Correctional Training Facility Cycle 6 Medical Inspection Report

Amarik K. Singh, Inspector General Neil Robertson, Chief Deputy Inspector General OFFICE of the OIG INSPECTOR GENERAL Independent Prison Oversight September 2022 Cycle 6 Medical Inspection Report Correctional Training Facility Revised on 9-15-22; see next page for explanation. Report revised and republished on 9-15-22: On page 2 the second paragraph was edited to clarify this institution was delegated back to CDCR by the receiver. Electronic copies of reports published by the Office of the Inspector General are available free in portable document format (PDF) on our website. We also offer an online subscription service. For information on how to subscribe, visit www.oig.ca.gov. For questions concerning the contents of this report, please contact Shaun Spillane, Public Information Officer, at 916-255-1131. Cycle 6, Correctional Training Facility | iii Contents Introduction 1 Summary 3 Overall Rating: Inadequate 3 Medical Inspection Results 7 Deficiencies Identified During Case Review 7 Case Review Results 7 Compliance Testing Results 7 Population-Based Metrics 8 HEDIS Results 9 Recommendations 11 Access to Care 14 Diagnostic Services 20 Emergency Services 24 Health Information Management 29 Health Care Environment 35 Transfers 42 Medication Management 49 Preventive Services 57 Nursing Performance 60 Provider Performance 66 Specialized Medical Housing 71 Specialty Services 76 Administrative Operations 82 Appendix A: Methodology 86 Case Reviews 87 Compliance Testing 90 Indicator Ratings and the Overall Medical Quality Rating 91 Appendix B: Case Review Data 92 Appendix C. Compliance Sampling Methodology 95 California Correctional Health Care Services’ Response 104 Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | iv Illustrations Tables 1. CTF Summary Table 3 2. CTF Policy Compliance Scores 4 3. CTF Master Registry Data as of September 2021 5 4. CTF Health Care Staffing Resources as of August 2021 6 5. CTF Results Compared With State HEDIS Scores 10 6. Access to Care 17 7. Other Tests Related to Access to Care 18 8. Diagnostic Services 22 9. Health Information Management 32 10. Other Tests Related to Health Information Management 33 11. Health Care Environment 40 12. Transfers 46 13. Other Tests Related to Transfers 47 14. Medication Management 54 15. Other Tests Related to Medication Management 55 16. Preventive Services 58 17. Specialized Medical Housing 74 18. Specialty Services 79 19. Other Tests Related to Specialty Services 80 20. Administrative Operations 83 A–1. Case Review Definitions 87 B–1. Case Review Sample Sets 92 B–2. Case Review Chronic Care Diagnoses 93 B–3. Case Review Events by Program 94 B–4. Case Review Sample Summary 94 Figures A-1. Inspection Indicator Review Distribution for CTF 86 A–2. Case Review Testing 89 A–3. Compliance Sampling Methodology 90 Photographs 1. B North Specialty Clinic Outdoor Waiting Area 35 2. North Clinic Indoor Waiting Area 36 3. Multiple Patients Serviced at the Same Time in the Triage Station and in Close Proximity 36 4. Examination Rooms That Lacked Visual Privacy When Conducting Patient Examinations 37 5. Expired Medical Supplies Dated March 2021 37 6. Expired Medical Supplies Dated September 11, 2021 37 7. Unlabeled and Disorganized Medical Supplies; Also Unsanitary Storage of Tongue Depressors 38 8. EMRB Compromised Oral Airway Sterile Packaging 38 Cover: Rod of Asclepius courtesy of Thomas Shafee Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 1 Introduction Pursuant to California Penal Code section 6126 et seq., the Office of the Inspector General (the OIG) is responsible for periodically reviewing and reporting on the delivery of the ongoing medical care provided to incarcerated persons1 in the California Department of Corrections and Rehabilitation (the department).2 In Cycle 6, the OIG continues to apply the same assessment methodologies used in Cycle 5, including clinical case review and compliance testing. These methods provide an accurate assessment of how the institution’s health care systems function regarding patients with the highest medical risk who tend to access services at the highest rate. This information helps to assess the performance of the institution in providing sustainable, adequate care.3 We continue to review institutional care using 15 indicators, as in prior cycles. Using each of these indicators, our compliance inspectors collect data in answer to compliance- and performance-related questions as established in the medical inspection tool (MIT).4 We determine a total compliance score for each applicable indicator and consider the MIT scores in the overall conclusion of the institution’s performance. In addition, our clinicians complete document reviews of individual cases and also perform on-site inspections, which include interviews with staff. In reviewing the cases, our clinicians examine whether providers used sound medical judgment in the course of caring for a patient. In the event we find errors, we determine whether such errors were clinically significant or led to a significantly increased risk of harm to the patient.5 At the same time, our clinicians examine whether the institution’s medical system mitigated the error. The OIG rates the indicators as proficient, adequate, or inadequate. 1 In this report, we use the terms patient and patients to refer to incarcerated persons. 2 The OIG’s medical inspections are not designed to resolve questions about the constitutionality of care, and the OIG explicitly makes no determination regarding the constitutionality of care the department provides to its population. 3 In addition to our own compliance testing and case reviews, the OIG continues to offer selected Healthcare Effectiveness Data and Information Set (HEDIS) measures for comparison purposes. 4 The department regularly updates its policies. The OIG updates our policy-compliance testing to reflect the department’s updates and changes. 5 If we learn of a patient needing immediate care, we notify the institution’s chief executive officer. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 2 The OIG has adjusted Cycle 6 reporting in two ways. First, commencing with this reporting period, we interpret compliance and case review results together, providing a more holistic assessment of the care; and second, we consider whether institutional medical processes lead to identifying and correcting provider or system errors. The review assesses the institution’s medical care on both system and provider levels. As we did during Cycle 5, our office is continuing to inspect both those institutions remaining under federal receivership and those delegated back to the department. There is no difference in the standards used for assessing a delegated institution versus an institution not yet delegated. At the time of the Cycle 6 inspection Correctional Training Facility (CTF), the receiver had delegated this institution back to the department. We completed our sixth inspection of CTF, and this report presents our assessment of the health care provided at this institution during the inspection period February 2021 and July 2021.6 The data obtained for CTF, and the on-site inspections occurred during the COVID-19 pandemic.7 Correctional Training Facility (CTF) is located five miles north of the city of Soledad, in Monterey County. The institution’s primary mission is to provide custody, care, treatment, and rehabilitation for Level I and II general population. CTF runs multiple medical clinics where staff members handle nonurgent requests for medical services. The institution also treats patients needing urgent or emergent care in its triage and treatment area (TTA) and treats patients requiring outpatient health services and assistance with the activities of daily living in its outpatient housing unit (OHU). In addition, patients departing from or arriving to the institution are screened in receiving and release (R&R) clinic. CCHCS has designated CTF as a basic care institution; these institutions are predominantly located in rural areas, away from tertiary care centers and specialty care providers whose services are likely to be used frequently by high- risk patients. 6 Samples are obtained per case review methodology shared with stakeholders in prior cycles. The case reviews include emergency noncardiopulmonary resuscitation (non-CPR) reviews between February 2021 and August 2021, CPR reviews between December 2020 and April 2021, death reviews between June 2020 and July 2021, diabetes reviews between March 2021 and August 2021, RN sick call reviews between January 2021 and August 2021, and outpatient housing unit (OHU) reviews between June 2020 and July 2021. 7 As of May 7 2022,, the department reports on its public tracker that 90% of its incarcerated population at CTF is fully vaccinated while 80% of CTF staff are fully vaccinated: http://www.cdcr.ca.gov/covid19/population-status-tracking/. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 3 Summary We completed the Cycle 6 inspection of CTF in December 2021. OIG inspectors monitored the institution’s medical care that occurred between February 2021 and July 2021. The OIG rated the overall quality of health care at CTF as inadequate. We list the individual indicators and ratings applicable for this institution in Table 1 below. Table 1. CTF Summary Table Cycle 6 Cycle 6 Cycle 6 Change Health Care Indicators Case Review Compliance Overall Since Rating Rating Rating Cycle 5 Access to Care Proficient Proficient Proficient Diagnostic Services Adequate Inadequate Adequate Emergency Services Inadequate N/A Inadequate Health Information Management Adequate Adequate Adequate Health Care Environment N/A Inadequate Inadequate Transfers Adequate Adequate Adequate Medication Management Adequate Inadequate Inadequate Prenatal and Postpartum Care N/A N/A N/A N/A Preventive Services N/A Inadequate Inadequate Nursing Performance Inadequate N/A Inadequate Provider Performance Inadequate N/A Inadequate Reception Center N/A N/A N/A N/A Specialized Medical Housing Adequate Proficient Adequate Specialty Services Adequate Inadequate Adequate Administrative Operations† N/A Proficient Proficient * The symbols in this column correspond to changes that occurred in indicator ratings between the medical inspections conducted during Cycle 5 and Cycle 6. The equals sign means there was no change in the rating. The single arrow means the rating rose or fell one level, and the double arrow means the rating rose or fell two levels (green, from inadequate to proficient; pink, from proficient to inadequate). † Administrative Operations is a secondary indicator and is not considered when rating the institution’s overall medical quality. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 4 The OIG completed the Cycle 6 inspection for Correctional Training Facility in December 2021. OIG inspectors monitored the institution’s medical care that occurred between February 2021 and July 2021. To test the institution’s policy compliance, our compliance inspectors, (a team of registered nurses) monitored the institution’s compliance with its medical policies by answering a standardized set of questions that measure specific elements of health care delivery. Our compliance inspectors examined 381 patient records and 1,058 data points and used the data to answer 88 policy questions. In addition, we observed CTF processes during an on-site inspection in October 2021. Table 2 below lists CTF’s average scores from Cycles 4, 5, and 6. Table 2. CTF Policy Compliance Scores Scoring Ranges 100%–85.0% 84.9%–75.0% 74.9%–0 Medical Cycle 4 Cycle 5 Cycle 6 Inspection Policy Compliance Category Average Average Average Tool (MIT) Score Score Score 1 Access to Care 83.9% 78.2% 89.3% 2 Diagnostic Services 86.7% 80.7% 72.5% 4 Health Information Management 58.4% 92.0% 82.8% 5 Health Care Environment 63.5% 69.1% 57.5% 6 Transfers 66.6% 92.5% 80.0% 7 Medication Management 80.5% 75.2% 67.1% 8 Prenatal and Postpartum Care N/A N/A N/A 9 Preventive Services 53.8% 81.3% 59.4% 12 Reception Center N/A N/A N/A 13 Specialized Medical Housing 94.0% 56.7% 87.5% 14 Specialty Services 77.5% 81.7% 73.7% 15 Administrative Operations 71.6%* 71.8% 90.8% * In Cycle 4, there were two secondary (administrative) indicators, and this score reflects the average of those two scores. In Cycle 5 and moving forward, the two indicators were merged into one, with only one score as the result. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 5 The OIG clinicians (a team of physicians and nurse consultants) reviewed 58 cases, which contained 850 patient-related events. After examining the medical records, our clinicians conducted a follow-up on-site inspection in December 2021 to verify their initial findings. The OIG physicians rated the quality of care for 22 comprehensive case reviews. Of these 22 cases, our physicians rated 18 adequate and four inadequate. Our physicians did not find any adverse deficiencies during this inspection. The OIG then considered the results from both case review and compliance testing, and drew overall conclusions, which we report in the health care indicators.8 Multiple OIG physicians and nurses performed quality control reviews; their subsequent collective deliberations ensured consistency, accuracy, and thoroughness. Our clinicians acknowledged institutional structures that catch and resolve mistakes that may occur throughout the delivery of care. As noted above, we listed the individual indicators and ratings applicable for this institution in Table 1, the CTF Summary Table. In September 2021, the Health Care Services Master Registry showed that CTF had a total population of 4,511. A breakdown of the medical risk level of the CTF population as determined by the department is set forth in Table 3 below.9 Table 3. CTF Master Registry Data as of September 2021 Medical Risk Level Number of Patients Percentage High 1 175 3.9% High 2 428 9.5% Medium 1,676 37.2% Low 2,232 49.5% Total 4,511 100.0% Source: Data for the population medical risk level were obtained from the CCHCS Master Registry dated 9-24-21. 8 The indicators for Reception Center and Prenatal Care do not apply to CTF. 9 For a definition of medical risk, see CCHCS HCDOM 1.2.14, Appendix 1.9. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 6 Based on staffing data the OIG obtained from California Correctional Health Care Services (CCHCS), as identified in Table 4 below, CTF had 3.0 vacant executive leadership positions, 1.0 primary care provider vacancies, 0.2 nursing supervisor vacancies, and 2.6 nursing staff vacancies. Table 4. CTF Health Care Staffing Resources as of September 2021 Executive Primary Care Nursing Nursing Positions Leadership* Providers Supervisors Staff† Total Authorized Positions 6.0 11.0 12.7 77.7 107.4 Filled by Civil Service 3.0 10.0 12.5 107.6 133.1 Vacant 3.0 1.0 .2 2.6 6.8 Percentage Filled by Civil Service 50.0% 90.9% 98.4% 138.5% 123.9% Filled by Telemedicine 0 2.0 0 0 2.0 Percentage Filled by Telemedicine 0% 18.2% 0% 0% 1.9% Filled by Registry 0 1.5 0 26.5 28.0 Percentage Filled by Registry 0% 13.6% 0% 34.1% 26.0% Total Filled Positions 3.0 13.5 12.5 134.1 163.1 Total Percentage Filled 50.0% 122.7% 98.4% 172.6% 151.8% Appointments in Last 12 Months 0 0 4.0 22.0 26.0 Redirected Staff 0 0 0 0 7.0 Staff on Extended Leave‡ 0 0 0 2.0 2.0 Adjusted Total: Filled Positions 3.0 13.5 18.5 148.0 184.0 Adjusted Total: Percentage Filled 50.0% 112.5% 91.6% 103.3% 102.5% * Executive Leadership includes the Chief Physician and Surgeon. † Nursing Staff includes Senior Psychiatric Technician and Psychiatric Technician. ‡ In Authorized Positions. Notes: The OIG does not independently validate staffing data received from the department. Positions are based on fractional time-base equivalents. Source: Cycle 6 medical inspection preinspection questionnaire received September 2021, from California Correctional Health Care Services. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 7 Medical Inspection Results Deficiencies Identified During Case Review Deficiencies are medical errors that increase the risk of patient harm. Deficiencies can be minor or significant, depending on the severity of the deficiency. An adverse event occurs when the deficiency caused harm to the patient. All major health care organizations identify and track adverse events. We identify deficiencies and adverse events to highlight concerns regarding the provision of care and for the benefit of the institution’s quality improvement program to provide an impetus for improvement.10 The OIG did not find any adverse deficiencies at CTF during the Cycle 6 inspection. Case Review Results OIG case reviewers assessed 10 of the 15 indicators applicable to CTF. Of these 10 indicators, OIG clinicians rated one proficient, six adequate, and three inadequate. The OIG physicians also rated the overall adequacy of care for each of the 22 detailed case reviews they conducted. Of these 22 cases, 18 were adequate and four were inadequate. In the 850 events reviewed, there were 210 deficiencies, 84 of which the OIG clinicians considered to be of such magnitude that, if left unaddressed, would likely contribute to patient harm. Our clinicians found the following strengths at CTF: • Staff ensured excellent access to providers and nurses during the review period. • Staff performed well in the completion of diagnostic tests. Our clinicians found CTF could improve in the following areas: • Similar to Cycle 5, CTF’s emergency services continued to be poor; both provider and nursing care needed improvement. The Emergency Medical Response Review Committee (EMRRC) often did not recognize the lapses in emergency care that we identified. • Providers performed poorly in emergency care and chronic care, which are essential aspects of patient care. Compliance Testing Results Our compliance inspectors assessed 10 of the 13 indicators applicable to CTF. Of these 10 indicators, our compliance inspectors rated three proficient, two 10 For a further discussion of an adverse event, see Table A-1. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 8 adequate, and five inadequate. We tested policy compliance in the Health Care Environment, Preventive Services, and Administrative Operations as these indicators do not have a case review component. CTF demonstrated a high rate of policy compliance in the following areas: • Providers excelled in providing timely appointments for chronic care patients, patients returning from hospital admission, and patients returning from specialty services. Moreover, patients were referred within required time frames to their providers upon arrival at the institution. • Nursing staff reviewed health care services request forms and performed face-to-face encounters timely. • Providers timely completed history and physical examinations for patients admitted to the OHU. CTF demonstrated a low rate of policy compliance in the following areas: • Clinical staff did not consistently follow universal hand hygiene precautions before or after patient encounters. • Medical clinics lacked properly calibrated medical equipment and the medical supplies needed to provide standard medical care. • Nursing staff did not regularly inspect emergency response bags or the treatment cart. • CTF did not perform well in ensuring that approved specialty services were provided within required time frames. • Providers often did not communicate results of diagnostic services to patients. Most letters communicating these results were missing the date of the diagnostic service, the date of the results, and whether the results were within normal limits. Population-Based Metrics In addition to our own compliance testing and case reviews, as noted above, the OIG presents selected measures from the Healthcare Effectiveness Data and Information Set (HEDIS) for comparison purposes. The HEDIS is a set of standardized quantitative performance measures designed by the National Committee for Quality Assurance to ensure that the public has the data it needs to compare the performance of health care plans. Because the Veterans Administration no longer publishes its individual HEDIS scores, we removed them from our comparison for Cycle 6. Likewise, Kaiser (commercial plan) no longer publishes HEDIS scores. However, through the California Department of Health Care Services’ Medi-Cal Managed Care Technical Report, the OIG obtained Kaiser Medi-Cal HEDIS scores for three of five diabetic measures to use in conducting our analysis, and we present them here for comparison. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 9 HEDIS Results We used population-based metrics in considering CTF’s performance to assess the macroscopic view of the institution’s health care delivery. CTF’s results compared favorably with those found in State health plans for diabetic care measures. We list the applicable HEDIS measures in Table 5. Comprehensive Diabetes Care When compared with statewide Medi-Cal programs—California Medi-Cal, Kaiser Northern California (Medi-Cal), and Kaiser Southern California (Medi-Cal)—CTF performed better in all three diabetic measures that have statewide comparative data: HbA1c screening, poor HbA1c control, and blood pressure control, with a score of 100 percent for HbA1c screening. Immunizations Statewide comparative data were also not available for immunization measures; however, we include this data for informational purposes. CTF had a 77 percent influenza immunization rate for adults 18 to 64 years old and a 76 percent influenza immunization rate for adults 65 years of age and older.11 The pneumococcal vaccine immunization rate was 92 percent.12 Cancer Screening Statewide comparative data were not available for colorectal cancer screening; however, we include these data for informational purposes. CTF had an 86 percent colorectal cancer screening rate. 11 The HEDIS sampling methodology requires a minimum sample of 10 patients to have a reportable result. 12 The pneumococcal vaccines administered are the 13, 15, and 20 valent pneumococcal vaccines (PCV13, PCV 15, and PCV 20), or 23 valent pneumococcal vaccine (PPSV23), depending on the patient’s medical conditions. For the adult population, the influenza or pneumococcal vaccine may have been administered at a different institution other than the one in which the patient was currently housed during the inspection period. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 10 Table 5. CTF Results Compared With State HEDIS Scores California California CTF Kaiser Kaiser California NorCal SoCal Cycle 6 Medi-Cal Medi-Cal Medi-Cal HEDIS Measure Results* 2018† 2018† 2018† HbA1c Screening 100% 90% 94% 96% Poor HbA1c Control (> 9.0%) ‡, § 11% 34% 25% 18% HbA1c Control (< 8.0%) ‡ 78% – – – Blood Pressure Control (< 140/90) ‡ 91% 65% 78% 84% Eye Examinations 58% – – – Influenza – Adults (18–64) 77% – – – Influenza – Adults (65+) 76% – – – Pneumococcal – Adults (65+) 92% – – – Colorectal Cancer Screening 86% – – – Notes and Sources * Unless otherwise stated, data were collected in October 2021 by reviewing medical records from a sample of CTF’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. † HEDIS Medi-Cal data were obtained from the California Department of Health Care Services publication titled Medi-Cal Managed Care External Quality Review Technical Report, dated July 1, 2019–June 30, 2020 (published April 2021). www.dhcs.ca.gov/documents/MCQMD/CA2019-20-EQR-Technical-Report-Vol3-F2.pdf ‡ For this indicator, the entire applicable CTF population was tested. § For this measure only, a lower score is better. Source: Institution information provided by the California Department of Corrections and Rehabilitation. Health care plan data were obtained from the CCHCS Master Registry. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 11 Recommendations As a result of our assessment of CTF’s performance, we offer the following recommendations to the department: Diagnostic Services • The department should consider developing and implementing an electronic solution to ensure that culture results from the laboratory portal automatically populate into the electronic health record system (EHRS). • Medical leadership should remind providers to send patient notification letters for diagnostic services with the appropriate key elements required by CCHCS policy. Emergency Services • Medical leadership should consider performing and documenting clinical reviews for patients who transfer to a higher level of care. • The Chief Nurse Executive (CNE) should ensure that supervisors reviewing transfers for a higher level of care identify nursing care clinical deficits. • The department should consider whether patient vital signs taken in the triage and treatment area (TTA) can automatically populate into the EHRS. Health Information Management • Medical leadership should consider routinely assessing each provider’s message center to ensure providers are timely reviewing and endorsing diagnostic and specialty reports. Health Care Environment • To ensure that staff are following equipment and medical supply management protocols, nursing leadership should consider performing random spot checks. • Medical leadership should remind staff to follow universal hand hygiene precautions. Implementing random spot checks could improve compliance. • Nursing leadership should direct nurse supervisors at each clinic to review the monthly emergency medical response bag (EMRB) and treatment cart logs to ensure they are regularly inventoried and sealed. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 12 Transfers • Nursing leadership should consider educating receiving and release (R&R) nurses in the proper completion of initial health screening questions. Medication Management • Medical and nursing leadership should ensure that chronic care, hospital discharge, and en route patients receive their medications timely and without interruption. • Nursing leadership and the public health nurse should instruct nursing staff to properly document the monitoring of patients taking tuberculosis (TB) medications. Preventive Services • Nursing leadership and the public health nurse should instruct nursing staff to properly document the monitoring of patients taking tuberculosis (TB) medications. • Nursing leadership should consider developing and implementing measures to ensure that nursing staff timely screen patients for TB. • Medical leadership should determine the root cause of challenges that prevent the timely provision of chronic care vaccinations. Nursing Performance • The department should consider strategies to improve recruitment and retention of nursing leadership and staff. • Nursing executive leadership should ensure that nursing supervisors, who conduct clinical care reviews, identify opportunities for improvement. Provider Performance • To improve provider decision-making, medical leadership should consider including a review of emergency care when completing annual provider reviews. • Medical leadership should remind providers to assess pertinent physical findings for patient medical issues and document patient encounters appropriately. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 13 Specialized Medical Housing • Medical leadership should consider reminding OHU providers to perform appropriate physical exams and document findings accurately.13 Specialty Services • Medical leadership should ensure that providers review and endorse specialty reports timely. • Medical leadership should ensure that the institution receives specialty reports timely. • Medical leadership should ensure that patients receive routine specialty follow-up appointments timely. • Medical leadership should ensure that patients who recently transferred into the institution receive their previously scheduled specialty appointments within the required time frames. Administrative Operations • Medical leadership should ensure that the institution’s Emergency Medical Response Review Committee (EMRRC) review cases timely and include all required documents. 13 OHU is the outpatient housing unit. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 14 Access to Care Overall Rating In this indicator, OIG inspectors evaluated the institution’s performance in providing patients with timely clinical appointments. Our inspectors reviewed Proficient the scheduling and appointment timeliness for newly arrived patients, sick calls, Case Review and nurse follow-up appointments. We examined referrals to primary care Rating providers, provider follow-ups, and specialists. Furthermore, we evaluated the follow-up appointments for patients who received specialty care or returned from Proficient an off-site hospitalization. Compliance Score Results Overview Proficient (89.3%) CTF provided excellent access to care. This was remarkable in light of the impacts from COVID-19, which presented a unique challenge. We considered specific concerns affecting CTF during the review period such as reducing unnecessary appointments to minimize spread of COVID-19. However, it is important not to reschedule or cancel appointments when patients need to be seen clinically. The OIG case reviewers evaluated each case with the understanding that these circumstances may have affected patient care. CTF ensured that patients were seen by providers when nurses and providers when medically necessary. Nurses reviewed sick calls and performed face-to-face appointments timely. CTF also ensured that patients saw specialists as needed. Providers in specialized medical housing also saw their patients appropriately. Overall, the OIG rated this indicator proficient. Case Review and Compliance Testing Results We reviewed 372 provider, nursing, specialty, and hospital events that required the institution to generate appointments. We identified nine deficiencies relating to this indicator, seven of which were significant.14 Access to Clinic Providers Access to clinic providers is an integral part of patient care in health care delivery. In case review, CTF performed well with provider referrals and provider follow-up requests. We reviewed 77 outpatient provider encounters and identified four deficiencies.15 Compliance testing showed provider chronic care follow-up appointments, nurse-to-provider sick call referrals, and provider follow-up appointments occurred timely (MIT 1.001, 83.3%, MIT 1.005, 83.3%, MIT 1.006, 100%).Case review clinicians also found CTF ensured that patients had good access to 14 Deficiencies occurred in cases 17, 24, 26, 30, 37, 38, 39, and 58. Significant deficiencies occurred in cases 17, 24, 26, 37, 38, 39, and 58. 15 Deficiencies occurred in cases 17, 24, 26, and 39. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 15 providers. In the following cases, we identified several opportunities for improvement: • In case 17, the sick call nurse initiated a provider appointment for flank pain, but this appointment did not occur. During the on-site inspection, the provider explained that nurses generate a provider appointment to have a nurse discussion with the provider and then complete the appointment after their discussion. However, the patient had flank pain with trace blood in his urine and should have been seen by the provider. • In case 39, the clinic nurse planned for the patient to have a follow- up appointment with the provider within 14 days, but did not place the order. By happenstance, the patient had a chronic care appointment 19 days later. Access to Specialized Medical Housing Providers CTF performed very well with access to care in the outpatient housing unit (OHU). Providers performed history and physical examinations promptly. Compliance testing showed an excellent score (MIT 13.002, 100%) and case reviewers found no deficiencies with access in the OHU. Access to Clinic Nurses CTF performed well with access to nursing sick calls and provider-to-nurse referrals. Compliance testing showed that nurses reviewed patient sick-call requests the same day they were received (MIT 1.003, 100%) and performed face- to-face visits within one business day after the sick call was reviewed (MIT 1.004, 96.9%). Case review clinicians also found good performance in this area and only found two instances in which sick call patients should have been seen sooner. Access to Specialty Services CTF’s performance was mixed in access to specialty appointments. Compliance testing showed good high-priority (MIT 14.001, 80.0%), medium-priority (MIT 14.004, 93.3%) and routine-priority (MIT 14.007, 80.0%) access to specialty services. Compliance testing showed timely high-priority (MIT 14.003, 90.0%) and medium-priority (MIT 14.006, 100%) specialist follow-up appointments, but a lack of timely routine-priority appointments (MIT 14.009, 50.0%). Case reviewers found good access for specialty services at the institution. However, the following was an example for improvement: • In case 58, the pulmonologist recommended imaging studies and specialty follow-up for the patient to rule out malignancy. This did not occur until 11 months later. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 16 Follow-up After Specialty Service CTF provided great access to providers after patients had specialty appointments. Compliance testing showed very good score of 85.7 percent (MIT 1.008) and case review found patients were seen when medically necessary. Patients were usually in COVID-19 quarantine after an off-site specialty appointment. The OIG clinicians reviewed 68 specialty events and did not assign deficiencies when CTF providers appropriately performed chart review to order the necessary appointments, medications, and diagnostics. Follow-up After Hospitalization CTF provided excellent access to patients after they returned from the hospital. Compliance testing showed providers followed up with patients after hospitalization 100 percent of the time (MIT 1.007). Case review clinicians reviewed 31 hospitalizations and found no deficiencies with delays or missed appointments after hospitalization. Follow-up After Urgent or Emergent Care (TTA) CTF performed well for patients with provider follow-up appointments after urgent care in the triage and treatment area (TTA). We reviewed 11 TTA events in which patients needed and received provider follow-up, and found no deficiencies. Follow-up After Transferring Into the Institution CTF performed well in providing initial provider appointments for newly arrived patients within required time frames (MIT 1.002, 88.0%). Our case review clinicians reviewed five transfer-in events and found only one minor delay with a late provider appointment. Clinician On-Site Inspection We spoke with scheduling supervisors, utilization management, leadership, providers, and nurses during the inspection process. They stated that the COVID-19 pandemic impacted their access initially, but that they worked diligently to ensure care for their patients. We attended morning huddles via teleconferencing software and heard primary care teams discuss patients they had on the schedule and any other patients that needed to be seen. At the time of our on-site inspection, CTF reported no patient appointment backlogs. We learned that in September 2020, CTF’s South facility was closed due to a decrease in population numbers. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 17 Compliance Testing Results TTaabbllee 66.. AAcccceessss ttoo CCaarree Scored Answer Compliance Questions Yes No N/A Yes % Chronic care follow-up appointments: Was the patient’s most recent chronic care visit within the health care guideline’s maximum 20 4 1 83.3% allowable interval or within the ordered time frame, whichever is chgs per Ron, new Excel sheet shorter? (1.001) * sent 3-14, 2 figs for 1.001 and a For endorsed patients received from another CDCR institution: Based on the patient’s clinical risk level during the initial health chg in percentage = 89.3 22 3 0 88.0% screening, was the patient seen by the clinician within the required time frame? (1.002) * Clinical appointments: Did a registered nurse review the patient’s 32 0 0 100% request for service the same day it was received? (1.003) * Clinical appointments: Did the registered nurse complete a face-to- face visit within one business day after the CDCR Form 7362 was 31 1 0 96.9% reviewed? (1.004) * Clinical appointments: If the registered nurse determined a referral to a primary care provider was necessary, was the patient seen within 5 1 26 83.3% the maximum allowable time or the ordered time frame, whichever is the shorter? (1.005) * Sick call follow-up appointments: If the primary care provider ordered a follow-up sick call appointment, did it take place within the time 1 0 31 100% frame specified? (1.006) * Upon the patient’s discharge from the community hospital: Did the patient receive a follow-up appointment within the required time 20 0 0 100% frame? (1.007) * Specialty service follow-up appointments: Did the clinician follow-up visits occur within required time frames? (1.008) *,† 30 5 10 85.7% Clinical appointments: Do patients have a standardized process to 4 2 0 66.7% obtain and submit health care services request forms? (1.101) Overall percentage (MIT 1): 89.3% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician follow-up visits following specialty services. As a result, we tested MIT 1.008 only for high-priority specialty services or when staff ordered follow-ups. The OIG continued to test the clinical appropriateness of specialty follow-ups through its case review testing. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 18 Table 7. Other Tests Related to Access to Care Table 7. Other Tests Related to Access to Care Scored Answer Compliance Questions Yes No N/A Yes % For patients received from a county jail: If, during the assessment, the nurse referred the patient to a provider, was the patient seen within the N/A N/A N/A N/A required time frame? (12.003) * For patients received from a county jail: Did the patient receive a history and physical by a primary care provider within seven calendar N/A N/A N/A N/A days? (12.004) * For CTC and SNF only (effective 4/2019, include OHU): Was a written history and physical examination completed within the required time 4 0 0 100% frame? (13.002) * For OHU, CTC, SNF, and Hospice (applicable only for samples prior to 4/2019): Did the primary care provider complete the Subjective, Objective, 0 0 4 N/A Assessment, and Plan notes on the patient at the minimum intervals required for the type of facility where the patient was treated? (13.003) *,† Did the patient receive the high-priority specialty service within 14 calendar days of the primary care provider order or the Physician 12 3 0 80.0% Request for Service? (14.001) * Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care provider? 9 1 5 90.0% (14.003) * Did the patient receive the medium-priority specialty service within 15-45 calendar days of the primary care provider order or the Physician 14 1 0 93.3% Request for Service? (14.004) * Did the patient receive the subsequent follow-up to the medium- priority specialty service appointment as ordered by the primary care 11 0 4 100% provider? (14.006) * Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician 12 3 0 80.0% Request for Service? (14.007) * Did the patient receive the subsequent follow-up to the routine-priority specialty service appointment as ordered by the primary care provider? 3 3 9 50.0% (14.009) * * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † CCHCS changed its policies and removed mandatory minimum rounding intervals for patients located in specialized medical housing. After April 2, 2019, MIT 13.003 only applied to CTCs that still had state- mandated rounding intervals. OIG case reviewers continued to test the clinical appropriateness of provider follow-ups within specialized medical housing units through case reviews. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 19 Recommendations The OIG offers no recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 20 Diagnostic Services Overall Rating In this indicator, OIG inspectors evaluated the institution’s performance in Adequate timely completing radiology, laboratory, and pathology tests. Our inspectors determined whether the institution properly retrieved the resultant reports and Case Review whether providers reviewed the results correctly. In addition, in Cycle 6, we Rating examined the institution’s performance in timely completing and reviewing Adequate immediate (STAT) laboratory tests. Compliance Score Results Overview Inadequate (72.5%) CTF performed well in completing and retrieving diagnostic tests, with the exception of culture results. The institution completed tests timely, and providers reviewed and endorsed laboratory and radiology reports within required time frames. The institution had difficulty both with incomplete patient result notification letters and not sending patient notification letters. Compliance testing also revealed that the institution did not send patient notification letters for pathology reports. Considering the findings from case review and compliance testing, we rated this indicator adequate. Case Review and Compliance Testing Results We reviewed 235 diagnostic event and found 15 deficiencies, four of which were significant. All deficiencies we found were related to health information management. There were no deficiencies pertaining to the completion of diagnostic tests.16 Test Completion CTF performed very well with completion of diagnostic tests. Compliance testing found that X-rays were completed timely 100 percent of the time (MIT 2.001) and laboratory tests were completed timely 90.0 percent of the time (MIT 2.004). There were no STAT laboratory tests available for compliance testing or case review. Case review did not identify any deficiencies related to test completion of diagnostic studies. Health Information Management Providers reviewed radiology (MIT 2.002, 90.0%) and laboratory (MIT 2.005, 100%) reports timely. The institution retrieved pathology reports (MIT 2.010, 80.0%) and reviewed (MIT 2.011, 75.0%) them timely, but did not communicate the results to patients timely (MIT 2.012, 37.5%). 16 Deficiencies occurred in cases 1, 10, 11, 12, 14, 16, 18, 20, 23, 24, 27, and 58. Significant deficiencies occurred in cases 1, 14, 20, and 24. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 21 Our case review clinicians identified a few issues with CTF’s information management of diagnostic reports. An important concern was that laboratory culture results do not auto populate from the laboratory into the EHRS. The following are examples: • In case 1, the patient had a urinary bacterial infection; however, the urine culture result was not available in the EHRS. • In case 24, the patient had a negative fungal smear, but the final culture showed a specific fungus. However, this final culture result was not in the EHRS. Another prevalent issue that case reviews identified was related to patient notifications. In five examples, providers did not send a patient notification letter to inform the patient of their results. In five other occurrences, the patient notification letter was missing at least one element required per policy.17 Clinician On-Site Inspection We spoke with the laboratory supervisor, who reported no issues with collecting laboratory samples or performing on-site radiology studies. The supervisor explained that EHRS automatically sends notifications to the ordering provider to review and endorse laboratory results. 17 Lack of patient test notification letters occurred in cases 14, 20, 23, and twice in 27. Notification letters were missing required elements in cases 10, 12, 16, and 24. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 22 Compliance Testing Results TTaabbllee 88.. DDiiaaggnnoossttiicc SSeerrvviicceess Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Was the radiology service provided within the time frame 10 0 0 100% specified in the health care provider’s order? (2.001) * Radiology: Did the ordering health care provider review and endorse 9 1 0 90.0% the radiology report within specified time frames? (2.002) * Radiology: Did the ordering health care provider communicate the results of the radiology study to the patient within specified time 6 4 0 60.0% frames? (2.003) Laboratory: Was the laboratory service provided within the time 9 1 0 90.0% frame specified in the health care provider’s order? (2.004) * Laboratory: Did the health care provider review and endorse the 10 0 0 100% laboratory report within specified time frames? (2.005) * Laboratory: Did the health care provider communicate the results of the laboratory test to the patient within specified time frames? 2 8 0 20.0% (2.006) Laboratory: Did the institution collect the STAT laboratory test and N/A N/A N/A N/A receive the results within the required time frames? (2.007) * Laboratory: Did the provider acknowledge the STAT results, OR did nursing staff notify the provider within the required time frames? N/A N/A N/A N/A (2.008) * Laboratory: Did the health care provider endorse the STAT laboratory N/A N/A N/A N/A results within the required time frames? (2.009) Pathology: Did the institution receive the final pathology report 8 2 0 80.0% within the required time frames? (2.010) * Pathology: Did the health care provider review and endorse the 6 2 2 75.0% pathology report within specified time frames? (2.011) * Pathology: Did the health care provider communicate the results of the pathology study to the patient within specified time frames? 3 5 2 37.5% (2.012) Overall percentage (MIT 2): 72.5% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 23 Recommendations • The department should consider developing and implementing an electronic solution to ensure that culture results from the laboratory portal automatically populate into the electronic health record system (EHRS). • Medical leadership should remind providers to send patient notification letters for diagnostic services with the appropriate key elements required by CCHCS policy. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 24 Emergency Services Overall In this indicator, OIG clinicians evaluated the quality of emergency medical care. Rating Our clinicians reviewed emergency medical services by examining the timeliness Inadequate and appropriateness of clinical decisions made during medical emergencies. Our evaluation included examining the emergency medical response, Case Review cardiopulmonary resuscitation (CPR) quality, triage and treatment area (TTA) Rating care, provider performance, and nursing performance. Our clinicians also Inadequate evaluated the Emergency Medical Response Review Committee’s (EMRRC) Compliance performance in identifying problems with its emergency services. The OIG Score assessed the institution’s emergency services mainly through case review only. (N/A) Results Overview Similar to Cycle 5, CTF continued to deliver poor emergency care. Providers and nurses made poor clinical decisions and did not always recognize potentially urgent symptoms in patients. In addition, TTA nurses did not always provide complete physical assessments or sufficiently monitor patients. Furthermore, the institution’s emergency medical response review process did not identify all clinical opportunities for improvement. The OIG rated this indicator inadequate. Case Review Results We reviewed 31 urgent or emergent events and found 56 emergency care deficiencies, 19 of which were significant.18 Emergency Medical Response CTF staff generally responded appropriately to emergency events; first medical responders evaluated the patient and situation, requested clinical health care staff timely, and notified emergency medical services without delay. Our clinicians reviewed 14 events that involved a first medical responder and identified both documentation and assessment deficiencies.19 These documentation deficiencies did not affect the overall patient care. In one of the five CPR events we reviewed, there was a delay in initiating CPR.20 Although custody staff determined the patient was not breathing and requested medical staff, first responders did not start CPR for five minutes. 18 Deficiencies occurred in cases 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 17, 19–22, and 24. Cases 1, 3, 4, 9, 11, 17, 19, 21, and 24 had significant deficiencies. 19 Documentation deficiencies occurred in cases 3, 6, 8, and 21. Assessment deficiencies occurred in cases 1, 3, and 19. 20 A delay in CPR occurred in case 3. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 25 Provider Performance We reviewed 24 emergency events in which providers either evaluated the patient directly or were consulted by telephone, and identified seven deficiencies.21 The providers did performed poorly with urgent and emergent care. Providers needed to have a higher level of consideration of life-threatening conditions in emergency situations. There were a few instances in which providers did not document their decision-making process, and it was unclear whether they considered the potential severe consequence of the patient’s symptom. A compounding issue was that these deficiencies were not identified and discussed during EMRRC meetings. It is difficult to improve performance if opportunities for improvement are not identified. The following are some examples: • In case 17, the patient, who had cardiac risk factors and chest pain, was evaluated in the TTA. The on call provider only recommended a follow-up with the RN instead of a provider. The patient required either an in-person provider evaluation during the TTA event or a close in-person provider follow-up. • In case 19, the patient who had pain in his left side was in the TTA with pneumonia. The provider on call was notified that the patient’s oxygen levels had dropped significantly and the patient’s heart rate increased with exertion. The provider did not send the patient to the hospital in an ambulance and decided to use a state car instead, which placed the patient at further medical risk. • In case 21, the patient had chest pain, shortness of breath, and a recent cardiac stress test that indicated reduced blood flow to parts of the heart. The provider on call did not send the patient out to the hospital or ensure an urgent cardiology follow-up. The patient had a heart attack about one month later. Nursing Performance The OIG clinicians found that TTA nurses did not always make safe, appropriate triage decisions, and frequently made incomplete assessments and interventions for their patients. Compared to Cycle 5, we identified more significant deficiencies.22 Following are some examples: • In case 1, a psychiatric technician contacted the TTA RN regarding a patient with severe abdominal pain, high blood pressure, and a fast heart rate. The RN did not arrange a medical transport to the TTA, and instead, inappropriately instructed the patient to walk to the 21 Provider deficiencies occurred in cases 1, 2, 17, 19, 21, and 24. 22 Significant deficiencies occurred in cases 4, 9, 11, and 21. Significant deficiencies occurred on three occasions in case 1. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 26 TTA. In addition, the RN did not perform a full reassessment of the patient after the initial evaluation. • In case 9, the high-risk, 62-year-old patient had a decrease in oxygen levels. A nurse who was conducting COVID-19 rounds, contacted a TTA RN to evaluate the patient. However, the TTA RN did not assess the patient until one hour and fifty minutes later, at which time the patient’s oxygen levels had further declined, and the patient required administration of supplemental oxygen and a transfer to a higher level of care. • In case 11, the patient had low blood oxygen levels. The TTA RN did not respond to a medical alarm for the patient, and instead, instructed the LVN to escort the patient to the TTA. Subsequently, there was a delay in administering oxygen to the patient. Once the patient arrived to the TTA, the RN found that the patient also had an unsteady gait, a swollen abdomen, and lower extremity weakness and numbness. However, the TTA RN did not consult a provider about these abnormal findings for one hour and 35 minutes and also did not reevaluate the patient’s abnormal findings or monitor the patient’s blood pressure, pulse, and respiratory rates for four hours. • In case 21, a TTA RN evaluated the patient, who complained of chest pain. The nurse identified both subjective and objective findings consistent for a myocardial infarction (heart attack). However, the nurse did not follow the CCHCS nursing chest pain protocol and administer aspirin to the patient. Nursing Documentation Nursing documentation in CTF’s TTA was frequently incomplete. We found that nurses did not always document their assessment findings and interventions thoroughly. At times, TTA nurses documented timeline information inaccurately or failed to document this information at all. The following are some examples: • In case 1, the nurse noted the patient had an abdominal wound, but did not document the size of the wound or the presence of the wound’s dressing. • In case 5, the nurse did not document the TTA arrival and departure times of emergency medical personnel. Similar findings were also identified in cases 1, 2, 3, and 20. • In case 8, a TTA nurse documented that the patient’s vital signs were monitored every five minutes, but did not document the results. Emergency Medical Response Review Committee (EMRRC) Our clinicians reviewed 10 cases in which patients were transferred to a higher level of care and identified several opportunities for improvements. We found that nursing supervisors frequently reviewed the transfer events, but there was Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 27 no evidence of a physician clinical review. However, the OIG clinicians found deficiencies not identified in the reviews of supervisors or by the EMRRC. In addition, the EMRRC did not review the cases and incident packages timely (MIT 15.003, zero). Clinician On-Site Inspection CTF’s TTA was centrally located and had three beds. It was staffed with two RNs for each shift. According to nurses, a provider was only intermittently assigned to the TTA. However, even when a provider was assigned to the TTA, the provider was sometimes redirected to a clinic. When a provider was not assigned to the TTA, nurses consulted the patient’s primary care provider via phone during business hours, or a provider on call if it was after business hours. During the second and third shifts, the LVNs served as the first medical responders. TTA RNs responded to all medical alarms on the first shifts. In addition to the traditional TTA duties, we learned that at CTF the TTA nurses also assisted when COVID-19 quarantined and isolated patients required care. The nurses explained that during the institution’s COVID-19 outbreak, they were very busy, and the volume of patients was challenging to manage at times. According to the nurses, this made thorough documentation difficult. They indicated it would be helpful if patient vital signs taken in the TTA would auto populate into EHRS so they would not need to spend time manually entering this data. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 28 Recommendations • Medical leadership should consider performing and documenting clinical reviews for patients who transfer to a higher level of care. • The Chief Nurse Executive (CNE) should ensure that supervisors reviewing transfers for a higher level of care identify nursing care clinical deficits. • The department should consider whether patient vital signs taken in the triage and treatment area (TTA) can automatically populate into the EHRS. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 29 Health Information Management Overall Rating In this indicator, OIG inspectors evaluated the flow of health information, a Adequate crucial link in high-quality medical care delivery. Our inspectors examined whether the institution retrieved and scanned critical health information Case Review (progress notes, diagnostic reports, specialist reports, and hospital discharge Rating reports) into the medical record in a timely manner. Our inspectors also tested Adequate whether clinicians adequately reviewed and endorsed those reports. In addition, our inspectors checked whether staff labeled and organized documents in the Compliance medical record correctly. Score Adequate (82.8%) Results Overview Overall, CTF performed satisfactorily in health information management. The institution had excellent performance in hospital and emergency health information. Performance in diagnostics was good; however, patient notification of pathology results was lacking. Both compliance testing and case review identified specialty information management as an area that needed improvement. We reviewed the various levels of performance and rated this indicator adequate. Case Review and Compliance Results OIG clinicians reviewed 851 events and found 41 deficiencies related to health information management, 18 of which were significant.23 Hospital Discharge Reports CTF performed very well with management of hospital discharge reports. Our clinicians reviewed 31 off-site emergency department and hospital visits, and found no retrieval delays; however, we found two late endorsements and one missing provider endorsement. Compliance testing showed a perfect score in the retrieval and scanning reports into the EHRS (MIT 4.003, 100%), and in the reviewing hospital discharge records (MIT 4.005, 100%). Specialty Reports CTF did not perform well in the management of specialty reports. While the institution performed acceptably in scanning specialty reports timely (MIT 4.002, 76.7%), CTF performed poorly with retrieving of high-priority (MIT 14.002, 66.7%), medium-priority (MIT 14.005, 53.3%), and routine-priority specialty reports (MIT 14.008, 61.5%). Our case review clinicians found a few delayed 23 Deficiencies occurred in cases 1, 2, 3, 5, 7–14, 16, 18–21, 23, 24, 26, 27, and 58. Significant deficiencies occurred in cases 1, 8, 13, 14, 19–21, 23, 24, 26, 27, and 58. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 30 retrievals and a pattern of delayed provider reviews and endorsements.24 OIG clinicians reviewed 46 specialty service encounters and found two delayed retrievals and thirteen delayed provider reviews and endorsements. • In case 8, the institution did not ensure that the provider endorsed the gastroenterology consultation within policy time frames; the report was endorsed 10 days after it was available. • In case 27, the institution retrieved the neurosurgery report 40 days after the consultation. Diagnostic Reports CTF had a mixed performance in diagnostic reports. Compliance testing showed providers reviewed and endorsed the pathology reports 75.0 percent of the time (MIT 2.011); however, communicating the pathology results to the patient revealed room for improvement (MIT 2.012, 37.5%). Our clinicians reviewed 240 diagnostic events and identified 15 deficiencies.25 Most deficiencies resulted from providers sending patient notification letters late or not at all. There were no applicable STAT laboratory tests to test or review during this inspection. Please refer to the Diagnostic Services indicator for a detailed discussion about diagnostics health information management. Urgent and Emergent Records OIG clinicians reviewed 45 emergency care events and found that the nurses recorded these events well. The providers also recorded their emergency care sufficiently, including the off-site telephone encounters. However, our clinicians found that the AED discharge summary was not scanned into the EHRS in three different cases.26 The Emergency Services indicator provides additional information regarding emergency care documentation. Scanning Performance CTF had a mixed performance in the scanning process. Compliance testing found poor scanning performance (MIT 4.004, 37.5%); however, our clinicians identified only a few scanning errors.27 The following is an example: • In case 26, the report of the positron emission tomography (PET) and computed tomography (CT) scans was not scanned into the patient’s 24 Retrieval deficiencies occurred in cases 26 and 27. Review and endorsement deficiencies occurred in cases 8, 9, 13, 20, 21, 23, and 58. 25 Diagnostic health information management deficiencies occurred in cases 1, 10, 11, 12, 14, 16, 18, 20, 23, 24, 27, and 58. Significant deficiencies occurred in cases 1, 14, 20, and 24. 26 The AED discharge summary was not scanned into the record in cases 3, 5, and 7. 27 The scanning errors occurred in cases 20 and 26. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 31 EHRS, and the patient did not receive a notification letter. During the on-site inspection, the supervisor reported that the provider was not notified the report was available until one month later. Clinician On-Site Inspection We discussed health information management processes with health information management supervisors, ancillary staff, nurses, and providers. According to medical records supervisors, once the off-site specialty reports were scanned into EHRS, CTF providers automatically received a notification through the EHRS system to review the report. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 32 Compliance Testing Results Table 9. Health Information Management Table 9. Health Information Management Scored Answer Compliance Questions Yes No N/A Yes % Are health care service request forms scanned into the patient’s electronic health record within three calendar days of the encounter 20 0 12 100% date? (4.001) Are specialty documents scanned into the patient’s electronic health 23 7 15 76.7% record within five calendar days of the encounter date? (4.002) * Are community hospital discharge documents scanned into the patient’s electronic health record within three calendar days of 20 0 0 100% hospital discharge? (4.003) * During the inspection, were medical records properly scanned, 9 15 0 37.5% labeled, and included in the correct patients’ files? (4.004) * For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements 20 0 0 100% and did a provider review the report within five calendar days of discharge? (4.005) * Overall percentage (MIT 4): 82.8% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 33 TTaabbllee 1100.. OOtthheerr TTeessttss RReelalatteedd t too H Heeaaltlhth I nInfoformrmataiotino nM Manaangaegmeemnetnt Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Did the ordering health care provider review and endorse 9 1 0 90.0% the radiology report within specified time frames? (2.002) * Laboratory: Did the health care provider review and endorse the 10 0 0 100% laboratory report within specified time frames? (2.005) * Laboratory: Did the provider acknowledge the STAT results, OR did nursing staff notify the provider within the required time frame? N/A N/A N/A N/A (2.008) * Pathology: Did the institution receive the final pathology report within 8 2 0 80.0% the required time frames? (2.010) * Pathology: Did the health care provider review and endorse the 6 2 2 75.0% pathology report within specified time frames? (2.011) * Pathology: Did the health care provider communicate the results of the 3 5 2 37.5% pathology study to the patient within specified time frames? (2.012) Did the institution receive and did the primary care provider review the high-priority specialty service consultant report within the required time 10 5 0 66.7% frame? (14.002) * Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the required 8 7 0 53.3% time frame? (14.005) * Did the institution receive and did the primary care provider review the routine-priority specialty service consultant report within the required 8 5 2 61.5% time frame? (14.008) * * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 34 Recommendations • Medical leadership should consider routinely assessing each provider’s message center to ensure providers are timely reviewing and endorsing diagnostic and specialty reports. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 35 Health Care Environment Overall Rating In this indicator, OIG compliance inspectors tested clinics’ waiting areas, infection control, sanitation procedures, medical supplies, equipment Inadequate management, and examination rooms. Inspectors also tested clinics’ performance Case Review in maintaining auditory and visual privacy for clinical encounters. Compliance Rating inspectors asked the institution’s health care administrators to comment on their facility’s infrastructure and its ability to support health care operations. The OIG (N/A) rated this indicator solely on the compliance score, using the same scoring Compliance thresholds as in the Cycle 4 and Cycle 5 medical inspections. Our case review Score clinicians do not rate this indicator. Inadequate (57.5%) Results Overview For this indicator, CTF’s performance declined, compared with its performance in Cycle 5. In the present cycle, multiple aspects of CTF’s health care environment needed improvement: multiple clinics contained expired medical supplies and improperly calibrated or nonfunctional equipment; emergency medical response bag (EMRB) logs were missing staff verification or inventory was not performed and treatment carts were missing log entries; and staff did not regularly sanitize their hands before or after examining patients. These factors resulted in an inadequate rating for this indicator. Compliance Testing Results Outdoor Waiting Areas We examined outdoor patient waiting areas (see Photo 1). Health care and custody staff reported existing waiting areas had sufficient seating capacity. The staff reported the outdoor waiting area was only used when the indoor waiting area was at capacity. Staff also reported that during inclement weather, they only called patients close to their appointment time. Photo 1. B North specialty clinic outdoor waiting area (photographed on October 19, 2021). Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 36 Indoor Waiting Areas We inspected indoor waiting areas (see Photo 2). Health care and custody staff reported existing waiting areas contained sufficient seating capacity. During our inspection, we did not observe overcrowding or noncompliance with social distancing requirements in any of the clinics’ indoor waiting areas. Photo 2. North clinic indoor waiting area (photographed on October 21, 2021). Clinic Environment Four of six clinic environments were sufficiently conducive to medical care: they provided reasonable auditory privacy, appropriate waiting areas, wheelchair accessibility, and nonexamination room workspace (MIT 5.109, 66.7%). In two clinic environments, we observed nursing staff providing services to multiple patients concurrently in the vital sign check stations which did not allow for auditory privacy Photo 3. Multiple patients serviced at the same time in the triage station and (see Photo 3). in close proximity to each other, which prohibited auditory privacy (photographed on October 21, 2021). Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 37 Of the nine clinics we observed, five contained appropriate space, configuration, supplies, and equipment to allow clinicians to perform proper clinical examinations (MIT 5.110, 55.6%). Two clinics had examination rooms that lacked visual privacy when conducting patient examinations (see Photo 4). One clinic had unsecured confidential medical records. The remaining clinic’s examination room lacked adequate space (less than 100 square feet). Photo 4. Examination rooms that lacked visual privacy when conducting patient examinations (photographed on October 21, 2021). Clinic Supplies Two of the nine clinics followed adequate medical supply storage and management protocols (MIT 5.107, 22.2%). We found one or more of the following deficiencies in seven clinics: expired medical supplies (see Photos 5 and 6), unidentified or mislabeled medical supplies, compromised original medical supply packaging, a disorganized medical supply cabinet or drawer (see Photo 7, next page), medical supplies stored directly on the floor, or cleaning materials stored with medical supplies. Photo 5. Expired medical supplies dated March 2021 (photographed on October 20, 2021). Photo 6. Expired medical supplies dated September 11, 2021 (photographed on October 20, 2021). Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 38 One of the nine clinics met requirements for essential core medical equipment and supplies (MIT 5.108, 11.1%). The remaining eight clinics lacked medical supplies or contained improperly calibrated or nonfunctional equipment. The missing items included examination table disposable paper and a peak flow meter and tips. The improperly calibrated or nonfunctional equipment included a nebulizer, weight scale, pulse oximeter, and several nonfunctional oto- ophthalmoscopes. We also found unsanitary storage of tongue Photo 7. Unlabeled and disorganized medical supplies; depressors (see also Photo 7). also of note: unsanitary storage of tongue depressors stored in an open box with other supplies (photographed on October 10, 2021). We examined emergency medical response bags (EMRBs) to determine whether they contained all essential items. We checked whether staff inspected the bags daily and inventoried them monthly. None of the seven EMRBs we reviewed passed our test (MIT 5.111, zero). We found one or more of the following deficiencies with six EMRBs: staff failed to ensure that the EMRB’s compartments were sealed and intact, EMRBs contained oral airways with compromised sterile packaging (see Photo 8), and staff had not inventoried the EMRBs when the seal tags were replaced or had not been opened in the last 30 days. In the remaining clinic, staff in the OHU did not maintain the treatment cart daily check sheet (CDCR form 7544) and the defibrillator performance test log (CDCR form 7548). In addition, the treatment cart contained previously Photo 8. EMRB compromised oral airway sterile packaging sterilized reusable medical (photographed on October 20, 2021). equipment stored beyond the documented shelf life. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 39 Medical Supply Management All the medical supply storage areas located outside the medical clinics stored medical supplies adequately (MIT 5.106, 100%). According to the chief executive officer (CEO), CTF expressed no concerns about the medical supplies process. Health care managers and medical warehouse managers expressed no concerns about the medical supply chain or their communication process with the existing system. Infection Control and Sanitation Staff appropriately disinfected, cleaned, and sanitized six of eight clinics (MIT 5.101, 75.0%). In one clinic, we found examination room cabinets under the sink had accumulated grime. In the remaining clinic, test strips used to show whether the cleaning solution meets the proper sanitation level were expired. Staff in six of eight clinics (MIT 5.102, 75.0%) properly sterilized or disinfected medical equipment. In one clinic, staff did not date stamp and initial the packaging of sterilized medical equipment. In another clinic, as part of their daily cleaning protocol, staff relied on the incarcerated person porters to disinfect the examination table prior to the start of their shift. We found operating sinks and hand hygiene supplies in the examination rooms of seven of nine clinics (MIT 5.103, 77.8%). However, patient restrooms in two clinics lacked antiseptic soap. We observed patient encounters in five clinics. In two clinics, clinicians did not wash their hands before examining their patients, before applying gloves, after performing blood draws, or before handling specimen vials (MIT 5.104, 60.0%). Health care staff in eight of nine clinics followed proper protocols to mitigate exposure to blood-borne pathogens and contaminated waste (MIT 5.105, 88.9%). In one clinic, we found the sharps container overfilled. Physical Infrastructure CTF’s health care management and plant operations manager reported all clinical area infrastructures were in good working order and did not hinder health care services. At the time of our medical inspection, the institution reported the health care facility improvement program (HCFIP) project to renovate the Q Wing and the specialty clinic spaces, designed to provide improvements in the quality of patient care, was delayed due to the COVID-19 pandemic. CTF estimated groundbreaking would occur in the first quarter of 2022, and the project would be completed by the first quarter of 2023 (MIT 5.999). Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 40 Compliance Testing Results Table 11. Health Care Environment Table 11. Health Care Environment Scored Answer Compliance Questions Yes No N/A Yes % Infection control: Are clinical health care areas appropriately 6 2 1 75.0% disinfected, cleaned, and sanitary? (5.101) Infection control: Do clinical health care areas ensure that reusable invasive and noninvasive medical equipment is properly sterilized or 6 2 1 75.0% disinfected as warranted? (5.102) Infection control: Do clinical health care areas contain operable sinks 7 2 0 77.8% and sufficient quantities of hygiene supplies? (5.103) Infection control: Does clinical health care staff adhere to universal 3 2 4 60.0% hand hygiene precautions? (5.104) Infection control: Do clinical health care areas control exposure to 8 1 0 88.9% blood-borne pathogens and contaminated waste? (5.105) Warehouse, conex, and other nonclinic storage areas: Does the medical supply management process adequately support the needs 1 0 0 100% of the medical health care program? (5.106) Clinical areas: Does each clinic follow adequate protocols for 2 7 0 22.2% managing and storing bulk medical supplies? (5.107) Clinical areas: Do clinic common areas and exam rooms have 1 8 0 11.1% essential core medical equipment and supplies? (5.108) Clinical areas: Are the environments in the common clinic areas 4 2 3 66.7% conducive to providing medical services? (5.109) Clinical areas: Are the environments in the clinic exam rooms 5 4 0 55.6% conducive to providing medical services? (5.110) Clinical areas: Are emergency medical response bags and emergency crash carts inspected and inventoried within required time frames, 0 7 2 0 and do they contain essential items? (5.111) Does the institution’s health care management believe that all clinical This is a nonscored test. Please areas have physical plant infrastructures that are sufficient to provide see the indicator for discussion of adequate health care services? (5.999) this test. Overall percentage (MIT 5): 57.5% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 41 Recommendations • To ensure that staff are following equipment and medical supply management protocols, nursing leadership should consider performing random spot checks. • Medical leadership should remind staff to follow universal hand hygiene precautions. Implementing random spot checks could improve compliance. • Nursing leadership should direct nurse supervisors at each clinic to review the monthly emergency medical response bag (EMRB) and treatment cart logs to ensure they are regularly inventoried and sealed. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 42 Transfers Overall Rating In this indicator, OIG inspectors examined the transfer process for those patients Adequate who transferred into the institution as well as for those who transferred to other institutions. For newly arrived patients, our inspectors assessed the quality of Case Review health screenings and the continuity of provider appointments, specialist Rating referrals, diagnostic tests, and medications. For patients who transferred out of Adequate the institution, inspectors checked whether staff reviewed patient medical records and determined the patient’s need for medical holds. They also assessed Compliance whether staff transferred patients with their medical equipment and gave correct Score medications before patients left. In addition, our inspectors evaluated the Adequate performance of staff in communicating vital health transfer information, such as (80.0%) preexisting health conditions, pending appointments, tests, and specialty referrals; and inspectors confirmed whether staff sent complete medication transfer packages to the receiving institution. For patients who returned from off-site hospitals or emergency rooms, inspectors reviewed whether staff appropriately implemented the recommended treatment plans, administered necessary medications, and scheduled appropriate follow-up appointments. Results Overview CTF had a mixed performance in this indicator. Compared with Cycle 5, CTF’s compliance score declined from 92.9 percent to 80.0 percent. However, our clinicians found a similar number of deficiencies. As was seen in Cycle 5, CTF performed well with ensuring newly arrived patients received their prescribed medications. However, medications were not always administered to patients who had brief layovers at CTF. Furthermore, our compliance and clinician teams found that nurse assessments were not always complete for patients transferring into the institution or returning from a community hospital. After reviewing the compliance testing and case review results, we rated this indicator adequate. Case Review and Compliance Testing Results Our clinicians reviewed 18 cases in which patients transferred into or out of the institution or returned from an off-site hospital or emergency room. We identified 18 deficiencies, seven of which were significant.28 Transfers In Both case review and compliance testing found room for improvement in nurses’ initial assessments of patients. Compliance testing revealed that CTF nurses did not thoroughly complete initial health screening forms and did not always assess patients when warranted (MIT 6.001, 40.0%). In one of the three cases our clinicians reviewed, the nurse did not accurately document which medications 28 Deficiencies occurred in cases 1, 2, 11, 19–22, 28, 29, 30, and 59. Cases 2, 11, 19, 21, and 29 had significant deficiencies. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 43 the patient was prescribed, did not address the diabetic patient’s sugar level, and did not correctly document that the patient had coccidioidomycosis risk factors. Our compliance team found CTF’s medication continuity was excellent for patients at the time of transfer (MIT 6.003, 100%). Our clinicians found only one significant medication deficiency: • In case 28, the patient transferred into CTF, but did not receive two of his chronic care medications for six days and another three of his chronic care medications for 28 days. Compliance testing found that when patients transferred into CTF with preapproved specialty services, only 30.0 percent of specialty appointments were completed within the required time frames (MIT 14.010). Our clinicians reviewed one patient who transferred into the institution with a pending specialty appointment and found he was evaluated by a specialist within the ordered time frame. Transfers Out CTF’s transfer-out process was acceptable. Our clinicians reviewed three transfer-out cases and identified three deficiencies.29 All deficiencies were related to CTF’s failure to communicate with the transferring facility regarding necessary specialist appointments. The following is an example: • In case 32, the patient sustained a fracture on the day he transferred from CTF. There was no documentation that a CTF nurse or provider communicated this information with the receiving institution. Fortunately, the receiving institution arranged a timely specialist evaluation. CTF’s transfer-out process was not observed by the compliance team because no patients transferred out on the day of the OIG compliance on-site inspection (MIT 6.101, N/A). Hospitalizations Patients returning from an off-site hospitalization or emergency room are at high risk for lapses in care quality. These patients typically experienced severe illness or injury. They require more care and place strain on the institution’s resources. Also, because the patients have complex medical issues, successful health information transfer is necessary for good quality care. Any transfer lapse can result in serious consequences for these patients. 29 Deficiencies occurred once in case 33 and twice in case 32. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 44 Our clinicians reviewed 19 events and found 12 deficiencies related to hospital or emergency room after care, five of which were significant.30 Many of the deficiencies were related to incomplete nursing assessments and care plans. The following are some examples: • In case 2, the patient returned to CTF after a community emergency room evaluation. In the emergency room, the physician noted the patient was paranoid and delusional. However, the CTF nurse did not perform a mental health assessment or consult with a mental health provider. • In case 11, the patient returned to CTF after a 13-day community hospital admission with a new diagnosis of metastatic cancer. The nurse did not weigh the patient, did not assess the patient for pain, and did not complete a thorough physical exam. • In case 21, the patient returned to CTF after a three-day hospital admission for a cardiac condition. The CTF nurse inappropriately advised the patient to discontinue taking aspirin, which increased the risk of harm to the patient. CTF’s performance was excellent in retrieving and reviewing hospital records (MIT 4.003 and MIT 4.005, 100%). Our clinicians reviewed 19 hospital or emergency room returns and found three deficiencies.31 One deficiency was considered significant when the provider did not endorse hospital records for 13 days. Both our case review and compliance teams found CTF’s performance was excellent in providing follow-up appointments within required time frames to patients returning from the hospital and emergency room visits (MIT 1.007, 100%). Compliance testing showed CTF’s performance was poor in medication continuity (MIT 7.003, 40.0%). Similarly, our clinicians identified two occasions in which the institution’s providers did not initiate medication as recommended at the time hospital discharge.32 In addition, our clinicians identified a significant deficiency in which medications were not issued to the patient as prescribed.33 Clinician On-Site Inspection The OIG clinician met with the receiving and release (R&R) nurse, who was knowledgeable about the transfer process and job duties. At the time of our 30 Deficiencies occurred in cases 1, 2, 11, 19-22, and 59. Significant deficiencies occurred in cases 2, 11, 19, and twice in case 21. 31 Deficiencies occurred in cases 2, 19, and 20. A significant deficiency occurred in case 19. 32 Deficiencies occurred in cases 21 and 59. 33 A significant deficiency occurred in case 21. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 45 inspection, the R&R was staffed with a registered nurse on each shift. R&R nurses evaluated patients arriving and transferring to other departmental institutions. According to the R&R nurse, the central pharmacy reconciled all medications for arriving patients. Although the R&R does not have an Omnicell machine, the nurse explained that medications could be easily obtained in the triage and treatment area (TTA) due to its proximity to R&R.34 Patients who returned from a community hospital or emergency room were evaluated in the TTA. The TTA nurses reported that when patients return from a higher level of care, providers reconcile medications. 34 An Omnicell is an automated medication dispensing machine. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 46 Compliance Testing Results TTaabbllee 1122.. TTrraannssffeerrss Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution or COCF: Did nursing staff complete the initial health screening and 10 15 0 40.0% answer all screening questions within the required time frame? (6.001) * For endorsed patients received from another CDCR institution or COCF: When required, did the RN complete the assessment and disposition section of the initial health screening form; refer the 23 0 2 100% patient to the TTA if TB signs and symptoms were present; and sign and date the form on the same day staff completed the health screening? (6.002) For endorsed patients received from another CDCR institution or COCF: If the patient had an existing medication order upon arrival, 13 0 12 100% were medications administered or delivered without interruption? (6.003) * For patients transferred out of the facility: Do medication transfer packages include required medications along with the corresponding 0 0 0 N/A transfer packet required documents? (6.101) * Overall percentage (MIT 6): 80.0% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 47 Table 13. Other Tests Related to Transfers Table 13. Other Tests Related to Transfers Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution: Based on the patient’s clinical risk level during the initial health screening, was the 22 3 0 88.0% patient seen by the clinician within the required time frame? (1.002) * Upon the patient’s discharge from the community hospital: Did the patient receive a follow-up appointment with a primary care provider 20 0 0 100% within the required time frame? (1.007) * Are community hospital discharge documents scanned into the patient’s electronic health record within three calendar days of hospital 20 0 0 100% discharge? (4.003) * For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements and did a 20 0 0 100% provider review the report within five calendar days of discharge? (4.005) * Upon the patient’s discharge from a community hospital: Were all ordered medications administered, made available, or delivered to the 8 12 0 40.0% patient within required time frames? (7.003) * Upon the patient’s transfer from one housing unit to another: Were 21 4 0 84.0% medications continued without interruption? (7.005) * For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications 3 7 0 30.0% administered or delivered without interruption? (7.006) * For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the 6 14 0 30.0% sending institution, was the appointment scheduled at the receiving institution within the required time frames? (14.010) * * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 48 Recommendations • Nursing leadership should consider educating receiving and release (R&R) nurses in the proper completion of initial health screening questions. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 49 Medication Management Overall Rating In this indicator, OIG inspectors evaluated the institution’s performance in administering prescription medications on time and without interruption. The Inadequate inspectors examined this process from the time a provider prescribed medication Case Review until the nurse administered the medication to the patient. When rating this Rating indicator, the OIG strongly considered the compliance test results, which tested medication processes to a much greater degree than case review testing. In Adequate addition to examining medication administration, our compliance inspectors also Compliance tested many other processes, including medication handling, storage, error Score reporting, and other pharmacy processes. Inadequate (67.1%) Results Overview CTF performed poorly overall in this indicator. CTF staff had difficulty ensuring medication continuity in multiple areas. Similar to Cycle 5, patients who transferred into the institution and returned from a community hospital did not always receive their medications timely. Compliance testing found that patients often did not receive their chronic care medications prior to exhaustion. When patients had a layover at CTF, they frequently did not receive their medications. Although our clinicians found medication management adequate, compliance testing is a more encompassing approach in this indicator. Factoring in both compliance testing and case reviews, we rated this indicator inadequate. Case Review and Compliance Testing Results We reviewed 39 cases related to medications and identified 20 medication deficiencies, 12 of which were significant.35 New Medication Prescriptions Compliance testing found that 80.0 percent of new medications were available or administered timely (MIT 7.002). Our clinicians found three medication delays:36 • In case 11, the patient did not receive the newly prescribed metoprolol and ondansetron for a month.37 • In case 17, the patient received the newly prescribed metoprolol medication one month late. 35 Deficiencies occurred in cases 1, 6, 9, 10, 11, 12, 14, 17, 20, 21, 25, 27, 28, and 59. Cases 11, 12, 14, 17, 20, 21, 25, 27, 28, and 59 had significant deficiencies. 36 Deficiencies occurred in cases 6 and 20. Case 20 had a significant deficiency. 37 Metoprolol is a blood pressure medication. Ondansetron is a medication used for nausea and vomiting. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 50 • In case 20, the patient received an antifungal medication one day late, which resulted in two missed doses. Chronic Medication Continuity CTF performed poorly with ensuring medication continuity for chronic conditions. Compliance testing found that patients did not receive their chronic care medications within the required time frames (MIT 7.001, 20.0%). Our clinicians identified 12 deficiencies, seven of which were considered significant.38 • In case 14, the diabetic patient did not receive his chronic care diabetes medication for two months. • In case 21, the patient did not receive two of his chronic care medications for one month. • In case 25, the patient was prescribed a daily dose of aspirin; however, the patient did not receive the medication for one month. Hospital Discharge Medications CTF performed poorly in ensuring patients received their medications when they returned from an off-site hospital or emergency room. Compliance testing showed that when patients returned from an off-site hospital or emergency room, they did not receive their medications within required time frames (MIT 7.003, 40.0%). Our clinicians reviewed 19 hospital returns and found one significant deficiency.39 Please see the Transfers indicator for further details. Specialized Medical Housing Medications CTF’s medication management in the specialized medical housing was acceptable. Compliance testing showed that when patients were admitted to the outpatient housing unit (OHU), medications were administered timely 75.0 percent of the time (MIT 13.004). Our clinical team found two significant deficiencies related to specialized medical housing.40 The following is an example: • In case 59, the patient returned from a community hospital and was admitted to the OHU. There was no evidence the patient received two of his prescribed medications after returning to CTF. 38 Deficiencies occurred in cases 1, 9, 12, 14, 17, 21, 25, and 27. Cases 12, 14, 17, 21, 25, and 27 had significant deficiencies. 39 Significant deficiencies occurred in cases 11, 17, and 20. 40 Cases 27 and 59 had significant deficiencies. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 51 Transfer Medications CTF scored very high in compliance testing of medication continuity for patients transferring into the institution (MIT 6.003, 100%). Our clinicians identified one significant medication deficiency for a patient arriving at CTF.41 Compliance testing found good medication continuity when patients transferred within the institution (MIT 7.005, 84.0%). However, CTF scored low in compliance testing of medication continuity for patients who had had layovers at CTF (MIT 7.006, 30.0%). Medication Administration Compliance testing showed that 66.7 percent of TB medications were administered timely (MIT 9.001). However, compliance testing also found that nurses did not thoroughly monitor patients with prescribed TB medications (MIT 9.002, zero). Clinician On-Site Inspection Our clinicians interviewed nurses, the pharmacist-in-charge (PIC), and other pharmacy personnel and discussed cases in which our clinicians had questions about specific medications. The PIC showed our clinicians evidence that many medications were delivered to the medication administration areas, but agreed there was no evidence that patients received these medications. We found both the nurses and pharmacy staff knowledgeable about the medication process. Nursing leadership indicated the pharmacist was available after hours when urgent medication issues occurred. Compliance Testing Results Medication Practices and Storage Controls The institution adequately stored and secured narcotic medications in seven of eight clinic and medication line locations (MIT 7.101, 87.5%). In one location, medication nurses could not describe the narcotic medication discrepancy reporting process. CTF appropriately stored and secured nonnarcotic medications in six of nine clinic and medication line locations (MIT 7.102, 66.7%). In two locations, the refrigerated medications did not have a designated area for medications to be returned to pharmacy. In another location, medications were not stored in an orderly manner, and the medication cart did not have enough space to avoid crowding of medications. Staff kept medications protected from physical, chemical, and temperature contamination in seven of the nine clinic and medication line locations (MIT 41 Case 28 had a significant deficiency. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 52 7.103, 77.8%). In one location, staff did not store oral and topical medications separately. In another location, staff did not consistently record room and refrigerator temperatures. Staff successfully stored valid, unexpired medications in five of the nine applicable medication line locations (MIT 7.104, 55.6%). In three locations, medication nurses failed to label the multiple-use medication, as required by CCHCS policy. In another location, medication nurses did not discard a previously opened single-use solution and instead stored it in the medication room. Nurses exercised proper hand hygiene and contamination control protocols in four of six locations (MIT 7.105, 66.7%). In two locations, nurses neglected to wash or sanitize their hands before donning gloves and before each subsequent regloving. Staff in four of six medication preparation and administration areas demonstrated appropriate administrative controls and protocols (MIT 7.106, 66.7%). In one location, a medication nurse could not describe the process to reconcile newly received medication and the medication administration record (MAR) against the corresponding physician’s order. In another location, medication nurses did not maintain unissued medications in their original labeled packaging. Staff in four of six medication areas used appropriate administrative controls and protocols when distributing medications to their patients (MIT 7.107, 66.7%). In one location, medication nurses did not disinfect the top of a previously opened insulin vial prior to withdrawing the medication. In another location, medication nurses inaccurately logged the daily glucometer quality control test results prior to use. Pharmacy Protocols CTF’s pharmacy staff followed general security, organization, and cleanliness management protocols in its pharmacy, and properly stored nonrefrigerated and refrigerated medications, scoring 100 percent in these tests (MIT 7.108, MIT 7.109, and MIT 7.110). The PIC did not correctly review monthly inventories of controlled substances in the institution’s clinic and medication storage locations. The nurses present at the time of the medication area inspection did not correctly complete several medication area inspection checklists. In addition, the PIC did not correctly complete several medication area inspection checklists (CDCR Form 7477) and neglected to record names, signatures, or dates on several inventory records. These errors resulted in a score of zero in this test (MIT 7.111). We examined 25 medication error reports. The PIC timely or correctly processed all 25 reports (MIT 7.112, 100%). Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 53 Nonscored Tests In addition to testing the institution’s self-reported medication errors, our inspectors also followed up on any significant medication errors found during compliance testing. We do not score this test; we provide these results for informational purposes only. At CTF, the OIG did not find any applicable medication errors (MIT 7.998). CTF did not have a restricted housing unit at the time of inspection (MIT 7.999). Compliance On-Site Inspection During our onsite inspection at the North B clinic, we observed medication nurses and a custody officer stop an active medication administration line due to a medical emergency in the housing unit. According to medication nurses, LVNs assigned in the medication room are primarily responsible in responding to any medical emergency. When the LVNs arrived at the scene, they determined that the patient needed a higher level of care and waited for TTA RNs from the Central clinic to arrive. Meanwhile, the RNs assigned to conduct face-to-face appointments in the North B clinic continued their appointments and did not provide support to the LVNs. The medication nurses reported that this process has been in practice for several years, as instructed by their nursing leadership. This practice may increase the risk of delay in time sensitive medications as well as a delay in emergency patient care. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 54 Table 14. Medication Management ccaann’’tt aacccceepptt oovveerr-- Table 14. Medication Management rriiddeess ffoorr qquueessttiioonn Scored Answer ccoolluummnn;; ttoooo ffuullll.. Compliance Questions Yes No N/A Yes % Did the patient receive all chronic care medications within the required time frames or did the institution follow departmental policy for refusals or 3 12 10 20.0% no-shows? (7.001) * Did health care staff administer, make available, or deliver new order 20 5 0 80.0% prescription medications to the patient within the required time frames? (7.002) Upon the patient’s discharge from a community hospital: Were all ordered medications administered, made available, or delivered to the patient within 8 12 0 40.0% required time frames? (7.003) * For patients received from a county jail: Were all medications ordered by the institution’s reception center provider administered, made available, or N/A N/A N/A N/A delivered to the patient within the required time frames? (7.004) * Upon the patient’s transfer from one housing unit to another: Were 21 4 0 84.0% medications continued without interruption? (7.005) * For patients en route who lay over at the institution: If the temporarily housed patient had an existing medication order, were medications administered or 3 7 0 30.0% delivered without interruption? (7.006) * All clinical and medication line storage areas for narcotic medications: Does the institution employ strong medication security controls over narcotic 7 1 2 87.5% medications assigned to its storage areas? (7.101) All clinical and medication line storage areas for nonnarcotic medications: Does the institution properly secure and store nonnarcotic medications in the 6 3 1 66.7% assigned storage areas? (7.102) All clinical and medication line storage areas for nonnarcotic medications: Does the institution keep nonnarcotic medication storage locations free of 7 2 1 77.8% contamination in the assigned storage areas? (7.103) All clinical and medication line storage areas for nonnarcotic medications: Does the institution safely store nonnarcotic medications that have yet to expire in 5 4 1 55.6% the assigned storage areas? (7.104) Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols during medication 4 2 4 66.7% preparation and medication administration processes? (7.105) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when preparing medications 4 2 4 66.7% for patients? (7.106) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when administering 4 2 4 66.7% medications to patients? (7.107) Pharmacy: Does the institution employ and follow general security, organization, and cleanliness management protocols in its main and remote 1 0 0 100% pharmacies? (7.108) Pharmacy: Does the institution’s pharmacy properly store nonrefrigerated 1 0 0 100% medications? (7.109) Pharmacy: Does the institution’s pharmacy properly store refrigerated or frozen 1 0 0 100% medications? (7.110) Pharmacy: Does the institution’s pharmacy properly account for narcotic 0 1 0 0 medications? (7.111) Pharmacy: Does the institution follow key medication error reporting 25 0 0 100% protocols? (7.112) Pharmacy: For Information Purposes Only: During compliance testing, did the This is a nonscored test. Please OIG find that medication errors were properly identified and reported by the see the indicator for discussion of institution? (7.998) this test. Pharmacy: For Information Purposes Only: Do patients in restricted housing This is a nonscored test. Please units have immediate access to their KOP prescribed rescue inhalers and see the indicator for discussion of nitroglycerin medications? (7.999) this test. Overall percentage (MIT 7): 67.1% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 55 Table 15. Other Tests Related to Medication Management Table 15. Other Tests Related to Medication Management Scored Answer Compliance Questions Yes No N/A Yes % For endorsed patients received from another CDCR institution or COCF: If the patient had an existing medication order upon arrival, 13 0 12 100% were medications administered or delivered without interruption? (6.003) * For patients transferred out of the facility: Do medication transfer packages include required medications along with the corresponding 0 0 0 N/A transfer-packet required documents? (6.101) * Patients prescribed TB medication: Did the institution administer the 2 1 0 66.7% medication to the patient as prescribed? (9.001) * Patients prescribed TB medication: Did the institution monitor the patient per policy for the most recent three months he or she was on 0 3 0 0 the medication? (9.002) * Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient 3 1 0 75.0% within required time frames? (13.004) * * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 56 Recommendations • Medical and nursing leadership should ensure that chronic care, hospital discharge, and en route patients receive their medications timely and without interruption. • Nursing leadership and the public health nurse should instruct nursing staff to properly document the monitoring of patients taking tuberculosis (TB) medications. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 57 Preventive Services Overall Rating In this indicator, OIG compliance inspectors tested whether the institution Inadequate offered or provided cancer screenings, tuberculosis (TB) screenings, influenza vaccines, and other immunizations. If the department designated the institution Case Review as high risk for coccidioidomycosis (valley fever), we tested the institution’s Rating performance in transferring out patients quickly. The OIG rated this indicator (N/A) solely according to the compliance score, using the same scoring thresholds as in the Cycle 4 and Cycle 5 medical inspections. Our case review clinicians do not rate this indicator. Compliance Score Inadequate Results Overview (59.4%) CTF had a mixed performance in preventive services. Staff performed well in offering patients an influenza vaccine for the most recent influenza season and offering colorectal cancer screening for all patients from ages 45 through 75. However, they faltered in administering and monitoring patients who were taking prescribed TB medications, screening patients annually for TB, and in offering required immunizations for chronic care patients. We rated this indicator inadequate. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 58 Compliance Testing Results Table 16. Preventive Services Table 16. Preventive Services Scored Answer Compliance Questions Yes No N/A Yes % Patients prescribed TB medication: Did the institution administer the 2 1 0 66.7% medication to the patient as prescribed? (9.001) Patients prescribed TB medication: Did the institution monitor the patient per policy for the most recent three months he or she was on 0 3 0 0 the medication? (9.002) † Annual TB screening: Was the patient screened for TB within the last 13 12 0 52.0% year? (9.003) Were all patients offered an influenza vaccination for the most recent 25 0 0 100% influenza season? (9.004) All patients from the age of 45 through the age of 75: Was the 22 3 0 88.0% patient offered colorectal cancer screening? (9.005) Female patients from the age of 50 through the age of 74: Was the N/A N/A N/A N/A patient offered a mammogram in compliance with policy? (9.006) Female patients from the age of 21 through the age of 65: Was N/A N/A N/A N/A patient offered a pap smear in compliance with policy? (9.007) Are required immunizations being offered for chronic care patients? 4 4 17 50.0% (9.008) Are patients at the highest risk of coccidioidomycosis (valley fever) N/A N/A N/A N/A infection transferred out of the facility in a timely manner? (9.009) Overall percentage (MIT 9): 59.4% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † In April 2020, after our review but before this report was published, CCHCS reported adding the symptom of fatigue into the electronic health record system (EHRS) PowerForm for tuberculosis (TB)-symptom monitoring. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 59 Recommendations • Nursing leadership and the public health nurse should instruct nursing staff to properly document the monitoring of patients taking tuberculosis (TB) medications. • Nursing leadership should consider developing and implementing measures to ensure that nursing staff timely screen patients for TB. • Medical leadership should determine the root cause of challenges that prevent the timely provision of chronic care vaccinations. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 60 Nursing Performance Overall Rating In this indicator, the OIG clinicians evaluated the quality of care delivered by the Inadequate institution’s nurses, including registered nurses (RNs), licensed vocational nurses (LVNs), psychiatric technicians (PTs), and certified nursing assistants (CNAs). Our clinicians evaluated nurses’ performance in making timely and appropriate Case Review assessments and interventions. We also evaluated the institution’s nurses’ Rating documentation for accuracy and thoroughness. Clinicians reviewed nursing Inadequate performance in many clinical settings and processes, including sick call, outpatient care, care coordination and management, emergency services, Compliance specialized medical housing, hospitalizations, transfers, specialty services, and Score medication management. The OIG assessed nursing care through case review (N/A) only and performed no compliance testing for this indicator. When summarizing overall nursing performance, our clinicians understand that nurses perform numerous aspects of medical care. As such, specific nursing quality issues are discussed in other indicators, such as Emergency Services, Specialty Services, and Specialized Medical Housing. Results Overview At CTF, nursing care was insufficient. Unlike in Cycle 5, CTF nurses did not have an experienced appointed leadership team. In this cycle, most members of the leadership nursing team were serving in acting roles. The majority of significant nursing deficiencies occurred when RNs did not make appropriate triage decisions, did not perform thorough assessments, and did not monitor their patients. In addition, we identified patterns of incomplete and missing nursing documentation, and that most of the deficiencies were made by nurses working in the TTA, nurses caring for COVID-19 patients, and nurses working in the medical clinics. After considering all aspects of CTF’s nursing performance, the OIG rated this indicator inadequate. Case Review Results We reviewed 216 nursing encounters in 53 cases. Of the nursing encounters we reviewed, 122 were in the outpatient setting. We identified 91 nursing performance deficiencies, 21 of which were significant.42 Nursing Assessment and Interventions At CTF, we identified patterns of deficiencies for incomplete nursing assessments and interventions. Most of the significant deficiencies were made by nurses in the TTA and outpatient areas. However, we also identified several 42 Deficiencies occurred in cases 1–6, 8, 9, 11, 16, 17, 19-22, 24, 29, 32, 33, 25, 37, 29, 44, 45, 46, 50, 54, 58, and 59. Cases 1, 2, 4, 8, 9, 11, 20, 21, 29, 35, 38, and 59 had significant deficiencies. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 61 deficiencies when patients returned to the institution after a hospital or emergency room visit. The following are examples: • In case 8, this patient was isolated for a COVID-19 infection. The nurse performing rounds noted that the patient’s oxygen saturation result was very low. Despite the dangerously low oxygen level, the nurse did not initiate oxygen, and did not assess the patient’s skin and nail beds for changes in color. In addition, the nurse did not listen to the patient’s lung sounds to ensure adequate oxygen exchange. • In case 9, this patient’s blood pressure was high. The patient informed the licensed vocational nurse (LVN) that the patient had stopped taking the KOP blood pressure medication because of itching, which would normally require a clinical follow up.43 The LVN did not consult a provider or initiate a follow-up appointment. • In case 11, the nurse evaluated a quarantined patient who complained of shortness of breath, but the nurse did not ask the patient how often this occurred or when it first began. The nurse did not recognize that this symptom could be associated with a COVID- 19 infection and perform a point-of-care test. In addition, the nurse did not assess the patient’s blood pressure and pulse rate, and did not consult a provider to discuss a plan of care. • In case 19, the nurse evaluated the patient for pneumonia but did not listen to the patient’s lungs for abnormal sounds. • In case 22, the patient returned to CTF after an abdominal surgery and hospitalization. The nurse did not auscultate the patient’s lungs or listen for active bowel sounds.44 • In case 45, the nurse performing sick call did not obtain the patient’s vital signs. In cases 9 and 44, the nurses also did not assess the patient’s vital signs during clinical encounters. Nursing Documentation Complete and accurate documentation is an essential component of patient care. Without proper documentation, health care staff may overlook changes in a patient’s condition and assessing care quality becomes challenging. We identified patterns of incomplete and inaccurate documentation at CTF. The following are some examples: 43 KOP means keep on person. 44 Abdominal surgery places a person at an elevated risk of pneumonia and constipation. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 62 • In case 4, the patient was isolated for a COVID-19 infection. Nurses administered medications to lower the patient’s fever, but did not document the patient’s temperature in EHRS or the MAR. • In case 9, the patient was isolated for a COVID-19 infection. The nurse noted that the patient’s oxygen saturation level had decreased, and the patient would be monitored. However, there was no documentation that this monitoring occurred. • In case 20, a nurse documented in the MAR that a medication was not administered because the patient had died; however, the patient had not died. Nursing Sick Call Our clinicians reviewed 41 sick call requests in 28 cases. Compared to Cycle 5, CTF improved in reviewing sick call requests timely, and our clinicians found that most patients were evaluated timely. However, we identified that nurses did not always consult providers or initiate follow-up appointments when clinically warranted. The following are examples: • In case 17, the diabetic patient had a foot wound; however, the nurse did not consult a provider or initiate an urgent appointment.45 • In case 21, this patient had concerns of cardiac disease and was awaiting a cardiac test. The nurse documented that the patient had new lower extremity edema, which can be sign of heart disease, but did not consult a provider. Emergency Services We identified patterns of poor triage decisions, incomplete nursing assessments and interventions, and incomplete or missing nursing documentation. Of the 19 deficiencies identified, seven were significant. See the Emergency Services indicator for more details. Hospital Returns We reviewed 12 cases involving patients who returned from a community hospital or emergency room and identified seven nursing deficiencies. Most deficiencies were related to incomplete nursing assessments. See the Transfers indicator for more details. 45 Diabetic patients may have impaired circulation that can cause a delay in wound healing. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 63 Transfers We reviewed six cases and found that when patients transferred out of CTF to another institution, nurses did not inform the receiving institution of specialty appointments in their documentation. Furthermore, when patients arrived to CTF, nurses did not always perform thorough initial health screening assessments or accurately document their findings. Additional information can be found in the Transfers indicator. Specialized Medical Housing Case reviewers evaluated five OHU cases and found 11 nursing deficiencies, two of which were significant. Please refer to the Specialized Medical Housing indicator for more details. Specialty Services Nurses provided good care for patients returning from an off-site specialty appointment. Most nurses performed appropriate assessments, reviewed specialist recommendations, and communicated pertinent information to the providers. The Specialty Services indicator provides further information. Medication Management Our clinicians reviewed 150 events involving medication management and administration and identified 20 deficiencies, 12 which were significant. During our on-site inspection, the pharmacy department was able to show that on several occasions, medications were delivered to the medication administration areas. However, there was no evidence that the patient received the medication. The Medication Management indicator provides further information. Clinician On-Site Inspection During our on-site inspection, our clinicians toured the TTA, R&R, OHU, the COVID-19 quarantine and isolation area, and the medical clinics. We met with medical executives, nursing supervisors, medical staff, and custody staff. Our clinicians met with CTF’s COVID-19 crisis team, who discussed their pandemic operations. They explained that the institution’s COVID-19 outbreak occurred between October and December 2020. Custody and medical staff reported they had faced challenges during the outbreak including ensuring sufficient staffing levels. At the time of our inspection, CTF’s housed both isolation and quarantined patients in the central facility, which had 56 cells, each with solid doors. Staff reported that they housed COVID-19 patients on the second floor and quarantined patients on the first floor. Oxygen was stored within the housing unit. The institution’s two dormitory-style housing units were located in its North facility. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 64 We were informed of a high COVID-19 vaccination compliance rate (93%–95%). The CEO indicated that when patients refused a COVID-19 vaccination, the public health nurse or designee would meet with the patient to learn the reason and address any concerns related to the vaccination. According to the medical team, this extra step had a positive impact on CTF’s vaccination compliance. Nursing leadership faced many challenges during the institution’s COVID-19 surge and expressed that staffing shortages had been challenging. The acting CNE was not present during the onsite inspection, and we were informed that this individual had been away for several months. However, the acting director of nursing (DON) was present during our interview and had covered this position for several months. In addition to the acting CNE and DON, there were three acting supervising registered nurses (SRN). CTF had a total of four SRN vacancies as well as 3.8 RN vacancies. The entire nursing team was pleasant and accommodating during our inspection. Our clinician and the CTF nursing leadership team discussed our case review questions. Although the DON had reviewed and prepared written responses to our questions, some of the nursing supervisors were not familiar with the cases and did not always agree with the DON’s responses. Our clinician appreciated the collaborative discussions. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 65 Recommendations • The department should consider strategies to improve recruitment and retention of nursing leadership and staff. • Nursing executive leadership should ensure that nursing supervisors who are conducting clinical care reviews identify opportunities for improvement. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 66 Provider Performance Overall Rating In this indicator, OIG case review clinicians evaluated the quality of care Inadequate delivered by the institution’s providers: physicians, physician assistants, and nurse practitioners. Our clinicians assessed the institution’s providers’ performance in evaluating, diagnosing, and managing their patients properly. We Case Review examined provider performance across several clinical settings and programs, Rating including sick call, emergency services, outpatient care, chronic care, specialty Inadequate services, intake, transfers, hospitalizations, and specialized medical housing. We assessed provider care through case review only and performed no compliance Compliance testing for this indicator. Score (N/A) Results Overview CTF providers generally delivered poor care due to their decision-making, emergency care, and diabetes care. Furthermore, emergency provider deficiencies were not recognized, compounding this issue. While some areas, such as hospital return care and hypertension care improved compared with Cycle 5, decision- making, particularly in emergency and chronic care, continued to be problematic. The OIG rated this indicator inadequate. Case Review Results In our inspection, we reviewed 110 provider events and identified 30 deficiencies.46 Of these deficiencies, 21 were significant.47 In addition, the OIG clinicians examined the care quality in 22 comprehensive case reviews and found 18 adequate and four inadequate. Assessment and Decision-Making We identified several issues in provider assessments and decision-making. The providers did not always perform assessments such as clinically relevant examinations.48 CTF providers made questionable decisions, particularly in emergency care and chronic care. The following are some examples: • In case 2, the patient had a lab test for bilirubin, which was elevated.49 The provider reviewed this elevated bilirubin result, but sent a letter to the patient that the result was normal and did not follow the bilirubin or discuss this with the patient. On site, the 46 Deficiencies occurred in cases 1, 2, 8, 10, 14, 15, 16, 17, 19, 21, 23, 24, 27, 32 and 59. 47 Significant provider deficiencies occurred in cases 1, 2, 8, 10, 14-17, 19, 21, 23, 24, 27, and 59. 48 Deficiencies occurred in cases 16, 17, and 21. 49 Bilirubin is a chemical made by the liver. An increased level may indicate liver, gallbladder, or biliary tract disease. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 67 provider suggested the patient had Gilbert Syndrome, but we could not find a documented history of this diagnosis as of the interview.50 • In case 16, the patient with psoriatic arthritis had been off his medication for three months. The dermatologist recommended monitoring the patient for signs of relapse and to consider restarting the medication, if needed. However, the primary care provider did not examine the patient’s skin for rash or joints. • In case 17, the patient complained of bilateral foot pain during a chronic care appointment; however, provider did not perform an examination of the patient’s feet. • In case 21, the patient had an elevated liver enzymes from simvastatin, for which the hospitalist recommended rosuvastatin; however, the provider on call did not start the patient on any statin and did not document the reason why.51 • In case 23, the provider started the patient on scheduled morphine for arthritis, but did not consider other therapies, monitor effectiveness, indicate the goals of therapy, or plan the duration of the patient’s opioid therapy. Review of Records Review of records is an important facet of provider care and thoroughness in this area will allow for the best decisions for the patients. The providers generally reviewed medical records carefully. We identified a few lapses in the following cases: • In case 10, the provider did not review that the patient had an elevated hemoglobin A1c and did not optimize the patient’s blood sugar control.52 This was unfortunate because the patient was going to have surgery and better sugar management would reduce complications from surgery and aid healing. During the on-site inspection, the provider agreed that it was an oversight. • In case 21, the patient had a heart attack. The primary care provider followed up with the patient after the hospitalization, but did not order the rosuvastatin and liver enzyme laboratory tests that were recommended.53 During the on-site inspection, the provider verbally 50 Gilbert syndrome is a condition where the liver does not process the bilirubin properly, resulting in an elevated bilirubin level. 51 Statin is a cholesterol reducing medication. Rosuvastatin and simvastatin are both statin medications, but rosuvastatin can be used in patients with elevated liver enzymes. 52 The hemoglobin A1c is a test used to monitor and assess a patient’s diabetic sugar control. 53 Rosuvastatin is a cholesterol reducing medication and secondary prevention for heart disease such as a heart attack. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 68 admitted he was distracted by the patient’s cellulitis and missed the recommendation. Emergency Care Appropriate and timely decision-making, prompt evaluation and assessment, and stabilization of heart and lung function are critical in an urgent or emergent situation. Providers managed patients poorly in the TTA. We found problems with the provider’s decisions in the following cases: • In case 17, the patient had chest pain. The TTA nurse contacted the provider about the patient; however, the provider requested a nurse follow-up instead of seeing the patient or ordering a provider follow- up. Providers need to see patients during or after a TTA evaluation to ensure patients have the proper diagnosis and treatment plans. • In case 19, the provider sent the patient, who had low oxygen levels, to the hospital with a state car instead of an ambulance. This placed the patient at increased risk of complications during patient transport. • In case 21, a patient had cardiac risk factors and a recent cardiac stress test that indicated reduced blood flow to a portion of the heart. He had also complained of chest pain and shortness of breath. The provider sent the patient back to housing instead of transferring him to the hospital. Chronic Care Chronic care appointments are an important component of provider care. These appointments allow providers to review the patient’s chronic medical issues to determine whether symptoms and physical findings have changed and whether management needs to be modified. In several cases, the providers had chances to improve diabetes care, but did not utilize the opportunities: • In case 8, the provider recognized worsening blood sugar control and only recommended the same diet that he recommended three months prior. During the on-site inspection, the provider explained that the provider was expecting the results for the hemoglobin A1c in a few days to make a decision on further changes. However, the patient passed away two months later without a provider appointment or therapy modification. • In case 14, the provider decided not to modify the patient’s diabetes therapy because he erroneously documented that the patient’s medication had recently been adjusted; however, it was adjusted about 10 months prior. During the on-site inspection, the provider reported that he had not reviewed when the therapy was last modified. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 69 Specialty Services Providers appropriately referred patients for specialty consultation when needed. Providers also followed up with patients after specialty appointments and generally carried out recommendations from the specialists. However, case reviewers identified a deficiency where this did not happen. • In case 27, the provider did not order the imaging study that the specialist recommended. We discuss providers’ specialty performance further in the Specialty Services indicator. Documentation Quality CTF documentation had room for improvement. Our clinicians identified two deficiencies in which the provider on call did not document a note after being notified by the TTA RN. In two of the three specialized medical housing cases we reviewed, we found that the provider copied and pasted his physical exam from an earlier note. • In case 27, the provider’s physical exam of the patient was an exact copy from a previous appointment. Accurate serial exams were extremely important in this case because the patient had worsening weakness and progressive degradation of his leg muscles. Provider Continuity The OIG clinicians did not find any problems with provider continuity in the cases reviewed. Clinician On-Site Inspection We observed an efficient morning huddle in which pertinent information was distributed within the primary care team. The providers reported good working relationships with nurses, custody, and other providers. According to providers, they support medical leadership and receive appropriate feedback. We discussed provider deficiencies with medical leadership and providers. We discussed the deficiency in case 21 with medical leadership, who supported the provider’s decision-making and did not feel that the patient at risk of a heart attack needed to be sent out to the hospital. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 70 Recommendations • To improve provider decision-making, medical leadership should consider including a review of emergency care when completing annual provider reviews. • Medical leadership should remind providers to assess pertinent physical findings for patient medical issues and document patient encounters appropriately. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 71 Specialized Medical Housing Overall Rating In this indicator, OIG inspectors evaluated the quality of care in the specialized Adequate medical housing units. We evaluated the performance of the medical staff in assessing, monitoring, and intervening for medically complex patients requiring Case Review close medical supervision. Our inspectors also evaluated the timeliness and Rating quality of provider and nursing intake assessments and care plans. We assessed Adequate staff members’ performance in responding promptly when patients’ conditions deteriorated, and we looked for good communication when staff consulted one Compliance another while providing continuity of care. Our clinicians also interpreted Score relevant compliance results and incorporated them into this indicator. At the Proficient time of our inspection, CTF's specialized medical housing consisted of an (87.5%) outpatient housing unit (OHU). Results Overview CTF staff delivered good patient care in the OHU. Nurses took care of patients timely and appropriately with minimal lapses in care. Medication administration was acceptable. Provider performance in the OHU was good, except for several instances of cloned documentation of physical exams. After reviewing the different aspects of care in the OHU, we rated this indicator adequate. Case Review and Compliance Testing Results We reviewed five OHU cases, which included 24 provider events and 34 nursing events.54 Because of the care volume that occurs in specialized medical housing units, each provider and nursing event represents up to one month of provider care and two weeks of nursing care. We identified 16 deficiencies, six of which were significant.55 Provider Performance CTF OHU providers performed well. Compliance testing showed that providers completed admission history and physicals timely (MIT 13.002, 100%). Case review clinicians one decision-making deficiency and several instances of physical exams that were copied from previous appointments: • In case 27, on several occasions, the provider documented the same physical exam from the patient’s previous appointment. Because the patient was suffering progressive weakness and loss of his leg muscles, the physical exams should have reflected these changes. 54 The five OHU cases were cases 19, 20, 27, 58, and 59. 55 Deficiencies occurred in cases 19, 20, 27, 58, and 59. Cases 20, 27, and 59 had significant deficiencies. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 72 When asked about this during our on-site inspection, the CME agreed that the provider should have performed the examinations. • In case 59, the patient with a recent cardiac stent placement complained of chest pain. The provider noted the complaint and patient’s history but did not order a cardiology follow-up appointment. Because the patient had his cardiac procedure less than a month prior, the medical standard would necessitate the patient follow-up with a cardiologist after the medical procedure, especially within a month of a cardiac stent placement. Nursing Performance Compliance testing showed OHU nurses completed 75.0 percent of initial assessments within required time frames (MIT 13.001). Our clinicians found that OHU nurses performed timely admission assessments and conducted rounds on patients. Our clinicians identified 11 deficiencies related to nursing care, two of which were significant.56 • In case 20, the nurses did not change the dressing on the patient’s hand and central line as required.57 • In case 59, the patient had low blood pressure and bleeding at a surgical site. The nurse did not recheck the patient's blood reassess the site to ensure the bleeding had stopped, and the patient’s blood pressure was not rechecked for 11 hours. Medication Administration Compliance testing showed 75.0 percent of newly admitted patients received their medications within the required time frames (MIT 13.004). Our clinicians found two deficiencies related to medication management; both were considered significant.58 We discuss these deficiencies in more detail in the Medication Management indicator. Clinician On-Site Inspection At CTF, the OHU was in the central building, near the TTA. The OHU had 17 medically designated beds and four alternative-housing beds. Four beds were in two of the medical rooms, and another room had five beds. All remaining rooms 56 Deficiencies occurred in cases 19, twice in cases 58 and 59, and six times in case 20. Significant deficiencies occurred in cases 20 and 59. 57 A central line is a catheter that is inserted into a large vein in the neck, chest, or groin to deliver medication, fluids, or nutrition. 58 Significant deficiencies occurred in cases 27 and 59. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 73 were for single-person use. Our compliance onsite testing found the call light system functional (MIT 13.101, 100%). The OHU was staffed with an RN on second shift, and an LVN on other shifts. According to staff, an RN from the TTA comes to the OHU at least once on the first and third shifts and as needed. RN visits are recorded in an OHU logbook. We also learned that on September 9, 2021, the CNE implemented new OHU nursing expectations. A memorandum instructed the OHU nurses to perform a complete skin assessment for each patient admitted to the OHU. Nurses were also instructed to perform focused assessments each day and update care plans weekly. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 74 Compliance Testing Results Table 17. Specialized Medical Housing Table 17. Specialized Medical Housing Scored Answer Compliance Questions Yes No N/A Yes % For OHU, CTC, and SNF: Prior to 4/2019: Did the registered nurse complete an initial assessment of the patient on the day of admission, or within eight hours of admission to CMF’s Hospice? 3 1 0 75.0% Effective 4/2019: Did the registered nurse complete an initial assessment of the patient at the time of admission? (13.001) * For CTC and SNF only (effective 4/2019, include OHU): Was a written history and physical examination completed within the required time 4 0 0 100% frame? (13.002) * For OHU, CTC, SNF, and Hospice (applicable only for samples prior to 4/2019): Did the primary care provider complete the Subjective, Objective, Assessment, and Plan notes on the patient at the 0 0 4 N/A minimum intervals required for the type of facility where the patient was treated? (13.003) *,† Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the 3 1 0 75.0% patient within required time frames? (13.004) * For OHU and CTC only: Do inpatient areas either have properly working call systems in its OHU & CTC or are 30-minute patient 1 0 0 100% welfare checks performed; and do medical staff have reasonably unimpeded access to enter patient’s cells? (13.101) * For specialized health care housing (CTC, SNF, Hospice, OHU): Do health care staff perform patient safety checks according to 0 0 1 N/A institution’s local operating procedure or within the required time frames? (13.102) * Overall percentage (MIT 13): 87.5% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. † CCHCS changed its policies and removed mandatory minimum rounding intervals for patients located in specialized medical housing. After April 2, 2019, MIT 13.003 only applied to CTCs that still have state-mandated rounding intervals. OIG case reviewers continued to test the clinical appropriateness of provider follow-ups within specialized medical housing units through case reviews. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 75 Recommendations • Medical leadership should consider reminding OHU providers to perform appropriate physical exams and document findings accurately. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 76 Specialty Services Overall Rating In this indicator, OIG inspectors evaluated the quality of specialty services. The Adequate OIG clinicians focused on the institution’s performance in providing needed specialty care. Our clinicians also examined specialty appointment scheduling, Case Review providers’ specialty referrals, and medical staff’s retrieval, review, and Rating implementation of any specialty recommendations. Adequate Results Overview Compliance Score Inadequate CTF provided acceptable specialty services for their patients. Staff appropriately (73.7%) ordered and provided access to specialists. Nurses evaluated all patients who returned from specialty appointments, but CTF staff often did not retrieve reports timely or did not ensure the timeliness of provider endorsements. However, providers generally followed specialists’ recommendations timely. After considering these factors, we rated this indicator adequate. Case Review and Compliance Testing Results We reviewed 68 events related to specialty services; 51 were specialty consultations and procedures. We found 24 deficiencies in this category, 16 of which were significant.59 Access to Specialty Services CTF staff ensured good access to specialty services. Compliance testing showed good access for routine-priority, medium-priority, and high-priority specialty appointment requests ordered by CTF providers (MIT 14.007, 80.0%; MIT14.004, 93.3%; and MIT 14.001, 80.0%, respectively), but poor access to specialists for requests ordered prior to transfer into the institution (MIT 14.010, 30.0%). Case review clinicians also found good specialty access, but identified two access deficiencies as show below: • In case 26, a patient with spinal stenosis had his request for service with the neurosurgeon denied.60 No provider discussed the denial with the patient, and there was no record of a plan regarding the patient’s spinal stenosis in the EHRS. • In case 58, the pulmonologist evaluated a patient who had a fungal lung infection and recommended a CT scan to look for evidence of cancer, lung function tests, and a follow-up appointment in one month to evaluate the possible cancer. However, these tests were not 59 Specialty deficiencies were found in cases 8, 9, 13, 16, 20, 21, 22, 23, 24, 26, 27, and 58. Significant deficiencies were found in cases 8, 13, 21, 23, 24, 26, 27, and 58. 60 Spinal stenosis is a medical condition where the spinal column narrows and compresses on the spinal cord. This may cause pain and disability. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 77 ordered until nine months later. Some factors that led to this significant delay were different providers caring for the patient during this time period, and the COVID-19 pandemic reducing specialist availability. Provider Performance The providers generally ordered specialty consultations with clinically appropriate time frames. After the consultation, providers followed up with patients when clinically necessary. Compliance testing found that providers usually saw patients within five days of a high-priority specialty consultation (MIT 1.008, 85.7%). During case review, we found the following exception: • In case 27, the neurosurgeon requested an MRI of the patient’s cervical spine. However, the provider did not put in the request until the neurosurgeon requested it a second time. Furthermore, the provider did not order the neurosurgery follow-up after reviewing the patient’s MRI results. A subsequent provider had to order the follow-up. Nursing Performance CTF’s nursing performance with specialty services was good. Nurses properly performed evaluations and complete assessments for patients returning from specialty appointments. Case reviewers identified only two minor deficiencies. Health Information Management CTF staff did not retrieve specialty reports within required time frames or consistently and timely obtain provider reviews and endorsements. Compliance testing showed poor performance with retrieval of routine-priority (MIT 14.008, 61.5%), medium-priority (MIT 14.005, 53.3%), and high-priority (MIT 14.002, 66.7%) reports. Scanning performance of specialty reports was poor as well (MIT 4.002, 76.7%) Case review clinicians found two deficiencies with retrieving specialty reports and also identified 12 deficiencies in which providers endorsed reports late or not at all. Clinician On-Site Inspection During our on-site inspection, clinicians met with nurses and office staff from the specialty department who were knowledgeable and answered our questions concerning specific patients. Staff reported that most specialists continued to evaluate patients and that CTF frequently utilized telemedicine providers during the institution’s COVID-19 outbreak. According to staff, if a specialist appointment could not be completed within the ordered time frame, the provider would determine whether the service was still needed. Staff explained that some appointments were cancelled and providers were tasked with reordering necessary appointments. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 78 Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 79 Compliance Testing Results Table 18. Specialty Services Table 18. Specialty Services Scored Answer Compliance Questions Yes No N/A Yes % Did the patient receive the high-priority specialty service within 14 calendar days of the primary care provider order or the Physician 12 3 0 80.0% Request for Service? (14.001) * Did the institution receive and did the primary care provider review the high-priority specialty service consultant report within the 10 5 0 66.7% required time frame? (14.002) * Did the patient receive the subsequent follow-up to the high-priority specialty service appointment as ordered by the primary care 9 1 5 90.0% provider? (14.003) * Did the patient receive the medium-priority specialty service within 15-45 calendar days of the primary care provider order or Physician 14 1 0 93.3% Request for Service? (14.004) * Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the 8 7 0 53.3% required time frame? (14.005) * Did the patient receive the subsequent follow-up to the medium- priority specialty service appointment as ordered by the primary care 11 0 4 100% provider? (14.006) * Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician 12 3 0 80.0% Request for Service? (14.007) * Did the institution receive and did the primary care provider review the routine-priority specialty service consultant report within the 8 5 2 61.5% required time frame? (14.008) * Did the patient receive the subsequent follow-up to the routine- priority specialty service appointment as ordered by the primary care 3 3 9 50.0% provider? (14.009) * For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the 6 14 0 30.0% sending institution, was the appointment scheduled at the receiving institution within the required time frames? (14.010) * Did the institution deny the primary care provider’s request for 19 1 0 95.0% specialty services within required time frames? (14.011) Following the denial of a request for specialty services, was the patient informed of the denial within the required time frame? 17 3 0 85.0% (14.012) Overall percentage (MIT 14): 73.7% * The OIG clinicians considered these compliance tests along with their case review findings when determining the quality rating for this indicator. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 80 Table 19. Other Tests Related to Specialty Services Table 19. Other Tests Related to Specialty Services Scored Answer Compliance Questions Yes No N/A Yes % Specialty service follow-up appointments: Did the clinician follow-up 30 5 10 85.7% visits occur within required time frames? (1.008) *, † Are specialty documents scanned into the patient’s electronic health 23 7 15 76.7% record within five calendar days of the encounter date? (4.002) * * The OIG clinicians considered these compliance tests along with their own case review findings when determining the quality rating for this indicator. † CCHCS changed its specialty policies in April 2019, removing the requirement for primary care physician follow-up visits following most specialty services. As a result, we test 1.008 only for high-priority specialty services or when the staff orders PCP or PC RN follow-ups. The OIG continues to test the clinical appropriateness of specialty follow-ups through its case review testing. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 81 Recommendations • Medical leadership should ensure that providers review and endorse specialty reports timely. • Medical leadership should ensure that the institution receives specialty reports timely. • Medical leadership should ensure that patients receive routine specialty follow-up appointments timely. • Medical leadership should ensure that patients who recently transferred into the institution receive their previously scheduled specialty appointments within the required time frames. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 82 Administrative Operations Overall Rating In this indicator, OIG compliance inspectors evaluated health care Proficient administrative processes. Our inspectors examined the timeliness of the medical grievance process and checked whether the institution followed reporting Case Review requirements for adverse or sentinel events and patient deaths. Inspectors Rating checked whether the Emergency Medical Response Review Committee (EMRRC) (N/A) met and reviewed incident packages. We investigated and determined whether the institution conducted the required emergency response drills. Inspectors also assessed whether the Quality Management Committee (QMC) met regularly and Compliance addressed program performance adequately. In addition, our inspectors Score determined whether the institution provided training and job performance Proficient (90.8%) reviews for its employees. We checked whether staff possessed current, valid professional licenses, certifications, and credentials. The OIG rated this indicator solely based on the compliance score, using the same scoring thresholds as in the Cycle 4 and Cycle 5 medical inspections. Our case review clinicians do not rate this indicator. Because none of the tests in this indicator affected clinical patient care directly (it is a secondary indicator), the OIG did not consider this indicator’s rating when determining the institution’s overall quality rating. Results Overview CTF performed well in this indicator and scored high in most applicable tests. However, one area showed room for improvement. Compliance testing revealed the institution’s EMMRC was using incomplete checklists and did not timely review cases. These findings are set forth in the table on the next page. We rated this indicator proficient. Nonscored Results At CTF, the OIG did not have any applicable adverse sentinel events requiring root cause analysis during our inspection period (MIT 15.001). We obtained CCHCS Death Review Committee (DRC) reporting data. Five unexpected (Level 1) and five expected (Level 2) deaths occurred during our review period. In our inspection, the DRC did not complete any death review reports promptly. The DRC finished five reports 22 to 182 days late, and submitted the reports to the institution’s CEO 15 to 175 days. The remaining five reports were overdue at the time of OIG’s inspection (MIT 15.998). Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 83 Compliance Testing Results Table 20. Administrative Operations Table 20. Administrative Operations Scored Answer Compliance Questions Yes No N/A Yes % For health care incidents requiring root cause analysis (RCA): Did the N/A N/A N/A N/A institution meet RCA reporting requirements? (15.001) * Did the institution’s Quality Management Committee (QMC) meet 6 0 0 100% monthly? (15.002) For Emergency Medical Response Review Committee (EMRRC) reviewed cases: Did the EMRRC review the cases timely, and did 0 12 0 0 the incident packages the committee reviewed include the required documents? (15.003) For institutions with licensed care facilities: Did the Local Governing Body (LGB) or its equivalent meet quarterly and discuss local N/A N/A N/A N/A operating procedures and any applicable policies? (15.004) Did the institution conduct medical emergency response drills during each watch of the most recent quarter, and did health care and 3 0 0 100% custody staff participate in those drills? (15.101) Did the responses to medical grievances address all of the inmates’ 10 0 0 100% appealed issues? (15.102) Did the medical staff review and submit initial inmate death reports 10 0 0 100% to the CCHCS Death Review Unit on time? (15.103) Did nurse managers ensure the clinical competency of nurses who 10 0 0 100% administer medications? (15.104) Did physician managers complete provider clinical performance 9 1 0 90.0% appraisals timely? (15.105) Did the providers maintain valid state medical licenses? (15.106) 12 0 0 100% Did the staff maintain valid Cardiopulmonary Resuscitation (CPR), Basic Life Support (BLS), and Advanced Cardiac Life Support (ACLS) 2 0 1 100% certifications? (15.107) Did the nurses and the pharmacist-in-charge (PIC) maintain valid professional licenses and certifications, and did the pharmacy 5 0 2 100% maintain a valid correctional pharmacy license? (15.108) Did the pharmacy and the providers maintain valid Drug Enforcement 1 0 0 100% Agency (DEA) registration certificates? (15.109) Did nurse managers ensure their newly hired nurses received the 1 0 0 100% required onboarding and clinical competency training? (15.110) This is a nonscored test. Please Did the CCHCS Death Review Committee process death review refer to the discussion in this reports timely? (15.998) indicator. This is a nonscored test. Please What was the institution’s health care staffing at the time of the OIG refer to Table 4 for CCHCS- medical inspection? (15.999) provided staffing information. Overall percentage (MIT 15): 90.8% * Effective March 2021, this test was for informational purposes only. Source: The Office of the Inspector General medical inspection results. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 84 Recommendations • Medical leadership should ensure that the institution’s Emergency Medical Response Review Committee (EMRRC) review cases timely and include all required documents. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 85 This page left blank for reproduction purposes. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 86 Appendix A: Methodology In designing the medical inspection program, the OIG met with stakeholders to review CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. We 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, the department, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of our inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates the delivery of medical care 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. We rate each of the quality indicators applicable to the institution under inspection based on case reviews conducted by our clinicians or compliance tests conducted by our registered nurses. Figure A–1 below depicts the intersection of case review and compliance. Figure A-1. Inspection Indicator Review Distribution for CTF Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 87 Case Reviews The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders, which continues in the Cycle 6 medical inspections. Below, Table A–1 provides important definitions that describe this process. Table A–1. Case Review Definitions Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 88 The OIG eliminates case review selection bias by sampling using a rigid methodology. No case reviewer selects the samples he or she reviews. Because the case reviewers are excluded from sample selection, there is no possibility of selection bias. Instead, nonclinical analysts use a standardized sampling methodology to select most of the case review samples. A randomizer is used when applicable. For most basic institutions, the OIG samples 20 comprehensive physician review cases. For institutions with larger high-risk populations, 25 cases are sampled. For the California Health Care Facility, 30 cases are sampled. Case Review Sampling Methodology We obtain a substantial amount of health care data from the inspected institution and from CCHCS. Our analysts then apply filters to identify clinically complex patients with the highest need for medical services. These filters include patients classified by CCHCS with high medical risk, patients requiring hospitalization or emergency medical services, patients arriving from a county jail, patients transferring to and from other departmental institutions, patients with uncontrolled diabetes or uncontrolled anticoagulation levels, patients requiring specialty services or who died or experienced a sentinel event (unexpected occurrences resulting in high risk of, or actual, death or serious injury), patients requiring specialized medical housing placement, patients requesting medical care through the sick call process, and patients requiring prenatal or postpartum care. After applying filters, analysts follow a predetermined protocol and select samples for clinicians to review. Our physician and nurse reviewers test the samples by performing comprehensive or focused case reviews. Case Review Testing Methodology An OIG physician, a nurse consultant, or both review each case. As the clinicians review medical records, they record pertinent interactions between the patient and the health care system. We refer to these interactions as case review events. Our clinicians also record medical errors, which we refer to as case review deficiencies. Deficiencies can be minor or significant, depending on the severity of the deficiency. If a deficiency caused serious patient harm, we classify the error as an adverse event. On the next page, Figure A–2 depicts the possibilities that can lead to these different events. After the clinician inspectors review all the cases, they analyze the deficiencies, then summarize their findings in one or more of the health care indicators in this report. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 89 Figure A–2. Case Review Testing Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 90 Compliance Testing Compliance Sampling Methodology Our analysts identify samples for both our case review inspectors and compliance inspectors. Analysts follow a detailed selection methodology. For most compliance questions, we use sample sizes of approximately 25 to 30. Figure A–3 below depicts the relationships and activities of this process. Figure A–3. Compliance Sampling Methodology Compliance Testing Methodology Our inspectors answer a set of predefined medical inspection tool (MIT) questions to determine the institution’s compliance with CCHCS policies and procedures. Our nurse inspectors assign a Yes or a No answer to each scored question. OIG headquarters nurse inspectors review medical records to obtain information, allowing them to answer most of the MIT questions. Our regional nurses visit and inspect each institution. They interview health care staff, observe medical processes, test the facilities and clinics, review employee records, logs, medical grievances, death reports, and other documents, and obtain information regarding plant infrastructure and local operating procedures. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 91 Scoring Methodology Our compliance team calculates the percentage of all Yes answers for each of the questions applicable to a particular indicator, then averages the scores. The OIG continues to rate these indicators based on the average compliance score using the following descriptors: proficient (85.0 percent or greater), adequate (between 84.9 percent and 75.0 percent), or inadequate (less than 75.0 percent). Indicator Ratings and the Overall Medical Quality Rating To reach an overall quality rating, our inspectors collaborate and examine all the inspection findings. We consider the case review and the compliance testing results for each indicator. After considering all the findings, our inspectors reach consensus on an overall rating for the institution. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 92 Appendix B: Case Review Data Table B–1. CTF Case Review Sample Sets Sample Set Total OHU 2 Death Review/Sentinel Events 4 Diabetes 4 Emergency Services – CPR 5 Emergency Services – Non-CPR 2 High Risk 4 Hospitalization 4 Intra-system Transfers In 3 Intra-system Transfers Out 3 RN Sick Call 23 Specialty Services 4 58 Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 93 Table B–2. CTF Case Review Chronic Care Diagnoses Diagnosis Total Anemia 1 Arthritis/Degenerative Joint Disease 10 Asthma 7 COPD 5 COVID-19 8 Cancer 2 Cardiovascular Disease 3 Chronic Kidney Disease 4 Chronic Pain 11 Cirrhosis/End-Stage Liver Disease 2 Coccidioidomycosis 3 Diabetes 11 Gastroesophageal Reflux Disease 14 Hepatitis C 10 Hyperlipidemia 20 Hypertension 24 Mental Health 15 Migraine Headaches 2 Seizure Disorder 2 Sleep Apnea 1 Substance Abuse 8 Thyroid Disease 4 167 Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 94 Table B–3. CTF Case Review Events by Program Diagnosis Total Diagnostic Services 251 Emergency Care 45 Hospitalization 31 Intra-system Transfers In 8 Intra-system Transfers Out 4 Outpatient Care 360 Specialized Medical Housing 83 Specialty Services 68 850 Table B–4. CTF Case Review Sample Summary Total MD Reviews Detailed 22 MD Reviews Focused 2 RN Reviews Detailed 15 RN Reviews Focused 35 Total Reviews 74 Total Unique Cases 58 Overlapping Reviews (MD & RN) 16 Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 95 Appendix C. Compliance Sampling Methodology Correctional Training Facility Quality No. of Indicator Sample Category Samples Data Source Filters Access to Care MIT 1.001 Chronic Care 25 Master Registry • Chronic care conditions (at least Patients one condition per patient—any risk level) • Randomize MIT 1.002 Nursing Referrals 25 OIG Q: 6.001 • See Transfers MITs 1.003–006 Nursing Sick Call 32 Clinic Appointment • Clinic (each clinic tested) (6 per clinic) List • Appointment date (2–9 months) • Randomize MIT 1.007 Returns From 20 OIG Q: 4.005 • See Health Information Community Management (Medical Records) Hospital (returns from community hospital) MIT 1.008 Specialty Services 45 OIG Q: 14.001, • See Specialty Services Follow-Up 14.004 & 14.007 MIT 1.101 Availability of 6 OIG on-site review • Randomly select one housing unit Health Care from each yard Services Request Forms Diagnostic Services MITs 2.001–003 Radiology 10 Radiology Logs • Appointment date (90 days–9 months) • Randomize • Abnormal MITs 2.004–006 Laboratory 10 Quest • Appt. date (90 days–9 months) • Order name (CBC or CMPs only) • Randomize • Abnormal MITs 2.007–009 Laboratory STAT 0 Quest • Appt. date (90 days–9 months) • Order name (CBC or CMPs only) • Randomize • Abnormal MITs 2.010–012 Pathology 10 InterQual • Appt. date (90 days–9 months) • Service (pathology related) • Randomize Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 96 Quality No. of Indicator Sample Category Samples Data Source Filters Health Information Management (Medical Records) MIT 4.001 Health Care Services 32 OIG Qs: 1.004 • Nondictated documents Request Forms • First 20 Ips for MIT 1.004 MIT 4.002 Specialty Documents 45 OIG Qs: 14.002, • Specialty documents 14.005 & 14.008 • First 10 Ips for each question MIT 4.003 Hospital Discharge 20 OIG Q: 4.005 • Community hospital discharge Documents documents • First 20 Ips selected MIT 4.004 Scanning Accuracy 24 Documents for any • Any misfiled or mislabeled tested inmate document identified during OIG compliance review (24 or more = No) MIT 4.005 Returns From 20 CADDIS Off-site • Date (2–8 months) Community Hospital Admissions • Most recent 6 months provided (within date range) • Rx count • Discharge date • Randomize Health Care Environment MITs 5.101–105 Clinical Areas 9 OIG inspector • Identify and inspect all on-site MITs 5.107–111 on-site review clinical areas. Transfers MITs 6.001–003 Intrasystem Transfers 25 SOMS • Arrival date (3–9 months) • Arrived from (another departmental facility) • Rx count • Randomize MIT 6.101 Transfers Out 0 OIG inspector • R&R IP transfers with medication on-site review Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 97 Quality No. of Indicator Sample Category Samples Data Source Filters Pharmacy and Medication Management MIT 7.001 Chronic Care 25 OIG Q: 1.001 See Access to Care Medication • At least one condition per patient—any risk level • Randomize MIT 7.002 New Medication 25 Master Registry • Rx count Orders • Randomize • Ensure no duplication of Ips tested in MIT 7.001 MIT 7.003 Returns From 20 OIG Q: 4.005 • See Health Information Community Hospital Management (Medical Records) (returns from community hospital) MIT 7.004 RC Arrivals— N/A at this OIG Q: 12.001 • See Reception Center Medication Orders institution MIT 7.005 Intrafacility Moves 25 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) • Randomize MIT 7.006 En Route 10 SOMS • Date of transfer (2–8 months) • Sending institution (another departmental facility) • Randomize • NA/DOT meds MITs 7.101–103 Medication Storage Varies OIG inspector • Identify and inspect clinical Areas by test on-site review & med line areas that store medications MITs 7.104–107 Medication Varies OIG inspector • Identify and inspect on-site Preparation and by test on-site review clinical areas that prepare and Administration Areas administer medications MITs 7.108–111 Pharmacy 1 OIG inspector • Identify & inspect all on-site on-site review pharmacies MIT 7.112 Medication Error 25 Medication error • All medication error reports with Reporting reports Level 4 or higher • Select total of 25 medication error reports (recent 12 months) MIT 7.999 Restricted Unit 0 On-site active • KOP rescue inhalers & KOP Medications medication listing nitroglycerin medications for Ips housed in restricted units Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 98 Quality No. of Indicator Sample Category Samples Data Source Filters Prenatal and Postpartum Care MITs 8.001–007 Recent Deliveries N/A at this OB Roster • Delivery date (2–12 months) institution • Most recent deliveries (within date range) Pregnant Arrivals N/A at this OB Roster • Arrival date (2–12 months) institution • Earliest arrivals (within date range) Preventive Services MITs 9.001–002 TB Medications 3 Maxor • Dispense date (past 9 months) • Time period on TB meds (3 months or 12 weeks) • Randomize MIT 9.003 TB Evaluation, 25 SOMS • Arrival date (at least 1 year prior Annual Screening to inspection) • Birth month • Randomize MIT 9.004 Influenza 25 SOMS • Arrival date (at least 1 year prior Vaccinations to inspection) • Randomize • Filter out Ips tested in MIT 9.008 MIT 9.005 Colorectal Cancer 25 SOMS • Arrival date (at least 1 year prior Screening to inspection) • Date of birth (45 or older) • Randomize MIT 9.006 Mammogram N/A at this SOMS • Arrival date (at least 2 yrs. Prior institution to inspection) • Date of birth (age 52–74) • Randomize MIT 9.007 Pap Smear N/A at this SOMS • Arrival date (at least three yrs. institution Prior to inspection) • Date of birth (age 24–53) • Randomize MIT 9.008 Chronic Care 25 OIG Q: 1.001 • Chronic care conditions (at least Vaccinations 1 condition per IP—any risk level) • Randomize • Condition must require vaccination(s) MIT 9.009 Valley Fever 0 Cocci transfer • Reports from past 2–8 months status report • Institution • Ineligibility date (60 days prior to inspection date) • All Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 99 Quality No. of Indicator Sample Category Samples Data Source Filters Reception Center MITs 12.001–008 Reception Center N/A at this SOMS • Arrival date (2–8 months) institution • Arrived from (county jail, return from parole, etc.) • Randomize Specialized Medical Housing MITs 13.001–004 Specialized Health 4 CADDIS • Admit date (2–8 months) Care Housing Unit • Type of stay (no MH beds) • Length of stay (minimum of 5 days) • Rx count • Randomize MITs 13.101–102 Call Buttons All OIG inspector • Specialized Health Care Housing on-site review • Review by location Specialty Services MITs 14.001–003 High-Priority 15 Specialty Services • Approval date (3–9 months) Initial and Follow-Up Appointments • Remove consult to audiology, RFS chemotherapy, dietary, Hep C, HIV, orthotics, gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, physiatry, podiatry, and radiology services • Randomize MITs 14.004–006 Medium-Priority 15 Specialty Services • Approval date (3–9 months) Initial and Follow-Up Appointments • Remove consult to audiology, RFS chemotherapy, dietary, Hep C, HIV, orthotics, gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, physiatry, podiatry, and radiology services • Randomize MITs 14.007–009 Routine-Priority 15 Specialty Services • Approval date (3–9 months) Initial and Follow-Up Appointments • Remove consult to audiology, RFS chemotherapy, dietary, Hep C, HIV, orthotics, gynecology, consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 100 therapy, physiatry, podiatry, and radiology services • Randomize MIT 14.010 Specialty Services 20 Specialty Services • Arrived from (other departmental Arrivals Arrivals institution) • Date of transfer (3–9 months) • Randomize MITs 14.011–012 Denials 20 InterQual • Review date (3–9 months) • Randomize N/A IUMC/MAR • Meeting date (9 months) Meeting Minutes • Denial upheld • Randomize Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 101 Quality No. of Indicator Sample Category Samples Data Source Filters Administrative Operations MIT 15.001 Adverse/sentinel 0 Adverse/sentinel • Adverse/Sentinel events events (ASE) events report (2–8 months) MIT 15.002 QMC Meetings 6 Quality • Meeting minutes (12 months) Management Committee meeting minutes MIT 15.003 EMRRC 12 EMRRC meeting • Monthly meeting minutes minutes (6 months) MIT 15.004 LGB 0 LGB meeting • Quarterly meeting minutes minutes (12 months) MIT 15.101 Medical Emergency 3 On-site summary • Most recent full quarter Response Drills reports & • Each watch documentation for ER drills MIT 15.102 Institutional Level 10 On-site list of • Medical grievances closed Medical Grievances grievances/closed (6 months) grievance files MIT 15.103 Death Reports 10 Institution-list of • Most recent 10 deaths deaths in prior • Initial death reports 12 months MIT 15.104 Nursing Staff 10 On-site nursing • On duty one or more years Validations education files • Nurse administers medications • Randomize MIT 15.105 Provider Annual 10 On-site • All required performance Evaluation Packets provider evaluation documents evaluation files MIT 15.106 Provider Licenses 12 Current provider • Review all listing (at start of inspection) MIT 15.107 Medical Emergency All On-site • All staff Response certification ◦ Providers (ACLS) Certifications tracking logs ◦ Nursing (BLS/CPR) • Custody (CPR/BLS) MIT 15.108 Nursing Staff and All On-site tracking • All required licenses and Pharmacist in Charge system, logs, or certifications Professional Licenses employee files and Certifications Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 102 Quality No. of Indicator Sample Category Samples Data Source Filters Administrative Operations MIT 15.109 Pharmacy and All On-site listing • All DEA registrations Providers’ Drug of provider DEA Enforcement Agency registration #s (DEA) Registrations & pharmacy registration document MIT 15.110 Nursing Staff New All Nursing staff • New employees (hired within last Employee training logs 12 months) Orientations MIT 15.998 Death Review 10 OIG summary log: • Between 35 business days & Committee deaths 12 months prior • California Correctional Health Care Services death reviews Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 103 This page left blank for reproduction purposes. Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6, Correctional Training Facility | 104 California Correctional Health Care Services’ Response (cid:16)(cid:27)(cid:21)(cid:29)(cid:20)(cid:24)(cid:23)(cid:26)(cid:1)(cid:17)(cid:26)(cid:30)(cid:22)(cid:25)(cid:27)(cid:28)(cid:22)(cid:1)(cid:19)(cid:16)(cid:12)(cid:1)(cid:3)(cid:6)(cid:7)(cid:6)(cid:7)(cid:6)(cid:15)(cid:10)(cid:2)(cid:16)(cid:16)(cid:5)(cid:17)(cid:2)(cid:7)(cid:10)(cid:6)(cid:9)(cid:2)(cid:13)(cid:11)(cid:9)(cid:7)(cid:2)(cid:11)(cid:18)(cid:5)(cid:6)(cid:15)(cid:10)(cid:15)(cid:8)(cid:16)(cid:18)(cid:14)(cid:4) August 19, 2022 Amarik Singh, Inspector General Office of the Inspector General 10111 Old Placerville Road, Suite 110 Sacramento, CA 95827 Dear Ms. Singh: The Office of the Receiver has reviewed the draft Medical Inspection Report for the Correctional Training Facility (CTF) conducted by the Office of the Inspector General (OIG) from February to July 2021. California Correctional Health Care Services (CCHCS) acknowledges the OIG findings. Thank you for preparing the report. Your efforts have advanced our mutual objective of ensuring transparency and accountability in CCHCS operations. If you have any questions or concerns, please contact me at (916) 896-6780. Sincerely, Robin Hart Associate Director Risk Management Branch California Correctional Health Care Services cc: Clark Kelso, Receiver Diana Toche, D.D.S., Undersecretary, Health Care Services, CDCR Directors, CCHCS Roscoe Barrow, Chief Counsel, CCHCS Office of Legal Affairs Jackie Clark, Deputy Director, Institution Operations, CCHCS DeAnna Gouldy, Deputy Director, Policy and Risk Management Services, CCHCS Renee Kanan, M.D., Deputy Director, Medical Services, CCHCS Barbara Barney-Knox, R.N., Deputy Director, Nursing Services, CCHCS Annette Lambert, Deputy Director, Quality Management, CCHCS Regional Health Care Executive, Region II, CCHCS Regional Deputy Medical Executive, Region II, CCHCS Regional Nursing Executive, Region II, CCHCS Chief Executive Officer, CTF Katherine Tebrock, Chief Assistant Inspector General, OIG Doreen Pagaran, R.N., Nurse Consultant Program Review, OIG Misty Polasik, Staff Services Manager I, OIG P.O. Box 588500 Elk Grove, CA 95758 Office of the Inspector General, State of California Inspection Period: February 2021 – July 2021 Report Issued: September 2022 Cycle 6 Medical Inspection Report for Correctional Training Facility OFFICE of the INSPECTOR GENERAL Amarik K. Singh Inspector General Neil Robertson Chief Deputy Inspector General STATE of CALIFORNIA September 2022 OIG