medical appeals (12 months) (all) appeals reports MIT 15.002 Adverse/Sentinel Adverse/sentinel  Adverse/sentinel events (2–8 months) Events events report (0) MITs 15.003–004 QMC Meetings Quality  Meeting minutes (12 months) Management Committee (6) meeting minutes MIT 15.005 EMRRC EMRRC meeting  Monthly meeting minutes (6 months) (12) minutes MIT 15.006 LGB LGB meeting  Quarterly meeting minutes (12 months) (4) minutes MIT 15.101 Medical Emergency Onsite summary  Most recent full quarter Response Drills reports &  Each watch documentation (3) for ER drills MIT 15.102 2nd Level Medical Onsite list of  Medical appeals denied (6 months) Appeals appeals/closed (10) appeals files MIT 15.103 Death Reports Institution-list of  Most recent 10 deaths deaths in prior 12  Initial death reports (3) months MIT 15.104 RN Review Onsite supervisor  RNs who worked in clinic or emergency setting Evaluations periodic RN six or more days in sampled month reviews  Randomize (5) MIT 15.105 Nursing Staff Onsite nursing  On duty one or more years Validations education files  Nurse administers medications (10)  Randomize MIT 15.106 Provider Annual Onsite provider  All required performance evaluation documents Evaluation Packets evaluation files (7) MIT 15.107 Provider licenses Current provider  Review all listing (at start of (8) inspection) MIT 15.108 Medical Emergency Onsite  All staff Response certification o Providers (ACLS) Certifications tracking logs o Nursing (BLS/CPR) (all)  Custody (CPR/BLS) MIT 15.109 Nursing staff and Onsite tracking  All required licenses and certifications Pharmacist in system, logs, or Charge Professional employee files Licenses and Certifications (all) California State Prison, Corcoran, Cycle 5 Medical Inspection Page 81 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.110 Pharmacy and Onsite listing of  All DEA registrations Providers’ Drug provider DEA Enforcement Agency registration #s & (DEA) Registrations pharmacy registration (all) document MIT 15.111 Nursing Staff New Nursing staff  New employees (hired within last 12 months) Employee training logs  Orientations (all) MIT 15.998 Death Review OIG summary  Between 35 business days & 12 months prior Committee log - deaths  CCHCS death reviews (3) California State Prison, Corcoran, Cycle 5 Medical Inspection Page 82 Office of the Inspector General State of California C C ALIFORNIA ORRECTIONAL H C S ’ EALTH ARE ERVICES R ESPONSE California State Prison, Corcoran, Cycle 5 Medical Inspection Page 83 Office of the Inspector General State of California