California Rehabilitation Center Cycle 6 Medical Inspection Report

Roy W. Wesley, Inspector General Bryan B. Beyer, Chief Deputy Inspector General OFFICE of the OIG INSPECTOR GENERAL Independent Prison Oversight December 2020 Cycle 6 Medical Inspection Report California Rehabilitation Center 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. Return to Contents California Rehabilitation Center iii Contents Introduction 1 Summary 3 Overall Rating: Adequate 3 Medical Inspection Results 7 Deficiencies Identified During Case Review 7 Case Review Results 7 Compliance Testing Results 8 Population-Based Metrics 9 HEDIS Results 9 Recommendations 11 Indicators 13 Access to Care 13 Diagnostic Services 18 Emergency Services 21 Health Information Management 24 Health Care Environment 28 Transfers 34 Medication Management 39 Preventive Services 45 Nursing Performance 46 Provider Performance 50 Specialized Medical Housing 53 Specialty Services 56 Administrative Operations 60 Appendix A: Methodology 63 Case Reviews 64 Compliance Testing 67 Indicator Ratings and the Overall Medical Quality Rating 68 Appendix B: Case Review Data 69 Appendix C: Compliance Sampling Methodology 72 California Correctional Health Care Services’ Response 79 Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents iv Cycle 6 Medical Inspection Report Illustrations Tables 1. CRC Summary Table 3 2. CRC Policy Compliance Scores 4 3. CRC Master Registry Data as of January 2020 5 4. CRC Health Care Staffing Resources as of January 2020 6 5. CRC Results Compared With State HEDIS Scores 10 6. Access to Care 16 7. Other Tests Related to Access to Care 17 8. Diagnostic Services 20 9. Health Information Management 26 10. Other Tests Related to Health Information Management 27 11. Health Care Environment 33 12. Transfers 37 13. Other Tests Related to Transfers 38 14. Medication Management 43 15. Other Tests Related to Medication Management 44 16. Preventive Services 45 17. Specialized Medical Housing 55 18. Specialty Services 58 19. Other Tests Related to Specialty Services 59 20. Administrative Operations 61 A–1. Case Review Definitions 64 B–1. Case Review Sample Sets 69 B–2. Case Review Chronic Care Diagnoses 70 B–3. Case Review Events by Program 71 B–4. Case Review Sample Summary 71 Figures A–1. Inspection Indicator Review Distribution for CRC 63 A–2. Case Review Testing 66 A–3. Compliance Sampling Methodology 67 Photographs 1. Overcrowded Indoor Patient Waiting Area (View 1) 29 2. Overcrowded Indoor Patient Waiting Area (View 2) 29 3. Expired Medical Supplies 30 4. Disinfectants Stored With Medical Supplies 30 Cover: Rod of Asclepius courtesy of Thomas Shafee Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 1 Introduction Pursuant to California Penal Code section 6126 et seq., the Office of the Inspector General (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).4We 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. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 2 Cycle 6 Medical Inspection Report 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 of California Rehabilitation Center (CRC), the receiver had not delegated this institution back to the department. We completed our sixth inspection of CRC, and this report presents our assessment of the health care provided at that institution during the inspection period between July 2019 and February 2020.6 Notably, our report of CRC was not impacted by the novel coronavirus disease pandemic (COVID-19). The data we obtained for CRC predates COVID-19, so neither case review nor compliance testing were affected. Similarly, the on-site regional nurse review was not impacted by COVID-19. However, during our on-site case review inspection, CRC had patients who had tested positive for the virus.7 The inspection was otherwise completed with no further adjustments. California Rehabilitation Center, located in the city of Norco in Riverside County, is a medium Level II correctional facility, which houses more than 3,700 inmates. The institution runs multiple clinics in which medical staff handle nonurgent requests for health care services. CRC also treats patients requiring urgent or emergent care in its triage and treatment area (TTA) and houses patients who need assistance with activities of daily living in its outpatient housing unit (OHU). In addition, all patients who arrive at or depart from the institution are screened in the prison’s receiving and release (R&R) clinic. CRC has been designated by CCHCS as a basic care institution. Basic institutions are located in rural areas, away from tertiary care centers and specialty care providers whose services would likely be used frequently by higher-risk patients. Basic institutions have the capability to provide only limited specialty medical services and consultations for a patient population that is generally healthy. 6. Samples are obtained per case review methodology shared with stakeholders in prior cycles. The case reviews include death reviews that occurred between January 2019 and December 2019, emergency care reviews between April 2019 and January 2020, diabetes reviews between June 2019 and December 2019, high risk patient reviews between June 2019 and January 2020, specialty care reviews between May 2019 and January 2020, and transfer- in reviews between May 2019 and December 2019. 7. The OIG is completing a separate review related to the department’s efforts to address COVID-19 pursuant to a request from the California Speaker of the Assembly dated April 17, 2020. The OIG will be releasing reports related thereto. Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 3 Summary We completed the Cycle 6 inspection of California Rehabilitation Center (CRC) in July 2020. OIG Overall inspectors monitored the institution’s delivery of medical care that occurred between July 2019 and Rating February 2020. Adequate The OIG rated the overall quality of health care at CRC as adequate. We list the individual indicators and ratings applicable for this institution in Table 1 below. Table 1. CRC Summary Table Ratings Proficient Adequate Inadequate Cycle 6 Ratings Change Since Health Care Indicators Case Review Compliance Overall Cycle 5 * Access to Care Diagnostic Services Emergency Services N/A Health Information Management Health Care Environment N/A Transfers Medication Management Prenatal and Postpartum Care N/A N/A N/A N/A Preventive Services N/A Nursing Performance N/A Provider Performance N/A Reception Center N/A N/A N/A N/A Specialized Medical Housing Specialty Services Administrative Operations † N/A * 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. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 4 Cycle 6 Medical Inspection Report 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 374 patient records and 1,107 data points and used the data to answer 90 policy questions. In addition, we observed CRC’s processes during an on-site inspection in March 2020. Table 2 below lists CRC’s average scores from Cycles 4, 5, and 6. OIG case review clinicians (a team of physicians and nurse consultants) reviewed 42 cases, which contained 870 patient-related events. After examining the medical records, our clinicians conducted a follow-up on-site inspection in June 2020 to verify their initial findings. The OIG physicians rated the quality of care for 20 comprehensive case reviews. Table 2. CRC Policy Compliance Scores Scoring Ranges 100% – 86% 85% – 75% 74% – 0 Average Score Medical Inspection Tool (MIT) Policy Compliance Category Cycle 4 Cycle 5 Cycle 6 1 Access to Care 95% 87% 84% 2 Diagnostic Services 91% 73% 63% 4 Health Information Management 69% 65% 93% 5 Health Care Environment 62% 67% 80% 6 Transfers 95% 79% 71% 7 Medication Management 80% 68% 86% 8 Prenatal and Postpartum Care N/A N/A N/A 9 Preventive Services 86% 85% 69% 12 Reception Center N/A N/A N/A 13 Specialized Medical Housing 100% 83% 83% 14 Specialty Services 88% 72% 81% 15 Administrative Operations 79% 66% 71% * 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: July 2019 – February 2020 Return to Contents California Rehabilitation Center 5 Of these 20 cases, our clinicians rated 18 adequate and two inadequate. Our clinicians found no adverse events 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 13 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 which 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 CRC Summary Table. In January 2020, the Health Care Services Master Registry showed that CRC had a total population of 3,743. A breakdown of the medical risk level of the CRC population as determined by the department is set forth in Table 3 below.9 Table 3. CRC Master Registry Data as of January 2020 Medical Risk Level Number of Patients Percentage High 1 17 0.5% High 2 100 2.7% Medium 1,765 47.2% Low 1,861 49.7% Total 3,743 100.0% Source: Cycle 6 medical inspection preinspection questionnaire staffing matrix received on January 24, 2020, from California Rehabilitation Center. 8. The indicators for Reception Center and Prenatal Care do not apply to CRC. 9. For a definition of medical risk, see CCHCS HCDOM 1.2.14, Appendix 1.9. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 6 Cycle 6 Medical Inspection Report Based on staffing data the OIG obtained from California Correctional Health Care Services (CCHCS), as identified in Table 4 below, CRC had one vacant nursing supervisor position, one vacant nursing position, and one vacant executive leadership position. There were no vacant primary care provider positions. Table 4. CRC Health Care Staffing Resources as of January 2020 Executive Primary Care Nursing Nursing Positions Leadership * Providers Supervisors Staff † Total Authorized Positions 5 7 10.5 59.6 82.1 Filled by Civil Service 4 7 9.5 61.2 81.7 Vacant 1 0 1 1 20 Percentage Filled by Civil Service 80% 100% 90.5% 102.7% 99.5% Filled by Telemedicine N/A 0 0 0 0 Percentage Filled by Telemedicine 0 0 0 0 0 Filled by Registry 0 1 0 0 1 Percentage Filled by Registry 0 0.1% 0 0 0.1% Total Filled Positions 4 8 9.5 61.2 82.7 Total Percentage Filled 80% 114.3% 90.5% 102.7% 100.7% Appointments in Last 12 Months 0 3 5 9.2 17.2 Redirected Staff 0 0 0 0 0 Staff on Extended Leave ‡ 0 1 0 1 2 Adjusted Total: Filled Positions 4 7 9.5 60.2 80.7 Adjusted Total: Percentage Filled 80% 100% 90.5% 101% 98.3% * Executive Leadership includes the Chief Physician and Surgeon. † Nursing Staff includes Senior Psychiatric Technician and Psychiatric Technician. ‡ In Authorized Positions. Note: The OIG does not independently validate staffing data received from the department. Source: Cycle 6 medical inspection preinspection questionnaire staffing matrix received on January 24, 2020, from California Rehabilitation Center. Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 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 Our inspectors did not find any adverse events at CRC during the Cycle 6 inspection. Case Review Results OIG case reviewers (a team of physicians and nurse consultants) assessed 10 of the 13 indicators applicable to CRC. Of these 10 indicators, OIG clinicians rated one proficient, nine adequate, and none inadequate. The OIG physicians also rated the overall adequacy of care for each of the 20 detailed case reviews they conducted. Of these 20 cases, 18 were adequate and two were inadequate. In the 870 events reviewed, there were 121 deficiencies, 19 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 CRC: • Compared with the Cycle 5 inspection, CRC providers had improved their performance and delivered good patient care. They generally made appropriate assessments and decisions, managed chronic medical conditions effectively, reviewed medical records well, and addressed the specialists’ recommendations adequately. • The medical records staff timely retrieved and scanned hospital discharge records, diagnostic results, and specialty reports. • The specialty staff coordinated specialty appointments well, and most specialty appointments were completed as requested. • The nursing staff communicated thoroughly with the providers on multiple issues such as patient’s blood sugar levels and specialty appointments to assist them with patient care and decision-making. Our clinicians found CRC could improve in the following areas by ensuring: 10. For a further discussion of an adverse event, see Table A–1. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 8 Cycle 6 Medical Inspection Report • Clinic provider appointments are completed within the requested time frame. • All patients transferring to other facilities have a five-day supply of all medications and are screened appropriately, including obtaining vital signs. • Nursing staff are cognizant of abnormal vital signs and intervene appropriately. • Medical staff perform complete assessments, reconcile medications, document accurately, and acknowledge discharge recommendations for all patients returning from off-site appointments and hospitalizations. Compliance Testing Results Our compliance inspectors assessed 10 of the 13 indicators applicable to CRC. Of these 10 indicators, our compliance inspectors rated two proficient, four adequate, and four inadequate. In the Health Care Environment, Preventive Services, and Administrative Operations indicators, we tested policy compliance only, because how the institution performed in these indicators usually does not significantly affect the institution’s overall quality of patient care. CRC demonstrated a high rate of policy compliance in the following areas: • Timely scanning of health care service request forms, specialty services reports, and hospital discharge reports. OIG inspectors also found medical records staff properly scanning, labeling, and entering reports in patient files. • Providers reviewed hospital discharge reports within CCHCS guidelines. • Pharmacy staff performed exceptionally in employing and following security, organization, and cleanliness protocols in the pharmacy. The pharmacy properly tracked narcotic medications and appropriately stored nonrefrigerated, refrigerated, and frozen medications. • Delivery of high-priority, medium-priority, and routine-priority specialty services within specified time frames. The institution’s providers timely reviewed high-priority and routine-priority specialty services reports. CRC demonstrated a low rate of policy compliance in the following areas: • Providers poorly communicated radiology, laboratory, and pathology test results. Patient letters did not have required key elements specified by CCHCS guidelines. • Nursing staff failed to complete initial and health screening questions within the required time frame. Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 9 • Nursing staff poorly monitored patients taking tuberculosis (TB) medications and improperly documented TB screening results. 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, but the OIG obtained Kaiser Medi-Cal HEDIS scores through the California Department of Health Care Services’ Medi‑Cal Managed Care Technical Report to use in conducting our analysis, and we present them here for comparison. HEDIS Results We considered CRC’s performance with population-based metrics to assess the macroscopic view of the institution’s health care delivery. CRC’s results compared favorably with those found in State health plans for diabetic care measures. We list the five 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) ), CRC performed better in three of the five diabetic measures. The institution scored higher in HbA1c screening, had better HbA1c control, and blood pressure control. For eye examinations, CRC scored lower than Kaiser Southern California, but higher than both Medi-Cal and Kaiser Northern California plans. Immunizations Statewide comparative data were not available for immunization measures; however, we include these data for informational purposes. CRC had a 70 percent immunization rate for adults 18 to 64 years old, and a 94 percent immunization rate for adults 65 years of age and older.11 The pneumococcal vaccines are only administered once for patients who are older than 65 years of age; therefore, the vaccine may not have 11. The pneumococcal vaccines administered are the 13 valent pneumococcal vaccine (PCV13) 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. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 10 Cycle 6 Medical Inspection Report Table 5. CRC Results Compared With State HEDIS Scores California California CRC Kaiser Kaiser California NorCal SoCal Cycle 6 Medi-Cal Medi-Cal Medi-Cal HEDIS Measure Results * 2018 † 2018 † 2018 † HbA1c Screening 100% 87% 95% 95% Poor HbA1c Control (> 9.0%) ‡,§ 5% 35% 24% 19% HbA1c Control (< 8.0%) ‡ 85% 54% 63% 71% Blood Pressure Control (< 140/90) ‡ 90% 66% 76% 85% Eye Examinations 79% 61% 75% 84% Influenza – Adults (18 – 64) 70% – – – Influenza – Adults (65 +) 94% – – – Pneumococcal – Adults (65 +) 100% – – – Colorectal Cancer Screening 81% – – – Notes and Sources * Unless otherwise stated, data were collected in August 2019 by reviewing medical records from a sample of CRC’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, 2017 – June 30, 2018 (published April 2019). ‡ For this indicator, the entire applicable CRC 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 obtained from the CCHCS Master Registry. Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 11 occurred during the inspection period. The pneumococcal vaccination rate was 100 percent. Cancer Screening Statewide comparative data were not available for colorectal cancer screening; however, we include these data for informational purposes. CRC had an 81 percent colorectal cancer screening rate. Recommendations • The department should consider developing and implementing an electronic alert within the electronic health record system (EHRS) for the user to check that appointment orders are entered correctly to ensure nurse and provider appointments occur within requested time frames. • Medical leadership should develop internal auditing to ensure provider follow-up appointments are completed within required time frames. • Medical leadership should develop internal auditing to ensure providers send pathology results letters to their patients within the required time frames. • The department should consider developing and implementing a patient results letter template which autopopulates with all elements required per CCHCS policy. • Laboratory leadership should develop and implement internal auditing to ensure laboratory orders are completed within ordered time frames. • Nursing leadership should develop and implement internal auditing to ensure that nurses completely and accurately document emergent events. • Nursing leadership should have each clinic nurse supervisor review the monthly EMRB logs to ensure that the EMRBs are regularly inventoried and sealed. • Medical leadership should remind staff to follow universal hand hygiene precautions. Implementing random spot checks could improve compliance. • The department should consider development and implementation of an electronic alert to ensure that the nurses in receiving and release (R&R) properly complete initial health screening questions and follow up as needed. • Nursing leadership should develop and implement internal auditing of staff to ensure complete and thorough assessments Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 12 Cycle 6 Medical Inspection Report are done for patients returning from hospitalization and emergency room visits. • Medical leadership should develop and implement a routine audit of medication delivery to ensure chronic medications are delivered per CCHCS policy before the patient’s supply is depleted. • Medical leadership should remind nursing staff to perform weekly monitoring and address the symptoms of patients taking TB medications. • Nursing leadership should develop and implement internal auditing to ensure that outpatient nurses perform complete assessments and document care accurately. • Nursing leadership should consider the development and implementation of an audit to ensure the OHU admission assessments for patients are completed within the required time frames. • The department should consider including the patient off-site specialty returns on the daily huddle report to ensure that the specialty reports are retrieved and scanned within the required time frames. • Medical leadership should ensure that incidents needing EMRRC review are timely completed, presented, and discussed at the monthly meetings. Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 13 Access to Care Overall In this indicator, OIG inspectors evaluated the institution’s ability to Rating Adequate provide patients with timely clinical appointments. Our inspectors reviewed the scheduling and appointment timeliness for newly arrived patients, sick calls, and nurse follow-up appointments. We examined Case Review referrals to primary care providers, provider follow-ups, and specialists. Rating Furthermore, we evaluated the follow-up appointments for patients who Adequate received specialty care or returned from an off-site hospitalization. Compliance Score Results Overview Adequate (84%) CRC provided appropriate access to care in most clinical areas. Most clinic provider, outpatient housing unit (OHU) provider, nurse, and specialty appointments were completed within the required time frames. Compliance testing was consistent with the clinical review, with an overall access to care score of 84 percent. The OIG rated this indicator adequate. Case Review Results The OIG clinicians reviewed 451 provider, nurse, specialty, and hospital events that required the institution to generate appointments. We identified 12 deficiencies relating to this indicator, five of which were significant.12 Access to Clinic Providers Access to clinic providers is an integral part of patient care in health care delivery. CRC performed satisfactorily with access to providers in both compliance testing and case review. Compliance testing found chronic care follow-up appointments occurred on time (MIT 1.001, 68%), and nurse-to-provider sick call referrals occurred as requested (MIT 1.005, 75%). We reviewed 105 clinic provider appointments and identified five deficiencies,13 three of which were clinically significant: • In cases 15 and 16, the OHU provider discharged the patients and requested clinic provider appointments in seven and five days, respectively. The appointments did not occur. • In case 31, concerned that the patient had hypothyroidism, the provider requested a clinic provider appointment in seven days, but the appointment did not occur. Access to Specialized Medical Housing Providers CRC performed well with access in the OHU. When staff admitted patients to the OHU, providers evaluated and documented their 12. Deficiencies occurred in cases 9, 10, 11, 15, 16, 31, 33, 35, and 39. Cases 9, 10, 15, 16, and 31 had significant deficiencies. 13. Cases 15, 16, 31, and 35 had deficiencies. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 14 Cycle 6 Medical Inspection Report progress notes within the appropriate time frames. Compliance testing found providers performed all OHU admission history and physical exams timely (MIT 13.002, 100%). The OIG clinicians assessed 16 OHU provider encounters and identified one minor deficiency related to a late admission history and physical exam.14 Access to Clinic Nurses CRC performed well with access for nursing sick calls and provider-to- nurse referrals. Compliance testing found all nurse sick call requests were addressed within the required time frame (MIT 1.003, 100%). Also, nurses evaluated most patients within the required one business day (MIT 1.004, 83%). The OIG clinicians identified only three minor delays related to clinic nurse access.15 CRC performed adequately with provider-to-nurse referrals. We identified one significant deficiency: • In case 10, the patient had an elevated blood pressure, and the nurse did not perform the requested blood pressure recheck. Access to Specialty Services CRC provided excellent specialty access. The compliance testing found all high-priority specialty appointments occurred timely (MIT 14.001, 100%). Most medium-priority and routine-priority specialty appointments occurred 93 percent of the time (MIT 14.004, MIT 14.007). The OIG clinicians reviewed 81 specialty events and did not identify any missed or delayed specialty appointments. CRC performed satisfactorily in specialty follow-up appointments. Compliance testing found most high-priority specialty follow-up appointments occurred timely (MIT 14.003, 80%). Most medium-priority and routine-priority specialty follow-up appointments occurred as requested (MIT 14.006, 78%; MIT 14.009, 91%). Follow-Up After Specialty Service CRC performed well in ensuring patients saw their providers after specialty appointments. The compliance testing revealed most provider appointments after specialty services occurred timely (MIT 1.008, 76%). The OIG clinicians reviewed 81 specialty appointments and did not identify any missed provider follow-up appointments after specialty service. This positive finding was the result of CRC bundling two or three specialty follow-up appointments into one specialty follow-up appointment. 14. A minor deficiency occurred in case 39. 15. Minor deficiencies occurred in cases 11, 16, and 33. Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 15 Follow-up After Hospitalization CRC ensured patients saw their providers promptly after hospitalizations. Compliance testing found all provider appointments occurred timely after a hospitalization (MIT 1.007, 100%). The OIG clinicians reviewed 27 hospital returns and did not identify any missed or delayed provider appointments after a hospitalization. Follow-up After Urgent or Emergent Care (TTA) CRC providers generally saw their patients following a triage and treatment area (TTA) event as requested. The OIG clinicians assessed 30 TTA events and identified one delayed appointment: • In case 9, the patient was seen in the TTA for swelling in the left eye. The TTA nurse requested a provider follow-up in two days; however, the appointment did not occur until 11 days later. Follow-up After Transferring Into the Institution Providers generally saw patients who recently transferred into CRC at a rate of 84 percent on compliance testing (MIT 1.002). The OIG clinicians evaluated eight transfer-in events and did not identify any missed or delayed provider appointments. Clinician On-Site Inspection There are two main clinics at CRC, central health and delta yard. Central health clinic had three provider lines and delta yard had two provider lines. Each clinic had an office technician who attended the morning huddles and identified appointments that could be bundled, maximizing access to care. The providers saw about 10 to 12 patients per day. During the on-site inspection, OIG clinicians inquired about missed appointments, which the scheduling supervisor and providers explained were the result of providers or nurses not properly ordering appointments. Recommendations • The department should consider developing and implementing an electronic alert within the electronic health record system (EHRS) for the user to check that appointment orders are entered correctly to ensure nurse and provider appointments occur within requested time frames. • Medical leadership should develop internal auditing to ensure provider follow-up appointments are completed within required time frames. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 16 Cycle 6 Medical Inspection Report Compliance Testing Results Table 6. Access to Care 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 allowable interval or within the ordered time frame, whichever is 17 8 0 68% shorter? (1.001) * For endorsed patients received from another CDCR institution: Based on the patient’s clinical risk level during the initial health screening, was the patient seen by the clinician within the required time frame? 21 4 0 84% (1.002) * Clinical appointments: Did a registered nurse review the patient’s request for service the same day it was received? (1.003) * 30 0 0 100% Clinical appointments: Did the registered nurse complete a face-to- face visit within one business day after the CDCR Form 7362 was 25 5 0 83% reviewed? (1.004) * Clinical appointments: If the registered nurse determined a referral to a primary care provider was necessary, was the patient seen within the maximum allowable time or the ordered time frame, whichever is the 6 2 22 75% 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 0 0 30 N/A 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 22 0 0 100% frame? (1.007) * Specialty service follow-up appointments: Did the clinician follow-up visits occur within required time frames? (1.008) * ,† 25 8 12 76% Clinical appointments: Do patients have a standardized process to obtain and submit health care services request forms? (1.101) 5 1 0 83% Overall percentage (MIT 1): 84% * 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: July 2019 – February 2020 Return to Contents California Rehabilitation Center 17 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 10 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 10 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 15 0 0 100% 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? 8 2 5 80% (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% 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 7 2 6 78% provider? (14.006) * Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician 14 1 0 93% 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? 10 1 4 91% (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. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 18 Cycle 6 Medical Inspection Report Diagnostic Services Overall Rating In this indicator, OIG inspectors evaluated the institution’s ability Adequate to timely complete radiology, laboratory, and pathology tests. Our inspectors determined whether the institution properly retrieved the Case Review resultant reports and whether providers reviewed the results correctly. Rating In addition, in Cycle 6, we examined the institution’s ability to timely Adequate complete and review stat (immediate) laboratory tests. Compliance Results Overview Score Inadequate CRC performed adequately in completing and retrieving diagnostic (63%) tests. However, the provider did not always send letters to the patients informing them of the pathology results. The providers also did not include laboratory dates in the patient results letters. The OIG did not consider these communication errors an impediment to patient care. The OIG rated this indicator adequate. Case Review Results The OIG clinicians reviewed 129 diagnostic events and did not identify any missed or delayed diagnostic tests. However, our clinicians found a pattern of missing dates on patient results letters. Although required by policy, the missing dates were not clinically significant because the providers discussed the results with the patients during subsequent appointments. We identified six minor deficiencies16 in this indicator related to health information management. Test Completion Compliance testing showed the institution completed most radiology tests within required time frames (MIT 2.001, 90%). The OIG clinicians reviewed five radiology tests and also did not identify any missed or delayed tests. All 10 electrocardiograms (EKG) were completed timely. Compliance testing also found laboratory tests were completed at a rate of 70 percent (MIT 2.004). In the 112 laboratory tests reviewed by clinicians, we did not identify any missed or delayed tests. Health Information Management CRC performed well in retrieving and endorsing diagnostic reports. Compliance testing showed providers endorsed all radiology reports timely (MIT 2.002, 100%) and endorsed most laboratory reports timely (MIT 2.005, 90%). We identified only one missing laboratory report: • In case 6, although the preliminary blood culture report was negative, CRC did not retrieve or scan the final blood culture result. 16. Minor deficiencies occurred four times in case 41, and once each in cases 6 and 15. Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 19 Compliance testing showed the providers did not thoroughly communicate the results of radiology studies or laboratory tests to patients (MIT 2.003, 20%, and MIT 2.006, zero, respectively). The OIG clinicians identified four minor deficiencies17 related to providers not documenting dates of the laboratory tests in letters to patients. The following case is one example: • In case 41, the provider did not identify the date the laboratory test was performed in the patient letter. CRC generally retrieved and reviewed pathology reports timely. Compliance testing found CRC retrieved 70 percent of pathology reports timely (MIT 2.010), and the provider endorsed all pathology reports (MIT 2.011, 100%). Our clinicians found all pathology reports were retrieved; however, providers did not send results letters to patients within the required time frames (MIT 2.012, zero). We found the providers timely endorsed these reports and discussed the results with their patients during the subsequent provider encounters. Clinician On-Site Inspection To ensure that all laboratory tests, especially time-sensitive tests, are completed as ordered, CRC assigned a designated phlebotomist to each of its two main clinics. CRC also employed medical staff who tracked and retrieved all pathology reports. Recommendations • Medical leadership should develop internal auditing to ensure providers send pathology results letters to their patients within the required time frames. • The department should consider developing and implementing a patient results letter template which autopopulates with all elements required per CCHCS policy. • Laboratory leadership should develop and implement internal auditing to ensure laboratory orders are completed within specific time frames. 17. Four minor deficiencies occurred in case 41. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 20 Cycle 6 Medical Inspection Report Compliance Testing Results Table 8. Diagnostic Services Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Was the radiology service provided within the time frame specified in the health care provider’s order? (2.001) * 9 1 0 90% Radiology: Did the ordering health care provider review and endorse the radiology report within specified time frames? (2.002) * 10 0 0 100% Radiology: Did the ordering health care provider communicate the results of the radiology study to the patient within specified time 2 8 0 20% frames? (2.003) Laboratory: Was the laboratory service provided within the time frame specified in the health care provider’s order? (2.004) * 7 3 0 70% Laboratory: Did the health care provider review and endorse the laboratory report within specified time frames? (2.005) * 9 1 0 90% Laboratory: Did the health care provider communicate the results of the laboratory test to the patient within specified time frames? (2.006) 0 10 0 0 Laboratory: Did the institution collect the STAT laboratory test and receive the results within the required time frames? (2.007) * 7 3 0 70% Laboratory: Did the nursing staff notify the health care provider within one (1) hour from receiving the STAT laboratory results? (2.008) * 4 6 0 40% Laboratory: Did the health care provider endorse the STAT laboratory results within the required time frames? (2.009) 10 0 0 100% Pathology: Did the institution receive the final pathology report within the required time frames? (2.010) * 7 3 0 70% Pathology: Did the health care provider review and endorse the pathology report within specified time frames? (2.011) * 9 0 1 100% Pathology: Did the health care provider communicate the results of the pathology study to the patient within specified time frames? 0 9 1 0 (2.012) Overall percentage (MIT 2): 63% * 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: July 2019 – February 2020 Return to Contents California Rehabilitation Center 21 Emergency Services Overall In this indicator, OIG clinicians evaluated the quality of emergency Rating Adequate medical care. Our clinicians reviewed emergency medical services by examining the timeliness and appropriateness of clinical decisions made during medical emergencies. Our evaluation included examining Case Review the emergency medical response, cardiopulmonary resuscitation (CPR) Rating quality, triage and treatment area (TTA) care, provider performance, Adequate and nursing performance. Our clinicians also evaluated the Emergency Medical Response Review Committee’s (EMRRC) ability to identify Compliance problems with its emergency services. The OIG assessed the institution’s Score emergency services through case review only; we did not perform (N/A) compliance testing for this indicator. Results Overview CRC providers delivered good emergency care which improved from Cycle 5. Nursing staff responded promptly to emergent events and provided appropriate care. However, the OIG clinicians identified a pattern of deficiencies for incomplete nursing assessments and documentation, and supervising registered nurses did not identify deficiencies in some of their clinical review of emergent events. Most of these deficiencies were minor. Our case review rated this indicator adequate. Case Review Results Our clinicians reviewed 30 urgent and emergent events, and found 20 emergency care deficiencies, two of which were significant.18 Compared with Cycle 5, CRC had a comparable number of deficiencies, but significant deficiencies had decreased. Emergency Medical Response CRC responded promptly to emergencies throughout the institution. Staff initiated CPR, activated emergency medical service, and notified TTA staff timely. Provider Performance CRC providers performed well in urgent and emergent situations. For patients who presented emergently to the TTA, providers made appropriate decisions. Also, providers were available for consultation with TTA staff. Our clinicians identified two minor deficiencies19 related to a lack of progress notes for an emergent event. 18. Deficiencies occurred in cases 1, 4, 9, 15, 16, 17, and 18. Significant deficiencies occurred in cases 9 and 15. 19. Minor deficiencies occurred in case 15. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 22 Cycle 6 Medical Inspection Report Nursing Performance The institution’s nurses generally provided appropriate assessments and interventions. The nurses recognized opioid overdose and implemented a nursing overdose protocol. Nonetheless, our clinicians found room for improvement in the following nursing assessments: • In case 4, the patient complained of severe chest pain. The TTA nurse’s failure to reassess the patient’s severe pain prior to the arrival of emergency medical services (EMS) fell below the nursing standards of care. • In case 17, the patient, who had a history of bone infection, complained of leg pain and swelling. A nurse responded and notified the TTA nurse. The TTA nurse should have assessed the patient the same day, however, instead of referring the patient for a provider appointment the next day. Nursing Documentation Nursing documentation at the institution was acceptable; however, first medical responders and TTA nurses did not always document pertinent information. We found opportunities for improvement in four of 15 cases,20 including the following two examples: • In case 1, first medical responders (FMR) did not document the time evaluations were performed. The TTA nurse noted the patient’s oxygen level and pulse were monitored, but did not document the actual readings. • In case 17, the nurse did not document the patient’s pulse or respiratory rate. Emergency Medical Response Review Committee The EMRRC met monthly and reviewed emergency response care within the required time frames. We found three minor deficiencies21 relating to the committee not identifying incomplete nursing assessments and documentation, including the following example: • In case 15, the committee did not identify the failure of the nurse to check the blood sugar level for a diabetic patient with an altered level of consciousness. Clinician On-Site Inspection The TTA maintained two beds, and the patient care area had sufficient space to provide emergency care. We discussed some of the case review findings with nursing leadership, who explained they planned to implement training for quality improvement. 20. Minor deficiencies occurred in cases 1, 15, 16, and 17. 21. Minor deficiencies occurred in cases 1, 15, and 16. Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 23 Recommendations • Nursing leadership should develop and implement internal auditing to ensure that nurses completely and accurately document emergent events. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 24 Cycle 6 Medical Inspection Report Health Information Management Overall Rating In this indicator, OIG inspectors evaluated the flow of health Proficient information, a crucial link in high-quality medical care delivery. Our inspectors examined whether the institution retrieved and scanned Case Review critical health information (progress notes, diagnostic reports, specialist Rating reports, and hospital-discharge reports) into the medical record in a Proficient timely manner. Our inspectors also tested whether clinicians adequately reviewed and endorsed those reports. In addition, our inspectors Compliance checked whether staff labeled and organized documents in the medical Score record correctly. Proficient (93%) Results Overview CRC performed well with health information management in compliance testing and case review. Staff retrieved and scanned most hospital discharge records, diagnostic results, and specialty reports timely. The OIG rated this indicator proficient. Case Review Results The OIG clinicians reviewed 870 events and found 30 deficiencies related to health information management, of which only two were significant.22 Hospital-Discharge Reports CRC performed well in retrieving and scanning hospital records. Compliance testing found CRC staff timely retrieved and scanned hospital discharge records (MIT 4.003, 90%). Most discharge records included the important physician discharge summary, and providers endorsed reports within five days (MIT 4.005, 95%). Our clinicians reviewed 27 hospital events and identified one delay23 retrieving a hospital record. Specialty Reports CRC generally performed well retrieving and reviewing specialty reports. Compliance testing showed most specialty reports were retrieved timely (MIT 4.002, 93%). CRC providers generally reviewed the high- priority, medium-priority, and routine-priority specialty reports within the required time frame (MIT 14.002, 100%, MIT 14.005, 67%, and MIT 14.008, 86%). Our clinicians reviewed 81 specialty reports and identified seven deficiencies24 related to health information management, most of which were not clinically significant. Two of these deficiencies were considered 22. Deficiencies occurred in case 4, 9, 11, 12, 13, 14, 15, 17, 18, 19, 20, 27, 28, 29, 31, 32, 33, 35, 38, 39, and 41. Significant deficiencies occurred in cases 4 and 39. 23. A minor delay occurred in case 17. 24. Deficiencies occurred three times in case 9 and once in cases 4, 12, 20, and 39. Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 25 significant and were related to a delayed retrieval of a report and a missing report. These two significant deficiencies are discussed further in the Specialty Services indicator. Diagnostic Reports CRC proficiently retrieved and endorsed diagnostic reports. Compliance testing showed providers endorsed all radiology reports timely (MIT 2.002, 100%), and generally endorsed laboratory reports timely (MIT 2.005, 90%). The OIG clinicians reviewed 129 diagnostic events and identified only one missing laboratory report, which is detailed in the Diagnostic Services indicator. Compliance testing found the staff retrieved pathology reports 70 percent of the time (MIT 2.010), and providers endorsed all pathology reports timely (MIT 2.011, 100%). We found that all pathology reports were retrieved timely, and providers endorsed the reports and discussed the results with their patients during subsequent encounters. Urgent and Emergent Records The OIG clinicians reviewed 30 emergency care events and found providers generally recorded these events sufficiently. We identified four minor deficiencies, which are discussed in the Emergency Services indicator. Scanning Performance CRC performed adequately with the scanning process. Compliance testing found most records were properly scanned and labeled without errors (MIT 4.004, 88%). Our clinicians identified only one mislabeled document.25 Clinician On-Site Inspection At CRC’s central medical record office, medical staff scan records as they receive them. The institution sent most of its patients to CRC contract hospitals, and as a result, medical records staff were able to access the hospital electronic systems to print out discharge records. However, when patients were sent to noncontract hospitals, the care coordinator or TTA staff had to contact the hospital to retrieve discharge records when the patient returned without records. For on-site specialty reports, the on-site specialty nurses scanned the reports the same day as the visit. For off-site specialty reports, the medical records staff scanned specialty reports as they received them. 25. A minor mislabeled deficiency occurred in case 18. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 26 Cycle 6 Medical Inspection Report Recommendations We offer no specific recommendations for this indicator. Compliance Testing Results 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 10 100% date? (4.001) Are specialty documents scanned into the patient’s electronic health 28 2 15 93% 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 18 2 2 90% hospital discharge? (4.003) * During the inspection, were medical records properly scanned, 21 3 0 88% 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 21 1 0 95% and did a provider review the report within five calendar days of discharge? (4.005) * Overall percentage (MIT 4): 93% * 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: July 2019 – February 2020 Return to Contents California Rehabilitation Center 27 Table 10. Other Tests Related to Health Information Management Scored Answer Compliance Questions Yes No N/A Yes % Radiology: Did the ordering health care provider review and endorse 10 0 0 100% the radiology report within specified time frames? (2.002) * Laboratory: Did the health care provider review and endorse the 9 1 0 90% laboratory report within specified time frames? (2.005) * Laboratory: Did the nursing staff notify the health care provider within 4 6 0 40% one (1) hour from receiving the STAT laboratory results? (2.008) * Pathology: Did the institution receive the final pathology report within 7 3 0 70% the required time frames? (2.010) * Pathology: Did the health care provider review and endorse the 9 0 1 90% pathology report within specified time frames? (2.011) * Pathology: Did the health care provider communicate the results of the 0 9 1 0 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 14 0 1 100% frame? (14.002) * Did the institution receive and did the primary care provider review the medium-priority specialty service consultant report within the required 10 5 0 67% 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 12 2 1 86% 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. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 28 Cycle 6 Medical Inspection Report Health Care Environment Overall Rating In this indicator, OIG compliance inspectors tested clinics’ waiting areas, Adequate infection control, sanitation procedures, medical supplies, equipment management, and examination rooms. Inspectors also tested clinics’ Case Review ability to maintain auditory and visual privacy for clinical encounters. Rating Compliance inspectors asked the institution’s health care administrators (N/A) to comment on their facility’s infrastructure and its ability to support health care operations. The OIG rated this indicator solely on the Compliance compliance score, using the same scoring thresholds as in the Cycle 4 Score and Cycle 5 medical inspections. Our case review clinicians do not rate Adequate this indicator. (81%) Compliance Testing Results For this indicator, CRC’s performance improved compared with its performance in Cycle 5. Clinic environments were sufficiently conducive to medical care and were appropriately cleaned and disinfected. Clinics followed protocols for managing and storing bulk medical supplies. However, other aspects of CRC’s health care environment had room for improvement. For example, the logs for emergency medical response bags (EMRBs) were missing staff verification indicating bag compartments were properly sealed. Additionally, CRC staff did not regularly wash their hands when examining their patients or when applying gloves. Overall, CRC performed adequately, resulting in an adequate rating for this indicator. Outdoor Waiting Areas CRC had no waiting areas that required patients to be outdoors. Indoor Waiting Areas During our inspection of the indoor waiting areas, prior to the mask order due to COVID-19 guidelines, we observed overcrowding of patients in the central health clinic (see Photos 1 and 2, next page). According to health care custody staff, who were not aware of the waiting area’s maximum capacity, the indoor waiting areas had insufficient seating capacity. However, the clinic’s nursing supervisor reported benches located outside the clinic were available as additional seating for patients. Unfortunately, health care custody staff were not aware of this additional seating. Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 29 Photo 1. Overcrowded indoor waiting area (view 1) (photographed on March 3, 2020). Photo 2. Overcrowded indoor waiting area (view 2) (photographed on March 3, 2020). Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 30 Cycle 6 Medical Inspection Report Clinic Environment All clinic environments were sufficiently conducive to medical care. Our inspectors found reasonable auditory privacy, good wheelchair accessibility, and ample workspace (MIT 5.109, 100%). Of the eight clinics we observed, seven had sufficient space, configuration, supplies, and equipment, permitting CRC clinicians to perform proper clinical examinations (MIT 5.110, 88%). The remaining clinic had a torn examination table cover. Clinic Supplies Six of the eight clinics followed adequate medical supply storage and management protocols (MIT 5.107, 75%). In two other clinics, we found either expired medical supplies (see Photo 3, left) or cleaning materials stored with medical supplies (see Photo 4, below), or both. Photo 3. Expired medical supplies dated January 2019 and March 2019 (photographed on March 3, 2020). Photo 4. Disinfectants stored with medical supplies (photographed on March 3, 2020). Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 31 Six of the eight clinics met the requirements for essential core medical equipment and supplies (MIT 5.108, 75%). In the remaining two clinics, we found nonfunctional oto-ophthalmoscopes. We examined EMRBs to determine if they contained all essential items. We checked if staff inspected the bags daily and inventoried them monthly. Only three of the five EMRBs passed the compliance test (MIT 5.111, 60%). In two clinics, staff failed to ensure that the compartments of EMRBs were sealed and intact. Medical Supply Management CRC scored 100 percent for this compliance test. The medical supply storage areas outside the clinics (e.g., warehouse, Conex containers, etc.) provided good storage for clinic medical supplies (MIT 5.106). According to the chief executive officer (CEO), the institution did not have any concerns about the medical supply process. Health care managers and the warehouse manager expressed no concerns about the medical supply chain or with their communication process. CRC has a material and stores supervisor (MSS I), who performs the inventory of medical supplies for each clinic on a weekly basis and delivers needed medical supplies the following day. Infection Control and Sanitation Staff appropriately cleaned, sanitized, and disinfected seven of eight clinics (MIT 5.101, 88%). In one clinic, we found accumulated dirt and grime in examination room cabinets. In six of eight clinics, staff properly sterilized or disinfected medical equipment (MIT 5.102, 75%). In one other clinic, staff relied on incarcerated Prison Industry Authority (PIA) workers to disinfect the examination table as part of their daily start-up protocol. In another clinic, staff did not change the examination table paper in between patient encounters. The OIG inspectors found operating sinks and hand hygiene supplies in the examination rooms in all applicable clinics (MIT 5.103, 100%). We observed patient encounters in four clinics. We found in three clinics clinicians did not wash their hands before or after examining their patients, before applying gloves, before performing blood draws, or after performing physical assessments (MIT 5.104, 25%). Additionally, in one of the aforementioned three clinics, we observed a provider wash his hands with water before and after patient encounters; however, he did not use antiseptic soap. Health care staff in all eight applicable clinics followed proper protocols to mitigate exposure to blood-borne pathogens and contaminated waste (MIT 5.105, 100%). Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 32 Cycle 6 Medical Inspection Report Physical Infrastructure At the time of the compliance inspection, CRC was adding mobile medical clinics, and renovating and adding clinic space. These projects began in 2019, and health care management estimated they will be complete by summer 2023. CRC’s CEO reported the renovation and expansion of clinics will experience delays due to personnel changes, but that the delay will not negatively impact patient care (MIT 5.999). Recommendations • Nursing leadership should have each clinic nurse supervisor review the monthly EMRB logs to ensure that the EMRBs are regularly inventoried and sealed. • Medical leadership should remind staff to follow universal hand hygiene precautions. Implementing random spot checks could improve compliance. Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 33 Table 11. Health Care Environment Scored Answer Compliance Questions Yes No N/A Yes % Infection control: Are clinical health care areas appropriately 7 1 0 88% 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 0 75% disinfected as warranted? (5.102) Infection control: Do clinical health care areas contain operable sinks 8 0 0 100% and sufficient quantities of hygiene supplies? (5.103) Infection control: Does clinical health care staff adhere to universal 1 3 4 25% hand hygiene precautions? (5.104) Infection control: Do clinical health care areas control exposure to 8 0 0 100% 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 6 2 0 75% managing and storing bulk medical supplies? (5.107) Clinical areas: Do clinic common areas and exam rooms have 6 2 0 75% essential core medical equipment and supplies? (5.108) Clinical areas: Are the environments in the common clinic areas 8 0 0 100% conducive to providing medical services? (5.109) Clinical areas: Are the environments in the clinic exam rooms 7 1 0 88% 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, 3 2 3 60% 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 adequate health care services? (5.999) of this test. Overall percentage (MIT 5): 81% * 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. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 34 Cycle 6 Medical Inspection Report Transfers Overall Rating In this indicator, OIG inspectors examined the transfer process for Adequate those patients who transferred into the institution, as well as for those who transferred to other institutions. For newly arrived patients, our Case Review inspectors assessed the quality of health screenings and the continuity Rating of provider appointments, specialist referrals, diagnostic tests, and Adequate medications. For patients who transferred out of the institution, inspectors checked whether staff reviewed patient medical records and Compliance determined the patient’s need for medical holds. They also assessed if Score staff transferred patients with their medical equipment and gave correct Inadequate medications before patients left. In addition, our inspectors evaluated the (71%) ability of staff to communicate vital health transfer information, such as preexisting health conditions, pending appointments, tests, and specialty referrals; and inspectors confirmed if 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 CRC performed satisfactorily in this indicator. Compared with Cycle 5, our case reviewers found fewer deficiencies, including significant deficiencies. We identified instances in which nursing staff did not appropriately assess patients, medications were not reconciled upon return to the facility, and transfer-out patients did not have their medications with them. Although the institution scored well in three areas of compliance testing, CRC’s overall compliance score was negatively affected by the failure to complete the initial health and tuberculosis (TB) screening within the required time frame. Given the overall findings, we rated this indicator adequate. Case Review Results The OIG clinicians reviewed 44 events in 25 cases in which patients transferred into and out of the institution or returned from an off-site hospital or emergency room. Of the 44 events, case reviewers identified 13 deficiencies, three of which were significant.26 Transfers In For patients who transferred into CRC, compliance testing showed nursing staff did not complete initial health screenings or answer all screening questions within the required time frames (MIT 6.001, zero). Nursing staff did not address the signs and symptom of fatigue 26. Deficiencies occurred in cases 1, 2, 4, 15, 16, 17, 21, 24, and 25. Significant deficiencies occurred once in case 2 and twice in case 15. Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 35 when screening for TB and did not follow up on additional health care screening questions requiring explanation.27 The OIG case reviewers found newly arrived patients to CRC were evaluated within required time frames and usually received appropriate assessments. We identified one significant deficiency in which nursing staff did not recognize a patient’s abnormal vital signs: • In case 2, the newly arrived patient had an abnormally low blood pressure and low pulse rate. The intake R&R nurse did not recheck the patient’s blood pressure and pulse, did not send the patient to the TTA, did not notify the provider, and did not order a high-priority follow-up appointment with a provider, placing the patient at risk for delayed diagnosis and treatment of possible serious medical conditions. For patients who transferred in from another CDCR institution, compliance testing found CRC did well with administering or delivering medications without interruption (MIT 6.003, 88%). However, for two patients, medications were administered one day late. In case review, we also identified one minor deficiency in which the patient received his antidepressant one day late. In compliance testing, providers saw patients at a rate of 84 percent (MIT 1.002). Compliance testing found 21 patients were seen timely. For only three patients, provider follow-up appointments occurred between one and 12 days late. For one other patient, there was no evidence the patient had a provider follow-up appointment. Our clinicians reviewed eight transfer-in events and did not identify any missed or delayed provider appointments. CRC scored low on compliance testing for patients transferring into CRC with preapproved specialty appointments (MIT 14.010, 20%). Our clinical case reviewers assessed eight transfer-in events and did not identify any missed or delayed preapproved specialty appointments. Transfers Out CRC’s transfer-out process was adequate. Compliance testing found all patients who transferred out had required documents and medications (MIT 6.101, 100%). Our clinicians reviewed five transfer-out events and identified two instances of patients transferring out emergently to other institutions without all their medications. The nursing staff also did not obtain these patients’ vital signs before transfer. 27. In April 2020, after our review but before this report was published, CCHCS reported adding the symptom of fatigue into the EHRS powerform for tuberculosis symptom monitoring. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 36 Cycle 6 Medical Inspection Report Hospitalizations Patients returning from an off-site hospitalization or an emergency room visit are at high risk for lapses in care. These patients have typically experienced severe illness or injury. They require more care and place a strain on the institution’s resources. Because these patients have complex medical issues, the successful transfer of health information is necessary for quality care. Any lapse of care can result in serious consequences for these patients. Our clinicians reviewed 27 hospital or emergency room returns in 12 cases28 and identified seven deficiencies, two of which were significant.29 While we found the overall care adequate, we noted several areas for performance improvement. All patients were assessed upon return to CRC, but we identified two minor deficiencies in which assessments were incomplete. CRC performed well providing follow-up appointments within the required time frames to patients returning from hospital and emergency room visits (MIT 1.007, 100%). The majority of discharge documents were scanned into the patient’s electronic health record within three calendar days of discharge (MIT 4.003, 90%). Compliance testing also found providers reviewed and endorsed documents timely (MIT 4.005, 95%). Case review identified one minor delay in obtaining a hospital discharge summary. Compliance testing showed CRC had room for improvement in medication continuity and hospital discharge recommendations. Ordered medications were administered, made available, or delivered to patients within the required time frames 70 percent of the time (MIT 7.003). Our clinicians identified significant deficiencies in medication continuity and addressing the hospital discharge recommendations. These significant deficiencies are discussed further in the Medication Management and Provider Performance indicators. Clinician On-Site Inspection Our clinicians discussed some of the case review findings with nursing and pharmacy leadership, who planned to implement training for quality improvement. In response to our inquiries about patient transfer medications, CRC reported utilizing the licensed correctional clinic automated drug delivery system30 to provide medications for patients. 28. Hospitalization/ER returns occurred in cases 1, 3, 4, 6, 7, 9, 15, 16, 17, 18, 19, and 41. 29. Hospitalization/ER return deficiencies were identified in cases 1, 4, 15, 16, and 17. Significant deficiencies were identified twice in case 15. 30. This system utilizes an automated dispensing cabinet to provide the top prescribed medications that are nurse-administered to the patient population and are not patient- specific. This is a fairly new policy rolled out by headquarters, and not all institutions are live. Patient-specific medications, which are keep-on-person, are transferred with the patients. Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 37 Recommendations • The department should consider development and implementation of an electronic alert to ensure the nurses in R&R properly complete initial health screening questions and follow up as needed. • Nursing leadership should develop and implement internal auditing of staff to ensure complete and thorough assessments are done for patients returning from hospitalization and emergency room visits. Compliance Testing Results Compliance On-site Inspection R&R nurses ensured that all patients transferring out of the institution had the required medications, transfer documents, and assigned durable medical equipment (DME). In addition, R&R nurses performed face-to- face evaluations and verified patients had their DME in their possession. Table 12. Transfers 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 0 25 0 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 24 1 0 96% 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, 15 2 8 88% 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 2 0 1 100% transfer packet required documents? (6.101) * Overall percentage (MIT 6): 71% * 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. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 38 Cycle 6 Medical Inspection Report 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 21 4 0 84% 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 22 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 18 2 2 90% discharge? (4.003) * For patients discharged from a community hospital: Did the preliminary or final hospital discharge report include key elements and did a 21 1 0 95% 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 14 6 2 70% patient within required time frames? (7.003) * Upon the patient’s transfer from one housing unit to another: Were 22 3 0 88% 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 4 4 0 50% 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 4 16 0 20% 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: July 2019 – February 2020 Return to Contents California Rehabilitation Center 39 Medication Management Overall In this indicator, OIG inspectors evaluated the institution’s ability to Rating administer prescription medications on time and without interruption. Adequate The inspectors examined this process from the time a provider prescribed medication until the nurse administered the medication to Case Review the patient. When rating this indicator, the OIG strongly considered Rating the compliance test results, which tested medication processes to a Adequate much greater degree than case review testing. In addition to examining medication administration, our compliance inspectors also tested many Compliance other processes, including medication handling, storage, error reporting, Score Proficient and other pharmacy processes. (86%) Results Overview CRC performed well in this indicator. Case reviewers found good performance with newly prescribed medications, chronic care medication continuity, and hospital-discharge-medications’ reconciliation. Although the overall compliance testing received a score of 86 percent, compliance testing also found that CRC needed improvement for chronic care medication continuity and TB monitoring. On the whole, we rated this indicator adequate. Case Review Results We reviewed 26 cases related to medications and found 10 medication deficiencies, three of which were significant.31 New Medication Prescriptions Compliance testing showed most new medications were available and administered or delivered timely (MIT 7.002, 88%). The OIG clinicians identified only two minor delays32 in delivery of newly prescribed medications. Chronic Care Medication Continuity Compliance testing found the patients did not receive most of their chronic care medications within the required time frames (MIT 7.001, 22%). We found patients received their keep-on-person (KOP) medications every 30 days; however, patients did not always receive their refill medications at least one business day prior to expiration, as required by policy. The OIG clinicians did not identify any lapses in continuity of chronic care medications. 31. Deficiencies occurred in case 3, 4, 15, 16, 21, 24, and 25. Significant deficiencies occurred twice in case 16 and once in case 15. 32. Minor delays occurred in cases 3 and 4. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 40 Cycle 6 Medical Inspection Report Hospital Discharge Medications CRC ensured that patients received their recommended medications when they returned from an off-site hospital or emergency room. Our clinicians reviewed 27 hospital returns and identified one significant deficiency: • In case 15, the patient returned from the hospital with diagnoses of a low sodium level, a skull fracture, and stroke. Medication reconciliation did not occur, and the patient did not receive the recommended salt tablet, blood thinner, and antiseizure medication. Subsequently, the patient was hospitalized again for the low sodium condition. Compliance testing found not all hospital-recommended medications were available or administered timely (MIT 7.003, 70%). Specialized Medical Housing Medications The OIG clinicians evaluated seven OHU admissions and did not identify any delays in ordering or administering medications. Compliance testing found that when patients were admitted to the OHU, not all medications were ordered, made available, or administered timely (MIT 13.004, 70%). Delays in administering medication ranged from one hour to two days, and most did not place the patients at risk of harm. Transfer Medications CRC performed well with transfer medications. Compliance testing showed that patients transferring into CRC received most of their medications within the required time frames (MIT 6.003, 88%). Patients transferring to another institution had all their medications in the transfer package (MIT 6.101, 100%). Patients transferring within the institution received most of their medications timely (MIT 7.005, 88%). The OIG clinicians evaluated 13 transfer events and identified three minor deficiencies.33 Medication Administration CRC nurses generally performed well with administering medication. Compliance testing showed how nurses administered and monitored patients taking TB medications. Nurses administered TB medications as prescribed (MIT 9.001, 96%). However, nurses often did not monitor these patients as required per policy (MIT 9.002, 28%). 33. Minor deficiencies occurred in cases 21, 24, and 25. Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 41 CRC nurses administered medications properly in most cases; however, we identified significant deficiencies in one case below: • In case 16, the patient had an allergy to codeine. The OHU provider prescribed acetaminophen with codeine. The pharmacy staff did not cross-check for allergies, and the medication nurse identified the allergy, but did not notify the provider. The nurse administered a dose of the medication to the patient the following day. Fortunately, after the patient was discharged from the OHU, an outpatient nurse recognized the codeine allergy, and the medication was discontinued. Clinician On-Site Inspection Medication nurses were knowledgeable about the medication administration process. They attend the clinic huddles to notify the providers of expiring chronic care medications. We met with the pharmacist and nurse managers to discuss some of our findings. They reported that training would be provided to the staff for quality improvement. The pharmacist-in-charge (PIC) explained that for a patient with a medication allergy, the EHRS should prompt a medication allergy alert, and the nurse should review the order and the allergy, then notify the provider. The pharmacist should also verify the allergy warning and notify the provider. Compliance Testing Results Medication Practices and Storage Controls The institution adequately stored and secured narcotic medications in all applicable clinic and medication line locations (MIT 7.101, 100%). CRC appropriately stored and secured nonnarcotic medications in nine of 10 clinic and medication line locations (MIT 7.102, 90%). In one location, the medication area lacked a designated area for refrigerated medications to be returned to the pharmacy. Staff kept medications protected from physical, chemical, and temperature contamination in nine of the 10 clinic and medication line locations (MIT 7.103, 90%). In one location, staff did not separate storage of oral and topical medications. Staff successfully stored valid, unexpired medications in eight of the 10 applicable medication line locations (MIT 7.104, 80%). In two locations, we found one or more of the following deficiencies: medication nurses failed to label the multiuse medication as required by CCHCS policy, and a multidose medication was stored beyond the label date. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 42 Cycle 6 Medical Inspection Report Nurses exercised proper hand hygiene and contamination control protocols in five of six locations (MIT 7.105, 83%). In one location, some nurses neglected to wash or sanitize their hands before donning gloves or before preparing and administering medications. Staff in all applicable medication preparation and administration areas demonstrated appropriate administrative controls and protocols (MIT 7.106, 100%). Staff in CRC’s six medication areas used appropriate administrative controls and protocols when distributing medications to their patients (MIT 7.107, 100%). Pharmacy Protocols Pharmacy staff followed general security, organization, and cleanliness management protocols in the prison’s main and remote pharmacies (MIT 7.108, 100%). In its main pharmacy, CRC properly stored nonrefrigerated (MIT 7.109, 100%) and refrigerated medication (MIT 7.110, 100%). The PIC properly accounted for narcotic medications stored in the pharmacy (MIT 7.111, 100%). We examined 25 medication error reports. The PIC timely and correctly processed all 25 reports (MIT 7.112, 100%). 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 did not score this test; we provide these results for informational purposes only. At CRC, we did not find any applicable medication errors (MIT 7.998). Recommendations • Medical leadership should develop and implement a routine audit of medication delivery to ensure chronic care medications are delivered per CCHCS policy before the patient’s supply is depleted. Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 43 Table 14. Medication Management Scored Answer 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 4 14 7 22% no-shows? (7.001) * Did health care staff administer, make available, or deliver new order 22 3 0 88% 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 14 6 2 70% 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 22 3 5 88% 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 4 4 8 50% 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 8 0 2 100% 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 9 1 0 90% 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 9 1 0 90% 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 8 2 0 80% the assigned storage areas? (7.104) Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols during medication 5 1 4 83% preparation and medication administration processes? (7.105) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when preparing medications 6 0 4 100% for patients? (7.106) Medication preparation and administration areas: Does the institution employ appropriate administrative controls and protocols when administering 6 0 4 100% 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 1 0 0 100% 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 isolation 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): 86% * 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. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 44 Cycle 6 Medical Inspection Report 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, 15 2 8 88% 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 2 0 0 100% transfer-packet required documents? (6.101) * Patients prescribed TB medication: Did the institution administer the 24 1 0 96% 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 7 18 0 28% the medication? (9.002) * Upon the patient’s admission to specialized medical housing: Were all medications ordered, made available, and administered to the patient 7 3 0 70% 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: July 2019 – February 2020 Return to Contents California Rehabilitation Center 45 Preventive Services Overall In this indicator, OIG compliance inspectors tested whether the Rating institution offered or provided cancer screenings, tuberculosis (TB) Inadequate screenings, influenza vaccines, and other immunizations. The OIG rated this indicator solely based on the compliance score, using the same Case Review scoring thresholds as in the Cycle 4 and Cycle 5 medical inspections. Our Rating case review clinicians do not rate this indicator. (N/A) Recommendations Compliance Score • Medical leadership should remind nursing staff to perform Inadequate weekly monitoring and address the symptoms of patients taking (69%) TB medications. Table 16. Preventive Services Scored Answer Compliance Questions Yes No N/A Yes % Patients prescribed TB medication: Did the institution administer the 24 1 0 96% 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 7 18 0 28% the medication? (9.002) Annual TB screening: Was the patient screened for TB within the last 0 25 0 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 50 through the age of 75: Was the 25 0 0 100% 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? 10 1 14 91% (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): 69% * 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. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 46 Cycle 6 Medical Inspection Report Nursing Performance Overall Rating In this indicator, the OIG clinicians evaluated the quality of care Adequate delivered by the institution’s nurses, including registered nurses (RNs), licensed vocational nurses (LVNs), psychiatric technicians (PTs), and Case Review certified nursing assistants (CNAs). Our clinicians evaluated nurses’ Rating ability to make timely and appropriate assessments and interventions. Adequate We also evaluated the institution’s nurses’ documentation for accuracy and thoroughness. Clinicians reviewed nursing performance in many Compliance clinical settings and processes, including sick call, outpatient care, care Score coordination and management, emergency services, specialized medical (N/A) housing, hospitalizations, transfers, specialty services, and medication management. The OIG assessed nursing care through case review 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 CRC nurses generally provided good care, especially for patients receiving specialty services. Compared with Cycle 5, CRC had a decrease in the number of deficiencies in this indicator; however, we identified opportunities for improvement in several areas of the nursing process described in the subcategories below. Considering all these factors, the OIG rated this indicator adequate. Case Review Results We reviewed 246 nursing encounters in 42 cases. Of the nursing encounters we reviewed, 110 were in the outpatient setting. We identified 46 nursing performance deficiencies, seven of which were significant.34 Nursing Assessment and Intervention A critical component of nursing care is the quality of nursing assessment, which includes both subjective (patient interview) and objective (observation and examination) elements. CRC nurses generally provided appropriate assessments and interventions within the required time frames. However, we identified a pattern of deficiencies for incomplete nursing assessment in the outpatient setting. Of the 28 cases our clinicians reviewed, 11 showed room for improvement.35 The following are examples: 34. Deficiencies occurred in cases 1, 2, 4, 11, 12, 13, 15, 16, 17, 18, 24, 25, 29, 31, 32, 33, 34, 35, 36, and 37. Significant deficiencies occurred twice in case 17, and once in cases 2, 16, 31, 33, and 35. 35. Cases showing room for improvement were 11, 12, 13, 16, 17, 31, 32, 33, 34, 35, and 37. Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 47 • In case 11, the patient complained of a sore, itchy throat. The nurse did not examine the patient’s mouth. • In case 17, the patient had a scheduled follow-up appointment for his rash; however, during the appointment the nurse did not examine the patient’s rash. • In case 31, the patient complained of painful constipation and blood in his stool. The nurse did not perform a complete abdominal assessment on the patient or inquire about the patient’s last bowel movement. Additionally, the nurse ordered a provider follow-up appointment in 30 days instead of 14 days. Nursing Documentation Complete and accurate nursing documentation is an essential component of patient care. Without proper documentation, health care staff can overlook changes in patients’ condition. CRC nurses generally documented their care appropriately. However, outpatient nursing and nursing in emergency services showed room for improvement. The following outpatient cases are examples: • In case 31, the patient complained of constipation and no bowel movement for four days. The nurse did not document whether the patient’s abdomen was flat or distended. • In case 33, the nurse administered the patient an over-the- counter pain medication and did not document it on the medication administration record. • In case 34, the patient complained of toe pain and swelling. The nurse did not document the color of the patient’s toe. Nursing Sick Call Our clinicians reviewed 52 sick call requests. Clinic nurses saw an average of 10 patients per day, and staff reported no nurse appointment backlog. Most nurses triaged patient sick calls appropriately and scheduled timely evaluations. However, the following examples we found during our inspection demonstrate room for improvement: • In case 35, the patient complained of syncope (fainting) and migraine headaches with blurred vision. The nurse did not evaluate the patient the same day, but instead requested a follow- up appointment for the next day. • In case 36, the patient complained of a severe sore throat, constant cough, and inability to clear his throat. The nurse did not evaluate the patient the same day, but instead requested a follow-up appointment for the next day. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 48 Cycle 6 Medical Inspection Report Care Coordinator The institution’s LVN care coordinators provided acceptable care. The duties of the care coordinators included TB screenings, chronic care education, weekly monitoring of diabetic patients’ blood sugar levels, and retrieving specialty reports from outside facilities. The OIG clinicians reviewed five cases and identified two minor deficiencies in which the LVN did not provide colon screening education. Emergency Services Nurses responded promptly to emergencies and provided appropriate assessments and interventions. However, nursing documentation demonstrated room for improvement, and this is detailed in the Emergency Services indicator. Transfers Overall, CRC nurses performed acceptably for patients transferring into and out of the institution and returning from hospitals. However, nurses did not always obtain vital signs for patients transferring out of the institutions, which is detailed further in the Transfers indicator. Specialized Medical Housing The OHU nurses performed appropriate nursing assessments and adequately implemented providers’ orders. The Specialized Medical Housing indicator provides further information. Specialty Services CRC nurses provided good nursing care for patients returning from off- site specialty and telemedicine appointments. Most nurses performed appropriate nursing assessments, reviewed specialist recommendations properly, and communicated pertinent information to providers. The Specialty Services indicator provides further information. Medication Management CRC nurses generally performed well with administering medications. The Medication Management indicator provides further information. Clinician On-Site Inspection While our inspection period did not include cases impacted by COVID-19, by the time of our on-site inspection, the institution had treated patients with COVID-19. During our on-site inspection, we observed COVID-19 posters on clinic walls in the patient waiting areas, saw seating areas were clearly marked as being more than six feet apart, and noted that patients and staff wore masks. Leadership held a meeting devoted to managing COVID-19 cases. The chief nursing executive Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 49 (CNE) was proactive in requesting outside registry staff, anticipating the need for additional nursing staff for COVID-19 surveillance, medication rounds, and sick call rounds. The OIG clinicians spoke with nurses and nurse managers in the TTA, OHU, R&R, specialty services, outpatient clinics, and medication areas. We attended organized clinic huddles as well as a population health management meeting for patients with hepatitis C through a teleconference due to COVID-19 precaution. We also met with the nurse managers to discuss some of our case review findings. The nurse managers acknowledged several opportunities for improvement and planned to implement training based on our findings. Recommendations • Nursing leadership should develop and implement internal auditing to ensure outpatient nurses perform complete nursing assessments and document care accurately. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 50 Cycle 6 Medical Inspection Report Provider Performance Overall Rating In this indicator, OIG case review clinicians evaluated the quality of Adequate care the institution’s providers (physicians, physician assistants, and nurse practitioners) delivered. Our clinicians assessed the institution’s Case Review providers’ ability to evaluate, diagnose, and manage their patients Rating properly. We examined provider performance across several clinical Adequate settings and programs, including sick call, emergency services, outpatient care, chronic care, specialty services, intake, transfers, Compliance hospitalizations, and specialized medical housing. The OIG assessed Score provider care through case review only and performed no compliance (N/A) testing for this indicator. Results Overview Compared with Cycle 5, CRC providers improved their performance and delivered good patient care. They generally made appropriate assessments and decisions, managed chronic medical conditions effectively, reviewed medical records thoroughly, and addressed the specialists’ recommendations adequately. The OIG rated this indicator adequate. Case Review Results During our inspection we found a total of 17 deficiencies, two of which were significant.36 The OIG clinicians also examined the quality of care in 20 comprehensive case reviews. Assessment and Decision-Making In most cases, providers made appropriate assessments and sound medical plans for their patients. Providers generally diagnosed medical conditions correctly, ordered appropriate tests, and referred their patients to proper specialists. Our clinicians identified one minor deficiency related to poor decision-making.37 Review of Records CRC providers performed well in reviewing medical records when the patients returned from hospitalizations; however, we identified one significant deficiency in reviewing a hospital record: • In case 15, a provider evaluated the patient for hospital return, but did not address the patient’s new diagnosis of a low serum sodium level with the recommendation to prescribe salt tablets. The provider also did not address the patient’s diagnosis of 36. Deficiencies occurred in cases 1, 4, 6, 10, 11, 15, 16, and 31. Significant deficiencies occurred in cases 15 and 16. 37. A minor deficiency occurred in case 4. Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 51 stroke and the recommendations to prescribe a blood thinner and antiseizure medications. CRC providers generally performed well in reviewing the medication administration record (MAR) and reconciling patients’ medications. However, we identified one significant deficiency related to poor medical record review prior to prescribing a medication: • In case 16, a provider prescribed acetaminophen with codeine, but did not review the patient’s medical record for medication allergy. The patient had a documented codeine allergy. Emergency Care CRC providers made appropriate triage decisions when the patients presented emergently to the TTA. Additionally, the providers were available for consultation with the TTA nursing staff. We did not identify any significant provider deficiencies in emergency care. Chronic Care CRC providers performed well in managing chronic medical conditions, such as hypertension, diabetes, asthma, hepatitis C infection, and cardiovascular disease. We identified only four minor deficiencies related to diabetic care.38 The institution’s providers also effectively managed patients on anticoagulants. Providers appropriately monitored INR (a blood test for monitoring the effects of warfarin) levels and adjusted oral anticoagulants accordingly. Specialty Services CRC providers appropriately referred and reviewed specialty reports timely. Also, providers adequately addressed the specialists’ recommendations. We identified two minor deficiencies in which providers did not address all specialist recommendations, as illustrated in the example below: • In case 1, the cardiologist recommended obtaining multiple laboratory tests, including a magnesium level test. The provider ordered all laboratory tests except the magnesium level test. Documentation Quality CRC providers generally documented outpatient and TTA encounters on the same day of the encounter. The OIG identified three minor deficiencies related to missing emergent event progress or a procedure note.39 38. Four minor deficiencies occurred in case 10. 39. Minor deficiencies occurred twice in case 15 and once in case 16. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 52 Cycle 6 Medical Inspection Report Provider Continuity CRC assigned providers to specified clinics to ensure continuity of care. The OIG clinicians did not identify any significant deficiencies related to provider continuity. Clinician On-Site Inspection Our clinicians attended a daily provider meeting that was conducted by telephone. The on-call provider discussed events that occurred during the evening and overnight, such as patients returning from the hospital, specialty appointments, and TTA events. The chief medical executive (CME) discussed the newly diagnosed COVID-19 cases and implemented quarantine plans. At CRC, the morning huddles were productive, attended by providers, nurses, a laboratory technician, an office technician, custody staff, and a care coordinator. The team discussed patients returning from hospitalization or specialty appointments with recommendations. The nurse informed the provider of expiring medications, TTA events, and new arrivals from other institutions. We also attended a population health management meeting during which medical staff identified patients with newly diagnosed hepatitis C infections and assessed these patients for treatment. The medical staff identified patients with end-stage liver disease and ordered screening liver ultrasounds or upper endoscopes as indicated. At the time of our inspection, CRC had eight full-time providers with no vacancies. Providers were enthusiastic about their work and generally satisfied with nursing, diagnostic, and specialty services. The CME and the chief physician and surgeon (CP&S) were committed to patient care and quality improvement. The providers screened patients for possible opioid abuse and prescribed specific medications for treatment. Recommendations We offer no specific recommendations for this indicator. Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 53 Specialized Medical Housing Overall Rating In this indicator, OIG inspectors evaluated the quality of care in the Adequate specialized medical housing units. We evaluated the performance of the medical staff in assessing, monitoring, and intervening for medically Case Review complex patients requiring close medical supervision. Our inspectors Rating also evaluated the timeliness and quality of provider and nursing intake Adequate assessments and care plans. We considered staff members’ performance in responding promptly when patients’ conditions deteriorated and Compliance looked for good communication when staff consulted with one another Score while providing continuity of care. At the time of our inspection, CRC’s Adequate only specialized medical housing was an outpatient housing unit (OHU). (83%) Results Overview CRC delivered good patient care in the OHU, performing well both with case review and in compliance testing. The providers generally completed admission history and physical exams timely. The nurses performed appropriate admission assessments and administered essential medications such as intravenous antibiotics. We rated this indicator adequate. Case Review Results We reviewed seven OHU cases, which included seven provider events and 23 nursing events. Because of the high volume of care that occurs in specialized medical housing units, each provider and nursing event represents up to one month of provider care and one week of nursing care. We identified seven deficiencies, four of which were significant.40 Provider Performance Compliance testing found providers completed all admission history and physical exams without delays (MIT 13.002, 100%). Most admission history and physical exams were completed timely with the exception of one minor delay.41 Providers generally performed thorough evaluations, and addressed all hospital and specialist recommendations; however, we identified one significant deficiency which is discussed in the Provider Performance indicator.42 Nursing Performance OHU nurses provided adequate care. Our case reviewers noted the nurses usually completed assessments within required time frames and intervened appropriately when needed. In contrast, our compliance 40. We reviewed cases 9, 15, 16, 17, 39, 40, and 41. Deficiencies occurred in cases 15, 16, and 39. Case 16 had the four significant deficiencies. 41. A minor delay occurred in case 39. 42. A significant deficiency occurred in case 16. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 54 Cycle 6 Medical Inspection Report testing findings showed OHU nurses did not always complete timely admission assessments (MIT 13.001, 60%). Two assessments were not completed. One other assessment was completed three hours late, and another assessment was completed two days late. Nurses ensured patients were educated concerning the use of the patient call system when they were admitted to the OHU (MIT 13.101, 100%). Medication Administration Compliance findings showed patients usually received their medications within the required time frames upon admission to the OHU (MIT 13.004, 70%). We identified medication delays ranging from one hour to two days. However, the delayed medications were not life- sustaining medications and consequently were not clinically significant. Our clinicians identified three significant medication administration deficiencies. These deficiencies are further discussed in the Medication Management indicator. Case reviewers found medication continuity adequate and did not identify any deficiencies. Clinician On-Site Inspection The institution’s OHU had 10 medical beds. During the time of our medical inspection, four patients occupied the unit. A designated OHU provider made daily rounds with nursing staff and weekly grand rounds.43 In addition, CRC staffed the primary OHU shift with an RN, an LVN, and office technician. The institution staffed two other OHU shifts with an LVN, a nursing supervisor, and TTA nurses who were available to assist the LVN as needed. Recommendations • Nursing leadership should consider the development and implementation of an audit to ensure the OHU admission assessments for patients are completed within the required time frames. 43. A meeting to discuss medical problems and treatment of patients to an audience of administrators, doctors, nurses, pharmacists, and staff. Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 55 Compliance Testing Results 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? 6 0 0 100% 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 10 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 N/A N/A N/A 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 7 3 0 70% 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): 83% * 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. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 56 Cycle 6 Medical Inspection Report Specialty Services Overall Rating In this indicator, OIG inspectors evaluated the quality of specialty Adequate services. The OIG clinicians focused on the institution’s ability to provide needed specialty care. Our clinicians also examined Case Review specialty appointment scheduling, providers’ specialty referrals, Rating and medical staff’s retrieval, review, and implementation of any Adequate specialty recommendations. Compliance Results Overview Score Adequate CRC provided satisfactory specialty services. Specialty staff performed (81%) well, coordinating specialty service appointments for their patients. CRC scored well both with case review and in compliance testing. Most specialty appointments were timely completed, and staff retrieved most specialty reports timely. We rated this indicator adequate. Case Review Results Our clinicians reviewed 137 events related to specialty services, including 81 specialty consultations and procedures, and found 14 deficiencies, two of which were significant.44 Access to Specialty Services Compliance testing showed CRC completed all high-priority specialty appointments (MIT 14.001, 100%), and completed medium-priority and routine-priority specialty appointments at a rate of 93 percent (MIT 14.004 and MIT 14.007). However, when patients transferred into CRC with preapproved specialty services, less than a quarter of their specialty appointments were completed timely (MIT 14.010, 20%). Our clinicians found specialty access excellent at CRC. We reviewed 81 specialty appointments and did not find any delayed or missed specialty appointments. Our clinicians also assessed eight transfer- in events and did not identify any missed or delayed preapproved specialty appointments. Provider Performance CRC providers generally referred appropriately, reviewed specialty reports timely, and addressed specialists’ recommendations. We identified two minor deficiencies45 related to providers not addressing all specialists’ recommendations. Nursing Performance Specialty nurses reviewed requests for specialty services and appropriately arranged for specialty appointments. The nurses generally 44. Deficiencies occurred in cases 1, 4, 9, 11, 12, 13, 18, 20, and 39. Significant deficiencies occurred in cases 4 and 39. 45. Minor deficiencies occurred in cases 1 and 11. Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 57 made appropriate assessments and interventions for patients who returned from off-site and telemedicine specialty appointments. Nurses informed providers of specialists’ recommendations, obtained orders, and scheduled timely provider follow-up appointments. Specialty nurses also provided appropriate records for the specialists to review. Our clinicians reviewed 48 nursing encounters related to specialty services and identified only four minor deficiencies.46 The deficiencies identified were related to off-site specialty nurses not thoroughly examining patients or obtaining vital signs upon patient returns. Health Information Management CRC performed adequately in retrieving and reviewing specialty reports. Compliance testing showed CRC staff retrieved and scanned most specialty reports timely (MIT 4.002, 93%). Our clinicians identified eight deficiencies47 related to health information management, most of which were not clinically significant. Two deficiencies were considered significant: • In case 4, the patient had an urgent cardiac stress test. Medical staff did not retrieve or scan the patient’s report into the medical record until almost three weeks later. • In case 39, the patient had a jaw fracture repair. Medical staff failed to retrieve or scan the patient’s surgical report into the medical record. Clinician On-Site Inspection The institution employed multiple staff for on-site, off-site, and telemedicine specialty services and had a tracking process to ensure all specialty appointments were completed within the requested time frames. Nursing staff processed specialty requests and arranged for specialty appointments. Specialty nurses alerted providers concerning specialty appointments that were close to missing compliance dates, and providers would assist with different options for the scheduled appointments. CRC’s medical records staff and specialty nurses tracked and retrieved specialty reports, and utilization managers assisted in retrieving specialty reports. Recommendations • The department should consider including the patient off- site specialty returns on the daily huddle report to ensure the specialty reports are retrieved and scanned within required time frames. 46. Minor deficiencies occurred twice in case 13, and once in cases 1 and 11. 47. Deficiencies occurred three times in case 9, and once in cases 4, 12, 18, 20, and 39. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 58 Cycle 6 Medical Inspection Report Compliance Testing Results 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 15 0 0 100% 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 14 0 1 100% 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 8 2 5 80% 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% 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 10 5 0 67% 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 7 2 6 78% provider? (14.006) * Did the patient receive the routine-priority specialty service within 90 calendar days of the primary care provider order or Physician 14 1 0 93% 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 12 2 1 86% 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 10 1 4 91% provider? (14.009) * For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at the 4 16 0 20% 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 0 0 1 N/A 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? 0 0 1 N/A (14.012) Overall percentage (MIT 14): 81% * 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: July 2019 – February 2020 Return to Contents California Rehabilitation Center 59 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 25 8 12 76% visits occur within required time frames? (1.008) *, † Are specialty documents scanned into the patient’s electronic health 28 2 0 93% 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. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 60 Cycle 6 Medical Inspection Report Administrative Operations Overall Rating In this indicator, OIG compliance inspectors evaluated health care Inadequate administrative processes. Our inspectors examined the timeliness of the medical grievance process and checked whether the institution Case Review followed reporting requirements for adverse or sentinel events and Rating patient deaths. Inspectors checked whether the Emergency Medical (N/A) Response Review Committee (EMRRC) met and reviewed incident packages. We investigated and determined if the institution conducted Compliance the required emergency response drills. Inspectors also assessed whether Score the Quality Management Committee (QMC) met regularly and addressed Inadequate program performance adequately. In addition, the inspectors examined (71%) if the institution provided training and job performance reviews for its employees. They 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. Nonscored Results We obtained CCHCS Death Review Committee (DRC) reporting records. After a patient dies, the DRC must complete a death review summary report within 60 calendar days for unexpected deaths and within 30 calendar days for expected deaths. When the DRC completes the death review summary report, it must submit the report to the institution’s CEO within seven calendar days after completion. At CRC, one unexpected (Level 1) death occurred during the inspection review period. We found the DRC completed the death review 17 days late. Furthermore, we found no evidence that the report was submitted to the institution’s CEO (MIT 15.998). Recommendations • Medical leadership should ensure that incidents needing EMRRC review are timely completed, presented, and discussed at the monthly meetings. Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 61 Table 20. Administrative Operations Scored Answer Compliance Questions Yes No N/A Yes % For health care incidents requiring root cause analysis (RCA): Did the 0 1 0 0 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 0 0 1 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 2 1 0 67% custody staff participate in those drills? (15.101) Did the responses to medical grievances address all of the inmates’ 10 0 0 100% grieved issues? (15.102) Did the medical staff review and submit initial inmate death reports 1 1 0 50% 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 0 5 1 0 appraisals timely? (15.105) Did the providers maintain valid state medical licenses? (15.106) 7 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): 71% Source: The Office of the Inspector General medical inspection results. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 62 Cycle 6 Medical Inspection Report (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 63 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 CRC Access to Care Emergency Health Care W Services Diagnostic Services Environment C O E I Health Information Management M V P E Nursing Preventive Transfers L R Performance Services I A E Medication Management N S C A C Provider Specialized Medical Housing Administrative E Performance Operations Specialty Services Source: The Office of the Inspector General medical inspection results. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 64 Cycle 6 Medical Inspection Report 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 The medical care provided to one patient over a Case, Sample, specific period, which can comprise detailed or focused or Patient case reviews. A review that includes all aspects of one patient’s medical Comprehensive care assessed over a six-month period. This review allows Case Review the OIG clinicians to examine many areas of health care delivery, such as access to care, diagnostic services, health information management, and specialty services. A review that focuses on one specific aspect of medical Focused care. This review tends to concentrate on a singular Case Review facet of patient care, such as the sick call process or the institution’s emergency medical response. A direct or indirect interaction between the patient and the health care system. Examples of direct interactions Event include provider encounters and nurse encounters. An example of an indirect interaction includes a provider reviewing a diagnostic test and placing additional orders. Case Review A medical error in procedure or in clinical judgment. Both procedural and clinical judgment errors can result in policy Deficiency noncompliance, elevated risk of patient harm, or both. Adverse Event An event that caused harm to the patient. Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 65 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, nonclinician 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 standardized protocol and select samples for clinicians to review. Samples are obtained per the case review methodology shared with stakeholders in prior cycles. 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 scenarios 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. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 66 Cycle 6 Medical Inspection Report Figure A–2. Case Review Testing The OIG clinicians examine the chosen samples, performing either a comprehensive case review or a focused case review, to determine the events that occurred. Sample = Patient = Case No Deficiency or Minor Deficiency Sample Events Significant Deficiency * A sample leading to events Deficiencies Not all events lead to deficiencies (medical errors); however, if errors did occur, then the OIG clinicians determine whether any were adverse. Significant Sample Events Deficiency * A sample leading to events that could cause harm Did the event cause harm to the patient? * If an event (in this case, a significant deficiency) caused harm, the OIG clinician labels it adverse. Yes No AAddvveerrssee Significant EEvveenntt Deficiency Source: The Office of the Inspector General medical inspection analysis. Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 67 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 Total Patient Population Filters Subpopulation Randomize Sample Flagging Source: The Office of the Inspector General medical inspection analysis. 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. Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 68 Cycle 6 Medical Inspection Report 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 also obtain information regarding plant infrastructure and local operating procedures. 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 (greater than 85 percent), adequate (between 75 percent and 85 percent), or inadequate (less than 75 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: July 2019 – February 2020 Return to Contents California Rehabilitation Center 69 Appendix B: Case Review Data Table B–1. Case Review Sample Sets Sample Set Total Anticoagulation 2 CTC / OHU 3 Death Review / Sentinel Events 2 Diabetes 3 Emergency Services – CPR 1 Emergency Services – Non-CPR 2 High Risk 4 Hospitalization 4 Intrasystem Transfers In 3 Intrasystem Transfers Out 3 RN Sick Call 12 Specialty Services 3 42 Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 70 Cycle 6 Medical Inspection Report Table B–2. Case Review Chronic Care Diagnoses Diagnosis Total Anemia 2 Anticoagulation 2 Arthritis/Degenerative Joint Disease 2 Asthma 9 COPD 2 Cardiovascular Disease 3 Chronic Kidney Disease 0 Chronic Pain 8 Cirrhosis/End-Stage Liver Disease 0 Coccidioidomycosis 1 Deep Venous Thrombosis/Pulmonary Embolism 1 Diabetes 11 Gastroesophageal Reflux Disease 6 Hepatitis C 7 Hyperlipidemia 11 Hypertension 13 Mental Health 21 Migraine Headaches 0 Seizure Disorder 1 Sleep Apnea 2 Thyroid Disease 1 103 Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 71 Table B–3. Case Review Events by Program Diagnosis Total Diagnostic Services 140 Emergency Care 38 Hospitalization 51 Intrasystem Transfers In 12 Intrasystem Transfers Out 5 Not Specified 0 Outpatient Care 418 Specialized Medical Housing 69 Specialty Services 137 870 Table B–4. Case Review Sample Summary MD Reviews Detailed 20 MD Reviews Focused 0 RN Reviews Detailed 11 RN Reviews Focused 21 Total Reviews 52 Total Unique Cases 42 Overlapping Reviews (MD & RN) 10 Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 72 Cycle 6 Medical Inspection Report Appendix C: Compliance Sampling Methodology California Rehabilitation Center 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 30 MedSATS • Clinic (each clinic tested) (6 per clinic) • Appointment date (2 – 9 months) • Randomize MIT 1.007 Returns From 22 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 10 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: July 2019 – February 2020 Return to Contents California Rehabilitation Center 73 Quality No. of Indicator Sample Category Samples Data Source Filters Health Information Management (Medical Records) MIT 4.001 Health Care Services 20 OIG Qs: 1.004 • Nondictated documents Request Forms • First 20 IPs for MIT 1.004 MIT 4.002 Specialty Documents 30 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 22 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 8 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 2 OIG inspector • R&R IP transfers with medication on-site review Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 74 Cycle 6 Medical Inspection Report 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 22 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 8 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 Isolation Unit KOP N/A at this On-site active • KOP rescue inhalers & Medications institution medication listing nitroglycerin medications for IPs housed in isolation units Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 75 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 25 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 (51 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 N/A at this Cocci transfer • Reports from past 2 – 8 months (number will vary) institution status report • Institution • Ineligibility date (60 days prior to inspection date) • All Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 76 Cycle 6 Medical Inspection Report Quality No. of Indicator Sample Category Samples Data Source Filters Reception Center MITs 12.001 – 008 RC 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 10 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 MIT 13.101 Call Buttons All OIG inspector • Specialized Health Care Housing on-site review • Review by location Specialty Services MITs 14.001 – 003 High-Priority 15 MedSATS • Approval date (3 – 9 months) Initial and Follow-Up • Remove consult to gynecology, RFS consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, or podiatry • Randomize MITs 14.004 – 006 Medium-Priority 15 MedSATS • Approval date (3 – 9 months) Initial and Follow-Up • Remove consult to gynecology, RFS consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, or podiatry • Randomize MITs 14.007 – 009 Routine-Priority 15 MedSATS • Approval date (3 – 9 months) Initial and Follow-Up • Remove consult to gynecology, RFS consult to public health/Specialty RN, dialysis, ECG 12-Lead (EKG), mammogram, occupational therapy, ophthalmology, optometry, oral surgery, physical therapy, or podiatry • Randomize MIT 14.010 Specialty Services 20 MedSATS • Arrived from (other departmental Arrivals institution) • Date of transfer (3 – 9 months) • Randomize MITs 14.011 – 012 Denials N/A 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: July 2019 – February 2020 Return to Contents California Rehabilitation Center 77 Quality No. of Indicator Sample Category Samples Data Source Filters Administrative Operations MIT 15.001 Adverse/sentinel 1 Adverse/sentinel • Adverse/Sentinel events events events (ASE) (2 – 8 months) report 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 N/A 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 1 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 6 On-site • All required performance Evaluation Packets provider evaluation documents evaluation files MIT 15.106 Provider Licenses 7 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 Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 78 Cycle 6 Medical Inspection Report 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 All Nursing staff • New employees (hired within last New Employee training logs 12 months) Orientations MIT 15.998 Death Review 1 OIG summary log: • Between 35 business days & Committee deaths 12 months prior • Health Care Services death reviews Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents California Rehabilitation Center 79 California Correctional Health Care Services’ Response December 1, 2020 Roy Wesley, Inspector General Office of the Inspector General 10111 Old Placerville Road, Suite 110 Sacramento, CA 95827 Dear Mr. Wesley: The Office of the Receiver has reviewed the draft report of the Office of the Inspector General (OIG) Medical Inspection Results for California Rehabilitation Center (CRC) conducted from July 2019 to February 2020. Although it is likely CRC may have potential disputes with the OIG findings, all resources are currently focused on direct patient care and containment of the coronavirus. California Correctional Health Care Services (CCHCS) will acknowledge 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) 691-0697. Sincerely, Julie Digitally signed by Julie Inderkum Inderkum Date: 2020.12.01 14:21:15 -08'00' Julie Inderkum Associate Director (A) Risk Management Branch California Correctional Health Care Services cc: Clark Kelso, Receiver Diana Toche, D.D.S., Undersecretary, Health Care Services, CDCR Richard Kirkland, Chief Deputy Receiver Katherine Tebrock, Chief Assistant Inspector General, OIG Doreen Pagaran, R.N., Nurse Consultant Program Review, OIG Lara Saich, Director (A), Health Care Policy and Administration, CCHCS Joseph Bick, M.D., Director, Health Care Services, CCHCS Tammy Foss, Director, Corrections Services, CCHCS Jackie Clark, Deputy Director (A), Institution Operations, CCHCS Roscoe Barrow, Chief Counsel, CCHCS Office of Legal Affairs DeAnna Gouldy, Deputy Director (A), Policy and Risk Management Services, CCHCS Renee Kanan, M.D., Deputy Director, Medical Services, CCHCS Barbra Barney-Knox, R.N., Deputy Director (A), Nursing Services, CCHCS Annette Lambert, Deputy Director, Quality Management, CCHCS Robert Herrick, Regional Health Care Executive, Region IV, CCHCS Elizabeth dos Santos Chen, D.O., Regional Deputy Medical Executive, Region IV, CCHCS Nyreith Adeyemi, R.N., Regional Nursing Executive (A), Region IV, CCHCS Kerry Oglesby, Chief Executive Officer, CRC Amanda Oltean, Staff Services Manager II, Health Care Compliance Support Section, CCHCS Allan Blackwood, Staff Services Manager I, Health Care Compliance Support Section, CCHCS Misty Polasik, Staff Services Manager I, OIG P.O. Box 588500 Elk Grove, CA 95758 Report Issued: December 2020 Office of the Inspector General, State of California Return to Contents 80 Cycle 6 Medical Inspection Report (This page left blank for reproduction purposes.) Office of the Inspector General, State of California Inspection Period: July 2019 – February 2020 Return to Contents Cycle 6 Medical Inspection Report for California Rehabilitation Center OFFICE of the INSPECTOR GENERAL Roy W. Wesley Inspector General Bryan B. Beyer Chief Deputy Inspector General STATE of CALIFORNIA December 2020 OIG