Correctional Training Facility Medical Inspection Report Cycle 4

Robert A. Barton Office of the Inspector General Inspector General Correctional Training Facility Medical Inspection Results Cycle 4 June 2015 Office of the Inspector General CORRECTIONAL TRAINING FACILITY Medical Inspection Results Cycle 4 Robert A. Barton Inspector General Roy W. Wesley Chief Deputy Inspector General Shaun R. Spillane Public Information Officer June 2015 TABLE OF CONTENTS Executive Summary ............................................................................................................................. i Overall Assessment: Adequate ....................................................................................... iii Clinical Case Review and OIG Clinician Inspection Results ......................................... iii Compliance Testing Results ........................................................................................... iv Population-Based Metrics .............................................................................................. vii Introduction ......................................................................................................................................... 1 About the Institution............................................................................................................................ 1 Objectives, Scope, and Methodology .................................................................................................. 5 Case Reviews ................................................................................................................................ 6 Patient Selection for Retrospective Case Reviews ................................................................. 6 Benefits and Limitations of Targeted Subpopulation Review ............................................... 7 Case Reviews Sampled .......................................................................................................... 8 Compliance Testing ...................................................................................................................... 9 Sampling Methods for Conducting Compliance Testing ....................................................... 9 Scoring of Compliance Testing Results ................................................................................. 9 Dashboard Comparisons ...................................................................................................... 10 Overall Quality Indicator Rating for Case Reviews and Compliance Testing ........................... 10 Population-Based Metrics ........................................................................................................... 10 Medical Inspection Results ............................................................................................................... 11 Primary (Clinical) Quality Indicators of Health Care ................................................................. 11 Access to Care ...................................................................................................................... 12 Case Review Results...................................................................................................... 12 Compliance Testing Results .......................................................................................... 12 CCHCS Dashboard Comparative Data .......................................................................... 14 Recommendations.......................................................................................................... 14 Diagnostic Services .............................................................................................................. 15 Case Review Results...................................................................................................... 15 Compliance Testing Results .......................................................................................... 16 Recommendations.......................................................................................................... 17 Emergency Services ............................................................................................................. 17 Case Review Results...................................................................................................... 18 Recommendations.......................................................................................................... 19 Health Information Management (Medical Records) .......................................................... 19 Case Review Results...................................................................................................... 20 Compliance Testing Results .......................................................................................... 21 CCHCS Dashboard Comparative Data .......................................................................... 22 Recommendations.......................................................................................................... 23 Health Care Environment .................................................................................................... 24 Compliance Testing Results .......................................................................................... 25 Recommendations.......................................................................................................... 28 Inter- and Intra-System Transfers ........................................................................................ 29 Case Review Results...................................................................................................... 29 Compliance Testing Results .......................................................................................... 31 Recommendations.......................................................................................................... 33 Pharmacy and Medication Management ............................................................................. 34 Case Review Results...................................................................................................... 34 Compliance Testing Results .......................................................................................... 37 CCHCS Dashboard Comparative Data .......................................................................... 40 Recommendations.......................................................................................................... 40 Preventive Services .............................................................................................................. 41 Compliance Testing Results .......................................................................................... 41 CCHCS Dashboard Comparative Data .......................................................................... 42 Recommendations.......................................................................................................... 43 Quality of Nursing Performance .......................................................................................... 43 Case Review Results...................................................................................................... 44 Recommendations.......................................................................................................... 48 Quality of Provider Performance ......................................................................................... 48 Case Review Results...................................................................................................... 49 Recommendations.......................................................................................................... 51 Specialized Medical Housing (OHU, CTC, SNF, Hospice) ................................................. 52 Case Review Results...................................................................................................... 52 Compliance Testing Results .......................................................................................... 55 Recommendations.......................................................................................................... 55 Specialty Services ................................................................................................................. 56 Case Review Results...................................................................................................... 56 Compliance Testing Results .......................................................................................... 58 Recommendations.......................................................................................................... 59 Secondary (Administrative) Quality Indicators of Health Care ................................................. 60 Internal Monitoring, Quality Improvement, and Administrative Operations ...................... 60 Compliance Testing Results .......................................................................................... 60 CCHCS Dashboard Comparative Data .......................................................................... 63 Recommendations.......................................................................................................... 64 Job Performance, Training, Licensing, and Certifications .................................................. 64 Compliance Testing Results .......................................................................................... 64 Recommendations.......................................................................................................... 65 Population-Based Metrics ........................................................................................................... 66 Appendix A—Compliance Test Results ........................................................................................... 71 Appendix B—Clinical Data .............................................................................................................. 85 Appendix C—Compliance Sampling Methodology ......................................................................... 89 California Correctional Health Care Services’ Response ................................................................. 94 LIST OF TABLES AND FIGURES Health Care Quality Indicators ............................................................................................................ ii CTF Executive Summary Table ......................................................................................................... ix CTF Health Care Staffing Resources—February 2015 ....................................................................... 2 CTF Master Registry Data as of June 4, 2015 .................................................................................... 3 Abbreviations Used in This Report ..................................................................................................... 4 Access to Care—CTF Dashboard and OIG Compliance Results ..................................................... 14 Health Information Management—CTF Dashboard and OIG Compliance Results ......................... 23 Pharmacy and Medication Management— CTF Dashboard and OIG Compliance Results ............ 40 Preventive Services—CTF Dashboard and OIG Compliance Results .............................................. 43 Internal Monitoring, Quality Improvement, and Administrative Operations—CTF Dashboard and OIG Compliance Results ............................................................................................................ 63 Table 1 - CTF Results Compared to State and National HEDIS Scores ........................................... 69 Table 2 - CTF Results Compared to Medi-Cal Minimum and Maximum Performance ................... 70 EXECUTIVE SUMMARY As a result of the April 2001 Plata v. Brown federal court class action lawsuit, and under the authority of California Penal Code Section 6126, which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), the OIG developed a comprehensive inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. To further augment the breadth and quality of the OIG’s medical inspection program, for this fourth cycle of inspections the OIG added a clinical case review component and significantly enhanced the compliance portion of the inspection process from that used in prior cycles. In addition, the OIG added a population-based metric comparison of selected Healthcare Effectiveness Data Information Set (HEDIS) measures from other State and national health care organizations and compared that data to similar results for the Correctional Training Facility (CTF). From February to April 2015, the OIG performed its Cycle 4 medical inspection at CTF. The inspection included in-depth reviews of 64 inmate-patient files conducted by clinicians as well as reviews of documents from 425 inmate-patient files conducted by deputy inspectors general, covering 92 objectively scored tests of compliance with policies and procedures applicable to the delivery of medical care. The OIG assessed the case review and compliance results at CTF using 14 health care quality indicators applicable to the institution, which included 12 primary clinical indicators and 2 secondary administrative indicators. See Health Care Quality Indicators Table on page ii. Based on that analysis, OIG experts made a considered and measured opinion overall about the quality of health care that was observed. Medical Inspection Unit Page i Office of the Inspector General State of California Health Care Quality Indicators All Institutions– Fourteen Primary Indicators (Clinical) CTF Applicability Applicability Both case review 1–Access to Care All institutions and compliance Both case review 2–Diagnostic Services All institutions and compliance 3–Emergency Services All institutions Case review only 4–Health Information Management Both case review All institutions (Medical Records) and compliance 5–Health Care Environment All institutions Compliance only Both case review 6–Inter- and Intra-System Transfers All institutions and compliance Both case review 7–Pharmacy and Medication Management All institutions and compliance Female institutions 8–Prenatal and Post-Delivery Services Not Applicable only 9–Preventive Services All institutions Compliance only 10–Quality of Nursing Performance All institutions Case review only 11–Quality of Provider Performance All institutions Case review only Institutions with 12–Reception Center Arrivals Not Applicable reception centers All institutions with 13–Specialized Medical Housing Both case review an OHU, CTC, SNF, (OHU, CTC, SNF, Hospice) and compliance or Hospice Both case review 14–Specialty Services All institutions and compliance Two Secondary Indicators All Institutions– CTF (Administrative) Applicability Applicability 15–Internal Monitoring, Quality Improvement, and Administrative All institutions Compliance only Operations 16–Job Performance, Training, Licensing, All institutions Compliance only and Certifications Medical Inspection Unit Page ii Office of the Inspector General State of California Overall Assessment: Adequate Based on the clinical case reviews, compliance testing, and population-based metrics, the OIG’s overall assessment rating for Overall Assessment CTF was adequate. For the 12 primary (clinical) quality indicators Rating: applicable to CTF, the OIG found 2 proficient, 5 adequate, and 5 inadequate. For the two secondary (administrative) quality Adequate indicators, the OIG found one inadequate and one adequate. To determine the overall assessment for CTF, the OIG considered individual clinical ratings and individual compliance question scores within each of the indicator categories, putting emphasis on the results for the primary indicators. For example, while the institution received overall ratings of inadequate for five of the primary indicators, ratings for two of them, Specialty Services and Inter-and Intra-System Transfers were deemed to be only borderline inadequate. Also, the institution’s strong performance in three key primary indicators, Quality of Provider Performance, Quality of Nursing Performance, and Access to Care helped to offset many deficiencies in other systems. Based on that analysis, OIG experts made a considered and measured opinion overall about the quality of health care that was observed. Clinical Case Review and OIG Clinician Inspection Results The OIG’s clinical case review results supported CTF’s overall rating of adequate. The clinicians’ case reviews sampled patients with high medical needs. For the 12 primary indicators applicable to CTF, 10 were evaluated by clinician case review; 1 was proficient, 7 were adequate, and 2 were inadequate. When determining the overall adequacy of care, extra emphasis was placed on the clinical nursing and provider quality indicators, as adequate health care staff can sometimes overcome suboptimal processes and programs. However, the opposite is not true. Inadequate health care staff cannot provide adequate care, even though the established processes and programs onsite may be adequate. Program Strengths • The institution employed providers and nurses of sufficient quality that successfully mitigated many of the deficiencies identified in this report, especially with regard to Health Information Management, Health Care Environment, Inter- and Intra- System Transfers, Preventive Services, and Specialty Services. • During the period of review, CTF provided proficient access to primary care services at the institution, including both the nursing sick call and chronic care programs. The combination of timely appointments and quality medical staff allowed overall adequate medical care despite other significant system deficiencies. CTF provided timely access to high quality Medical Inspection Unit Page iii Office of the Inspector General State of California emergency services. In general, CTF performed well with emergency response times, basic life support care, and 9-1-1 call activation times. All deficiencies noted were minor and not likely to affect patient care. • The Coumadin Clinic provided exemplary care in this otherwise difficult area to manage. • The patients with higher medical needs in the Outpatient Housing Unit (OHU) benefitted from excellent quality care by the physician in that unit. Program Weaknesses Some of the major shortcomings found by the OIG clinicians during this inspection are as follows: • Health Information Management (HIM) was inadequate. Frequently, records were not available when needed, were misfiled, or were missing. Additionally, many documents were illegible. These deficiencies markedly increase the risk of a lapse in care, especially when patients are transferred to other care providers. • Specialty Services was inadequate. In contrast to Access to Care, where deficiencies were rare and insignificant, the specialty services suffered from significant delays in specialty appointments. Specialty services also suffered from inadequate HIM processes such as delays in obtaining records, misfiling, or missing records. • There were two significant Adverse/Sentinel Events. There was a significant delay in diagnosis for a patient with acute liver failure (case 2). Another patient had a significant delay for laboratory test results for a toxic phenytoin medication level (case 4). Adverse Events are further described within the Medical Inspection Results section of this report. Because of the anecdotal description of these events, the OIG cautions against drawing inappropriate conclusions regarding the institution based solely on adverse events. Compliance Testing Results The OIG’s compliance testing results supported CTC’s overall rating of adequate. Of the 14 total indicators of health care applicable to CTF, 11 were evaluated by compliance inspectors. There were 92 individual compliance questions within those 11 indicators that tested CTF’s compliance with California Correctional Health Care Services (CCHCS) policies and procedures.1 Those 92 questions are detailed in Appendix A—Compliance Test Results. The institution’s inspection scores for the 11 indicators ranged from 53.8 percent to 94.0 percent, with the primary (clinical) indicator Preventive Services receiving the lowest score, and the primary (clinical) indicator Specialized 1 The OIG used its own clinicians to provide clinical expert guidance for testing compliance in certain areas where CCHCS policies and procedures did not specifically address an issue. Medical Inspection Unit Page iv Office of the Inspector General State of California Medical Housing receiving the highest. For the nine primary indicators, the OIG inspectors rated two proficient, three adequate, and four inadequate. For the two secondary indicators, which involve administrative health care functions, one was rated adequate and the other inadequate. As the CTF Executive Summary Table on page ix indicates, the institution’s compliance scores were in the proficient range for the following two indicators: Diagnostic Services (86.7 percent) and Specialized Medical Housing (94.0 percent). Below are some of the strengths identified based on CTF’s compliance scores for individual questions within all primary health care indicators: • Nursing staff timely reviewed patient health service requests and timely completed face-to-face (FTF) visits. • When a primary care provider determined that a patient needed a follow-up appointment, providers conducted the appointments timely. • The institution ensured that inmate-patients timely received their radiology, laboratory, and pathology diagnostic services. In addition, providers reviewed and communicated radiology and laboratory services test results to the inmate-patient within the required time frames. • Of the clinicians observed during patient encounters, all followed good hand hygiene practices. Also, all clinics followed adequate medical supply storage and management protocols. • In CTF’s main pharmacy, management protocols for general security, organization, cleanliness, medication storage, and medication error reporting were followed without exception. • Nursing staff timely administered newly-ordered prescriptions to inmate-patients and ensured that patients who transferred from one housing unit to another received their prescribed medications without interruption. • For patients assigned to the OHU, nurses timely completed initial inmate-patient assessments. Also, providers timely completed patients’ written history and physical examinations upon admission, and timely completed additional evaluations of patients at required intervals. • Routine specialty service appointments occurred timely and CTF’s denials of providers’ requests for specialty services were made timely. Medical Inspection Unit Page v Office of the Inspector General State of California Strengths identified within the two secondary administrative indicators included the following: • Monthly Quality Management Committee meeting minutes were well documented. • Providers, the pharmacist-in-charge, and the pharmacy had current licenses and registrations. • Nursing staff were current on required training requirements, licenses, and certifications. The institution received ratings in the inadequate range for the following four primary indicators: Health Information Management (58.4 percent), Health Care Environment (63.5 percent), Inter- and Intra-System Transfers (66.6 percent), and Preventive Services (53.8 percent). CTF also received an inadequate rating in the secondary indicator Internal Monitoring, Quality Improvement, and Administrative Operations (65.6 percent). Below are some of the weaknesses identified based on CTF’s compliance scores for individual questions within all primary health care indicators: • Providers did not always timely communicate the results of diagnostic pathology reports to the patient or did not communicate results at all. Also, providers did not timely review specialists’ reports for routine services. In addition, when providers’ requests for specialty services were denied, the providers did not timely meet with patients to discuss the denial and propose alternative treatment strategies. • Inspected health care documents were incorrectly labeled or filed in patients’ eUHRs. Also, the institution did not always timely scan hospital discharge summary reports, specialty service consultant reports, and medication administration records into patients’ eUHRs. Further, clinical staff did not always legibly sign or print their names on health care documents. • Community Hospital Discharge Reports lacked key elements and providers did not always timely review the reports. • Clinic common areas and exam rooms were missing essential supplies and core equipment, and emergency response bags were not always inventoried monthly. Also, some exam rooms and clinic common areas where patient encounters were held did not provide auditory or visual privacy, and the space or configuration of furniture in some exam rooms was not optimal for conducting clinical exams. In addition, outdoor waiting areas for yard pill-lines did not provide overhangs or shade protection for inmate-patients during extreme or inclement weather. • Of the inmate-patients received from another institution, nursing staff did not routinely complete all sections of the Initial Health Screening Form. Also, previously approved or scheduled specialty service appointments for transfer-in patients were not scheduled or Medical Inspection Unit Page vi Office of the Inspector General State of California rescheduled in a timely manner, or were not scheduled or re-scheduled at all. In addition, providers did not always conduct timely appointments with newly arrived inmate-patients who received a provider referral during their initial health screening. • Of the patients who transfer out of the institution, their approved and pending specialty service appointments were not always identified on the transfer form. • Inmate-patients either discharged from a community hospital or en route to another institution, who had a temporary layover at CTF, did not always receive their required medications without interruption. • At clinics and medication line storage locations, nursing staff did not always follow standard procedures when storing non-narcotic medications and some nursing staff were not familiar with standard procedures regarding controlled substance discrepancies. Also, medication line nurses did not always properly sanitize their hands during glove changes. • The institution did not offer annual influenza vaccinations to all inmate-patients and did not offer all required immunizations to those with certain types of chronic care conditions. Some of the low-scoring questions within the two secondary administrative indicators included the following: • Required documentation was absent from medical emergency response drill packets. Also, the institution did not follow requirements for timely reporting adverse/sentinel events. • Supervising nurses did not conduct required reviews of nursing staff. Also, providers’ performance evaluation packets did not always include required 360-Degree Evaluations. In addition, not all providers and custody managers maintained current medical emergency response certifications. Population-Based Metrics In general, CTF performed well for population-based metrics. In four of the five comprehensive diabetes care measures, CTF outperformed other State and national organizations, including Kaiser Permanente, typically one of the highest scoring health organizations in California. Especially notable was CTF’s low percentage of diabetics considered to be under poor control and high percentage of diabetics considered to be under good control. In the fifth measure, eye exam rates in diabetic patients, CTF outperformed all other organizations except the Veterans Affairs (VA). With regard to the immunization measures for influenza shots to older adults, CTF’s rates were significantly lower than comparable rates reported by Kaiser Permanente, the VA, and Commercial health plans (based on data obtained from health maintenance organizations). The institution’s lower performance in this area was attributed, in part, to its high number of patient refusals. For pneumococcal immunizations, CTF scored lower than the VA’s rate‒no other organizations Medical Inspection Unit Page vii Office of the Inspector General State of California reported data for this measure. For colorectal cancer screening, the institution’s rates were similar to rates for both Kaiser Permanente and the VA, and were much higher than Commercial and Medicare rates. Overall, CTF’s performance demonstrated by the population-based metrics indicated that the chronic care program was well-run and operating as intended. Medical Inspection Unit Page viii Office of the Inspector General State of California The CTF Executive Summary Table below lists the quality indicators the OIG inspected and assessed during the clinical case reviews and objective compliance tests, and provides the institution’s rating in each area. The overall indicator ratings were based on a consensus decision by the OIG’s clinicians and non-clinical inspectors. CTF Executive Summary Table Case Compliance Overall Indicator Primary Indicators (Clinical) Review Score Rating Rating Access to Care Proficient 83.9% Proficient Diagnostic Services Adequate 86.7% Adequate Emergency Services Adequate Not Applicable Adequate Health Information Management Inadequate 58.4% Inadequate (Medical Records) Health Care Environment Not Applicable 63.5% Inadequate Inter- and Intra-System Transfers Adequate 66.6% Inadequate Pharmacy and Medication Management Adequate 80.5% Adequate Preventive Services Not Applicable 53.8% Inadequate Quality of Nursing Performance Adequate Not Applicable Adequate Quality of Provider Performance Adequate Not Applicable Adequate Specialized Medical Housing Adequate 94.0% Proficient (OHU, CTC, SNF, Hospice) Specialty Services Inadequate 77.5% Inadequate Note: Prenatal and Post Delivery Services and Reception Center Arrivals indicators did not apply to this institution. Case Compliance Overall Indicator Secondary Indicators (Administrative) Review Score Rating Rating Internal Monitoring, Quality Improvement, Not Applicable 65.6% Inadequate and Administrative Operations Job Performance, Training, Licensing, and Not Applicable 77.5% Adequate Certifications Note: Ratings for quality indicators range from proficient (greater than 85.0 percent), adequate (75.0 percent to 85.0 percent), or inadequate (below 75.0 percent). Medical Inspection Unit Page ix Office of the Inspector General State of California INTRODUCTION Under the authority of California Penal Code Section 6126, which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), and at the request of the federal Receiver, the OIG developed a comprehensive medical inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. For this fourth cycle of inspections, the OIG augmented the breadth and quality of its inspection program used in prior cycles, adding a clinical case review component and significantly enhancing the compliance component of the program. The Correctional Training Facility (CTF) was the second Cycle 4 medical inspection completed. During the inspection process, the OIG assessed the delivery of medical care to inmate-patients for 14 primary clinical health care indicators and 2 secondary administrative health care indicators, as applicable to the institution under inspection. It is important to note that while the primary quality indicators represent the clinical care being provided by the institution at the time of the inspection, the secondary quality indicators are purely administrative and are not reflective of the actual clinical care provided. The OIG is committed to reporting on each institution’s delivery of medical care to assist in identifying areas for improvement, but the federal court will ultimately determine whether any institution’s medical care meets constitutional standards. ABOUT THE INSTITUTION The primary mission of CTF is to provide custody, care, treatment, and rehabilitative programs for Level I and II general population and sensitive needs inmates in three separate facilities. The CTF runs five medical clinics where staff handle non-urgent requests for medical services. The institution also treats inmate-patients needing urgent or emergency care in its triage and treatment area (TTA) and provides inpatient care at its Outpatient Housing Unit. In addition, inmate-patients who leave or arrive at the institution are screened in the prison’s receiving and release (R&R) clinic. Also, CTF has been designated as a “basic care prison,” located in a rural area away from tertiary care centers and specialty care providers whose services are likely to be used frequently by high- risk patients. The CTF reported that the most significant staffing level change since the OIG’s last medical inspection relates to the reduction in nursing staff. Because the institution is now designated as a basic care facility, CTF has fewer sick patients and the number of TTAs decreased from three to one. Based on staffing data the OIG obtained from the institution, CTF had an overall vacancy rate of 12 percent for key health care staff in February 2015, which consisted of the following vacancies: 1 management position, 1 provider position, 1.5 nurse supervisor positions, and 8.5 nurse staff Medical Inspection Unit Page 1 Office of the Inspector General State of California positions. In addition, the institution also reported that in December 2014 a new statewide nurse staffing model took effect that resulted in the loss of almost 19 registered nurse (RN) positions. Total RN positions were reduced from a previous high of 46 personnel years (PYs) to approximately 27 PYs in the fiscal year 2014–15. In brief, CTF’s nursing levels were realigned to match the statewide acuity-based nursing model so that it was consistent with other similar institution staffing levels. The California Correctional Health Care Services’ (CCHCS) Health Care Operations Nursing unit is currently working with CTF to ensure all medical areas are staffed appropriately. Adjustments to staffing levels will be updated at CTF, if necessary. CTF Health Care Staffing Resources—February 2015 Primary Care Nursing Management Nursing Staff Totals Providers Supervisors Description Number % Number % Number % Number % Number % Authorized 5 5% 12 12% 11.5 11% 72.5 72% 101 100% Positions Filled Positions 4 80% 11 92% 10 87% 64 88% 89 88% Vacancies 1 20% 1 8% 1.5 13% 8.5 12% 12 12% Recent Hires (within 12 2 50% 4 36% 4 40% 8 13% 18 20% months) Staff Utilized 0 0% 0 0% 0 0% 11 17% 11 12% from Registry Redirected Staff (to Non-Patient 0 0% 0 0% 0 0% 0 0% 0 0% Care Areas) Staff under Disciplinary 0 0% 0 0% 0 0% 1 2% 1 1% Review Staff on Long-term 0 0% 0 0% 0 0% 0 0% 0 0% Medical Leave Note: CTF Health Care Staffing Resources data was not validated by the OIG. Medical Inspection Unit Page 2 Office of the Inspector General State of California As of June 4, 2015, CCHCS data showed that CTF had 5,037 inmates. Within that total population, 2.0 percent of the patients were designated as high-risk Level I, and 5.5 percent were designated as high-risk Level II. High-risk patients are at greater risk for poor health outcomes than average patients. The chart below illustrates the inmate-patient breakdown. CTF Master Registry Data as of June 4, 2015 Risk Level # of Inmate-Patients Percentage High I 99 2.0% High II 278 5.5% Medium 2,637 52.3% Low 2,023 40.2% Total 5,037 100.0% Medical Inspection Unit Page 3 Office of the Inspector General State of California For ease of reference, the following is a table of common abbreviations that may be used throughout this report. Abbreviations Used in This Report ACLS Advanced Cardiovascular Life Support HIV Human Immunodeficiency Virus AHA American Heart Association HTN Hypertension ASU Administrative Segregation Unit INH Isoniazid (anti-tuberculosis medication) BLS Basic Life Support IV Intravenous CBC Complete Blood Count KOP Keep-on-Person (in taking medications) CC Chief Complaint LPT Licensed Psychiatric Technician CCHCS California Correctional Health Care Services LVN Licensed Vocational Nurse CCP Chronic Care Program MAR Medication Administration Record California Department of Corrections and CDCR MRI Magnetic Resonance Imaging Rehabilitation CEO Chief Executive Officer MD Medical Doctor CHF Congestive Heart Failure NA Nurse Administered (in taking medications) CME Chief Medical Executive N/A Not Applicable CMP Comprehensive Metabolic (Chemistry) Panel NP Nurse Practitioner CNA Certified Nursing Assistant OB Obstetrician CNE Chief Nurse Executive OHU Outpatient Housing Unit C/O Complains of OIG Office of the Inspector General COPD Chronic Obstructive Pulmonary Disease P&P Policies and Procedures (CCHCS) CP&S Chief Physician and Surgeon PA Physician Assistant CPR Cardio-Pulmonary Resuscitation PCP Primary Care Provider CSE Chief Support Executive POC Point of Contact CT Computerized Tomography PPD Purified Protein Derivative CTC Correctional Treatment Center PRN As Needed (in taking medications) DM Diabetes Mellitus RN Registered Nurse Directly Observed Therapy (in taking DOT Rx Prescription medications) Dx Diagnosis SNF Skilled Nursing Facility Subjective, Objective, Assessment, Plan, EKG Electrocardiogram SOAPE Education ENT Ear, Nose and Throat SOMS Strategic Offender Management System ER Emergency Room S/P Status post eUHR electronic Unit Health Record TB Tuberculosis FTF Face-to-Face TTA Triage and Treatment Area History and Physical (reception center H&P UA Urinalysis examination) HIM Health Information Management UM Utilization Management Medical Inspection Unit Page 4 Office of the Inspector General State of California OBJECTIVES, SCOPE, AND METHODOLOGY In designing the medical inspection program, the OIG reviewed CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. The OIG also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the Receiver’s office, CDCR, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of the OIG’s inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates medical care delivery by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population-based metrics. To maintain a metric-oriented inspection program that evaluates medical care delivery consistently at each State prison, the OIG identified 14 primary (clinical) and 2 secondary (administrative) quality indicators of health care to measure. The primary quality indicators cover clinical categories directly relating to the health care provided to inmate-patients, whereas the secondary quality indicators address the administrative functions that support a health care delivery system. The 14 primary quality indicators are Access to Care, Diagnostic Services, Emergency Services, Health Information Management (Medical Records), Health Care Environment, Inter- and Intra-System Transfers, Pharmacy and Medication Management, Prenatal and Post-Delivery Services, Preventive Services, Quality of Nursing Performance, Quality of Provider Performance, Reception Center Arrivals, Specialized Medical Housing (OHU, CTC, SNF, Hospice), and Specialty Services. The two secondary quality indicators are Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications. The OIG rates each of the quality indicators applicable to the institution under inspection based on case reviews conducted by OIG clinicians and compliance tests conducted by OIG deputy inspectors general. The ratings may be derived from the case review results alone, the compliance test results alone, or a combination of both these information sources. For example, the ratings for the primary quality indicators Quality of Nursing Performance and Quality of Provider Performance are derived entirely from the case review results, while the ratings for both of the secondary quality indicators are derived entirely from compliance test results. As another example, primary quality indicators such as Diagnostic Services and Specialty Services receive ratings derived from both sources. Consistent with the OIG’s agreement with the Receiver, the report only addresses the conditions found related to medical care criteria. Further, the OIG does not review for efficiency and economy of operations. Moreover, if the OIG learns of an inmate-patient needing immediate care, the OIG notifies the Chief Executive Officer of Healthcare Services and requests a status report. Additionally, if the OIG learns of significant departures from community standards, it may report Medical Inspection Unit Page 5 Office of the Inspector General State of California such departures to the institution’s Chief Executive Officer or to CCHCS. Because these matters involve confidential medical information protected by State and federal privacy laws, specific identifying details related to any such cases are not included in the OIG’s public report. In all areas, the OIG is alert for opportunities to make appropriate recommendations for improvement. Such opportunities may be present regardless of the scoring awarded to any particular quality indicator; therefore, recommendations for improvement should not necessarily be interpreted as indicative of deficient medical care delivery. CASE REVIEWS The OIG’s Cycle 4 medical inspections have added case reviews in which OIG physicians and nurses evaluate selected cases in detail to determine the overall quality of health care provided to the inmate-patients. The OIG’s clinicians perform a retrospective chart review of selected patient files to evaluate the care given by an institution’s primary care providers and nurses. Retrospective chart review is a well-established method for health care organizations that perform peer reviews and patient death reviews. California Correctional Health Care Services currently uses retrospective chart review as part of its death review process and in its pattern-of-practice reviews; the CCHCS also uses a more limited form of retrospective chart review when performing appraisals of individual primary care providers. PATIENT SELECTION FOR RETROSPECTIVE CASE REVIEWS Because retrospective chart review is time-consuming and requires qualified health care professionals to perform it, patient selection must be carefully considered. Accordingly, the group of patients the OIG targeted for chart review carried the highest clinical risk and utilized the majority of medical services. A majority of the patients selected for retrospective chart review were classified by CCHCS as high-risk patients. The reason the OIG targeted these patients for review is twofold: 1. The goal of retrospective chart review is to evaluate all aspects of the health care system. Statewide, high-risk/high-utilization patients consume medical services at a disproportionate rate; 9 percent of the patient population who are considered high risk account for more than half of the institution’s pharmaceutical, specialty, community hospital, and emergency costs. 2. Selecting this target group for chart review provides a significantly greater opportunity to evaluate all the various aspects of the health care delivery system at an institution. Medical Inspection Unit Page 6 Office of the Inspector General State of California Underlying the choice of high-risk patients for detailed case review are three assumptions: 1. If the institution is able to provide adequate clinical care to the most challenging patients with multiple complex and interdependent medical problems, it will be providing adequate care to patients with less complicated health care issues. Such an analysis requires clinical expertise and is, therefore, provided by experienced correctional physicians and registered nurses. 2. The health of less complex patients is more likely to be affected by processes such as timely appointment scheduling, medication management, routine health screening, immunizations, etc. For this reason the OIG simultaneously performs a broad compliance review using non-clinical staff. 3. Patient charts from death reviews, adverse/sentinel events (an unexpected occurrence involving death or serious injury, or risk thereof), and hospitalizations are mostly of high-risk patients. BENEFITS AND LIMITATIONS OF TARGETED SUBPOPULATION REVIEW Because the selected patients utilize the broadest range of services offered by the health care system, the OIG’s retrospective chart review provides adequate data for a qualitative assessment of the most vital system processes (referred to by the OIG as “primary quality indicators”). The OIG maintains that retrospective chart review provides an accurate qualitative assessment of the relevant primary quality indicators as applied to the targeted subpopulation of high-risk and high-utilization patients. While this targeted subpopulation does not represent the prison population as a whole, the OIG considers the ability of the institution to provide adequate care to this subpopulation a crucial and vital indicator of how the institution provides health care to its whole patient population. Simply put, if the institution’s medical system does not adequately care for those patients needing the most care, then it is not fulfilling its obligations even if it takes good care of patients with less complex medical needs. Since the targeted subpopulation does not represent the institution’s general prison population, the OIG cautions against inappropriate extrapolation of conclusions from the retrospective chart reviews to the general population. For example, if the high-risk diabetic patients reviewed have poorly-controlled diabetes, one cannot conclude that the entire diabetic population is inadequately controlled. Similarly, if the high-risk diabetic patients under review have poor outcomes and require significant specialty interventions, one cannot conclude that the entire diabetic population is having similarly poor outcomes. Nonetheless, the health care system’s response to this subpopulation can be accurately evaluated and yields valuable systems information. In the above example, if the health care system is providing appropriate diabetic monitoring, medication therapy, and specialty referrals for the Medical Inspection Unit Page 7 Office of the Inspector General State of California high-risk patients reviewed, then it can be reasonably inferred that the health care system is also providing appropriate diabetic services to the entire diabetic subpopulation. However, if these same high-risk patients needing monitoring, medications, and referrals are generally not getting those services, it is likely that the health care system is not providing appropriate diabetic services to the greater diabetic subpopulation. CASE REVIEWS SAMPLED As indicated in Appendix B, Table B-4 CTF Case Review Sample Summary, OIG clinicians evaluated medical charts for 64 unique inmate-patients. Charts for ten of those patients were reviewed by both nurses and physicians, for 74 reviews. Physicians performed detailed reviews of 30 charts, and nurses performed detailed reviews of 11 charts, totaling 41 detailed reviews. For detailed case reviews, the clinicians looked at all encounters occurring in approximately six months of medical care. Nurses also performed a limited or focused review of medical records for an additional 33 inmate-patients. This generated 1,299 clinical events for review (Appendix B-3). For 64 sampled patients reviewed (Appendix B, Table B-1) and only 7 specific chronic care patient records pulled (4 diabetes patients and 3 anticoagulation patients), the final samples included patients with 194 chronic care diagnoses (Appendix B, Table B-2). In addition, even though the process resulted in only 4 patients with diabetes, the case reviews included 13 patients with diabetes; 9 additional patients with diabetes were pulled from other sample requests. Many chronic care programs were evaluated with the OIG’s sample selection tool because the complex and high-risk patients selected from the different categories often had multiple medical problems. While not every chronic disease or health care staff member was evaluated, the overall operation of the institution’s system and staff were assessed for adequacy. The OIG’s case review methodology and sample size matched other qualitative research. The empirical findings, supported by expert statistical consultants, showed adequate conclusions after 10 to 15 charts had undergone full clinician review. In qualitative statistics, this phenomenon is known as “saturation.” The OIG asserts that the sample size of over 30 detailed case reviews certainly far exceeds the saturation point necessary for an adequate qualitative review. With regard to reviewing charts from different providers, the OIG’s pilot inspections have shown that most providers have been adequately reviewed. The case review is not intended to be a focused search for poorly performing providers; rather, it is focused on how the system cares for those patients who need care the most. Providers would only escape OIG case review if institutional management successfully mitigated patient risk by having the more poorly performing PCPs care for the less complicated, low-utilizing, and lower-risk patients. The OIG’s clinicians concluded the sample size was adequate to assess the quality of services provided. The reporting format provides details on whether the encounter was adequate or had significant deficiencies. Further, the deficiencies are identified by programs and processes to help focus the institution on improvement areas. Medical Inspection Unit Page 8 Office of the Inspector General State of California Based on the collective results of clinicians’ case reviews, the OIG rated each quality indicator as either proficient (excellent), adequate (passing), inadequate (failing), or not applicable. A separate confidential CTF Supplemental Medical Inspection Results: Individual Patient Case Review Summaries report details the case reviews OIG clinicians conducted and is available to specific stakeholders. For further details regarding the sampling methodologies and counts, see Appendix B—Clinical Data: Table B-1 CTF Sample Sets; Table B-2 CTF Chronic Care Diagnoses, Table B-3 CTF Event - Program, and Table B-4 CTF Case Review Sample Summary. COMPLIANCE TESTING SAMPLING METHODS FOR CONDUCTING COMPLIANCE TESTING From February to April 2015, deputy inspectors general obtained answers to 92 objective test questions designed to assess the institution’s compliance with critical policies and procedures applicable to the delivery of medical care. The inspectors conducted these tests by reviewing individual inmate-patients’ electronic health records and conducting an onsite inspection of CTF during the week of February 16, 2015. In total, inspectors reviewed health records for 425 inmate-patients and inspected various transactions within their records for evidence that critical events occurred. During the onsite inspection, field inspectors conducted detailed inspections of the institution’s medical facilities and clinics; interviewed key institutional employees; and reviewed employee records, logs, medical appeals, death reports, and other documents. For details of the compliance results, see Appendix A—Compliance Test Results. For details of the OIG’s compliance sampling methodology, see Appendix C—Compliance Sampling Methodology. SCORING OF COMPLIANCE TESTING RESULTS The OIG rated the institution in the following nine primary (clinical) and two secondary (administrative) quality indicators applicable to the institution for compliance testing: • Primary indicators: Access to Care, Diagnostic Services, Health Information Management (Medical Records), Health Care Environment, Inter- and Intra-System Transfers, Pharmacy and Medication Management, Preventive Services, Specialized Medical Housing, and Specialty Services. • Secondary indicators: Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications. After compiling the answers to the 92 questions, the OIG derived a score for each primary and secondary quality indicator identified above by calculating the percentage score of all Yes answers for each of the questions applicable to a particular indicator, then averaging those scores. Based on Medical Inspection Unit Page 9 Office of the Inspector General State of California those results, the OIG assigned a rating to each quality indicator of proficient, adequate, or inadequate using the following scale: proficient (greater than 85.0 percent), adequate (75.0 percent to 85.0 percent), or inadequate (below 75.0 percent). DASHBOARD COMPARISONS For some of the individual compliance questions, the OIG identified where similar metrics were available within the CCHCS Dashboard. The OIG compared its compliance test results with the institution’s Dashboard results and reported on that comparative data under various applicable quality indicators within the Medical Inspection Results section of this report. OVERALL QUALITY INDICATOR RATING FOR CASE REVIEWS AND COMPLIANCE TESTING The OIG derived the final rating for each quality indicator by combining the ratings from the case reviews and from the compliance testing, as applicable. When combining these ratings, the case review evaluations and the compliance testing results usually agreed, but there were instances when the rating differed for a particular quality indicator. In those instances, the inspection team assessed the quality indicator based on the collective ratings from both components. Specifically, the team discussed the nature of individual exceptions found within that indicator category and considered the overall effect on the ability of patients to receive adequate medical care. To derive an overall assessment rating for the institution’s medical inspection, the OIG evaluated the various rating categories assigned to each of the quality indicators applicable to the institution, giving more weight to the rating results for the primary quality indicators, which directly relate to the health care provided to inmate-patients. Based on that analysis, OIG experts made a considered and measured opinion overall about the quality of health care that was observed. POPULATION-BASED METRICS The OIG identified a subset of HEDIS measures applicable to the CDCR inmate-patient population. To identify outcomes for CTF, the OIG reviewed some of the compliance testing results, randomly sampled additional inmate-patients’ records, and obtained CTF data from the CCHCS Master Registry. The OIG compared those results to metrics reported by other State and federal agencies. Medical Inspection Unit Page 10 Office of the Inspector General State of California MEDICAL INSPECTION RESULTS PRIMARY (CLINICAL) QUALITY INDICATORS OF HEALTH CARE The primary quality indicators assess the clinical aspects of health care. As shown on the Health Care Quality Indicators table on page ii of this report, 12 of the OIG’s primary indicators were applicable to CTF. Of those 12 indicators, 7 were rated by both the case review and compliance components of the inspection, 3 were rated by the case review component, and 2 were rated by the compliance component. Summary of Case Review Results: There were 30 case reviews rated on adequacy of care. Of those 30 cases, 8 were proficient, 15 were adequate, and 7 were inadequate. For 1,299 events reviewed, there were 343 deficiencies, of which the reviewer determined 33 to be of such magnitude that if left unaddressed, would likely contribute to patient harm. These deficiencies lacked a pattern of systemic errors. Adverse Events Identified During Case Review: Medical care is a complex dynamic process with many moving parts, and subject to human error even within the best health care organizations. Adverse events are typically identified and tracked by all major health care organizations for the purpose of quality improvement. They generally are not representative of medical care delivered by the organization. The OIG identified adverse events for the dual purposes of quality improvement and the illustration of problematic patterns of practice found during the inspection. Because of the anecdotal description of these events, the OIG cautions against drawing inappropriate conclusions regarding the institution based solely on adverse events. There were two patients with significant adverse/sentinel events identified in the case reviews. They were not reflective of the overall medical care provided at CTF. • There was a significant delay in diagnosis for a patient with acute liver failure (case 2). This case is discussed in the Quality of Provider Performance indicator. • There was a significant delay in laboratory test result management for a toxic phenytoin medication (case 4). This case is discussed in detail in the Diagnostic Services indicator. Compliance Results: The compliance component assessed 9 of the 12 primary (clinical) indicators. The results of those assessments are summarized within this section of the report. The test questions used to assess compliance for each indicator are detailed in Appendix A. Medical Inspection Unit Page 11 Office of the Inspector General State of California ACCESS TO CARE This indicator evaluates the institution’s ability to provide Case Review Rating: inmate-patients with timely clinical appointments. Areas specific Proficient to inmate-patients’ access to care are reviewed, such as initial Compliance Score: assessments of newly arriving inmate-patients, acute and chronic 83.9% care follow-ups, face-to-face (FTF) nurse appointments when an Overall Rating: inmate-patient requests to be seen, provider referrals from nursing Proficient lines, and follow-ups after hospitalization or specialty care. Compliance testing for this indicator also evaluates whether inmate-patients have Health Care Services Request Forms (CDCR Form 7362) available in their housing units. Case Review Results The OIG clinicians reviewed 571 provider and nursing encounters—236 provider encounters and 335 nursing encounters. Out of 571 total encounters, only six deficiencies were found related to access to care. None of the deficiencies were significant, or likely to contribute to patient harm. The OIG found there were no significant problems with access to care within the institution. Appointments were timely for RN sick call appointments, RN to Provider sick call referrals, TTA, hospital follow-ups, intra-system transfers, and outpatient provider follow-ups. The clinicians also found that chronic care appointments were timely. This finding did not match with the compliance testing (in MIT 1.001), which was only 60 percent for the chronic care provider visits. This difference was mainly due to the providers’ encounters with patients who had multiple chronic care conditions that required different follow-up time frames. Because documentation in the medical record was either unclear or lacking for each medical problem’s specific follow-up time frame, CTF did not always receive credit for the compliance testing score. However, the OIG clinicians found almost every chronic care medical problem to be managed within appropriate time frames. Overall, CTF did an excellent job with regard to access to care within the institution, and the case rating is thus proficient. Compliance Testing Results The institution received an overall score of 83.9 percent in the Access to Care indicator, scoring well in several areas, as described below: • The OIG inspectors found that inmates had access to the Health Care Services Request Forms (CDCR Form 7362) at all six housing units inspected, receiving a score of 100 percent for this test (MIT 1.101). Medical Inspection Unit Page 12 Office of the Inspector General State of California • Inspectors sampled 32 health care service requests submitted by inmate-patients across all facility clinics. As documented on the service request (CDCR Form 7362), nursing staff reviewed the request form on the same day it was received for 31 (97 percent) of the inmate- patients. For one patient, the nursing staff reviewed the request form one day late (MIT 1.003). For the 30 service requests reviewed for timely nursing FTF encounters, inspectors found that 29 (97 percent) were conducted timely within one business day of receiving the request. The only noted exception related to an encounter that occurred two days late (MIT 1.004). • For nine of the health care service requests sampled where the nursing staff referred the inmate-patient for a Primary Care Provider (PCP) appointment, eight (89 percent) of the inmate-patients received a timely appointment. Only one inmate-patient was not seen within the 14-day maximum allowable time frame; the patient was seen 26 days late (MIT 1.005). In addition, for the five inmate-patients for whom the PCP determined a follow-up appointment was necessary, all five patients (100 percent) received a timely appointment (MIT 1.006). Scores for the following two areas were in the adequate range: • When inspectors sampled 30 inmate-patients who had been discharged from a community hospital, they found that only 24 patients (80 percent) received a follow-up appointment within the minimum required time frame of five days after discharge or sooner, if specified within the TTA provider orders. For the six patients who received untimely follow-up appointments after discharge, on average, they were seen four days late (MIT 1.007). • Inspectors also sampled 30 inmate-patients who had received a specialty service and found that only 23 (77 percent) received a timely PCP follow-up appointment. Two high-priority follow-up visits were 3 and 6 days late, four routine follow-up visits ranged between 6 and 23 days late, and one routine follow-up visit never occurred at all (MIT 1.008). The institution needs to improve in the following areas: • Inmate-patients who transfer into CTF from another institution and are referred to a PCP for a routine appointment, based on nursing staff’s initial health care screening of the patient, are not being seen timely. Inspectors found that only 9 of the 16 patients sampled (56 percent) received PCP appointments within required time frames. Six of the appointments were from 10 to 44 days late; one appointment never occurred at all (MIT 1.002). • Finally, when OIG reviewed recent appointments for 30 inmate-patients with chronic care conditions, they found that only 18 (60 percent) received timely appointments. Inspectors Medical Inspection Unit Page 13 Office of the Inspector General State of California found that providers who saw patients for a specific chronic care condition did not clearly document in their progress notes whether the patient’s other chronic care conditions were also assessed at the same time. As a result, there was no evidence that those inmate-patients had received required follow-up appointments for all of their chronic care conditions (MIT 1.001). CCHCS Dashboard Comparative Data The CCHCS Dashboard uses the average of eight medical access measure indicators to calculate the score for access to medical services. The OIG compared similar CTF compliance scores with that Dashboard average score. As indicated in the following table, the OIG’s comparative score for Access to Care was 3 percentage points lower than CTF’s Dashboard score. This difference can be partially explained by differences in methodologies. For example, CCHCS Dashboard data includes access to care for inmate-patients returning from CDCR inpatient housing units and from emergency departments, whereas the OIG excluded those patients. Access to Care—CTF Dashboard and OIG Compliance Results CTF DASHBOARD RESULTS OIG COMPLIANCE RESULTS Scheduling & Access to Care: Medical Services Access to Care (1.001, 1.004, 1.005, 1.007) Diagnostic Services (2.001, 2.004) Specialty Services (14.001, 14.003) February 2015 February 2015 89% 86% Recommendations The institution must take steps to ensure that inmate-patients who transfer into CTF and receive RN referrals to see a provider are seen within required time frames. The institution must also ensure that providers document follow-up time frames for each chronic care condition when multiple conditions exist. Medical Inspection Unit Page 14 Office of the Inspector General State of California DIAGNOSTIC SERVICES This indicator addresses several types of diagnostic services. Case Review Rating: Specifically, it addresses whether radiology and laboratory Adequate services were timely provided to inmate-patients, whether the Compliance Score: primary care provider timely reviewed the results, and whether 86.7% the results were communicated to the inmate-patient within the required time frames. In addition, for pathology services, the OIG Overall Rating: Adequate determines whether the institution received a final pathology report and whether the primary care provider timely reviewed and communicated the pathology results. The case reviews also factor in the appropriateness, accuracy, and quality of the diagnostic test(s) ordered and the clinical response to the results. Case Review Results The OIG clinicians reviewed 224 diagnostic-related events and found 17 deficiencies. Of those 17 deficiencies, 7 were considered to be of such magnitude that, if left unaddressed, would likely contribute to patient harm. Otherwise, all the other reviewed tests were performed as ordered, reviewed timely by providers, and relayed quickly to patients. For critical lab values, there should be documentation of verbal communication of the abnormalities to the nursing staff and the providers. For one deficiency, a critical lab was not appropriately communicated to the provider. • In case 4, a critically high drug level was faxed to the CTF laboratory drawing station and a message was left on the laboratory voicemail; however, there was no direct communication made to the TTA nursing staff. Due to the lack of verbal communication, the patient continued to receive his next dose of the medication. Most laboratory tests and x-rays were performed timely when ordered by a provider; however, in cases 5, 27, 37, and 40 diagnostic tests were not done as requested. • In case 5, a provider ordered seizure medication levels to be drawn in one week, but the draw never occurred. • In case 3, stat lab test results were significantly delayed. Health Information Management also significantly contributed to the diagnostic services deficiencies. Some diagnostic reports were not routed to the providers for review, or appropriately scanned into the electronic Unit Health Record (eUHR). • In case 30, the diagnostic report was not scanned into the eUHR. Medical Inspection Unit Page 15 Office of the Inspector General State of California • In case 12, an x-ray report was scanned into the wrong patient’s chart. • In cases 1, 3, 14, and 21, diagnostic reports were not scanned timely. • In cases 2, 17, 21, 25, and 35, diagnostic reports were not signed-off by a provider before scanning. The CTF had a small percentage of diagnostic orders sometimes not completed or completed outside of the requested period. The predominant problem with diagnostic services was within the processes for health information management (HIM). The compliance testing results were generally consistent with case review findings. After taking all factors into consideration, the OIG clinicians rated Diagnostic Services at CTF as Adequate. Compliance Testing Results The institution received an overall score of 86.7 percent in the Diagnostic Services indicator, which encompasses radiology, laboratory, and pathology services. Diagnostic Services scored proficient in all test areas except for communicating pathology reports to inmate-patients, which scored inadequate. For clarity, each type of diagnostic service is discussed separately below: Radiology Services • Inspectors found that for nine of the ten radiology services sampled (90 percent), the service was performed timely. The only exception was an x-ray exam that was conducted one day late (MIT 2.001). Also, for nine of those ten services (90 percent), the diagnostic report results were timely reviewed by the ordering provider and timely communicated to the inmate-patient. The exception was an x-ray result that was communicated to the patient 22 days late and contained no evidence of provider review (MIT 2.002, 2.003). Laboratory Services • Nine of ten laboratory services ordered (90 percent) were performed timely. The one exception was a service request that was performed five days late (MIT 2.004). Also, all ten of the laboratory diagnostic reports (100 percent) included evidence that the provider had timely reviewed and initialed the diagnostic test results and timely communicated the results to the inmate-patient (MIT 2.005, 2.006). Pathology Services • The institution documented the final pathology report in the eUHR for nine of ten inmate-patients sampled (90 percent), and the provider timely reviewed the pathology Medical Inspection Unit Page 16 Office of the Inspector General State of California results for all ten patients (100 percent). The one exception was due to a final pathology report that was received 11 days late (MIT 2.007, 2008). • With regard to providers’ communication of results, the institution scored poorly. Inspectors found that final pathology results were timely communicated to only three of the ten patients sampled (30 percent). For three of the seven patients who did not receive timely communication, when the provider initially met with the patient, the pathology results were not yet available in the eUHR and the appointment had to be rescheduled. For those three patients and two others, the provider did not discuss the final pathology results with each patient within two business days of receipt of the final diagnostic test results. On average, the results were communicated nine days late. For two additional patients, there was no evidence that the provider discussed the results with either patient at all (MIT 2.009). Recommendations The institution should implement a tracking system or follow-up process to monitor diagnostic orders and ensure that all diagnostic orders are performed and that test results are timely received by the institution or timely communicated directly to a provider prior to the scheduled FTF consult appointment with the patient. This system should also ensure that radiology reports and other test results are routed to a provider for review and signature, timely scanned into the eUHR, and timely communicated to the patient. If, during a consult appointment, the provider realizes that needed diagnostic test results are not available, the provider should follow-up to obtain the test results and timely communicate them to the patient at a rescheduled appointment or by completing the Notification of Diagnostic Test Results (CDCR Form 7393). EMERGENCY SERVICES An emergency medical response system is essential to providing Case Review Rating: effective and timely emergency medical response, assessment, Adequate treatment, and transportation 24 hours per day. Provision of Compliance Score: urgent and emergent care is based on a patient’s emergency Not Applicable situation, clinical condition, and need for higher level of care. The OIG reviews emergency response services including first aid, Overall Rating: basic life support (BLS), and advanced cardiac life support Adequate (ACLS) consistent with the American Heart Association guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care, and the provision of services by knowledgeable staff appropriate to each individual’s training, certification, and authorized scope of practice. The OIG evaluates this quality indicator entirely through clinicians’ review of case files and conducts no separate compliance testing element. Medical Inspection Unit Page 17 Office of the Inspector General State of California Case Review Results The OIG clinicians reviewed 97 urgent and emergent events and found 46 deficiencies in a variety of areas. Most deficiencies were minor and did not significantly affect patient care. There were no errors likely to contribute to patient harm. In general, CTF performed well with emergency response time, BLS care, and 9-1-1 call activation time. Overall, the case reviews found that patients requiring urgent or emergent services received timely and adequate care in the majority of cases. Provider Care The Triage and Treatment Area (TTA) providers generally evaluated the patients in a timely manner and made adequate assessments and plans. The triage decisions were sound and the patients were sent out appropriately for higher levels of care. The quality of provider care in emergency services was adequate; however, the OIG identified a few deficiencies: • In case 2, the patient had melena (black colored stool) suggestive of an upper gastrointestinal bleed; thus, the provider should have started intravenous access and fluids prior to transferring the patient to an outside hospital. • In case 35, TTA nursing staff made two calls to the physician on call for an urgent consultation; however, the physician did not respond to the calls. The nursing staff appropriately sent the dehydrated patient to the local hospital, where he received fluids and care. Nursing Care The quality of nursing care provided by the TTA Registered Nurses (RNs) and during emergency medical responses was generally adequate and timely. In at least one incident, case 8, nursing staff performed at a proficient level. However, the following cases demonstrated areas for improvement: • In case 2, the patient collapsed on the yard and complained of abdominal pain and dizziness. The TTA RN did not perform an adequate assessment of the patient’s abdomen and did not monitor elevated vital signs with sufficient frequency. • In case 12, the patient was sent to the TTA due to a high blood sugar level. The RN obtained an order for regular insulin and released the patient to return to housing. The RN did not perform a nursing assessment or keep the patient in the TTA to monitor him for signs and symptoms of hyperglycemia. • In case 23, oxygen administration was delayed due to missing equipment in the emergency response bag. Medical Inspection Unit Page 18 Office of the Inspector General State of California Several documentation deficiencies were found: • In case 5, there was no documentation by the scene’s first medical responder. • Nurse’s notes were missing in cases 12, 14, and 25. • The timeline of emergency response activities was not clearly documented in cases 2, 5, and 18. Onsite Clinician Inspection During the onsite visit, OIG clinicians found that patient confidentiality in the TTA was compromised. The TTA examination room has a very large window without a curtain, shade or other cover to provide visual privacy during an examination. Conclusion The Correctional Training Facility staff provided adequate emergency services to their patients despite physical and spatial constraints. Recommendations The emergency services provided at CTF were appropriate and, in general, were adequately documented. The OIG recommends that medical and nursing leadership work with custody staff to ensure patients’ privacy (yet maintain safety and security) by providing a visual barrier to the large window in the TTA and portable barriers in between examination tables. HEALTH INFORMATION MANAGEMENT (MEDICAL RECORDS) Health information management is a crucial link in the delivery of Case Review Rating: medical care. Medical personnel require accurate information in Inadequate order to make sound judgments and decisions. This indicator Compliance Score: examines whether the institution adequately manages its health care 58.4% information. This includes determining whether the information is correctly labeled and organized, and available in the electronic Unit Overall Rating: Inadequate Health Record (eUHR); whether the various medical records (internal and external, e.g., progress notes and hospital and specialty reports) are obtained and scanned timely into the inmate-patient’s eUHR; whether records routed to and signed off by clinicians include legible signatures or stamps; and whether hospital discharge reports include key elements and are timely reviewed by providers. Medical Inspection Unit Page 19 Office of the Inspector General State of California Case Review Results The OIG clinicians identified 63 deficiencies related to Health Information Management (HIM), of which 9 were likely to contribute to patient harm. Overall, the HIM processes were inadequate. Hospital Records • Most hospital records were retrieved, reviewed, and scanned into the eUHR. Nearly all hospital records were signed-off and reviewed by a provider. However, there were some significant deficiencies. The most severe deficiency occurs when hospitals records (especially discharge summaries) were not retrieved and did not appear in the eUHR. These types of records contain the most vital information for the continuity of care between the inpatient and outpatient settings. In cases 8, 14, and 28, the hospital discharge summaries were not retrieved or found in the eUHR. Missing Encounters • Most nursing and provider progress notes were scanned into the eUHR; however, in seven cases, progress notes were missing. Scanning Performance • Delay in scanning time can be problematic and significantly affect patient care. There were nine cases of delayed scanning. For example, in case 1, an ultrasound report was not retrieved and scanned into the eUHR until six months after the procedure was done. The primary care provider documented the delay in a progress note. • Mislabeled or misfiled documents were identified in two cases. These errors can greatly hinder the ability to find relevant clinical information. Specialty Services • Most specialty reports were processed without any significant problems. However, deficiencies in the processing of specialty consult reports occurred at a moderate rate. There was no specialist report for case 37. These findings are discussed in detail in the Specialty Services indicator. Legibility • Illegible progress notes, signatures, or initials were found throughout this period of review from both nurses and providers. Illegible progress notes pose a significant medical risk to Medical Inspection Unit Page 20 Office of the Inspector General State of California patients, especially when the medical care must be reviewed by other staff, or when there is a transfer of care to another team. Clinical staff at CTF, especially the providers, have to contend with misfiled and missing documents in the eUHR. The providers often had to request missing specialty and diagnostic reports. Ineffective HIM processes will hinder CTF providers in delivering quality patient care. Compliance Testing Results The institution received an overall score of 58.4 percent in the Health Information Management (Medical Records) indicator and needs to improve in the following areas: • Community hospital discharge summary reports were not always scanned into the patient’s eUHR within three calendar days of the hospital discharge. Only 9 of the 20 reports sampled (45 percent) were timely scanned. Of the 11 reports scanned untimely, 2 were scanned more than 30 days late (MIT 4.004). Specialty service consultant reports were also not always timely scanned, with only 12 of the 20 sampled documents (60 percent) scanned within five calendar days. Of the 8 reports scanned untimely, 5 were high-priority reports scanned between 1 and 20 days late, and 3 were routine reports scanned between 1 and 15 days late (MIT 4.003). Similarly, medication administration records (MARs) were not always scanned timely. Only 13 of the 20 sampled documents (65 percent) were scanned within three calendar days. The untimely documents were scanned from one to four days late (MIT 4.005). • The OIG reviewed eUHR files for 30 sampled inmate-patients who were sent or admitted to the hospital and found that the community hospital discharge reports or treatment records were complete and had been timely reviewed by a CTF provider for only 19 of the patients (63 percent). Inspectors could not find a discharge report at all for one patient. In this case, the hospital discharge report for another patient had been filed in the sampled patient’s eUHR file. For ten other patients, the discharge report lacked key elements such as the patient’s discharge medications, the diagnosis, and the date of discharge; the discharge summary lacked evidence that the CTF provider had timely reviewed the report; or, when the TTA provider contacted the hospital to obtain key discharge report information, the provider spoke with a nurse rather than the patient’s physician (MIT 4.008). • When the OIG reviewed various medical documents such as hospital discharge reports, initial health screening forms, certain medication records, and specialty service reports to ensure that clinical staff legibly documented their names on the forms, inspectors found that only 21 of 32 samples (66 percent) showed compliance (MIT 4.007). Medical Inspection Unit Page 21 Office of the Inspector General State of California • The institution scored a 25 percent in its labeling and filing of documents that were scanned into inmate-patients’ eUHR. The most common error involved progress and specialty notes including hospital discharge documents that were mislabeled. In one instance, as discussed above, a hospital discharge document was incorrectly scanned into another patient’s eUHR file (MIT 4.006). The institution performed well in its scanning of the miscellaneous non-dictated health care documents: • Miscellaneous non-dictated documents, including providers’ progress notes, inmate-patients’ initial health screening forms, and requests for health care services were scanned timely. Inspectors found that 17 of the 20 documents sampled (85 percent) were appropriately scanned into the patient’s eUHR within three calendar days of the inmate-patient’s encounter. The three documents scanned late included two Initial Health Screenings (CDCR Form 7277) and one Health Care Services Request Form (CDCR Form 7362) that were scanned one or two days late (MIT 4.001). CCHCS Dashboard Comparative Data As indicated below, the OIG’s compliance results related to the institution’s scanning of miscellaneous non-dictated medical documents and specialty documents were inconsistent with the February 2015 CTF Dashboard results. These inconsistencies can be attributed to OIG’s sampling time frames. For example, OIG’s testing results were based on inspectors’ review of current documents as well as documents dating nine months back, whereas CTF’s February 2015 Dashboard data reflects the institution’s January 2015 performance. However, results from both the OIG and the Dashboard indicate that the institution needs to improve in its scanning of specialty documents and community hospital discharge documents. Medical Inspection Unit Page 22 Office of the Inspector General State of California Health Information Management— CTF Dashboard and OIG Compliance Results CTF DASHBOARD RESULTS OIG COMPLIANCE RESULTS Availability of Health Information: Health Information Management (4.001) Non-Dictated Documents Non-Dictated Documents February 2015 February 2015 76% 85% Note: The Dashboard results were obtained from the Non-Dictated Documents Drilldown data for “Medical Documents 3 Days.” CTF DASHBOARD RESULTS OIG COMPLIANCE RESULTS Availability of Health Information: Health Information Management (4.003) Specialty Notes Specialty Documents February 2015 February 2015 74% 60% Note: The Dashboard measure includes specialty notes from dental, optometry, and physical therapy appointments, which the OIG omits from its sample. CTF DASHBOARD RESULTS OIG COMPLIANCE RESULTS Availability of Health Information: Health Information Management (4.004) Community Hospital Records Community Hospital Discharge Documents February 2015 February 2015 50% 45% Recommendations The institution should review its current processes and procedures regarding all aspects of Health Information Management to ensure that all patient health information, from both internal and external sources, is retrieved and timely routed to responsible providers or made available in patients’ eUHR. High priority should be placed on ensuring that community hospital discharge records, specialty service consultant reports, and radiology reports are properly processed. Also, to improve the legibility of documentation, the OIG encourages the dictation of clinical documents and the use of signature stamps, especially for nursing staff. In addition, the medical records unit staff need to be more diligent in labeling and properly filing hospital discharge documents, and in Medical Inspection Unit Page 23 Office of the Inspector General State of California timely scanning hospital discharge reports, specialty service consultant reports, and MARs documents into patients’ eUHR. Although some of these problems will be corrected once the electronic health record (EHR) is in place, the EHR will not correct the problem with external reports. HEALTH CARE ENVIRONMENT This indicator addresses the general operational aspects of the Case Review Rating: institution’s clinics, including certain elements of infection control Not Applicable and sanitation, medical supplies and equipment management, the Compliance Score: availability of both auditory and visual privacy for inmate-patient 63.5% visits, and the sufficiency of facility infrastructure to conduct Overall Rating: comprehensive medical examinations. For most institutions, rating Inadequate of this component will be based entirely on the compliance testing results from the visual observations inspectors make during their onsite visit at the institution. Clinician Comments The OIG clinicians observed the following information during their onsite visit in April 2015: • The CTF medical clinics had limited space, which hindered patient auditory and visual privacy. The clinics were well lit. The Outpatient Housing Unit (OHU) had adequate working space for both nurses and providers. The TTA had three beds and working areas for both nurses and providers. However, the TTA door with a large window did not provide visual privacy. In addition, the TTA lacked auditory privacy when both exam tables were occupied. The TTA was well lit and appropriately stocked with medications and medical equipment, such as an automated external defibrillator (AED) and an emergency crash cart. • In the North Clinic, sick call interviews were conducted without auditory privacy. • The morning huddles were led by providers, attended by nurses and office technicians, and were productive. Pertinent matters of both nurses’ and physicians’ lines were discussed. Medical Inspection Unit Page 24 Office of the Inspector General State of California Compliance Testing Results The institution received an overall score of 63.5 percent in the Health Care Environment indicator, and needs improvement in several key areas, as described below: • Clinic common areas and exam rooms were often missing essential supplies and core equipment necessary to conduct a comprehensive exam. As a result, none of the eight clinics received a passing score for this test. Missing items in clinic common areas included glucometers and nebulization units for asthmatics, an established distance marker for Snellen vision charts, a weight scale, a medication refrigerator, and automated vital sign equipment. Missing exam room items included bio-hazard waste receptacles, tongue depressors, hemoccult cards and developer, oto-ophthalmoscopes and tips, and an exam table (in the R&R area) (MIT 5.108). • The institution’s clinic common areas did not always have an adequate environment conducive to providing medical services, with only two of the eight clinics (25 percent) receiving a passing score for this area. Of the six clinics with a deficiency, five lacked adequate auditory privacy for inmate-patients seen in the clinic common areas during the initial triage and vital sign encounter (as shown in the photograph on this page). One other clinic had insufficient exam room space to accommodate a wheelchair (MIT 5.109). • The OIG inspected exam rooms within the eight clinics to determine if appropriate space, configuration, supplies, and equipment allowed clinicians to perform a proper clinical exam. Inspectors found that exam rooms or treatment spaces in only three of the eight clinics (38 percent) passed this test. Several deficiencies were found in both the Central clinic and the R&R clinic and one exception was found in each of three other clinics. Specifically, three nursing staff shared one exam room, negating reasonable assurance of patients’ auditory or visual privacy when they conducted patient exams at the same time. As shown in the photographs on the following page, one exam table was positioned in a manner that allowed a nearby cabinet to intrude on a patient’s needed head space and supply cart drawers lacked labeling. Further, confidential medical records were not shredded daily or stored in a locked container, making them accessible to other patients or inmate-porters. Also, the R&R Medical Inspection Unit Page 25 Office of the Inspector General State of California clinic exam room was cluttered and disorganized. The seat area of the exam chair was covered with tape and needed replacement. Food and drink items belonging to staff were stored in the filing cabinet with the medication supplies. Finally, the Ad-Seg clinic exam room space was too small and cramped to allow for an appropriate examination. The room measured 8-feet by 8 ½-feet and included an exam table, exam desk, and medication cart (MIT 5.110). • The OIG examined emergency response bags to determine if they were inspected daily, inventoried monthly, and contained all essential items. Emergency response bags were compliant in only two of the five clinics inspected (40 percent). In three clinics, the staff had not completed monthly inventories of the response bag contents (MIT 5.111). • Clinical health care staff in only five of eight clinics (63 percent) ensured that reusable invasive and non-invasive medical equipment was properly sterilized or disinfected. In one clinic, inspectors observed that staff did not disinfect the exam table and change the exam table paper after an encounter with a patient who received wound care. In two other clinics, equipment packages did not include a sterilization date stamp (MIT 5.102). • Inspectors found that five of seven clinics (71 percent) were appropriately disinfected, cleaned, and sanitary. Because cleaning logs were not maintained for the other two clinics, inspectors could not determine if the clinics were cleaned regularly (MIT 5.101). • When inspectors examined CTF’s eight clinics to verify that adequate hygiene supplies were available and sinks were operable, six clinics were found to be compliant (75 percent). In two clinics, the inmate-patient restroom lacked disposable towels or antiseptic hand soap (MIT 5.103). Medical Inspection Unit Page 26 Office of the Inspector General State of California The institution performed in the proficient range for the following four areas, scoring 100 percent in three of them: • The OIG inspectors observed clinicians’ encounters with inmate-patients in all seven of the institution’s applicable clinics and found that clinicians followed good hand hygiene practices. Inspectors did not observe any patient encounters during their inspection of the OHU clinic (MIT 5.104). • Inspectors found that the non-clinic medical storage area, located in CTF’s Central facility warehouse, met the supply management process and support needs of the medical health care program (MIT 5.106). • All eight clinics tested followed adequate protocols for managing and storing bulk medical supplies (MIT 5.107). • When inspecting for proper protocols to mitigate exposure to blood borne pathogens and contaminated waste, the OIG found that the institution was doing a proficient job in seven of the eight clinics. Overall, the institution received a score of 88 percent. The only notable deficiency was that the Ad-Seg clinic did not have a sharps container in the clinic (MIT 5.105). Other Information Obtained from Non-Scored Results The OIG gathered information to determine if the institution’s physical infrastructure is maintained in a manner that supports health care management’s ability to provide timely or adequate health care. The information was based on interviews with CTF’s health care management. This question is not scored and is only reported for informational purposes. When asked if all clinical areas have physical plant infrastructures sufficient to provide adequate health care services, staff indicated that while they had typical concerns associated with a 69-year-old facility, nothing affected their ability to provide adequate health care. As identified on the following page, the institution has several projects planned for construction (MIT 5.999). Medical Inspection Unit Page 27 Office of the Inspector General State of California CTF Projects Construction Time Frame North facility: • New A-yard Primary Care (PC) Clinic July 2015 to June 2016 • Renovation of existing A/B-Yard Clinic for new B-Yard July 2016 to July 2017 PC Clinic South facility: • New PC Clinic to replace existing PC Clinic June 2015 to April 2016 Central facility: • New PC clinic June 2015 to June 2017 • New TTA June 2015 to June 2016 • Renovation of existing Specialty Care/TTA Clinic for July 2016 to July 2017 new Specialty Care Clinic Recommendations The institution must ensure that all clinics have exam areas that provide auditory and visual privacy to inmate-patients. Also, the institution should ensure that each clinic has a full complement of core items that include a nebulization unit, glucometer, Snellen chart (with established line markers), weight scales, medication refrigerator, automated vital sign equipment, and at least one exam room that can accommodate a wheelchair. Each exam room within the clinic should have an oto- ophthalmoscope, tongue depressors, a sharps container, a bio-hazard waste receptacle, and an exam table. All exam rooms should have minimal clutter and staff should not store their food and drinks in medication storage areas. Exam rooms should have sufficient space to conduct inmate-patient examinations. The rooms should include exam tables that allow patients to lie fully extended and unhindered on the table, and have adequate floor space to allow for a standing exam, if needed. In addition, all provider exam rooms must have hemoccult cards and developer. Clinical staff should ensure that exam tables are sanitized prior to the start of each shift, exam table paper is changed between inmate-patients, and cleaning logs are maintained for all clinics. Staff should also ensure that all inmate-patient restrooms have a supply of disposable paper towels and antiseptic soap. All confidential medical records must be shredded daily or locked away, and made inaccessible to inmates and non-healthcare staff. Finally, clinical staff must ensure that emergency response bags are inventoried monthly and that supply carts and sterilized equipment are labeled properly. Medical Inspection Unit Page 28 Office of the Inspector General State of California INTER- AND INTRA-SYSTEM TRANSFERS This indicator focuses on the management of inmate-patients’ Case Review Rating: medical needs and continuity of patient care during the inter- and Adequate intra-facility transfer process. The OIG review includes evaluation Compliance Score: of the institution’s ability to provide and document health 66.6% screening assessments (including tuberculin screening tests), initiation of relevant referrals based on patient needs, and the Overall Rating: Inadequate continuity of medication delivery to patients received from another institution. For those patients, the clinicians also review the timely completion of pending health appointments, tests, and requests for specialty services. For inmate-patients who transfer out of the facility, the OIG evaluates the ability of the institution to document transfer information that includes pre-existing health conditions, pending appointments, tests and requests for specialty services, medication transfer packages, and medication administration prior to transfer. The patients reviewed for Inter- and Intra-System Transfers include endorsed inmates received from other CDCR facilities and inmates transferring out of CTF to another CDCR facility. Case Review Results Ninety-six encounters were reviewed related to inter- and intra-system transfers including information from both the sending and receiving institutions. Thirteen encounters were reviewed for inmate-patients transferring out of CTF to other institutions, and 24 encounters were reviewed for inmate-patients transferring into CTF from other institutions. The OIG reviewed 59 hospitalization events, each of which resulted in a transfer back to the institution. In general, the inter- and intra-system transfer processes at CTF were adequate2 with the majority of transferring inmate-patients receiving timely continuity of health care services. Sixteen deficiencies were found; none were likely to contribute to patient harm. There were deficiencies in delayed appointment scheduling for specialty services, missed medication doses, and inadequate nursing screening. Specific examples of case review findings are listed below. Transfers In • In case 4, the patient had a seizure disorder with his last seizure one month prior to his transfer to CTF. The initial provider visit occurred 17 days beyond the time frame ordered from the last chronic care visit. • In case 16, the patient arrived on October 7, 2014. The initial CTF provider visit occurred 20 days beyond the time frame ordered from the last chronic care visit. A cardiology follow-up 2 The OIG case review rating is applicable only to CTF’s existing, nursing-only inter- and intra-system transfer processes. The rating is not applicable to the CCHCS systemwide transfer process, of which the OIG has significant concerns, and is discussed in this section. Medical Inspection Unit Page 29 Office of the Inspector General State of California due October 27, 2014, occurred on February 10, 2015. The receiving and reception nurse did not identify the patient’s automatic internal cardiac defibrillator. A check of this device due November 27, 2014 has yet to occur at the end of the OIG inspection period. • In case 17, the patient had diagnoses of chronic obstructive lung disease, high blood pressure and a seizure disorder. The patient complained of wheezing upon his arrival on July 2, 2014. The receiving and release nurse failed to obtain a thorough, focused, and subjective assessment including the patient’s recent use of a rescue inhaler. The RN did not listen to lung sounds. In addition, the RN did not refer the patient for a chronic care appointment due August 22, 2014. The patient was evaluated in the TTA on July 20, 2014, for difficulty breathing and as a result had his first primary care provider visit at CTF on July 21, 2014. • In cases 17 and 21, the patients did not receive all their medications on the evening of arrival. Transfers Out Very few deficiencies were found with inmates transferring out of CTF. Those deficiencies found were largely due to incomplete and inadequate nursing documentation of significant medical information on the Health Care Transfer Information (CDCR Form 7371). • In case 18, the patient had surgery to repair facial fractures, an eye injury on March 30, 2014, and was housed in the OHU. The RN did not document on the transfer out form that the patient was on a mechanical soft diet, had complaints of loose teeth, had an optometry follow-up due April 10, 2014, had surgery follow-up due April 6, 2014, and that the patient’s weight should be monitored. However, the provider completed a discharge summary. The patient paroled on April 15, 2014. • In case 19, the nurse did not state the type of telemedicine specialty services needed on the transfer out form due November 20, 2014. Hospitalizations Patients returning from hospitalizations are some of the highest risk encounters due to two factors. These patients are of higher acuity with a severe illness in most cases. Also, these patients are at significant risk due to the potential lapses with hand-offs in care. For most patients, CTF did a good job despite some inconsistencies in the location where hospital return patients were processed. Some were processed in the TTA, some in the R&R area, and most of the returns for patients housed in the OHU went directly to the Outpatient Housing area. Nursing staff appropriately reviewed the discharge medications, the plan of care, and obtained physician orders to implement them. Some discharge summaries were obtained, reviewed by a provider and scanned into the eUHR appropriately. The primary care provider timely followed up on the patients, most often the Medical Inspection Unit Page 30 Office of the Inspector General State of California next day. This process worked well for the majority of hospitalization events that were reviewed. However, the following problems were found: • In case 8, the RN noted that hospital paperwork was not sent back with the patient. The hospital records were not available the next day for the PCP visit. • In case 28, the provider on call discussed the treatment plan with the emergency room physician prior to the patient’s return. The RN noted that paperwork was sent back with the patient, and that a colonoscopy had been scheduled. The emergency physician’s final summary was not in the eUHR. • In case 14, the CTF nurse received information from the community hospital prior to discharge including diagnosis and recommendations. The nurse documented the information on a progress note. The nurse evaluating the patient upon return noted that the paperwork was sent with the patient. The nurse contacted the provider and obtained orders for new medications. However, the patient returned without a discharge summary. This same patient was not seen by the primary care provider within five days after hospitalization. • In case 11, the patient received intravenous antibiotics in the hospital for infected kidney cysts. The CTF provider ordered oral antibiotics. Upon the patient’s return at 1515 hours, the RN failed to clarify when the first dose should be administered. The patient picked up the self-administered antibiotics the next day. Systemwide Transfer Challenges In reviewing inter- and intra-system transfers, the OIG acknowledges systemwide challenges that are common to all institutions regarding pending specialty services referrals, reports, and the potential for delay in needed follow-up and services. Other than OHU or CTC transfers, nurses are mainly responsible for accurately communicating pertinent information, identifying health care conditions that need treatment, monitoring, and facilitating continuity of care during the transfer process. While this is sufficient for most CDCR patients, it has not been adequate for some patients with complex medical conditions, or for some patients referred requiring complex specialty care. Often, the Health Care Transfer Information form (CDCR Form 7371) are initiated by nurses not part of the primary care team, and not familiar with the patient’s care. In addition, providers are often left out of the transfer process altogether, with the patients transferred without the provider’s knowledge. The risk for lapses in care can increase significantly without provider communication. Compliance Testing Results The CTF obtained an inadequate score of 67 percent in the Inter- and Intra-System Transfers indicator and needs to improve in three of the five areas tested, as described below: Medical Inspection Unit Page 31 Office of the Inspector General State of California • When the OIG tested inmate-patients who transferred out to another CDCR institution to determine whether their scheduled specialty service appointments were listed on the Health Care Transfer Information form (CDCR Form 7371), inspectors found that the specialty service appointment was identified on the transfer form for only 5 of 20 inmate-patients sampled (25 percent) (MIT 6.004). • The institution received a score of 60 percent when the OIG tested 30 patients who transferred into CTF from another CDCR institution to determine whether they received a complete initial health screening assessment from nursing staff on their day of arrival. Nursing staff timely completed the Initial Health Screening (CDCR Form 7277) assessment for 18 of the patients. However, nursing staff either neglected to answer all screening questions or neglected to document additional information required to supplement the answer to some questions for 12 other patients. For example, nursing staff often failed to document additional information in answering Question 11 regarding the patient meeting elevated risk criteria for valley fever and Question 15 regarding the patient’s mental illness treatment (MIT 6.001). • The OIG also reviewed the health screening assessment form to determine if nursing staff completed the assessment and disposition sections of the form on the same day staff completed the initial screening of the patient. Inspectors found that both the assessment and disposition sections had been timely completed for only 20 of the 30 patients sampled (67 percent). For ten patients, the nurse did not complete or sign the disposition section of the form (MIT 6.002). The institution scored in the adequate and proficient ranges for the following two areas, respectively: • Sixteen of the sampled transfer-in patients had an existing medication order upon arrival to CTF. Inspectors tested those patients’ records to determine if they received their medications without interruption and found that 13 of those 16 patients (81 percent) had received their medications timely. One patient missed one dosage of his medication, another patient received his medication one day late, and a third patient who arrived at CTF without his keep-on-person medications did not receive them for one week (MIT 6.003). • The institution scored 100 percent when the OIG tested three inmate-patients who transferred out of the institution during the onsite inspection to determine whether their transfer packages included required medications and related documentation (MIT 6.101). Medical Inspection Unit Page 32 Office of the Inspector General State of California Recommendations Recommendations for CTF For inmate-patients who transfer out of CTF to another facility, ensure that the patients’ pending and scheduled specialty services appointments are properly identified on the Health Care Transfer Information form (CDCR Form 7371). For inmate-patients who transfer into CTF, nursing staff who complete the Initial Health Screening (CDCR Form 7277) must ensure that all form questions are answered, and that required supplemental information is provided for certain questions. Also, nursing staff should complete and sign both the assessment and disposition sections of the Initial Health Screening form. The institution could improve its medication continuity process for patients who return to CTF from a community hospital. One suggestion is the creation of a special hospital return medication order that discontinues all prior outpatient medications and specifies the medication, dose, route, frequency, duration, and start time for each new prescription. When given verbally, nurses can be expected to verify each prescription in detail, requiring a “read back” with the ordering physician. These orders can be audited to ensure completeness by both physicians and nurses. In addition, the pre-hospitalization MARs should be removed from the medication binder, or the pre-hospital medication MARs clearly marked as discontinued. Finally, nurses who evaluate patients upon return to the institution should list the specific documents that are sent back with the patient and document their efforts to obtain missing information. Recommendations for CCHCS With regard to systemwide transfers, the majority of patients that do not have complex medical conditions or do not require complex specialty services care would be well served with the existing nursing-only transfer process. However, CCHCS should consider a process to identify patients that require special transfer handling. Those patients should require physician involvement in the transfer process. In addition, for complex patients, the transfer process should include the specific housing and the primary care for the receiving institution. The transferring physician should dictate a transfer summary for the accepting physician prior to transfer. The transfer should only occur after the physicians have had an opportunity to discuss the case for these patients. The OIG understands that these recommendations would place a significant burden on both sending and receiving institutions. However, these changes may lessen the high risk in hand-off errors for patient transfers, which are frequent within CDCR. The OIG understands CCHCS is currently working to revise the transfer policy with its Patient Management Care Coordination Initiative and looks forward to reviewing that new policy once it is finalized. Medical Inspection Unit Page 33 Office of the Inspector General State of California PHARMACY AND MEDICATION MANAGEMENT This indicator is an evaluation of the institution’s ability to provide Case Review Rating: appropriate pharmaceutical administration and security Adequate management, encompassing the process from the written Compliance Score: prescription to the administration of the medication. By combining 80.5% both a quantitative compliance test with case review analysis, this assessment may identify issues in various stages of the medication Overall Rating: Adequate management process, including ordering and prescribing, transcribing and verifying, dispensing and delivering, administering, and documenting and reporting. Since effective medication management may be affected by numerous entities across various departments, this assessment includes the PCP prescriber, internal review and approval processes, pharmacy, nursing, health information systems, custody processes, staff, and the patient. Based on results from prior pilot inspections, the OIG has found that the most accurate evaluation of this indicator is largely derived from a detailed analysis of the OIG compliance scores in addition to the clinical case reviews. The case reviews often add specific examples of the findings revealed by the compliance scores and identify problems in other processes that may not be evident when viewed solely from a compliance standpoint. Case Review Results Office of the Inspector General clinicians evaluate pharmacy and medication management as secondary processes as they relate to the quality of clinical care provided. Compliance testing is a more targeted approach and is heavily relied on for the overall rating for this indicator. New Prescriptions Case review found that for the majority of cases, patients received their medications timely and as prescribed. However, there were rare cases where prescriptions were not processed timely: • In case 25, a colonoscopy showed severe ulcerative colitis. The provider ordered adalimumab (an antibody medication to reduce inflammation) injections for four doses to start on January 13, 2015; however, the medication was not administered until January 22, 2015. • In case 12, the patient was vomiting and the emesis was positive for blood. The provider ordered omeprazole on June 3, 204, but the medication was not started until June 5, 2014. • In case 24, the provider diagnosed a middle ear infection on November 14, 2014, and ordered an oral antibiotic to be started immediately along with antibiotic eardrops. The Medical Inspection Unit Page 34 Office of the Inspector General State of California Pharmacy did not fill the orders until seven days later, after the patient submitted a sick call request due to continued symptoms. Chronic Care Medication Continuity Medication continuity was maintained in the majority of transfer-in cases and outpatient setting cases reviewed. There were four exceptions for transfer-in patients, two patients who were admitted to the OHU and two patients who transferred-in from other institutions. • In case 1, the patient was admitted to the OHU from regular housing on January 20, 2014, and the nurse did not administer two of his medications the next morning. • In case 17, the nurse did not administer an evening anal treatment suppository on the evening of the patient’s arrival because the medication was not received until 2000 hours. • In case 21, the patient transferred to CTF on August 13, 2014, and was not administered the evening dose of Dilantin and tramadol. • In case 44, the nurse did not administer two evening medications on the day of the patient’s transfer-in to the OHU. Post-Hospitalization Medication Continuity Medication continuity for patients returning from a hospitalization was adequately maintained in most cases reviewed. However, the following problems were found: • In case 7, the patient was sent to the emergency room due to confusion. The nurse found his self-administered medications in his cell in a bag of mixed pills, and removed the bag. The on-call provider planned to notify the primary care provider to re-order that all medications be administered by a nurse upon the patient’s return from the hospital. This was not done, and when the patient returned he did not receive his medications over the weekend. • In case 18, the patient returned from the hospital after surgery. An antibiotic was ordered but was not administered at noon on the day of his return, or on the following day. In total, four doses were missed. • In case 23, the patient returned from the hospital and received the evening dose of colchicine, a medication for gout. However, the patient did not receive the morning dose the next day. The specialized housing nurse noted the medication was not available. Medical Inspection Unit Page 35 Office of the Inspector General State of California • In case 42, the patient was admitted to the OHU after hospitalization. An antibiotic was not started on the day of admission, and several medications were not given the following morning. Medication Administration The OIG reviewers found several deficiencies in medication administration. This topic is discussed in the Quality of Nursing Performance indicator. • In case 1, the nurses administering intramuscular injections in November 2014 did not document the times of administration, the areas of the injections, or effectiveness of the medications. • In case 2, the RN did not notify the provider that the patient’s heart rate was slow (53) before administering propranolol, a medication that may further slow the pulse rate. • In case 9, there was no MAR for self-administered azithromycin ordered on October 29, 2014, although the patient reported that he had received the medication. • In case 10, evening doses of Bactrim and doxycycline were missed on August 4, 2014, when they were changed from nurse-administered to self-administered. • In case 42, the patient was taking Lantus insulin every evening. On August 13, 2014, the provider added regular insulin on a sliding scale basis three times per day. Blood glucose levels were not consistently checked and regular insulin coverage was not always administered until August 19, 2014. This concern is also discussed in the Specialized Medical Housing indicator. Medication Follow-up Case review found that medication line nurses provided timely notification when patients missed medications. Onsite Clinician Inspection During the onsite visit, OIG clinicians met with medical, nursing, and pharmacy representatives regarding case review findings. The CTF administrators were well aware of these specific cases, and had conducted interdisciplinary internal discussions and policy revisions. Nursing had implemented various educational/training interventions and internal monitoring strategies to ensure compliance. Medical Inspection Unit Page 36 Office of the Inspector General State of California Conclusion Overall, the Pharmacy and Medication Management indicator was rated adequate. Compliance Testing Results The institution received an overall score of 80.5 percent for the Pharmacy and Medication Management indicator. For discussion purposes below, this indicator is divided into three sub-indicators that consist of Medication Administration, Medication Preparation and Administration Controls, and Pharmacy Protocols. Medication Administration For this sub-indicator, the institution received an average score of 78 percent and needs to improve in the following administration and delivery of medication areas: • When OIG sampled ten inmate-patients who were en route to another institution and were temporarily laid-over at CTF, inspectors found that only six (60 percent) of the patients received their medications without interruption (MIT 7.006). • The institution timely provided hospital discharge medications to only 22 of 30 patients sampled who had returned from a community hospital (73 percent). For eight patients, the medications were administered one to three days late (MIT 7.003). • Also, CTF timely dispensed chronic care medications to only 22 of the 29 inmate-patients sampled (76 percent). Seven patients either received their medication late, received their required counseling for missed doses late, received the wrong dosage of a medication, or failed to receive their medication at all (MIT 7.001). The institution scored well in the following medication administration areas: • The institution scored in the proficient range for its administration of new medication orders. Inspectors found that 28 of the 30 patients sampled (93 percent) received their medications timely. One patient’s medication was filled one day late and the OIG was unable to find evidence that another patient’s medication was administered at all (MIT 7.002). • The institution also performed well in ensuring that inmate-patients who transferred from one housing unit to another received their medications without interruption. Of the 30 patients sampled, 26 patients (87 percent) received their medications timely. Four patients did not receive their medication at the proper dosing interval (MIT 7.005). Medical Inspection Unit Page 37 Office of the Inspector General State of California Medication Preparation and Administration Controls For this sub-indicator, the institution received an average score of 66 percent and needs to improve in five of the following six areas: • The OIG interviewed nursing staff and inspected narcotic storage areas at seven applicable medication line (pill-line) locations. Inspectors found no exceptions at four of the seven locations (57 percent). However, for two pill-line locations the licensed vocational nurses (LVNs) were not aware of key standard procedures that should be followed when a controlled substance discrepancy occurs. For another pill-line location, the narcotics log book had not been counter-signed by two licensed nursing staff on the morning of February 18, 2015 (MIT 7.101). • The institution did not always properly store non-narcotic medications that require refrigeration at its clinics and medication line storage locations. When the OIG tested eight applicable clinics and pill-line locations, inspectors found that only five were in compliance (63 percent). At the OHU clinic, there was no process to separate refrigerated medications awaiting return to the pharmacy. In one pill-line refrigerator, inspectors found two vials of opened insulin that did not show the correct expiration date. For another pill-line, the refrigerator temperature log did not contain entries for the five-day period of January 1 to January 5, 2015 (MIT 7.103). • Inspectors observed medication preparation and administration processes for seven pill-line locations and found that nursing staff were compliant with proper hand hygiene contamination control protocols for only four of the seven pill-lines tested (57 percent). For three of the pill-lines, nursing staff failed to sanitize their hands prior to initially putting on gloves or when changing gloves before each subsequent re-glove (MIT 7.104). Also, when observing the medication distribution process at those seven pill-line locations, inspectors found that only four of the seven pill-line locations (57 percent) were compliant with appropriate administrative controls and protocols. Specifically, inmate-patients waiting outside to receive their medications at three pill-line yard areas did not have an overhang or shade protection available during extreme or inclement weather (MIT 7.106). • The institution properly stored non-narcotic medications that did not require refrigeration at only 9 of its 14 applicable clinics and medication line storage locations (64 percent). For three pill-line locations, inspectors found pre-designated medications that had been removed from all packaging and placed loosely in zip-lock bags ready for dispensing to the inmate-patient at a later time. Although each bag contained an expiration date for the patient’s prescription, it did not contain the medication expiration date. Also, a crash cart in the TTA clinic had medications for Medical Inspection Unit Page 38 Office of the Inspector General State of California internal (oral) use that were not stored separately from medications for external (topical) use. In addition, the crash cart log in the OHU did not include the lock number for the four-day period from February 14 to February 17, 2015 (MIT 7.102). The institution scored 100 percent in the following Medication Preparation and Administration Controls area: • At all seven medication preparation and medication administration locations tested, the nursing staff followed appropriate administrative controls and protocols when preparing medications for inmate-patients, resulting in a score of 100 percent (MIT 7.105). Pharmacy Protocols The institution received 100 percent for this sub-indicator, which is comprised of five scores received at the institution’s main pharmacy. • In its main pharmacy, the institution follows general security, organization, and cleanliness management protocols; properly stores both non-refrigerated and refrigerated medications; maintains adequate controls and properly accounts for narcotic medications; and follows key medication error reporting protocols. As a result, CTF received a score of 100 percent in all five areas tested (MIT 7.107, 7.108, 7.109, 7.110, and 7.111). Other Information Obtained from Non-Scored Results The OIG inspectors followed up on two medication errors identified by OIG clinicians during their clinical case reviews to determine if the institution’s staff had identified and reported the medication errors. For one medication error, the institution’s pharmacist-in-charge (PIC) had no record that the error was reported by staff. For the other medication error, the PIC received the Medication Error Report but reviewed the report five days late. Also, the PIC had assigned the medication error with a severity level of “1,” which OIG’s clinicians deemed was too low. This test result was provided for information purposes only and was not scored (MIT 7.998). Also, the OIG inspectors interviewed inmate-patients in isolation units to determine if they had immediate access to their prescribed KOP rescue inhalers and nitroglycerin medications. All ten of the inmate-patients interviewed had access to their asthmatic inhaler and/or nitroglycerin medications (MIT 7.999). Medical Inspection Unit Page 39 Office of the Inspector General State of California CCHCS Dashboard Comparative Data Medication Administration The CCHCS Dashboard uses five indicators from the Medication Administration Process Improvement Program (MAPIP) audit tool to calculate the average score for medication administration. The OIG compared CTF compliance scores with three of the five applicable Dashboard indicators. As indicated below, the OIG compliance score was 12 percentage points higher than the CTF Dashboard score with regard to medication administration. Pharmacy and Medication Management— CTF Dashboard and OIG Compliance Results CTF DASHBOARD RESULTS OIG COMPLIANCE RESULTS Medication Management: Medication Administration (7.001, 7.002) Medication Administration (Chronic Care & New Meds) Preventive Services (9.001) (Administering INH Medication) February 2015 February 2015 74% 86% Note: The Dashboard results were obtained from the Medication Administration Drilldown data for Chronic Care Meds - Medical, New Outpatient Orders - Medical, and Administration - TB Medications. Variances may exist because CCHCS includes medication administration of KOP medications only for the first two drilldown measures, while the OIG tests both KOP and NA/DOT medication administration. Recommendations The CTF needs to ensure that chronic care patients receive their medication within the required dosing intervals and that staff follow proper protocols for ensuring that counseling occurs for patients who miss doses. The institution should also ensure that patients discharged from a community hospital timely receive new medications ordered, and that patients en route to another institution receive their medications without interruption while temporarily laid-over at CTF. For those patients returning from higher levels of care, CTF should develop a process to assure new medications, such as antibiotics, have a clear start time identified. In addition, nurses should receive training regarding the information that must be documented when administering an injection and SRNs should perform subsequent audits to ensure compliance with CCHCS policy and state nursing regulations. Nursing staff would also benefit from training on protocols for controlling and storing medications, and hand hygiene contamination control protocols when dispensing medications. Finally, the institution should ensure that all outdoor pill-line locations provide an overhang or shade protection to protect inmate-patients from extreme or inclement weather. Medical Inspection Unit Page 40 Office of the Inspector General State of California PREVENTIVE SERVICES This indicator assesses whether various preventive medical services Case Review Rating: are offered or provided to inmate-patients. These include cancer Not Applicable screenings; tuberculosis evaluation; influenza immunizations; Compliance Score: chronic care immunizations; and, where applicable, 53.8% coccidioidomycosis (valley fever) as recommended by the Centers Overall Rating: for Disease Control and Prevention as well as the US Preventive Inadequate Services Task Force. Compliance Testing Results The institution performed poorly in the Preventive Services indicator, with an overall score of 53.8 percent. Overall, the institution scored in the inadequate range for four of the six tests. The weaker areas are described below: • The OIG tests whether inmate-patients who suffer from a chronic care condition were offered vaccinations for influenza, pneumovax, and hepatitis. At CTF, only 8 of 22 chronic care patients sampled (36 percent) received all recommended vaccinations at the required interval for their chronic care conditions (MIT 9.008). • The institution was only 50 percent compliant in offering inmate-patients annual influenza vaccinations. Inspectors found that only 15 of 30 sampled patients either received or were offered the vaccine for the calendar year 2014 (MIT 9.004). • The institution scored poorly for conducting annual tuberculosis (TB) screenings. The OIG found that only 20 of 30 sampled inmate-patients (67 percent) who received TB screenings within the last year had their screening forms appropriately completed, and had the results of required skin tests read by an RN. For seven patients, nursing staff did not complete the “Signs and Symptoms” or “History” sections of the annual TB screening form; and three other patients had their required TB skin test results read by an LVN, rather than an RN (MIT 9.003). The institution received mixed results for two tests applicable to INH: • The institution scored well in administering anti-tuberculosis medications (INH) to patients with tuberculosis. Of the 30 patients sampled, 27 (90 percent) received all doses of INH medication timely when inspectors reviewed their records for the most recent three-month period (MIT 9.001). Medical Inspection Unit Page 41 Office of the Inspector General State of California • However, CTF received a score of 0 percent in monitoring INH patients’ conditions, primarily because staff did not scan patients’ monitoring logs into their eUHR file on a monthly basis. Specifically, for 23 of the 30 patients sampled, their monthly monitoring results were not scanned into the eUHR until the patient’s TB treatment plan was complete. For example, if an inmate-patient was on an eight-month treatment plan, monthly monitoring results were not available in the patient’s eUHR for eight months. This practice prevents other health care staff from verifying whether the inmate-patient is receiving ongoing monitoring during the treatment plan period. Also, for four other patients, providers did not document evidence that all TB signs and symptoms were evaluated during the patient’s monthly monitoring. For the three remaining patients, there was no evidence of monthly monitoring found in the eUHR at all (MIT 9.002). The institution scored in the adequate range for the following key Preventive Services test: • The CTF offered colorectal cancer screenings to 24 of 30 sampled inmate-patients subject to the annual screening requirement (80 percent). For four patients, there was no evidence in the eUHR that the patient was either offered a fecal occult blood test (FOBT) within the previous 12 months or received a normal colonoscopy within the previous ten years. For two other patients who had abnormal colonoscopies within the past three years, inspectors found no evidence that they had received or refused an annual screening within the last 12 months. (MIT 9.005). CCHCS Dashboard Comparative Data As indicated below, the OIG’s compliance results were 19 percentage points lower than the data reported within CTF’s February Dashboard. This variance is partly attributable to differences in CCHCS and OIG methodologies used in developing the comparative figures. Specifically, the CCHCS’ Dashboard calculation methodology gives the institution credit if the patient received a colonoscopy within the prior ten-year period, even if the results were abnormal; the OIG does not follow this practice. The OIG follows CCHCS policy, which requires certain patients aged 50 to 75 to have an annual FOBT unless the patient had a normal colorectal cancer screening within the last ten years. Further, for Dashboard comparative purposes, the OIG only gives credit if inspectors can find evidence in the eUHR that the patient had a normal colonoscopy within the last ten years or actually received a FOBT within the last 12 months. Although CCHCS does not generally include colonoscopy records prior to 2011 in patient’s eUHR files, it may rely on other data sources to determine if a patient received a colonoscopy in the last ten years. Medical Inspection Unit Page 42 Office of the Inspector General State of California Preventive Services—CTF Dashboard and OIG Compliance Results CTF DASHBOARD RESULTS OIG COMPLIANCE RESULTS Colon Cancer Screening Colon Cancer Screening (9.005) February 2015 February 2015 99% 80% Recommendations The institution should ensure that all inmate-patients receive an annual TB screening and that TB skin test results are read by a registered nurse. For patients with tuberculosis, providers should use approved TB monitoring forms or ensure that their progress notes provide the same basic monitoring detail that would normally be included on the TB monitoring forms. The documentation of monthly monitoring should be scanned into each patient’s eUHR on a monthly basis. In addition, the institution’s clinicians should ensure that inmate-patients who suffer from chronic care conditions such as diabetes, hepatitis C, and HIV are routinely offered required vaccinations. The institution should also modify its annual influenza vaccination process to ensure all inmate-patients are offered a seasonal flu vaccine. Finally, during their annual reviews of patients aged 50 to 75, providers should ensure evidence of either an annual colon cancer screening or a normal colonoscopy (conducted within the past ten years) is documented in the eUHR. QUALITY OF NURSING PERFORMANCE This indicator is a qualitative evaluation of nursing services Case Review Rating: performed entirely by OIG nursing clinicians within the case review Adequate process. Therefore, there is no compliance testing component Compliance Score: associated with this quality indicator. The OIG nurses conduct case Not Applicable reviews that include FTF encounters related to nursing sick call Overall Rating: requests identified on the Health Care Services Request Form Adequate (CDCR Form 7362), urgent walk-in visits, referrals for medical services by custody staff, RN case management, RN utilization management, clinical encounters by Licensed Vocational Nurses (LVNs) and Licensed Psychiatric Technicians (LPTs), and any other nursing service performed on an outpatient basis. The OIG case review also includes activities and processes performed by nursing staff that are not considered direct patient encounters, such as the initial receipt and review of CDCR Form 7362 service requests and follow-up with primary care providers and other staff on behalf of the Medical Inspection Unit Page 43 Office of the Inspector General State of California patient. Key focus areas for evaluation of outpatient nursing care include appropriateness and timeliness of patient triage and assessment, identification and prioritization of health care needs, use of the nursing process to implement interventions including patient education and referrals, and documentation that is accurate, thorough, and legible. Nursing services provided in the OHU, CTC, or other inpatient units are reported under Specialized Medical Housing. Nursing services provided in the TTA or related to emergency medical responses are reported under Emergency Services. Case Review Results The OIG clinicians evaluated 452 nursing encounters for CTF, of which 289 were outpatient nursing encounters. These include nursing sick calls, transfers-in and transfers-out of the institution, hospital returns, and specialty services nursing encounters. Overall, 217 deficiencies were found, of which 109 (50 percent) were due to poor quality of nursing care related to inadequate, poor, or illegible nursing documentation. Only four deficiencies were of such magnitude that, if left unaddressed, would likely contribute to patient harm (case 28 below). Nursing Sick Call Overall, outpatient-nursing performance for sick call was adequate. Nurses generally triaged sick call forms adequately and timely, saw patients quickly, and made proper assessments and dispositions. The types of deficiencies identified generally fell into the three broad categories of nursing triage, assessment, and referral. Sick Call Deficiencies The majority of nursing encounters demonstrated adequate triage, assessment, and referral of sick call requests. Among the few assessment deficiencies, all were unlikely to cause serious patient harm. However, several cases were considered more serious in nature due to an increased potential for adverse outcomes or unnecessary delays in needed health care services in the outpatient clinics. The following examples should be used for quality improvement. Lack of Assessment: • In case 1, the RN received and reviewed a sick call request from a day earlier asking to see the PCP for feeling tired and having poor sleep. The RN did not meet with the patient to assess his symptoms and to evaluate a possible need for modified housing placement. The RN made a routine referral to the PCP but should have contacted the PCP to discuss pain management. • In case 11, the patient’s medical condition required him to periodically use a catheter to remove urine from his bladder. The patient submitted a sick call request. He was seen in the TTA for a urinary tract infection after using a dirty catheter. The provider ordered an antibiotic for the infection. The patient was advised to follow-up in the RN line in three days Medical Inspection Unit Page 44 Office of the Inspector General State of California for follow-up assessment. The patient did not show up for the RN visit. The RN should have either asked custody to locate the patient and send him to the clinic or re-schedule him for the next day. It was important for the RN to have evaluated the patient’s self-catheterization technique and to discuss medical supply needs. • In case 62, the RN reviewed a sick call request asking for stronger pain medication for headaches the patient was experiencing three weeks after surgery for a brain tumor. The RN obtained an order to renew his pain medication, but did not assess the patient to ensure his condition was not deteriorating. Weekend Delay: • In case 3, the RN received and reviewed a sick call request on a Friday from an older patient with lung cancer. The patient reported that by the time he arrived at work each day his hands and feet were swollen and he could not walk. The RN noted the patient had a primary care provider visit scheduled on Monday and did not meet with the patient. The RN should have assessed the patient’s edema on Friday to ensure he was medically stable and could safely walk to medication lines and meal areas over the weekend. Inadequate Assessment: • In case 1, the patient submitted a sick call request stating he could not sleep due to pain. The RN noted the patient’s diagnosis of liver cancer. The RN did not perform an adequate assessment or provide any interventions but noted a PCP visit was scheduled in 11 days. Failure to Identify Urgent or Emergent Conditions: • In case 12, the RN received and reviewed a sick call request on a Saturday. The patient reported that his leg was swollen and he needed antibiotics. The patient had chronic myelogenous leukemia, diabetes, and a chronic ulcer on his big toe. The RN referred the patient to the RN line on the next business day (Monday). The RN failed to recognize an urgent or emergent condition and did not refer the patient for same-day evaluation in the TTA. • In case 28, the RN who received and reviewed sick call requests on August 26, 2014, and September 27, 2014, failed to identify urgent or emergent symptoms reported by the patient that required same-day evaluation. On August 27, 2014, the RN did an incomplete assessment of this patient with inflammatory bowel disease and acute bleeding. On September 9, 2014, the RN inappropriately offered this patient naproxen, which could have further aggravated his bleeding. Medical Inspection Unit Page 45 Office of the Inspector General State of California • In case 64, the RN performed an assessment for a sick call request received that morning. The patient was currently receiving treatment for Hepatitis C. The patient complained of severe stomach pain, poor appetite, abdominal distention, and yellow eyes. The RN failed to either contact the on-call provider or send the patient to the TTA. Out to Medical Return and Specialty Services Registered nurses assess patients when they return from offsite medical appointments with specialty providers and for diagnostic tests and procedures. These assessments are usually performed in the TTA. The OIG clinicians reviewed 76 encounters. • In case 2, the RN did not notify the on-call provider of the patient’s slow heart rate. The patient was not assessed when he returned from a CT scan on three occasions. • In case 3, the RNs did not always assess the patient upon his returns. When the patient was housed in the OHU, the nurses did not comment on whether paperwork was sent back with the patient. The patient also was not assessed upon return from a CT scan to regular housing. Emergency Care The TTA nurses, as well as CTF emergency responders, demonstrated knowledge and skill in emergency nursing. One case reviewed showed impressive teamwork, competent decision-making, and immediate intervention. See the Emergency Services indicator for specific findings. Specialized Housing The nursing care provided was adequate but the OIG clinicians had concerns about the quality of nursing care and delayed communication with a provider. See the Specialized Medical Housing indicator for specific findings and recommendations. Medication Administration Medication administration was generally timely and reliable. Several minor deficiencies were found with missed doses and delays in starting antibiotics. During the onsite visit, it was found that the medication line LVNs did not participate in the morning huddles where information about new or changed medication orders should have been discussed. See the Pharmacy and Medication Management Indicator for specific findings. Inter-and Intra-System Transfers In general, the CTF inter- and intra-system transfer processes were adequate with the majority of transferring inmate-patients receiving timely continuity of health care services. However, there were a few deficiencies found for transfers-in related to a delay in appointment scheduling for specialty services, missed medication doses, and inadequate nurse screening. Very few deficiencies were Medical Inspection Unit Page 46 Office of the Inspector General State of California found for transfers-out and they were related to nurses’ failure to include significant medical information on the transfer form. Patients returning from hospitalizations were assessed by RNs upon their return. Nurses generally assessed the patients adequately, reviewed discharge plans and obtained medication orders in a timely manner. See the Inter- and Intra-system Transfers indicator for specific examples. Nursing Documentation Deficiencies Overall, the nursing documentation deficiencies were rare and deemed generally unlikely to cause patient harm. However, the following findings demonstrate deficiencies in the documentation requirements clearly established by CCHCS nursing policy and protocols, and are included as part of the institutional nursing education and training orientation. • In case 1, the nurse’s note did not indicate if the patient was seen in the yard clinic or TTA. • In case 18, the RN failed to document the time the patient arrived at the institution after hospitalization. Onsite Clinician Inspection During the onsite visit by OIG clinicians, the nurses in outpatient settings at CTF were found to be active participants in morning huddles. Although it was sometimes unclear who was facilitating the huddle, the primary care RN, office technicians (OTs), and PCP were present. They discussed the TTA visits, transfers-out and transfers-in, patients remaining in outside hospitals, significant labs or diagnostic reports, MD and RN line backlogs, and add-on appointments and referrals from the previous day. The morning huddle started a little late due to a PCP’s delay in reporting to the huddle site. The OT used a huddle script, although OIG clinicians did not see a sign-in sheet to document who attended. In addition, minutes were not recorded. The OIG clinicians visited various clinical areas and spoke freely with nursing staff during walking rounds. Supervising nurses, RNs (assigned to R&R, Utilization Management, Specialty Services, and yard clinics), and LVNs were knowledgeable about their duties and responsibilities, the patient populations within their assigned areas, and specific communication channels for making requests and reporting issues. Nursing staff at all levels verbalized having no major barriers with initiating communication with providers, nursing supervisors, and custody staff in meeting patient care needs and providing nursing care. During this onsite inspection, the OIG clinicians were notified that CTF utilizes the on-call process rather than 24-hour nursing coverage onsite for supervising nurses out on sick or vacation leave. The OHU is only staffed with an RN on the day shift, with LVNs covering evenings and nights. The TTA RN makes rounds during those periods. Medical Inspection Unit Page 47 Office of the Inspector General State of California Recommendations Although the case review process revealed that quality of outpatient nursing care at CTF was adequate, the following strategies for quality improvement are indicated for ongoing nursing education and monitoring: • Nurses should provide FTF assessments for all CDCR Form 7362 service requests containing complaints of medical symptoms. • Nurses should conduct and document subjective and objective assessments for all complaints. Specific training on abdominal assessments is indicated based on case reviews. • Nurses should provide urgent or same day nursing FTF assessments, as appropriate, based on the patient’s health history and current complaint(s). Supervising RNs should monitor triage decisions of sick call requests. • Morning huddles should be standardized throughout the institution. The OIG recommends the primary physician lead each huddle with active participation by nursing staff including medication nurses. Huddle decisions must be documented and follow-up review performed to ensure decisions were implemented. The CTF should utilize the clinic with the best and most timely practice huddles as a starting point. Each huddle should follow a predefined huddle script and hold each team member accountable for identifying potential lapses in care. • The institution should have a process in place to ensure an RN makes rounds in the OHU during evening and night shifts and documents each visit. This is important for more complex OHU patients, such as those with intravenous lines and those requiring thorough nursing assessments. The institution should also ensure OHU LVNs are informed of the designated RN for each shift and how to contact that RN. QUALITY OF PROVIDER PERFORMANCE Case Review Rating: Adequate In this indicator, the OIG physicians provide a qualitative Compliance Score: evaluation of the adequacy of provider care at the institution. Not Applicable Appropriate evaluation, diagnosis, and management plans are reviewed for programs including, but not limited to, nursing sick Overall Rating: call, chronic care programs, TTA, CTC, and specialty services. Adequate The assessment of provider care is performed entirely by OIG Medical Inspection Unit Page 48 Office of the Inspector General State of California physicians. Therefore, there is no compliance testing component associated with this quality indicator. Case Review Results The OIG clinicians reviewed over 326 medical provider encounters and identified 52 deficiencies related to provider performance. Of those 52 deficiencies, 7 were considered likely to contribute to patient harm (cases 2, 26, and 34 below). As a whole, CTF provider performance is rated adequate. Assessment and Decision-Making In general, the providers made appropriate assessments and sound medical plans. However, there were a few isolated deficiencies. • In case 26, the provider suspected that the patient may have appendicitis and ordered a CT scan of the abdomen, which was done seven days later. An appropriate order would be for an immediate CT scan. • Medication prescribing was inappropriate for case 34. The provider prescribed a combination of gemfibrozil and a statin (cholesterol lowering medication). The use of gemfibrozil with a statin drug is associated with a high risk of muscle toxicity and renal failure. A safer alternative, such as fenofibrate, would have been appropriate. This patient also had two encounters (on August 14, 2014 and November 24, 2014) where guidelines were not followed for poorly controlled diabetes. • In case 2, the provider prescribed naproxen for pain control; however, the patient had a recent history of acute duodenal ulcers. Naproxen is a nonsteroidal anti-inflammatory drug (NSAID), which increases the risk of gastrointestinal inflammation, ulceration, bleeding, and perforation. Furthermore, even without the peptic ulcer history, patients with cirrhosis are at increased risk of gastrointestinal adverse events with NSAIDs use. Thus, alternative medications for pain control should have been given. • In case 2, the provider did not adequately recognize or address the markedly elevated liver transaminases and bilirubin (on September 9, 2014 and September 11, 2014), which were highly suggestive of acute liver failure. The patient should have been referred to a higher level of care immediately. Anticoagulation Management The CTF had a proficient Coumadin clinic to manage patients on anticoagulants. A staff pharmacist worked closely with providers to calculate the doses of warfarin, which are often difficult for primary care providers to manage. Medical Inspection Unit Page 49 Office of the Inspector General State of California Emergency Care Providers generally made appropriate triage decisions when patients presented emergently to the TTA. In addition, they were generally available for consultation with the TTA nursing staff. The overall care provided was adequate; however, there were two deficiencies. • In case 2, the patient had melena (black bowel movements suggestive of an upper gastrointestinal bleed); thus, the provider should have started an intravenous line with fluid replacement prior to transferring the patient out to community hospital. • In case 35, the TTA nursing staff placed two telephone calls to the physician on call. The physician did not respond to the calls. The nursing staff appropriately sent the dehydrated patient to the local hospital, where he received fluids and care. Chronic Care Chronic care performance was generally adequate as most providers demonstrated good care in regard to hypertension, asthma, hepatitis C, and cardiovascular disease. However, there were deficiencies in diabetic management. • In case 12, the patient had diabetes, but was not prescribed a statin. • The management of diabetes was sometimes inadequate. For example, in case 13, the patient’s poorly controlled diabetes was indicated by two consecutive elevated hemoglobin A1c levels; however, the provider failed to adjust the diabetic medications. In case 34, the patient had poorly controlled diabetes with elevated blood glucose levels before his meal in both the morning and evening readings. The increase of the Lantus dose given was insufficient, and the follow-up interval was inadequate to ensure proper management of the fasting glucose. • In case 33, the patient had diabetes, but did not receive a pneumococcal vaccine. Specialty Services The institution providers generally referred patients appropriately and reviewed specialty reports timely; however, not all the reports were signed-off. Specialty care was otherwise performed well except for one deficiency. • In case 14, the hospitalist recommended the patient follow up with a nephrologist, but this did not occur. Medical Inspection Unit Page 50 Office of the Inspector General State of California Pain Management The institution providers appropriately managed acute pain, chronic arthritic pain, neuropathic pain, and cancer pain. The institution had a Pain Management Committee, which assisted providers in managing chronic pain. In one cancer patient, his pain was adequately managed and the patient was made comfortable at the end of his life. However, there was one deficiency. • In case 2, the patient had significant abdominal and back pain due to cancer, and his pain was not adequately managed with a NSAID. The provider should have prescribed an order for a more optimal pain control medication. Health Information Management Providers generally documented outpatient and TTA encounters on the same day, but there were some deficiencies. • Illegibility was found in cases 3, 14, 33, and 65. Also, in cases 25 and 31 progress notes lacked a provider’s name and signature. • In cases 32 and 40, provider progress notes were not found in the eUHR. Onsite Inspection The OIG found that most CTF providers were enthusiastic about their work. Most of the providers were supportive of the Chief Medical Executive. The providers overcame the existing deficiencies in Specialty Services, Health Information Management, and Diagnostic Services with their diligent work ethic. The daily provider meeting was attended by all providers, as they discussed significant medical care issues such as events from the previous day. Morning huddles were led by the providers, attended by nurses and office technicians, and were productive. Most providers expressed general job satisfaction, and overall morale was positive. Conclusion The deficiencies did not significantly affect this indicator’s overall rating. Overall, the CTF providers delivered good care in the majority of the reviewed cases. Eight cases were rated proficient, fifteen cases were rated adequate, and seven were rated inadequate. After taking all factors into consideration, the OIG rated CTF’s Quality of Provider Performance as adequate. Recommendations The OIG recommends CTF implement a review process for chronic care cases such as diabetes. Providers could benefit from continuing medical education for the management of diabetes, chronic liver diseases, acid-base, electrolyte management, and the drug-to-drug interactions. Also, the Medical Inspection Unit Page 51 Office of the Inspector General State of California institution should take steps to improve ancillary services. Supportive services such as Health Information Management, Diagnostic Services, and Specialty Services were found to be deficient. Although providers are ultimately responsible for the patient’s medical care, it would be difficult for providers to perform adequately when the support systems are inadequate. SPECIALIZED MEDICAL HOUSING (OHU, CTC, SNF, HOSPICE) This indicator addresses whether the institution follows appropriate Case Review Rating: policies and procedures when admitting inmate-patients to onsite Adequate inpatient facilities, including completion of timely nursing and Compliance Score: provider assessments. The chart review assesses all aspects of 94.0% medical care related to these housing units, including quality of provider and nursing care. The institution’s only specialized medical Overall Rating: Proficient housing unit is the Outpatient Housing Unit (OHU). Case Review Results The Correctional Training Facility had a total of 26 OHU beds at the time of the OIG clinicians’ visit, of which 13 beds were occupied. A total of 95 provider encounters and 129 nursing encounters were reviewed. The inspection revealed 64 deficiencies, only 1 of which was likely to contribute to patient harm (case 42 below). For this indicator, the quality of provider performance was deemed proficient. However, the quality of OHU nursing services was deemed adequate. Practice issues primarily related to inadequate documentation, care coordination with other clinical staff, and timely communication with providers on urgent cases. Provider Performance The OHU was generally under the care of one provider and the overall quality of care given by this physician was proficient. The provider performed admission exams in an appropriate period as well as following-up with the patients at medically appropriate intervals. The progress notes were legible and easy to follow. Dictated discharge summaries were done on all patients leaving the OHU to the general population. There were challenging patients requiring close monitoring and frequent specialty consultation, for which the provider made accurate assessments and recommendations. For example, in case 35, the patient had cancer with surgical resection of the tumor and extensive reconstruction surgery. After surgery, the patient continued with chemotherapy and radiation therapy. The provider did an exceptional job of coordinating five different specialty services for this patient and even communicated directly with specialists for urgent matters. The provider also had good pain management skills. For example, in case 3, the patient had end stage cancer; his pain was adequately managed and the patient was made comfortable at the end of his life. Medical Inspection Unit Page 52 Office of the Inspector General State of California Of the 95 provider encounters, there were five deficiencies, which did not significantly affect patient care. • In case 3, the provider failed to address anemia for two encounters with hemoglobin levels of 8.6 and 11.2. • In case 29, the patient had a pelvic x-ray, which showed osteopenia and a vertebral body fracture; thus, the provider should have evaluated the patient for osteoporosis. • In case 38, the provider did not address the elevated blood pressure. • In case 38, the provider failed to follow preventive measures, as recommended by the Centers for Disease Control and Prevention, and order a pneumococcal vaccine for this 69-year-old patient. Nursing Performance Nursing performance was generally adequate with some lapses in medication administration, failure to implement providers’ orders, and minimally acceptable nursing assessments. Of the 129 nursing encounters reviewed, there were 46 deficiencies, none significantly affecting patient care. Of the 46 deficiencies, 35 involved the quality of nursing care, and 9 involved medication administration and delivery. Case 42 had the single deficiency likely to contribute to patient harm. The remaining deficiencies were for health information management and scheduling issues. Examples of deficiencies are: • In case 3, nurses did not always document daily peripherally inserted central catheter intravenous line flushes, dressing changes, or catheter port cap changes. At one point, daily flushes were not documented either in a progress note or on a MAR for seven days. Nurses failed to notify the provider promptly when one of the catheters became clogged. • In case 3, the patient developed a fever at midnight on first watch. The nurse provided a warm compress without explanation. In addition, the nurse did not assess the reason for the fever, nor notify the on-call provider. The second watch nurse also did not notify the provider, although the temperature had returned to normal by then. A nurse notified a provider almost 24 hours after the fever onset when the patient developed other symptoms. • In case 41, the nurse failed to adequately assess the patient after a fall. Also, nurses failed to follow a provider's order to weigh the patient weekly, and failed to notify the provider when the patient was uncooperative. Although nurses documented that the patient was able to move himself in bed, the provider noted the patient had difficulty moving from side to side due to weakness. Medical Inspection Unit Page 53 Office of the Inspector General State of California • In case 42, the nurses did not check blood glucose levels three times a day as ordered. Also, sliding scale insulin (insulin given is determined by the blood glucose level) was not always administered from August 13, 2014 through August 8, 2014. On the evening of August 14, 2014, the patient’s blood glucose level was very high (452). The nurse did not administer regular insulin as ordered, nor evaluate the patient for signs/symptoms of hyperglycemia. • In case 43, the nurse failed to adequately assess the patient with a swollen foot after a fall. • In case 44, the nurse failed to adequately assess the patient’s bruised knee after hitting a wall. • Lapses in medications also occurred in cases 1, 42, and 44. Health Information Management The HIM services were adequate. The provider and most nursing progress notes were legible and timely scanned into the eUHR. Nurses’ signatures were sometimes illegible. Consultation reports were generally available for the provider’s review as well as timely scanned into the eUHR. The OHU discharge summaries were timely dictated and scanned into the eUHR. Onsite Visit OHU staff maintained weekly huddles to review all cases and daily huddles for significant patient-specific cases. During the OIG onsite visit, OHU equipment and unit cleanliness were noted. However, an RN on duty reported that the OHU did not have a CPR backboard readily available in case of an emergency. According to the nurse, this was previously reported to the unit supervisor. The CNE was not aware of this issue. Due to the lack of RN staff on all shifts, OIG clinicians requested a copy of the OHU rounds log to confirm that RN rounds were completed as required by policy. The CNE presented a binder for weekly and daily huddles instead of the OHU rounds log. It was also pointed out to the OIG clinicians that CTF had rotating on-call backup OHU supervisors (SRNs), where the backup SRN may not be familiar with the OHU patients. Conclusion The OIG found the specialized medical housing care to be adequate in general. However, the quality of care needs monitoring. There have been recent staffing changes with reduced LVN staffing to evening and night shifts. In addition, the rotating on-call backup OHU SRN should be familiar with the OHU patients. Finally, as the CTF patients were generally uncomplicated with only basic nursing care requirements, CTF must ensure that the nurses’ skills and knowledge are adequate should more complex patients be admitted. Medical Inspection Unit Page 54 Office of the Inspector General State of California Compliance Testing Results The institution received an overall score of 94 percent for the Specialized Medical Housing indicator, which focused on the institution’s OHU. The OIG found that CTF scored in the proficient range for the following areas: • When the OIG tested whether the institution’s providers completed a written history and physical (H&P) examination of inmate-patients housed in the OHU, the OIG found that all ten patients sampled (100 percent) had an H&P completed timely, within 72 hours of admission (MIT 13.003). • Providers also scored well at completing their Subjective, Objective, Assessment, Plan, and Education (SOAPE) notes at required 14-day intervals. The OIG’s testing showed that providers completed SOAPE notes within required time frames for all ten patients (100 percent) (MIT 13.004). • When the OIG observed the working order of a sample of call buttons in OHU patient rooms, inspectors found that the call buttons were in good, working condition. Also, according to knowledgeable staff working in the OHU, custody officers and clinicians respond and access inmate-patient’s rooms in less than one minute when an emergent event occurs. As a result, the institution received a score of 100 percent in this area (MIT 13.101). • For nine of the ten patients sampled (90 percent), nursing staff timely completed an initial assessment on the day the patient was admitted to the OHU. For one patient, the nursing assessment was performed on the day of admission, but the assessment was incomplete (MIT 13.001). The institution scored well in the above areas, but performed slightly lower in the following area: • When the OIG tested whether providers evaluated the inmate-patients within 24 hours of admission to the OHU, inspectors found that evaluations were completed timely for only eight of the ten patients (80 percent). For two patients, the evaluations were completed six and ten hours late, respectively (MIT 13.002). Recommendations The Correctional Training Facility should identify processes monitored by the SRN. Examples of such processes are medication continuity and completion of provider orders. The institution should identify activities only the RN can perform, such as nursing assessments, and ensure an RN is readily available to perform these activities at all times. The institution should encourage LVNs to consult with the designated RN when needed, even if the consultation occurs outside the established Medical Inspection Unit Page 55 Office of the Inspector General State of California rounds on evening and night shifts. Finally, CTF should evaluate the education/skill needs of nurses assigned to work in the OHU. Training should be provided to ensure appropriate care is given by all nurses within their scope of licensure, and that documentation is complete and accurate. In addition, the institution should ensure all patients assigned to the OHU receive an evaluation from a provider within 24 hours of admission. SPECIALTY SERVICES This indicator focuses on specialist care from the time a request for services or physician’s order for specialist care is completed to the Case Review Rating: Inadequate receipt of related recommendations from specialists. This indicator Compliance Score: also evaluates the providers’ timely review of specialist records and 77.5% documentation reflecting the patients’ care plans, including course of care when specialist recommendations were not ordered, and Overall Rating: whether the results of specialists’ reports are communicated to the Inadequate patients. For specialty services denied by the institution, the OIG determines whether the denials are timely and appropriate, and whether the inmate-patient is updated on the plan of care. Case Review Results The OIG clinicians reviewed 203 events related to specialty services and there were 60 deficiencies related to this category. Of those 60 deficiencies, 9 were considered likely to contribute to patient harm. Specialty appointments were generally provided within the requested time frames. However, significant problems with the processing of specialty information (health information management) and specialty access were ultimately responsible for the inadequate rating for this section. Provider-Specialty Performance Case review showed that providers generally referred patients to specialists appropriately. Occasionally, providers failed to process specialist recommendations. There was also one occasion when the provider inappropriately requested a routine service when an urgent service was needed. These episodes are discussed further in the indicator Quality of Provider Performance. Specialty Access Case review found that specialty services were provided within excellent periods for both routine and urgent services. However, there were significant delays in cases 23, 28, 31, and 37. • In case 23, a two-week cardiology appointment was ordered as recommended after hospital discharge; however, the appointment occurred three months later. Medical Inspection Unit Page 56 Office of the Inspector General State of California • In case 28, the provider referred the patient to see gastroenterology but the patient was seen by oncology instead. • In case 31, the provider ordered a one-month optometry visit. The appointment did not occur. • In case 37, the provider ordered removal of an intravenous catheter in three to four weeks. However, this did not occur for more than five months. Health Information Management Case review found that specialty reports were generally retrieved, sent to providers for review, and scanned in timely manner. However, this was not always the case, with a pattern of problems for specialty reports identified. • Specialty reports were sometimes neither retrieved from nor found in the eUHR. This deficiency was identified in cases 36 and 37. In case 37, despite the provider’s request to review the specialty report, it was not made available for review. • Specialty reports were sometimes delayed in their retrieval. This deficiency was identified in cases 1, 14, 24, and 36. For example, in case 36 a magnetic resonance imaging (MRI) report was not available until one month after the examination was performed. • Specialty reports were misfiled in cases 12 and 24. In case 12, a patient’s specialty report was scanned into another patient’s chart. • Specialty reports were not signed-off by a provider in cases 28, 31, 35, 36, 37, and 39. However, most cases showed that providers were aware of the specialty reports, and had made related recommendations during follow-up visits. Nursing-Specialty Performance RNs assessed patients when they returned from offsite medical appointments with specialists, and for diagnostic tests or procedures. These assessments were usually performed in the TTA. In the 76 encounters reviewed, 14 deficiencies were found. Only one deficiency was considered serious in nature with the potential for adverse outcome. • In case 2, the RN did not notify the on-call provider of the patient’s low heart rate. The patient was not assessed when he returned from a CT scan on three occasions. Medical Inspection Unit Page 57 Office of the Inspector General State of California The remaining deficiencies pertained to failures to assess the patient and/or documentation issues. • In case 3, RNs did not always assess the patient upon return from the specialty services encounter. Whenever the patient was housed in the OHU, the nurses did not comment on whether paperwork was returned with the patient. The patient was not assessed upon return from a CT scan to regular housing. Compliance Testing Results The institution received a marginally adequate overall score of 77.5 percent in the Specialty Services access indicator. Although CTF scored in the proficient range for three out of seven tests, it received an inadequate rating for three other tests, and an adequate rating on one other test. The institution scored in the proficient or adequate range in the following areas: • For all 15 inmate-patients sampled (100 percent), their routine specialty service appointment (or service) occurred within 90 calendar days of the provider’s order (MIT 14.003). • For 12 of 15 inmate-patients sampled (80 percent), their high-priority specialty service appointment (or service) occurred within 14 calendar days of the provider’s order. For three patients, the appointments were provided only one day late (MIT 14.001). The OIG also found that providers timely reviewed the specialists’ reports within three business days for all 15 (100 percent) of the sampled patients (MIT 14.002). • The institution received a score of 89 percent when OIG tested the timeliness of CTF’s denials of providers’ specialty services requests for 18 inmate-patients. For two patients, the denial decision was made two and three days late, respectively (14.006). The institution also needs to improve in the following key areas: • For the 18 patients who were denied a specialty service, inspectors found that only half of them (50 percent) received timely notification of the denied service. California Correctional Health Care Services policy requires that when a specialty service is deferred or denied, the provider will document the decision and provide the patient with alternate treatment strategies during a follow-up visit, within 30 days. For two patients this requirement was not met at all, and for seven others the follow-up visit was not held timely (MIT 14.007). • When the institution ordered routine specialty services, the OIG found that providers did not always review the specialists’ reports within three business days. Only 8 of the 15 reports sampled (53 percent) were timely reviewed by a provider. In three instances, the provider Medical Inspection Unit Page 58 Office of the Inspector General State of California reviewed the specialist’s report 1 to 13 days late; in the other four instances, the OIG could not find conclusive evidence that the provider reviewed the report at all (MIT 14.004). • When inmate-patients are approved or scheduled for specialty services appointments from one institution and then transfer to another institution, policy requires that the receiving institution ensure that the patient’s appointment is timely rescheduled or scheduled, and held. For 14 of the 20 (70 percent) patients sampled, the patient received their specialty service appointment within the required action date. However, three patients did not receive their specialty service appointment, and three patients received their appointment from 9 to 47 days late (MIT 14.005). Recommendations While CTF did a reasonable job of providing basic access to specialty care, all steps preceding and following the specialty appointments need improvement. This is important for HIM processes related to specialty services. A systematic process is needed for timely retrieving specialty reports, routing them to the provider for review and signature, and scanning them into the eUHR. Specialist reports need to be available for the required primary care provider follow-up appointment. The provider-ordered specialty services time frames should be appropriate for the patients. Specialist recommendations need timely provider review, and implementation. Where not implemented, providers should document the reasoning to support the decision. A system of tracking complex or urgent patients should be implemented to ensure delivery of prompt care. Also, CTF should ensure that patients who transfer into the facility timely receive their previously approved specialty appointments. In addition, CTF should ensure that patients are timely notified when providers’ requests for specialty services are denied. Medical Inspection Unit Page 59 Office of the Inspector General State of California SECONDARY (ADMINISTRATIVE) QUALITY INDICATORS OF HEALTH CARE The last two quality indicators involve health care administrative systems and processes. Testing in these areas applies only to the compliance component of the process. Therefore, there is no case review assessment associated with either of the two indicators. As part of the compliance component for the first indicator below, the OIG did not score several questions. Instead, the OIG presented the findings for informational purposes only. For example, the OIG described certain local processes in place at CTF. To test both the scored and non-scored areas within these two secondary quality indicators, OIG inspectors interviewed key institutional employees and reviewed documents during their onsite visit to CTF in February 2015. The OIG inspectors also reviewed documents obtained from the institution and from CCHCS prior to the start of the inspection. INTERNAL MONITORING, QUALITY IMPROVEMENT, AND ADMINISTRATIVE OPERATIONS This indicator focuses on the institution’s administrative health care Case Review Rating: oversight functions. The OIG evaluates whether the institution Not Applicable promptly processes inmate-patient medical appeals and addresses Compliance Score: all appealed issues. Inspectors also verify that the institution follows 65.6% reporting requirements for adverse/sentinel events and inmate deaths, and whether the institution is making progress toward its Overall Rating: Inadequate Performance Improvement Work Plan initiatives. In addition, the OIG verifies that the Emergency Medical Response Review Committee (EMRRC) performs required reviews and that staff perform required emergency response drills. Inspectors also assess whether the Quality Management Committee (QMC) meets regularly and adequately addresses program performance. For those institutions with licensed facilities, inspectors also verify that required committee meetings are held. Compliance Testing Results The institution scored poorly in the Internal Monitoring, Quality Improvement, and Administrative Operations indicator, receiving an overall score of 65.6 percent. Although CTF received a score of 100 percent in three of the nine test areas applicable to the institution, it scored 0 percent in two others. All low-scoring areas are described below: • When the OIG reviewed the summary reports and related documentation for three medical emergency response drills conducted in the prior quarter, inspectors found that none of drills included a 1st Medical Responder - Data Collection Tool (CDCR Form 7463) or a Triage Medical Inspection Unit Page 60 Office of the Inspector General State of California and Treatment Services Flowsheet (CDCR Form 7464). Also, for one of the three drills, the time frames were not identified for all elements of the drill. As a result, the institution received a score of 0 percent for this test (MIT 15.101). • To determine if the institution adequately reported adverse/sentinel events (ASE), the OIG reviewed three ASEs that required a root cause analysis and had occurred at CTF during the prior six-month period. Inspectors found that two of the events were not reported to CCHCS’ ASE Committee within 24 hours. One event was reported 47 days late and the other was reported 4 days late. For the remaining event, the institution had not submitted any monthly status reports describing its corrective action taken (or planned) to address identified system and process lapses that led to the ASE. Therefore, the institution received a score of 0 percent for this test (MIT 15.002). • When the OIG reviewed CTF’s 2014 Performance Improvement Work Plan, inspectors found that the institution improved or reached the targeted performance objectives for four of its seven quality improvement initiatives (57 percent). For the three remaining initiatives, the institution did not improve performance or reach its performance objective, nor did it identify the status of its performance objective (MIT 15.005). The institution scored within the adequate range for the following three test areas: • When the OIG inspected documentation for 12 emergency medical response incidents reviewed by the Emergency Medical Response Review Committee (EMRRC) during the prior six-month period, inspectors found that the current Emergency Medical Response Event Checklist (revised June 2011) was not included for any of the incidents reviewed. However, 10 of 12 incident packets (83 percent) included an older version of the form, the Emergency Medical Response Evaluation (CDCR Form 7404, dated April 2003) (MIT 15.007). • The OIG reviewed the institution’s reported medical appeal data for calendar year 2014 and found that CTF promptly processed its inmate medical appeals during only 9 of the 12 months. As a result, the institution received a score of 75 percent for this test. For the three- month period from January through March 2014, the institution did not receive credit because it did not timely process at least 95 percent of its appeals each month. In fact, CTF’s reported data for calendar year 2014 showed that 145 of its 152 overdue medical appeals occurred during that three-month period and only seven other overdue appeals occurred during more recent months (MIT 15.001). Medical Inspection Unit Page 61 Office of the Inspector General State of California • Medical staff sent the Initial Inmate Death Report (CDCR Form 7229A) to CCHCS’ Death Review Unit timely in three of four cases tested, resulting in a score of 75 percent. In the untimely case, the death was reported approximately 25 hours late, but had occurred at an outside hospital, which can cause delays in reporting time frames (MIT 15.103). The institution scored 100 percent in the following three test areas: • The OIG reviewed six recent months of QMC meeting minutes to determine if the QMC met monthly to evaluate program performance and take action when improvement opportunities were identified. Meeting minute packages for each of the six months included Dashboard and other data summary reports for various programs. The CTF’s meeting minutes addressed whether the QMC used the data to evaluate and discuss each program’s performance, identify where improvements were needed, and identify improvement action plans. Consequently, the institution received a score of 100 percent for this test (MIT 15.003). • The OIG inspectors determined that CTF takes adequate steps to ensure the accuracy of its Dashboard data reporting (MIT 15.004) • When the OIG sampled ten second-level medical appeals, inspectors found that the institution’s response addressed all of the patients’ appealed issues (MIT 15.102). Other Information Obtained From Non-Scored Areas • The OIG gathered informational data regarding four deaths that occurred during the prior 12-month period. Inspectors found that the death review summaries for all four deaths were not completed by CCHCS’ Death Review Committee within 30 business days of the death and were not submitted to the institution within 35 business days of the death. The Death Review Committee completed three of the summaries from 44 to 86 days late. The fourth summary was 42 days late at the time of our inspection and had not yet been completed (MIT 15.996). • Inspectors met with the institution’s coordinator for health care appeals and Chief Executive Officer to inquire about CTF’s protocols for tracking appeals. The coordinator provides management with appeals reports on a daily, weekly, and monthly basis. The reports break down the number of appeals and each appeal’s category and status, including the number of appeals that are pending review and those that are overdue for the period. According to the CEO, trend reports and inmate complaints on policy and procedure are reviewed weekly, and are addressed at the weekly meetings to strategize and develop solutions to correct any identified problem areas. Substantiated problems become action items for review to Medical Inspection Unit Page 62 Office of the Inspector General State of California determine if the issue is an isolated incident or systemic problem. Problems are then promptly addressed via training and/or corrective action (MIT 15.997). • Informational data gathered regarding the institution’s practices for implementing local operating procedures (LOPs) indicated that the institution has an effective process in place for developing LOPs. The Health Program Specialist (HPS) monitors existing LOPs to ensure they are current, and reviews new and revised CCHCS policies and procedures to determine whether they impact existing LOPs or require a new LOP. The HPS consults with executive management and other institution staff members to draft revisions to existing LOPs and develop new LOPs, as needed. After approval by the Chief Support Executive or Chief Quality Officer, a final draft of the revised or new LOP is prepared and submitted to the warden and CEO for review and approval. Once approved, medical staff are provided training on the LOP by their immediate supervisor. The institution has implemented all 44 of the applicable stakeholder recommended LOPs (100 percent) (MIT 15.998). • The OIG discusses the institution’s health care staffing resources in the About the Institution section on page 2. CCHCS Dashboard Comparative Data Both the Dashboard and OIG testing results show that CTF currently has a high level of compliance for timely processing its medical appeals. Internal Monitoring, Quality Improvement, and Administrative Operations— CTF Dashboard and OIG Compliance Results CTF DASHBOARD RESULTS OIG COMPLIANCE RESULTS Timely Appeals Medical Appeals—Timely Processing (15.001) February 2015 12months, ending December 2014 (Last nine months of 2014 = 100%) 100% 75% Note: The CCHCS Dashboard data includes appeal data for: American Disability Act (ADA), mental health, dental, and staff complaint areas, whereas the OIG excluded these appeal areas. Medical Inspection Unit Page 63 Office of the Inspector General State of California Recommendations The EMRRC should use the current Emergency Medical Response Event Checklist (revised June 2011) to conduct its incident package reviews. Also, when conducting medical emergency response drills, staff should include the 1st Medical Responder - Data Collection Tool (CDCR Form 7463) and the Triage and Treatment Services Flowsheet (CDCR Form 7464) in their drill packets. In addition, when updating its Performance Improvement Work Plan, especially at calendar-year end, health care management should identify whether it has improved or reached its targeted performance objective for each initiative. Further, due to their critical nature, the institution must ensure that all adverse/sentinel events and inmate death notifications are reported timely to the Adverse/Sentinel Event Committee and the CCHCS Death Review Unit, respectively. The institution should also ensure that it submits required status reports on corrective actions taken to address its adverse/sentinel events. JOB PERFORMANCE, TRAINING, LICENSING, AND CERTIFICATIONS In this indicator, the OIG examines whether the institution Case Review Rating: adequately manages its health care staffing resources by evaluating Not Applicable whether job performance reviews are completed as required; Compliance Score: specified staff possess current, valid credentials and professional 77.5% licenses or certifications; nursing staff receive new employee orientation training and annual competency testing; and clinical and Overall Rating: Adequate custody staff have current medical emergency response certifications. Compliance Testing Results The institution received an overall adequate score of 77.5 percent in the Job Performance, Training, Licensing, and Certifications indicator. For five of the indicator’s eight tests, the institution scored 100 percent. Those tests included the following: • The OIG found that all nursing staff and the PIC are current with their professional licenses and certification requirements. Similarly, all providers are current with their professional licenses (MIT 16.105, 16.001). • The institution’s pharmacy and providers who prescribe controlled substances are current with their Drug Enforcement Agency registration (MIT 16.106). Medical Inspection Unit Page 64 Office of the Inspector General State of California • When the OIG reviewed training records for ten nursing staff who administer medications, inspectors found that all ten had current clinical competency validations. In addition, inspectors confirmed that all nursing staff hired within the last year timely received new employee orientation training (MIT 16.102, 16.107). While the institution scored well in the areas above, the following three areas need improvement: • The institution does not perform complete structured clinical performance appraisals for its primary care providers. The OIG reviewed performance evaluation packets for the institution’s nine providers and found that CTF only completed required 360-Degree Evaluations for six of the nine PCPs, who are all subject to the requirement. Due to the absence of the 360-Degree Evaluations, the institution received a score of 67 percent for this test (MIT 16.103). • The OIG found that supervising registered nurses (SRN) are not conducting required periodic reviews of nursing staff. Inspectors reviewed files for five nurses and found that, during the sampled month, the SRN had completed the required nursing reviews for only one nurse (20 percent). For two nurses, no reviews had been completed at all; for one other nurse, the number of reviews completed was insufficient; and for the other nurse, there was no evidence that the SRN discussed the results of the review with the nurse (MIT 16.101). • The OIG tested provider, nursing, and custody staff records to determine if the institution ensures that those staff members have current emergency response certifications. While the institution’s nursing staff was compliant, two providers and several custody managers were not. Specifically, the acting chief medical executive and another provider, and all but one custody Captain did not have a current certification on file. It should be noted that while the California Penal Code exempts those custody managers who primarily perform managerial duties from medical emergency response certification training, CCHCS policy does not allow for such an exemption. The institution received a score of 33 percent for this test (MIT 16.104). Recommendations The supervising physician who evaluates providers’ clinical performance should conduct a 360-Degree Evaluation as part of the provider’s annual performance evaluation. Also, supervising registered nurses should ensure that they conduct an adequate number of periodic reviews for their nursing staff and document that they discussed the results of the review with each nurse. In addition, the institution must ensure that all providers and custody managers receive and maintain a current emergency response certification. Medical Inspection Unit Page 65 Office of the Inspector General State of California POPULATION-BASED METRICS The compliance testing and the case reviews give an accurate assessment of how the institution’s health care systems are functioning with regard to the patients with the highest risk and utilization. This information is vital to assess the capacity of the institution to provide sustainable, adequate care. However, one significant limitation of the case review methodology is that it does not give a clear assessment of how the institution performs for the entire population. For better insight into this performance, the OIG has turned to population-based metrics. For comparative purposes, the OIG has selected several Healthcare Effectiveness Data and Information Set (HEDIS) measures for disease management to gauge the institution’s effectiveness in outpatient health care, especially chronic disease management. What is HEDIS? Healthcare Effectiveness Data and Information Set is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA) with input from over 300 organizations representing every sector of the nation’s health care industry. It is used by over 90 percent of the nation’s health plans as well as many leading employers and regulators. It was designed to ensure that the public (including employers, the Centers for Medicare and Medicaid Services, and researchers) has the information it needs to accurately compare the performance of health care plans. HEDIS data is often used to produce health plan report cards, analyze quality improvement activities, and create performance benchmarks. Methodology For population-based metrics, the OIG used a subset of HEDIS measures applicable to the CDCR inmate-patient population. Selection of the measures was based on the availability, reliability, and feasibility of the data required for performing the measurement. The OIG collected data utilizing various information sources, including the eUHR, the Master Registry (maintained by CCHCS), as well as a random sample of patient records analyzed and abstracted by trained personnel. Data obtained from the CCHCS Master Registry and Diabetic Registry was not independently validated by the OIG and is presumed to be accurate. For some measures, the OIG used the entire population rather than statistically random samples. While the OIG is not a certified HEDIS compliance auditor, the OIG uses similar methods to ensure that measures are comparable to those published by other organizations. Comparison of Population-Based Metrics For the Correctional Training Facility, nine HEDIS measures were selected and are listed in Table 1 – CTF Results Compared to State and National HEDIS Scores. Multiple health plans publish their HEDIS performance measures at the State and national levels. The OIG has provided selected results for several health plans in both categories for comparative purposes. In addition, the OIG Medical Inspection Unit Page 66 Office of the Inspector General State of California selected California’s Medi-Cal Managed Care Program as the population most similar to that of the CDCR inmate population. As indicated in Table 2 – CTF Results Compared to Medi-Cal Minimum and Maximum Performance, the California Department of Health Care Services annually establishes a minimum performance level (MPL) and a high performance level (HPL) for each of its required performance measures. Where applicable, the OIG compared CTF’s results to the Medi- Cal MPL and HPL results. Results of Population-Based Metric Comparison Comprehensive Diabetes Care For chronic care management, the OIG chose measures related to the management of diabetes. Diabetes is the most complex common chronic disease requiring a high level of intervention on the part of the health care system in order to produce optimal results. The CTF performed very well with its management of diabetes. When compared statewide, CTF significantly outperformed the Medi-Cal average scores (Table 1) and also exceeded the Medi-Cal HPL scores (Table 2) in each of the five diabetic measures selected. In fact, for diabetic patients whose diabetes was considered to be under poor control and patients whose diabetes was considered to be under good control, CTF’s scores were 27 and 28 percentage points, respectively, better than Medi-Cal’s average scores. The Correctional Training Facility also outperformed Kaiser Permanente (Table 1) in all five diabetic measures. When compared nationally (Table 1), CTF outperformed HMO averages for Medicaid, Commercial, and Medicare in each of the five diabetic measures listed. When compared to the Department of Veterans Affairs (VA), CTF scored similar to the VA in its diabetic monitoring, outperformed the VA with respect to diabetics considered to be under poor control, and outperformed the VA with respect to blood pressure control for diabetic patients. However, for diabetic patient eye exams, CTF scored 5 percentage points lower than the VA. Immunizations Comparative data for immunizations (Table 1) was only fully available nationally for the VA and partially available for Kaiser Permanente (statewide) and Commercial (national). With respect to administering influenza shots to adults aged 50 to 64, CTF performed significantly lower than all three organizations that reported data. The OIG inspectors found that only 11 of CTF’s 42 patients sampled (26 percent) actually received the influenza shot. However, inspectors noted that 16 additional patients (38 percent) were offered the shot and refused it. For the remaining 15 patients (36 percent), there was no record of the shot being offered or received. The CTF also scored lower than the VA with respect to administering influenza shots to adults aged 65 and older. However, of the 33 patients sampled, inspectors did not find any patients who had been offered the shot and refused it. Medical Inspection Unit Page 67 Office of the Inspector General State of California With respect to pneumococcal vaccinations, CTF performed at 82 percent, which was lower than the VA’s 93 percent performance. The OIG inspectors found that 2 of the 33 patients sampled (6 percent) had been timely offered the pneumococcal vaccination and refused it. Cancer Screening For colorectal cancer screening (Table 1), CTF’s score was the same as Kaiser Permanente’s statewide average. Nationally, CTF performed much higher than Commercial and Medicare, and slightly lower than the VA. Summary Compared statewide, CTF’s population-based performance exceeded the Medi-Cal and Kaiser Permanente performance in almost all measures evaluated except influenza shots for adults aged 50 to 64. On a national level, CTF outperformed the Medicaid, Commercial, and Medicare performance in all measures except influenza shots for older adults. The CTF outperformed the VA in three of the four diabetes care measures for which the VA reported data. Overall, CTF’s performance reflects a good-performing chronic care program, which is corroborated by the institution’s adequate ratings in the Quality of Provider Performance and Quality of Nursing Performance indicators, and its proficient rating in the Access to Care indicator. However, as evidenced by its poor performance in both the HEDIS immunization measures and the compliance scores related to immunization tests within the Preventive Services indicator, the institution should improve its immunization processes and make interventions to lower the rate of refusal when immunizations are offered to patients. Medical Inspection Unit Page 68 Office of the Inspector General State of California Table 1 - CTF Results Compared to State and National HEDIS Scores Institution California National Kaiser Kaiser CTF HEDIS (No.CA) (So.CA) HEDIS Clinical Measures Medi- HEDIS HEDIS HEDIS Com- HEDIS VA Cycle 4 Cal Scores Scores Medicaid mercial Medicare Average Results 1 2013 2 2014 3 2014 3 2013 4 2013 4 2013 4 2012 5 Comprehensive Diabetes Care HbA1c Testing 100% 83% 95% 94% 84% 90% 92% 99% Poor HbA1c Control (>9.0%) 6,7 13% 40% 18% 21% 46% 31% 25% 19% HbA1c Control (<8.0%) 6 77% 49% 70% 67% 46% 59% 66% - Blood Pressure Control (<140/90) 88% 63% 82% 85% 60% 65% 66% 80% Eye Exams 85% 51% 69% 82% 54% 56% 69% 90% Immunizations Influenza Shots - Adults (50–64) 8 26% - 59% 55% - 50% - 65% Influenza Shots - Adults (65+) 58% - - - - - - 76% Immunizations: Pneumococcal 82% - - - - - - 93% Cancer Screening Colorectal Cancer Screening 79% - 78% 80% - 63% 64% 82% 1. Unless otherwise stated, data was collected in February 2015 by reviewing medical records from a sample of CTF's population of applicable inmate-patients. These random statistical sample sizes were based on a 95 percent confidence level with a 15 percent maximum margin of error. 2. HEDIS Medi-Cal data was obtained from the California Department of Health Care Services 2013 HEDIS Aggregate Report for the Medi-Cal Managed Care Program. 3. Data was obtained from Kaiser Permanente November 2014 reports for the Northern and Southern California regions. 4. National HEDIS data for Medicaid, Commercial, and Medicare was obtained from the 2014 State of Health Care Quality Report, available on the NCQA website: www.ncqa.org. The results for Commercial were based on data received from various health maintenance organizations. 5. The Department of Veterans Affairs (VA) data was obtained from the VHA Facility Quality and Safety Report - Fiscal Year 2012 Data. 6. For this indicator, the entire applicable CTF population was tested. 7. For this measure only, a lower score is better. For Kaiser, the OIG derived the Poor HbA1c Control indicator using the reported data for the <9.0% HbA1c control indicator. 8. The Kaiser and Commercial HEDIS data is for the age range 18–64. Medical Inspection Unit Page 69 Office of the Inspector General State of California Table 2 - CTF Results Compared to Medi-Cal Minimum and Maximum Performance California HEDIS California HEDIS CTF Medi-Cal High Medi-Cal Minimum Clinical Measures Cycle 4 Performance Level Performance Level Inspection Results 2013 2013 Comprehensive Diabetes Care HbA1c Testing 100% 91% 79% Poor HbA1c Control (>9.0%) 13% 29% 50% *Lower score is better HbA1c Control (<8.0%) 77% 59% 42% Blood Pressure Control (<140/90) 88% 75% 54% Eye Exams 85% 70% 45% Medical Inspection Unit Page 70 Office of the Inspector General State of California APPENDIX A—COMPLIANCE TEST RESULTS Correctional Training Facility Range of Summary Scores: 53.84%–94.00% Overall Score Indicator (Yes %) Access to Care 83.93% Diagnostic Services 86.67% Emergency Services Not Applicable Health Information Management (Medical Records) 58.42% Health Care Environment 63.54% Inter- and Intra-System Transfers 66.58% Pharmacy and Medication Management 80.46% Prenatal and Post-Delivery Services Not Applicable Preventive Services 53.84% Quality of Nursing Performance Not Applicable Quality of Provider Performance Not Applicable Reception Center Arrivals Not Applicable Specialized Medical Housing (OHU, CTC, SNF, Hospice) 94.00% Specialty Services 77.46% Internal Monitoring, Quality Improvement, and Administrative Operations 65.61% Job Performance, Training, Licensing, and Certifications 77.50% Medical Inspection Unit Page 71 Office of the Inspector General State of California Scored Answers Yes + Reference Access to Care Number Yes No No Yes % N/A 1.001 Chronic care follow-up appointments: Was the 18 12 30 60.0% 0 inmate-patient’s most recent chronic care visit within the health care guideline’s maximum allowable interval or within the ordered time frame, whichever is shorter? 1.002 For endorsed inmate-patients received from another 9 7 16 56.25% 14 CDCR institution: If the nurse referred the inmate-patient to a provider during the initial health screening, was the inmate-patient seen within the required time frame? 1.003 Clinical appointments: Did a registered nurse review the 31 1 32 96.88% 0 inmate-patient’s request for service the same day it was received? 1.004 Clinical appointments: Did the registered nurse complete 29 1 30 96.67% 2 a face-to-face visit within one business day after the CDCR Form 7362 was reviewed? 1.005 Clinical appointments: If the registered nurse determined 8 1 9 88.89% 23 a referral to a primary care provider was necessary, was the inmate-patient seen within the maximum allowable time or the ordered time frame, whichever is the shorter? 1.006 Sick-call follow-up appointments: If the primary care 5 0 5 100% 27 provider ordered a follow-up sick-call appointment, did it take place within the time frame specified? 1.007 Upon the inmate-patient’s discharge from the 24 6 30 80.00% 0 community hospital: Did the inmate-patient receive a follow-up appointment with a primary care provider within the required time frame? 1.008 Specialty service follow-up appointments: Do specialty 23 7 30 76.67% 0 service primary care physician follow-up visits occur within required time frames? 1.101 Clinical appointments: Do inmate-patients have a 6 0 6 100% 0 standardized process to obtain and submit Health Care Services Request Forms? Overall percentage: 83.93% Medical Inspection Unit Page 72 Office of the Inspector General State of California Scored Answers Yes + Reference Diagnostic Services Number Yes No No Yes % N/A 2.001 Radiology orders: Was the radiology service provided 9 1 10 90.00% 0 within the time frame specified in the provider’s order? 2.002 Radiology orders: Did the primary care provider review 9 1 10 90.00% 0 and initial the diagnostic report within specified time frames? 2.003 Radiology orders: Did the primary care provider 9 1 10 90.00% 0 communicate the results of the diagnostic study to the inmate-patient within specified time frames? 2.004 Laboratory orders: Was the laboratory service provided 9 1 10 90.00% 0 within the time frame specified in the provider’s order? 2.005 Laboratory orders: Did the primary care provider review 10 0 10 100% 0 and initial the diagnostic report within specified time frames? 2.006 Laboratory orders: Did the primary care provider 10 0 10 100% 0 communicate the results of the diagnostic study to the inmate-patient within specified time frames? 2.007 Pathology: Did the institution receive the final diagnostic 9 1 10 90.00% 0 report within the required time frame? 2.008 Pathology: Did the primary care provider review and initial 10 0 10 100% 0 the diagnostic report within specified time frames? 2.009 Pathology: Did the primary care provider communicate the 3 7 10 30.00% 0 results of the diagnostic study to the inmate-patient within specified time frames? Overall percentage: 86.67% Medical Inspection Unit Page 73 Office of the Inspector General State of California Scored Answers Yes + Reference Emergency Services Number Yes No No Yes % N/A Assesses reaction times and responses to emergency 3 situations. The OIG RN clinicians will use detailed Not Applicable information obtained from the institution’s incident packages to perform focused case reviews. Scored Answers Yes Health Information Management + Reference (Medical Records) Number Yes No No Yes % N/A 4.001 Are non-dictated progress notes, initial health screening 17 3 20 85.00% 0 forms, and health care service request forms scanned into the eUHR within three calendar days of the inmate-patient encounter date? 4.002 Are dictated/transcribed documents scanned into the eUHR within five calendar days of the inmate-patient encounter Not Applicable date? 4.003 Are specialty documents scanned into the eUHR within five 12 8 20 60.00% 0 calendar days of the inmate-patient encounter date? 4.004 Are community hospital discharge documents scanned into 9 11 20 45.00% 0 the eUHR within three calendar days of the inmate-patient date of hospital discharge? 4.005 Are medication administration records (MARs) scanned 13 7 20 65.00% 0 into the eUHR within the required time frames? 4.006 During the eUHR review, did the OIG find that documents 3 9 12 25.00% 0 were correctly labeled and included in the correct inmate-patient’s file? 4.007 Did clinical staff legibly sign health care records, when 21 11 32 65.63% 0 required? 4.008 For inmate-patients discharged from a community 19 11 30 63.33% 0 hospital: Did the preliminary hospital discharge report include key elements, and did a provider review the report within three calendar days of discharge? Overall percentage: 58.42% Medical Inspection Unit Page 74 Office of the Inspector General State of California Scored Answers Yes + Reference Health Care Environment Number Yes No No Yes % N/A 5.101 Infection control: Are clinical health care areas 5 2 7 71.43% 1 appropriately disinfected, clean, and sanitary? 5.102 Infection control: Do clinical health care areas ensure that 5 3 8 62.50% 0 reusable invasive and non-invasive medical equipment is properly sterilized or disinfected as warranted? 5.103 Infection control: Do clinical health care areas contain 6 2 8 75.00% 0 operable sinks and sufficient quantities of hygiene supplies? 5.104 Infection control: Do clinical health care staff adhere to 7 0 7 100% 1 universal hand hygiene precautions? 5.105 Infection control: Do clinical health care areas control 7 1 8 87.50% 0 exposure to blood-borne pathogens and contaminated waste? 5.106 Warehouse, Conex, and other non-clinic storage areas: 1 0 1 100% 0 Does the medical supply management process adequately support the needs of the medical health care program? 5.107 Clinical areas: Does each clinic follow adequate protocols 8 0 8 100% 0 for managing and storing bulk medical supplies? 5.108 Clinical areas: Do clinic common areas and exam rooms 0 8 8 0.00% 0 have essential core medical equipment and supplies? 5.109 Clinical areas: Do clinic common areas have an adequate 2 6 8 25.00% 0 environment conducive to providing medical services? 5.110 Clinical areas: Do clinic exam rooms have an adequate 3 5 8 37.50% 0 environment conducive to providing medical services? 5.111 Emergency response bags: Are TTA and clinic emergency 2 3 5 40.00% 0 medical response bags inspected daily and inventoried monthly, and do they contain essential items? 5.999 For Information Purposes Only: Does the institution’s health care management believe that all clinical areas have Information Only physical plant infrastructures sufficient to provide adequate health care services? Overall percentage: 63.54% Medical Inspection Unit Page 75 Office of the Inspector General State of California Scored Answers Yes + Reference Inter- and Intra-System Transfers Number Yes No No Yes % N/A 6.001 For endorsed inmate-patients received from another 18 12 30 60.0% 0 CDCR institution: Did nursing staff complete the initial health screening and answer all screening questions on the same day the inmate-patient arrived at the institution? 6.002 For endorsed inmate-patients received from another 20 10 30 66.67% 0 CDCR institution: When required, did the RN complete the assessment and disposition section of the health screening form; refer the inmate-patient to the TTA, if TB signs and symptoms were present; and sign and date the form on the same day staff completed the health screening? 6.003 For endorsed inmate-patients received from another 13 3 16 81.25% 14 CDCR institution: If the inmate-patient had an existing medication order upon arrival, were medications administered or delivered without interruption? 6.004 For inmate-patients transferred out of the facility: Were 5 15 20 25.00% 0 scheduled specialty service appointments identified on the Health Care Transfer Information Form 7371? 6.101 For inmate-patients transferred out of the facility: Do 3 0 3 100% 0 medication transfer packages include required medications along with the corresponding Medical Administration Record and Medication Reconciliation? Overall percentage: 66.58% Medical Inspection Unit Page 76 Office of the Inspector General State of California Scored Answers Yes + Reference Pharmacy and Medication Management Number Yes No No Yes % N/A 7.001 Did the inmate-patient receive all chronic care medications 22 7 29 75.86% 1 within the required time frames, or did the institution follow departmental policy for refusals or no-shows? 7.002 Did health care staff administer or deliver new order 28 2 30 93.33% 0 prescription medications to the inmate-patient within the required time frames? 7.003 Upon the inmate-patient’s discharge from a community 22 8 30 73.33% 0 hospital: Were all medications ordered by the institution’s primary care provider administered or delivered to the inmate-patient within one calendar day of return? 7.004 For inmate-patients received from a county jail or COCF: Were all medications ordered by the institution’s Not Applicable reception center provider administered or delivered to the inmate-patient within the required time frames? 7.005 Upon the inmate-patient’s transfer from one housing 26 4 30 86.67% 0 unit to another: Were medications continued without interruption? 7.006 For en route inmate-patients who lay over at the 6 4 10 60.00% 0 institution: If the temporarily housed inmate-patient had an existing medication order, were medications administered or delivered without interruption? 7.101 All clinical and medication line storage areas for 4 3 7 57.14% 0 narcotic medications: Does the institution employ strong medication security controls over narcotic medications assigned to its clinical areas? 7.102 All clinical and medication line storage areas for 9 5 14 64.29% 0 non-narcotic medications: Does the institution properly store non-narcotic medications that do not require refrigeration in assigned clinical areas? 7.103 All clinical and medication line storage areas for 5 3 8 62.50% 0 non-narcotic medications: Does the institution properly store non-narcotic medications that require refrigeration in assigned clinical areas? 7.104 Medication preparation and administration areas: Do 4 3 7 57.14% 0 nursing staff employ and follow hand hygiene contamination control protocols during medication preparation and medication administration processes? 7.105 Medication preparation and administration areas: Does 7 0 7 100% 0 the institution employ appropriate administrative controls and protocols when preparing medications for inmate-patients? Medical Inspection Unit Page 77 Office of the Inspector General State of California Scored Answers Yes + Reference Pharmacy and Medication Management Number Yes No No Yes % N/A 7.106 Medication preparation and administration areas: Does 4 3 7 57.14% 0 the institution employ appropriate administrative controls and protocols when administering medications to inmate-patients? 7.107 Pharmacy: Does the institution employ and follow general 1 0 1 100% 0 security, organization, and cleanliness management protocols in its main and satellite pharmacies? 7.108 Pharmacy: Does the institution’s pharmacy properly store 1 0 1 100% 0 non-refrigerated medications? 7.109 Pharmacy: Does the institution’s pharmacy properly store 1 0 1 100% 0 refrigerated or frozen medications? 7.110 Pharmacy: Does the institution’s pharmacy properly 1 0 1 100% 0 account for narcotic medications? 7.111 Pharmacy: Does the institution follow key medication 24 0 24 100% 0 error reporting protocols? 7.998 For Information Purposes Only—Medication Errors: During eUHR compliance testing and case reviews, did the Information Only OIG find that medication errors were properly identified and reported by the institution? 7.999 For Information Purposes Only—Pharmacy: Do inmate-patients in isolation housing units have immediate Information Only access to their KOP prescribed rescue inhalers and nitroglycerin medications? Overall percentage: 80.46% Scored Answers Yes + Reference Prenatal and Post-Delivery Services Number Yes No No Yes % N/A 8 This indicator is not applicable to this institution. Not Applicable Medical Inspection Unit Page 78 Office of the Inspector General State of California Scored Answers Yes + Reference Preventive Services Number Yes No No Yes % N/A 9.001 Inmate-patients prescribed INH: Did the institution 27 3 30 90.00% 0 administer the medication to the inmate-patient as prescribed? 9.002 Inmate-patients prescribed INH: Did the institution 0 30 30 0.00% 0 monitor the inmate-patient monthly for the most recent three months he or she was on the medication? 9.003 Annual TB screening: Was the inmate-patient screened for 20 10 30 66.67% 0 TB within the last year? 9.004 Were all inmate-patients offered an influenza vaccination 15 15 30 50.00% 0 for the most recent influenza season? 9.005 All inmate-patients from the age of 50 through the age 24 6 30 80.00% 0 of 75: Was the inmate-patient offered colorectal cancer screening? 9.006 Female inmate-patients from the age of 50 through the age of 74: Was the inmate-patient offered a mammogram in Not Applicable compliance with policy? 9.007 Female inmate-patients from the age of 21 through the age of 65: Was the inmate-patient offered a pap smear in Not Applicable compliance with policy? 9.008 Are required immunizations being offered for chronic care 8 14 22 36.36% inmate-patients? 9.009 Are inmate-patients at the highest risk of coccidioidomycosis (valley fever) infection transferred out Not Applicable of the facility in a timely manner? Overall percentage: 53.84% Medical Inspection Unit Page 79 Office of the Inspector General State of California Scored Answers Yes + Reference Quality of Nursing Performance Number Yes No No Yes % N/A The quality of nursing performance will be assessed during 10 case reviews, conducted by OIG clinicians, and is not applicable for the compliance portion of the medical inspection. The methodologies OIG clinicians use to Not Applicable evaluate the quality of nursing performance are presented in a separate inspection document entitled OIG MIU Retrospective Case Review Methodology. Scored Answers Yes + Reference Quality of Provider Performance Number Yes No No Yes % N/A The quality of provider performance will be assessed during case reviews, conducted by OIG clinicians, and is not 11 applicable for the compliance portion of the medical inspection. The methodologies OIG clinicians use to Not Applicable evaluate the quality of provider performance are presented in a separate inspection document entitled OIG MIU Retrospective Case Review Methodology. Scored Answers Yes + Reference Reception Center Arrivals Number Yes No No Yes % N/A 12 This indicator is not applicable to this institution. Not Applicable Medical Inspection Unit Page 80 Office of the Inspector General State of California Scored Answers Yes Specialized Medical Housing + Reference (OHU, CTC, SNF, Hospice) Number Yes No No Yes % N/A 13.001 For all higher level care facilities: Did the registered nurse 9 1 10 90.00% 0 complete an initial assessment of the inmate-patient on the day of admission, or within eight hours of admission to CMF’s Hospice? 13.002 For OHU, CTC, and SNF only: Did the primary care 8 2 10 80.00% 0 provider for OHU or attending physician for CTC & SNF evaluate the inmate-patient within 24 hours of admission? 13.003 For OHU, CTC, and SNF only: Was a written history and 10 0 10 100% 0 physical examination completed within 72 hours of admission? 13.004 For all higher level care facilities: Did the primary care 10 0 10 100% 0 provider complete the Subjective, Objective, Assessment, Plan, and Education (SOAPE) notes on the inmate-patient at the minimum intervals required for the type of facility where the inmate-patient was treated? 13.101 For OHU and CTC Only: Do in-patient areas either have 1 0 1 100% 0 a properly working call system in its OHU, CTC & GACH or are 30-minute patient welfare checks performed; and do medical staff have reasonably unimpeded access to enter inmate-patient’s cells? Overall percentage: 94.00% Medical Inspection Unit Page 81 Office of the Inspector General State of California Scored Answers Yes + Reference Specialty Services Number Yes No No Yes % N/A 14.001 Did the inmate-patient receive the high-priority specialty 12 3 15 80.00% 0 service within 14 calendar days of the PCP order? 14.002 Did the PCP review the high-priority specialty service 15 0 15 100% 0 consultant report within three business days after the service was provided? 14.003 Did the inmate-patient receive the routine specialty service 15 0 15 100% 0 within 90 calendar days of the PCP order? 14.004 Did the PCP review the routine specialty service consultant 8 7 15 53.33% 0 report within three business days after the service was provided? 14.005 For endorsed inmate-patients received from another 14 6 20 70.00% 0 CDCR institution: If the inmate-patient was approved for a specialty services appointment at the sending institution, was the appointment scheduled at the receiving institution within the required time frames? 14.006 Did the institution deny the primary care provider request 16 2 18 88.89% 0 for specialty services within required time frames? 14.007 Following the denial of a request for specialty services, was 9 9 18 50.00% 0 the inmate-patient informed of the denial within the required time frame? Overall percentage: 77.46% Medical Inspection Unit Page 82 Office of the Inspector General State of California Scored Answers Internal Monitoring, Quality Yes Improvement, and Administrative + Reference Operations Number Yes No No Yes % N/A 15.001 Did the institution promptly process inmate medical appeals 9 3 12 75.00% 0 during the most recent 12 months? 15.002 Does the institution follow adverse/sentinel event reporting 0 3 3 0.00% 0 requirements? 15.003 Did the institution Quality Management Committee (QMC) 6 0 6 100% 0 meet at least monthly to evaluate program performance, and did the QMC take action when improvement opportunities were identified? 15.004 Did the institution’s Quality Management Committee 1 0 1 100% 0 (QMC) or other forum take steps to ensure the accuracy of its Dashboard data reporting? 15.005 For each initiative in the Performance Improvement Work 4 3 7 57.14% 1 Plan (PIWP), has the institution performance improved or reached the targeted performance objective(s)? 15.006 For institutions with licensed care facilities: Does the local Not applicable 0 governing body (LGB), or its equivalent, meet quarterly and exercise its overall responsibilities for the quality management of patient health care? 15.007 Does the Emergency Medical Response Review Committee 10 2 12 83.33% 0 perform timely incident package reviews that include the use of required review documents? 15.101 Did the institution complete a medical emergency response 0 3 3 0.00% 0 drill for each watch and include participation of health care and custody staff during the most recent full quarter? 15.102 Did the institution’s second level medical appeal response 10 0 10 100% 0 address all of the inmate-patient’s appealed issues? 15.103 Did the institution’s medical staff review and submit the 3 1 4 75.00% 0 initial inmate death report to the Death Review Unit in a timely manner? 15.996 For Information Purposes Only: Did the CCHCS Death Review Committee submit its inmate Death Review Information Only Summary to the institution timely? 15.997 For Information Purposes Only: Identify the institution’s Information Only protocols for tracking medical appeals. 15.998 For Information Purposes Only: Identify the institution’s protocols for implementing health care local operating Information Only procedures (LOPs). 15.999 For Information Purposes Only: Identify the institution’s Information Only health care staffing resources. Overall percentage: 65.61% Medical Inspection Unit Page 83 Office of the Inspector General State of California Scored Answers Yes Job Performance, Training, Licensing, + Reference and Certifications Number Yes No No Yes % N/A 16.001 Do all providers maintain a current medical license? 13 0 13 100% 0 16.101 Does the institution’s Supervising Registered Nurse conduct 1 4 5 20.00% 0 periodic reviews of nursing staff? 16.102 Are nursing staff who administer medications current on 10 0 10 100% 0 their clinical competency validation? 16.103 Are structured clinical performance appraisals completed 6 3 9 66.67% 0 timely? 16.104 Are staff current with required medical emergency response 1 2 3 33.33% 0 certifications? 16.105 Are nursing staff and the pharmacist-in-charge current with 5 0 5 100% 1 their professional licenses and certifications? 16.106 Do the institution’s pharmacy and authorized providers who 1 0 1 100% 0 prescribe controlled substances maintain current Drug Enforcement Agency (DEA) registrations? 16.107 Are nursing staff current with required new employee 1 0 1 100% 0 orientation? Overall percentage: 77.50% Medical Inspection Unit Page 84 Office of the Inspector General State of California APPENDIX B—CLINICAL DATA Table B-1 CTF Sample Sets Sample Set Total Anticoagulation 3 Death Review and Sentinel Events 4 Diabetes 4 Emergency Services - CPR 3 Emergency Services - Non-CPR 4 CTC and OHU 5 High Risk 5 Hospitalization 5 Intra-System Transfers-In 3 Intra-System Transfers-Out 3 Nursing Sick Call 20 Specialty Services 5 64 Medical Inspection Unit Page 85 Office of the Inspector General State of California Table B-2 CTF Chronic Care Diagnoses Diagnosis Total Anemia 5 Anticoagulation 3 Arthritis or Degenerative Joint Disease 10 Asthma 8 COPD 5 Cancer 6 Cardiovascular Disease 8 Chronic Kidney Disease 1 Chronic Pain 11 Cirrhosis or End Stage Liver Disease 9 Coccidioidomycosis 1 Diabetes 13 Gastroesophageal Reflux Disease 11 Gastrointestinal Bleed 1 Hepatitis C 19 Hyperlipidemia 21 Hypertension 40 Mental Health 7 Rheumatological Disease 1 Seizure Disorder 9 Sleep Apnea 3 Thyroid Disease 2 194 Medical Inspection Unit Page 86 Office of the Inspector General State of California Table B-3 CTF Event - Program Program Total Diagnostic Services 224 Emergency Care 97 Hospitalization 58 Intra-System Transfers-In 24 Intra-System Transfers-Out 8 Outpatient Care 441 Specialized Medical Housing 255 Specialty Services 192 1,299 Medical Inspection Unit Page 87 Office of the Inspector General State of California Table B-4 CTF Case Review Sample Summary Total MD Reviews Detailed 30 MD Reviews Focused 0 RN Reviews Detailed 11 RN Reviews Focused 33 Total Reviews 74 Total Unique Cases 64 Overlapping Reviews (MD & RN) 10 Medical Inspection Unit Page 88 Office of the Inspector General State of California APPENDIX C—COMPLIANCE SAMPLING METHODOLOGY Correctional Training Facility Sample Category Quality (number of Indicator patients) Data Source Filters Access to Care Chronic Care Master Registry • Chronic care conditions (at least one condition per (30—Basic Level) inmate-patient—any risk level) (40—Inter Level) • Randomize Nursing Sick Call MedSATS • Clinic (each clinic tested) (5 per clinic) • Appt. date (2–9 months) (minimum of 30) • Randomize Returns from Inpatient Claims • See Health Information Management (Medical Community Hospital Data Records) (returns from community hospital) (30) Diagnostic Radiology Radiology Logs • Appt. Date (90 days–9 months) Services (10) • Randomize • Abnormal Laboratory Quest • Appt. date (90 days–9 months) (10) • Order name (CBC or CMPs only) • Randomize • Abnormal Pathology InterQual • Appt. date (90 days–9 months) (10) • Service (pathology related) • Randomize Health Timely Scanning OIG Qs: 1.001, • Non-dictated documents Information (20 each) 1.002, & 1.006 • First five inmate-patients selected for question Management 1.001 & 1.002; first ten inmate-patients for 1.006 (Medical OIG Q: 1.001 • Dictated documents Records) • First 20 inmate-patients selected OIG Qs: 14.002 • Specialty documents & 14.004 • First 10 inmate-patients selected for each question OIG Q: 4.008 • Community hospital discharge documents • First 20 inmate-patients selected for the question OIG Q: 7.001 • MARs • First 20 inmate-patients selected Legible Signatures OIG Qs: 4.008, • First 8 inmates sampled for each question selected and Review 6.001/ 6.002, • One source document per inmate-patient (40) 7.001, 12.001/12.002, & 14.002 Complete and Documents for • Any incorrectly scanned eUHR document Accurate Scanning any tested inmate identified during OIG eUHR file review, e.g., mislabeled, misfiled, illegibly scanned, or missing Returns from Inpatient Claims • Date (2–8 months) Community Hospital Data • Most recent 6 months provided (within date range) (30) • Rx count • Discharge date • Randomize (each month individually) • First 5 inmate-patients from each of the 6 months (if not 5 in a month, supplement from another, as needed) Medical Inspection Unit Page 89 Office of the Inspector General State of California Sample Category Quality (number of Indicator patients) Data Source Filters Health Care Clinical Areas OIG Inspector • Identify and inspect all onsite clinical areas. Environment (number varies by Onsite Review institution) Inter- and Intra-System SOMS • Arrival date (3–9 months) Intra-System transfers • Arrived from (another CDCR facility) Transfers (30) • Rx count • Randomize Specialty Service MedSATS • Date of Transfer (3–9 months) Send-outs • Randomize (20) Pharmacy and Chronic Care OIG Q: 1.001 See Access to Care Medication Medication • (At least one condition per inmate-patient—any Management (30—Basic Level) risk level) (40—Inter Level) • Randomize New Medication Master Registry • Rx Count Orders • Randomize (30—Basic Level) • Ensure no duplication of inmate-patients tested in (40—Inter Level) chronic care medications Intra-Facility moves MAPIP Transfer • Date of transfer (2–8 months) (30) Data • To location/from location (yard to yard and to/from ASU) • Remove any to/from MHCB • NA/DOT meds (high–low)–inmate-patient must have NA/DOT meds to qualify for testing • Randomize En Route SOMS • Date of transfer (2–8 months) (10) • Sending institution (another CDCR facility) • Randomize • Length of stay (minimum of 2 days) • NA/DOT meds Returns from Inpatient Claims • See Health Information Management (Medical Community Hospital Data Records) (returns from community hospital) (30) Medication OIG Inspector • Identify and inspect onsite clinical areas that Preparation and Onsite Review prepare and administer medications Administration Areas Pharmacy OIG Inspector • Identify and inspect onsite pharmacies Onsite Review Medication Error OIG Inspector • Any medication error identified during OIG eUHR Reporting Review file review, e.g., case reviews and/or compliance testing Prenatal and Recent Deliveries OB Roster • Delivery date (2–12 months) Post-delivery (5) • Most recent deliveries (within date range) Services N/A at this institution Pregnant Arrivals OB Roster • Arrival date (2–12 months) (5) • Earliest arrivals (within date range) N/A at this institution Medical Inspection Unit Page 90 Office of the Inspector General State of California Sample Category Quality (number of Indicator patients) Data Source Filters Preventive Chronic Care OIG Q: 1.001 • Chronic care conditions (at least 1 condition per Services Vaccinations inmate-patient—any risk level) (30—Basic Level) • Randomize (40—Inter Level) • Condition must require vaccination(s) Not all conditions require vaccinations INH Maxor • Dispense date (past 9 months) (all applicable up to • Time period on INH (at least a full 3 months) 30) • Randomize Colorectal Screening SOMS • Arrival date (at least 1 year prior to inspection) (30) • Date of birth (51 or older) • Randomize Influenza SOMS • Arrival date (at least 1 year prior to inspection) Vaccinations • Randomize (30) • Filter out inmate-patients tested in chronic care vaccination sample TB Code 22, annual SOMS • Arrival date (at least 1 year prior to inspection) TST • TB Code (22) (15) • Randomize TB Code 34, annual SOMS • Arrival date (at least 1 year prior to inspection) screening • TB Code (34) (15) • Randomize Mammogram SOMS • Arrival date (at least 2 years prior to inspection) (30) • Date of birth (age 52–74) • Randomize N/A at this institution Pap Smear SOMS • Arrival date (at least three years prior to (30) inspection) • Date of birth (age 24–53) N/A at this institution • Randomize Valley Fever Cocci Transfer • Reports from past 2–8 months (number will vary) Status Report • Institution • Ineligibility date (60 days prior to inspection date) N/A at this institution • All Reception RC SOMS • Arrival date (2–8 months) Center Arrivals (20) • Arrived from (county jail, return from parole, etc.) • Randomize N/A at this institution Specialized OHU, CTC, SNF, CADDIS • Admit date (1–6 months) Medical Hospice • Type of stay (no MH beds) Housing (10 per housing area) • Length of stay (minimum of 5 days) • Randomize Medical Inspection Unit Page 91 Office of the Inspector General State of California Sample Category Quality (number of Indicator patients) Data Source Filters Specialty High-Priority MedSATS • Appt. date (3–9 months) Services Access (10) • Randomize Routine MedSATS • Appt. date (3–9 months) (10) • Remove optometry, physical therapy or podiatry • Randomize Specialty Service MedSATS • Sending institution Arrivals • Date of transfer (3–9 months) (20) • Sent to (another CDCR facility) • Randomize Denials InterQual • Review date (3–9 months) (20)* • Randomize IUMC/MAR • Meeting date (9 months) *Ten InterQual Meeting Minutes • Denial upheld Ten MARs • Randomize Internal Medical Appeals Monthly Medical • Medical appeals (12 months) Monitoring, (all) Appeals Reports Quality Adverse/Sentinel Adverse/Sentinel • Adverse/sentinel events (2–8 months) Improvement Events Events Report and (5) Administrative QMC Meetings Quality • Meeting minutes (12 months) Operations (12) Management Committee Meeting Minutes Performance Performance • Performance Improvement Work Plan with Improvement Plans Improvement updates (12 months) (12) Work Plan Local Governing Local Governing • Meeting minutes (12 months) Body Body Meeting (12) Minutes EMRRC EMRRC • Meeting minutes (6 months) (6) Meeting Minutes Medical Emergency OIG Inspector • Most recent full quarter Response Drills Onsite Review • Each watch (3) 2nd Level Medical OIG Inspector • Medical appeals denied (6 months) Appeals Onsite Review (10) Death Reports OIG Inspector • Death reports (12 months) (10) Onsite Review Local Operating OIG Inspector • Review all Procedures Onsite Review (all) Medical Inspection Unit Page 92 Office of the Inspector General State of California Sample Category Quality (number of Indicator patients) Data Source Filters Job Performance RN Review OIG Inspector • Current Supervising RN reviews and Training, Evaluations Onsite Review Licensing and (5) Certifications Nursing Staff OIG Inspector • Review annual competency validations Validations Onsite Review • Randomize (10) Provider Annual OIG Inspector • All required performance evaluation documents Evaluation Packets Onsite Review (all) Medical Emergency OIG Inspector • All staff Response Onsite Review Providers (ACLS) o Certifications Nursing (BLS/CPR) o (all) Custody (CPR/BLS) o Nursing staff and OIG Inspector • All licenses and certifications Pharmacist-in-charge Onsite Review Professional Licenses and Certifications (all) Pharmacy and OIG Inspector • All current DEA registrations Providers’ Drug Onsite Review Enforcement Agency (DEA) Registrations (all) Nursing Staff New OIG Inspector • New employees (within the last 12 months) Employee Onsite Review Orientations (all) Medical Inspection Unit Page 93 Office of the Inspector General State of California C C ALIFORNIA ORRECTIONAL H C S ’ EALTH ARE ERVICES R ESPONSE Medical Inspection Unit Page 94 Office of the Inspector General State of California