Correctional Training Facility Medical Inspection Report Cycle 5

Roy W. Wesley Office of the Inspector General Inspector General Correctional Training Facility Medical Inspection Results Cycle 5 June 2018 Medical Inspection Unit Page 1 Office of the Inspector General State of California Office of the Inspector General CORRECTIONAL TRAINING FACILITY Medical Inspection Results Cycle 5 Roy W. Wesley Inspector General Bryan B. Beyer Chief Deputy Inspector General Shaun R. Spillane Public Information Officer June 2018 T C ABLE OF ONTENTS Foreword ........................................................................................................................................ i Executive Summary ...................................................................................................................... iii Overall Rating: Inadequate ........................................................................................................ iii Clinical Case Review and OIG Clinician Inspection Results .............................................. v Compliance Testing Results ............................................................................................. vi Recommendations ........................................................................................................... vii Population-Based Metrics ................................................................................................ vii Introduction ................................................................................................................................... 1 About the Institution ................................................................................................................... 1 Objectives, Scope, and Methodology.............................................................................................. 4 Case Reviews ............................................................................................................................. 5 Patient Selection for Retrospective Case Reviews .............................................................. 6 Benefits and Limitations of Targeted Subpopulation Review ............................................. 7 Case Review Sampling Methodology ................................................................................ 7 Breadth of Case Reviews ................................................................................................... 8 Case Review Testing Methodology.................................................................................... 9 Compliance Testing .................................................................................................................. 11 Sampling Methods for Conducting Compliance Testing................................................... 11 Scoring of Compliance Testing Results............................................................................ 12 Overall Quality Indicator Rating for Case Reviews and Compliance Testing ............................. 12 Population-Based Metrics ......................................................................................................... 13 Medical Inspection Results .......................................................................................................... 14 Access to Care ............................................................................................................ 17 Case Review Results ....................................................................................................... 17 Compliance Testing Results ............................................................................................ 19 Diagnostic Services .................................................................................................... 21 Case Review Results ....................................................................................................... 21 Compliance Testing Results ............................................................................................ 22 Emergency Services .................................................................................................... 23 Case Review Results ....................................................................................................... 23 Health Information Management ................................................................................ 26 Case Review Results ....................................................................................................... 26 Compliance Testing Results ............................................................................................ 27 Health Care Environment ........................................................................................... 29 Compliance Testing Results ............................................................................................ 29 Inter- and Intra-System Transfers ............................................................................... 32 Case Review Results ....................................................................................................... 32 Compliance Testing Results ............................................................................................ 34 Pharmacy and Medication Management ..................................................................... 36 Case Review Results ....................................................................................................... 36 Compliance Testing Results ............................................................................................ 38 Correctional Training Facility, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California Prenatal and Post-Delivery Services ........................................................................... 41 Preventive Services ..................................................................................................... 42 Compliance Testing Results ............................................................................................ 42 Quality of Nursing Performance................................................................................ 44 Case Review Results ....................................................................................................... 44 Quality of Provider Performance .............................................................................. 48 Case Review Results ....................................................................................................... 48 Reception Center Arrivals ......................................................................................... 53 Specialized Medical Housing .................................................................................... 54 Case Review Results ....................................................................................................... 54 Compliance Testing Results ............................................................................................ 55 Specialty Services ..................................................................................................... 56 Case Review Results ....................................................................................................... 56 Compliance Testing Results ............................................................................................ 57 Administrative Operations (Secondary) ..................................................................... 59 Compliance Testing Results ............................................................................................ 59 Recommendations ........................................................................................................................ 62 Population-Based Metrics ............................................................................................................ 63 Comparison of Population-Based Metrics..................................................................................... 63 Results of Population-Based Metric Comparison .......................................................................... 64 Comprehensive Diabetes Care ...................................................................................................... 64 Immunizations ............................................................................................................................. 64 Cancer Screening ......................................................................................................................... 64 Summary ..................................................................................................................................... 64 Appendix A — Compliance Test Results ..................................................................................... 66 Appendix B — Clinical Data ....................................................................................................... 79 Appendix C — Compliance Sampling Methodology .................................................................... 83 California Correctional Health Care Services’ Response .............................................................. 90 Correctional Training Facility, Cycle 5 Medical Inspection Table of Contents Office of the Inspector General State of California L T F IST OF ABLES AND IGURES CTF Executive Summary Table ..................................................................................................... iv CTF Health Care Staffing Resources as of August 2017 ................................................................. 2 CTF Master Registry Data as of July 31, 2017 ................................................................................ 3 Exhibit 1. Case Review Definitions ................................................................................................ 5 Chart 1. Case Review Sample Selection .......................................................................................... 8 Chart 2. Case Review Testing and Deficiencies ............................................................................ 10 Chart 3. Inspection Indicator Review Distribution ......................................................................... 14 CTF Results Compared to State and National HEDIS Scores ........................................................ 65 Table B-1: CTF Sample Sets ........................................................................................................ 79 Table B-2: CTF Chronic Care Diagnoses ...................................................................................... 80 Table B-3: CTF Event – Program ................................................................................................. 81 Table B-4: CTF Review Sample Summary ................................................................................... 82 Correctional Training Facility, Cycle 5 Medical Inspection List of Tables and Figures Office of the Inspector General State of California This page intentionally left blank. Correctional Training Facility, Cycle 5 Medical Inspection Office of the Inspector General State of California F OREWORD Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), the OIG conducts a comprehensive inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG explicitly makes no determination regarding the constitutionality of care in the prison setting. That determination is left to the Receiver and the federal court. The assessment of care by the OIG is just one factor in the court’s determination whether care in the prisons meets constitutional standards. The OIG’s inspections are mandated by the Penal Code and not aimed at specifically resolving the court’s questions on constitutional care. To the degree that they provide another factor for the court to consider, the OIG is pleased to provide added value to the taxpayers of California. In Cycle 5, for the first time, the OIG will be inspecting institutions delegated back to CDCR from the Receivership. There is no difference in the standards used for assessment of a delegated institution versus an institution not yet delegated. The receiver delegated the Correctional Training Facility back to CDCR in March 2016. This fifth cycle of inspections will continue evaluating the areas addressed in Cycle 4, which included clinical case review, compliance testing, and a population-based metric comparison of selected Healthcare Effectiveness Data Information Set (HEDIS) measures. In agreement with stakeholders, the OIG made changes to both the case review and compliance components. The OIG found that in every inspection in Cycle 4, larger samples were taken than were needed to assess the adequacy of medical care provided. As a result, the OIG reduced the number of case reviews and sample sizes for compliance testing. Also, in Cycle 4, compliance testing included two secondary (administrative) indicators (Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications). For Cycle 5, these have been combined into one secondary indicator, Administrative Operations. Correctional Training Facility, Cycle 5 Medical Inspection Page i Office of the Inspector General State of California This page intentionally left blank. Correctional Training Facility, Cycle 5 Medical Inspection Page ii Office of the Inspector General State of California E S XECUTIVE UMMARY The OIG performed its Cycle 5 medical inspection at Correctional Training Facility (CTF) from August to October of 2017. The inspection included in-depth reviews of 52 patient files conducted OVERALL RATING: by clinicians, as well as reviews of documents from 404 patient Inadequate files, covering 87 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 13 health care quality indicators applicable to the institution. To conduct clinical case reviews, the OIG employs a clinician team consisting of a physician and a registered nurse consultant, while compliance testing is done by a team of registered nurses trained in monitoring medical policy compliance. Of the applicable indicators, ten were rated by both case review clinicians and compliance inspectors, three were rated by case review clinicians only, and three were rated by compliance inspectors only. The CTF Executive Summary Table on the following page identifies the applicable individual indicators and scores for this institution. The OIG experts made a considered and measured overall opinion that the quality of health care at CTF was inadequate. Correctional Training Facility, Cycle 5 Medical Inspection Page iii Office of the Inspector General State of California CTF Executive Summary Table Cycle 5 Cycle 4 Case Review Compliance Inspection Indicators Overall Overall Rating Rating Rating Rating 1—Access to Care Proficient Adequate Adequate Proficient 2—Diagnostic Services Proficient Adequate Proficient Adequate 3—Emergency Services Inadequate Not Applicable Inadequate Adequate 4—Health Information Proficient Proficient Proficient Inadequate Management 5—Health Care Environment Not Applicable Inadequate Inadequate Inadequate 6—Inter- and Intra-System Adequate Proficient Adequate Inadequate Transfers 7—Pharmacy and Medication Adequate Adequate Adequate Adequate Management 8—Prenatal and Post-Delivery Not Applicable Not Applicable Not Applicable Not Applicable Services 9—Preventive Services Not Applicable Adequate Adequate Inadequate 10—Quality of Nursing Adequate Not Applicable Adequate Adequate Performance 11—Quality of Provider Inadequate Not Applicable Inadequate Adequate Performance 12—Reception Center Arrivals Not Applicable Not Applicable Not Applicable Not Applicable 13—Specialized Medical Housing Adequate Inadequate Adequate Proficient 14—Specialty Services Adequate Adequate Adequate Inadequate 15—Administrative Operations Not Applicable Inadequate Inadequate Inadequate* (Secondary) *In Cycle 4, there were two secondary (administrative) indicators. This score reflects the average of those two scores. Correctional Training Facility, Cycle 5 Medical Inspection Page iv Office of the Inspector General State of California Clinical Case Review and OIG Clinician Inspection Results The clinicians’ case reviews sampled patients with high medical needs and included a review of more than 857 patient care events.1 Of the 13 indicators applicable to CTF, 10 were evaluated by clinician case review; three were proficient, five were adequate, and two were inadequate. When determining the overall adequacy of care, the OIG paid particular attention to the clinical nursing and provider quality indicators, as adequate health care staff can sometimes overcome suboptimal processes and programs. However, the opposite is not true; inadequate health care staff cannot provide adequate care, even though the established processes and programs onsite may be adequate. The OIG clinicians identify inadequate medical care based on the risk of significant harm to the patient, not the actual outcome. CTF experienced a severe decline in provider quality compared to Cycle 4. At the time of the OIG clinician onsite inspection, there were six provider vacancies. Since Cycle 4, five providers, including the chief physician and surgeon, had left CTF to join the medical staff in the adjacent state facility, Salinas Valley State Prison (SVSP). Another provider resigned while under review by the statewide Professional Practice Executive Committee (PPEC). The sudden loss of providers contributed significantly to the institution’s Cycle 5 overall rating. Program Strengths — Clinical • Diagnostic services at CTF were excellent. The institution almost always properly processed diagnostic orders. Each of the main clinics had an assigned phlebotomist for performing blood draws to ensure tests were completed timely. CTF also had an effective tracking process for its diagnostic procedures. • CTF staff retrieved and scanned medical records as soon as they received them; hospital records, diagnostic reports, and specialty service reports were readily available for providers to review. Program Weaknesses — Clinical • CTF’s emergency services were poor. Poor provider and nurse care placed patients at risk of harm. The Emergency Medical Response Review Committee (EMRRC) was ineffective and did not identify lapses in emergency care. • CTF providers performed poorly in multiple aspects of patient care, from emergency care, chronic care, hospital return, to specialty services. The OIG clinicians rated the Quality of Provider Performance indicator inadequate. 1 Each OIG clinician team includes a board-certified physician and registered nurse consultant with experience in correctional and community medical settings. Correctional Training Facility, Cycle 5 Medical Inspection Page v Office of the Inspector General State of California Compliance Testing Results Of the 13 health care indicators applicable to CTF, 10 were evaluated by compliance inspectors.2 Two indicators were proficient, five were adequate, and three were inadequate. There were 87 individual compliance questions within those ten indicators, generating 1,096 data points, which tested CTF’s compliance with California Correctional Health Care Services (CCHCS) policies and procedures.3 Those 87 questions are detailed in Appendix A — Compliance Test Results. Program Strengths — Compliance The following are some of CTF’s strengths based on its compliance scores on individual questions in the health care indicators: • The health information management team at CTF did an excellent job of supporting overall patient health by timely and accurately scanning, updating, and maintaining medical records in patients’ files. • CTF excelled at managing patient’s medical needs and providing continuity of patient care during the inter- and intra-facility transfer process, including initial health screenings and uninterrupted delivery of patients’ previously ordered medications. • The main pharmacy at CTF maintained security and cleanliness management protocols, safely stored medications, and maintained proper control of narcotic medications. • CTF did very well at ensuring that specialty services were either timely provided or appropriately denied to its patients. Program Weaknesses — Compliance The following are some of CTF’s weaknesses based on its compliance scores on individual questions in all the health care indicators: • Patients’ access to medical care was poor at CTF in several important areas. Chronic care medical appointments, requests for face-to-face nurse appointments, and provider follow-ups were often late or did not occur. • CTF staff at several medication lines did not safely store either refrigerated or non-refrigerated narcotic medications. • CTF’s medication nurses did not properly wash their hands and did not employ appropriate administrative controls and protocols when administering medications to patients. 2 The OIG’s compliance inspectors are trained registered nurses with expertise in CDCR policies regarding medical staff and processes. 3 The OIG used its own clinicians to provide clinical expert guidance for testing compliance in certain areas where CCHCS policies and procedures did not specifically address an issue. Correctional Training Facility, Cycle 5 Medical Inspection Page vi Office of the Inspector General State of California • Some of the administrative health care oversight functions of the institution were inadequate, including the reporting of “adverse events,” performing emergency medical response drills, examining death reviews, conducting provider performance appraisals, and providing new employee orientations. As these were administrative processes, these deficiencies did not affect the institution’s overall rating for Cycle 5. Recommendations Based on the results of the Cycle 5 medical inspection at CTF, the OIG recommends CTF provide additional EHRS training so that staff gain proficiency in using the built-in EHRS functions and can easily identify all orders that were active before a patient’s hospitalization. Additional training should help with some of the hospital return medication errors that CTF staff explained were due to their inability to identify previously active medication orders before a patient’s hospitalization. Population-Based Metrics In general, CTF performed sufficiently as measured by population-based metrics. In comprehensive diabetes care, CTF outperformed all state and national health care plans in four of the five diabetic measures; however, CTF scored lower than Kaiser, North and South regions, and the VA for diabetic blood pressure control. With regard to immunization measures, CTF scored higher than all reporting health plans for administering influenza vaccinations to younger adults but scored 2 percentage points lower than the VA in administering influenza vaccinations to older adults. CTF’s rates for colorectal cancer screening were excellent, outperforming all other state and national health plans. Overall, CTF performed well in its chronic care preventive services compared to other state and national plans. Correctional Training Facility, Cycle 5 Medical Inspection Page vii Office of the Inspector General State of California This page intentionally left blank. Correctional Training Facility, Cycle 5 Medical Inspection Page viii Office of the Inspector General State of California I NTRODUCTION Pursuant to California Penal Code Section 6126 et seq., which assigns the Office of the Inspector General (OIG) responsibility for oversight of the California Department of Corrections and Rehabilitation (CDCR), and at the request of the federal Receiver, the OIG developed a comprehensive medical inspection program to evaluate the delivery of medical care at each of CDCR’s 35 adult prisons. The OIG conducts a clinical case review and a compliance inspection, ensuring a thorough, end-to-end assessment of medical care within CDCR. Correctional Training Facility (CTF) was the 22nd medical inspection of Cycle 5. During the inspection process, the OIG assessed the delivery of medical care to patients using the primary clinical health care indicators applicable to the institution. The Administrative Operations indicator is secondary because it does not reflect the actual clinical care provided. ABOUT THE INSTITUTION Located five miles north of Soledad in Monterey County, CTF’s primary mission is to provide custody, care, treatment, and rehabilitation for Level I and II general population and sensitive needs inmates in three separate facilities. CTF is also a CDCR Reentry Hub, focusing on providing life skills for inmates through educational and work assignments to assist them toward a successful reintegration into communities throughout California. CTF runs multiple medical clinics where staff members handle non-urgent requests for medical services. The institution also treats patients needing urgent or emergent care in its triage and treatment area (TTA) and treats patients requiring outpatient health services and assistance with the activities of daily living in its Outpatient Housing Unit (OHU). In addition, patients who leave or arrive at the institution are screened in the institution’s receiving and release clinic. CCHCS has designated CTF 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. On August 8, 2016, the institution received national accreditation from the Commission on Accreditation for Corrections. This accreditation program is a professional peer review process based on national standards set by the American Correctional Association. Based on staffing data the OIG obtained from the institution, CTF’s vacancy rate among medical managers, primary care providers, supervisors, and rank-and-file nurses was 15 percent in August, 2017 with the highest vacancy percentages among primary care providers at 42 percent. There were also 14 health care staff members on extended leave. At the time of the OIG’s inspection, the CEO reported that there were ongoing challenges to health care staffing at CTF. The institution lost a chief physician and surgeon (CP&S) as well as six other primary care providers in January 2017. This left the facility without dedicated OHU or TTA coverage. CTF was mitigating the impact of its decreased staffing by utilizing tele-medicine and registry staff. Correctional Training Facility, Cycle 5 Medical Inspection Page 1 Office of the Inspector General State of California CTF Health Care Staffing Resources as of August 2017 Primary Care Nursing Management Nursing Staff Totals Providers Supervisors Description Number % Number % Number % Number % Number % Authorized 5 4% 12 10% 10.5 8% 96.4 78% 123.9 100% Positions Filled Positions 4 80% 7 58% 8.5 81% 86 89% 105.5 85% Vacancies 1 20% 5 42% 2 19% 10.4 11% 18.4 15% Recent Hires (within 12 0 0% 2 29% 3 35% 16 19% 21 20% months) Staff Utilized 0 0% 1 14% 0 0% 9 10% 10 9% from Registry Redirected Staff (to Non-Patient 2 50% 0 0% 1 12% 0 0% 3 3% Care Areas) Staff on 0 0% 0 0% 6 71% 8 9% 14 13% Extended Leave Note: CTF Health Care Staffing Resources data was not validated by the OIG. Correctional Training Facility, Cycle 5 Medical Inspection Page 2 Office of the Inspector General State of California As of July 31, 2017, the Master Registry for CTF showed that the institution had a total population of 5,083. Within that total population, 1.8 percent was designated as high medical risk, Priority 1 (High 1), and 4.7 percent were designated as high medical risk, Priority 2 (High 2). Patients’ assigned risk levels are based on the complexity of their required medical care related to their specific diagnoses, frequency of higher levels of care, age, and abnormal labs and procedures. High 1 has at least two high-risk conditions; High 2 has only one. Patients at high medical risk are more susceptible to poor health outcomes than those at medium or low medical risk. Patients at high medical risk also typically require more health care services than do patients with lower assigned risk levels. The table below illustrates the breakdown of the institution’s medical risk levels at the start of the OIG medical inspection. CTF Master Registry Data as of July 31, 2017 Medical Risk Level Number of Patients Percentage High 1 91 1.8% High 2 239 4.7% Medium 2,188 43.0% Low 2,565 50.5% Total 5,083 100% Correctional Training Facility, Cycle 5 Medical Inspection Page 3 Office of the Inspector General State of California O , S , M BJECTIVES COPE AND ETHODOLOGY In designing the medical inspection program, the OIG reviewed CCHCS policies and procedures, relevant court orders, and guidance developed by the American Correctional Association. The OIG also reviewed professional literature on correctional medical care; reviewed standardized performance measures used by the health care industry; consulted with clinical experts; and met with stakeholders from the court, the Receiver’s office, CDCR, the Office of the Attorney General, and the Prison Law Office to discuss the nature and scope of the OIG’s inspection program. With input from these stakeholders, the OIG developed a medical inspection program that evaluates medical care delivery by combining clinical case reviews of patient files, objective tests of compliance with policies and procedures, and an analysis of outcomes for certain population-based metrics. To maintain a metric-oriented inspection program that evaluates medical care delivery consistently at each state prison, the OIG identified 15 indicators (14 primary (clinical) indicators and one secondary (administrative) indicator) of health care to measure. The primary quality indicators cover clinical categories directly relating to the health care provided to patients, whereas the secondary quality indicator addresses the administrative functions that support a health care delivery system. The CTF Executive Summary Table on page iv of this report identifies these 15 indicators. The OIG rates each of the quality indicators applicable to the institution under inspection based on case reviews conducted by OIG clinicians and compliance tests conducted by OIG registered nurses. The case review results alone, the compliance test results alone, or a combination of both these information sources may influence an indicator’s overall rating. For example, the OIG derives the ratings for the primary quality indicators Quality of Nursing Performance and Quality of Provider Performance entirely from the case review done by clinicians, while the ratings for the primary quality indicators Health Care Environment and Preventive Services are derived entirely from compliance testing done by registered nurse inspectors. As another example, primary quality indicators such as Diagnostic Services and Specialty Services receive ratings derived from both sources. The OIG does not inspect for efficiency or cost-effectiveness of medical operations. Consistent with the OIG’s agreement with the Receiver, this report only addresses the quality of CDCR’s medical operations and its compliance with quality-related policies. Moreover, if the OIG learns of a patient needing immediate care, the OIG notifies the chief executive officer of health care services and requests a status report. Additionally, if the OIG learns of significant departures from community standards, it may report such departures to the institution’s chief executive officer or to CCHCS. Because these matters involve confidential medical information protected by state and federal privacy laws, the OIG does not include specific identifying details related to any such cases in the public report. Correctional Training Facility, Cycle 5 Medical Inspection Page 4 Office of the Inspector General State of California In all areas, the OIG is alert for opportunities to make appropriate recommendations for improvement. Such opportunities may be present regardless of the score awarded to any particular quality indicator; therefore, recommendations for improvement are not necessarily indicative of deficient medical care delivery. CASE REVIEWS The OIG added case reviews to the Cycle 4 medical inspections at the recommendation of its stakeholders, which continues in the Cycle 5 medical inspections. The following exhibit provides definitions that describe this process. Exhibit 1. Case Review Definitions Case = Sample = Patient An appraisal of the medical care provided to one patient over a specific period, which can comprise detailed or focused case reviews. Detailed Case Review A review that includes all aspects of one patient’s medical care assessed over a six-month period. This review allows the OIG clinicians to examine many areas of health care delivery, such as access to care, diagnostic services, health information management, and specialty services. Focused Case Review A review that focuses on one specific aspect of medical care. This review tends to concentrate on a singular facet of patient care, such as the sick call process or the institution’s emergency medical response. Case Review Event A direct or indirect interaction between the patient and the health care system. Examples of direct interactions include provider encounters and nurse encounters. An example of an indirect interaction includes a provider reviewing a diagnostic test and placing additional orders. Case Review Deficiency A medical error in procedure or in clinical judgment. Both procedural and clinical judgment errors can result in policy non-compliance, elevated risk of patient harm, or both. Adverse Deficiency A medical error that increases the risk of, or results in, serious patient harm. Most health care organizations refer to these errors as adverse events. Correctional Training Facility, Cycle 5 Medical Inspection Page 5 Office of the Inspector General State of California The OIG’s clinicians perform a retrospective case review of selected patient files to evaluate the care given by an institution’s primary care providers and nurses. Retrospective case review is a well-established review process used by health care organizations that perform peer reviews and patient death reviews. Currently, CCHCS uses retrospective case review as part of its death review process and in its pattern-of-practice reviews. CCHCS also uses a more limited form of retrospective case review when performing appraisals of individual primary care providers. Patient Selection for Retrospective Case Reviews Because retrospective case review is time consuming and requires qualified health care professionals to perform it, OIG clinicians must carefully select a sample of patient records. Accordingly, the group of patients the OIG targeted for case review carried the highest clinical risk and utilized the majority of medical services. The majority of patients selected for retrospective case review were high-utilizing patients with chronic care illnesses who were classified as high or medium risk. The reason the OIG targeted these patients for review is twofold: 1. The goal of retrospective case review is to evaluate all aspects of the health care system. Statewide, high-risk and high-utilization patients consume medical services at a disproportionate rate; 11 percent of the total patient population is high-risk and accounts for more than half of the institution’s pharmaceutical, specialty, community hospital, and emergency costs. 2. Selecting this target group for case review provides a significantly greater opportunity to evaluate all the various aspects of the health care delivery system at an institution. Underlying the choice of high-risk patients for detailed case review, the OIG clinical experts made the following three assumptions: 1. If the institution is able to provide adequate clinical care to the most challenging patients with multiple complex and interdependent medical problems, it is more likely to provide adequate care to patients with less complicated health care issues. Because clinical expertise is required to determine whether the institution has provided adequate clinical care, the OIG utilizes experienced correctional physicians and registered nurses to perform this analysis. 2. The health of less complex patients is more likely to be affected by processes such as timely appointment scheduling, medication management, routine health screening, and immunizations. To review these processes, the OIG simultaneously performs a broad compliance review. 3. Patient cases generated during death reviews, sentinel events (unexpected occurrences involving death or serious injury, or risk thereof), and hospitalizations are more likely to comprise high-risk patients. Correctional Training Facility, Cycle 5 Medical Inspection Page 6 Office of the Inspector General State of California Benefits and Limitations of Targeted Subpopulation Review Because the patients selected utilize the broadest range of services offered by the health care system, the OIG’s retrospective case review provides adequate data for a qualitative assessment of the most vital system processes (referred to as “primary quality indicators”). Retrospective case 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 institution’s ability to respond with adequate medical care to this subpopulation is a crucial and vital indicator of how the institution provides health care to its whole patient population. Simply put, if the institution’s medical system does not respond adequately 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 medical conditions or outcomes from the retrospective case reviews to the general population. For example, if the high-risk diabetic patients reviewed have poorly controlled diabetes, one cannot conclude that all the diabetics’ conditions are poorly controlled. Similarly, if the high-risk diabetic patients under review have poor outcomes, one cannot conclude that the entire diabetic population is having similarly poor outcomes. The OIG does not extrapolate conditions or outcomes, but instead extrapolates the institution’s response for those patients needing the most care because the response yields valuable system information. In the above example, if the institution responds by providing appropriate diabetic monitoring, medication therapy, and specialty referrals for the high-risk patients reviewed, then it is reasonable to infer that the institution is also responding appropriately to all the diabetics in the prison. However, if these same high-risk patients needing monitoring, medications, and referrals are not getting those needed services, it is likely that the institution is not providing appropriate diabetic services. Case Review Sampling Methodology Using a predefined case review sampling algorithm, OIG analysts apply various filters to each institution’s patient population. The various filters include medical risk status, number of prescriptions, number of specialty appointments, number of clinic appointments, and other health-related data. The OIG uses these filters to narrow down the population to those patients with the highest utilization of medical resources (see Chart 1, next page). To prevent selection bias, the OIG ensures that the same clinicians who perform the case reviews do not participate in the sample selection process. Correctional Training Facility, Cycle 5 Medical Inspection Page 7 Office of the Inspector General State of California Chart 1. Case Review Sample Selection Sample Selection Analysts apply filters to the population to obtain samples (S) with high utilization. Six permutations, Population or arrangements, of case review types are possible for each sample. S S MD RN MD RN MD RN S S S S D F D D F D Case = Sample = Patient MD RN RN D D F MD = Provider RN = Registered Nurse D = Detailed Review F = Focused Review The OIG’s case sample sizes matched those of other qualitative research. The empirical findings, supported by expert statistical consultants, showed adequate conclusions after 10 to 15 cases had undergone comprehensive, or detailed, clinician review. In qualitative statistics, this phenomenon is known as “saturation.” The OIG found the Cycle 4 medical inspection sample size of 30 for detailed physician reviews far exceeded the saturation point necessary for an adequate qualitative review. At the end of Cycle 4 inspections, the OIG re-analyzed the case review results using half the number of cases; there were no significant differences in the ratings. To improve inspection efficiency while preserving the quality of the inspection, the OIG reduced the number the samples for Cycle 5 medical inspections to the current levels. For most basic institutions, the OIG samples 20 cases for detailed physician review. For intermediate institutions and several basic institutions with larger high-risk populations, the OIG samples 25 cases. For California Health Care Facility, the OIG samples 30 cases for detailed physician review. Breadth of Case Reviews As indicated in Appendix B, Table B-1: CTF Sample Sets, the OIG clinicians evaluated medical records for 40 unique cases. Appendix B, Table B-4: CTF Case Review Sample Summary clarifies that both nurses and physicians reviewed medical records for 23 of those cases, for 52 reviews in total. Physicians performed detailed reviews of 20 cases, and nurses performed detailed reviews of 12 cases, totaling 32 detailed reviews. Nurses also performed a focused review for an additional 22 Correctional Training Facility, Cycle 5 Medical Inspection Page 8 Office of the Inspector General State of California cases. These reviews generated 857 case review events (Appendix B, Table B-3: CTF Event – Program). While the sample method specifically pulled only three chronic care patient records, i.e., three diabetes patients (Appendix B, Table-B1: CTF Sample Sets), the 40 unique patients sampled included patients with 125 chronic care diagnoses, including 9 additional patients with diabetes (for a total of 12) (Appendix B, Table B-2: CTF Chronic Care Diagnoses). The OIG’s sample selection tool allowed evaluation of many chronic care programs because the complex and high-risk patients selected from the different categories often had multiple medical problems. While the OIG did not evaluate every chronic disease or health care staff member, the OIG did assess for adequacy the overall operation of the institution’s system and staff. Case Review Testing Methodology A physician, nurse consultant, or both clinician inspectors review each case. The OIG clinician inspector can perform one of two different types of case review: detailed, or focused (see Exhibit 1, page 5, and Chart 1, page 8). As the OIG clinician inspector reviews the medical record for each sample, the inspector records pertinent interactions between the patient and the health care system. These interactions are also known as case review events. When an OIG clinician inspector identifies a medical error, the inspector also records these errors as case review deficiencies. If a deficiency is of such magnitude that it caused, or had the potential to cause, serious patient harm, then the OIG clinician records it as an adverse deficiency (see Chart 2, next page). Correctional Training Facility, Cycle 5 Medical Inspection Page 9 Office of the Inspector General State of California Chart 2. Case Review Testing and Deficiencies Case Review Testing The OIG clinicians examine the chosen samples, performing a detailed case review or a focused case review, to determine the events that occurred. Sample = Patient = Case No Deficiency Sample Events Deficiency A sample leading to events Deficiencies Not all events lead to deficiencies (medical errors); however, if there are errors, then the OIG clinicians determine whether any are adverse. Sample Events Deficiency* A sample leading to events with deficiencies observed Adverse * If a deficiency is serious Deficiency enough, the OIG clinician labels it adverse. When the OIG clinician inspectors have reviewed all cases, they analyze the deficiencies. OIG inspectors search for similar types of deficiencies to determine if a repeating pattern of errors existed. When the same type of error occurs multiple times, the OIG inspectors identify those errors as findings. When the error is frequent, the likelihood is high that the error is regularly recurring at the institution. The OIG categorizes and summarizes these deficiencies in one or more health care indicators in this report to help the institution focus on areas for improvement. Correctional Training Facility, Cycle 5 Medical Inspection Page 10 Office of the Inspector General State of California Additionally, the OIG physicians also rate each of the detailed physician cases for adequacy based on whether the institution met the patient’s medical needs and if it placed the patient at significant risk of harm. The cumulative analysis of these cases gives the OIG clinicians additional perspective to help determine whether the institution is providing adequate medical services or not.4 Based on the collective results of clinicians’ case reviews, the OIG clinicians rated each quality indicator proficient (excellent), adequate (passing), inadequate (failing). A separate confidential CTF Supplemental Medical Inspection Results: Individual Case Review Summaries report details the case reviews OIG clinicians conducted and is available to specific stakeholders. For further details regarding the sampling methodologies and counts, see Appendix B — Clinical Data, Table B-1; Table B-2; Table B-3; and Table B-4. COMPLIANCE TESTING Sampling Methods for Conducting Compliance Testing From August to October 2017, registered nurse inspectors attained answers to 87 objective medical inspection test (MIT) questions designed to assess the institution’s compliance with critical policies and procedures applicable to the delivery of medical care. To conduct most tests, inspectors randomly selected samples of patients for whom the testing objectives were applicable and reviewed their electronic unit health records. In some cases, inspectors used the same samples to conduct more than one test. In total, inspectors reviewed health records for 404 individual patients and analyzed specific transactions within their records for evidence that critical events occurred. Inspectors also reviewed management reports and meeting minutes to assess certain administrative operations. In addition, during the week of August 14, 2017, field registered nurse inspectors conducted a detailed onsite inspection of CTF’s medical facilities and clinics; interviewed key institutional employees; and reviewed employee records, logs, medical appeals, death reports, and other documents. This generated 1,096 scored data points to assess care. In addition to the scored questions, the OIG obtained information from the institution that it did not score. This included, for example, information about CTF’s plant infrastructure, protocols for tracking medical appeals and local operating procedures, and staffing resources. For Cycle 5 medical inspection testing, the OIG reduced the number of compliance samples tested for 18 indicator tests from a sample of 30 patients to a sample of 25 patients. The OIG also, upon 4 Regarding individual provider performance, the OIG did not design the medical inspection to be a focused search for poorly performing providers; rather, the inspection assesses each institution’s systemic health care processes. Nonetheless, while the OIG does not purposefully sample cases to review each provider at the institution, the cases usually involve most of the institutions’ providers. Providers would only escape OIG case review if institutional managers assigned poorly performing providers the care of low-utilizing and low--risk patients, or if the institution had a relatively high number of providers. Correctional Training Facility, Cycle 5 Medical Inspection Page 11 Office of the Inspector General State of California stakeholder agreement, removed some inspection tests that were either duplicated in the case reviews or of limited value. Lastly, for Cycle 4 medical inspections, the OIG tested two secondary (administrative) indicators; Internal Monitoring, Quality Improvement, and Administrative Operations; and Job Performance, Training, Licensing, and Certifications, and have combined these tests into one Administrative Operations indicator for Cycle 5 inspections. For details of the compliance results, see Appendix A — Compliance Test Results. For details of the OIG’s compliance sampling methodology, see Appendix C — Compliance Sampling Methodology. Scoring of Compliance Testing Results After compiling the answers to the 87 questions in the ten applicable indicators, the OIG derived a score for each indicator by calculating the percentage score of all Yes answers for each of the questions applicable to a particular indicator, then averaging those scores. Based on those results, the OIG assigned a rating to each quality indicator of proficient (greater than 85 percent), adequate (between 75 percent and 85 percent), or inadequate (less than 75 percent). OVERALL QUALITY INDICATOR RATING FOR CASE REVIEWS AND COMPLIANCE TESTING The OIG derived the final rating for each quality indicator by combining the ratings from the case reviews and from the compliance testing, as applicable. When combining these ratings, the case review evaluations and the compliance testing results usually agreed, but there were instances when the rating differed for a particular quality indicator. In those instances, the inspection team assessed the quality indicator based on the collective ratings from both components. Specifically, the OIG clinicians and registered nurse inspectors discussed the nature of individual exceptions found within that indicator category and considered the overall effect on the ability of patients to receive adequate medical care. To derive an assessment rating of the institution’s medical inspection, the OIG evaluated the various rating categories assigned to each of the quality indicators applicable to the institution, giving more weight to the rating results of the primary quality indicators, which directly relate to the health care provided to patients. Based on that analysis, OIG experts made a considered and measured opinion about the quality of health care observed. Correctional Training Facility, Cycle 5 Medical Inspection Page 12 Office of the Inspector General State of California POPULATION-BASED METRICS The OIG identified a subset of Healthcare Effectiveness Data Information Set (HEDIS) measures applicable to the CDCR patient population. To identify outcomes for CTF, the OIG reviewed some of the compliance testing results, randomly sampled additional patients’ records, and obtained CTF data from the CCHCS Master Registry. The OIG compared those results to HEDIS metrics reported by other statewide and national health care organizations. Correctional Training Facility, Cycle 5 Medical Inspection Page 13 Office of the Inspector General State of California M I R EDICAL NSPECTION ESULTS The OIG’s case review and clinician teams use quality indicators to assess the clinical aspects of health care. The CTF Executive Summary Table on page iv of this report identifies the 13 indicators applicable to this institution. The following chart depicts their union and intersection: Chart 3. Inspection Indicator Review Distribution Case Review Compliance 1 — Access to Care 2 — Diagnostic Services 3 — Emergency 5 — Health Care Services 4 — Health Information Environment Management 10 — Quality of 9 — Preventive Nursing 6 — Inter- and Intra-System Services Performance Transfers 11 — Quality of 15 — Administrative 7 — Pharmacy and Medication Provider Operations Management Performance 13 — Specialized Medical Housing 14 — Specialty Services The Administrative Operations indicator is a secondary indicator; therefore, the OIG did not rely upon this indicator when determining the institution’s overall scores. Based on the analysis and results in all the primary indicators, the OIG experts made a considered and measured opinion that the quality of health care at CTF was inadequate. Summary of Case Review Results: The clinical case review component assessed 10 of the 12 primary (clinical) indicators applicable to CTF. Of these ten indicators, OIG clinicians rated three proficient, five adequate, and two inadequate. The OIG physicians rated the overall adequacy of care for each of the 20 detailed case reviews they conducted. Of these 20 cases, 11 were adequate and 9 were inadequate. In the 857 events reviewed, Correctional Training Facility, Cycle 5 Medical Inspection Page 14 Office of the Inspector General State of California there were 151 deficiencies, of which 59 were of such magnitude that, if left unaddressed, they would likely contribute to patient harm. Adverse Deficiencies Identified During Case Review: Adverse deficiencies are medical errors that cause, or that are more likely than not to cause, serious patient harm. Medical care is a complex and dynamic process with many moving parts, subject to human error even within the best health care organizations. Often called “adverse events,” they typically are identified and tracked by all major health care organizations for quality improvement. They are not generally representative of medical care delivered by the organization. The OIG identified adverse events for the dual purposes of quality improvement and the illustration of problematic patterns of practice found during the inspection. Because of the anecdotal nature of these events, the OIG cautions against drawing inappropriate conclusions regarding the institution based solely on adverse events. Six adverse deficiencies occurred in the case reviews at CTF: • In case 5, the patient had colon cancer and submitted four requests for symptoms related to his abdominal mass, abdominal pain, or back pain. The patient also had an ultrasound test that resulted in recommendations for further imaging tests to better identify the abdominal mass. Providers evaluated the patient on six occasions but did not assess for the return of cancer, which may have readily explained the patient’s symptoms. They also did not order the necessary imaging test. These errors placed the patient at risk for complications due to the delayed diagnosis of recurrent cancer. Four and a half months later, a general surgeon evaluated the patient and immediately transferred the patient to a community hospital, where the physicians found that cancer had spread widely into the patient’s liver. The Quality of Provider Performance indicator also discusses this case. • Also in case 5, the patient had returned from the hospital. The hospital physicians discovered that cancer had spread to his liver, where a blood clot had formed. The patient was taking anticoagulant blood thinners for the clot. The patient again went to the TTA with severe abdominal pain. The provider prescribed the patient a nonsteroidal anti-inflammatory drug (NSAID), which, in combination with the patient’s blood thinners, significantly increased the patient’s risk of serious bleeding. The Emergency Services indicator also discusses this case. • In case 12, the patient had never taken long-acting insulin for his diabetes. Nevertheless, a provider prescribed a high, long-acting insulin dose without monitoring the patient’s fasting blood sugar levels. By prescribing long-acting insulin without properly monitoring blood sugar, the provider placed the patient at risk of hypoglycemia, which could have led to serious harm, including coma or death. The Quality of Provider Performance indicator also discusses this case. • In case 15, the patient had blood in his stool, and a provider ordered an esophagogastroduodenoscopy (EGD, a test to look directly into the esophagus and Correctional Training Facility, Cycle 5 Medical Inspection Page 15 Office of the Inspector General State of California stomach) to look for a possible gastrointestinal bleeding or ulcers. While waiting for the EGD, the provider prescribed an NSAID medication in addition to aspirin, both of which increased the risk for bleeding and ulcers. The Quality of Provider Performance indicator also discusses this case. • In case 17, the patient had developed an open wound under his left big toe that hampered his ability to walk and to climb on and off an upper bunk. The patient was also blind in one eye and severely obese. The patient requested a lower-bunk accommodation, but the TTA provider did not order the accommodation. This decision placed the patient at risk of physical injury. The Emergency Services indicator also discusses this case. • In case 22, the patient had a persistent cough, chest pain, and shortness of breath. A computed tomography (CT) chest scan showed a mass causing obstruction and collapse of the left upper lung. The radiologist recommended a test to examine the mass directly and to perform a biopsy. The provider should have considered lung cancer as a possible diagnosis and should have ordered the test urgently. Instead, the provider requested a routine test, which was performed more than three months later. In addition, the patient made multiple health care service requests for persistent cough, difficulty breathing, chest pain, and fever. When CTF finally performed the test, the biopsy showed lung cancer. The delay in diagnosis placed the patient at increased risk of cancer complications, including death. The Quality of Provider Performance indicator also discusses this case. Summary of Compliance Results: The compliance component assessed ten of the 13 indicators applicable to CTF. Of these ten indicators, OIG inspectors rated two proficient, five adequate, and three inadequate. The results of those assessments are summarized within this section of the report. The test questions used to assess compliance for each indicator are detailed in Appendix A. Correctional Training Facility, Cycle 5 Medical Inspection Page 16 Office of the Inspector General State of California ACCESS TO CARE This indicator evaluates the institution’s ability to provide patients Case Review Rating: with timely clinical appointments. Areas specific to patients’ access Proficient to care are reviewed, such as initial assessments of newly arriving Compliance Score: inmates, acute and chronic care follow-ups, face-to-face nurse Adequate appointments when a patient requests to be seen, provider referrals (78.2%) from nursing lines, and follow-ups after hospitalization or specialty Overall Rating: care. Compliance testing for this indicator also evaluates whether Adequate patients have Health Care Services Request forms (CDCR Form 7362) available in their housing units. In this indicator, the OIG case review and compliance review processes yielded different results, with the case review giving a proficient rating and the compliance review resulting in an adequate score. Compliance testing identified delays with chronic care provider appointments as well as nurse to provider referrals for episodic care and new arrivals. Given the clinical importance of the compliance deficiencies identified, the OIG determined the overall rating of adequate was appropriate for this indicator. Case Review Results The OIG clinicians reviewed 567 provider, nurse, specialty, and hospital events that required a follow-up appointment and identified only 8 deficiencies. The case review rating for Access to Care was proficient. Provider-to-Provider Follow-up Appointments CTF performed well with scheduling provider-ordered follow-up appointments. These appointments are important elements of the Access to Care indicator. The OIG clinicians did not identify deficiencies in the form of delayed or dropped provider-to-provider follow-up appointments. RN Sick Call Access CTF performed well concerning sick call access. CTF scheduled most sick call appointments timely, as there was no reported backlog for nursing sick call appointments. The OIG clinicians reviewed 66 sick call events and identified only one significant deficiency: • In case 2, the patient submitted a sick call request for valley fever testing, and CTF staff scheduled an appointment. However, the appointment did not occur, which placed the patient at risk of a missed diagnosis and treatment of valley fever. CTF staff explained that the scheduling system automatically canceled the appointment when the patient was hospitalized, and the staff did not reschedule the appointment when he returned. Correctional Training Facility, Cycle 5 Medical Inspection Page 17 Office of the Inspector General State of California RN-to-Provider Referrals Sick call nurses are required to assess patients and make referrals to a provider if they determine it necessary based on their patient assessment. CTF performed well with access to RN-to-provider appointments; there were no deficiencies in the cases reviewed. RN Follow-up Appointments The institution performed well with scheduling and completing RN appointments that providers or other nurses generated. RN follow-up appointments were late or did not occur in three out of 12 applicable cases. There was only one significant deficiency: • In case 6, a provider requested a red blood cell count test daily for two days. The nurse was supposed to collect the specimens, but the follow-up appointments to perform the tests did not occur. These errors increased the patient’s risk of undiagnosed anemia. Intra-System Transfers CTF performed well by providing timely provider and RN appointments for patients who transferred in from other CDCR institutions. All patients who transferred into CTF had provider and RN appointments with 30 days. Additionally, CTF timely scheduled all patients who transferred with pending specialty appointments. Follow-up After Hospitalization Provider follow-up appointments after hospitalizations should occur in a period that ensures patient safety and optimal clinical outcomes. In all cases, the institution should schedule this follow-up no later than five days after the hospital discharge date. CTF performed well with access to these appointments, as there were no deficiencies identified in the cases reviewed. Specialized Medical Housing The providers saw patients in the outpatient housing unit (OHU) timely. They performed history and physical exams on all newly admitted patients promptly. There were also no deficiencies related to access to follow-up encounters from the OHU. Access to Specialty Services The OIG clinicians found that most specialty appointments occurred within requested time frames. However, there was one significant deficiency related to a missed specialty appointment, which the Specialty Services indicator discusses. Correctional Training Facility, Cycle 5 Medical Inspection Page 18 Office of the Inspector General State of California Provider Follow-Up after Specialty Service Visits After specialty service visits, all patients should be evaluated by a provider within 14 days or earlier if indicated. CTF performed well by providing access to these appointments; however, there was one notable deficiency: • In case 16, the patient had an offsite CT angiogram, but the provider appointment to address the CT angiogram findings did not occur until 26 days after the procedure. Follow-up After Urgent/Emergent Care CTF performed well with scheduling patients with their providers after TTA visits. All appointments occurred within the time frames specified as there were no identified deficiencies. Clinician Onsite Inspection During the onsite visit, clinic nurses reported seeing eight to ten patients each day in the RN clinics, and the providers were seeing about 10 to 15 patients each day. Each clinic had a designated office technician (OT) who attended daily clinic huddles and coordinated with the providers to ensure that all the important follow-up appointments were scheduled. The OTs indicated that there were no significant backlogs of provider appointments in the three main clinics and no nursing appointment backlogs in any of the clinics. Case Review Conclusion CTF performed well with Access to Care. Most provider, nursing, and specialty appointments occurred timely. The case review team rated this indicator at CTF proficient. Compliance Testing Results The institution performed in the adequate range in the Access to Care indicator, with a compliance score of 78.2 percent. In five of the nine applicable tests in the indicator, CTF received scores in the proficient range, as follows: • The one patient sampled who was referred to and seen by a provider and for whom that provider subsequently ordered a follow-up, received his appointment timely (MIT 1.006). • Patients had access to health care services request forms at all six housing units the OIG inspected (MIT 1.101). • Nursing staff reviewed 29 of 30 sampled Health Care Services Request forms (CDCR Form 7362) on the same day they received them (96.7 percent). For one patient, nursing staff reviewed the request form two days late (MIT 1.003). Correctional Training Facility, Cycle 5 Medical Inspection Page 19 Office of the Inspector General State of California • Among 25 sampled patients who were discharged from a community hospital, 22 (88.0 percent) received a timely provider follow-up appointment upon their return to CTF. Three patients received their appointments one, three, and four days late (MIT 1.007). • For 26 of the 30 patients sampled who submitted Health Care Services Request forms (CDCR Form 7362) (86.7 percent), nursing staff completed a face-to-face encounter within one business day of reviewing the service request form. For the remaining four sampled patients, nursing staff completed the face-to-face encounter from one to two days late (MIT 1.004). One test earned CTF an adequate score: • Inspectors sampled 27 applicable patients who received a specialty services appointment; 22 patients (81.5 percent) received their required provider follow-up appointments timely. Three patients received follow-up appointments 2, 7, and 15 days late; two patients did not receive a follow-up appointment at all (MIT 1.008). The following three tests revealed areas for improvement: • Inspectors sampled 25 patients with one or more chronic care conditions; only 17 patients (68.0 percent) received their provider-ordered follow-up appointments timely. Four patients’ appointments were between 5 and 47 days late, and for four other patients, there was no evidence a follow-up appointment occurred (MIT 1.001). • Among 30 Health Care Services Request forms (CDCR form 7362) sampled, only six patients were referred for a provider appointment by nursing staff. Of those six patients referred, four (66.7 percent) received their appointments timely. Two patients received their appointments one and 11 days late (MIT 1.005). • Among 25 patients sampled who transferred into CTF from other institutions, only 4 (16.0 percent) were timely seen by a provider based on their medical risk level. Four patients received their provider appointments 5, 17, 33, and 51 days late. For 17 patients, there was no medical record evidence found to indicate they were seen by a provider (MIT 1.002). Correctional Training Facility, Cycle 5 Medical Inspection Page 20 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 services Proficient were timely provided to patients, whether the primary care provider Compliance Score: timely reviewed the results, and whether the results were Adequate communicated to the patient within the required time frames. In (80.7%) addition, for pathology services, the OIG determines whether the Overall Rating: institution received a final pathology report and whether the Proficient provider timely reviewed and communicated the pathology results to the patient. The case reviews also factor in the appropriateness, accuracy, and quality of the diagnostic test(s) ordered and the clinical response to the results. In this indicator, the OIG case review and compliance review processes yielded different results, with the case review giving a proficient rating and the compliance review resulting in an adequate score. Compliance testing identified problems with the communication of diagnostic results to the patient. Most of these were because the provider neglected to specify the name of the test on the letter to the patient. The OIG’s internal review process considered those factors that led to both scores and found that the problems were not clinically significant. The OIG determined the overall rating of proficient was appropriate for this indicator. Case Review Results The OIG clinicians reviewed 150 events in diagnostic services and found only two deficiencies, one of which was significant. The case review rating for the Diagnostic Services indicator was proficient. Test Completion CTF had an effective laboratory process. Nearly all requested laboratory tests, X-rays, onsite ultrasounds, CT scans, and MRI scans were timely. Health Information Management CTF retrieved and scanned most lab reports, diagnostic procedure reports, and pathology reports into the medical records timely. However, there was a significant deficiency: • In case 19, the patient went to the hospital and received a heart muscle biopsy. CTF did not retrieve or scan the report into the medical record until almost three months later. Clinician Onsite Inspection CTF had an effective tracking process to ensure that staff completed diagnostic procedures timely. Each of the main clinics had an assigned phlebotomist to draw blood and to ensure prompt test completion. Correctional Training Facility, Cycle 5 Medical Inspection Page 21 Office of the Inspector General State of California Case Review Conclusion CTF performed well in this indicator. Deficiencies were rare, and the OIG clinicians identified no patterns of problems. The case review team rated the Diagnostic Services indicator at CTF proficient. Compliance Testing Results The institution received an adequate compliance score of 80.7 percent in the Diagnostic Services indicator, which encompasses radiology, laboratory, and pathology services. For clarity, each type of diagnostic service is discussed separately below: Radiology Services • Radiology services were performed timely, and diagnostic reports were timely reviewed, for all ten patients sampled (MIT 2.001, 2.002). Providers communicated the test results to seven of the ten patients timely (70.0 percent); for two patients, providers communicated test results seven and eight days late. For one sampled patient, there was no evidence that test results were communicated (MIT 2.003). Laboratory Services • Providers timely performed and timely reviewed all ten sampled laboratory services (MIT 2.004, 2.005). Providers timely communicated the results to seven of the ten sampled patients (70.0 percent); one patient received his results 15 days late; there was no evidence found that other two patients received their test results (MIT 2.006). Pathology Services • Clinicians at CTF timely received seven of ten sampled final pathology reports (70.0 percent). One report was received 43 days late, and there was no evidence that two reports were received by the institution (MIT 2.007). Providers timely reviewed the pathology results for seven of the eight reports received (87.5 percent). There was no evidence that the provider reviewed one report (MIT 2.008). Providers timely communicated the final pathology results to only two of the seven applicable patients (28.6 percent). For the other five patients, providers communicated pathology reports one, 6, 15, 26, and 62 days late (MIT 2.009). Correctional Training Facility, Cycle 5 Medical Inspection Page 22 Office of the Inspector General State of California EMERGENCY SERVICES An emergency medical response system is essential to providing effective and timely emergency medical response, assessment, Case Review Rating: treatment, and transportation 24 hours per day. Provision of Inadequate Compliance Score: urgent/emergent care is based on a patient’s emergency situation, Not Applicable clinical condition, and need for a higher level of care. The OIG reviews emergency response services including first aid, basic life Overall Rating: Inadequate support (BLS), and advanced cardiac life support (ACLS) consistent with the American Heart Association guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care, and the provision of services by knowledgeable staff appropriate to each individual’s training, certification, and authorized scope of practice. The OIG evaluates this quality indicator entirely through clinicians’ reviews of case files and conducts no separate compliance testing element. Case Review Results The OIG clinicians reviewed 16 patient cases that yielded 39 urgent/emergent events. There were 19 deficiencies, 8 of which were significant, in various aspects of emergency care. Emergency care was substandard for 5 of the 16 patients reviewed. The case review rating for the Emergency Services indicator was inadequate. CPR Response In the emergency medical response cases reviewed, custody staff started CPR and promptly notified health care staff. Nursing staff responded to the scenes timely. Custody and nursing staff worked well to coordinate CPR after medical responders arrived on the scene. Provider Performance CTF providers performed poorly in emergency services. Multiple encounters in two cases were substandard due to provider performance. In those cases, there were five significant deficiencies: • In case 5, the patient had colon cancer and partial resection of the large bowel. He went to the TTA with severe abdominal pain. The nurse and the provider both identified a large mass in the patient’s abdominal area. This mass could have represented a recurrence of the patient’s cancer, but the provider failed to consider the possibility, even though an ultrasound performed two months prior confirmed the presence of the mass. Providers should have ordered urgent diagnostic tests to exclude recurrence or spread of cancer. The delayed or missed diagnosis of a possible return of cancer placed the patient at risk of harm. The provider sent the patient back to his housing with no provider follow-up, only a nurse follow-up. Correctional Training Facility, Cycle 5 Medical Inspection Page 23 Office of the Inspector General State of California • Also in case 5, the patient with colon cancer went to the TTA for the second time within four days for severe back pain. Back pain in patients with colon cancer could represent a dangerous condition if cancer spread to the spine. The provider should have performed complete back and lower extremity neurological examinations to test for this possibility. Instead, the provider released the patient back to his housing with no provider follow-up. These recurrent errors were not corrected until an offsite surgeon examined the patient and sent the patient to the hospital emergently. • Two weeks later in the same case, the patient had already returned from the hospital, where physicians had discovered that cancer had spread to his liver where a blood clot had formed. The patient was taking anticoagulant blood thinners for the clot. The patient again went to the TTA with severe abdominal pain. The provider prescribed the patient a nonsteroidal anti-inflammatory drug (NSAID), which, in combination with the patient’s blood thinners, significantly increased the risk of serious bleeding. Furthermore, the patient was suffering from cancer pain. The provider’s prescription of weak opioid pain medication was insufficient for the patient’s cancer pain. • Five days later in the same case, the patient returned to the TTA for similar complaints. A different provider repeated the same errors by prescribing NSAID medication and by not treating the patient’s cancer pain appropriately. • In case 17, the patient had developed an open wound under his left big toe, which hampered his ability to walk and to climb onto and off the upper bunk. The patient was also blind in one eye and severely obese. The patient requested a lower-bunk accommodation, but the TTA provider did not order the accommodation. This decision placed the patient at risk of physical injury. Nursing Performance Nurses at CTF did not consistently provide appropriate assessments and interventions during medical emergencies. Deficiencies in nursing assessment occurred in cases 1, 3, 5, 6, 13, and 17. Additionally, significant deficiencies in nursing intervention increased the risk of harm in the following three cases: • In case 4, the patient had pulmonary aspiration (foreign material in his respiratory tract) with low blood oxygen levels. The TTA nurse did not administer oxygen until nine minutes later. This placed the patient at risk for hypoxemia (low level of blood oxygen), which increased the risk of serious complications such as heart attack or coma. • In case 12, the diabetic patient had a critically high blood glucose level. The nurse did not perform a urine test to check for the presence of ketones, which may have suggested the diagnosis of diabetic ketoacidosis (a serious complication of poor glycemic control). Additionally, the nurse did not notify the provider of the critically high blood glucose level and did not order any provider follow-up. The patient was not treated for his poorly Correctional Training Facility, Cycle 5 Medical Inspection Page 24 Office of the Inspector General State of California controlled diabetes until a provider saw him two months later. These errors placed the patient at risk for diabetic complications. • In case 16, the patient complained of severe chest pain and the nurse administered nitroglycerin (medication to relieve chest pain). The nurse should have reassessed the patient’s chest pain within five minutes after each dose of nitroglycerin. Instead, the nurse did not reassess the chest pain until 20 minutes after administering the first dose of nitroglycerin, at which time the patient remained in severe pain. The nurse then administered a second dose of nitroglycerin but did not reassess the patient’s chest pain after that. The delay in treatment increased the patient’s risk of cardiac complications. Nursing Documentation The nurses’ documentation of emergency assessments and interventions showed room for improvement. The OIG clinicians identified minor nursing deficiencies in the form of incomplete or missing documentation, which was unlikely to increase the patients’ risk of harm. At times, nurses did not document the amount of oxygen administered to the patient or record what the automated external defibrillator analyzed (AED, a portable electronic device that automatically diagnoses life-threatening cardiac arrhythmias and can treat them with electrical shock therapy). Often, nursing staff did not document when the emergency medical response team arrived or departed with the patient. Documentation deficiencies occurred in cases 1, 2, 3, 4, 5, 16, and 19. Emergency Medical Response Review Committee The Emergency Medical Response Review Committee (EMRRC) met regularly and discussed emergency events. The committee discussed topics including timeline discrepancies, incomplete nursing assessments, and lack of documentation. The committee did not identify or discuss the substandard provider or nursing care that the OIG found. CTF managers planned to provide additional training to the nursing staff. Clinician Onsite Inspection During the onsite visit, the OIG clinicians found the TTA patient care area to be sufficient for providing emergent medical care. There were three medical beds. There were two RNs assigned to the TTA, but no provider was assigned to the TTA. During an emergent event, CTF nurses notified the patient’s clinic provider if the emergency occurred during clinic hours. After hours, TTA nurses notified the on-call provider for any medical concerns. Case Review Conclusion The substandard provider and nurse emergency performance placed patients at risk of harm. The OIG clinicians rated the CTF Emergency Services indicator inadequate. Correctional Training Facility, Cycle 5 Medical Inspection Page 25 Office of the Inspector General State of California HEALTH INFORMATION MANAGEMENT Health information management is a crucial link in the delivery of Case Review Rating: medical care. Medical personnel require accurate information in Proficient order to make sound judgments and decisions. This indicator Compliance Score: examines whether the institution adequately manages its health care Proficient information. This includes determining whether the information is (92.0%) correctly labeled and organized and available in the electronic Overall Rating: medical record; whether the various medical records (internal and Proficient external, e.g., hospital and specialty reports and progress notes) are obtained and scanned timely into the patient’s electronic medical record; whether records routed to clinicians include legible signatures or stamps; and whether hospital discharge reports include key elements and are timely reviewed by providers. Case Review Results The OIG clinicians reviewed 857 events and identified only 5 deficiencies related to health information management, 2 of which were significant. The case review rating for the Health Information Management indicator was proficient. Interdepartmental Transmission The OIG did not identify any problems in medical record transmission among the departments within the institution. Hospital Records The OIG clinicians reviewed 25 community hospitalizations and emergency department visits. The hospital records were retrieved, reviewed, and scanned into the medical records timely. There was only one significant deficiency: • In case 5, the patient visited a community emergency department. CTF staff did not retrieve or scan the medical report into the medical record until more than two months later. Missing Documents (Progress Notes and Forms) CTF Staff scanned nearly all nursing and provider progress notes into the medical record appropriately. However, there was one missing document: • In case 14, the patient refused an RN follow-up visit; however, the refusal form was not located in the patient’s medical record. Correctional Training Facility, Cycle 5 Medical Inspection Page 26 Office of the Inspector General State of California Laboratory, Diagnostic and Pathology Reports CTF staff retrieved and scanned laboratory, diagnostic procedure, and pathology reports into the medical records properly. However, there was one significant deficiency: • In case 19, the patient had heart problems and required hospitalization. During the hospital stay, doctors performed a heart muscle biopsy. CTF staff did not retrieve or scan the biopsy report into the medical record until almost three months later. Specialty Services Reports CTF staff retrieved and scanned specialty services reports into the medical record timely. There were no deficiencies in this area. Legibility Provider and nurses typed or dictated their progress notes; there were no legibility issues. Scanning Performance CTF staff scanned most documents accurately and timely. There only were two minor deficiencies related to scanning performance. Case Review Conclusion The OIG clinicians identified only rare deficiencies regarding health information management. The OIG clinicians rated the CTF Health Information Management indicator proficient. Compliance Testing Results With a compliance score of 92.0 percent, CTF performed in the proficient range in the Health Information Management indicator. Three tests scored in the proficient range, as follows: • CTF's medical record staff timely scanned all ten sampled non-dictated progress notes, patients’ initial health screening forms, and requests for health care services into the patients’ health record (MIT 4.001). • The medical records staff at CTF timely scanned community hospital discharge reports and treatment records into patients’ electronic medical records for all 20 sampled reports (MIT 4.004). • CTF scored 95.8 percent in its labeling and filing of documents scanned into patients’ electronic medical records. For this test, the OIG bases its score on allowing a maximum of 24 mislabeled or misfiled documents. Inspectors found one scanned document that was faded and illegible (MIT 4.006). Correctional Training Facility, Cycle 5 Medical Inspection Page 27 Office of the Inspector General State of California Two tests earned scores in the adequate range: • Inspectors reviewed hospital discharge reports and treatment records for 25 sampled patients sent by CTF to outside hospitals. For 21 of the 25 patients (84.0 percent), the discharge summary reports were complete and timely reviewed by the institution’s providers. For two patients, providers reviewed the hospital discharge summary reports one and two days late. There was no evidence of a discharge summary found in two patients’ electronic medical records (MIT 4.007). • Institution staff timely scanned 16 of 20 specialty service consultant reports sampled into the patients’ electronic medical records (80.0 percent). One high priority specialty consultant report was scanned seven days late. Two routine specialty service reports were scanned two days late and one final report was not received at all (MIT 4.003). Correctional Training Facility, Cycle 5 Medical Inspection Page 28 Office of the Inspector General State of California HEALTH CARE ENVIRONMENT This indicator addresses the general operational aspects of the Case Review Rating: institution’s clinics, including certain elements of infection control Not Applicable and sanitation, medical supplies and equipment management, the Compliance Score: availability of both auditory and visual privacy for patient visits, and Inadequate the sufficiency of facility infrastructure to conduct comprehensive (69.1%) medical examinations. Rating of this component is based entirely on Overall Rating: the compliance testing results from the visual observations inspectors Inadequate make at the institution during their onsite visit. This indicator is evaluated entirely by compliance testing. There is no case review portion. Compliance Testing Results The institution received an inadequate compliance score of 69.1 percent in the Health Care Environment indicator, showing the need for improvement in 6 of 11 test areas, as described below: • The non-clinic bulk medical supply storage areas did not meet the supply management process and support needs of the medical health care program, earning CTF a score of zero. Several sterile liquid bottles were accumulating condensation in a non-temperature-controlled warehouse. The digital thermometer monitoring warehouse temperature was non-operational at the time of the OIG’s inspection (MIT 5.106). • Inspectors found that 6 of the 13 clinics (46.2 percent) followed Figure 1: Personal and food items stored in medical adequate medical supply storage and supplies storage area. management protocols. Seven clinic storage rooms displayed one or more of the following deficiencies: medical supplies were stored beyond manufacturers guidelines; medical supplies were not orderly or clearly identifiable; staff’s personal items were stored in the same area as medical supplies (Figure 1); and disinfectant agents were stored in the same area with medical supplies (MIT 5.107). Correctional Training Facility, Cycle 5 Medical Inspection Page 29 Office of the Inspector General State of California • Clinicians whom inspectors observed in 7 of 12 clinics adhered to universal hand hygiene precautions (58.3 percent). In five clinics, clinicians did not sanitize or wash their hands prior to putting on gloves and after physically assessing patients (MIT 5.104). • Common areas at six of nine clinics had an environment conducive to providing medical services (66.7 percent). The location of triage and blood draw stations in two clinics compromised patients’ auditory privacy. One clinic was unable to accommodate a wheelchair, and medical staff had insufficient working space (MIT 5.109). • Among 13 clinic locations, 9 (69.2 percent) met compliance requirements for essential core medical equipment and supplies. Figure 2: The location of triage and blood draw stations The remaining four clinics were in clinics compromised patients’ auditory privacy. missing one or more functional pieces of properly calibrated core equipment or other medical supplies necessary to conduct comprehensive exams. The missing items included a demarcation line for the Snellen eye examination chart, a nebulization unit, and an examination table. An ophthalmoscope was non-operational, and a digital thermometer did not have calibration sticker (MIT 5.108). • Nine of 13 clinic exam rooms (69.2 percent) had appropriate space, configuration, supplies, and equipment to allow clinicians to perform proper clinical examinations. In four clinics, one or more of the following deficiencies were identified: the exam table vinyl cover was torn; furniture was in disrepair; confidential records were clearly visible and easily accessible; exam rooms had inadequate space for providing medical services; and an exam table was obstructed so patients could not lie fully extended (MIT 5.110). Two tests earned CTF adequate scores: • Clinical health care staff at 9 of 12 applicable clinics (75.0 percent) ensured that reusable invasive and non-invasive medical equipment was properly sterilized or disinfected. In three clinics, the following deficiencies were identified: clinics did not properly process, package, or store previously sterilized instruments; inspectors observed staff not replace the exam table paper between patient encounters; and clinicians relied on porters to disinfect examination tables before starting their shifts (MIT 5.102). Correctional Training Facility, Cycle 5 Medical Inspection Page 30 Office of the Inspector General State of California • The institution scored 83.3 percent when inspectors examined emergency response bags in clinics to determine if clinical staff inspected the bags daily and inventoried them monthly, and whether the bags contained all essential items. Five of the six clinics’ bags were compliant; in one clinic, the EMRB log was missing one entry evidencing that staff verified the bag’s compartments were sealed and intact (MIT 5.111). Three tests in this indicator received scores in the proficient range: • All 13 clinic locations inspected had operable sinks and sufficient quantities of hand hygiene supplies in the exam areas (MIT 5.103). • When inspecting for proper protocols to mitigate exposure to blood borne pathogens and contaminated waste, the OIG inspectors found all clinics compliant (MIT 5.105). • Among 13 clinics examined, 12 (92.3 percent) were appropriately disinfected, cleaned, and sanitized. In one clinic, the staff did not maintain the cleaning log (MIT 5.101). Non-Scored Results • The OIG gathered information to determine if the institution’s physical infrastructure was maintained in a manner that supported health care management’s ability to provide timely or adequate health care. The OIG does not score this question. When OIG inspectors interviewed health care managers, they did not identify any significant concerns. At the time of the OIG’s medical inspection, CTF had several significant infrastructure projects underway, which included increasing clinic space at four yards, renovation of TTA, and expanding medication distribution rooms. These projects started in the fall of 2015, and the institution estimates that these projects will be completed by the end of summer 2018 (MIT 5.999). Correctional Training Facility, Cycle 5 Medical Inspection Page 31 Office of the Inspector General State of California INTER- AND INTRA-SYSTEM TRANSFERS This indicator focuses on the management of patients’ medical needs Case Review Rating: and continuity of patient care during the inter- and intra-system Adequate transfer process. The patients reviewed for this indicator include Compliance Score: those received from, as well as those transferring out to, other CDCR Proficient institutions. The OIG review includes evaluation of the institution’s (92.5%) ability to provide and document health screening assessments, Overall Rating: initiation of relevant referrals based on patient needs, and the Adequate continuity of medication delivery to patients arriving from other institutions. For those patients, the OIG clinicians also review the timely completion of pending health appointments, tests, and requests for specialty services. For patients who transfer out of the institution, the OIG evaluates the ability of the institution to document transfer information that includes pre-existing health conditions, pending appointments, tests and requests for specialty services, medication transfer packages, and medication administration prior to transfer. The OIG clinicians also evaluate the care provided to patients returning to the institution from an outside hospital and check to ensure appropriate implementation of the hospital assessment and treatment plans. In this indicator, the OIG case review and compliance review processes yielded different results, with the case review giving an adequate rating and the compliance review resulting in a proficient score. Case review testing identified problems with nurses who did not assess patients that were transferring to other CDCR institutions. Also, CTF occasionally made errors for patients that returned from an outside hospital. The OIG’s internal review process considered those factors that led to both scores and found that the case review findings were clinically significant. The OIG determined the overall rating of adequate was appropriate for this indicator. Case Review Results The OIG clinicians reviewed 19 cases and 65 inter- and intra-system transfer events, including information from both the sending and receiving institutions. These included 25 hospitalizations and outside emergency room visits, each of which resulted in a transfer back to the institution. There were 17 deficiencies, 7 of which were significant. The case review rating for the Inter- and Intra- System Transfers indicator was adequate. Transfers In CTF’s transfer-in process was acceptable. CTF staff generally ensured medication continuity for patients who arrived without their medications and provided appropriate medical accommodations. In the five transfers-in cases reviewed, one significant deficiency occurred: Correctional Training Facility, Cycle 5 Medical Inspection Page 32 Office of the Inspector General State of California • In case 23, the newly arrived patient with hypertension did not receive his blood pressure medications until two days after his arrival at CTF. The patient also did not receive his other medications until 15 days after arrival. Transfers Out CTF’s transfer-out process was problematic. Nursing staff did not always facilitate an organized process for patients who transferred to other institutions. Of the four transfers-out cases reviewed, nurses did not complete transfer information in three of them (cases 26, 27, and 28). Nurses also did not consistently examine patients before transfer. • In case 26, the nurse did not assess the patient before the patient’s transfer. Subsequently, CTF did not send some of the patient’s health information and medical equipment to the next institution. The patient had sleep apnea (temporary cessation of breathing during sleep), but CTF did not send the patient’s breathing machine to the receiving institution. Without the breathing machine, the patient was at higher risk for low oxygen levels and heart rhythm disturbances while he slept. Hospitalizations Patients returning from hospitalizations are some of the highest-risk encounters due to two factors. First, these patients usually require hospitalization for a severe illness or injury. Second, they are at risk due to potential lapses in care that can occur during the transfer. In all 25 reviewed cases in which patients returned from the hospital or emergency department, CTF successfully scheduled a provider follow-up within five days. However, nurses did not consistently make complete assessments for patients returning from the hospital. This deficiency occurred in cases 1, 2, 20, and the following: • In case 17, the nurse did not complete an assessment for a patient who returned from the hospital with a leg infection and a foot ulcer. CTF did not always maintain medication continuity for patients who returned from the hospital. • In case 19, the patient with kidney disease returned from the hospital with recommendations for certain blood pressure medications. Instead of following the hospital recommendations, CTF staff mistakenly prescribed the patient two medications that were similar. This combination of medications could have worsened the patient’s kidney condition and caused electrolyte imbalances. • In case 20, the patient returned from the hospital with diagnoses of high blood pressure and a stroke. The hospital physician recommended that the patient be given blood pressure medications and aspirin. The patient did not receive the medications until two days after he returned, which placed him at risk of untreated elevated blood pressure and recurrent stroke. Correctional Training Facility, Cycle 5 Medical Inspection Page 33 Office of the Inspector General State of California Also, CTF staff did not always retrieve, review, or sign the hospital discharge summaries. This deficiency occurred in cases 5 and 9. Clinician Onsite Inspection The receiving and release clinic nurse was highly knowledgeable about job duties and the transfer process. Nurses in the TTA completed patient assessments and consistently reviewed hospital discharge recommendations with providers. The OIG clinicians discussed the case review deficiencies with medical and nursing management. CTF managers acknowledged the deficiencies and indicated that they would provide additional nurses’ training. The pharmacist in charge (PIC) explained that the format of the electronic medical record did not allow medical staff to identify easily a patient’s medication orders that were active before staff sent the patient out to a community hospital. The PIC said that the medication list was not intended to be used for medication reconciliation and that it gave misleading information, resulting in errors, which occurred in case 19. Case Review Conclusion Though CTF performed well for patients transferring into the institution, it had difficulty with patients who transferred to other institutions. CTF also demonstrated inconsistent performance for those who returned from the hospital. Overall, CTF performance regarding Inter- and Intra-System Transfers indicator was acceptable, but there was room for improvement. The indicator rating was adequate. Compliance Testing Results The institution obtained a proficient score of 92.5 percent in the Inter- and Intra-System Transfers indicator, with four of five tests earning proficient scores, as described below: • For all 25 sampled patients who transferred into CTF from other CDCR institutions, nursing staff completed an Initial Health Screening form (CDCR Form 7277) on the same day the patient arrived (MIT 6.001). • Nursing staff timely completed the assessment and disposition sections of the screening form for all 25 patients received by CTF from other CDCR institutions (MIT 6.002). • The OIG inspected the transfer packages of two patients who were transferring out of CTF to determine whether the packages included required medications and supporting documentation. Inspectors concluded that both transfer packages were compliant (MIT 6.101). • Of the 25 sampled patients who transferred into CTF, 14 had an existing medication order upon arrival; 12 of those 14 patients (85.7 percent) received their medication without Correctional Training Facility, Cycle 5 Medical Inspection Page 34 Office of the Inspector General State of California interruption. One patient missed one dose of his medication, and one other patient missed two days’ doses of his medication (MIT 6.003). One test in this indicator received a score in the adequate range: • Inspectors sampled 13 patients who transferred out of CTF to other CDCR institutions to determine whether CTF identified scheduled specialty service appointments on the patients’ health care transfer forms. Nursing staff listed the pending specialty service appointments for 10 of 13 patients (76.9 percent). For one patient, CTF nurses did not document the pending specialty service on the transfer form; for two final patients, the transfer forms were not found (MIT 6.004). Correctional Training Facility, Cycle 5 Medical Inspection Page 35 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 management, Adequate encompassing the process from the written prescription to the Compliance Score: administration of the medication. By combining both a quantitative Adequate compliance test with case review analysis, this assessment identifies (75.2%) issues in various stages of the medication management process, Overall Rating: including ordering and prescribing, transcribing and verifying, Adequate dispensing and delivering, administering, and documenting and reporting. Because effective medication management is affected by numerous entities across various departments, this assessment considers internal review and approval processes, pharmacy, nursing, health information systems, custody processes, and actions taken by the prescriber, staff, and patient. Case Review Results The OIG clinicians evaluated pharmacy and medication management as a secondary process as they related to the quality of clinical care provided. Compliance testing is a more target approach and is heavily relied on for the rating of this indicator. The OIG clinicians reviewed 48 events related to medication management and found nine deficiencies, six of which were significant. The case review rating of the Pharmacy and Medication Management indicator was adequate. Medication Continuity CTF performed well with chronic care medication continuity. The OIG did not identify any deficiencies in this area. However, CTF did not consistently ensure medication continuity for patients returning from community hospitals or transferring from other institutions. In most cases reviewed, the patients received their medications without delay, but three significant deficiencies occurred during the transfer-in and the hospital return processes (cases 19, 20, and 23). The patients in these cases experienced breaks in medication continuity that increased their risk for medical complications. The Inter- and Intra-System Transfers indicator discusses these cases. Medication Administration CTF performed acceptably with medication administration. Patients at CTF usually received their self-administered and nurse-administered medications timely and as prescribed. Most nurses ensured that the correct patients received the correct medications and correct dosages at the correct times. The nurses compared all new medication prescriptions to the orders before administering the Correctional Training Facility, Cycle 5 Medical Inspection Page 36 Office of the Inspector General State of California medications. However, there was room for improvement in this area; the OIG found multiple occasions in which the patient did not receive medications as ordered. This deficiency occurred in cases 1, 15, 23 and the following: • In case 5, the pharmacist noted that the patient’s INR level (blood test for monitoring risk of bleeding) was high, discontinued the patient’s warfarin (blood thinner) for two days, and restarted the medication at a lower dose on the third day. However, the medication nurse erroneously administered the discontinued medication on the second day. This error placed the patient at risk for bleeding complications. Nurses discovered the error and completed a medication error report. Additionally, several system errors occurred with regard to discontinuing and reordering warfarin. CTF staff reported that these errors occurred due to the implementation of the new electronic medical record and staff members’ lack of familiarity with the new system and their inability to identify discontinued medications. • In case 17, a provider increased the dosage of the patient’s blood pressure medication lisinopril; however, the patient did not receive the increased dose until seven days later, placing the patient at risk of high blood pressure. Clinician Onsite Inspection During the onsite visit, the OIG clinicians met with providers, nursing staff, and the pharmacist to discuss case review findings. CTF staff acknowledged the deficiencies and provided information regarding the medication delays and errors. The medication nurses were knowledgeable regarding medication preparation and administration processes and procedures. Case Review Conclusion CTF performed well with chronic care medication continuity but had problems with ensuring medication continuity for patients who transferred into the institution or who returned from the hospital. CTF was also inconsistent with administering medications. Nevertheless, most patients received their medications without excessive delay, so the OIG clinicians rated the Pharmacy and Medication Management indicator adequate. Correctional Training Facility, Cycle 5 Medical Inspection Page 37 Office of the Inspector General State of California Compliance Testing Results The institution received an adequate compliance score of 75.2 percent in the Pharmacy and Medication Management indicator. For discussion purposes, this indicator is divided into three sub-indicators: medication administration, observed medication practices and storage controls, and pharmacy protocols. Medication Administration In this sub-indicator, the institution received an adequate score of 84.8 percent, with proficient scores on the following tests: • Chronic care medications were provided timely to all 20 patients sampled (MIT 7.001). • Nursing staff administered medications without interruption to all ten patients sampled who were en route from one institution to another with a temporary layover at CTF (MIT 7.006). The institution scored in the adequate range on the following tests: • Of the 25 sampled patients at CTF who had transferred from one housing unit to another, 21 (84.0 percent) received their prescribed medications without interruption. Three patients did not receive one or two doses of their medications at the next dosing interval after the transfer occurred; staff did not refer one other patient who refused medications multiple times (MIT 7.005). • The institution timely administered or delivered new medication orders to 19 of the 25 patients sampled (76.0 percent). For five patients, nursing staff administered the medications one to four days late; there was no evidence found that one patient received his medication (MIT 7.002). The institution received an inadequate score on the following test: • Clinical staff timely provided new and previously prescribed medications to 16 of 25 patients sampled who returned from a community hospital (64.0 percent). Seven patients received their medication one to five days late; there was no evidence found that two patients received their medication (MIT 7.003). Correctional Training Facility, Cycle 5 Medical Inspection Page 38 Office of the Inspector General State of California Observed Medication Practices and Storage Controls In this sub-indicator, the institution received an inadequate score of 58.5 percent, scoring in the inadequate range on the following tests: • Only two of the seven inspected medication preparation and administration areas demonstrated appropriate administrative controls and protocols (28.6 percent). At five different locations, one or more of the following deficiencies occurred: medication nurses did not always ensure that patients swallowed direct observation therapy medications; patients waiting to receive their medications did not have sufficient outdoor cover to protect them from heat or inclement weather; and a medication nurse discarded confidential patient medication records in the trash bin. OIG inspectors also observed CTF medication nurses not following manufacturers’ guidelines related to the proper administration of insulin to diabetic patients. Those guidelines require medication nurses to calibrate the glucometer before performing blood sugar checks and to disinfect previously opened multi-use insulin vials before withdrawing and administering medication (MIT 7.106). • CTF safely stored non-refrigerated, non-narcotic medications in 6 of the 12 applicable clinic and medication line storage locations (50.0 percent). In six locations, one or more of the following deficiencies occurred: topical and oral medications were not properly separated when stored; a medication cart was unlocked; and multi-use medications were not labeled with the date they were opened (MIT 7.102). • The institution employed adequate security controls over narcotic medications in five of the nine applicable clinic and medication line locations where narcotics were stored (55.6 percent). At four clinics, the following one or more deficiencies occurred: the narcotics log book lacked evidence on multiple dates that a controlled substance inventory was performed by two licensed nursing staff; medication nurses waited until the end of medication administration line to update the narcotics log book; and there was a discrepancy during the OIG inspectors’ spontaneous physical count of narcotics (MIT 7.101). • Inspectors observed the medication preparation and administration processes at seven applicable medication line locations. Nursing staff were compliant regarding proper hand hygiene and contamination control protocols at four locations (57.1 percent). At three locations, not all nursing staff washed or sanitized their hands when required, such as prior to putting on gloves or before re-gloving (MIT 7.104). • CTF safely stored refrigerated, non-narcotic refrigerated medications in 6 of 10 clinics and medication line storage locations (60.0 percent). At four locations, the following one or more deficiencies occurred: the medication area lacked a designated area for return-to-pharmacy refrigerated medications; refrigerator temperatures for non-narcotic medications were out of the required range; and other medication areas had previously Correctional Training Facility, Cycle 5 Medical Inspection Page 39 Office of the Inspector General State of California opened medications without identifiable labels with the date they were first opened (MIT 7.103). The institution scored in the proficient range on the following test: • Nursing staff at all seven of the inspected medication line locations employed appropriate administrative controls and followed appropriate protocols during medication preparation (MIT 7.105). Pharmacy Protocols In this sub-indicator, the institution received a proficient score of 85.6 percent, receiving proficient scores for the following tests: • In its main pharmacy, the institution followed general security, organization, and cleanliness management protocols; safely stored and monitored refrigerated and non-refrigerated non-narcotic medications; and maintained adequate controls over and properly accounted for narcotic medications (MIT 7.107, 7.108, 7.109, 7.110). The institution showed room for improvement in the following test: • OIG inspectors examined 25 medication error follow-up reports and medication error statistics generated by the institution’s pharmacist in charge (PIC). Only seven of the PIC’s 25 reports were timely or correctly processed (28.0 percent). The PIC at CTF did not complete 18 medication error follow-up reports within the required period. The institution’s PIC completed the reports between one to 34 days late (MIT 7.111). Non-Scored Tests • In addition to the OIG’s testing of reported medication errors, inspectors follow up on any significant medication errors that were found during the case reviews or compliance testing to determine whether the errors were properly identified and reported. The OIG provides those results for information purposes only. At CTF, the OIG did not find any applicable medication errors (MIT 7.998). • The OIG interviewed patients in isolation units to determine if they had immediate access to their prescribed KOP rescue inhalers and nitroglycerin medications. All nine applicable patients had access to their rescue inhalers or nitroglycerin medications (MIT 7.999). Correctional Training Facility, Cycle 5 Medical Inspection Page 40 Office of the Inspector General State of California PRENATAL AND POST-DELIVERY SERVICES This indicator evaluates the institution’s capacity to provide timely and appropriate prenatal, delivery, and postnatal services to pregnant Case Review Rating: patients. This includes the ordering and monitoring of indicated Not Applicable Compliance Score: screening tests, follow-up visits, referrals to higher levels of care, Not Applicable e.g., high-risk obstetrics clinic, when necessary, and postnatal follow-up. Overall Rating: Not Applicable Because CTF is a male-only institution, this indicator was not applicable. Correctional Training Facility, Cycle 5 Medical Inspection Page 41 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 patients. These include cancer screenings, Not Applicable tuberculosis screenings, and influenza and chronic care Compliance Score: immunizations. This indicator also assesses whether certain Adequate institutions take preventive actions to relocate patients identified as (81.3%) being at higher risk for contracting coccidioidomycosis Overall Rating: (valley fever). Adequate The OIG rates this indicator entirely through the compliance testing component; the case review process does not include a separate qualitative analysis for this indicator. Compliance Testing Results The institution performed in the adequate range for the Preventive Services indicator, with a compliance score of 81.3 percent and proficient scores in the following test areas: • Among 25 patients sampled, CTF timely gave or offered 24 (96.0 percent) influenza (flu) vaccinations during the most recent flu season. There was no medical record evidence that one patient received or refused the vaccination (MIT 9.004). • CTF timely administered tuberculosis (TB) medications to 16 of 17 patients sampled (94.1 percent). There was no evidence of one patient’s receipt or refusal of one dosage of TB medication (MIT 9.001). • Among 17 patients sampled, 16 (94.1 percent) received required monthly or weekly monitoring while taking TB medications. There was no evidence of one patient’s monitoring during one week of treatment (MIT 9.002). • Among 30 patients sampled, 28 (93.3 percent) received their annual TB screening timely. For two patients, CTF staff did not perform the TB screening during their birth months as required by CCHCS policy (MIT 9.003). • CTF offered colorectal cancer screenings to 23 of 25 sampled patients subject to the annual screening requirement (92.0 percent). For two patients, there was no medical record evidence that health care staff offered a colorectal cancer screening within the previous 12 months or that the patient had a normal colonoscopy within the last ten years (MIT 9.005). Correctional Training Facility, Cycle 5 Medical Inspection Page 42 Office of the Inspector General State of California The institution showed room for improvement in the following test: • For only 2 of the 11 applicable patients who suffered from a chronic condition, CTF offered required influenza, pneumonia, and hepatitis vaccinations (18.2 percent). For nine patients, there was no evidence that they either received or refused their required vaccinations (MIT 9.008). Correctional Training Facility, Cycle 5 Medical Inspection Page 43 Office of the Inspector General State of California QUALITY OF NURSING PERFORMANCE The Quality of Nursing Performance indicator is a qualitative Case Review Rating: evaluation of the institution’s nursing services. The evaluation is Adequate completed entirely by OIG nursing clinicians within the case review Compliance Score: process and does not have a score under the OIG compliance testing Not Applicable component. Case reviews include face-to-face encounters and Overall Rating: indirect activities performed by nursing staff on behalf of the patient. Adequate Review of nursing performance includes all nursing services performed onsite, such as outpatient, inpatient, urgent/emergent, inmate transfers, care coordination, and medication management. The key focus areas for evaluation of nursing care include appropriateness and timeliness of patient triage and assessment, identification and prioritization of health care needs, use of the nursing process to implement interventions, and accurate, thorough, and legible documentation. Although nursing services provided in specialized medical housing units are reported in the Specialized Medical Housing indicator, and those provided in the TTA or related to emergency medical responses are reported in the Emergency Services indicator, all areas of nursing services are summarized in this Quality of Nursing Performance indicator. Case Review Results The quality of nursing performance at CTF was adequate. The OIG clinicians reviewed 284 nursing encounters, 130 of which were in the outpatient setting. Most outpatient nursing encounters were for sick call requests, walk-in visits, and RN follow-up visits. In all, there were 76 deficiencies identified related to nursing care performance, 16 of which were significant. The case review rating of the Quality of Nursing Performance indicator was adequate. Nursing Assessment A major part of adequate nursing care is the quality of nursing assessment, which includes both subjective (patient interview) and objective (evaluation and observation) portions. The majority of CTF’s nurses documented sufficient subjective and objective assessments. However, some nursing assessments were incomplete. These problems occurred in cases 5, 13, 14, 15, 16, 17, 19, 24, 31, 34, and 35. Most of these deficiencies were minor and did not negatively affect patient care. The following examples, in contrast, were significant deficiencies: • In case 14, the patient had a history of coronary artery disease with stent placement. He complained of mid-chest pain after returning from a specialty appointment. The nurse did not assess the patient’s pain severity, type, or onset; this error placed the patient at risk of a missed diagnosis of a possible heart attack. Correctional Training Facility, Cycle 5 Medical Inspection Page 44 Office of the Inspector General State of California • In case 24, the nurse did not assess a patient who complained of ringing sounds in his ear, headaches, dizziness, and vomiting. The provider evaluated the patient four days later and found that he had an ear infection. Nursing Intervention Nurses at CTF usually provided appropriate and timely interventions based on subjective and objective assessments. Most nurses utilized the nursing protocols to implement nursing interventions. Deficiencies in this area were minor and usually consisted of nurses neglecting to measure a patient’s weight or blood pressure. Minor deficiencies such as these occurred in cases 5, 15, 19, 31, 32, 34, and 35. Nursing Documentation Overall, nursing documentation was appropriate. After assessing patients and providing interventions, nurses documented their information in the electronic medical record. In addition, nurses provided and documented patient education well. However, there were patterns of documentation deficiencies. At times in the TTA, nursing staff did not document when outside emergency medical services arrived or departed with the patient or the amount of oxygen administered to the patient during medical emergencies. Although these deficiencies were not significant, they displayed areas to target for quality improvement. Nursing Sick Call Most sick call nurses reviewed sick call requests the same day they received them and assessed patients within one business day. While most nurses performed appropriately and utilized CCHCS nursing protocols, sick call nurses did not always perform timely face-to-face assessment for patients with symptoms. However, in the administrative segregation unit (ASU) nurses frequently did not review sick call requests the same day they received them. The psychiatric technicians received sick call requests, but the sick call nurses did not review the requests until one to five days later. This finding occurred in cases 1, 2, 14, and the following: • In case 19, the patient had congestive heart failure and complained of worsening breathing problems. The nurse reviewed the sick call request but did not see the patient the same day. Instead, the nurse saw the patient three days later; fortunately, no harm occurred. • In case 30, the patient complained of having a fever and cold symptoms. The psychiatric technician received the sick call request, but the sick call nurse reviewed it five days later. The nurse should have reviewed the sick call request the same day staff received it. • In case 40, the sick call nurse did not assess the diabetic patient the same day the nurse reviewed the sick call request. The patient complained of an infected swollen toe with the presence of green drainage. Diabetic patients are at risk for developing pressure ulcers. The Correctional Training Facility, Cycle 5 Medical Inspection Page 45 Office of the Inspector General State of California nurse should have assessed the patient with potential lower leg and foot infections timely and treated him appropriately. Urgent/Emergent Care Nurses in the TTA and first medical responders did not consistently provide appropriate assessments and interventions to the patients during emergency medical responses. There were several significant deficiencies identified. The Emergency Services indicator further discusses these patients. Post-Hospital Returns TTA nurses assessed most patients returning to CTF after a hospital discharge appropriately. Patients usually received correct follow-up interventions and evaluations. The Inter- and Intra-System Transfers indicator further discusses this performance. Specialized Medical Housing Most patients in the OHU received appropriate assessments and interventions by the CTF nurses. At times, the OHU nurses failed to reassess abnormal vital signs promptly. The Specialized Medical Housing indicator further discusses this performance. Intra-system Transfers For patients who transferred into CTF, the transfer process was satisfactory. The nurses provided good nursing care and documentation. Patients received their appointment timely. However, nursing staff did not always facilitate an organized process for patients who transferred out of CTF to other institutions. The Inter- and Intra-System Transfers indicator further discusses this process. Offsite Specialty Services Returns Nurses at CTF appropriately assessed patients returning from offsite specialty appointments in the TTA upon the patients’ return to CTF. The TTA nurses routinely communicated follow-up recommendations from specialty consultations to providers without delays. The Specialty Services indicator further discusses this process. Clinician Onsite Inspection The OIG clinicians visited several clinical areas and spoke with nursing administrators and staff in the receiving and release clinic, outpatient clinics, specialty services, medication lines, the TTA, and the OHU. The OIG clinicians found morning huddles that were well organized, attended by various members of the multidisciplinary team, and demonstrated active participation by team members. There was no backlog of nursing sick call appointments at the time of the OIG onsite inspection visit. Correctional Training Facility, Cycle 5 Medical Inspection Page 46 Office of the Inspector General State of California The OIG nurse consultant attended the weekly CTF supervising nurses’ meeting. The director of nursing facilitated the well-organized meeting in which nursing supervisors discussed topics including implementing more case audits to identify areas for quality improvement. The chief support executive (CSE) was present and was knowledgeable regarding current medical and nursing operations. Nursing supervisors also discussed implementing additional audits of the emergency response bags to ensure that the staff maintained the bags and that they were stocked fully with no expired items. Nursing supervisors also discussed ways to increase nursing morale by recognizing high-performing nurses. The nursing leadership team at CTF demonstrated an effective collaborative process, supported by an experienced chief nurse executive (CNE) and knowledgeable CSE who valued the input from the supervising nurses and nursing staff on clinical quality improvement issues. The CNE and supervising nurses had researched the OIG case review questions before the onsite inspection and were well organized and prepared to discuss the case review findings and their potential interventions for improvement. Additionally, the nurses interviewed at CTF were familiar with their assigned patient population, responsibilities, and duties. The nursing staff also verbalized having a good relationship with their supervisors, who they saw as easily accessible and very receptive to open communication. Case Review Conclusion CTF nurses performed sufficiently with the sick call process, post-hospital returns, specialized medical housing, transfers, and specialty services. However, CTF nurses did not perform appropriately with ASU sick calls and emergency care. As a whole, the OIG rated the Quality of Nursing Performance indicator at CTF adequate. Correctional Training Facility, Cycle 5 Medical Inspection Page 47 Office of the Inspector General State of California QUALITY OF PROVIDER PERFORMANCE In this indicator, the OIG physicians provide a qualitative evaluation Case Review Rating: of the adequacy of provider care at the institution. Appropriate Inadequate evaluation, diagnosis, and management plans are reviewed for Compliance Score: programs including, but not limited to, nursing sick call, chronic care Not Applicable programs, TTA, specialized medical housing, and specialty services. Overall Rating: The assessment of provider care is performed entirely by OIG Inadequate physicians. There is no compliance testing component associated with this quality indicator. Case Review Results OIG clinicians reviewed 185 medical provider encounters and identified 52 deficiencies related to provider performance. Of those 52 deficiencies, 29 were significant. Provider performance at CTF was inadequate. Assessment and Decision-Making CTF providers made numerous errors in the form of inadequate assessment or unsound medical decision-making. These deficiencies occurred frequently and were present in 12 of the 20 detailed physician case reviews (cases 5, 10, 11, 12, 13, 14, 15, 17, 18, 19, 20, and 22). The following examples demonstrated providers’ poor assessment: • In case 5, the patient had colon cancer and submitted four requests for symptoms related to his abdominal mass, abdominal pain, or back pain. The patient also had an ultrasound test, the results of which indicated that further imaging tests be done to identify the abdominal mass better. CTF providers evaluated the patient on six occasions but did not assess for the return of cancer, which may have readily explained the patient’s symptoms. They also failed to order the necessary imaging test. These errors placed the patient at risk for complications due to the delayed diagnosis of recurrent cancer. Four and a half months later, a general surgeon evaluated the patient and immediately transferred the patient to a community hospital, where the physicians found that cancer had spread widely into the liver. • In case 12, a provider canceled a 14-day follow-up appointment; the delayed treatment of the patient’s poorly controlled diabetes placed him at risk of complications such as heart attack, stroke, kidney failure, and blindness. • In case 22, the patient had a persistent cough, chest pain, and shortness of breath. A chest computed tomography (CT) scan showed a mass causing obstruction and collapse of the left upper lung. The radiologist recommended performing a test to examine the mass directly and performing a biopsy. The provider should have considered the possibility of lung cancer and should have ordered the test urgently. Instead, the provider requested a routine test, Correctional Training Facility, Cycle 5 Medical Inspection Page 48 Office of the Inspector General State of California which was performed more than three months later. Furthermore, the patient filled out multiple health care service requests for a persistent cough, difficulty breathing, chest pain, and fever. When CTF finally performed the test, the biopsy showed lung cancer. The delay in diagnosis placed the patient at increased risk of cancer complications, including death. CTF providers often did not recognize potential adverse medication side effects or drug interactions. There were seven significant deficiencies related to poor decision-making in prescribing medications: • In case 5, the patient had a blood clot in his liver that required anticoagulation with warfarin (blood thinner). A provider gave the patient ketorolac, a nonsteroidal anti-inflammatory drug (NSAID), which placed the patient at increased risk of serious bleeding. The provider should not have prescribed the NSAID while the patient was taking warfarin. • In case 12, the patient had never taken long-acting insulin for his diabetes. Nevertheless, a provider prescribed a high insulin dose without monitoring the patient’s fasting blood sugar levels. By prescribing long-acting insulin without the proper monitoring of the blood sugar, the provider placed the patient at risk of hypoglycemia, which could have led to serious side effects, including coma or death. • In case 13, a provider increased a blood pressure medication but did not monitor the potassium and creatinine levels. This error placed the patient at risk of dangerously high potassium levels and kidney damage. • In case 14, a provider prescribed the patient two different cholesterol medications that should not have been prescribed together. The combination of drugs increased the risk for muscle damage and kidney failure. • In case 15, the patient had blood in the stool, and a provider ordered an esophagogastroduodenoscopy (EGD, a test to look directly into the esophagus and stomach) to look for possible gastrointestinal bleeding or ulcers. While waiting for the EGD, the provider prescribed an NSAID medication and aspirin, both of which further increased the risk for bleeding and ulcers. • In case 19, an on-call provider prescribed two similar blood pressure medications, the combination of which placed the patient at risk of dangerously high potassium levels and kidney damage; the provider should not have prescribed the combination of the two medications without a clear reason. Correctional Training Facility, Cycle 5 Medical Inspection Page 49 Office of the Inspector General State of California Hospital Return Care As patients returned from the hospital, CTF providers usually reviewed hospital discharge summaries; however, providers did not always address hospital findings or recommendations. There were two significant deficiencies: • In case 18, the patient required hospitalization for a new diagnosis of chronic obstructive pulmonary disease (COPD). A provider evaluated the patient after the recent hospitalization and documented that the hospital record was not available for review; nevertheless, the provider did not order a follow-up appointment to follow up on the missing hospital report. Thus, the provider did not know about the recent diagnosis of COPD and was unaware of the abnormal laboratory results. • In case 19, the patient required hospitalization for inflammation and weakness of the heart muscle. The hospital physicians obtained a heart muscle biopsy. The results of the biopsy were still pending at the time of the patient’s discharge. When the patient returned to CTF and saw a provider, the hospital discharge summary was not available for review; the provider did not review the patient’s medications properly and did not recognize that the patient had been prescribed two similar medications mistakenly. The provider also did not order a close follow-up visit to address the missing hospital recommendations or the pending biopsy results. Emergency Care CTF providers were usually available for consultation with TTA nursing staff when patients presented emergently to the TTA. However, provider performance in this area was inconsistent. The Emergency Services indicator further discusses provider performance in emergent situations. Chronic Care CTF providers performed poorly in managing chronic medical conditions. Chronic care errors occurred in cases 10, 11, 12, 13, 14, 17, 18, and 20. In diabetic care there were three significant deficiencies: • In case 10, over an eight-month period, the diabetic patient had out-of-control diabetes. Even though the patient was not interested in insulin treatment, the providers saw the patient six times but did not optimize the patient’s diabetic oral medications. Uncontrolled diabetes placed the patient at risk for diabetic complications such as heart attack, stroke, kidney failure, and blindness. • In case 11, a provider ordered a diabetic monitoring test, which showed poorly controlled diabetes. The provider reviewed the report but did not request a follow-up appointment to address diabetes. The provider did not see the patient for more than two and a half months later, resulting in an unnecessary delay in care. Correctional Training Facility, Cycle 5 Medical Inspection Page 50 Office of the Inspector General State of California • In case 12, the patient had out-of-control diabetes. A provider started the patient on insulin treatment but did not order a timely follow-up to monitor and treat the patient’s condition. During the eight-month OIG review period, CTF providers made only three insulin adjustments, whereas current medical current standards recommend weekly insulin adjustment. The delayed treatment of poorly controlled diabetes placed the patient at risk of diabetic complications. CTF providers performed poorly in managing hypertension. There were three significant deficiencies: • In case 13, the patient had uncontrolled hypertension. The provider increased the patient’s blood pressure medication but failed to order a follow-up visit to check the patient’s progress. The poor hypertension management placed the patient at risk of cardiovascular complications, such as heart attack or stroke. • In case 17, the patient had hypertension and glaucoma requiring oral and topical medications. On three encounters, providers did not address the patient’s elevated blood pressure. The poorly controlled hypertension placed the patient at risk of cardiovascular complications. • In case 20, providers made several errors. When a provider assessed the newly arrived patient, the provider erroneously judged that the patient’s blood pressure was well controlled, even though the blood pressure was high at 149/83 mmHg. The provider did not treat the patient until five and a half months later when the provider adjusted the medication but did not monitor the patient’s blood pressure levels or schedule a timely follow-up. Ninety days later, the patient’s blood pressure was still high. The provider adjusted the medication but again did not request a timely follow-up. Also, the patient had a high risk of heart disease and stroke, but the provider did not prescribe the recommended cholesterol medication. One month later, the patient had a stroke and required hospitalization. The OIG clinicians also identified the following two significant deficiencies in chronic care: • In case 12, the diabetic patient was at substantial risk for heart disease and stroke. The provider did not prescribe the recommended dose of cholesterol medication. This error placed the patient at risk of cardiovascular complications, such as heart attack or stroke. • In case 18, a provider evaluated a patient with chronic lung disease but did not offer the recommended pneumonia vaccine. The provider should have offered the vaccination because pneumonia is associated with a 5 to 7 percent mortality rate. Correctional Training Facility, Cycle 5 Medical Inspection Page 51 Office of the Inspector General State of California Specialty Services CTF providers generally referred to specialists appropriately and reviewed specialty reports timely; however, there were two significant deficiencies. The OIG discusses those deficiencies in the Specialty Services indicator. Health Information Management The providers documented their outpatient, TTA, and specialty housing encounters timely. The progress notes were either dictated or typed and were legible. Clinician Onsite Inspection The chief medical executive (CME) expressed concern because of the six provider vacancies. Five providers, including the chief physician and surgeon, had left CTF to join the medical staff in the adjacent state facility, Salinas Valley State Prison (SVSP). Another provider resigned while under review by the statewide Professional Practice Executive Committee (PPEC). Nearly all the CTF providers were new. CTF usually assigned each provider to one designated clinic to enhance continuity of care. Each provider saw approximately 10 to 15 patients per day. The providers attended a daily morning report meeting, during which they discussed patients in the hospital or returning from the hospital. After the morning report, the providers led the morning huddles. The huddles were productive and were attended by nurses, care coordinators, custody staff, and office technicians. The team discussed any significant TTA encounters or hospital returns from the previous day. Case Review Conclusion CTF providers performed poorly in multiple aspects of patient care, including emergency care, chronic care, hospital returns, and specialty services. The poor performance contributed to nine of the inadequate cases reviewed. The sudden departure of five providers, including the chief physician and surgeon contributed to this problem. CTF’s Quality of Provider Performance was inadequate. Correctional Training Facility, Cycle 5 Medical Inspection Page 52 Office of the Inspector General State of California RECEPTION CENTER ARRIVALS This indicator focuses on the management of medical needs and Case Review Rating: continuity of care for patients arriving from outside the CDCR Not Applicable system. The OIG review includes evaluation of the ability of the Compliance Score: institution to provide and document initial health screenings, initial Not Applicable health assessments, continuity of medications, and completion of Overall Rating: required screening tests; address and provide significant Not Applicable accommodations for disabilities and health care appliance needs; and identify health care conditions needing treatment and monitoring. The patients reviewed for reception center cases are those received from non-CDCR facilities, such as county jails. This indicator did not apply because CTF does not have a reception center. Correctional Training Facility, Cycle 5 Medical Inspection Page 53 Office of the Inspector General State of California SPECIALIZED MEDICAL HOUSING This indicator addresses whether the institution follows appropriate Case Review Rating: policies and procedures when admitting patients to onsite inpatient Adequate facilities, including completion of timely nursing and provider Compliance Score: assessments. The case review assesses all aspects of medical care Inadequate related to these housing units, including quality of provider and (56.7%) nursing care. CTF’s only specialized medical housing unit is an Overall Rating: Outpatient Housing Unit (OHU). Adequate In this indicator, the OIG case review and compliance review processes yielded different results, with the case review giving an adequate rating and the compliance review resulting in an inadequate score. Compliance testing found that CTF did not properly maintain call button test logs, resulting in an inadequate score. This finding did not affect the quality of care. As a result, the OIG rated this indicator adequate. Case Review Results The institution had 21 OHU beds: 17 medical beds and 4 alternative housing beds. There were no designated negative pressure rooms. The OIG clinicians reviewed seven OHU cases that spanned 32 provider and 42 nursing encounters. A total of 15 deficiencies were identified, 3 of which were significant. The significant deficiencies occurred in cases 2 and 17. The case review rating of the Specialized Medical Housing indicator was adequate. Provider Performance Providers gave diligent care to OHU patients at CTF. They rounded on the patients timely and made appropriate assessments and sound medical plans. There were no deficiencies in provider performance in the OHU. Nursing Performance Overall, nursing performance in the OHU was acceptable, but some nursing assessments were incomplete or not completed at all (cases 1, 2, 6, and 17). Additionally, nursing staff did not always implement providers’ orders and did not always notify the provider when needed. Examples of these deficiencies are as follows: • In case 2, the nurse did not implement the provider’s order to perform a finger stick hemoglobin (red blood cell count) test for a patient who had low hemoglobin and low blood pressure the day prior. Because the nurse did not implement the provider’s repeat test order, it could not be determined if the patient’s hemoglobin had improved or worsened. • In case 17, there were two significant deficiencies. The patient did not receive his full course of antibiotics for his toe infection. The nurse did not notify the provider that the patient had Correctional Training Facility, Cycle 5 Medical Inspection Page 54 Office of the Inspector General State of California missed antibiotics doses, which placed the patient at risk for worsening infection. Four days later the RN did not assess the patient’s swollen and discolored leg or the toe wound. The nurse should have assessed these areas daily due to the patient’s acute infection. Clinical Onsite Inspection During the onsite visit, patients occupied 13 of the 17 medical beds in the OHU. There was no primary care provider assigned specifically to the OHU, as that provider had recently left CTF to work at SVSP. Thus, during clinic hours, the clinic providers were responsible for the medical care of their patients who were in the OHU. After hours, nurses notified physicians on-call for any medical concerns. There was one assigned RN during the day shift and one assigned LVN during the evening and night shifts. Additionally, there was one CNA assigned during each shift, while the TTA RN provided supervision for the LVNs. The nurse staffing was sufficient for the patients in the OHU. Case Review Conclusion The OIG clinicians rated the Specialized Medical Housing indicator adequate. Compliance Testing Results The institution received an inadequate compliance score of 56.7 percent in the Specialized Medical Housing indicator, showing room for improvement on the following tests: • When inspectors observed the working order of call buttons in the OHU patient rooms, inspectors found all samples working properly. Also, according to staff members interviewed, custody officers and clinicians were able to expeditiously access patients’ locked rooms when emergent events occurred. However, on two occasions, staff did not maintain the log to confirm that they tested the call buttons daily. As a result, the institution received a score of zero on this test (MIT 13.101). • Nursing staff completed an initial assessment on the day of admission to the OHU for seven of ten sampled patients (70.0 percent). For two OHU admissions, no evidence showed that the nurse completed an initial assessment. For one OHU admission, the initial assessment was one day late (MIT 13.001). The institution received a proficient score on the following test: • CTF’s providers timely completed subjective, objective, assessment, plan, and education (SOAPE) notes at required intervals for all eight OHU patients sampled (MIT 13.003). Correctional Training Facility, Cycle 5 Medical Inspection Page 55 Office of the Inspector General State of California SPECIALTY SERVICES This indicator focuses on specialist care from the time a request for Case Review Rating: services or physician’s order for specialist care is completed to the Adequate time of receipt of related recommendations from specialists. This Compliance Score: indicator also evaluates the providers’ timely review of specialist Adequate records and documentation reflecting the patients’ care plans, (81.7%) including course of care when specialist recommendations were not Overall Rating: ordered, and whether the results of specialists’ reports are Adequate communicated to the patients. For specialty services denied by the institution, the OIG determines whether the denials are timely and appropriate, and whether the patient is updated on the plan of care. Case Review Results The OIG clinicians reviewed 148 events related to Specialty Services, which included 103 specialty consultations and procedures, and 45 nursing encounters. There were 15 deficiencies, 4 of which were significant deficiencies. The case review rating for the Specialty Services indicator was adequate. Access to Specialty Services Specialty appointments are integral aspects of specialty services, and the OIG clinicians found that most specialty appointments occurred within the requested time frame. However, there was one significant deficiency related to a missed specialty appointment: • In case 18, the patient had blurry vision, and the optometrist requested a follow-up appointment in two weeks, but the appointment did not occur. Nursing Performance Nursing care was acceptable for patients returning from specialty services. Nursing assessments, interventions, and documentation were sufficient. However, there was one significant deficiency: • In case 14, the patient with coronary artery disease and stent placement returned from an offsite specialty appointment and complained of chest pain; however, the receiving nurse did not perform a thorough pain assessment, placing the patient at risk of a missed diagnosis of a heart attack. Correctional Training Facility, Cycle 5 Medical Inspection Page 56 Office of the Inspector General State of California Provider Performance Case review showed that providers generally referred patients to specialists appropriately. Providers addressed most specialists’ recommendations, with two significant exceptions: • In case 14, the patient had a coronary artery stent placement. The cardiologist recommended a strong cholesterol-lowering medication. The provider did not review or follow the recommendation. This error placed the patient at risk of cardiovascular complications. • In case 15, the patient underwent an EGD, which showed that he had a stomach ulcer. A provider evaluated the patient after the procedure but misdiagnosed the patient with gastroesophageal reflux disease instead of a stomach ulcer. Furthermore, the provider should have reviewed patient medications because the patient was taking a medication that increased the risk of worsening ulcers and bleeding. Health Information Management Health information management was good. Most specialty reports were timely retrieved and scanned into the medical record. Clinical Onsite Inspection At the time of the OIG inspection, there was specialty service staff assigned to offsite, onsite, and telemedicine specialty services. They scheduled specialty appointments and made necessary orders and referrals. The custody staff ensured that escorts and transportations were readily available to all offsite specialty appointments. Case Review Conclusion Providers referred patients to specialists appropriately. CTF properly arranged most specialty appointments and retrieved and scanned the specialty reports were timely. In most instances, CTF providers then acted on specialty recommendations correctly. OIG clinicians rated the Specialty Services indicator at CTF adequate. Compliance Testing Results The institution received an adequate compliance score of 81.7 percent in the Specialty Services indicator, receiving proficient scores in the following test areas: • For all 15 patients sampled, routine specialty service appointments occurred within 90 days of the providers’ orders (MIT 14.003). • For 14 of 15 patients sampled (93.3 percent), high-priority specialty services appointments occurred within 14 days of the providers’ orders; however, one patient received his specialty service six days late (MIT 14.001). Correctional Training Facility, Cycle 5 Medical Inspection Page 57 Office of the Inspector General State of California • Providers timely received and reviewed 11 of the 14 routine specialists’ reports (78.6 percent). For one patient, the provider reviewed the report three days late, and for two other patients, there was no evidence that the report was either received or reviewed by the provider (MIT 14.004). The institution received adequate scores on the following tests: • The institution timely denied providers’ specialty service requests for 17 of 20 patients sampled (85.0 percent). Three of the specialty services requests were denied three, four, and six days late (MIT 14.006). • Providers timely received and reviewed high-priority specialists’ reports for 12 of the 15 sampled patients (80.0 percent). For two patients, CTF received the specialist’s report one and six days late, and for one other patient, CTF did not receive or review the specialist’s report at all (MIT 14.002). • Among 20 patients sampled who had a specialty service denied by CTF’s health care management, 15 (75.0 percent) received timely notification of the denied service, including the provider meeting with the patient within 30 days to discuss alternate treatment strategies. Four patients received their provider follow-up visits between two and ten days late. One patient still had not received their provider follow-up by the time of the OIG’s inspection (MIT 14.007). The institution showed room for improvement in the following test area: • When an institution approves or schedules a patient for specialty services appointments and then transfers the patient to another institution, policy requires that the receiving institution ensure the patient’s appointment occurs timely. At CTF, 12 of the 20 sampled patients who transferred into CTF with an approved specialty service (60.0 percent) received the appointment within the required time frame. The remaining eight patients did not timely receive their previously approved services at all (MIT 14.005). Correctional Training Facility, Cycle 5 Medical Inspection Page 58 Office of the Inspector General State of California ADMINISTRATIVE OPERATIONS (SECONDARY) This indicator focuses on the institution’s administrative health care Case Review Rating: oversight functions. The OIG evaluates whether the institution Not Applicable promptly processes patient medical appeals and addresses all Compliance Score: appealed issues. Inspectors also verify that the institution follows Inadequate reporting requirements for adverse/sentinel events and inmate deaths. (71.8%) The OIG verifies that the Emergency Medical Response Review Overall Rating: Committee (EMRRC) performs required reviews and that staff Inadequate perform required emergency response drills. Inspectors also assess whether the Quality Management Committee (QMC) meets regularly and adequately addresses program performance. For those institutions with licensed facilities, inspectors also verify that required committee meetings are held. In addition, OIG examines whether the institution adequately manages its health care staffing resources by evaluating whether job performance reviews are completed as required; specified staff possess current, valid credentials and professional licenses or certifications; nursing staff receive new employee orientation training and annual competency testing; and clinical and custody staff have current medical emergency response certifications. The Administrative Operations indicator is a secondary indicator, and, therefore, was not relied on for the overall score for the institution. Compliance Testing Results The institution received an inadequate compliance score of 71.8 percent in the Administrative Operations indicator, and showed room for improvement on the following tests: • The OIG reviewed the only reported adverse/sentinel event (ASE) that occurred in the prior twelve-month period., The event was reported to CCHCS’s ASE Committee 11 days late. As a result, CTF scored zero on this test (MIT 15.002). • Inspectors reviewed the summary reports and related documentation for three medical emergency response drills conducted in the prior quarter. CTF did not conduct a comprehensive response drill for all three watches. More specifically, multiple required forms, and necessary elements in an emergency response drill were missing. As a result, the institution received a score of zero on this test (MIT 15.101). • CTF had hired 16 nurses within 12 months. One nurse received the new employee orientation three weeks late. Because the institution did not orient every nurse timely, the institution received a score of zero on this test (MIT 15.111). • Supervisors completed a proper clinical performance appraisal for only one of the five CTF providers (20.0 percent). Four other providers did not have either timely or properly completed appraisals, including the following (MIT 15.106): Correctional Training Facility, Cycle 5 Medical Inspection Page 59 Office of the Inspector General State of California o Three providers had a Unit Health Record Clinical Appraisal completed, but the reviewers’ results were not discussed with the providers. o A fourth provider’s most recently completed evaluation did not include the required Unit Health Clinical Appraisal or a core competency-based evaluation. • CTF had six patient deaths that occurred during the OIG’s testing period. The institution did not timely notify CCHCS’ Death Review Unit of two death cases. The notification was required to be made by noon on the business day following the death. CTF made one notification one minute late, and the other notification was two business days late, resulting in a score of 66.7 percent (MIT 15.103). • Seven of the ten nurses sampled (70.0 percent) were current on their clinical competency validations. For three nurses, there was no evidence they received a clinical competency validation within the required timeframe (MIT 15.105). The institution scored in the proficient range on the following tests: • The institution timely processed all inmate medical appeals in each of the most recent 12 months (MIT 15.001). • CTF's QMC met monthly, evaluated program performance, and took action when management identified areas for improvement opportunities (MIT 15.003). • The institution took adequate steps to ensure the accuracy of its Dashboard data reporting (MIT 15.004). • Based on a sample of ten second level medical appeals, the institution’s responses addressed all of the patients’ appealed issues (MIT 15.102). • When inspectors examined records to determine if nursing supervisors were completing the required number of monthly case reviews on subordinate nurses as well as discussing the results of those reviews, all nursing supervisors properly did so (MIT 15.104). • All providers at the institution were current with their professional licenses. Similarly, all nursing staff and the pharmacist in charge were current with their professional licenses and certification requirements (MIT 15.107, 15.109). • All active-duty providers and nurses were current with their emergency response certifications (MIT 15.108). • All pharmacy staff and providers who prescribed controlled substances had current Drug Enforcement Agency registrations (MIT 15.110). Correctional Training Facility, Cycle 5 Medical Inspection Page 60 Office of the Inspector General State of California • The OIG inspected incident package documentation for 12 emergency medical responses reviewed by CTF’s Emergency Medical Response Review Committee (EMRRC) during the prior six-month period; 11 of 12 sampled packages (91.7 percent) complied with policy. One did not include the required EMRRC checklist (MIT 15.005). Non-Scored Results • The OIG gathered non-scored data regarding the completion of death review reports by CCHCS’s Death Review Committee (DRC). Six deaths occurred at CTF during the OIG’s review period, three unexpected (Level 1) deaths and three expected (Level 2) deaths. The DRC was required to complete its death review summary report within 60 days from the date of death for the Level 1 deaths and within 30 days from the date of death for the Level 2 deaths; the reports should then have been submitted to the institution’s chief executive officer (CEO) within seven calendar days thereafter. None of the death reviews met CCHCS’s reporting guidelines. One of the Level 1 death reviews was completed timely, but the report was communicated to the CEO four days late. For the other two Level 1 deaths, the DRC completed its reports 159 and 219 days late (189 and 249 days after death) and submitted them to CTF’s CEO 114 and 182 days late. For the three Level 2 deaths, the DRC completed its reports 11, 27, and 74 days late (41, 57, and 104 days after death) and submitted them to the CEO 3, 48, and 90 days late (MIT 15.998). • The OIG discusses the institution’s health care staffing resources in the About the Institution section of this report (MIT 15.999). Correctional Training Facility, Cycle 5 Medical Inspection Page 61 Office of the Inspector General State of California R ECOMMENDATIONS Based on the results of the Cycle 5 medical inspection at CTF, the OIG recommends CTF provide additional EHRS training so that staff gain proficiency in using the built-in EHRS functions and can easily identify all orders that were active before a patient’s hospitalization. Additional training should help with some of the hospital return medication errors that CTF staff explained were due to their inability to identify previously active medication orders before a patient’s hospitalization. Correctional Training Facility, Cycle 5 Medical Inspection Page 62 Office of the Inspector General State of California P -B M OPULATION ASED ETRICS The compliance testing and the case reviews give an accurate assessment of how the institution’s health care systems are functioning with regard to the patients with the highest risk and utilization. This information is vital to assess the capacity of the institution to provide sustainable, adequate care. However, one significant limitation of the case review methodology is that it does not give a clear assessment of how the institution performs for the entire population. For better insight into this performance, the OIG has turned to population-based metrics. For comparative purposes, the OIG has selected several Healthcare Effectiveness Data and Information Set (HEDIS) measures for disease management to gauge the institution’s effectiveness in outpatient health care, especially chronic disease management. The Healthcare Effectiveness Data and Information Set is a set of standardized performance measures developed by the National Committee for Quality Assurance with input from over 300 organizations representing every sector of the nation’s health care industry. It is used by over 90 percent of the nation’s health plans as well as many leading employers and regulators. It was designed to ensure that the public (including employers, the Centers for Medicare and Medicaid Services, and researchers) has the information it needs to accurately compare the performance of health care plans. Healthcare Effectiveness Data and Information Set data is often used to produce health plan report cards, analyze quality improvement activities, and create performance benchmarks. Methodology For population-based metrics, the OIG used a subset of HEDIS measures applicable to the CDCR patient population. Selection of the measures was based on the availability, reliability, and feasibility of the data required for performing the measurement. The OIG collected data utilizing various information sources, including the electronic medical record, 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 the following CTF Results Compared to State and National HEDIS Scores table. Multiple health plans publish their HEDIS performance measures at the State and national levels. The OIG has provided selected results for several health plans in both categories for comparative purposes. Correctional Training Facility, Cycle 5 Medical Inspection Page 63 Office of the Inspector General State of California Results of Population-Based Metric Comparison Comprehensive Diabetes Care For chronic care management, the OIG chose measures related to the management of diabetes. Diabetes is the most complex common chronic disease requiring a high level of intervention on the part of the health care system to produce optimal results. CTF performed well with its management of diabetes. When compared statewide, CTF outperformed most other reporting entities in all five diabetic measures. However, the institution scored lower than Kaiser, North and South regions for diabetic blood pressure control. When compared nationally, CTF outperformed Medicaid, commercial, and Medicare in all five diabetic measures. The institution outperformed the VA in four of the five diabetic measures but scored lower than the VA for diabetic blood pressure control. Immunizations Comparative data for immunizations was only fully available for the VA and partially available for Kaiser, commercial plans, Medicaid, and Medicare. With respect to administering influenza vaccinations to younger adults, CTF scored higher than all health plans. When administering influenza vaccinations to older adults, CTF outperformed both Medicare and the VA. With regard to administering pneumococcal vaccines to older adults, CTF scored higher than Medicare and 2 percentage points lower than the VA. Cancer Screening With respect to colorectal cancer screening, CTF scored higher than all health plans. Summary The population based-metrics performance of Correctional Training Facility reflects an adequate chronic care program in comparison to the other statewide and national health care plans. Correctional Training Facility, Cycle 5 Medical Inspection Page 64 Office of the Inspector General State of California CTF Results Compared to State and National HEDIS Scores California National HEDIS Clinical Measures CTF Kaiser HEDIS HEDIS HEDIS (No. Kaiser HEDIS Com- HEDIS VA Cycle 5 Medi-Cal CA) (So.CA) Medicaid mercial Medicare Average Results1 20152 20163 20163 20164 20164 20164 20155 Comprehensive Diabetes Care HbA1c Testing (Monitoring) 100% 86% 94% 94% 86% 90% 93% 98% Poor HbA1c Control (>9.0%)6, 7 8% 39% 20% 23% 45% 34% 27% 19% HbA1c Control (<8.0%)6 79% 49% 70% 63% 46% 55% 63% - Blood Pressure Control 70% 63% 83% 83% 59% 60% 62% 74% (<140/90)6 Eye Exams 95% 53% 68% 81% 53% 54% 69% 89% Immunizations Influenza Shots - Adults (18–64) 67% - 56% 57% 39% 48% - 55% Influenza Shots - Adults (65+) 82% - - - - - 72% 76% Immunizations: Pneumococcal 91% - - - - - 71% 93% Cancer Screening Colorectal Cancer Screening 91% - 79% 82% - 63% 67% 82% 1. Unless otherwise stated, data was collected in August 2017 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 2015 HEDIS Aggregate Report for Medi-Cal Managed Care. 3. Data was obtained from Kaiser Permanente November 2016 reports for the Northern and Southern California regions. 4. National HEDIS data for Medicaid, commercial plans, and Medicare was obtained from the 2016 State of Health Care Quality Report, available on the NCQA website: www.ncqa.org. The results for commercial plans were based on data received from various health maintenance organizations. 5. The Department of Veterans Affairs (VA) data was obtained from the VA's website, www.va.gov. For the Immunizations: Pneumococcal measure only, the data was obtained from the VHA Facility Quality and Safety Report - Fiscal Year 2012 Data. 6. For this indicator, the entire applicable 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. Correctional Training Facility, Cycle 5 Medical Inspection Page 65 Office of the Inspector General State of California A A — C T R PPENDIX OMPLIANCE EST ESULTS Correctional Training Facility Range of Summary Scores: 56.7% – 93.0% Indicator Compliance Score (Yes %) 1–Access to Care 78.2% 2–Diagnostic Services 80.7% 3–Emergency Services Not Applicable 4–Health Information Management (Medical Records) 92.0% 5–Health Care Environment 69.1% 6–Inter- and Intra-System Transfers 92.5% 7–Pharmacy and Medication Management 75.2% 8–Prenatal and Post-Delivery Services Not Applicable 9–Preventive Services 81.3% 10–Quality of Nursing Performance Not Applicable 11–Quality of Provider Performance Not Applicable 12–Reception Center Arrivals Not Applicable 13–Specialized Medical Housing (OHU, CTC, SNF, Hospice) 56.7% 14–Specialty Services 81.7% 15–Administrative Operations 71.8% Correctional Training Facility, Cycle 5 Medical Inspection Page 66 Office of the Inspector General State of California Scored Answers Yes Reference + 1–Access to Care Number Yes No No Yes % N/A Chronic care follow-up appointments: Was the patient’s most recent chronic care visit within the health care guideline’s 1.001 17 8 25 68.0% 0 maximum allowable interval or within the ordered time frame, whichever is shorter? For endorsed patients received from another CDCR institution: If 1.002 the nurse referred the patient to a provider during the initial health 4 21 25 16.0% 0 screening, was the patient seen within the required time frame? Clinical appointments: Did a registered nurse review the patient’s 1.003 29 1 30 96.7% 0 request for service the same day it was received? Clinical appointments: Did the registered nurse complete a face- 1.004 to-face visit within one business day after the CDCR Form 7362 26 4 30 86.7% 0 was reviewed? Clinical appointments: If the registered nurse determined a referral to a primary care provider was necessary, was the patient 1.005 4 2 6 66.7% 24 seen within the maximum allowable time or the ordered time frame, whichever is the shorter? Sick call follow-up appointments: If the primary care provider 1.006 ordered a follow-up sick call appointment, did it take place within 1 0 1 100.0% 29 the time frame specified? Upon the patient's discharge from the community hospital: Did 1.007 the patient receive a follow-up appointment within the required 22 3 25 88.0% 0 time frame? Specialty service follow-up appointments: Do specialty service 1.008 primary care physician follow-up visits occur within required time 22 5 27 81.5% 3 frames? Clinical appointments: Do patients have a standardized process to 1.101 6 0 6 100.0% 0 obtain and submit health care services request forms? Overall percentage: 78.2% Correctional Training Facility, Cycle 5 Medical Inspection Page 67 Office of the Inspector General State of California Scored Answers Yes Reference + 2–Diagnostic Services Number Yes No No Yes % N/A Radiology: Was the radiology service provided within the time 2.001 10 0 10 100.0% 0 frame specified in the provider's order? Radiology: Did the primary care provider review and initial the 2.002 10 0 10 100.0% 0 diagnostic report within specified time frames? Radiology: Did the primary care provider communicate the results 2.003 7 3 10 70.0% 0 of the diagnostic study to the patient within specified time frames? Laboratory: Was the laboratory service provided within the time 2.004 10 0 10 100.0% 0 frame specified in the provider's order? Laboratory: Did the primary care provider review and initial the 2.005 10 0 10 100.0% 0 diagnostic report within specified time frames? Laboratory: Did the primary care provider communicate the 2.006 results of the diagnostic study to the patient within specified time 7 3 10 70.0% 0 frames? Pathology: Did the institution receive the final diagnostic report 2.007 7 3 10 70.0% 0 within the required time frames? Pathology: Did the primary care provider review and initial the 2.008 7 1 8 87.5% 2 diagnostic report within specified time frames? Pathology: Did the primary care provider communicate the results 2.009 2 5 7 28.6% 3 of the diagnostic study to the patient within specified time frames? Overall percentage: 80.7% 3–Emergency Services This indicator is evaluated only by case review clinicians. There is no compliance testing component. Correctional Training Facility, Cycle 5 Medical Inspection Page 68 Office of the Inspector General State of California Scored Answers Yes Reference + 4–Health Information Management Number Yes No No Yes % N/A Are non-dictated healthcare documents (provider progress notes) 4.001 10 0 10 100.0% 0 scanned within 3 calendar days of the patient encounter date? Are dictated/transcribed documents scanned into the patient’s 4.002 electronic health record within five calendar days of the encounter 0 0 0 NA 0 date? Are High-Priority specialty notes (either a Form 7243 or other 4.003 scanned consulting report) scanned within the required time 16 4 20 80.0% 0 frame? Are community hospital discharge documents scanned into the 4.004 patient’s electronic health record within three calendar days of 20 0 20 100.0% 0 hospital discharge? Are medication administration records (MARs) scanned into the 4.005 0 0 0 NA 0 patient’s electronic health record within the required time frames? During the inspection, were medical records properly scanned, 4.006 23 1 24 95.8% 0 labeled, and included in the correct patients’ files? For patients discharged from a community hospital: Did the preliminary hospital discharge report include key elements and 4.007 21 4 25 84.0% 0 did a primary care provider review the report within three calendar days of discharge? Overall percentage: 92.0% Correctional Training Facility, Cycle 5 Medical Inspection Page 69 Office of the Inspector General State of California Scored Answers Yes Reference + 5–Health Care Environment Number Yes No No Yes % N/A Are clinical health care areas appropriately disinfected, cleaned 5.101 12 1 13 92.3% 0 and sanitary? Do clinical health care areas ensure that reusable invasive and 5.102 non-invasive medical equipment is properly sterilized or 9 3 12 75.0% 1 disinfected as warranted? Do clinical health care areas contain operable sinks and sufficient 5.103 13 0 13 100.0% 0 quantities of hygiene supplies? Does clinical health care staff adhere to universal hand hygiene 5.104 7 5 12 58.3% 1 precautions? Do clinical health care areas control exposure to blood-borne 5.105 13 0 13 100.0% 0 pathogens and contaminated waste? Warehouse, Conex and other non-clinic storage areas: Does the 5.106 medical supply management process adequately support the needs 0 1 1 0.0% 0 of the medical health care program? Does each clinic follow adequate protocols for managing and 5.107 6 7 13 46.2% 0 storing bulk medical supplies? Do clinic common areas and exam rooms have essential core 5.108 9 4 13 69.2% 0 medical equipment and supplies? Do clinic common areas have an adequate environment conducive 5.109 6 3 9 66.7% 4 to providing medical services? Do clinic exam rooms have an adequate environment conducive 5.110 9 4 13 69.2% 0 to providing medical services? Emergency response bags: Are TTA and clinic emergency 5.111 medical response bags inspected daily and inventoried monthly, 5 1 6 83.3% 7 and do they contain essential items? Overall percentage: 69.1% Correctional Training Facility, Cycle 5 Medical Inspection Page 70 Office of the Inspector General State of California Scored Answers Yes Reference + 6–Inter- and Intra-System Transfers Number Yes No No Yes % N/A For endorsed patients received from another CDCR institution or COCF: Did nursing staff complete the initial health screening and 6.001 25 0 25 100.0% 0 answer all screening questions on the same day the patient arrived at the institution? For endorsed patients received from another CDCR institution or COCF: When required, did the RN complete the assessment and disposition section of the health screening form; refer the patient 6.002 25 0 25 100.0% 0 to the TTA, if TB signs and symptoms were present; and sign and date the form on the same day staff completed the health screening? For endorsed patients received from another CDCR institution or COCF: If the patient had an existing medication order upon 6.003 12 2 14 85.7% 11 arrival, were medications administered or delivered without interruption? For patients transferred out of the facility: Were scheduled 6.004 specialty service appointments identified on the patient’s health 10 3 13 76.9% 0 care transfer information form? For patients transferred out of the facility: Do medication transfer 6.101 packages include required medications along with the 2 0 2 100.0% 0 corresponding transfer packet required documents? Overall percentage: 92.5% Correctional Training Facility, Cycle 5 Medical Inspection Page 71 Office of the Inspector General State of California Scored Answers 7–Pharmacy and Medication Yes Reference + Management Number Yes No No Yes % N/A Did the patient receive all chronic care medications within the 7.001 required time frames or did the institution follow departmental 20 0 20 100.0% 5 policy for refusals or no-shows? Did health care staff administer, make available, or deliver new 7.002 order prescription medications to the patient within the required 19 6 25 76.0% 0 time frames? Upon the patient’s discharge from a community hospital: Were all 7.003 ordered medications administered, made available, or delivered to 16 9 25 64.0% 0 the patient within required time frames? For patients received from a county jail: Were all medications ordered by the institution’s reception center provider 7.004 0 0 0 NA 0 administered, made available, or delivered to the patient within the required time frames? Upon the patient’s transfer from one housing unit to another: 7.005 21 4 25 84.0% 0 Were medications continued without interruption? For patients en route who lay over at the institution: If the 7.006 temporarily housed patient had an existing medication order, were 10 0 10 100.0% 0 medications administered or delivered without interruption? All clinical and medication line storage areas for narcotic 7.101 medications: Does the Institution employ strong medication 5 4 9 55.6% 4 security over narcotic medications assigned to its clinical areas? All clinical and medication line storage areas for non-narcotic medications: Does the Institution properly store non-narcotic 7.102 6 6 12 50.0% 1 medications that do not require refrigeration in assigned clinical areas? All clinical and medication line storage areas for non-narcotic 7.103 medications: Does the institution properly store non-narcotic 6 4 10 60.0% 3 medications that require refrigeration in assigned clinical areas? Medication preparation and administration areas: Do nursing staff employ and follow hand hygiene contamination control protocols 7.104 4 3 7 57.1% 6 during medication preparation and medication administration processes? Medication preparation and administration areas: Does the 7.105 institution employ appropriate administrative controls and 7 0 7 100.0% 6 protocols when preparing medications for patients? Medication preparation and administration areas: Does the 7.106 Institution employ appropriate administrative controls and 2 5 7 28.6% 6 protocols when distributing medications to patients? Pharmacy: Does the institution employ and follow general 7.107 security, organization, and cleanliness management protocols in 1 0 1 100.0% 0 its main and satellite pharmacies? Correctional Training Facility, Cycle 5 Medical Inspection Page 72 Office of the Inspector General State of California Scored Answers 7–Pharmacy and Medication Yes Reference + Management Number Yes No No Yes % N/A Pharmacy: Does the institution’s pharmacy properly store non- 7.108 1 0 1 100.0% 0 refrigerated medications? Pharmacy: Does the institution’s pharmacy properly store 7.109 1 0 1 100.0% 0 refrigerated or frozen medications? Pharmacy: Does the institution’s pharmacy properly account for 7.110 1 0 1 100.0% 0 narcotic medications? Does the institution follow key medication error reporting 7.111 7 18 25 28.0% 0 protocols? Overall percentage: 75.2% 8–Prenatal and Post-Delivery Services The institution has no female patients, so this indicator is not applicable. Correctional Training Facility, Cycle 5 Medical Inspection Page 73 Office of the Inspector General State of California Scored Answers Yes Reference + 9–Preventive Services Number Yes No No Yes % N/A Patients prescribed TB medication: Did the institution administer 9.001 16 1 17 94.1% 0 the medication to the patient as prescribed? Patients prescribed TB medication: Did the institution monitor the 9.002 patient monthly for the most recent three months he or she was on 16 1 17 94.1% 0 the medication? Annual TB Screening: Was the patient screened for TB within the 9.003 28 2 30 93.3% 0 last year? Were all patients offered an influenza vaccination for the most 9.004 24 1 25 96.0% 0 recent influenza season? All patients from the age of 50 - 75: Was the patient offered 9.005 23 2 25 92.0% 0 colorectal cancer screening? Female patients from the age of 50 through the age of 74: Was the 9.006 0 0 0 NA 0 patient offered a mammogram in compliance with policy? Female patients from the age of 21 through the age of 65: Was 9.007 0 0 0 NA 0 patient offered a pap smear in compliance with policy? Are required immunizations being offered for chronic care 9.008 2 9 11 18.2% 14 patients? Are patients at the highest risk of coccidioidomycosis (valley 9.009 0 0 0 NA 0 fever) infection transferred out of the facility in a timely manner? Overall percentage: 81.3% 10–Quality of Nursing Performance This indicator is evaluated only by case review clinicians. There is no compliance testing component. 11–Quality of Provider Performance This indicator is evaluated only by case review clinicians. There is no compliance testing component. Correctional Training Facility, Cycle 5 Medical Inspection Page 74 Office of the Inspector General State of California 12–Health Information Management The institution has no reception center, so this indicator is not applicable Scored Answers Yes Reference + 13–Specialized Medical Housing Number Yes No No Yes % N/A For OHU, CTC, and SNF: Did the registered nurse complete an 13.001 initial assessment of the patient on the day of admission, or within 7 3 10 70.0% 0 eight hours of admission to CMF’s Hospice? For CTC and SNF only: Was a written history and physical 13.002 0 0 0 NA 10 examination completed within the required time frame? For OHU, CTC, SNF, and Hospice: Did the primary care provider complete the Subjective, Objective, Assessment, Plan, and 13.003 8 0 8 100.0% 2 Education (SOAPE) notes on the patient at the minimum intervals required for the type of facility where the patient was treated? For OHU and CTC Only: Do inpatient areas either have properly working call systems in its OHU & CTC or are 30-minute patient 13.101 0 1 1 0.0% 0 welfare checks performed; and do medical staff have reasonably unimpeded access to enter patient’s cells? Overall percentage: 56.7% Correctional Training Facility, Cycle 5 Medical Inspection Page 75 Office of the Inspector General State of California Scored Answers Yes Reference + 14–Specialty Services Number Yes No No Yes % N/A Did the patient receive the high priority specialty service within 14.001 14 calendar days of the primary care provider order or the 14 1 15 93.3% 0 Physician Request for Service? Did the primary care provider review the high priority specialty 14.002 12 3 15 80.0% 0 service consultant report within the required time frame? Did the patient receive the routine specialty service within 90 14.003 calendar days of the primary care provider order or Physician 15 0 15 100.0% 0 Request for Service? Did the primary care provider review the routine specialty service 14.004 11 3 14 78.6% 1 consultant report within the required time frame? For endorsed patients received from another CDCR institution: If the patient was approved for a specialty services appointment at 14.005 12 8 20 60.0% 0 the sending institution, was the appointment scheduled at the receiving institution within the required time frames? Did the institution deny the primary care provider request for 14.006 17 3 20 85.0% 0 specialty services within required time frames? Following the denial of a request for specialty services, was the 14.007 15 5 20 75.0% 0 patient informed of the denial within the required time frame? Overall percentage: 81.7% Correctional Training Facility, Cycle 5 Medical Inspection Page 76 Office of the Inspector General State of California Scored Answers Yes Reference 15–Administrative Operations + Number Yes No No Yes % N/A Did the institution promptly process inmate medical appeals 15.001 12 0 12 100.0% 0 during the most recent 12 months? Does the institution follow adverse / sentinel event reporting 15.002 0 1 1 0.0% 0 requirements? Did the institution Quality Management Committee (QMC) meet at least monthly to evaluate program performance, and did the 15.003 6 0 6 100.0% 0 QMC take action when improvement opportunities were identified? Did the institution’s Quality Management Committee (QMC) or 15.004 other forum take steps to ensure the accuracy of its Dashboard 1 0 1 100.0% 0 data reporting? Does the Emergency Medical Response Review Committee 15.005 perform timely incident package reviews that include the use of 11 1 12 91.7% 0 required review documents? For institutions with licensed care facilities: Does the Local Governing Body (LGB), or its equivalent, meet quarterly and 15.006 0 0 0 NA 4 exercise its overall responsibilities for the quality management of patient health care? Did the institution complete a medical emergency response drill 15.101 for each watch and include participation of health care and 0 3 3 0.0% 0 custody staff during the most recent full quarter? Did the institution’s second level medical appeal response address 15.102 10 0 10 100.0% 0 all of the patient's appealed issues? Did the institution's medical staff review and submit the initial 15.103 4 2 6 66.7% 0 inmate death report to the Death Review Unit in a timely manner? Does the institution's Supervising Registered Nurse conduct 15.104 5 0 5 100.0% 0 periodic reviews of nursing staff? Are nursing staff who administer medications current on their 15.105 7 3 10 70.0% 0 clinical competency validation? 15.106 Are structured clinical performance appraisals completed timely? 1 4 5 20.0% 0 15.107 Do all providers maintain a current medical license? 10 0 10 100.0% 0 Are staff current with required medical emergency response 15.108 2 0 2 100.0% 1 certifications? Are nursing staff and the Pharmacist-in-Charge current with their professional licenses and certifications, and is the pharmacy licensed as a correctional pharmacy by the California State Board 15.109 6 0 6 100.0% 0 of Pharmacy? Correctional Training Facility, Cycle 5 Medical Inspection Page 77 Office of the Inspector General State of California Scored Answers Yes Reference 15–Administrative Operations + Number Yes No No Yes % N/A Do the institution’s pharmacy and authorized providers who 15.110 prescribe controlled substances maintain current Drug 1 0 1 100.0% 0 Enforcement Agency (DEA) registrations? 15.111 Are nursing staff current with required new employee orientation? 0 1 1 0.0% 0 Overall percentage: 71.8% Correctional Training Facility, Cycle 5 Medical Inspection Page 78 Office of the Inspector General State of California A B — C D PPENDIX LINICAL ATA Table B-1: CTF Sample Sets Sample Set Total Anticoagulation 3 Death Review/Sentinel Events 2 Diabetes 3 Emergency Services – CPR 2 Emergency Services – Non-CPR 2 High Risk 4 Hospitalization 4 Intra-System Transfers In 3 Intra-System Transfers Out 3 RN Sick Call 12 Specialty Services 2 40 Correctional Training Facility, Cycle 5 Medical Inspection Page 79 Office of the Inspector General State of California Table B-2: CTF Chronic Care Diagnoses Diagnosis Total Anemia 5 Anticoagulation 3 Arthritis/Degenerative Joint Disease 4 Asthma 7 COPD 5 Cancer 5 Cardiovascular Disease 4 Chronic Kidney Disease 1 Chronic Pain 6 Coccidioidomycosis 1 Deep Venous Thrombosis/Pulmonary Embolism 4 Diabetes 12 Gastroesophageal Reflux Disease 4 Hepatitis C 7 Hyperlipidemia 23 Hypertension 27 Mental Health 5 Migraine Headaches 1 Thyroid Disease 1 125 Correctional Training Facility, Cycle 5 Medical Inspection Page 80 Office of the Inspector General State of California Table B-3: CTF Event – Program Program Total Diagnostic Services 150 Emergency Care 40 Hospitalization 45 Intra-System Transfers In 16 Intra-System Transfers Out 4 Not Specified 1 Outpatient Care 326 Specialized Medical Housing 97 Specialty Services 178 857 Correctional Training Facility, Cycle 5 Medical Inspection Page 81 Office of the Inspector General State of California Table B-4: CTF Review Sample Summary Total MD Reviews Detailed 20 MD Reviews Focused 0 RN Reviews Detailed 12 RN Reviews Focused 20 Total Reviews 52 Total Unique Cases 40 Overlapping Reviews (MD & RN) 12 Correctional Training Facility, Cycle 5 Medical Inspection Page 82 Office of the Inspector General State of California A C — C S M PPENDIX OMPLIANCE AMPLING ETHODOLOGY Correctional Training Facility (CTF) Sample Category Quality (number of Indicator samples) Data Source Filters Access to Care MIT 1.001 Chronic Care Patients Master Registry • Chronic care conditions (at least one condition per patient—any risk level) (25) • Randomize MIT 1.002 Nursing Referrals OIG Q: 6.001 • See Intra-system Transfers (25) MITs 1.003–006 Nursing Sick Call MedSATS • Clinic (each clinic tested) • Appointment date (2–9 months) 30 • Randomize MIT 1.007 Returns from OIG Q: 4.007 • See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (25) MIT 1.008 Specialty Services OIG Q: 14.001 & • See Specialty Services Follow-up 14.003 (30) MIT 1.101 Availability of Health OIG onsite • Randomly select one housing unit from each yard Care Services review Request Forms (6) Diagnostic Services MITs 2.001–003 Radiology Radiology Logs • Appointment date (90 days–9 months) • Randomize (10) • Abnormal MITs 2.004–006 Laboratory Quest • Appt. date (90 days–9 months) • Order name (CBC or CMPs only) • Randomize (10) • Abnormal MITs 2.007–009 Pathology InterQual • Appt. date (90 days–9 months) • Service (pathology related) (10) • Randomize Correctional Training Facility, Cycle 5 Medical Inspection Page 83 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Health Information Management (Medical Records) MIT 4.001 Timely Scanning OIG Qs: 1.001, • Non-dictated documents (10) 1.002, & 1.004 • 1st 10 IPs MIT 1.001, 1st 5 IPs MITs 1.002, 1.004 MIT 4.002 OIG Q: 1.001 • Dictated documents (0) • First 20 IPs selected MIT 4.003 OIG Qs: 14.002 • Specialty documents (20) & 14.004 • First 10 IPs for each question MIT 4.004 OIG Q: 4.007 • Community hospital discharge documents (20) • First 20 IPs selected MIT 4.005 OIG Q: 7.001 • MARs (0) • First 20 IPs selected MIT 4.006 Documents for • Any misfiled or mislabeled document identified (1) any tested inmate during OIG compliance review (24 or more = No) MIT 4.007 Returns From Inpatient claims • Date (2–8 months) Community Hospital data • Most recent 6 months provided (within date range) • Rx count • Discharge date • Randomize (each month individually) • First 5 patients from each of the 6 months (if not 5 in a month, supplement from another, as needed) (25) Health Care Environment MIT 5.101–105 Clinical Areas OIG inspector • Identify and inspect all onsite clinical areas. MIT 5.107–111 (13) onsite review Inter- and Intra-System Transfers MIT 6.001-–003 Intra-System SOMS • Arrival date (3–9 months) Transfers • Arrived from (another CDCR facility) • Rx count • Randomize (25) MIT 6.004 Specialty Services MedSATS • Date of transfer (3–9 months) Send-Outs • Randomize (13) MIT 6.101 Transfers Out OIG inspector • R&R IP transfers with medication (2) onsite review Correctional Training Facility, Cycle 5 Medical Inspection Page 84 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Pharmacy and Medication Management MIT 7.001 Chronic Care OIG Q: 1.001 See Access to Care Medication • At least one condition per patient—any risk level • Randomize (25) MIT 7.002 New Medication Master Registry • Rx count Orders • Randomize (25) • Ensure no duplication of IPs tested in MIT 7.001 MIT 7.003 Returns from OIG Q: 4.007 • See Health Information Management (Medical Community Hospital Records) (returns from community hospital) (25) MIT 7.004 RC Arrivals – OIG Q: 12.001 • See Reception Center Arrivals Medication Orders N/A at this institution MIT 7.005 Intra-Facility Moves MAPIP transfer • Date of transfer (2–8 months) data • To location/from location (yard to yard and to/from ASU) • Remove any to/from MHCB • NA/DOT meds (and risk level) (25) • Randomize MIT 7.006 En Route SOMS • Date of transfer (2–8 months) • Sending institution (another CDCR facility) • Randomize (10) • NA/DOT meds MITs 7.101–103 Medication Storage OIG inspector • Identify and inspect clinical & med line areas that Areas onsite review store medications (varies by test) MITs 7.104–106 Medication OIG inspector • Identify and inspect onsite clinical areas that Preparation and onsite review prepare and administer medications Administration Areas (varies by test) MITs 7.107–110 Pharmacy OIG inspector • Identify & inspect all onsite pharmacies (1) onsite review MIT 7.111 Medication Error Monthly • All monthly statistic reports with Level 4 or higher Reporting medication error • Select a total of 5 months (25) reports MIT 7.999 Isolation Unit KOP Onsite active • KOP rescue inhalers & nitroglycerin medications Medications medication for IPs housed in isolation units (9) listing Prenatal and Post-Delivery Services MIT 8.001–007 Recent Deliveries OB Roster • Delivery date (2–12 months) N/A at this institution • Most recent deliveries (within date range) Pregnant Arrivals OB Roster • Arrival date (2–12 months) N/A at this institution • Earliest arrivals (within date range) Correctional Training Facility, Cycle 5 Medical Inspection Page 85 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Preventive Services MITs 9.001–002 TB Medications Maxor • Dispense date (past 9 months) • Time period on TB meds (3 months or 12 weeks) (17) • Randomize MIT 9.003 TB Codes, Annual SOMS • Arrival date (at least 1 year prior to inspection) Screening • TB Codes (30) • Randomize MIT 9.004 Influenza SOMS • Arrival date (at least 1 year prior to inspection) Vaccinations • Randomize (25) • Filter out IPs tested in MIT 9.008 MIT 9.005 Colorectal Cancer SOMS • Arrival date (at least 1 year prior to inspection) Screening • Date of birth (51 or older) (25) • Randomize MIT 9.006 Mammogram SOMS • Arrival date (at least 2 yrs prior to inspection) • Date of birth (age 52–74) N/A at this institution • Randomize MIT 9.007 Pap Smear SOMS • Arrival date (at least three yrs prior to inspection) • Date of birth (age 24–53) N/A at this institution • Randomize MIT 9.008 Chronic Care OIG Q: 1.001 • Chronic care conditions (at least 1 condition per Vaccinations IP—any risk level) • Randomize (25) • Condition must require vaccination(s) MIT 9.009 Valley Fever Cocci transfer • Reports from past 2–8 months (number will vary) status report • Institution • Ineligibility date (60 days prior to inspection date) N/A at this institution • All Correctional Training Facility, Cycle 5 Medical Inspection Page 86 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Reception Center Arrivals MITs 12.001–008 RC SOMS • Arrival date (2–8 months) • Arrived from (county jail, return from parole, etc.) N/A at this institution • Randomize Specialized Medical Housing MITs 13.001–004 OHU CADDIS • Admit date (1–6 months) • Type of stay (no MH beds) • Length of stay (minimum of 5 days) (10) • Randomize MIT 13.101 Call Buttons OIG inspector • Review by location OHU (all) onsite review Specialty Services MITs 14.001–002 High-Priority MedSATS • Approval date (3–9 months) (15) • Randomize MITs 14.003–004 Routine MedSATS • Approval date (3–9 months) (15) • Remove optometry, physical therapy or podiatry • Randomize MIT 14.005 Specialty Services MedSATS • Arrived from (other CDCR institution) Arrivals • Date of transfer (3–9 months) (20) • Randomize MIT 14.006–007 Denials InterQual • Review date (3–9 months) (18) • Randomize IUMC/MAR • Meeting date (9 months) Meeting Minutes • Denial upheld (2) • Randomize Correctional Training Facility, Cycle 5 Medical Inspection Page 87 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.001 Medical Appeals Monthly medical • Medical appeals (12 months) (all) appeals reports MIT 15.002 Adverse/Sentinel Adverse/sentinel • Adverse/sentinel events (2–8 months) Events events report (1) MITs 15.003–004 QMC Meetings Quality • Meeting minutes (12 months) Management Committee (6) meeting minutes MIT 15.005 EMRRC EMRRC meeting • Monthly meeting minutes (6 months) (12) minutes MIT 15.006 LGB LGB meeting • Quarterly meeting minutes (12 months) (0) minutes MIT 15.101 Medical Emergency Onsite summary • Most recent full quarter Response Drills reports & • Each watch documentation (3) for ER drills MIT 15.102 2nd Level Medical Onsite list of • Medical appeals denied (6 months) Appeals appeals/closed (10) appeals files MIT 15.103 Death Reports Institution-list of • Most recent 10 deaths deaths in prior 12 • Initial death reports (6) months MIT 15.104 RN Review Onsite supervisor • RNs who worked in clinic or emergency setting Evaluations periodic RN six or more days in sampled month reviews • Randomize (5) MIT 15.105 Nursing Staff Onsite nursing • On duty one or more years Validations education files • Nurse administers medications (10) • Randomize MIT 15.106 Provider Annual OIG Q:16.001 • All required performance evaluation documents Evaluation Packets (5) MIT 15.107 Provider licenses Current provider • Review all listing (at start of (10) inspection) MIT 15.108 Medical Emergency Onsite • All staff Response certification o Providers (ACLS) Certifications tracking logs o Nursing (BLS/CPR) (all) • Custody (CPR/BLS) MIT 15.109 Nursing staff and Onsite tracking • All required licenses and certifications Pharmacist in system, logs, or Charge Professional employee files Licenses and Certifications (all) Correctional Training Facility, Cycle 5 Medical Inspection Page 88 Office of the Inspector General State of California Sample Category Quality (number of Indicator samples) Data Source Filters Administrative Operations MIT 15.110 Pharmacy and Onsite listing of • All DEA registrations Providers’ Drug provider DEA Enforcement Agency registration #s & (DEA) Registrations pharmacy registration (all) document MIT 15.111 Nursing Staff New Nursing staff • New employees (hired within last 12 months) Employee training logs • Orientations (all) MIT 15.998 Death Review OIG summary log • Between 35 business days & 12 months prior Committee - deaths • CCHCS death reviews (5) Correctional Training Facility, Cycle 5 Medical Inspection Page 89 Office of the Inspector General State of California C C ALIFORNIA ORRECTIONAL H C S ’ EALTH ARE ERVICES R ESPONSE Correctional Training Facility, Cycle 5 Medical Inspection Page 90 Office of the Inspector General State of California